An excellent review, but how is ‘harm reduction’ to be defined? Comment on Chapter 8: Modifying the drinking context

Abstract

The take-home conclusions of Chapter 8 are that (i) there are some promising results from interventions which seek to reduce harm by modifying the licensed drinking environment but more controlled research is required and (ii) the overall cost-effectiveness of these measures is likely to be lower than that from curbs on alcohol availability and price. The chapter mainly consists of a succinct summary of published work, mainly from the United States, Australia and the United Kingdom using clear and uncluttered prose. It certainly covers the literature as I know it—other than some sources excluded from the start as not being published in a peer-reviewed journal or as a chapter in a book by a recognized publisher. The result is an authoritative and easy-to-read summary of what is now an important body of literature. The framing of the chapter places interventions in licensed premises clearly within a harm reduction framework, defined here as measures which ‘start from an acceptance that there will be consumption of alcoholic beverages and seek to modify or limit the drinking or the drinking environment so that potential harm is minimised’. The term ‘harm reduction’ has tended to be used in subtly but importantly different ways. In Australia the related term ‘harm minimization’ has been adopted by the federal government as the defining purpose of its National Drug Strategic Framework and used so broadly as to even incorporate abstinence-orientated approaches. The origin of the term was alongside strategies to make injecting drug use safer following the emergence of HIV/AIDS in the early 1980s and, to my mind, the more correct usage of harm reduction is in relation to strategies that do not require any reduction in drug consumption for their effectiveness. This is not an idle point: in this context, refusing service to intoxicated and underage customers is not harm reduction but supply reduction. Many of the strategies identified in the chapter concern law enforcement or taking civil action against licensees who serve intoxicated customers. These, too, sit uncomfortably side-by-side with harm reduction strategies. About the only place where I would have wished to have described the detailed literature differently, however, was where policing strategies for enforcing liquor laws were described in this chapter as equivocal since only one study found evidence for effectiveness (Jeffs & Saunders 1983) while a replication in New South Wales did not—in fact, they reported increased assaults reported to the police (Burns et al. 1995). A major problem with the second study was that, unlike the first, the police did not actually check for underage or intoxicated customers but simply patrolled through bars at busy times. Furthermore, the main outcome measure was confounded by the far greater presence of police to report assaults and to be the targets of assaults themselves. Two other studies (one not published formally other than as a technical report) have also reported that increased policing of licensed premises results in increased reports of assaults, due almost certainly to the greater exposure of these under-reported crimes to police attention (Putnam et al. 1993; Hawks et al. 1999). The result of this, however, is not very different from the conclusions of the authors of this chapter: more well-conducted research is required to determine the effectiveness of various interventions available to remedy alcohol-related violence and other problems in and around licensed premises. Harm reduction needs to be a key focus for this work, given that much of what can be done (e.g. safer glassware and safer security staff) does not require a reduction in alcohol consumption. However, much else (refusing service to intoxicated and underage customers, law enforcement, civil action) does require the prevention or reduction of consumption and so I believe a broader framework is required within which to discuss this promising and neglected setting for prevention. These are relatively minor points compared with the overall achievement of an excellent and authoritative review contained within what will surely be a landmark publication. I am not in receipt of any funds from any body with a vested interest in the sale or production of alcohol, nor have I ever received fees or funds from such bodies. I have been in receipt of funds from bodies with a vested interest in the promotion of public health and safety.