Manuella Adrian

Gender and the social context of smoking behaviour

This paper examines the relative effect of both individual and societal factors that impinge directly on smoking behaviour of women and men. The societal factors are cigarettes price, tobacco control legislation, newspaper coverage of tobacco issues, overall economic factors, and social milieu characteristics. Three Canadian provinces are studied, from 1978 to 1995. A repeated cross-section design is used. Data are derived from national surveys and official documents. Results show that smoking occurs in social contexts within which the price of cigarettes appears to have a significant negative impact on the prevalence of smoking and the quantity of cigarettes smoked by men, but no effect on either the prevalence of smoking or the amount smoked by women. More comprehensive and restrictive no-smoking legislation and legislation on youth access to tobacco influence negatively the prevalence of smoking both for men and women. However, these laws do not have the same effects on the number of cigarettes smoked by women and men. Newspaper articles on the other hand, negatively influence smoking prevalence for women and men. As differences are observed in the responsiveness of men and women to tobacco control policies, policymakers and practitioners need to keep in mind that tobacco control policies have to be tailored to the broader context of the lives of women and men. Future work needs also to be done to clarify the interrelationships between social influences on smoking such as price, laws and media, and the relationships between these and intrapersonal and interpersonal factors, as well as other social and cultural factors.

CAN ALCOHOL PRICE POLICIES BE USED TO REDUCE DRUNK DRIVING? EVIDENCE FROM CANADA*

Drunk driving is one of the more serious negative consequences of alcohol consumption. Since consumption of alcohol is sensitive to the price of alcohol, and the occurrence of drunk driving is sensitive to the level of alcohol consumption, the possibility exists for alcohol pricing policie to be used to reduce drunk driving in the population. This paper reviews the evidence on this possibility in the literature and adds results based on data from the Canadian province of Ontario. Multiple regression analysis of time series data for Ontario from 1972 to 1990 indicate that, controlling for income, the proportion of young males in the population, changes in the minimum drinking age, and other confounding variables, increasing the price of alcohol has a significant effect in reducing alcohol-related motor vehicle accidents (elasticity = −1.2, p <. 05) and alcohol-related traffic offenses (elasticity = −0.50, p <. 05). Overall, the evidence strongly supports the view that alcohol tax and pricing policies can be used to reduce the extent of drunk driving. [Translations are provided in the International Abstracts Section of this issue.]

A critical perspective on cross-cultural contexts for addiction and multiculturalism: their meanings and implications in the substance use field.

Despite evidence of the antiquity and ubiquity of psychoactive substance use, much of the literature is devoted to addiction in minority ethnocultural subgroups. When researchers study drug use in isolated “primitive” communities, they consider drug use to serve as a mechanism of social integration; when they study drug use in ethnocultural subgroups in contact with mainstream society, they consider drug use as a marker, or sometimes as a cause of social disorganization. The implicit assumption appears to be that addiction and race, ethnicity, or other minority ethnocultural subgroup membership are linked, and more prevalent and/or more problematic in minorities, further problematizing the status of minorities. Empirical studies identified through ETOH, the U.S. National Institute of Alcohol and Alcoholism (NIAAA)s Internet-accessible computerized database, were subjected to content analysis of their abstracts (nabs = 44) as well as actual reports (nrep = 40). It was found that the content of neither abstracts nor actual reports supported the contention that there was a greater prevalence of drug use, drug-use-associated problems, or drug-use-enhancing attitudes in minority ethnocultural subgroups when compared to mainstream society (, d.f. = 3, n.s., and , d.f. = 2, n.s. respectively). Researchers need to be aware of possible implicit assumptions about the relation between ethnicity and addiction.

Do treatments and other interventions work? Some critical issues.

A variety of interventions, both therapeutic and preventive, have been used to control, reduce or eliminate substance use and misuse and their attendant problems. Yet, despite years of ever more sophisticated and expensive ways of responding to the use and misuse of a variety of legal and illegal substances, addiction continues to be experienced as a major social problem that plagues users, their families and communities, therapists and clinicians, policymakers, and the public. In view of a recidivist treatment population and finite resources, this paper considers whether and to what extent treatments and other interventions used for planned interventions with alcohol- and drug-use related problems work. It examines both clinical treatment outcomes and broad-based population prevention interventions, and reviews their underlying rationales. Finally, it identifies a number of areas that must be addressed if we are to improve the situation. These areas include a lack of agreement on what is meant by the problem of “addictions,” how successful interventions are to be defined and measured so that better interventions can be applied in the future, as well as integrating the processes of quality and appropriateness into the planning, implementation and assessment of effective, needed substance use intervention. [Translations are provided in the International Abstracts Section of this issue.]

Measuring Levels of Comorbidity in Drug User* Emergency Patients Treated in Ontario Hospitals

We examined the nature and extent of health problems in drug user patients initially treated in emergency departments and who were subsequently admitted to all hospitals in Ontario, using data from the Hospital Medical Records Institute (HMRI). The modified standardized morbidity ratio (modified SMR) is introduced to improve the measurement and visual display of reduced morbidity as well as excess morbidity. During 1985–86, about 75% of drug user patients entered hospital through the emergency department. There were 5077 emergency patients with primary drug use-related diagnoses and 9827 with secondary drug use-related diagnoses. Cases with poisoning diagnosis made up over 80% of all drug use cases treated in emergency departments. Cases with non-dependent abuse of drugs accounted for 8–12% of emergency drug user patients, whereas those with drug dependence accounted for about 3% of emergency drug user patients. These patients had more than three times the comorbidity experience of all hospital patients. They had excess comorbidity due to mental disorders, infectious and parasitic disorders, and injury and poisoning diagnoses. However, they had reduced comorbidity due to complications of pregnancy, childbirth, and the puerperium and from congenital anomalies and conditions originating in the perinatal period. Cocaine patients were more likely to have infectious parasitic diseases and diseases of the skin and subcutaneous tissue, while amphetamine patients were more likely to have diseases of the digestive system and of the musculo-skeletal system and connective tissue.

WHOSE NEEDS ARE TO BE MET? CUSTOMER SATISFACTION WITH DELIVERY OF TREATMENT SERVICES FOR HEROIN USERS

Studies like that of Fischer et al., whether intended or not, provide what marketing people call information on ‘‘customer satisfaction’’ with the delivery of treatment services for heroin users. Although such studies are done infrequently in the Canadian healthcare field, they are common in retail or other service industries, where a knowledge of consumer wants and needs leads to the development of improved services. This study provides a fascinating insight into the treatment wants of heroin users. However, it raises more questions than it answers. The first question it raises is ‘‘what is the point of interventions aimed at heroin users?’’ Do we intervene in order to cure, to control, or to punish? The dilemma is made manifest through the fact that addicts are dealt with through both the criminal justice and the medical systems, whose goals and methods sometimes overlap. Criminal justice has as its main official goals the punishment of offenders, the control of persons with antisocial behavior, and the reform of criminals into law-abiding persons. The medical system’s main formal goals are to effect a cure while also acting to maintain control

Is community-based treatment an add-on or a substitution for hospital treatment of alcoholism? Some evidence from Canada.

OBJECTIVES This study determined whether the development of community treatment of alcohol problems acted as an add-on or a substitution for the utilization of inpatient hospital services in Ontario. METHODS Complex modelling and graphic analyses using econometric multiple regression techniques were performed on data for the 48 counties of Ontario (Canada) for the period 1972 to 1988, combining both cross-sectional and time series analysis. RESULTS After controlling for differences in alcohol consumption, in health care characteristics such as the supply of physicians or hospital occupancy rates, and in socioeconomic characteristics of the population, when community treatment became available, hospital utilization for the treatment of alcohol problems decreased and community services were substituting for hospital treatment. In addition, nonresidential services had an overall greater importance in producing this effect (elasticities at the mean of -0.11 to -0.14 depending on the region) than community-based residential treatment. The effect was larger in the southern than in the northern counties of Ontario. Testing of the modelling techniques showed statistically significant and satisfactory modelling of the forces at work. CONCLUSIONS Where community-based treatment was available, it was used in preference to inpatient hospital treatment; however, there may be a slightly more complex relationship present in the southern urban counties (which contain the larger metropolitan areas) than in the northern and southern rural counties..

What Was Bad Is Now Good, and What Was Good Is Now Bad: Changes in Our Views and Images of Addiction and Addicts

In 1977, an elderly family member being treated for advanced cancer asked me to get him some marijuana. A conservative abstemious person, he was participating in an early stage clinical trial of an experimental treatment. Totally wretched with persistent nausea, unable to eat or swallow, he wanted marijuana because he had read in the newspaper that this was good for what ailed him. I was profoundly shocked. I was then head of the statistical research section at the Alcoholism and Drug Addiction Research Foundation of Ontario (ARF), then one of the world’s foremost addiction research organizations1. I thought I knew a lot about addiction2. Addiction was the term applied to the compulsive use of substances or the compulsive carrying out of selected behaviors (such as gambling, sex, porn, computers, exercise, shopping, gaming, etc.) that interfere with the ordinary conduct of normal everyday life. Physiological tolerance developed as the body became habituated and dependent on the substances (behaviors), and ever larger doses were needed to experience the same effect. Many addicted drug-deprived users developed unpleasant withdrawal symptoms, depending upon the drug they were using and the site of their use, that they sought to escape by continuing drug use. From a public policy viewpoint it was important to know:

A precursor to greater European integration of social and health policies

The Allamani and Voller’s article describes, in part, an ambitious European multinational project to delineate the European social, cultural, economic, and political context and its effects on preventive alcohol-consumption-control policies to reduce alcohol-consumption-related health and social problems. The results of this study are intended to identify the most efficient and cost-effective alcohol policy measures undertaken by European national and local governments, so as to improve the quality of alcoholconsumption-related prevention decision-making, and provide better recommendations to policy-makers and public health experts. The data for this study were selected because they are deemed to be operationalizable across countries. Data emanate from a dozen European countries and contain country-level data, as well as infranational and supranational data along with international agency data, the whole rendered comparable by using data parameters of the World Health Organization (WHO) and other United Nations (UN) agencies. A number of data elements are enumerated in the article along with noting the likely effect of each on alcohol use and use-associated health, social, and other problems. That each of these elements may have a different effect in each country and at different points in time is noted by the authors who are bravely not fazed by the complexity of coming up with universals from the particularities of timeand space-bound results. The overall goal of the project is admirable. Given the current economic crisis in much of the developed world, diminished fiscal resources are reallocated parsimoniously to reduced health and social programs. Alcohol-consumption-related programs are especially prone to such reductions. They are seen as being aimed at the “Other,” those marginalized populations (“drunks”) whose health and social problems are perceived as being self-inflicted. The person with an alcohol problem (“drunkard”) becomes the devalued victim of a victimless crime, a person whose problems stem from some inher-

Community-based facilities may be replacing hospitals for the treatment of alcoholism: the evidence from Ontario

We examined hospital utilization and use of community facilities for the treatment of alcohol problems in Ontario using Statistics Canada, Hospital Medical Records Institute records, and other administrative records. Between 1974 and 1986 there was a large drop in utilization of hospital services for treatment of alcohol problems. Rates of alcohol inpatient cases in general hospitals dropped by 47% and in mental hospitals by 33%. At the same time, there was an increase in overall availability of hospital beds and bed-days of care for all medical conditions, and no change in the total number of hospital discharges (1.3 million) and occupancy rates (80-85%). Also at the same time, the number of community-based programs for the treatment of alcohol problems increased, as did the number of persons or cases treated by them. This was associated with a drop of inpatient cases treated for alcohol problems in 38 out of 48 counties in Ontario (P < .0005). Multiple regression techniques were used to take into account the effect of the slight decline in overall alcohol consumption in this period. We found that after controlling for changes in alcohol consumption, the addition of one community-based alcohol treatment program was associated with a reduction in the number of cases treated on a hospital inpatient basis for alcohol-related problems, with a short-run drop of 27.1 hospital cases within 1 year of a community facilitys availability and a long-run reduction of 52.2 cases. (P < .005).