Alcohol harm reduction education in schools: planning an efficacy study in Australia

The School Health and Alcohol Harm Reduction Project (SHAHRP) is a 4-year, quasi-experimental, evidence-based intervention research study designed to explore the effects of a student-focused, secondary school, alcohol education intervention in reducing alcohol-related harm experienced by school students. The SHAHRP study is unusual in that it has a primary aim of harm minimization rather than non-use or delayed use. The SHAHRP intervention aims to reduce harm by enhancing students' abilities to identify and deal with high-risk drinking situations particularly likely to be encountered by young people. The intervention involves eight lessons in the first year with five booster lessons in the subsequent year. The SHAHRP research will follow individual students exposed to both the alcohol and health promotion interventions over 3 successive years taking measures in: knowledge; attitudes; patterns of use; context of use; alcohol-related harm associated with the student' own use; alcohol-related harm associated with other people's use of alcohol. This paper describes the evidence-based conceptual components and design of the study by providing a review of the health and drug education literature particularly related to components that have the potential of influencing behaviour.     

The benefits and harms of alcohol use in New Zealand: what politicians might consider

The New Zealand Government is currently considering ways to reduce alcohol-related harm, following on from a detailed report by the Law Commission. To inform discussions we briefly summarise the benefits and harms of alcohol use in this country. The most substantive benefits to society are probably pleasure to users and economic benefits (largely to industry). The most substantive harms are probably those to mental and physical health, harm to society (e.g. from crime) and adverse net economic impacts. Overall the picture is suggestive that New Zealand society would be likely to achieve a large net benefit from reducing heavy and binge drinking, and shifting alcohol consumption towards a pattern of smaller amounts. The substantial harm to non-users is a key argument for democratic governments to use regulations and taxes to minimise harm from alcohol.     

Alcohol supply,demand, and harm reduction: What is the strongest cocktail?

The concept of harm reduction emerged from the drug field in the 1980s in response to the urgent need to reduce the risk and spread of blood-borne viruses in people who continued to inject illicit drugs. The concept has since become increasingly influential in the alcohol and even tobacco fields. While there are many different applications of the term today, the distinction used by the International Harm Reduction Association (IHRA) between strategies relying on ‘use reduction’ and those that primarily strive for harm reduction without necessarily requiring reduction in consumption is used here. The evidence base for the effectiveness of harm reduction strategies on the one hand, and efforts that require a degree of use reduction via demand or supply reduction on the other hand, is summarised based on a comprehensive review funded by the Australian government. In the alcohol field, the concept of harm reduction has sometimes been proposed as an alternative to the view that alcohol-related harm will only be reduced via a reduction of the total population consumption of alcohol. This paper will present evidence to suggest that, in order to be most effective, a comprehensive policy to reduce alcohol-related harm needs also to include interventions to reduce the quantity of alcohol consumed per occasion. Furthermore, it is highly unlikely in most modern drinking societies that significant reductions in alcohol-related harm can occur without also a significant drop in total population consumption. Nonetheless, harm reduction is an important and influential principle in alcohol policy that can be incorporated alongside such effective strategies as controls on the physical and economic availability of alcohol and the routine delivery of brief interventions in primary health care settings.     

Alcohol and harm reduction in Brazil

Alcohol consumption is an important health issue in Brazil. This paper provides an overview of alcohol-related problems in the country and explores some of the initiatives employed to address these problems. Although the notion of alcohol harm reduction is relatively new in Brazil, much work has been done to incorporate it further into the country's drug policy. The paper discusses some of the federal and state government efforts in the realm of alcohol harm reduction and provides examples of good practice from a variety of other actors, such as NGOs and universities. Looking forward, a number of challenges are outlined, such as providing better treatment to all in need of assistance, establishing a fruitful and consistent partnership between private and public sectors, measuring the size and consequences of illicit alcohol production, and addressing alcohol-related problems among Brazil's indigenous populations. In general, there is a lack of national drug and alcohol data in Brazil. Further research related to alcohol consumption, therefore, is necessary in order to provide Brazil's decision-makers with comprehensive and reliable data that could guide public health policies.     

Overview of harm reduction treatments for alcohol problems

As evidenced by the tremendous range of scholarly articles included in this special issue, it is readily apparent that harm reduction is more than a theory, treatment approach, or policy. Rather, harm reduction is an orientation and belief system that has widespread empirical support as a means to improve the lives and functioning of individuals who use and abuse alcohol. In this article, we review recent empirical articles and scholarly reviews of harm reduction treatments for alcohol abuse and dependence. We focus this review on peer-reviewed articles published in the last 3 years, with a particular emphasis on interventions designed to reduce alcohol-related harm, including overall levels of consumption and alcohol-related problems. We conclude with a section on books, Web sites, and training and treatment centres devoted to harm reduction psychotherapy.     

Perceptions of Alcohol Advertising Vary Based on Psychological Characteristics

Background: The alcohol industry recognizes children and pregnant women as population sub-groups vulnerable to the effects of alcohol marketing. Research indicates that heavy alcohol users are also potentially vulnerable to alcohol marketing. The purpose of the current study is to determine if sub-groups defined by psychological characteristics should be classified as potentially vulnerable as well. Methods: College students (n?=?326) from two northeast schools were recruited to complete a survey containing questions on demographics, alcohol use, and psychological characteristics (alcohol expectancies, alcohol dependence, sensation seeking traits, and past delinquent behaviors). Additionally, after viewing each of five alcohol ads (4 television and 1 magazine), participants answered questions about their perceptions of alcohol consumption, responsible drinking, excessive drinking, and appeal of the ads. Main effects were assessed using hierarchical linear modeling, with adjustment for age, sex, race, ethnicity, and AUDIT score. Results: Alcohol expectancies (p?<?.001), particularly the social and physical pleasure and social expressiveness sub-scales, and sensation seeking traits (p?=?.002) were positively associated with alcohol ad appeal. Alcohol dependence symptoms, specifically impaired control and tolerance, were positively associated with perceptions of responsible drinking (p?=?.035), even though mean perceived number of drinks consumed met the definition of binge drinking. Conclusions: Individuals with positive alcohol expectancies, sensation seeking traits, and alcohol dependence may be vulnerable to alcohol advertising and marketing. Because alcohol advertising often contains content that can serve as a cue or reinforce to drink, specific regulations may be needed to prevent alcohol-related harm from occurring in these sub-populations.     

Alcohol advertising in the New Zealand university student press

University students drink more heavily than their non-student peers in New Zealand. The promotion of alcohol via advertising is a known contributor to heavy drinking. The aim of this paper was to determine the nature and extent of alcohol-related advertising and related policies at New Zealand universities. We sought to obtain all issues for 2005, of student newspapers at five New Zealand universities that had participated in an ongoing research project examining alcohol-related harm. The number of alcohol-related advertisements was determined and counts were weighted by the proportion of the page they took up. We surveyed senior university administrators to determine whether policies existed to regulate alcohol advertising on campus. The number of alcohol-related advertisements in student publications ranged from 1 to 129 across the academic year (median: 74 advertisements, 34 full-page equivalents). At three universities, most advertisements promoted bars, pubs and restaurants, while at the other two universities, most alcohol-related advertising was for events sponsored by a brewery, alcohol company or local pub. At one university with almost no advertising, a brewery sponsorship agreement with the student association forbade other parties from advertising alcohol and related events. Alcohol-related advertising is pervasive in the New Zealand university student press. Student associations should consider the ethics of alcohol industry sponsorship in light of the high prevalence of heavy drinking in this population group.     

Early unsupervised drinking--reducing the risks. The School Health and Alcohol Harm Reduction Project

The School Health and Alcohol Harm Reduction Project (SHAHRP) aimed to reduce alcohol-related harm by enhancing students' abilities to identify and deal with high-risk drinking situations and issues. The SHAHRP study involved a quasi-experimental research design, incorporating intervention and control groups and measuring change over a 32-month period. The study occurred in metropolitan, government secondary schools (13 - 17-year-olds) in Perth, Western Australia. The 14 intervention and control schools involved in the SHAHRP study represent approximately 23% of government secondary schools in the Perth metropolitan area. The sample was selected using cluster sampling, with stratification by socio-economic area, and involved over 2,300 intervention and control students from junior secondary schools. The retention rate of the study was 75.9% over 32 months. The intervention incorporated evidence-based approaches to enhance potential for behaviour change in the target population. The intervention was a classroom-based programme, with an explicit harm minimization goal, and was conducted in two phases over a 2-year period. The results were analysed by baseline context of alcohol use to assess the impact of the programme on students with varying experience with alcohol. Knowledge and attitudes were modified simultaneously after the first phase of the intervention in all baseline context of use groups. The programme had little behavioural impact on baseline supervised drinkers; however, baseline non-drinkers and unsupervised drinkers were less likely to consume alcohol in a risky manner, compared to their corresponding control groups. In line with programme goals, early unsupervised drinkers from the intervention group were also significantly less likely to experience harm associated with their own use of alcohol compared to the corresponding control group. Unsupervised drinkers experienced 18.4% less alcohol-related harm after participating in both phases of the programme and this difference was maintained (19.4% difference) 17 months after the completion of the programme. This study indicates that a school drug education programme needs to be offered in several phases, that programme components may need to be included to cater for the differing baseline context of use groups, and that early unsupervised drinkers experience less alcohol-related harm after participating in a harm reduction programme.     

Harm reduction approaches to alcohol use: health promotion,prevention, and treatment

Harm reduction approaches to alcohol problems have endured a controversial history in both the research literature and the popular media. Although several studies have demonstrated that controlled drinking is possible and that moderation-based treatments may be preferred over abstinence-only approaches, the public and institutional views of alcohol treatment still support zero-tolerance. After describing the problems with zero-tolerance and the benefits of moderate drinking, the research literature describing prevention and intervention approaches consistent with a harm reduction philosophy are presented. Literature is reviewed on universal prevention programs for young adolescents, selective and indicated prevention for college students, moderation-based self-help approaches, prevention and interventions in primary care settings, pharmacological treatments, and psychosocial approaches with moderation goals. Overall, empirical studies have demonstrated that harm reduction approaches to alcohol problems are at least as effective as abstinence-oriented approaches at reducing alcohol consumption and alcohol-related consequences. Based on these findings, we discuss the importance of individualizing alcohol prevention and intervention to accommodate the preferences and needs of the targeted person or population. In recognizing the multifaceted nature of behavior change, harm reduction efforts seek to meet the individual where he or she is at and assist that person in the direction of positive behavior change, whether that change involves abstinence, moderate drinking, or the reduction of alcohol-related harm. The limitations of harm reduction and recommendations for future research are discussed.     

The role of social and health statistics in measuring harm from alcohol

Since excess use of alcohol contributes to so many varieties of health and social harms, in most countries, there are many potential sources of data indicative of alcohol-related harms. In few instances, compilation and interpretation of these data are straightforward, but, mostly, they are open to various sources of measurement error, which need to be taken into account if they are to be applied for research purposes. Police and health statistics are the major source of such information, but the underlying systems are not usually set up with the purpose of monitoring alcohol-related events. In both of these domains, types of events can be identified, which are wholly attributable to excess alcohol use, i.e. drunk-driving, alcoholic liver cirrhosis. Specific alcohol-related events are particularly prone to variations in, respectively, police enforcement practices, medical diagnostic fashion and sensitivity to prejudices about alcohol-related problems. A case will be made in this paper for the use of multiple surrogate measures of alcohol-related harm drawn from several sources in order to measure and track local, regional and national trends. For health statistics on mortality and morbidity, the aetiologic fraction (AF) method will be recommended for such monitoring purposes. It will also be recommended that these data be categorised by the degree to which cases are attributable to alcohol and also by whether the underlying hazardous drinking pattern is a brief drinking bout or a sustained pattern of heavy intake over a number of years. Nighttime occurrences of road crashes, public violence from both police and emergency room attendance data will also be recommended. It will be argued that routine recording of alcohol relatedness of events is usually unreliable, and the above surrogate measures are preferable. Recommendations will also be made for utilising national surveys of drinking behaviour to improve the calculation of alcohol-related morbidity and mortality, as well as refine estimates of per capita alcohol consumption, another major 'surrogate' measure of alcohol-related harm. The arguments will be illustrated with reference to Australia's National Alcohol Indicators Project and related research projects.     

National survey of drugs and alcohol provisions within further education colleges in England in 2006

The potential for a contribution to be made by further education colleges to reduce drug- and alcohol-related harm has recently been recognized at a national level. Little is known, however, about the extent of actual drug- and alcohol-related activities taking place. A national survey for England was undertaken via a semi-structured interview administered by telephone, targeting all medium to large colleges and achieving a 92% response rate. Non-curriculum student welfare staff were identified to be widely available and most commonly involved in activities such as referral, provision of leaflets, with teaching staff delivering formal curriculum and tutorial-based work. External agencies were involved with three quarters of colleges, with a similar proportion of colleges also having a drug policy in place. The known contents of these policies were variable. Although drug and alcohol use were not generally viewed as being greatly problematic within the colleges, it is highly likely that there exist opportunities for early interventions that have not yet been well-explored.     

The ‘Lugna Gatan’ Project—An Example of Enterprise in Crime Prevention Work

The potential for a contribution to be made by further education colleges to reduce drug- and alcohol-related harm has recently been recognized at a national level. Little is known, however, about the extent of actual drug- and alcohol-related activities taking place. A national survey for England was undertaken via a semi-structured interview administered by telephone, targeting all medium to large colleges and achieving a 92% response rate. Non-curriculum student welfare staff were identified to be widely available and most commonly involved in activities such as referral, provision of leaflets, with teaching staff delivering formal curriculum and tutorial-based work. External agencies were involved with three quarters of colleges, with a similar proportion of colleges also having a drug policy in place. The known contents of these policies were variable. Although drug and alcohol use were not generally viewed as being greatly problematic within the colleges, it is highly likely that there exist opportunities for early interventions that have not yet been well-explored.     

Problem drinking in relation to treatment outcome among opiate addicts in methadone maintenance treatment

This study analyzed indicators of alcohol-related problems in opiate addicts before, during, and after leaving methadone maintenance treatment (MMT), in relation to illicit drug use and retention in treatment. The study was based on 204 patients, admitted to MMT for the first time between 1 January 1995 and 31 July 2000, and followed until 31 December 2000. Three measures were used to indicate alcohol use and alcohol-related problems; records of hospital care with an alcohol-related diagnosis, any treatment with alcohol-sensitizing drugs (disulfiram or calcium carbimide) during MMT, and results of the 5-hydroxytryptophol to 5-hydroxyindoleacetic acid ratio (5HTOL/5HIAA) in urine, a sensitive biomarker for recent drinking. Use of illicit drugs was determined by routine urine drug testing. About one third of the patients (n = 69) had a lifetime prevalence of hospital treatment for an alcohol-related diagnosis, 45 of whom had been hospitalized (mean 4.2 stays) prior to the start of MMT. There was a significant association (p<0.05) between the number of alcohol-related diagnoses prior to treatment and a positive 5HTOL/5HIAA test during MMT. The alcohol indicators first became positive on average 1.6 years after admission to treatment, compared with after about 4 months for illicit drugs. Use of cannabis or benzodiazepines was significantly associated with alcohol use. Female methadone patients with indications of alcohol-related problems relapsed more often into illicit drug use than did women without such indications (3.9 vs. 2.5 relapse periods/year; p<0.005), whereas no significant association was found for men. The results of the present study indicate that drinking problems among patients undergoing MMT is associated with an increased risk of relapse into illicit drug use and with discharge from treatment. Concurrent treatment of alcohol-related problems, including systematic monitoring of alcohol use, therefore should be recommended to reduce the risk for relapse into illicit drug use and improve overall treatment outcome in MMT.     

Depressive Symptoms and Drinking Outcomes: The Mediating Role of Drinking Motives and Protective Behavioral Strategies Among College Students

Background: College students with depressive symptoms tend to engage in more hazardous drinking and experience more alcohol-related consequences to cope with their symptoms. Given the perceived tension reducing effects of alcohol among these students, it is important to explore how protective factors, such as protective behavioral strategies, account for the relationships among depressive symptoms, drinking motives, and alcohol-related outcomes. Objective: To examine the mediating role of drinking motives and protective behavioral strategies on the associations that depressive symptoms have with typical weekly alcohol consumption, hazardous drinking, and alcohol-related negative consequences in a sample of college student drinkers. Methods: Traditional age college students (n = 566, 73% women; 58% White, non-Hispanic) completed measures of depression, drinking motives, protective behavioral strategies, weekly alcohol use, hazardous drinking, and alcohol-related negative consequences. Results: Coping with depression motives and controlled consumption PBS explained the association between depression and weekly alcohol consumption and hazardous drinking whereas coping with depression motives and serious harm reduction PBS explained the depression-negative consequences relationship. Conformity motives and serious harm reduction PBS explained the association between depression and hazardous drinking and alcohol-related negative consequences. Conclusions: Findings suggest that students with more depressive symptoms would benefit from clinical interventions tailored to address negative reinforcement drinking motives and, by extension, increase student utilization of PBS related to minimizing harm. Clinical and research implications are provided.     

Can you say no? Examining the relationship between drinking refusal self-efficacy and protective behavioral strategy use on alcohol outcomes

Preliminary research has demonstrated reductions in alcohol-related harm associated with increased use of protective behavioral strategies (PBS) and higher levels of drinking refusal self-efficacy (DRSE). To extend research that has evaluated these protective factors independently of one another, the present study examined the interactive effects of PBS use and DRSE in predicting alcohol outcomes. Participants were 1084 college students (63% female) who completed online surveys. Two hierarchical linear regression models revealed that both DRSE and PBS use predicted alcohol use and consequences. Additionally, DRSE moderated the relationship between PBS use and both typical weekly drinking and negative alcohol-related consequences, such that participants who reported lower levels of PBS use and DRSE in the social pressure or emotional regulation dimensions were at greatest risk for heavy drinking and consequences respectively. Interestingly, for those who reported higher levels of social and emotional DRSE, levels of PBS use had no impact on alcohol use or alcohol consequences respectively. These findings demonstrate that DRSE and PBS use differentially reduce risk, suggesting the utility of collegiate, alcohol harm reduction interventions that aim to both increase PBS use and bolster self-efficacy for greater harm reduction.     

On the outside looking in: Finding a place for managed alcohol programs in the harm reduction movement

Alcohol policy in North America is dominated by moderation and abstinence-based modalities that focus on controlling population-level alcohol consumption and modifying individual consumption patterns to prevent and reduce alcohol-related harms. However, conventional alcohol policies and interventions do not adequately address harms associated with high-risk drinking among individuals experiencing severe alcohol use disorder (AUD) and structural vulnerability such as poverty and homelessness. In this commentary we address this gap in alcohol harm reduction, and highlight the lack of, and distinct need for, alcohol-specific harm reduction for people experiencing structural vulnerability and severe AUD. These individuals, doubly impacted by structural oppression and severe AUD, engage in various high-risk drinking practices that contribute to a unique set of harms that conventional abstinence-based treatments and interventions fail to adequately attend to. Managed alcohol programs (MAPs) have been established to address these multiple intersecting harms, and though gaining momentum across Canada, have had a hard time finding their place within the harm reduction movement. We illustrate how MAPs play a crucial role in the harm reduction movement in their ability to not only address high-risk drinking practices among structurally marginalized individuals, but to respond to harms associated with broader structural inequities such as poverty and homelessness.     

Responding to alcohol and drug problems

Despondency about the efficacy of both diagnosis and treatment for alcohol-related problems is common. Several major causes of morbidity and mortality in our community are characterised by under-diagnosis in the community, under-diagnosis on presentation, lack of highly effective treatment or poor delivery of treatment to those most in need. Similar problems are encountered in the delivery of treatment to individuals with alcohol-related problems in the community. Most alcohol-related problems in the community are associated with only moderately elevated alcohol consumption, although the small number of individuals with exceptionally high intake have a higher relative risk of developing problems. The number of individuals exposed to a low risk of problems will be disproportionately influenced by changes in mean alcohol consumption. Approaches to prevention follow socio-cultural, public health, or consumption models. Compelling evidence closely links indices reflecting harm to changes in alcohol consumption. The challenge of prevention of alcohol-related problems is to devise measures which are acceptable to the entire population, yet also deal with problems associated with a small minority.     

Efficacy of an online intervention to reduce alcohol-related risks among community college students

Problems associated with alcohol use are well-documented among traditional 4-year college students, but less is known about community college students' alcohol use. The few published articles that have investigated alcohol consumption among community college students suggest that risky alcohol consumption is a concern. Online alcohol-related risk reduction programs may be well-suited to community college campuses, due to reduced cost and labour effort, as well as increased accessibility for students. The aim of the current study was to test the efficacy of an online intervention designed to reduce risks associated with alcohol use among community college students. Three hundred and nineteen community college students were randomised to one of two treatment conditions: reviewing the online alcohol-related risk reduction program or reviewing online educational newsletters. Generalised linear mixed models were conducted, testing for mean differences between conditions over time on each outcome (primary analyses: alcohol and other drug use, protective behaviours and consequences of substance use). Exploratory analyses for moderating effects of covariates and user engagement were also conducted. Twelve months after the intervention, students who reviewed the online intervention reported a reduction in the maximum number of drinks consumed on one occasion within the past week and a greater reduction in total drinks consumed within the past week, as compared to students who received educational e-newsletters. Online alcohol-related risk reduction programs for students beginning community college may offer a practical and effective way to reduce alcohol consumption, and may have the potential to increase the wellbeing of a largely underserved population.     

Community‐based drug and alcohol counselling: who attends and why?

In order to develop and tailor treatment approaches in drug and alcohol counselling accurately, it is necessary to identify characteristics of the relevant client group. This study describes the demographic and substance use characteristics of 1212 community-based drug and alcohol counselling clients from a regional Area Health Service in NSW, Australia. Findings identify these clients as predominantly young, unmarried, unemployed males with low incomes. Alcohol use is characterized by binge consumption (83%) and alcohol-related problems (94%). A substantial proportion use tobacco (74%), cannabis (61%), opiates (15%) and amphetamines (22%). Of those using illicit drugs other than marijuana, the incidence of sharing syringes (10%) is of concern. These data differ from those reported by both general practice patients in the same geographical area, as a treatment-seeking population in an alternative community-based setting, and a general community sample. It is argued that there is a need for interventions delivered in community-based drug and alcohol settings that are aimed specifically at polydrug use, attempt to minimize drug-related harm and are relevant to those of lower socio-economic status.     

Gender,intoxication and the developing brain: Problematisations of drinking among young adults in Australian alcohol policy

In this article, we draw on recent scholarly work in the poststructuralist analysis of policy to consider how policy itself functions as a key site in the constitution of alcohol ‘problems’, and the political implications of these problematisations. We do this by examining Australian alcohol policy as it relates to young adults (18–24 years old). Our critical analysis focuses on three national alcohol policies (1990, 2001 and 2006) and two Victorian state alcohol policies (2008 and 2013), which together span a 25-year period. We argue that Australian alcohol policies have conspicuously ignored young adult men, despite their ongoing over-representation in the statistical ‘evidence base’ on alcohol-related harm, while increasingly problematising alcohol consumption amongst other population subgroups. We also identify the development of a new problem representation in Australian alcohol policy, that of ‘intoxication’ as the leading cause of alcohol-related harm and rising hospital admissions, and argue that changes in the classification and diagnosis of intoxication may have contributed to its prioritisation and problematisation in alcohol policy at the expense of other forms of harm. Finally, we draw attention to how preliminary and inconclusive research on the purported association between binge drinking and brain development in those under 25 years old has been mobilised prematurely to support calls to increase the legal purchasing age from 18 to 21 years. Our critical analysis of the treatment of these three issues – gender, intoxication, and brain development – is intended to highlight the ways in which policy functions as a key site in the constitution of alcohol ‘problems’.