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.     

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.     

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.     

“Everyone can loosen up and get a bit of a buzz on”: Young adults,alcohol and friendship practices

In countries with liberalised alcohol policies, alcohol harm reduction strategies predominantly focus on young adults’ excessive drinking harms and risks. However, research shows such risks are largely irrelevant for young adults, who emphasise the sociability, release, pleasure and fun of drinking. Friendship is a central part of their lives and an integral part of their drinking experiences. This study aimed to explore everyday friendship practices, drinking, and pleasure in young people's routine and shared social lives. Twelve friendship discussion groups were conducted in urban and non-urban New Zealand, with 26 women and 25 men aged 18–25 years. Our Foucauldian discursive analysis enabled us to identify how the young adults drew on drinking as ‘friendship fun’ and ‘friends with a buzz’ discourses to construct drinking as a pleasurable and socially embodied friendship practice. Yet the young adults also drew on ‘good always outweighs bad experiences’ and friendship ‘caring and protection’ discourses to smooth over disruptive negative drinking experiences. Together these discourses function to justify young adults’ drinking as friendship pleasure, minimising alcohol harms, and setting up powerful resistances to individualised risk-based alcohol-harm reduction campaigns. These findings are discussed in terms of new insights and implications for alcohol harm reduction strategies that target young adults.     

Harm reduction, students and pleasure: an examination of student responses to a binge drinking campaign

BackgroundRecent debates about ‘binge drinking’ in New Zealand have positioned alcohol consumption amongst young drinkers as of concern. Research notes that students drink more heavily than their peers and that they have a higher incidence of alcohol related harms. In response, a harm reduction campaign aimed at first year university students was developed at a New Zealand university.MethodsThis mixed methods study used questionnaires (225) and a small number of semi-structured interviews (4) to elicit student responses to the harm reduction campaign.ResultsThe majority of students in this study can be characterised as binge drinkers, although their drinking does not appear to cause them concern. The term ‘binge drinking’ is explored in three developed categories; ‘light’, ‘moderate’ and ‘heavy’ bingeing. Results are considered within a discussion of pleasure as a hindrance to harm reduction campaigns.ConclusionsThe concept of ‘determined drunkenness’ and the notion of pleasure are important in students’ motivations for drinking and may contribute to the resistance they have in viewing their alcohol consumption as concerning. It is argued that students already felt that they exercised control over their drinking for pleasure and this produced contradictions in responses towards the campaign compared to actual behaviour.     

Teenage thinking on teenage drinking: 15- to 16-year olds' experiences of alcohol in Northern Ireland

Focus groups were conducted with 15- to 16-year olds in Northern Ireland looking at reasons for alcohol consumption and reflections on specific attitudes towards alcohol and behaviours resulting from alcohol use. Participants reported greater concern with ‘being caught’ drinking by parents than with any negative short- or long-term health impact from alcohol use. The results would also suggest that once initiated, young people are unlikely to stop drinking and therefore are in need of harm reduction advice and skills. Participants reported a desire to engage meaningfully with school teachers and parents concerning their use of alcohol; however, fear of being labelled as problematic by teachers and fear of disappointing their parents means that they would be more likely to keep their drinking secretive. Participants repeatedly reported that intoxication (or consumption of alcohol, more broadly) could be used to excuse both risky and illegal behaviours. Interventions with young drinkers might look to address some of the harms and attitudes discussed.     

"You become really close... you talk about the silly things you did, and we laugh": the role of binge drinking in female secondary students' lives

In Australia, negative attitudes regarding young women's drinking have eased, drinking is on the increase, and there are heightened concerns about 'heavy' or 'binge' drinking. In a climate where underage drinking is frequently considered undesirable, campaigns aimed at reducing 'heavy' alcohol use have failed. This article takes as its departure point the notion that alcohol plays a meaningful role in social lives and relationships. It is through the use of narrative that these young women make sense of their drinking, which is still stigmatized. Any harm encountered along the way tends to be filtered through the 'good story,' brimming with tales of fun, adventure, bonding, sex, gender transgressions, and relationships. Nevertheless, these women implemented their own practical harm minimization strategies, and it is here that professionals can gain a foothold and assist young people and help them to drink more safely.     

How do parents and friends accommodate alcohol consumption in young Thai people? A qualitative focus group study

Abstract

Despite a magnitude of quantitative data demonstrating the influence of parents and friends on youth drinking, few qualitative studies have explored these relationships in non-Western settings, including Thailand. This study aims to explore the perceived roles of parents and friends in influencing young Thais’ drinking. The data come from seventy-two 20–24-year-old students participating in focus groups. This study found that young people’s first alcohol experiences were often introduced by family members early in their childhood. Later in adolescence, their social contexts shifted from the family unit to focus more on their friends. They perceived drinking to be a norm and drank to enhance social conformity. Parental communication and approaches appeared to be critical in influencing youth drinking patterns. Surprisingly, especially in the context of limited information about the prevention of alcohol-related harm, young people created a self-regulated harm reduction intervention using a designated light drinker. This study suggests that family-support interventions should be introduced in conjunction with social norms and peer-based interventions to enhance parents’ awareness about their influences on youth drinking. The agency of the young people in this study also suggests that self-regulated harm reduction approaches may be considered to complement the abstinence-standpoint policy in Thailand.     

Still “at risk”: An examination of how street-involved young people understand,experience, and engage with “harm reduction” in Vancouver’s inner city

BackgroundVancouver is an international leader in implementing interventions to reduce harms related to drug use. However, street-involved young people who use drugs continue to be vulnerable to overdose death, hepatitis C (HCV) infection, and high rates of syringe sharing. To better understand this in the context of the intensive public health response, we examined how young people, who are involved in the ‘street drug scene’, understood, experienced and engaged with harm reduction.MethodsTwelve semi-structured interviews were conducted in 2013 with 13 young people (ages 17–28) recruited from the At-Risk Youth Study, a prospective cohort of street-involved and drug-using young people. These interviews were embedded within a larger, eight-year program of ethnographic research and explored participants’ understandings of harm reduction, their use of specific services, and their ideas about improving their day-to-day lives. Interviews were transcribed verbatim and a thematic analysis was performed.ResultsYoung peoples’ ideas about harm reduction were diverse and expansive. They articulated the limitations of existing programs, indicating that while they are positioned to reduce the risk of HIV and HCV transmission, they offer little meaningful support to improve young peoples’ broader life chances. Young people described strategies to mitigate risk and harm in their own lives, including transitioning to drugs deemed less harmful and attempting to gain access to drug treatment. Finally, young people indicated that spatial considerations (e.g., distance from Vancouver's Downtown Eastside) strongly determined access to services.ConclusionsIn Vancouver, a large, well established harm reduction infrastructure seeks to reduce HIV and HCV transmission among street-involved young people. However, young peoples’ multiple understandings, experiences and engagements with harm reduction in this setting illustrate the limitations of the existing infrastructure in improving their broader life chances.     

The role of alcohol price in young adult drinking cultures in Scotland

Minimum Unit Pricing (MUP) is one of the Scottish Government's key policy options to reduce alcohol consumption and related harm. Although strongly evidenced for efficacy in reducing headline population level consumption, efficacy in changing the role of alcohol in Scottish culture is unknown. Questions remain as to how MUP will play across population subgroups with different sensitivities to price. In this paper we explore the views of the young adult population and situate the influence of price paid for alcohol alongside broader cultural drivers of consumption. Qualitative data from two studies investigating the role of alcohol in the transition to adulthood from 130 participants (aged 16–30) are analysed to situate the influence of price paid in shaping drinking styles and practices. Findings highlight how considerations of price paid for alcohol compete with non-financial considerations associated with choosing to drink excessively, moderately or not at all. Two broad categories of response to potential price increases were anticipated by drinkers which indicate that young adults are not a homogenous group in relation to price sensitivity. These differences highlight the potential for variation in subgroup responses to a pricing policy conceived to be effective at a population level.     

Alcohol policy and harm reduction in Australia

With consultations having been held across Australia this year as part of the process of developing a new National Alcohol Strategy, it seemed timely to invite my colleagues from the National Drug Research Institute who are experts in the alcohol field to write this Harm Reduction Digest. The authors have canvassed a range of alcohol policy options and discussed their effectiveness in reducing harm for what is arguably Australia's number one drug problem. Australia's response to alcohol and other drug problems has, historically, been based on ‘harm minimization‐incorporating supply reduction, demand reduction and harm reduction’. At this time where the policy options for alcohol are being set for the next 5 years in a climate of ‘small government’, removing restrictions of ‘fair competition’ in business and a belief in the free market, what does the research have to say about recommended policies and strategies to reduce alcohol‐related harm?     

Uneven reductions in high school students' alcohol use from 2007 to 2012 by age,sex, and socioeconomic strata

Background: Many Western countries have reported declines in adolescent alcohol use. This study examined changes in adolescent alcohol use in New Zealand between 2007 and 2012 and explored variations across sociodemographic strata. Methods: Data from 2 nationally representative, cross-sectional high school surveys conducted in 2007 (n = 7709) and 2012 (n = 7266) were examined. Changes in the prevalence of drinking in the past 4 weeks were examined among the total sample, as well as the frequency of drinking in the past 4 weeks and typical drinking-occasion quantity among drinkers. Only students residing in urban areas were included. Variation in changes was investigated across 4 demographic groups characterized by age (<16 years, ≥16 years) and sex. Interactions with household- and neighborhood-level socioeconomic position (SEP) identified any differential changes between socioeconomic strata. Results: From 2007 to 2012, significantly fewer students consumed alcohol in the past 4 weeks. Interaction analyses demonstrated that, among young females (<16 years), declines were significantly greater among those of high household SEP when compared with those of low household SEP. Among drinkers, reductions in the frequency of drinking were found among all demographic groups and SEP strata. Interaction analyses revealed that only young males (<16 years) showed significantly reduced typical drinking-occasion quantities. Among young females, significant interactions revealed a shift towards increasing typical drinking-occasion quantities among those of low household and neighborhood SEP, whereas their more advantaged counterparts showed no significant change over time. Conclusions: Fewer drinking occasions characterized the major declines in adolescent drinking between 2007 and 2012. Whereas young males showed reductions in the typical quantity consumed, young females of low household and neighborhood SEP progressed towards higher typical quantities. To address the uneven distribution of alcohol-related harm and improve the targeting of harm reduction initiatives, it remains imperative to examine changes in both the overall shift and shape of the distribution curve.     

Social anxiety,daily moods,and alcohol use over time among heavy social drinking men

To investigate the tension reduction hypothesis of alcohol use in the natural environment and with several forms of tension, 36 heavy social drinking young men kept daily records of their drinking, anxiety, unhappiness, and anger for 3 months and for 1 month from 6 to 7 months from the start of the study. No significant correlations were found between the frequency and intensity of any of the daily moods and drinking rates or intoxication frequency, either concurrently or within a few days or weeks. Drinking was also unrelated to general trait anxiety, depression, stressful life experiences, and locus of control. However, trait social anxiety had a consistent but unexpected relationship to drinking-the less socially anxious the men were, the more they drank over time. Drinking and/or intoxication rates were also related to having more social supports and to traditionally masculine interests. The results cast doubt on the tension reduction hypothesis and suggest that having a strong social group and indifference to the social consequences of intoxication are more important predictors of heavy drinking rates in young social drinking men.     

Postsecondary education and heavy drinking by young adults: the moderating effect of race

OBJECTIVE: This study examined racial differences in the relationship between postsecondary education (PSE) and heavy drinking among young adults who participated in the 1998 National Household Survey on Drug Abuse. METHOD: In-home survey data collected from 6,374 18-25 year olds were analyzed to examine black-white differences in the relationship between PSE and past-month heavy drinking (five or more consecutive alcoholic beverages). Logistic regression analyses were conducted to examine the interactive effect of PSE and race on heavy drinking, and the degree to which selected psychosocial risk and protective factors help to explain the differential association between PSE and heavy drinking. RESULTS: The prevalence of past-month heavy drinking was significantly higher among whites with at least some PSE than whites without any PSE (41% vs 30%/6), whereas no differences in past-month heavy drinking were observed among blacks who did and did not have at least some PSE (15% vs 16%). This differential relationship persisted when early initiation of alcohol use and demographic characteristics were adjusted for. The effect of PSE on heavy drinking among whites was substantially reduced by controlling for perceived drinking among friends, friends' social support and subjects' propensity for risk taking or sensation seeking. PSE was inversely, although not significantly, associated with heavy drinking among blacks, after adjusting for early alcohol use and demographic characteristics. This inverse relationship was no longer present after controlling for psychosocial factors (e.g., religiosity, perceived harm of heavy drinking) that were associated with PSE and heavy drinking among blacks. CONCLUSIONS: The apparent effect of college attendance on heavy drinking among young adults is driven by the fact that the majority of young adults who attend college are white. College attendance does not appear to increase the likelihood of heavy drinking among black young adults. Additional research with longitudinal data is needed to better understand how the college environment affects alcohol use among whites, and whether blacks who attend predominantly white colleges are more likely to drink heavily than those who attend traditionally black colleges.     

“YOU BECOME REALLY CLOSE…YOU TALK ABOUT THE SILLY THINGS YOU DID,AND WE LAUGH”: THE ROLE OF BINGE DRINKING IN FEMALE SECONDARY STUDENTS’ LIVES

In Australia, negative attitudes regarding young women's drinking have eased, drinking is on the increase, and there are heightened concerns about ‘heavy’ or ‘binge’ drinking. In a climate where underage drinking is frequently considered undesirable, campaigns aimed at reducing ‘heavy’ alcohol use have failed. This article takes as its departure point the notion that alcohol plays a meaningful role in social lives and relationships. It is through the use of narrative that these young women make sense of their drinking, which is still stigmatized. Any harm encountered along the way tends to be filtered through the ‘good story,’ brimming with tales of fun, adventure, bonding, sex, gender transgressions, and relationships. Nevertheless, these women implemented their own practical harm minimization strategies, and it is here that professionals can gain a foothold and assist young people and help them to drink more safely.     

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.     

Mediational relations of substance use risk profiles,alcohol-related outcomes,and drinking motives among young adolescents in the Netherlands

Aim

To examine the mediation by drinking motives of the association between personality traits (negative thinking, anxiety sensitivity, impulsivity, and sensation seeking) and alcohol frequency, binge drinking, and alcohol-related problems using a sample of students (n = 3053) aged between 13 and 15, who reported lifetime use of alcohol.

Method

Structural equation modeling was used to examine the relationship between personality traits and alcohol-related outcomes. The Model Indirect approach was used to examine the hypothesized mediation by drinking motives of the association between personality traits and alcohol-related outcomes.

Results

In this study among young adolescents, coping motives, social motives and enhancement motives played a prominent mediating role between personality and the alcohol outcomes. Multi-group analyses revealed that the role of drinking motives in the relation between personality and alcohol outcomes were largely similar between the sexes, though there were some differences found for binge drinking. More specifically, for young males, enhancement motives seems to play a more prominent mediation role between personality and binge drinking, while for young females, coping motives play a more mediating role between personality and binge drinking. Few mediation associations were found for conformity motives, and no relationships were found between anxiety sensitivity and drinking motives.

Discussion

Already in early adolescence, personality traits are found to be associated with drinking motives, which in turn are related to alcohol use. This study provides indications that it is important to intervene in early adolescence with interventions focusing on personality traits in combination with drinking motives.     

Underage drinking in the UK: Changing trends,impact and interventions. A rapid evidence synthesis

The UK is a high prevalence country for underage alcohol use. We conducted an evidence synthesis to examine (1) the changing trends in underage drinking in the UK compared to Europe and the USA, (2) the impact of underage drinking in terms of hospital admissions, (3) the association between underage drinking and violent youth offending, and (4) the evidence base for the effectiveness of alcohol harm reduction interventions aimed at children and adolescents under the age of 18 years. The following databases were searched from November 2002 until November 2012: Cochrane Database of Systematic Reviews, National Institute for Health and Clinical Excellence, The Evidence for Policy and Practice Information, DARE, Medline, The Campbell Collaboration, CINAHL, Criminal Justice Abstracts, Psych INFO and Social Care Online. Our findings revealed changes in the way children drink in the UK and how much they drink. Alcohol related harms are increasing in the UK despite overall population levels of consumption reducing in this age group. Girls aged 15–16 years report binge drinking and drunkenness more than boys. Girls are also more likely than boys to be admitted to hospital for alcohol related harm. The evidence suggests a strong association between heavy episodic binge drinking and violent youth offending. Only 7 out of 45 randomised controlled trials (RCTs) identified for this review included children and adolescents under the age of 18 years. Most were delivered in the emergency department (ED) and involved a brief intervention. All were characterised by a wide age range of participants, heterogeneous samples and high rates of refusal and attrition. The authors conclude that whilst the ED might be the best place to identify children and adolescents at risk of harm related to alcohol use it might not be the best place to deliver an intervention. Issues related to a lack of engagement with alcohol harm reduction interventions have been previously overlooked and warrant further investigation.     

Mindfulness buffers the effects of cue-induced craving on alcohol demand in college drinkers

Alcohol consumption among young adult college students represents a significant public health problem. The presence of alcohol-related cues in drinkers' environments can trigger powerful alcohol cravings, which may influence drinking outcomes. Less is known about how this cue-induced craving influences behavioral economic demand for alcohol. In addition, research has suggested that trait mindfulness may be an important buffer of the effects of internal states of craving on drinking decisions. Based on this literature, we hypothesized that cue-induced cravings would be associated with increased alcohol demand, an effect that would be attenuated among drinkers who have higher levels of mindfulness. Young adult college student drinkers (n = 69) completed a laboratory-based cue-induced craving assessment, a self-report assessment of trait mindfulness, and an alcohol purchase task. Findings revealed that cue-induced craving was related to higher alcohol demand. Consistent with the study hypothesis, acceptance, a component of mindfulness, buffered the effects of cue-induced craving on alcohol demand. Results raise the possibility that mindfulness-based interventions may be useful in helping disrupt the link between internal states of craving and drinking decisions in young adult college student drinkers.     

Unravelling the preventive paradox for acute alcohol problems

Kreitman's discussion of the preventive paradox in relation to the prevention of alcohol problems has had profound implications for alcohol policy and has generated considerable controversy [1]. It is argued here that although Kreitman should be credited with the important observation that alcohol-related harm is not confined to a few dependent drinkers, none the less an apparent paradox is not an ideal platform from which to recommend policy. Furthermore, Kreitman's own data and data from an Australian survey of drinking are used to demonstrate that a commonplace truth underlies his apparently paradoxical findings. It is shown that the preventive paradox disappears when consideration is given to the amount of alcohol consumed on either (i) the day of highest alcohol intake out of the last four, or (ii) the day on which acute alcohol-related harm occurred. Episodic heavy consumption by people whose average alcohol intake can be classified as 'low' or 'medium' risk contributes to the bulk of such experiences of harm. It is suggested that the importance of intoxication as a public health and safety issue has been neglected. This neglect is compounded when public education campaigns and prevention policy are only based on average rates of alcohol consumption. Advice regarding the low risk levels of consumption for different types of harm should form one component of a comprehensive harm reduction policy. Other elements of such a policy should include a variety of other measures of proven effectiveness in relation to reducing levels of intoxication and related problems.