Collateral damage from alcohol: implications of ‘second‐hand effects of drinking’ for populations and health priorities

The term ‘second-hand effects of drinking’ is proposed for describing the costs and damages to the social fabric from individual alcohol consumption. This lens is a useful resource to meaningful healthy public policy and surveillance regarding alcohol consumption, and for narrowing the gap between burden of alcohol and effective responses. International analysis has indicated that the global burden from alcohol use is almost equal to that of tobacco [1,2]. In some low mortality countries in South America, the burden is even greater than that of tobacco [3]. At a global level, the burden from alcohol use is greater than the effects of each of the following: high cholesterol, body mass index, low fruit and vegetable consumption, physical inactivity and illicit drug use [1]. Despite the large body of evidence, there are still substantial inconsistencies between the epidemiological evidence of the damage from alcohol, on one hand, and the level of prevention and protection response on the other hand. The framework convention for tobacco, which arose as a result of the evidence regarding the harms, associated with tobacco and involved more than 200 non-governmental organizations (NGOs) from more than 90 countries, is used to provide a comparative example [4]. In contrast to tobacco, the mounting evidence with respect to the alcohol-related burden has not been sufficient to date to generate global interventions of equal potency [5]. It is hypothesized that there are a number of reasons for the current situation. These include public perceptions about alcohol's health benefits, the high prevalence of drinkers in many countries, normalization of drinking and integration of its use into many situations, cosy relationships between governments and alcohol industries and aggressive marketing of alcohol products [6,7]. Another probable factor involves misconceptions about the nature and extent of disruption and harm associated with alcohol use, including the harm to people other than the drinker. The topic of this editorial is the collateral damage of alcohol. Several terms have been used to describe the impacts of alcohol to those other than the person doing the drinking: they include social consequences [8], externalities [9,10], victimization [11,12] and second-hand effects [13]. While the scope of these terms is not identical, a common theme is that damage or social harm from the use of alcohol includes not only that experienced by the drinker, but by others, be they heavy drinkers [12] or non-drinkers [10], including the fetus. The term ‘second-hand effects of drinking’ is proposed here as shorthand for these impacts. This term refers to the damage from alcohol to people other than the drinker, although some of these victims of alcohol may themselves be heavy drinkers or impaired at the time of the incident. More broadly, it refers to social damage from alcohol—such as trauma to others [10], work-place incidents where impairment by another was a key factor, mass transportation incidents and family disruption, violence or abuse [8,13,14]. This editorial draws on information from Canada and other countries to illustrate that collateral consequences of an individual's drinking are widespread and entail substantial social costs. The burden of these consequences and costs encompass the general population, including children, abstainers, occasional moderate drinkers and heavy drinkers. The extent of this damage is not documented widely [4] and is therefore often ignored or rationalized when alcohol polices are being debated. On the other hand, the benefits of revenue generation are often highlighted, while the costs and consequences of collateral damage from alcohol are not. Focusing on the second-hand effects of drinking has substantial potential in moving the alcohol policy agenda forward. This is evident when examining the long-term, ongoing and multi-dimensional initiatives used to control drinking and driving. The impacts involve not only the impaired operator but the innocent victims of second-hand effects of drinking [10,15]. These comprehensive campaigns have been successful in influencing policy change by leveraging second-hand effects of drinking. The second-hand effects of drinking are not only evident with regard to drinking and driving, but also areas such as interpersonal violence. Aggregate data from the US Bureau of Justice Statistics established that over a 4-year period, 38% of individuals involved in violent incidents were under the influence of alcohol at the time the offence was committed [16]. Further, sexual assault and rape are more likely when the perpetrator is drinking: in 1997, 40% of sexual offenders in the United States indicated that they were intoxicated [16]. General population surveys provide another type of evidence. In the 2004 Canadian Addiction Survey, a representative population aged 18 years and older (n = 13 328) was asked if any had experienced disruption or harm in the past year resulting from drinking by others [17]. Almost 33% of respondents said that in the past year they had experienced one or more types of harm resulting from drinking by others. The 2008 data from Nova Scotia (aged 15 years and older) and 2006 data from Ontario (aged 18 years and older) illustrate similar patterns (Table 1) [18,19]. Similarly, a Norwegian study [12] of 2170 respondents found that 40% of respondents experienced one or more consequences from other people's drinking experienced during the past 12 months, including being harassed in public, harassed at a party and physically hurt. A US study by Greenfield et al.[9] is based on a subsample (n = 2550) of a 2005 national survey. Respondents were asked about six ‘externalities’ related to alcohol use, including family problems, assaults, accompanying an intoxicated driver, vehicular accidents and financial problems. Sixty per cent reported experiencing one or more of these problems in their life-time and 9% reported the same over a 12-month period. These examples from three countries are illustrative of the accumulating evidence of the collateral damage from alcohol. The concept of ‘second-hand effects of drinking’ has at least three implications. First, it needs to be introduced into the consciousness of those who manage alcohol policies and fund and implement prevention programmes, including those relevant to the work-place, youth and family settings. For example, knowing that up to one-third of the adult population is impacted negatively annually from alcohol-related incidents in some jurisdictions such as Canada is sufficient to justify a significant proportion of prevention funding. Secondly, more systematic and extensive research and surveillance is needed to explore the dimensions, including estimates of the burden on health and welfare systems from social and family disruptions related to ‘second-hand effects of drinking’[4]. This would include an examination of the costs to the drinkers, others, the government or the wider society. Thirdly, the concept of ‘second-hand effects of drinking’ provides further support for public policies and community-based initiatives that look beyond blaming the victim or focusing exclusively on the individual. The population-level policies that have been shown to be most effective [7] have implications for public health practitioners and policy advocates. Ensuring that alcohol prices at least keep pace with cost of living indices, controlling availability of alcohol, curtailing promotion, promoting lower-risk drinking through server and other policies and offering screening and brief intervention services will benefit not only the high-volume drinker but also his or her partners, family members, other members of the drinker's social networks and strangers. In order to generate strong prevention measures as well as health promotion and protection responses to the damage from alcohol, an appropriate emphasis is needed on tabulating not only the damage from drinking to the drinker but also the damage, costs and consequences to the larger social fabric. By raising the profile of alcohol through this lens of the ‘second-hand effects of drinking’ it will be more feasible to facilitate a process of healthy public policy and preventative action, and facilitate a response that will follow more synchronously the epidemiological evidence of the substantial burden of illness and other harm from alcohol use. Anca Ialomiteanu and Rose Schmidt contributed to the Ontario data reported in Table 1. We acknowledge source material provided by Thomas Greenfield, Robin Room and Ingeborg Rossow, and the insightful suggestions by the reviewers of an earlier version of this manuscript. With regard to the contribution by one author (N.G.), support to the Centre for Addiction and Mental Health for salary of scientists and infrastructure has been provided by the Ontario Ministry of Health and Long Term Care. The views expressed this paper do not necessarily reflect those of the Ministry of Health and Long Term Care. None.

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