HARM REDUCTION AND ALCOHOL

Henk F. L. Garretsen and Ien van de Goor

Harm reduction with regard to alcohol-related problems can take several forms. Contrary to what one might expect, harm reduction in relation to excessive drinking can consist of all kinds of activities aimed at reducing average consumption of all drinkers. The single distribution model of alcohol use in a population developed years ago by Ledermann ( 1956) - states that 'the distribution of alcohol consumption in a homogeneous population is best described by a one-parameter log normal distribution model'. Expressed in less statistical terms this means that there is a fixed relationship between the mean consumption of alcohol in a population and the prevalence or number of drinkers at certain levels of consumption. According to this model, a reduction in the mean consumption level will result in a disproportionately large reduction in the category of heavy drinkers. The model has not been without criticism (Lemmens, 1991 ) . However, the idea that a reduction in average consumption will lead to a reduction in the number of heavy drinkers is generally accepted.

A reduction in average consumption in society will help to reduce the number of excessive drinkers/problem drinkers. Thus primary prevention measures designed to reduce average consumption are very important tools in the context of harm reduction. In addition to primary prevention, secondary prevention (early recognition and minimising harm) is important.

PRIMARY PREVENTION MEASURES

When considered with regard to alcohol, primary prevention measures can be geared to different target groups and different settings/sectors. Various organisations and agencies can play a role, in particular the various levels of government, the health-care system and all the relevant organisations.

Different activities can be employed (Garretsen, 1983, 1992) and all kinds of regulations can be used. Activities include tax policy (the higher the price of alcoholic beverages, the lower average consumption: e.g. Bruun et al., 1975; van de Tempel, 1977; Moser, 1980; WHO, 1980) and regulations that restrict serving and/or selling alcoholic beverages in public places. Conditions may be imposed on local grants (e.g. for clubs and neighbourhood activities) and advertising may be banned (e.g. Garretsen, 1983, 1992).

Of course, some regulations may have negative side effects, e.g. a strong tax policy may lead to unemployment (in the alcohol industry), and to a rise in smuggling and in the number of illegal breweries/distilleries. People who drink a lot and use alcohol as a problem solver will not stop drinking and may consume cheaper alcohol of inferior quality. Obviously if prices increase, the lowest income categories come off worst.

In addition to regulations, health promotion/education is significant. Education may aim to influence the norms that apply to alcohol consumption and problem drinking; it may aim to increase the awareness of opportunities for care and support and to make other preventive measures more acceptable (Garretsen, 1983, 1992). However, alcohol education which aims to influence attitudes towards excessive drinking might have little effect in itself (WHO,1980).

Activities are also possible in various settings/sectors, such as at work, in education, in the social/cultural sector, in sport and traffic.

Various types of harm-reduction activities can be employed in the traffic sector. For example, public transport measures can be proposed based on the geographical relationships between alcohol consumption, the number of bars, liquor stores and traffic injuries (van Oers and Garretsen,1992). Random breath testing is another possibility.

SECONDARY PREVENTION

Secondary prevention is another important method of reducing further harm. Early recognition and minimising harm are principles of this type of prevention (Garretsen,1992). Early recognition can prevent enormous problems. An important contribution can be made by addiction treatment centres and by primary health care. It has been contended for many years that general practitioners should play a more active role in the detection of potential alcoholics (Wilkins, 1913, 1974). For several reasons they often see only the tip of the iceberg (Erckens and Vastbinder, 1985; van Limbeek,1989). However, there are techniques available which make earlier recognition of problem drinker! somewhat less difficult. They include criteria, lists of early indicators of alcohol abuse and various screening tests such as questionnaires and laboratory tests (e.g. Barber et al.,1986; Allan et al., 1988). Of course, the various methods are accompanied by problems with respect to sensitivity and specificity.

If early recognition takes place, what then? The general practitioner who recognises the problems can give advice (which can sometimes be effective: Anderson and Scott, 1992), can refer the client to specific help or offer to treat the problem drinker him- or herself. Expertise is essential, and so is enthusiasm (but often it is not great: Nahuys,1989) .

HenkF.L. Garretsen

Director/Professor of the Addiction Research Institute, University of Rotterdam; Head of the Department of Epidemioigy, Municipal Health Service Rotterdam Area

Ien van de Goor Senior Researcher at the Addiction Research Institute, University of Rotterdam, The Netherlands

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