Governance of Addictions: European Public Policies

263 Pages·2014·3.16 MB·English

by  Tamyko Ysa

Governance
of Addictions

Governance
of Addictions
European Public
Policies
Tamyko Ysa
Joan Colom
Adrià Albareda
Anna Ramon
Marina Carrión
Lidia Segura
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1
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Foreword
This book is the first in a planned series of six arising out of ALICE RAP (Addic-
tions and Lifestyles in Contemporary Europe—Reframing Addictions Project),
a five-year, €10-million endeavour co-financed by the Social Sciences and
Humanities division of FP7 within the European Commission and led by the
Foundation for Biomedical Research based in Barcelona and the Institute of
Health and Society in Newcastle University (<http://www.alicerap.eu>). The
other planned titles in the Governance of Addictive Substances and Behaviours
series are The Impact of Addictive Substances and Behaviours on Individual
and Societal Well-being; What Determines Harm from Addictive Substances and
Behaviours?; Concepts of Addictive Substances and Behaviours across Time and
Place; The Impact of Market Forces on Addictive Substances and Behaviours;
and The New Governance of Addictive Substances and Behaviours.
ALICE RAP studies the place of addictions and lifestyles in contemporary
Europe and aims to inform us how we can better redesign their governance. By
addictions, we mean the regular and sustained heavy use of drugs such as alco-
hol, nicotine, and cocaine and regular and sustained heavy engagement in
actions such as gambling or internet gaming (Rehm et al. 2013).
There are three potential frames in which we can understand addiction. The
first is an evolutionary one. We humans share a co-evolutionary relationship
with psychotropic plant substances that is millions of years old (Sullivan and
Hagen 2002). These include ethanol in fermenting fruit, ephedrine in khat,
arecoline in betel nut, nicotine in various tobacco plants, and cocaine in coca
plants. Exposure has both neurotransmitter and nutrient functions and we have
the biochemical pathways to metabolize these chemicals. But, of course, expo-
sure was usually only in tiny amounts. The problem is that we are now exposed
to these drugs in such huge doses that, for the most part, our bodies and brains
do not know how to deal with them in any meaningful way. These drugs also
trick our brains into acting as though the benefits of using them far outweigh
the harm, whereas this is blatantly not the case. And, of course, a lot of busi-
nesses and individuals make a great profit out of this—just think of alcohol and
the advertising industry.
The second frame is that when talking about drugs, we should consider not
only their relationship with health but also their relationship with societal well-
being in its entirety (OECD 2011a). Societal well-being includes many domains
vi FOREWORD
that impact on and are impacted by addictive substances—education, work-life
balance, productivity, and human capital, to name just a few. But—and for illicit
drugs perhaps more importantly—they also impact on personal security, crime,
social integration, and transparent governance regimes. As was the case with
prohibition of alcohol in the USA during the 1920s, it is the consequence of
prohibition, organized crime, and its political influence that has led to many
jurisdictions in the Americas, north and south, to call for the abandonment of
the prohibition of illicit drugs and adjustment of the existing drug conventions
in favour of legal availability managed by government regulations, but still
within the frame of global legal agreements.
The third frame is that we grossly underestimate the harm done by addictive
drugs. Let’s take alcohol as an example, the only psychoactive drug not subject
to a legally binding agreement. Alcohol was the world’s fifth most important
risk factor for ill-health and premature death in 2010, after high blood pressure,
tobacco, household air pollution from cooking fires, and a diet low in fruit,
moving up from eighth position in 1990 (Lim et al. 2012). The annual social
costs of alcohol from impaired health, crime, and lost productivity work out at
about €300 for every single EU citizen, man, woman, and child (Rehm et al.
2012). It is estimated that this would likely double to about €600 for every one
of us, if the social costs that alcohol causes to people surrounding the drinker
are included—friends, families, colleagues, and strangers (Laslett et al. 2010).
Much of these costs are preventable and ill-affordable in times of economic
downturn.
There are three groups of action that can inform better governance of addic-
tions. The first is to capitalize on the importance of social networks. Data from
the US Framingham Heart Study found that at any one time, for every addi-
tional contact among family and friends who chose not to drink alcohol, the
next time an individual was asked, the likelihood of heavy drinking was reduced
by ten per cent (Rosenquist et al. 2010). Likewise, for every additional contact
among friends and family who drank heavily—more than one drink (women)
or two drinks (men) a day—the next time an individual was asked, they were 18
per cent more likely to drink heavily.
The second action is to recognize that changing the social and physical envi-
ronment is far more effective in helping people improve their health than trying
to change individual behaviour alone. Social and physical changes that take the
healthiest route are the easiest to follow. This means that government action is
absolutely essential. There are powers only governments can exercise, policies
only governments can mandate and enforce, and results only governments can
achieve. Governments at all levels can regulate the markets in which private
businesses operate through mechanisms that impact particularly on price,
FOREWORD vii
availability, and advertising (World Economic Forum and WHO 2011). One of
the biggest impediments of governments putting health as their paramount
concern is a default in the democratic process and their unwillingness or inabil-
ity to stand up to big tobacco and big alcohol.
The third action is to develop better metrics. ALICE RAP is developing a tool
for managing the harm done by addictions, with the development of a footprint
of nations, regions and cities, sectors and organizations, and products and ser-
vices to promote accountability and monitor change. Modelled on a carbon
footprint (Williams et al. 2012), an addictions footprint would measure, for
example, the amount of alcohol-related ill-health and premature death result-
ing from the actions of an entity or organization, such as introducing a mini-
mum price per gram of alcohol by a government, bringing forward pub closing
times in a city, or from the amount of beer produced in different markets by the
world’s largest brewer.
If you want to redesign the governance of addictions, it is vital to identify
the starting point, and this book does just that. This is the first time that this
has ever been done in such a thorough and comprehensive way. And the
findings are remarkable. In addictions policies, the structure of the approach
follows the strategy of the approach. Countries that implement a well-being
and relational management strategy tend to embrace a comprehensive poli-
cy for addictions. They also tend to be those in which the Ministry of Health,
as opposed to the Ministry of the Interior, is the main body responsible for
planning and implementing drug policy. They have a harm-reduction as
opposed to a regulatory approach; decriminalize rather than criminalize
drug use; have proactive rather than post-factum policy-making; have a
health-oriented rather than a public-security approach; and aim to protect
the public and society in general rather than focus on individual responsibil-
ity. Countries that embrace a comprehensive policy for addictions tend to
tackle legal and illicit substances together, as opposed to split substance
policies; have a long experience in drug and addiction policies, as opposed
to little experience and poor continuity; have complex rather than simple
organizational structures; have multi-level governance and high levels of
devolution, rather than centralized organizational structures; and involve
rather than exclude stakeholders.
Since only just over one-quarter of the twenty-eight European countries
studied fall in the well-being and relational management strategy/comprehen-
sive policy for addictions cluster, there is clearly an enormous opportunity for
improvement for Europe as a whole. And there are no excuses for not seizing
this opportunity—this book lays out the clear elements of what would consti-
tute better policy.
viii FOREWORD
Peter Anderson
International Coordinator of the ALICE RAP project; Chief Series Editor, Gov-
ernance of Addictive Substances and Behaviours; Professor, Substance Use,
Policy and Practice, Newcastle University, England; Professor, Alcohol and
Health, Maastricht University, Netherlands
Acknowledgements
The authors want to thank the 7th European Framework for funding this
research and all the people involved in the ALICE RAP project for their sup-
port, comments, and contributions over the past few years. We would especially
like to thank Peter Anderson, Toni Gual, and all the team from the Hospital
Clínic of Barcelona for being excellent facilitators and providing the support we
needed to reach our desired goals.
We would like to express our special thanks to Lourdes Feans for the collec-
tion, management, and analysis of the mass media information, and to Xavier
Fernández-i-Marín for his sound methodological approach to analysing our
quantitative results. We are also in debt to Jan-Erik Karlsen for his contribu-
tions to the research meetings as well as his revisions of draft chapters, which
were remarkably valuable. We cannot forget Xavier Majó, who made a special
contribution to this work by participating in specific meetings, solving doubts,
and providing much-appreciated ideas and new ways of approaching this
research. Neither must we forget the help of Oriol Iglesias, marketing professor,
in conducting the naming session that led to the different labels used in the
book. As a collaborative project, this book could not have been done without
the help and contributions of our area partners in ALICE RAP; special thanks
to Franz Trautmann, Esa Österberg, Thomas Karlsson, and Mikaela Lindeman,
whose work has been especially useful to this study.
We would also like to thank all the people who have participated in inter-
views and/or revised our work: Joseph Barry, Gerhard Bühringer, Pieter de
Coninck, Fernanda Feijao, Vibeke Asmussen Frank, Sir Ian Gilmore, Cees
Goos, Matilda Hellman, John Holmes, Eric Janssen, Matej Kosir, David P. Mar-
tínez Oró, Maurice Mittelmark, David Nutt, Esa Österberg, Dag Rekve, Robin
Room, Emanuele Scafato, Sir Jack Stewart-Clark, Franz Trautman, and Witold
Zatonski.
Last but, as usual, not least, we would like to thank to all our colleagues from
ESADE and GENCAT for their patience and support throughout this project.