published in Critical Public Health 14:329-344, 2004




Robin Room

Centre for Social Research on Alcohol and Drugs

Stockholm University, Sveaplan

106 91 Stockholm, Sweden



            In the late 19th and early 20th centuries, a commitment to alcohol prohibition became the leading force in alcohol temperance movements in the U.S., Britain and its English-speaking colonies and dominions, and in most of the Nordic countries.  In the context of the First World War, these movements succeeded in their goals in the United States, Canada, Finland, and Russia, and came close to success in Norway, Sweden, Iceland and New Zealand.  In all of these countries, alcohol prohibition proved to be controversial, and was sooner or later abandoned.

            So far, the history in broad outlines is well known.  What is less well recognized is that there was a clear conceptual alternative to prohibition (Levine, 1985), which became in fact the replacement for prohibition in these countries when it was abandoned, and which also strongly influenced policy in other countries with strong temperance movements, such as Australia and Great Britain.   In the language of the time, this alternative was known as “liquor control”.  In current language, we might think of it as a harm reduction movement.  That is, it started from an acceptance of the use of alcohol, but sought to structure and influence the use so as to limit the social and health harm from drinking.

            The liquor control school of thought was not the only opposition to prohibition.  Alcohol producers and allied interests formed another bloc of opposition, and then there was the rather less organized opposition of drinkers themselves, including by the 1920s many literary and bohemian figures (Heron, 2003, Chapter 6; Room, 1984b).  But from the point of view of prohibitionists, the most formidable enemy was the movement for liquor control.  It was never a mass movement, and in fact was primarily elite-based.  Its power rather derived from the fact that it was willing to acknowledge and address the same problems as the temperance movement – the undoubted social and health problems associated with drinking – while offering an alternative to prohibition as an answer. As the prohibition solution lost its credibility in the 1920s and 1930s, in country after country the political process therefore turned to the ideas of the liquor control movement as a viable alternative.

            Most alcohol prohibitionists therefore had an abiding dislike for the liquor control alternative, and were willing to see things get worse, from their perspective, rather than accept its solutions.  Thus the Swedish prohibition movement long opposed the Swedish government control and alcohol rationing system, the existence of which had resulted in defeat of a prohibition referendum (by 49% to 51%) in 1922. As was noted by American observers in the 1930s, “curiously enough, the permit [alcohol rationing] system is opposed by a large number of [temperance movement members] in Sweden on the ground that possession of a permit is regarded by many holders as a badge of distinction, and that it places a premium on the right to buy liquor and thus tend to encourage the purchase of the total allowable quota” (Fosdick & Scott, 1933:104). However, when rationing was finally abandoned in 1955, still opposed by elements of the temperance movement, alcohol consumption immediately rose by 25%, and problem indicators even more sharply (Mäkelä et al., 2002).


Harm reduction, harm minimization and liquor control

            This paper describes the main emphases of the liquor control school of thought, and considers how it relates conceptually to two modern movements – the harm reduction movement with respect to illicit drugs, and the “new public health approach” to alcohol policy.  

To call the liquor control school of thought a harm reduction movement is itself somewhat controversial, primarily because the current meaning of “harm reduction” for drugs is much discussed and somewhat in flux.  Harm reduction can be conceptualized either in terms of goals or in terms of strategies (CCSA National Working Group, 1996).  In drug harm reduction, it has often been conceptualized in terms of strategies: a needle exchange, an injection room, or opiate substitution therapy are all strategies to reduce the harm from drug use, strategies which share in common that they do not require abstinence from drug use.  Drug harm reduction has primarily been concerned with providing services to drug users at the individual level that will reduce risk or rates of harm such as HIV infection or overdose deaths.  In fact harm reduction as a term and a movement in the drug field became strongly established only after the advent of AIDS. While the focus in the service provided is often on harm to the drug user him/herself, reducing perceived harm to others has also been a clear political motivation for providing harm reduction services.  Preventing HIV infection from dirty needles obviously potentially benefits others besides injection drug users.  Likewise, the primary criterion in evaluating methadone programs in the U.S. has been reduction in rates of property crimes committed. In the Netherlands and Switzerland, with the strong cultural emphasis on orderliness in public spaces, reducing “public nuisance” has often been a source of political support for harm reduction programs, factored into such specifics as the location of programs.

            The alternative framing is to define harm reduction in terms of the goal – a goal of reduction of harm from alcohol or drug use, as opposed to a goal of elimination or prevention of the use.  In this framing, a wide variety of strategies can be counted as harm reduction, including even the prevention of use.

            The definition adopted by a Canadian National Working Group (CCSA, 1996) opted for a definition in terms of strategies, including “only those programs and policies which aim at reducing drug-related harm without requiring abstention from drug use” (emphasis in original).  On the other hand, the International Harm Reduction Association (IHRA) offers a “definitive interpretation” on its website which frames the definition in terms of goals: “the term … should be understood to mean ‘policies and programs which attempt primarily to reduce the adverse health, social and economic consequences of mood altering substances to individual drug users, their families and their communities’” (IHRA, 2004).  The IHRA discussion explicitly includes an abstinence strategy as “a special subset of harm reduction”.

            In current Australian drug policy parlance, “harm minimization” is used for the broader, goal-oriented definition, which can encompass strategies of “supply reduction” and “demand reduction”, while “harm reduction” is used as in the Canadian definition for a narrower set of strategies (Blewett, 2004).  Making such a distinction is useful, but the particular choice of terms in the Australian parlance is likely to be confusing.  In contrast to the Australian usage, for instance, the IHRA discussion regards “harm minimization” as a stricter category included within “harm reduction”: “it is always difficult to be sure that harm has been minimized but easier to establish that harm has been reduced”.[2]

            In calling the liquor control school of thought a harm reduction movement, then, I am using the broader, IHRA definition of harm reduction.  In distinction to the focus of prohibitionists on the goal of abstinence, liquor control focused on the goal of minimizing or reducing the social and health problems resulting from drinking.  Particular emphasis, though not the only emphasis, was placed by liquor control thinkers on controlling the time, place and manner of selling alcohol.  


Liquor control as a school of thought

            The idea of reducing problems by controlling places where alcohol are sold and consumed is as old as recorded history.  Thus, for instance, three articles of the Code of Hammurabi (2000), from Babylon 3800 years ago, governed the behaviour of tavern-keepers and their customers.  Concern with orderliness in public drinking was a recurrent theme, and licensing sellers as a means of control (since licensing entailed the threat of the license being removed) was instituted in England as early as 1552 (Catlin, 1931).  These traditions were continued in British colonies and dominions, even after independence; thus, for instance, Virginia legislation of 1792 limited sales of liquor by the drink to those with a license to operate an inn (Womer, 1978). 

The modern period of alcohol control, however, can be considered to begin in Falun, Sweden in 1850 (Frånberg, 1987; Thompson, 1935).  The idea of municipal ownership and operation of public drinking places as a way to limit drinking and ensure public order, pioneered in Falun, was adopted soon after in Gothenburg, and by the late 19th century the idea, generally known as the “Gothenburg system”, had spread throughout not only the Nordic countries but also the English-speaking world.   The parallel arrangement of government-operated off-sales stores, selling liquor by the bottle, was apparently pioneered in the American south in 1891 (“Athens” in Cherrington, 1925-30), and the idea of such a “dispensary system” also spread more broadly.  In the early 20th century, then, what was often known as “state control” of the alcohol market was a prominent element in ideas of how alcohol control could reduce the harm from drinking.

As will be described, liquor control discussions covered a variety of measures directed at minimizing problems from drinking besides “state control”.   While the school of thought was most developed and influential in countries where the realistic alternative was prohibition, its influence extended more broadly, and particularly to most parts of the British Empire.  In southern Africa, for instance, the establishment of municipal beerhall systems (e.g., Parry, 1992) was in part an adoption of liquor control ideas.

            The full story of the liquor control school of thought in an international perspective remains to be told.  Even the choice of a phrase to describe it is not obvious.  “Liquor control” as a term only came into currency as a term well after early studies in the tradition had appeared (Levine, 1983).  I have termed it a “school of thought” rather than a social movement because it did not have many of the attributes associated with a social movement: while many longstanding institutions were set up as a result of its thinking, there do not seem to have been any continuing groups dedicated to and promoting its ideas, and publication arrangements for work in the tradition seem to have been mostly ad-hoc. As Levine (1983) puts it concerning the U.S. “literature on alcohol control” from the 1890s through the 1930s, it “was not written by reformers tied to broad social movements.  Rather, it was the work of members of the upper class, and of professionals, scientists, academics, journalists and administrators”.  The nearest to a continuing centre for the school of thought was probably the Institute of Public Administration at Columbia University, associated with a series of studies in the 1930s and 1940s (e.g., Fosdick & Scott, 1933; Thompson, 1935; Harrison & Laine, 1936).

            Though Levine (1983) and Rumbarger (1989) emphasize the connection of liquor control to an American power elite of industrialists, in an international perspective an interest in liquor control reached across the political spectrum.  Beatrice Webb, a co-founder of the Fabian Society, was the author of the classic study of the history of liquor licensing in Britain (Webb, 1903), and one strand of thought in the socialist movement was interested in liquor control (Roberts, 1985); while at the other end of the political spectrum Mussolini also took an interest in the subject (Morgan, 1988). 

            Liquor control studies were unusually international in their scope.  The Committee of Fifty to Investigate the Liquor Problem, a upper-class reform group in the U.S. which published 5 studies of the “liquor problem” between 1897 and 1905, set the tone by discussing with approval the “Norwegian or Company system” (a variant of the Gothenburg system) in their proposals for reform in the U.S. (Levine, 1985).  George Catlin, the author of an authoritative 1931 textbook on Liquor Control, had himself served as a young man in the primary crucible of British liquor control experience, the Central Liquor Control Board, an agency set up in World War I, and in the mid-1920s directed a social science commission studying the impact of U.S. prohibition.  His book draws extensively not only on the British and American experiences, but also on experience in Australia, New Zealand and Canada, and the Nordic countries, and more briefly on experience elsewhere in Europe (Room, forthcoming).  In the whirlwind 8 months of the study by Fosdick and Scott (1933:xiv-xv) of what should replace Prohibition in the U.S., members of the study group visited and studied alcohol control in Denmark, Finland, Norway, Sweden, England, Russia, Poland, Germany, Austria, Italy, and every Canadian province.

            As a school of thought, liquor control receded in the 1940s.  The question of how to structure the control systems which replaced prohibition in north America, Norway, Finland and the Soviet Union had been solved, and gradual decline of the temperance movement removed the main stimulus to provide a harm-reducing alternative. Succeeding generations were left with the alcohol control structures which the liquor control experts had helped to bring into being.  The process of erosion of the most stringent parts of these structures started relatively soon after the structures were set up, and continues today.  Some aspects of the structures, however, have proved quite durable, even as political climates and principles have changed. .   

            The succeeding generation of alcohol researchers in the U.S., in fact, was hostile to the liquor control approach, while apparently remaining ignorant of its actual work.  I have found no indication that the researchers at the Yale Center of Alcohol Studies knew its work.  After having been commissioned to study the effects of one of its major achievements, the alcohol control systems of the U.S. states, Selden Bacon, a sociologist who was then the director of the Center, took a critical stance.  In his view, the idea that the controls had “an iota of influence on preventing, controlling, or reducing any of the problems associated with the use of alcohol is most unlikely” (Bacon, 1971).   Ironically, this new postwar “wet” generation in U.S. alcohol research made no distinction between the two old adversaries, the liquor control approach and the classic temperance movement.   

            The history differed somewhat in the Nordic countries (Room, 2002b).  With strong roots in working-class movements, Nordic temperance movements remained strong long after temperance movements in English-speaking countries had decayed, and this kept liquor control issues alive as a politically contested territory (Sulkunen et al., 2002; Anttila & Sulkunen, 2001).  Finland, in particular, developed a tradition of evaluation research on the effects of alcohol control measures as a major task of the social research department within the Finnish state alcohol monopoly.  The author of a classic experimental study of the effects of opening liquor stores in rural communities (Kuusi, 1957) became director of the monopoly, and fostered the development of this tradition.  While there was a rupture in the liquor control tradition in the U.S., the Nordic tradition thus has much more continuity.


The aims of liquor control

Focus on the harms

            Liquor control studies were much concerned with the details of regulation of the market, but their primary aim was to make alcohol available in such ways that it minimized the harms from drinking.  Chief among these harms was the threat of alcohol consumption and the alcohol market to public order.  The Committee of Fifty set the frame for this emphasis already before 1900, in a classic statement of a harm reductionist position.   The aim should be to achieve “external improvements” in “order, quiet and outward decency”, even if it

remains doubtful, or at least not demonstrable, whether or not the visible improvements have been accompanied by a diminution in the amount of drinking…. The wise course for the community at large is to strive after all external visible improvements even if it be impossible to prove that internal fundamental improvements accompanies them. (Wines & Koren, 1897:75)

            By the time of Catlin’s textbook, the concerns had broadened somewhat.  The “liquor problem”, in Catlin’s view, includes “a limited, but not insignificant, portion of the population, which is peculiarly tempted to excess and even to chronic excess”, but also the interests of the “general public in so far as the protection of the rights of others, the maintenance of public order, and the industrial prosperity, health and efficiency of the country” (Catlin, 1931:41). The indicators of health and social problems Catlin considers include deaths from cirrhosis and “alcoholism”, public drunkenness arrests, homicide and other crime, suicide, pauperism, “public sexual morality”, industrial productivity and accidents (Catlin, 1931:27-40, 97-104).  In the context of the last years of American Prohibition, an end to the lawlessness of the illicit alcohol market was also a major concern in such studies as that by Fosdick and Scott (1933; see Levine, 1985).

Pragmatism in policy

            The liquor control literature was marked by an emphasis on “what works?”, in implied and sometimes explicit distinction from “the side of abstract principle”, whether this be “the moral demand, as an absolute principle, for total abstinence” or “the equally absolute principle of personal liberty” (Catlin, 1931:234).  This concern with “what works” fueled the broad international reach of the literature: liquor control arrangements in other countries and jurisdictions were regarded as natural experiments from which the policy analyst could learn.

            The list of policy levers considered varies from one study to another, but commonly included government ownership and a series of measures both structuring the market and attempting to control the individual drunkard. Catlin (1931:248) sums up the common list of measures as including “control by taxation, by discrimination between different liquors [by strength],... by the regulation of hours [of sale] and even by refusal of permits to buy to those convicted of offences”.     

            Government ownership and operation at least of off-sale retail outlets was a fairly consistent theme in the literature from the Committee of Fifty onwards.  “The cardinal principle in such legislation”, Wines and Koren (1987:151) noted, “is the removal of the element of profit from the sale of liquor”.  Across the political spectrum, social reformers were prepared to make a special case for the handling of alcohol as a commodity.  “Liquor … is no more an ordinary article of commerce than explosives, and it has the peculiarity, in common with narcotics, that its use does noticeably tend in the case of many people to end in abuse” (Catlin, 1931:249).   Thus John D. Rockefeller, in other circumstances no foe of private profit, insisted that “the point cannot be too heavily stressed” that “that only as the profit motive is eliminated is there any hope of controlling the liquor traffic in the interest of a decent society” (Preface to Fosdick & Scott, 1933:x).  Thus, although Catlin (1931:148) had felt as late as 1931 that “in view of the American tradition, no scheme of government ownership …  can probably be regarded as practicable by anyone who surveys the situation judicially”, in the event 18 U.S. states did adopt some form of state monopoly of part of the alcohol market.  The liquor control analyses tended to emphasize the removal of the profit motive, rather than what the literature today tends to emphasize as the public health benefits of government ownership: fewer outlets, fewer hours of sale, and better control over the conditions of sale.  

            The advice on taxation tended to be tempered by the strong recognition of the need for the legal alcohol market to offer effective competition to the illicit market.  There was also often some concern about the regressivity of sales taxes (Fosdick & Scott, 1933:118; Catlin, 1931:161-163), a concern which seems almost quaint in our era of ubiquitous VAT and goods and service taxes.  Fosdick and Scott (1933:124-125) offered detailed proposals on what the combined state and federal tax levels should be, at least “during the period of transition while the organized bootlegging system is being driven out of business”, noting that “as soon, however, as the illicit trade is no longer an outstanding menace, we anticipate that higher tax rates will be socially desirable”.  Their tax scheme, traces of which can be found in the US alcohol tax structure today, included a factor for increased tax for higher alcohol content, another “to discourage consumption” (essentially a further surcharge for spirits), and a further “to reach luxury consumption” (particularly aimed at sparkling wines and liqueurs). An unexplained small factor which was in step with the luxury factor was set as proportional to the estimated “average manufacturing cost” of the beverage. The main overall effect was to place a considerably higher tax per unit of alcohol on stronger distilled than on lighter fermented beverages, since the latter were seen as less productive of social disruption.

Perhaps the least studied aspects of the new alcohol control systems as they emerged were the controls on the purchases of the individual drinker.  This represented a direct effort to affect the top end of the “natural” free-market distribution of consumption, by which typically more than half of the alcohol is consumed by less than 10% of the drinkers (e.g., Greenfield & Rogers, 1999).  The best-studied such controls are the Swedish motbok system, by which the head of a household was assigned a ration of up to 4 litres of spirits per month (alcoholic beverages below 14% strength were not rationed).  The system can be compared with a prescription system for psychoactive substances, except that the prescription (the ration allowance) was decided by a state bureaucrat rather than by a doctor.  The rationing system was abolished in 1955, as such individual-level controls on ordinary consumers came to be seen as intolerable; the undoubted gender and class biases of the system also counted against it (Frånberg, 1987). As already indicated, the immediate results were substantial rises in alcohol-related mortality, delirium tremens cases, and drinking offences (Mäkelä et al., 2002).

            The Swedish system actually extended well beyond the ration-book.  In common with Finland and Norway, Sweden also had a system of local lay or semi-professional Temperance Boards, typically chaired by a local teacher or priest and composed of other local citizens, with combined functions of advice and control (Christie, 1965).  Public intoxication which came to police notice would be reported to the temperance board, and the result might well be a reduction or withdrawal of the alcohol ration.  By the 1970s, the functions of the temperance boards had been transferred to professional social workers in all three countries.

            Catlin’s book (1931:222-232) includes a fairly detailed consideration of the Swedish system. In his view, the basic system included “no more serious infringement upon the liberty of the individual than in procuring and automobile licence”, but the elaborations, including the temperance boards, clearly did go further.  As he notes, while the British system “leaves the excessive drinker to the arm of the police, the Swedish system concentrates upon the social problem of the excessive drinker.  By the permit-book it restricts him as a physician might restrict him and, finally, through the Temperance Boards, takes him sternly in charge.”  

            The new systems set up when prohibitions were repealed included various such efforts to control the inveterate drinker.  In five of the Canadian provinces (Alberta, British Columbia, Ontario, Manitoba and Nova Scotia), an individual purchase permit was required in the first years of the new systems (Fosdick & Scott, 1933:103); the last vestiges of such requirements disappeared in the 1960s.  Finland had a “buyer surveillance system” operated by the alcohol monopoly which sent social workers for a home visit to those who seemed to be purchasing too much (Järvinen, 1991); it was abolished in the late 1950s.  According to Fosdick and Scott (1933:103), the principal reasons for canceling or reducing the purchase quota in such systems in the early 1930s were “drunkenness, commission of a crime while under the influence of alcohol, driving an automobile while intoxicated, bootlegging of purchases and neglect to provide for the family”.  Though all except the last of these reasons would potentially draw the attention of police in the U.S. or Britain, liquor control authors from those countries tended to view the permit systems with skepticism; as Fosdick and Scott put it (1933:104), the systems involved “the necessity for social welfare work, and alcohol control administrators are not likely to be well equipped for this kind of activity”.

            The unease of the British and U.S. liquor control authors of the 1930s, then, was eventually mirrored in the abandonment of individual-level restrictions on the right to purchase in Canada and the Nordic countries.  Ironically, such individual-level banning orders are currently making a comeback in Britain, where the Home Office, local police and tavern owners seem to agree on formal or informal bans on particular disruptive drunks as the preferred strategy to reduce alcohol-related violence and trouble (UK Home Office, 2001)    

Liquor control and the inveterate drinker

            There is no doubt that some of those producing the liquor control literature were what today would be called “policy wonks”.  On the other hand, the literature often drew on a great deal of practical experience.  Particularly notable in this regard was the experience of the UK Central Liquor Control Board during and after World War I, which taught those involved that “however desirable the suppression of intemperance may be and however efficaceous the methods,… there are limits to their application; they cannot be effectively and safely pushed beyond a certain point…. Nor is the issue merely one between liberty and sobriety; it is also one between increasing and diminishing sobriety” (Shadwell, 1923:150).

            In discussions such as the report by Fosdick and Scott (1933), the inveterate heavy drinker – what would soon after become known as the “alcoholic” – is invisible.  Catlin (1931), on the other hand, proceeds through a discussion of various types of drinking, beginning with the “pathological alcoholic”.[3]  Catlin quotes a British Home Office physician’s statement that “the drunkard is a neurotic who … has an inherent tendency to be rapidly and deeply poisoned by certain drugs, of which alcohol is the most readily obtainable, and … has an inherent inability to resist the action of these poisons so that they quickly overcome him”.   Catlin quickly adds that “this inability, however, to resist alcohol is not limited to persons of so defined and pronouncedly abnormal a type that, for practical purposes, it would be sufficient to deal with them by special legislation for inebriates and mental patients”, and proceeds to cite “the immortal Dr. Johnson, who certainly was not a neuropath, in the ordinary sense, yet had to abstain because he found that, whenever he drank, he was unable to desist until he became drunken” (Catlin, 1931:83).

            Catlin thus resists what would become the model of the alcoholism movement: to define alcoholics as fundamentally different from “social drinkers”.  In the closing section, he sets his preferred solution of “scientific law making” against two alternatives. One of these is prohibition, which in his view can only succeed where there is a

marked measure of homogeneity of moral ideals in the community and of moral enthusiasm for the law.  Such moral unanimity supposes two conditions: a country inspired by a high enthusiasm – whether the ideals be those of national efficiency or of religious puritanism or of Fascist patriotism – and agreement that Prohibition is a necessary means. (Catlin, 1931:245)

The other alternative is, “Why not punish the drunkard?”  Catlin points out that this alternative is congenial to alcohol industry interests, who urge that the penalties be “increased against drunkards whose topings only serve to bring the legitimate trade into disrepute”, leaving others to drink “unhampered by the inquisitorial action of the law”.

            Catlin’s response is that this theory

involves an entirely false account of the psychological situation…. The drunken man is not, in fact, often so by deliberate choice of that condition but precisely by “excess”. It is probably not equitable moral practice and it is certainly not effective law to penalize a man solely and severely for overstepping a boundary line which not even the medical profession is able to define with any precision and which varies from individual to individual.  Such legislation, in the last analysis, becomes the penalization of sick men. Nor can it be for a moment supposed probable that all arrestable drunks could be certified and sent to inebriety homes.  (Catlin, 1931:244).

            Catlin thus agrees with the later alcoholism movement that singling out the alcoholic for punishment is inhumane. But he also rejects the alcoholism movement’s preferred remedy of providing treatment as the sufficient solution, on two grounds.  One of these is practical: that there will not be enough inebriety homes to accommodate all who could be sent. The other is more fundamental: he rejects the idea that there is a separate class of alcoholics that should be singled out at all.  Instead, excessive drinking lies on a continuum with no clear separating boundary from other drinking. By implication, his preferred solution is measures which would apply to the population of drinkers as a whole, without singling any out for special handling.


“New public health” approaches to alcohol and harm reduction    

In the anglophone world, at least, the intellectual bases of the liquor control tradition were totally forgotten in the postwar period, even though people lived every day with the results of the tradition, in the form of alcohol control systems adopted in their basic form in the period 1910-1935.  The alcoholism school of thought gained hegemony in the field (Roizen, 1991).  Social scientists may always have been uneasy at the alcoholism paradigm (Room, 1983), but there was little overt challenge to it before the 1970s.

What is now sometimes referred to as the “new public health approach” began to come together in the 1970s (Room, 1984a, 2002a).  Fundamental to the approach was a refocusing on rates of alcohol-related harm in the population as a whole. In the eventual reformulation, which accommodated alcoholism, now renamed the alcohol dependence syndrome, within this broader frame, there are a number of alcohol-related problems, and the alcohol dependence syndrome is one among them (Edwards et al., 1977).

An early statement of this new approach came in an article in Finnish by the sociologist Kettil Bruun (1970), a long English summary of which was published in 1973.  Bruun proposed that the object of alcohol policy was to reduce the harms from drinking, and he listed seven such harms.  If one successfully dealt with these harms, he added, there was no need to deal specifically with alcoholism; it would have already have been dealt with through dealing with the concrete social and health problems. A paper by the present author (Room, 1975) developed Bruun’s switch of gestalt from alcoholism to alcohol problems in an American context, outlining different strategies for minimizing the harm from alcohol.  One of the strategies discussed was to reduce the harm from drinking without necessarily affecting the drinking.

Another strand of the new approach involved the reopening by an international group of scholars of the issue of the potential role of alcohol control policies as public health instruments (Bruun et al., 1975).  The primary attention in this and the succeeding book in this tradition (Edwards et al., 1994) was on control measures such as taxes and limitations on availability which would reduce rates of harm from drinking by reducing the consumption level of a population as a whole.   But other reports within the frame of the new approach (Moore and Gerstein, 1981), including the third volume in the Bruun et al. tradition (Babor et al., 2003), explicitly included chapters on the strategies which reduced harm without necessarily reducing the amount of drinking.

The inclusion of such approaches within the “new public health” model was not accepted by all. Responding to Room’s paper (1975) at a 1974 conference, Edwards argued that approaches would be potentially “removing informal social controls….  What you’re doing is drowning the screams by buying yourself earmuffs” (comment in Room & Sheffield, 1976:142).  But these qualms were small potatoes compared with the continuing contention over the issue of whether the level of consumption in the population had anything to do with rates of alcohol problems.  This idea was particularly unwelcome to alcohol industry interests, and remains so.  From the research community, the main critique in recent years has been that the “distribution of consumption model” which Bruun et al. put forward paid insufficient attention to patterns of drinking (e.g., Stockwell et al., 1997).  Alcohol industry interests seized on these critiques and pushed the argument one step further to propose that an approach focused on patterns of drinking should replace attention to levels of consumption (Grant & Litvak, 1998).  But there is nothing inherent in attention to drinking patterns that would foreclose attention also to levels of consumption.  Current collaborative reports in the “new public health” tradition (e.g., Babor et al., 2003; Academy of Medical Sciences, 2004) usually include attention to both dimensions of drinking.

Somewhat separately from this tradition, studies and books have started to appear in the alcohol field which reflect the application to alcohol of the “harm reduction” rubric from the drugs field.   In this framing, the attention is usually to reducing the harm for relatively heavy drinkers without necessarily interfering with their drinking (Plant et al., 1997), although broader framings have also begun to appear (e.g., Buning et al., 2003).


Harm reduction traditions compared: alcohol and illicit drugs

One striking commonality between the modern drug harm reduction movement and the liquor control approach of the early 20th century is the positioning of both as the alternative to and antagonist of prohibitory approaches.  In both cases, the political weight tended to lie with the prohibitory approach (at least through the early 1920s in the case of liquor control), while both drug harm reduction and liquor control commanded strong intellectual resources as well as practitioners with much practical experience. 

The antagonism between the approaches was often not expressed particularly strongly either by the modern drug harm reduction movement or the old liquor control movement.  Modern drug harm reductionists typically seek an accommodation within a prohibitionist regime, and liquor control writers, as we have seen with Catlin, were often willing to concede a place for alcohol prohibition where popular support was strong. Rather, it was the prohibitionists who were most insistent on the antagonism, anathematizing harm reduction.  Concluding an early detailed critique of the Gothenburg system, Pitman (1880:247) offered a “final and fatal objection to this scheme.  It is absolutely repugnant to the moral sense and the enlightened conscience of the community.  Even the better portion of the friends of [licensing systems] would revolt at such active support of, and such close connection with, so disgusting a traffic”.   In much the same spirit, the U.S. delegation at the Commission on Narcotic Drugs in 1995 declared that “the U.S. cannot embrace ‘harm reduction’ as a goal. It connotes a tacit acceptance of drug abuse, and becomes a de-facto decriminalization” (Room, 1999).

On the other hand, a striking difference between the modern drug harm reduction movement and the liquor control approach has been the emphasis of drug harm reduction on the treatment and social handling of heavy users.  This partly reflects the impetus that the HIV epidemic gave to drug harm reduction.  But it also might be seen as reflecting the political hegemony of drug prohibition.  Although the discourse appears now to be opening up (e.g., McCoun and Reuter, 2001; Senlis Council, 2004), mainstream scholarship has until recently shied away from serious consideration of alternatives to the global drug prohibition regime.

The very different political milieux of drug harm reduction and the new public health approaches have influenced the particular denotations of “harm reduction” in the two areas.  In the alcohol field, harm reduction or harm minimization has primarily referred to a shift in goals: that the aim is not to stop use, nor necessarily to reduce dependence on the substance, but rather is to reduce the harm from use.  In this context, a wider range of strategies can be considered to qualify as harm reduction or minimization (Room, 1975).  These notably include strategies which affect the availability of the substance, such as taxes or hours of availability.  For licit substances, the supply is not automatically a matter for the police; and conversely, governments have more possibility to intervene in the market to reduce harm from use. As we have seen, harm reduction with respect to illicit drugs has tended instead to focus on strategies oriented to heavier users.

Another difference between current harm reduction approaches for illicit drugs and for alcohol has been in ethical stances, particularly concerning the provision of services.  As noted, drug harm reduction has primarily been concerned with providing services to users at risk – often particularly to heavy users.  Given the official antagonism of some national governments and the skepticism of the international drug control system, it has been easy to see these harm reduction services as “on the side of” the user, offering new options to be picked up at will.  And, indeed, “humanistic values” stressing respect for “the dignity and rights of the drug user” (CCSA, 1996) have often been seen as a main characteristic of the drug harm reduction movement.

However, the provision of services to individuals also inevitably involves some element of social control, if only the “soft” social control of attracting the user into a safer path.  Often the element of social control is more obtrusive, as in the inception of mass methadone maintenance in the U.S. during the Nixon administration, where the political argument for the provision of treatment emphasized that judges had to see that treatment was a realistic option if they were to be persuaded to pass harsh sentences on drug crimes (SAODAP, 1973). 

Providing services to individuals also tends to single them out and label them.  Even where the service is provided anonymously, children in the neighborhood may be well aware who are customers of the services. Alcohol and drug intoxication or addiction are among the most stigmatized conditions in one society after another (Room et al., 2001), so that such individual-level service provision, however kind and supportive its intentions, may result in adverse labelling and stigmatization.   

In recognition of these tendencies, a sometimes unspoken consideration in new public health approaches to alcohol has been the ethical preference for measures which apply generally to users, and do not single individuals out for intervention, treatment, or other processing.  A small impairment or influencing of individual choice, applied across a population as a whole, is seen as not only often more cost-effective but also ethically preferable to remedies tailored to the individual.  “The singling out of individuals for special handling, whether in the form of treatment or punishment, often carries with it adverse side effects, for example their permanent identification as deviants.  In our view, preventive alcohol policies” such as taxes and other controls on alcohol availability “should, therefore, be given a high priority as an alternative to the morally inspired control of problem drinkers” (Mäkelä et al., 1981:111).  The same consideration appears to lie behind the preference of liquor control analysts such as Catlin for measures which apply generally rather than singling out specific cases for special handling; and particularly behind his dislike of recourse to “legal penalties and the instinct of fear” (Catlin, 1931:90).  

Harm reduction in the drug field of course has started from a very different place, with populations who are often already thoroughly marginalized and stigmatized. As the drug harm reduction movement expands its focus, however, it might well take into consideration this issue of the extent to which identifying individual cases for treatment, however beneficial and well-intended the treatment or handling may be, carries with it a real risk of harm to the individual from stigmatization.

The aim in this paper has been to demonstrate the value in comparing harm reduction approaches across epochs and across psychoactive substances.  A broad historical and comparative approach, looking across psychoactive substances, cultures and epochs, has much to offer in terms both of suggesting alternatives which may lie outside the conventional frame of reference, and in terms of providing evidence on what the effects of particular measures in particular circumstances are.




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[1] Revised from a paper prepared for presentation at the 15th International Conference on the Reduction of Drug Related Harm, Melbourne, Victoria, Australia, April 20-24, 2004; and at the International Conference on Drugs and Alcohol in History, London, Ontario, Canada, May 13-16, 2004. Thanks to Harry G. Levine for his stimulating comments.

[2] In this spirit, when the present author used the term “harm minimization” concerning alcohol policy in 1974 (see below), a politically-attuned California official suggested verbally that perhaps “harm reduction” would be a less radical and more politically acceptable term. 

[3] Catlin’s other types are misery drinking (in poverty); industrial drinking (in the workplace); emergency drinking (calming situational nervousness); and finally convivial drinking.