Reducing Harms from Youth Drinking - Reducing Harms of Underage Drinking Violations

Written by Stanton Peele

CAS has tested a program that focuses on reducing harms rather than on abstinence per se.[37] The program, "A Matter of Degree" (AMOD), is funded by the Robert Wood Johnson Foundation and supported by the American Medical Association. AMOD entails a wide panoply of techniques, including advertising restrictions, enforcement of underage drinking violations, opening hours for alcohol sales, community norms against excessive drinking, and other environmental and local cultural factors. Many of these techniques, for instance enforcement of age restrictions on drinking, are part of existing zero-tolerance programs. Nonetheless, AMOD explicitly aims to forestall "heavy alcohol consumption" (p188) and acknowledges youthful drinking while attempting to reduce binge drinking. A test of AMOD at ten sites found no significant changes in actual drinking or harm associated with drinking. Nonetheless, the investigators conducted an internal analysis - based on those schools that implemented the most specific elements of AMOD - and found reduction of both alcohol consumption and alcohol-related harm due to adoption of AMOD policies.

Is Harm Reduction a Viable Policy for American Collegiate Drinking?

The AMOD goal of "reducing drinking" (like the phrase "reducing underage drinking") is actually ambiguous, in a significant way. It can mean either (a) reducing the number of people under 21 who drink at all with a goal of having few or no underage drinkers, or (b) reducing the amount of alcohol that underage age drinkers typically consume. Both would reduce the overall levels of alcohol consumed by young people. The first is a zero-tolerance approach, the second is harm reduction. Of course, the goal could be to increase both phenomena. An important question is whether it is possible to combine these policies - the question involves both political and technical, programmatic considerations.

AMOD does not explicitly endorse teaching students how to drink moderately, at the same time that the program aims to reduce excessive drinking. AMOD thus incorporates harm reduction without accepting underage drinking as a natural passage into adulthood, as is customary in cultures which inculcate moderate drinking patterns. Socializing children into drinking remains outside the pale of harm reduction programs like those represented by AMOD. It may be that exclusion of moderate-drinking concepts is necessary in the mixed cultural environment presented in the United States, at least in terms of gaining popular acceptance for harm reduction ideas.

Hope and Byrne, ECAS researchers working in the Irish context, analyzed the policy implications of ECAS results. These investigators recommend importing into Irish and other binge-drinking cultures what might be called the Mediterranean approach to youthful drinking:

The experience of the southern countries suggests that it is important to avoid both demonizing alcohol and promoting abstinence as key elements of alcohol control. In order to emulate the success of the alcohol control policies of the southern countries, the EU should consider a strategy that includes the following elements:

• Encourage moderate drinking among those who choose to drink with moderate drinking and abstinence being presented as equally acceptable choices.
• Clarify and promote the distinction between acceptable and unacceptable drinking.
• Firmly penalize unacceptable drinking, both legally and socially. Intoxication must never be humoured or accepted as an excuse for bad behavior. Avoid stigmatising alcohol as inherently harmful, as such stigmatization can create emotionalism and ambivalence.[38] (pp211-212, emphasis adde

In fact, Hope and Byrne themselves fall short of fully adopting harm reduction approaches, just as AMOD does, by understanding that a certain amount of drunkenness will inevitably occur, and that even intoxicated young people should also be protected from irreversible harmful consequences of their own actions - like accidents or medical harms.

Finally, the goal of achieving moderate drinking is most controversial in the United States in the case of alcoholism treatment. Although research continues to point to the value of such approaches [39], Alcoholics Anonymous and virtually all American treatment programs emphasize abstinence as the only way to resolve an alcohol problem. Moderation training for problem drinkers is one form of harm reduction. Research on training heavy or problematic collegiate drinkers to moderate their usage has proven highly successful, although this approach is still extremely limited in its utilization across the United States. [40]

There is no single optimal policy for youth drinking - there are dangers and drawbacks to both zero-tolerance and moderate-drinking approaches. Nonetheless, especially given the current policy imbalance that strongly favors the former, collegiate officials and health professionals should consider the following in developing harm reduction policies:

• Epidemiologic research has established advantages to moderate drinking, particularly when compared with binge drinking, advantages that should be acknowledged and encouraged as a model for alcohol use on campuses.
• Insisting on abstinence does not guarantee the absence of drinking on campus, and harm-reduction techniques for reducing the extent and impact of binge or other excessive collegiate drinking should be developed and implemented (e.g., safe rides, providing protected settings for intoxicated students).
• Alternative treatment/prevention approaches - approaches that recognize and encourage moderation - are particularly appropriate for younger drinkers for whom moderation is more achievable than it is for long-term alcoholics and for whom lifelong abstinence is very unlikely.

Unhealthy (or at least less than optimal) American attitudes towards alcohol are regularly promoted by governmental and public health officials, researchers, clinicians, and college administrators. Indeed, even when such individuals adopt moderate drinking practices in their personal lives, they are reluctant to consider them in formulating public policy. This disconnect between sensible drinking practices, identified both individually and epidemiologically, and policy implementation is not a healthy state of affairs for American alcohol policy towards young people.

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