week 10: Population-level interventions and the public health approach Flashcards
Outline the public health approach in relation to substance use and addiction
The public health approach adopted in Australia aims to combine evidence-based scientific, technological, and management systems to improve the health of individuals and populations. The main objective of this approach is to learn from past successes and failures in disease control, and to promote preventative measures to combat existing, evolving, and re-emerging health threats and risks.
The public health approach to substances/addictions
Since 1985 Australia has had a coordinated national policy approach to drugs, defined in the National Campaign Against Drug Abuse and, since 1993, the National Drug Strategy. Adopting a harm minimisation approach, the strategy provides a framework for action to minimise drug-related harms to individuals, families, and communities, which is based on the three core elements of demand reduction, supply reduction, and harm reduction.
Demand reduction
- The objective of the Strategy is to prevent the uptake and/or delay the onset of drug use, reduce the misuse of drugs, and support individuals to recover from drug dependence.
Methods include disseminating accurate information about drugs to the community, for example through school-based education programs and public awareness campaigns; unfortunately no government has actually made it a formal part of the curriculum yet. The availability of evidence-based early intervention treatment programs are important to assist drug users in reducing or stopping their drug use, leading to a reduction in the misuse of drugs within the community.
The second key objective of the Strategy is to reduce the supply of illegal drugs and control the supply of legal drugs.
An effective reduction in the supply of legal and illegal drugs requires a coordinated approach of government, law enforcement and the health professions. Reducing the supply of illegal drugs requires investigating, preventing and intervening in the importation of illegal drugs into Australia, as well as the domestic manufacture and supply of illegal drugs. Supply reduction for legal substances, including alcohol, tobacco, and pharmaceutical drugs, involves regulating legitimate access and investigating and interrupting illegal marketing. Regulating the sale of alcohol and tobacco to individuals aged over 18 years from licensed premises and liquor retailers, and limiting the supply of alcohol to intoxicated patrons are key strategies. State, territory and local government regulations control and enforce the regulation of these drugs.
Harm reduction
The final key objective is to reduce the negative health, social, and economic impacts of alcohol and drugs for individuals, their families, and the wider community.
Efforts to reduce alcohol-related harms include liquor licencing, the responsible serving of alcohol, and community-based information and education to prevent drink-driving, reduce the incidence of alcohol-related road accidents, and public and domestic violence. Tobacco-related harm minimisation efforts include the introduction of bans on smoking in workplaces and enclosed public spaces to minimise exposure to second-hand smoke. Safe injecting programs and the availability of needle disposal facilities have been effective at reducing the incidence of HIV and hepatitis C and improve community safety. Other strategies related to illegal drugs include provision of treatment interventions, road-side drug testing, and the availability of water, information and emergency medical services at public events where drug use may occur.
- most of the interventions that will lead to a significant reduction in harm at a community level are population based.
Smoking, in particular, has shown us that treating the individual alone is not enough, and that the most effective approaches relate to restrictions on where a substance can be used (i.e. smoking bans; alcohol consumption bans in public spaces) factors that influence consumption of the substance: price, purity (in relation to illegal drugs), availability, accessibility, and advertising/promotion of legal drugs.
-Interventions such as closing pubs earlier (say 2am rather than 7am) are tremendously effective, yet a combination of public ambivalence, political risk aversion, and the power and political influence of the alcohol industry mean that very few jurisdictions close early.
Identify key policies which are likely to fit within the public health approach
Since 1985 Australia has had a coordinated national policy approach to drugs, defined in the National Campaign Against Drug Abuse and, since 1993, the National Drug Strategy. Adopting a harm minimisation approach, the strategy provides a framework for action to minimise drug-related harms to individuals, families, and communities, which is based on the three core elements of demand reduction, supply reduction, and harm reduction. Additionally the strategy has a commitment to collaboration between government, law enforcement, health professions, and other stakeholders in the ASU field – which has successfully led to health teams and law enforcement working side by side.
Understand key concepts and elements of education campaigns, including what works and what does not
There are a number of different types of education campaigns, including: school-based, mass media, warning labels and the newest version of social media campaigns.
Education campaigns
Although education campaigns are the most widely used population level response, there is mixed evidence for their effectiveness, and virtually none of it is compelling (e.g., Foxcroft et al., 2003, or Wakefield et al., 2014). There are a number of different types of education campaigns, including: school-based, mass media, warning labels and the newest version of social media campaigns.
-School based education campaigns can increase knowledge and improve attitudes to drugs, however there is no evidence of a long-term effect on drug use behaviour (Anderson, 2007). A review of 14 systematic reviews of school-based alcohol education campaigns showed only six of 59 quality education campaigns to be effective (Jones et al., 2007). Similarly there is mixed evidence for the impact of parent-targeted education programs
In general, public education campaigns have been found to be ineffective in reducing alcohol-related harm (Babor et al., 2010). However mass media campaigns focused on reducing drink driving and tobacco control (in Australia) and have been found to be quite effective. Media campaigns focusing on drink driving are associated with a decrease in alcohol-related road accidents when delivered in conjunction with enforcement.
A recent example of this was a local education campaign in Geelong designed to reduce alcohol-related violence. The Just Think campaign was initiated by well-meaning football players, and was quickly adopted by the local newspaper and funded by the alcohol industry. The key message was that it was okay to continue to drink alcohol, but once you were drunk you needed to ‘just think’ about whether you are going to get into a fight. The problem was that no practical strategies to change behaviour were given, and unfortunately ‘just thinking’ is not something that is typical of those who are intoxicated. The advice to ‘just think’ runs contrary to the evidence around the role alcohol plays in violence.
While the Just Think campaign was being rolled out, with enthusiastic backing by politicians around the country, no evidence-based interventions, particularly closing pubs earlier, were rolled out during this time. During that period in Geelong, there was a 4.5 fold increase in alcohol-related assaults and emergency department attendances (Miller, Sonderlund et al., 2011). This increase is part of an increasing trend, which means that while the increase in the rate of alcohol-related assaults may not be directly related to the Just Think campaign, this campaign does not appear to have made a positive impact.
warning lables:
Alcohol and tobacco product warning labels help establish a social understanding that these are hazardous products and consumption should be reduced or avoided. While mandated text-based health warnings on alcohol products have not been shown to impact drinking behaviour, graphic warning labels on cigarette packaging are effective at reducing rates of smoking (Anderson et al., 2009). Interestingly, it has been found that the graphic warning labels on tobacco products need to be refreshed regularly or their impact diminishes (e.g., White et al., 2014).
Social media is a new frontier and is a constantly changing feast of interventions and responses. There are many different variations these days and social media campaigns are not necessarily about education, but can also be about action or reflection. A good example of this is Feb Fast, which encourages users of alcohol, social media, sugar, tobacco and junk food to have a break for the month of February. Feb Fast is a charity organisation that encourages users to raise money while fasting from their chosen vice; thus obtaining accountability through friends and family for their commitment to the fast. The program claims that 73% of users reduce their level of drinking after completing the program, 92% maintain their newfound good habits, 90% report improved health, and 70% have a greater awareness of the health impacts of their vice.
While the impact of education campaigns in isolation cannot change behaviour, the provision of accurate information and education is vital as a starting point for changing people’s attitudes towards drugs and alcohol, which in turn lead to healthy behaviour. Yet Australia does not have a standard school curriculum item for addiction and substance use issues.
Understand the role of vested interest, class and socio-economic status on addiction
Sociocultural factors are important considerations in ASU. Evidence suggests a bidirectional relationship between SES and drug use, such that low SES can cause an increase in drug use and, to a lesser extent, drug use can lower SES (for example through loss of employment). Low SES is associated with chronic stress and reduced access to resources and support, which can subsequently lead to increased drug use. Low SES communities often have high rates of unemployment, drug use and availability, and crime, and so provide a cultural environment conducive to problematic drug use (Spooner & Hetherington, 2004).
The label ‘vested interest’ can apply to both individuals and groups. Individuals may have a special interest in promoting a theory or distorting a finding for reasons of personal gain, as when the results of a drug trial are biased or fabricated by an investigator who stands to gain financially from the study’s outcome. Vested interests can also apply to organisations that seek to control research findings for private benefit, for example when the tobacco industry funds research on the measurement of second-hand smoke in order to delay tobacco control legislation, or when the alcohol industry pays consulting fees to academics to write papers critical of evidence-based policy. When an individual or an organisation seeks to influence research in order to advance private advantage, those with vested interests may benefit at the expense of the public good or scientific integrity. Governments can also have a vested interest in scientific research, as when science is misused to benefit a particular political agenda, ideology or favoured interest group (Miller et al., 2006).
There is a growing body of literature that points to the role of vested interests as barriers to the implementation of public health policies (e.g., Chapman & Carter, 2003; Miller et al., 2011). The best known of this literature concerns the tobacco industry and its attempts to undermine public health efforts to reduce smoking. The US Master Settlement Agreement has allowed researchers to access internal tobacco industry documents which have been invaluable in demonstrating strategies employed by tobacco companies over more than 50 years to counter and undermine policies that might adversely affect their interests (Bond, Daube & Chikritzhs, 2009). These documents have also pointed to similar tactics within the alcohol industry, including a five year plan (1992–1996) to counter advertising and labelling regulations and coordinate response efforts to proposed restrictions. The alcohol industry has previously opposed random breath testing and minimum blood alcohol levels for driving (Bond et al., 2009). At the same time, the industry spends less than 0.5% of its marketing budget encouraging drinkers to drink responsibly (Alcohol Policy Coalition, ND). The gambling industry has also acted collectively to protect its interests with good effect, focusing on individualising gambling problems and commissioning high profile academics to critique research findings supporting regulatory reform (Blaszczynski, Walker & Sharpe, 2001). Such strategic and long-term actions have important ramifications for national health initiatives and budgets, with the result that the most effective interventions are delayed or not implemented.
Multinational and multi-interest companies
Although the dangerous consumptions industries appear to be many different industries with distinct interests, there are strong links between them. The distinction between the alcohol, gambling and tobacco industries denies the reality of the multinational and linked corporations that control these different industries (Miller & Kypri, 2009). The largest shareholder of Miller Brewing is Phillip Morris tobacco. Similarly, Australia’s leading retailer of alcohol, Woolworths, is also Australia’s largest single operator of gambling machines and retailer of tobacco products. The relationship between these industries is multi-layered and enduring (Bond et al., 2009).
The changing nature of capitalism and consolidation of most dangerous consumptions into very large multinationals ultimately means that advocating for good health of the population becomes a political battle with extremely powerful opponents. The issue is complex and ever-changing, but continues to be one of the major issues, if not the major issue when trying to look at how to reduce harm associated with addictions and substance use across the globe.
