These interventions illustrate the effects of increasing the availability of a potentially harm-reducing product to a specific high-risk population. It appears that this one has slight impact on behavior, on either the frequency of the acts or their average safety. In the absence of a strong scientific base, the debate is largely in terms of values and impressions, a common characteristic of social policy fields in which harm reduction has been applied. Making condoms available to school students may “send the wrong signal.” It involves the state in apparently facilitating acts of which society disapproves. Since the evidence to date is that these interventions have at most a modest effect on the frequency and damage of the targeted behavior, the harm reduction framework has not been explicit.

Alcohol

Alcohol policy raises many harm reduction issues, reflecting the mixed social message with respect to alcohol’s health consequences. Light drinking is a socially acceptable behavior, with apparently health promoting consequences. Heavy drinking, particularly chronic heavy drinking, is the source of a huge burden of morbidity and mortality, and is acknowledged as dangerous both to the drinker and others.

Harm reduction enters alcohol control in a number of ways. Alcohol consumption is characterized, even for most light drinkers, by episodes of excessive drinking. Though each light drinker has only a small to moderate probability of an alcohol-related automobile accident or other kind of injury, their numbers are large enough that, as a group, light drinkers account almost half the damage associated with alcohol consumption (Kreitman, 1986). Duncan (1997) found that driving while intoxicated (DWI) rates across states were associated with binge drinking but not with chronic heavy drinking.

As a result, a central debate is whether alcohol policy should focus on heavy drinkers as a group, on the total amount of alcohol, consumed or primarily on intoxication as a behavior. For example, some programs in the last group emphasize how the potential harm of drinking a given amount can be reduced by consuming it over longer periods of time or eating food during the drinking session. That implies an acceptance of heavy drinking, itself an unhealthy behavior and one that is a risk factor for numerous diseases. In contrast, high alcohol taxes reduce aggregate consumption, including that which is nonharmful; these taxes can be seen as “punish[ing] the many for the sins of the few” (Stockwell et al, 1996). If all drinking is seen to generate some probability of adverse effects, as the total consumption model suggests, then measures that reduce overall drinking are likely to be harm-reducing. Single (1997) suggests that “[I]ncreased attention is likely to be given to prevention measures which



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