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27/05/2015

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Addiction

A EuroScientist Special Issue – May 2015

http://www.euroscientist.com/



27/05/2015




Contents

Introduction .................................................................................................................................................................... 3

Ethics ............................................................................................................................................................................... 4

The ethics of intervening in addicts’ lives ..................................................................................................................... 4

People-centric approach ................................................................................................................................................. 7

Nudge towards effective harm reduction ..................................................................................................................... 7

Drugs: time to fight for health .................................................................................................................................... 10

Policy solutions to various forms of addiction .............................................................................................................. 13

Do drug programs really work? .................................................................................................................................. 13

Juggling with drinking patterns, culture and policy responses ................................................................................... 16

Anti-smoking: “E” is for ethics .................................................................................................................................... 19




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Introduction

In this issue, EuroScientist is venturing into exploring policy issues, which have implications for individuals in society. Specifically, this special issue focuses on the interplay between science and policy making when dealing with substance addiction.

We all can identify with addictive behaviour. Some of our readers may be regular smokers or simply have an addiction to chocolate or to technologies such as the internet. In this issue, we specifically focus the debate around addiction by covering the science behind policy used to tackle addiction to tobacco, drugs and to alcohol.

We reproduce opinion pieces that have initially been published in much more extensive versions, following a series of independent international consultation events, organised by Brussels-based policy communication consultancy SciCom– Making Sense of Science, in areas related to the theme of substance addiction, discussing evidence-based policy versus policy-biased evidence to help assess the best practices and pitfalls inherent today, especially in institutional science. The original contributions are available via a hyperlink at the end of each article.

This issue is designed to give you food for thought on how scientific evidence may sometimes we used for best results in policy making, while demonstrating how, in other cases, such approach needs to be complemented by testing in the field before the best suitable approach can be adopted.

We are keen to receive your feedback on this special issue. So don’t forget to comment on each individual article and to share them widely within your circle.

Best wishes,

EuroScientist Team




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Ethics

The ethics of intervening in addicts’ lives

By Julian Kinderlerer

Published on EuroScientist: www.euroscientist.com

Balancing the rights and responsibilities of the individual and the State

Here is a philosophical puzzle especially pertinent to public health: if an individual decides to harm themselves–perhaps smoking, drinking or taking illegal drugs–but it does not affect the lives of others, should the State interfere? Over many centuries thinkers have explored this question, but today policy-makers are increasingly relying on rational analysis. Science offers new insights on the most effective ways to balance the rights and responsibilities of the individual and the State.

Like it or not, our lives are interwoven complex ways. If a girl chooses to end her life, other people are affected. If a boy smokes cigarettes, science shows that it can damage the health of people nearby; and cost the taxpayer significant sums in health care. We are all members of society and most of our choices have an impact for others. But while we talk up the rights and responsibilities of citizens and the importance of the individual, the balance of power often seems in favour of the State.

We shy away from legislation which prevents physicians prescribing potentially harmful drugs, for instance, even though doctors have a responsibility to do no harm! Misuse of prescription drugs in most countries accounts for more


http://www.euroscientist.com/time-to-reflect-on-the-ethics-of-intervening-in-addicts-lives

https://www.linkedin.com/in/juliankinderlerer




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deaths per annum than the use of ‘banned’ or illegal narcotics. In 2013, nearly 700,000 Americans dosed themselves with heroin. It is thought this is a result of the higher cost of prescription opiates and other drugs that are abused by as many as 11 million Americans annually!

In Western societies, many drugs are seen as dangerous and their use intolerable. Some banned drugs may have medicinal use but they cannot be prescribed. Other ‘drugs’ that may have more harmful effects are accepted as not only normal, but individuals who choose not to partake are often treated with scorn.

Am I normal?

The Universal Declaration of Human Rights and more recently the Charter of Fundamental Rights of the European Union embrace the fundamental principles of human dignity, freedom, equality and solidarity. To have dignity we need to be treated with respect. We should have the freedom to choose our own actions, but to act responsibly. In other words, we should be left to look after ourselves without interference from an overbearing state, provided our actions do not interfere with the rights of others to do exactly the same.

So can we justify laws which dictate which mind- or mood-altering chemicals we may use and the manner in which we choose to express our individuality? Many countries, including the USA, have attempted to introduce laws restricting the use of alcohol, but in most cases this was counterproductive as illegality and criminality increased.

The USA also introduced legislation in 1906 by which products containing dangerous substances had to be labelled; alcohol, morphine, opium and cannabis were on the list. Later, in 1914, the Harrison Narcotics Tax Act regulated and taxed imports and the production and sale of coca and opiate products. Yet, a damning editorial in Illinois Medical Journal for June 1926 stated that “as is the case with most prohibitive laws, however, this one fell far short of the mark. So far, in fact, that instead of stopping the traffic, those who deal in dope now make double their money from the poor unfortunates upon whom they prey.”

With the rise of drug-taking as a sign of dissent in the 1960s, in June 1971 President Nixon declared a “war on drugs”. He dramatically increased the size and presence of federal drug control agencies. And he pushed through measures such as mandatory sentencing and no-knock warrants. He temporarily placed marijuana in Schedule One, the most restrictive category of drugs, pending review by a commission.

In 1972, the commission unanimously recommended decriminalising the possession and distribution of marijuana for personal use. Nixon ignored the report and rejected its recommendations. When Reagan took office, the number of people behind bars for non-violent drug law offences increased from 50,000 in 1980 to over 400,000 by 1997.

Penalties make no sense

Western countries have inherited a system which penalises those who use drugs deemed by politicians as detrimental to society. But as we have seen, the law is inconsistent. History shows that prohibition achieves little more than fostering criminality and increasing harm.

Fortunately, politicians and policy-makers are starting to see sense, thanks, in part, to robust evidence from scientific studies. We are slowly seeing more balanced policies. For example, smoking and sometimes alcohol are not criminalised, but have been banned in public spaces where use could affect other people. Belgium and the Netherlands allow the cultivation of cannabis for personal use. The EU has a blanket sale ban–but no usage ban–of snus oral pouch tobacco outside Sweden.

The UK Commission, which looks only at illegal drug use, suggests that we need to look at “how society and government can enable and support individuals to behave responsibly. This means tackling underlying causes of drug use, providing the information and skills necessary for people to make sensible choices about drug use, and ensuring that where drug use does occur, it is undertaken in a way that minimises the harm to the user and others.”

This does not open the way for a free-for-all. After all, freedom to overdose is not freedom at all. We have to recognise that drugs do cause harm. But we must also give people options to opt out of reality; at least for a short


http://www.economist.com/blogs/economist-explains/2014/11/economist-explains-19

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time, provided they do not harm others. Scientists and ethicists must step in to inform a balanced debate and ensure that our new laws are not held in contempt.

Julian is president of the European Group on Ethics in Science and New Technologies (EGE). He reports to the European Commission President Juncker and the European Parliament. He is professor of intellectual property Law at Cape Town University, South Africa. He is also an adviser the South African government, the United Nations and other international organisations. Previous to his current role Julien was director of institutes on biotech law, ethics and societies at in the universities of Delft and Sheffield, UK.

This article is the edited version of a piece that was first published in Science in the Public Interest vol. 3: Addictions: Ethics, Integrity and the Policy-Maker, published by SciCom– Making Sense of Science.

Photo credit: Stephen Wu


http://ec.europa.eu/epsc/ege_en.htm

http://www.sci-com.eu/home/docs/scicom-science-in-the-public-interest-vol3.pdf


https://www.flickr.com/photos/stephenccwu/316669375



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People-centric approach

Nudge towards effective harm reduction

By Alberto Alemanno


Can people change their behaviour, in the case of addictions?

Against all forms of addiction, behavioural change is the holy grail for policy-makers. “All we need to do is alter what people think and do!” they muse as they try to tackle a broad range of social problems: excessive drinking, obesity, crime, even climate change.

In the past, policy makers assumed that governments could only change behaviours through rules and regulations. But now they are designing programmes that reflect how people really act; often irrationally and unpredictably it would seem. This new approach appears to deliver results without resorting to heavy-handed regulation and a nanny state.

The new ingredient is ‘nudge’. Inspired by ‘libertarian paternalism’, this theory suggests public policies should steer citizens towards positive decisions yet maintain individual choice. The policy-maker merely acts as the ‘choice architect,’ trying to change the context, process and environment in which individuals make their decisions.

Irrationality: the policy-maker friend


http://www.euroscientist.com/nudge-towards-effective-harm-reduction

http://www.albertoalemanno.eu/


http://dx.doi.org/10.2139/ssrn.405940



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At first glance it looks a bit sneaky. The policy-maker cunningly exploits our tendency to make irrational decisions, or ‘cognitive biases’, to manipulate our choices. For example, knowing how people tend to put off making affirmative decisions, the policy-maker deliberately sets “default rules” towards the positive choice.

Studies also show that we are heavily influenced by social norms. We care about our reputation and what other people think of us; these are powerful forces, which the policy-maker can also turn to their advantage.

Even the way information is presented and questions framed can influence our choices, scientists have found. Evidence suggests that vivid warnings work better than statistics. Rearranging food displays could “help” people choose more healthy meals.

Behaviourally-informed regulatory approaches are an attractive tool for public authorities for two reasons. First, nudging seems to make regulation more effective, yet still preserves individual choice. This is particularly crucial for health policies designed to reduce harm; mandating positive behaviour is all but pointless, but suggesting safer, possible alternatives is quite effective.

Second, these “soft” approaches tend to be cheaper to implement that rigid regulatory regimes, so it is hardly surprising governments have welcomed them so warmly.

President Barack Obama in the USA and Prime Minister David Cameron in the UK have both encouraged government agencies to draw on behavioural and social sciences. Nudging is fast becoming a global policy phenomenon.

Integration

There are dangers, however. Behaviourally-informed tactics, including default rules and disclosure requirements, raise important legal concerns about the rights of citizens vis-à-vis the regulatory state. What is the legal position when nudging preserves and compromises freedom at the same time?

More importantly, with no rational framework for integrating behavioural research into policy-making, the application of this science will remain haphazard and the impact small and anecdotal. A framework would help to make public health decision-making more transparent and accountable.

The USA has already set the precedent, imposing a general requirement on public administrations to adopt principled and consistent procedures for using behavioural science in policy-making. Clear processes should also help to protect policies and people from possible abuses. An emphasis on thorough regulatory impact assessments should also policy-makers to “test” a range of regulatory options and allow citizens to have a say too.

Tobacco: new regulations missing a trick

Let's take the example of policies towards the prevention of tobacco addiction. In Europe, the revised tobacco products Directive, for instance, embraces behaviourally-informed approaches. To its credit, newly-adopted approaches--such as combined graphic and health warnings--no longer inform the public about the adverse effects of smoking. Instead they seek to change social norms by "denormalising” tobacco. However, the Directive fails to use behavioural insights to promote harm reduction approaches.

Electronic and herbal cigarettes also fall under the legislation. Consequently, their marketing material must now also carry health warnings. In addition, e-cigarettes might become subject to the same authorisation required for medicinal products.

The overall stance on both conventional and alternative tobacco products favours an abstinence-only policy. And, it de facto rejects a risk-reduction approach, which would encourage smokers to switch to less damaging nicotine-delivery. The rules are understandable because people fear that e-cigarettes might encourage smoking. Nonetheless, millions of addicted smokers are left with only one choice: to get their nicotine by smoking or quit.

The Commission’s abstinence-only approach is questionable; it makes much more sense to nudge smokers towards less hazardous alternatives. We certainly need to build up the evidence about "safer" alternatives. But it is shameful


http://www.behaviouralinsights.co.uk/

http://ssrn.com/abstract=2006599



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that the ideological imperative to “denormalise” smoking could deprive society of the potential gains from harm-reduction through switching.

Indeed, this policy flaw highlights the major contribution that behavioural science has to make. It is time to shift policy discussion away from the morals of harm reduction to where it belongs: rooted in science.

Alberto is Jean Monnet Professor of EU Law and Risk Regulation at the HEC Paris and Global Clinical Professor at NYU School of Law HEC Paris and Global Clinical Professor at NYU School of Law.

This article is the edited version of a piece that was first published in Science in the Public Interest vol. 1: Harm Reduction, published by SciCom– Making Sense of Science.

Photo credit: theilr


http://www.sci-com.eu/home/docs/scicom-harm-reduction-vol1-web.pdf

http://www.sci-com.eu/home/docs/scicom-harm-reduction-vol1-web.pdf

https://www.flickr.com/photos/theilr/5092644137/



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Drugs: time to fight for health

By Michel Kazatchkine


Aligning drug policies with public health policies

We often hear about the ‘war on drugs’, but it is a fight that international drug enforcement is failing to win. This ailing prohibitionist approach costs tens of billions of euros in global diplomatic relations plus vast health and social costs, including thousands of deaths and millions of infections. And the root cause? Poor policy. Drug use and possession remain a criminal–often capital–offence in over 150 countries worldwide. Around 1,000 people are executed each year. This criminalisation has affected millions of lives, fuelled HIV and hepatitis C epidemics, fed human rights abuses across the globe and subverted the rule of law. So what needs to be done?

Lessons from Central and Eastern Europe

Speaking at a EuroScience conference ESOF2014 in Copenhagen, Georgian Minister of Corrections, Archil Talakvadze, put it thus: “Expecting to solve public health problems by enforcement-led policies can lead to a downward spiral of increased harm and ultimately death.” Until 2012, Georgia had one of the highest drug incarceration rates in the world. But in prison thousands became addicted to sedatives, psychotropic drugs or more damaging substances. Hepatitis C spread to 42% of all prisoners. Families broke up and lost all their personal wealth in fines and bail. Today, Georgia embraces harm reduction science. In just a few years Talakvadze has cut the prison population by 60%. Prisoners have universal access to counselling, testing and treatment of HIV and HCV infections.

At the same conference, Andrey Klepikov, executive director of the HIV/Aids Alliance in Ukraine, argued that the Russian government ideologically opposes any form of state intervention because addiction is too profitable. The


http://www.euroscientist.com/public-health-has-to-be-tackled-by-the-war-on-drugs

http://www.michelkazatchkine.com/




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Ukraine’s methadone programme caused an estimated loss of $31 (€27) million for illegal drugs traders in 2013. When Russia annexed Crimea around 800 patients were cut from methadone treatment, with dozens subsequently dying.

The evidence is conclusive. When countries align their drug policies to public health drug abuse falls. In Western Europe, for example, HIV/AIDS among people who inject drugs is under control. But in countries with harsh penalties, the epidemic continues to expand. This is predominantly the case in Eastern Europe–including many new EU member states–and Central Asia. In fact, Eastern Europe, not Africa, now has the highest HIV growth rates in the world.

HIV spreading East

There are several reasons for the high incidence and prevalence of HIV in Eastern Europe and Asia. First, is the lack of needle exchange. Needle exchange programmes are core to the package of interventions identified by the WHO, UNAIDS and the UN Office on Drugs and Crime, UNODC, to prevent HIV infection among people who inject drugs. In combination with antiretroviral treatment, needle exchanges reduce HIV transmission, decrease mortality, and reduce drug dependency, crime and public disorder. They improve quality of life.

Put simply, health-based drug policies start with harm reduction. In the face of the scientific evidence and contrary to international drug control conventions, substitutive opioid therapy remains illegal in the Russian Federation. Meanwhile, access to needle exchange programmes are being restricted in the USA. Sadly, needle exchange and substitutive opioid therapies remain the exception rather than the rule, globally.

Over-zealous law enforcement does not help either. When the police make arrests for syringe possession or put needle exchange programmes under surveillance, they simply drive drug users underground to inject in unsafe, unhygienic conditions.

What is more, under prohibitive enforcement regimes, drug production and clandestine sales are in the hands of criminals. The purity and potency of products is unregulated and unknown. Dodgy drugs are potentially dangerous, perhaps life threatening.

Finally, prisons are not drug-free so mass incarceration is bound to fail. But most prisons, even in several countries with health-focused drug policies, would never dream of needle exchange programmes or substitutive opioid therapies. In Western Europe, needle exchange is only available in Spain, Switzerland and in one women’s prison in Germany.

Human rights and wrong

Let us not pull any punches: restrictive policies increase the risk of death. Around 20,000 people die from overdose in the USA and more in the Russian Federation. In Georgia, citizens witnessing a possible overdose were required, by law, to call the police before an ambulance. And Naloxone, the drug that can immediately stop the effects of overdose and save lives, is far from universally available. Is “let them die” the easier option?

Punitive drug policies are severely undermining human rights in every region of the world. But there is a clear gap between countries with predominantly health-focused drug policies and those taking a prohibitionist approach.

Repressive laws have led to a dramatic increase in the number of people in detention, in prisons, as pre-trial detainees, or people held in administrative detention. In the USA, where ethnic minorities are much more likely to be incarcerated for drug offences than whites, prison has been identified as a key factor for the markedly elevated HIV infection rates among African Americans.

Some countries maintain compulsory drug detention programmes where evidence-based treatment of addiction is absent. In China and South East Asia, an estimated 235,000 people are held in such centres. And let’s not forget those 1,000 people executed each year for drug offences around the globe.

Levels of social violence are also noticeably different between countries. Countries fighting the ‘war on drugs’ in Latin and Central America have seen a major wave of violence, corruption and instability. At least 60,000 violent deaths are estimated to have occurred in Mexico, for example, in the last 10 years since the war on drugs was scaled up.


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In all these ways the gap continues to widen as ideology gets in the way of rational policy-making. Now, as the world prepares for a special session of the UN General Assembly on drugs in 2016, it is time that the consequences of criminalising drugs are acknowledged by the international community. And it is also time for the international community embrace policies that decriminalise drug use and possession.

Michel is UN Secretary-General Ban-ki Moon’s special envoy on HIV/AIDS to Eastern Europe and Central Asia. He is a member of the Global Commission on Drug Policy and former executive director of The Global Fund to fight AIDS, Tuberculosis & Malaria.

This article is the edited version of a piece that was first published in Science in the Public interest vol. 3: Addictions: Ethics,Integrity and the Policy-Maker, published by SciCom– Making Sense of Science.

Photo credit: GreatWhiteNorthEh


http://www.globalcommissionondrugs.org/



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Policy solutions to various forms of addiction

Do drug programs really work?

By Françoise Dubois-Arber


Lessons from current drug prevention programmes

We all know the sad stories of celebrities destroyed by illegal drugs. Occasionally, there is a glimmer of hope, as a star is coming out of rehab and staying clean. These top media scoops might make the headlines, but they should not influence debates about how to help addicts. Yet, public opinion is easy to be swayed; emotions, prejudices and personal experiences make it difficult to develop effective policies and programmes based on objective evidence. Fortunately, there is quite a bit of evidence out there. One of the best resources is the European Monitoring Centre for Drugs and Drug Addiction, the EMCDDA, which publishes full reviews of the evidence and current best practice in the areas of prevention, therapy and harm reduction.


http://www.euroscientist.com/do-drug-programs-really-work

http://www.unil.ch/actu/fr/home/menuguid/nouveaux-professeurs/professeurs-2012/dubois-arber-francoise.html


http://www.emcdda.europa.eu/

http://www.emcdda.europa.eu/

http://www.emcdda.europa.eu/best-practice



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Prevention’s effectiveness

Unfortunately, the evidence base for prevention programmes is rather patchy. For example, there is no consistent proof that mass media campaigns help to modify drug use; not if they are standalone campaigns, at least. On the other hand, a Cochrane review found that comprehensive family-oriented prevention is likely to reduce cannabis use.

School-based programmes also seem good at reducing or delaying illegal drug use, but students need more than just lessons about drugs. They respond better to their peers; they are influenced by their social networks and are more able to resist drugs if they develop good life skills. One systematic review shows the benefits of getting the local community, school and family all involved together in prevention and reduction programmes.

Tentative treatements

The evaluation of treatment programmes is also mixed. For heroin, at least, the evidence is compelling: diverse treatment options are effective. Methadone or buprenorphine, including for pregnant women, help to keep addicts on treatment; they reduce opioid use, HIV infection and mortality. Adding psycho-social interventions and case management into the mix also works.

The evidence for the treatment of cocaine addition is inconclusive. We still do not know whether treatment with antipsychotic drugs, anticonvulsivants or psychostimulants really works. Some pharmacological approaches, such as the use of antidepressants or dopamine agonists, and cognitive/behavioural psycho-social interventions do seem to help, however.

And what about that rehab clinic for the rich and famous? Unfortunately, the jury is still out on whether residential stays really work that well.

When prevention and treatments fail, you are left with little choice. All you can do is try to limit the harm illegal drug users do to themselves. As these addicts usually want anonymity, the programmes are difficult to monitor; research and experimental control trials are difficult.

Nevertheless observational studies and reviews provide enough evidence to conclude that several interventions are likely to be beneficial: These include needle/syringe exchange, which reduce risky injection practices and HIV infection, drug consumption rooms, which reduce risky injection practices, continuity of treatments from prison to community, which reduce mortality, and opiate substitution plus needle exchange, which reduce incidence of HIV and HCV.

For example, Switzerland set up a comprehensive continuous evaluation of national harm reduction policy in 1991, followed up in 2003. It included numerous studies and surveys, some repeated over time. The cumulative evidence reveals the widespread acceptance of the sale and distribution of syringes, no effect on numbers of drug users entering treatment, a decrease in new HIV cases and in needle sharing, now at very low levels. It also reveals no increase in number of injecting users as well as a reduction in syringe demand. Finally, the Availability of syringes remained high, risk behaviours and HIV incidence low, over time.

Beyond evidence

Despite the growing evidence base, policy-makers must remember this: context is everything. Most of the evidence comes from controlled experimental studies on the efficacy of programmes; they do not look at their effectiveness in the real world. But the implementation of a programme is also crucially important.

Moreover, interventions tend to work together. For example, in an area with high levels of addiction school-based prevention may coordinate activities with a local needle exchange and a treatment centre. These combinations may deliver results where a single programme would not.

Experience suggests that comprehensive and coherent drug policies are most likely to succeed. Although it is generally impossible to evaluate policies with randomised controlled trials, it is straightforward to gather and analyse data from many sources, including specific surveys, routine statistics such as drug treatment statistics, mortality


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statistics, police and justice statistics, etc. Over time this cumulative evidence will reveal whether a policy or programme is truly effective. In this way policy-makers can avoid subjective and misinformed debates and ensure the consolidation of firm action to tackle illicit drug addiction.

Françoise was formerly associate professor at the Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Switzerland. She is an expert in evaluation of public health policy and in prevention programmes.

This article is the edited version of a piece that was first published in Science in the Public Interest vol. 2: Addictions and Their Brain Reward Systems, published by SciCom– Making Sense of Science.

Photo credit: epSos.de


http://www.iumsp.ch/



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Juggling with drinking patterns, culture and policy responses

By Marjana Martinic


Can alcohol addiction can be tackled with consumer friendly policies?

Do you like a glass of wine with your dinner? Perhaps a trip with friends to a bar? Or do you recall parties getting out of hand? Have you ever seen a paramedic rush to someone’s aid as an alcoholic’s liver begins to fail? Whatever your drinking experiences, across Europe alcohol is the focus of political attention. Global action to reduce harmful use is already underway. Strategies have been outlined in the 2010 WHO Global Strategy to Reduce the Harmful Use of Alcohol and its Global Action Plan for the Prevention and Control of Non Communicable Diseases 2013-2020.

But governments still struggle to implement effective policies against drink abuse. One reason is that alcohol is unique: a two-faced product being both good and bad. On the one hand, it ranks fifth among risk factors for disease and disability. The social harm and damage to health that alcohol abuse can cause–from depression to domestic violence–is well documented. On the other hand, moderate drinking confers both physical and mental health benefits.

At the same time, global efforts to address alcohol-related problems may be hindered by conflicts with local needs and priorities. It is therefore imperative that policy-makers appreciate the complex individual, societal and cultural factors that affect their work.


http://www.euroscientist.com/can-alcohol-addiction-can-be-tackled-with-consumer-friendly-policies


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http://www.annalsofepidemiology.org/issue/S1047-2797%2807%29X0142-X



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Drinking patterns?

First, it is important to profile types of individual and groups. How do their characteristics affect the way they drink and how drinking affects them?

Take women, for example. As a group, they have a faster physiological response to alcohol. They are also affected at lower levels of consumption. Drinking is also a risk factor for breast cancer and a danger to foetal development. As a result, women are advised to drink less than men. And they generally do.

If we look at various demographics, young people are more at risk from drinking than adults; their physiology and development is different. And they also tend to take more risks. Similarly, individuals with particular health conditions or a genetic predisposition for alcohol dependence require tailored measures; in some cases they should not drink at all.

Second, policy-makers must understand cultural attitudes to drinking and drunkenness, which vary widely across Europe. At one extreme, drinking in Mediterranean countries is well integrated into daily life. But there is little tolerance for drunken behaviour. At the other end of the spectrum, the Nordic pattern sees people “bingeing” and a general acceptance of intoxication.

Finally, policies should consider the links between drinking behaviours and consequences. The danger of drinking and driving, for example, is now widely acknowledged. So are the harmful consequences of “extreme” drinking purely for getting drunk. In all cases, drinking can have a profound impact beyond the individual: on families and communities, productivity, public order and more.

Cultural shift

But here is the catch: a big one. Almost as soon as you have teased out all these complicated issues, you find the ground shifts;this is because culture is not static. Globalisation, urbanisation, migration and social integration are dramatically changing drinking patterns. In Italy, for example, consumption of wine has declined significantly. In Russia, more people, especially younger drinkers, are choosing beer instead of spirits.

The amount people drink is changing too, with a noticeable convergence in consumption between once disparate EU countries.

Another huge global shift is an increase in alcohol consumption among women in both developed and developing countries. This trend is thought to be a consequence of their changing role in society. Indeed, a longitudinal survey among students by the European School Survey Project on Alcohol and Other Drugs suggests that girls are increasingly keeping up with boys. In some cases, such as in the UK, they actually drink more.

The developing world is experiencing a move to more “Western” patterns of consumption. Unsurprisingly, reports of alcohol-related chronic diseases and alcohol dependence are on the rise, particularly in cities. Developing countries also have high consumption of unrecorded alcohol consumption, including home-brews, illicit and counterfeit products, even cleaning fluids and perfumes.

It is therefore clear that public health policy cannot ignore idiosyncratic drinking cultures and the diversity in drinking patterns that exist around the world. Simple regulations to reduce levels of consumption, for example by increasing prices or limiting trading hours, are not enough. Population-level regulations are blunt instruments.

For instance, marketing restrictions are often hailed as a panacea to curb drinking among young people. But in reality, parents and peers are significantly more influential in shaping drinking patterns.

A “one-size-fits-all” can sometimes badly backfire. Raising prices end up with heavy drinkers switching to cheaper, poor quality and unrecorded alcohol. Restrictions on trade, for example through alcohol retail monopolies in Nordic countries, has in part been responsible for high rates of smuggling and cross-border traffic.


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http://dx.doi.org/10.1111/j.1530-0277.2007.00467.x

http://dx.doi.org/10.1111/j.1360-0443.2006.01485.x



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Preventative engagement

So what is the solution? A strong regulatory framework around the production, sale and consumption of alcohol is clearly important. But people will continue to drink, to take risks and to ignore common sense. The imperative, therefore, is to ensure that drinking, when it occurs, is as safe as it possibly can be.

Previously considered policy options include: measures to reach young people through education, changes to social norms so under-age drinking and intoxication are unaccepted as well as screening, brief interventions and treatment for problem drinkers. Other possible approaches include altering drinking environments to reduce potential harm, improving the quality and integrity of beverages and raising consumer awareness to highlight potentially harmful drinking patterns and encouraging informed and responsible choices.

Finally it is also important to consider the degree to which particular interventions are likely both to be appropriate and to enjoy public support. Educators, health professionals, and prevention specialists have a role in crafting interventions that can raise awareness and encourage safe, responsible behaviours. Community leaders and civil society have an important role in responding to immediate needs and in setting priorities. Those who make, sell and serve alcohol beverages must also promote, perhaps enforce, responsible drinking.

And what about the consumer? Almost universally ignored–perhaps even vilified as an irresponsible drunk–drinkers also have a key role to play, not least in voicing dissent when measures unreasonably infringe upon individual rights.

Marjana is deputy president at the International Center for Alcohol Policies in Washington DC, USA.

This article is the edited version of a piece that was first published in Science in the Public Interest vol.2: Addictions and Their Brain Reward Systems, published by SciCom– Making Sense of Science.

Photo credit: Jasmin Fine


http://www.icap.org/



https://www.flickr.com/photos/1finecookie/6960733845



27/05/2015




Anti-smoking: “E” is for ethics

By Deborah Arnott


Tobacco: novel products challenging old ethical stances

Smoking is a global killer epidemic. During the 20th century tobacco caused 100 million death – roughly the same number as people killed in both World Wars. Without action, this century it could claim the lives of a billion people, mostly in low and middle income countries. Yet tackling smoking is a tricky business. Regulation must balance several fundamental principles: protecting people from harm whilst preserving human dignity and freedoms.

It is remarkable to observe how attitudes and policy have changed. A little more than 20 years ago, my colleagues would light up in front of me while I was heavily pregnant. It made me feel sick and I knew that the smoke was harmful, but I couldn’t ask them to stop. Their right to smoke took priority.

Back then I helped to organise a workplace ballot to prohibit smoking on the premises. We won by an overwhelming majority; the non-smokers, who had felt unable to speak up individually, made their wishes clear.

My campaigning continued in 2003 when I was recruited by ASH (UK). This evidence-based advocacy organisation was set up by the Royal College of Physicians to reduce the harm caused by tobacco. We were major advocates for the UK’s proposed legislation to ban smoking in indoor public spaces.

Preventing harm, promoting health

The UK consultation and media debates hinged around the question and evidence of harm. The pro-legislation argument won in the end. This was largely because the public accepted that the rights of workers in the hospitality


http://www.euroscientist.com/anti-smoking-e-is-for-ethics




27/05/2015




industry to be protected from second-hand smoke superseded the rights of smokers to light up wherever they wanted. Between May 2004 and December 2005, support for smoke-free legislation rose from one half to two thirds of the adult population. It become vote-winning policy and introduced in law in 2007.

ASH is not anti-smoker, but anti-smoking. The distinction is important. I believe there should be balance of rights and responsibilities, for smokers and non-smokers alike and across the globe.

The advent of electronic cigarettes, or e-cigarettes, has once more raised important ethical issues–and this time I worry that perhaps smokers’ rights are being ignored. From Canada to South Africa to New Zealand, with murmurs in France and Germany, countries are banning e-cigarettes or regulating them as strictly as tobacco products.

Yet the science suggests e-cigarettes are much less harmful. Yes, there are rational arguments about potential harm. But the bulk of evidence so far points to public health benefits, certainly in the UK where we engage with smokers and “vapers” to monitor health effects. Perhaps it is really fear of the unknown and a residual desire to punish smokers and vapers that are driving the call for strict regulation?

Research by ASH and government statistics show that almost no-one who is not a smoker is using e-cigarettes. Smokers, meanwhile, are increasingly using e-cigarettes to help them quit; they are proving significantly more effective than medicinal nicotine products bought over the counter. There is little sign that young people other than existing smokersare using e-cigarettes.

It is too soon to say how safe e-cigarette use is longer-term and more research is needed. The precise extent of harm from long-term use is not known, but tests show that the concentrations of potentially harmful inhalants in vapour are likely to be many magnitudes safer than smoking cigarettes. Exhaled vapour is unlikely to cause significant harm to bystanders.

European regulation

In Europe, we have an evolving twin track regulatory approach which will be in force by 2016/17. It will require novel nicotine delivery devices to be regulated under the EU Tobacco Products Directive or to have a medicines licence.

Ironically, the first licensed e-cigarette will be marketed by a wholly owned subsidiary of British American Tobacco. Despite the vociferous criticism, ASH believes that products, whoever they are made by, should be prescribed on the basis of clinical need. At the same time, we insist that, in line with the WHO Framework Convention on Tobacco Control, this product must not allow any tobacco company a foot in the door to unduly influence tobacco policy.

I understand why so many people want to clamp down with stringent regulation. It is more than 50 years since Richard Doll published the first evidence that smoking caused lung cancer. Yet smoking is still a world-wide epidemic.

We also know that traditional tobacco control policies are effective. But applying the same principles to e-cigarettes may prove to be counter-productive. The evidence that e-cigarettes have great potential for helping adults to quit is compelling, so we should avoid laws that hinder smokers from switching to less harmful alternatives.

I am convinced that banning or heavily regulating e-cigarettes in the same way as tobacco products–even just discouraging their use–does not equate to “do no harm”.

Deborah is Chief Executive of Action on Smoking & Health (ASH UK) and a respected public health campaigner for greater awareness about the tobacco epidemic worldwide. She champions evidence-based policy measures that do not attack smokers or condemn smoking. Reporting to the Royal College of Physicians, ASH provides the secretariat for the UK’s All Party Parliamentary Group on Smoking and Health.

Photo credit: [email protected]


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https://www.flickr.com/photos/csace/

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