Abstinence — a dirty word?
It has been for a very long time. Perhaps thousands of years and particularly so in certain centuries and certain places. Also it can depend upon how much scientific research has been done on the particular substance or behaviour.
Research:
When I started work in the Alcohol and other Drug field in the mid-1970s, we had a leaflet (I think I still have a copy) that said:
8 drinks a day was high risk drinking (ie 56 drinks per week);
12 drinks a day was tissue damage drinking (ie 84 drinks per week);
no mention of the difference between males and females; and over the years, the media has continued to report,
2 drinks of red wine a day as good for your heart (though I always wondered why 2 drinks of white wine did not do the trick).
It was explained to me that because there was a direct link (straight correlation) between number of cigarettes and the increase in health problems, that abstinence from all cigarettes was justified. But not so for alcohol, because of the blip at 2 drinks a day.
Fifty years later, with so much more research, the World Health Organisation states unequivocally that there is "no safe level of alcohol use".
Also that 84 drinks a week has come down by 70 drinks to only 14 drinks per week!
With no more than 4 drinks in one setting, which means doing so, would require one day alcohol free for each set of 4 drinks; women with lighter body mass and proportionally more fat, fewer drinks and so on.
Different cultures
In particular, the Muslim world recognised the physical health and other consequences of alcohol use, deciding it was not a safe drug at all.
It is important to remember that religions have played a major role in public (health) education until relatively recently and still do in many parts of the world. It may well be that abstinence position was arrived at - not by some 'divine voice' - but by careful observations over a long period of time - an important component of scientific method.
The Western World did not take that path. However, if we were to logically classify drugs strictly on their potential for harm, we would find it very hard to justify even getting alcohol on prescription, as it is a Group 1 Carcinogen.
Social Norms
It would appear that alcohol produced from fermentation could have started as long as 13,000 years ago. This alcohol was mostly what we would classify as beer of various alcoholic strengths, whilst distilled spirits did not become available until much later.
At what point, social norms developed around the use of alcohol, in what century and contexts is too complex for me to say definitively.
However, my belief is that when people drank stronger concentrations of alcohol (strong beers to distilled spirits) together in groups, it was the person who abstained or who drank this least, who was the person most in control of their facilities. As such, the abstainer was the most threat. That person could wait until the others were too inebriated to fight back, and then slit their throats and take their purses, or have some other advantage over them like being able to rape or physically assault them. Likewise the person who could remember other people’s bad behaviour, and not indulge themselves, had a greater advantage for better social standing or even to blackmail others.
The reverse is also likely to be true. A person drinking alone was much more likely to be compromised, taken advantage of and/or harmed by people who had not been drinking,
All of which means that the “abstainer” was untrustworthy and to be greatly feared, and alcohol more safely used in a group setting ie there is something wrong with people who drink alone.
Add religion - some of which labelled basic human drives (e.g sex) as “bad” as tools for manipulation and control - to these two social norms, and we have a huge moral overlay that greatly negatively influences our perceptions of “abstinence from alcohol”.
Such cultural beliefs can operate almost unconsciously, and the longer they have been around the more likely the more difficult to address. Given nicotine was only introduced in Europe in the mid sixteenth century, it has been perhaps more easy for us to accept an abstinence approach.
From a treatment perspective though, recommending abstinence from alcohol is no more radical than recommending abstinence from nicotine, and using a variety of strategies to support that treatment goal sensible and important.
Given nicotine addicts in Australia are increasing living in a society that sees smoking as not-OK, one could argue that alcohol addicts need far more support over a longer term of time to achieve abstinence.
Harm Minimisation vs Abstinence OR Abstinence as part of Harm Minimisation.
I was working in the field when NSW introduced random breath testing in the early 1980s.
The latter highlighted for me the “harm minimisation” approach to drink-driving. Prior to RBT, I and other Alcoholism Counsellors had run 6 weekly sessions for people convicted of DUIs (Driving Under the Influence). Our participants were being studied, I believe, though that was not discussed with us.
However, that and other research like it, found that the factor most likely to affect whether people drank alcohol and drove was their perception of getting caught!
True for occasional drinkers, so-called heavy drinkers and alcoholics (people with alcohol use disorder) alike!
Thus our courses may have been successful in reducing the participants’ alcohol use or becoming abstinent - but that was not the stated goals and so not studied (again as I understand it) - but unlikely to have really affected their drinking and driving behaviour.
Thus the randomness of the RBT units.
Harm minimisation brought more clarity into what we were doing and why. Harm minimisation broadened the perspective and really forced us to ask a series of really important questions.
Are we concerned with prevention, early intervention or treatment?
What drug, used by what target group, in what context, by what harm? by what negative consequences could be associated with the intervention.
It brought that perspective for me looking at the issue of Prohibition in America. From a health harm minimisation objective, Prohibition was very successful. The overall level of health problems due to alcohol, reduced significantly (even to the reduction of the number of babies smothered by intoxicated mothers). However, the criminalisation of drinking introduced problems associated with making the drug illegal, and what lead to the end of Prohibition in 1933. That is why today we understand there are not simple fixes to drug problems - just legalise or just ban - one has to balance the strategy to reduce harm, with the possible negative consequences.
How does all this affect our approach to “abstinence"
Bringing this clarity means “abstinence" is a “harm minimisation” strategy.
For nicotine addicts - as a treatment strategy, abstinence is the harm minimisation strategy.
Labelling of nicotine products, increasing the tax on their price in significant amounts, banning smoking in certain settings (both for the passive smoker as well as the smoker themselves) as well as being clear about an abstinence goal are useful strategies for prevention and early intervention.
Likewise we can bring this clarity to the treatment of alcoholics (alcohol addicts/ people with alcohol use disorder), as we do for smokers, abstinence is the harm minimisation strategy.
Ro Goold
PS And there are moves afoot to bring “Harm to health” labels to alcoholic beverages in Ireland and USA, similar to nicotine labeling :-)
