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’.     

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.     

The new policy mix: Alcohol,harm minimisation,and determined drunkenness in contemporary society

This paper reflects on the relationship between harm reduction, demand reduction, and supply reduction (collectively, harm minimisation) in relation to the individual, socio-economic, and legal regulation of alcohol, focusing on changing consumption patterns of youths and young adults in the UK. Firstly, harm reduction and practices of self-regulation are considered within the British context of an apparent culture of intoxication, with evidence of determined drunkenness amongst young people that builds upon a longstanding tradition of northern European drinking characterised by weekday restraint and weekend excess. Secondly, demand reduction and the predominant public health programme of recommended sensible drinking levels are discussed in relation to the credibility gap between such messages and contemporary alcohol-related attitudes and behaviours. Thirdly, looking at supply, recent legislative changes and broader developments in the alcohol industry are explored. They counterbalance economic deregulation of licensed leisure with the increased criminalisation of some drinkers. In order to produce the most effective policy mix, individualised models of harm reduction and demand reduction need to be located within broader, culturally appropriate, and context-specific policies that consider the socio-economic, political, and environmental factors influencing harm, demand, and supply.     

Effects on Alcohol Consumption and Alcohol Related Harm of a Community-Based Prevention Intervention With National Support in Sweden

Background: In order to strengthen local alcohol prevention work in Sweden the Swedish government has for the past almost 15 years commissioned the Public Health Agency of Sweden to initiate a series of community-based alcohol prevention projects. The latest of these, labeled local development with ambitions (LUMA), included 25 municipalities in Sweden. Objectives: Aim of this study is to examine if LUMA municipalities that received financial support, with requirements, increased local alcohol prevention and if alcohol consumption and harm declined. Methods: Twenty-five Swedish municipalities that received financial support aiming to strengthen local alcohol preventing activities (intervention group) were compared to municipalities that did not receive such support (control group, N = 224), before, during, and after the intervention period. Two composite measures of policy and activity were created and used. The composite activity measure includes seven activity indicators and the composite policy measure includes six policy indicators. Harm measures have been selected based on several recommended indicators for monitoring alcohol, tobacco, and other drugs in Sweden. A fixed effects model was used to analyze data. Results: The results reveal that prevention activities increased and several alcohol-related harm indicators were reduced in intervention municipalities (LUMA) compared with in control municipalities. Conclusions: It seems as if financial support, combined with specific requirements and support from the regional and national level, can stimulate local alcohol prevention activities and have a significant effect on alcohol consumption and alcohol-related harm. Similar evaluations in other countries would be of great value for assessing the generalizability of findings.     

Contextual determinants of alcohol consumption changes and preventive alcohol policies: a 12-country European study in progress

Beginning with France in the 1950s, alcohol consumption has decreased in Southern European countries with few or no preventive alcohol policy measures being implemented, while alcohol consumption has been increasing in Northern European countries where historically more restrictive alcohol control policies were in place, even though more recently they were loosened. At the same time, Central and Eastern Europe have shown an intermediate behavior. We propose that country-specific changes in alcohol consumption between 1960 and 2008 are explained by a combination of a number of factors: (1) preventive alcohol policies and (2) social, cultural, economic, and demographic determinants. This article describes the methodology of a research study designed to understand the complex interactions that have occurred throughout Europe over the past five decades. These include changes in alcohol consumption, drinking patterns and alcohol-related harm, and the actual determinants of such changes.     

Does alcohol advertising have an impact on the public health?

This presentation draws on recent New Zealand and international research to examine a number of questions about the possible public health impact of policy which allows alcohol to be advertised on the broadcast media. The relevant public health questions include: the contribution of alcohol advertising to aggregate levels of consumption and alcohol-related problems; the impact on the drinking and attitudes of the heaviest drinking sector, young males, who tend to be a primary target for the advertising; the impact on those already experiencing problems associated with their drinking and wanting to abstain or cut down; the impact on the young as they move towards becoming drinkers; the impact on the likely efficacy of educational campaigns about drinking; and the impact on the social climate surrounding alcohol and in turn on the support for effective public policies to reduce alcohol-related harm. Research in this area has increased in both conceptual and methodological sophistication in the past decade and studies using a number of complementary methods are available to assist our understanding of the likely impact of broadcast alcohol advertising. Evidence that advertising is likely to contribute to higher levels of drinking and related problems has strengthened over the past decade, suggesting that public health interests should be considered as one of the relevant voices in the ongoing policy debate around alcohol advertising.     

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.     

Contextual Determinants of Alcohol Consumption Changes and Preventive Alcohol Policies: A 12-Country European Study in Progress

Beginning with France in the 1950s, alcohol consumption has decreased in Southern European countries with few or no preventive alcohol policy measures being implemented, while alcohol consumption has been increasing in Northern European countries where historically more restrictive alcohol control policies were in place, even though more recently they were loosened. At the same time, Central and Eastern Europe have shown an intermediate behavior. We propose that country-specific changes in alcohol consumption between 1960 and are explained by a combination of a number of factors: (1) preventive alcohol policies and (2) social, cultural, economic, and demographic determinants. This article describes the methodology of a research study designed to understand the complex interactions that have occurred throughout Europe over the past five decades. These include changes in alcohol consumption, drinking patterns and alcohol-related harm, and the actual determinants of such changes.     

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.     

The Concept of Harm Reduction and its Application to Alcohol: The 6th Dorothy Black Lecture

Harm reduction has proved to be effective, and has gained increasing official. acceptance in many countries. However, the concept is poorly defined, as virtually any drug policy or programme, even abstinence-oriented programmes, attempts to reduce drug-related harm. The principle feature of harm reduction is the acceptance of the fact that some drug users cannot be expected to cease their drug use at the present time. Harm reduction accords a high priority to short-term realizable goals, but is consistent with a long-term goal of abstention. The trend toward harm reduction in illicit drugs is closely paralleled by a similar trend in alcohol prevention toward measures aimed at reducing the consequences of hea y drinking occasions. Examples of harm-reduction approaches to alcohol are discussed, including measures to reduce non-beverage alcohol consumption by 'Skidrow' inebriates, measures to reduce intake of alcohol by drinkers (e.g. promotion of low-alcohol beverages, server training programmes) and measures to reduce the consequences of intoxication. Increased attention is likely to be given to suck prevention measures, which focus on preventing problems associated with drinking rather than restricting access to alcohol. Public support for controls over the availability of alcohol will continue to decline, as evidence regarding the potential benefits of moderate consumption becomes more widely publicized. Further, the trend to harm-reduction approaches for alcohol is supported by new empirical evidence, including results from a recent Canadian national survey indicating that it may be more efiective to target prevention programming toward reducing kea y drinking occasions rather than the individual's level of drinking.     

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.     

Australian drinkers’ perceptions of alcohol-related risk by consumption status

Background: This study investigated Australian drinkers’ alcohol-related beliefs according to their alcohol risk status. The primary aims were to assess drinkers’ awareness of the association between alcohol consumption and a range of health consequences and their understanding of the degree of risk represented by their own alcohol consumption.

Method: An online survey was administered to 2168 drinkers who consume alcohol at least twice per month. Respondents reported their alcohol intake levels and their beliefs relating to the relationship between alcohol and shorter-term (proximal) risks (e.g., drink-driving) and longer-term (distal) risks (e.g., stroke and cancer).

Results: Just over half (52%) of those drinking at high or very high risk levels did not perceive their drinking to be harmful. A large majority (85%) of the sample was aware of various short-term risks of excessive alcohol consumption, but only half appeared aware of the association between alcohol consumption and more distal health conditions.

Conclusions: The relatively low levels of awareness of the alcohol–disease link and the weak relationship between perceived risk and alcohol consumption levels suggest that attempts to reduce current high levels of alcohol-related harm could include public education campaigns designed to (i) improve drinkers’ understanding of the prevalence of alcohol-related harms upon which current alcohol guidelines are based, (ii) prompt drinkers to review their intake levels in the light of the guidelines to assess their potential risk of harm, and (iii) make alcohol-related risks more salient to every-day consumption decisions.     

Public policy and alcohol related damage: media campaigns or social controls.

This paper discusses and criticizes the recurrent theme of “responsible drinking” that has been expressed in most educational programmes and media campaigns aimed at the prevention of alcohol abuse. Data on the impact of several such campaigns are reviewed and it is concluded that there is little evidence to date that the programmes have produced marked changes in attitudes. It is pointed out, however, that even if changes in attitudes could be demonstrated, this would not necessarily mean that the desired changes in behavior would have been achieved. Based on the distribution of consumption approach to understanding alcohol-related damage, it is suggested that the problem of changing behavior can best be addressed through social policy that manipulates market and other environmental variables that control availability and accessibility of alcoholic beverages. This approach to primary prevention then dictates that public educational campaigns might best be used to convince the general public of the need for specific alcohol control measures designed to prevent the rising incidence of alcohol-related damage.     

Advertising and alcohol sales: a legal impact study.

According to the single distribution theory increases in the availability of alcoholic beverages in the general population are associated with increases in average consumption and increases in alcohol-related damage. If it can be demonstrated that advertising contributes to availability, perhaps in the form of what has been called social or subjective availability, then advertising could be considered an appropriate target of prevention. A 58-year ban on advertising of alcoholic beverages was lifted in Saskatchewan in 1983. Data on monthly sales of beer, wine and distilled spirits were examined for the years 1981 to 1987. Box-Jenkins time series techniques were used to estimate the statistical relationship between the policy change and volume of sales of alcoholic beverages. The results revealed that sales of beer increased and sales of spirits decreased following the change in legislation that permitted alcohol advertising in Saskatchewan. The main finding is that there was no impact on wine and total alcohol sales from the introduction of alcohol advertising. Alcohol advertising may have produced a substitution effect with respect to beer and spirits, but this was not predicted. This evaluation suggests that alcohol advertising is not a contributory force that influences the overall level of alcohol consumption. The place of advertising in the single distribution theory remains not proven, and the place of advertising as an instrument of public policy with respect to the prevention of alcohol-related damage remains in question.     

Déjà vu? Opportunities and obstacles in developing alcohol policy in English prisons

Under the new Alcohol Harm Reduction Strategy for England published by the Prime Minister's Strategy Unit in 2004, there has been an increasing focus on crime and public order issues and alcohol-related harm experienced by 'vulnerable' or 'at risk' groups. Prisoners have been identified as a vulnerable group who have high rates of dependence on alcohol and problems with alcohol-related offending. In late 2004, the Prison Service launched its first alcohol strategy. Based on an analysis of key policy documents, official enquiries and research, this paper explores how the 'problem' of alcohol can be defined within the prison setting and the issues it raises for both the individual prisoner and the institution. It examines the lack of policy and strategic direction prior to the publication of the new prison alcohol strategy and the possible reasons for the complacency around alcohol in prisons in contrast to illicit drugs. The paper critically assesses the new strategy in relation to the testing and treatment initiatives proposed and the lack of research and resources underpinning them. There is a real risk that the strategy will fail unless adequate resources are forthcoming to expand treatment provision. Given the neglect and complacency around alcohol, policy champions or policy entrepreneurs are needed to lobby for funding and keep the prison alcohol issue on the policy agenda.     

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.     

Strategies and outcomes in translating alcohol harm reduction research into practice: the Alcohol Linking Program

Harm associated with consumption of alcohol on licensed premises is an issue of community concern. Interventions to reinforce responsible sale of alcohol such as server training and accords between licensees, police and health advocates are well known. However, while generally supported by police and licensees as 'a good thing', evaluations demonstrating that they reduce alcohol-related harm are rare. Lack of enforcement is often an issue. This paper reports on system intervention to enhance police enforcement of liquor laws by providing data-based feedback to police and licensees about alcohol-related crime following drinking on specific licensed premises. The system has been shown to contribute to a reduction of alcohol-related crime and has been adopted into routine practice by NSW police state-wide. It is a good example of how research can be conducted in a way that bridges the gap between policy research and policy practice.

SIMON LENTON

Editor, Harm Reduction Digest     

Modification of a traditional motivational interviewing-based brief intervention training for hospital staff: The approach and refer method

Under the new Alcohol Harm Reduction Strategy for England published by the Prime Minister's Strategy Unit in , there has been an increasing focus on crime and public order issues and alcohol-related harm experienced by ‘vulnerable’ or ‘at risk’ groups. Prisoners have been identified as a vulnerable group who have high rates of dependence on alcohol and problems with alcohol-related offending. In late 2004, the Prison Service launched its first alcohol strategy. Based on an analysis of key policy documents, official enquiries and research, this paper explores how the ‘problem’ of alcohol can be defined within the prison setting and the issues it raises for both the individual prisoner and the institution. It examines the lack of policy and strategic direction prior to the publication of the new prison alcohol strategy and the possible reasons for the complacency around alcohol in prisons in contrast to illicit drugs. The paper critically assesses the new strategy in relation to the testing and treatment initiatives proposed and the lack of research and resources underpinning them. There is a real risk that the strategy will fail unless adequate resources are forthcoming to expand treatment provision. Given the neglect and complacency around alcohol, policy champions or policy entrepreneurs are needed to lobby for funding and keep the prison alcohol issue on the policy agenda.     

Experience of harm from others’ drinking and support for stricter alcohol policies: Analysis of the Australian National Drug Strategy Household Survey

BackgroundPrevious research indicates that those who have experienced alcohol-related harm from others are more likely to support stricter alcohol control policies. This study investigates the association between types of harm experienced because of others’ drinking and support for stricter alcohol control policies.MethodsData from 20,570 Australians aged 18 and over who completed the 2013 National Drug Strategy Household Survey was used. Questions about experience of alcohol-related harm from others – being put in fear and abuse (verbal or physical) – were asked. Support for stricter alcohol control policies was quantified by a mean policy support score across 18 alcohol policy questions.ResultsTwenty seven percent of respondents reported harm from someone’s drinking. Respondents who were put in fear had a higher level of support for stricter alcohol control policies than respondents who were not harmed (p < 0.001), regardless of whether they were abused or not. Conversely, respondents who experienced abuse but were not put in fear did not significantly differ in their support for stricter policies from those who experienced no harm.ConclusionIt is the apprehension of harm (i.e. having been put in fear), and not the experience of harm itself (i.e. abuse), which is related to people’s support for stricter alcohol policies. These findings suggest that perceiving others’ intoxication as dangerous to oneself may motivate support for stricter alcohol policies.     

Local action to prevent alcohol problems: Is the UK Community Alcohol Prevention Programme the best solution?

Increasing evidence indicates that the UK has a serious alcohol problem. This crosses many patterns of drinking and all ages, whereas the public debate about alcohol tends to focus almost exclusively on binge drinking and on young people's alcohol-related anti-social behaviour. This paper addresses the interventions and policy developments currently implemented in the UK to reduce alcohol-related anti-social behaviour. There are two main approaches: a national (England) change in the licensing laws; and local harm reduction projects seeking to effect change independently of central Government initiatives. This paper describes the critique currently mounted against the expected efficacy of new licensing laws and describes the theoretical and practical developments of some local prevention initiatives that are part of the United Kingdom Alcohol Prevention Programme (UKCAPP), funded by the Alcohol Education and Research Council (AERC). Although it is too early to draw conclusions as to the effects of either of these developments, initial reports suggest that changes in the licensing regime have not yet created the increase in alcohol-related problems some commentators have argued would occur; and the local prevention initiatives have led to the formation of extremely strong community partnerships, with a range of innovative and integrated actions to tackle alcohol-related anti-social behaviour. Fundamental criticisms of both the new licensing laws and the National Alcohol Strategy remain, however. Even if the above interventions lead to reductions in alcohol-related anti-social behaviour, it is not clear how they might deal with the rising levels of alcohol-related health harms reported within the UK. Nevertheless, the community partnership approach may be the best possibility for dealing with at least some of the alcohol-related problems caused by the rise in availability and accessibility of alcohol within the UK.