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105
NORDIC STUDIES ON ALCOHOL AND DRUGS V OL . 28. 201 1 . 2
HANS OLAV MELBERG & PEKKA HAKKARAINEN & ESBEN HOUBORG &
MARKE JÄÄSKE LÄINEN & ASTRID SKRETTING & MATS RAMSTEDT & PIA ROSENQVIST
Measuring the harm of illicit drug use on
friends and family
ABSTRACT
AIMS – This paper explores different approaches to quantify the human costs related to drug use.
DATA AND METHODS – The data come from a representative survey of 3092 respondents above the
age of 18 in four Nordic capitals: Copenhagen, Helsinki, Oslo and Stockholm. RESULTS – The results
show that in most Nordic capitals more than half of the respondents at some time have known and
worried about the drug use of somebody they know personally. Moreover, while the average reported
harm was about 2 on a scale from 0 to 10, a significant minority (10%) of those knowing drug users
indicated that the harm was above 5. CONCLUSIONS – Many persons have at some time personally
known somebody who uses drugs. This causes significant human harm and should be included in the
estimate of the social cost of illegal drugs. These results are relevant in the debate on the size of the
drug problem as well as for targeting groups that experience the highest costs.
Introduction
Mark Kleiman (1999) has argued that the
standard method of estimating the eco-
nomic cost of illicit drugs ”ignores the
profound day-to-day harm living with
addiction imposes on addicts and their
intim ates.” To illustrate the importance of
this he employed a back-of-the envelope
analysis, which suggested that including
human harm would increase the estimat-
ed cost of drugs in the study presented in
Harwood et al. (1998) by more than 80%.
This estimate assumes that the drug user,
family and friends together are willing to
pay 10 000 USD for a year’s remission.
The purpose of this article is to follow up
on Kleiman’s suggestion about designing
Submitted Initial 02.07.2010 Review completed 06.10.2010 Final version accepted 11.03.2011
Research report
measures of harm that are wide enough
to include not only economic harm, but
also what we define as human harm i.e.
the emotional pain and suffering inflicted
on friends and relatives by the consump-
tion of illegal drugs. We do so, by using
the results from a large survey in the Nor-
dic capitals in which we explore different
ways of estimating how many individuals
are affected, in what ways, and the extent
to which drug use among friends and fam-
ily affects them.
The quantification of human harm is im-
portant in itself, but it also has important
policy implications. The immediate con-
sequence of leaving out human harm is to
Acknowledgement: The authors wish to thank the editor and the two anonymous referees for
important and constructive comments.
DOI: 10.2478/v10199-011-0012-5
N A D
N A D
106 NORDIC STUDIES ON ALCOHOL AND DRUGS VO L. 2 8. 2011 . 2
a monetary value on something, they tend
to give answers that reflect an underlying
opinion more than a true quantification
(”Drug treatment is a good thing, I will
support it”) or an answer that is largely
influenced by random factors. These prob-
lems imply that in addition to asking about
monetary valuations, one should also ex-
plore quantifications which may be easier
for respondents to understand.
There is also a relevant literature on
measuring harm in general and using
harm reduction as a policy goal (Nutt et al.
2010). This research has stimulated sever-
al attempts to create a harm index such as
the UK Drug Harm Index, the Australian
Drug Harm Index and New Zeeland Drug
Harm Index (Ritter 2007; MacDonald et
al. 2005; McFadden 2006). These indices
quantify some of the human harm associ-
ated with drugs, but with the exception
of Nutt et al. (2010) they do not include
harm experienced by family and friends of
drug users. For instance, the authors be-
hind the UK Drug Harm Index explicitly
stated, ”it does not capture all the harms
that illegal drug use generates, but rather a
subset of harms for which robust data (or
information) are available” (MacDonald et
al. 2005). This leaves the research commu-
nity with a challenge: Is it possible to de-
velop measurement methods that include
emotional pain and suffering related to il-
licit drug use?
Design and method
In order to quantify the human harm on
friends and relatives of drug users, it is
first necessary to determine how many are
affected. Second, we need to know in what
ways they are harmed. The third and most
difficult challenge is to convert the various
underestimate the cost of drugs use. Stud-
ies of the social cost of drugs often quan-
tify costs born by society at large – health
costs, crime costs, lost income – but not the
human consequences felt by those who are
close to the user (See, for instance, French
& Martin 1996; Single et al. 1998; Culyer
et al. 2002). This underestimation may
in turn lead to under-prioritization of the
drug area as a whole. Moreover, if the suc-
cess of a policy is measured by its ability
to reduce the costs associated with drugs,
then leaving out important cost categories
will lead to skewed policies. We will get
policies aimed at indicators that happen to
be easily available, instead of policies that
focus on the overall problem. For both of
these reasons, to avoid under-prioritization
and misguided policy aims, it is important
to gain a better understanding of the hu-
man harm associated with drug use.
Previous empirical research on the hu-
man harm related to illicit drug use is
sparse. There is a related literature on the
empirical and conceptual problems of
the cost-of-illness approach (Reuter 1999;
Moore & Caulkins 2006; Melberg 2010),
but the literature on the human harm of
drug use is small. A key reference is Zar-
kin et al. (2000) who present a pilot survey
that quantifies society’s willingness to pay
for treatment of drug users. On average
people indicated that they were willing to
pay 37 USD for a program that successfully
treated 100 drug addicts. They also found
that the willingness to pay for treatment
did not change when the number of suc-
cessfully treated addicts in the proposed
program increased from 100 to 500. This
reveals a common problem facing such
studies. Many people have not thought
about the problem and when asked to put
107
NORDIC STUDIES ON ALCOHOL AND DRUGS V OL . 28. 201 1 . 2
harms into a single unit so it can be ag-
gregated and provide an indication of total
harm, which may, but does not need to be
measured monetarily.
The questions were designed to test
several different ways of measuring harm.
Given the problems associated with direct
monetary questions used in different types
of contingent valuation studies (Klose
1999; Diener et al. 1998; Smith 2003), we
decided not to focus exclusively on meas-
uring harm in monetary values but also to
explore three different quantifications of
harms. First, after determining how many
people were affected, we asked about the
prevalence of specific types of harm such
as fear of violence, having to call the police
and seeking professional help. Second,
moving one step closer to measuring ag-
gregate harm, we also asked the respond-
ents to indicate how much they had been
affected on a scale from 0 (no negative im-
pact) to 10 (my life has been destroyed). In
these questions the respondents gave an-
swers both in terms of life experiences as
well as during the past 12 months.
In order to better interpret the reported
harm we asked the respondents to compare
drug addiction to several other illnesses or
events such as being paralyzed, becoming
blind, or suffer a severe burn injury. Fi-
nally, we also asked about monetary valu-
ation. In these questions we distinguished
between willingness to pay in general and
willingness to pay for a friend or relative.
In this way the survey was designed to ex-
plore different methods, to compare the
consistency of the answers and to explore
which method seemed to generate the
most valid and reliable answers.
Before completing the survey each re-
spondent was informed about the aim of
the study as well as the definition of key
phrases. Of special importance is the
phrase ”a drug user you personally know.”
This was explicitly defined in the instruc-
tions as ”a person who is close to you, a
relative or a friend, or a person you at least
know the name of and have talked to.” The
aim of this design was to avoid exaggerat-
ing the share of the populations that was
affected as well as making sure that the re-
spondents interpreted the question in the
same way.
In addition to standard cross-tables and
figures, we used hurdle regression mod-
els to analyse to what extent gender, age,
education, and nationality could explain
the observed differences in reported harm
(Jones 2007). Some answers contained re-
sponses that seemed to reflect misunder-
standings or unwillingness to confront the
difficult choices presented in the ques-
tions. For instance, a few respondents re-
ported a willingness to pay more than 999
million Norwegian krone (more than 100
million euro). The survey format required
a response before progressing to the next
question, which may have encouraged
some respondents to enter a very large
sum in order to indicate either a refusal
to answer, or more likely, to express an
infinite value – that no amount of money
would be too high. These extreme observa-
tions imply that taking averages could be
very misleading. We addressed this prob-
lem by focusing on median values in the
questions discussing monetary values.
The results in this paper are based on a
representative survey of 3092 respondents
above age 18 in four Nordic capitals: Co-
penhagen, Helsinki, Oslo and Stockholm.
The survey consisted of 34 questions and
was conducted by the opinion research
108 NORDIC STUDIES ON ALCOHOL AND DRUGS VO L. 2 8. 2011 . 2
company Synovate, which maintains a
survey panel of a representative sample of
the population. Members of this panel re-
ceived an e-mail invitation to participate
in the survey. The respondents responded
anonymously using a web-based interface.
Web-based surveys raise the possibility
of selection bias (Couper 2000), but it has
also been shown that web-surveys based
on pre-selected panels perform well com-
pared to telephone surveys (Braunsberger
et al. 2007).
As seen in Table 1 the samples differ from
the whole country or capitals with respect
to the level of education of the population.
More than half of our respondents had
completed a university degree. Men and
women seem to be accurately represented
and the average age is also fairly repre-
sentative considering that the survey only
targeted the population above age 18.
Although the participants were recruit-
ed from a representative panel, there is
still the quite likely possibility that those
who were more interested in the topic
of drugs than the average panel member
agreed to participate. However, more than
50% of those who were invited accepted
and responded. This means that although
there may be some selection effects, the re-
spondents do not represent a small minor-
ity of the representative panel.
How many are affected?
In Copenhagen, Oslo and Stockholm more
than half of the respondents had at some
point in their lives been concerned about
the drug use of somebody they knew per-
Table 1. The gender composition, average age and education of the sample compared to the
general population*
City Percentage female Average age Percentage with education
above high school
(university or polytechnic)
Sample Capital Country Sample Capital** Country Sample Country
Denmark 54 51 51 40 n/a 40 63 47
Finland 52 53 51 44 40 41 53 44
Norway 51 50 50 44 45 39 62 45
Sweden 50 50 49 44 43 41 53 54
* Sources: Organization for Economic Cooperation and Development (OECD) and The Nordic national statistical
databases. Information about educational level in the capital was available for the sample and the country, not
the capitals.
** In Norway and Sweden the average age in the capital relates to the population above 18 only.
Table 2. ”Have you ever felt worried about the drug use of a person you know personally?” and
”Do you personally know somebody who has been treated for addiction to illegal drugs?”
Yes, know & worried Yes, know treated
Life 12 Life 12
Copenhagen 67 % 27 % 38 % 10 %
Helsinki 45 % 13 % 38 % 14 %
Oslo 61 % 22 % 49 % 14 %
Stockholm 56 % 28 % 54 % 18 %
109
NORDIC STUDIES ON ALCOHOL AND DRUGS V OL . 28. 201 1 . 2
sonally (see Table 2). In Helsinki the share
of such persons was 45%. The share of
respondents worried within the past 12
months was over 20% for Copenhagen,
Oslo and Stockholm, and 13% for Helsinki.
A large share of the population, a majority
in Stockholm and more than one third in
other capital cities, personally knew some-
body who had been treated for addiction to
illegal drugs. More than 10% reported that
they knew somebody who had received
treatment within the past 12 months.
These numbers indicate, first of all, that
drug problems are not isolated to a small
minority. In most capitals more than half
of the respondents had personally known
and been worried about somebody with a
drug problem. This is perhaps a better and
more easily understood measure of how
large the problem is, compared to an ab-
stract and inaccurate monetary estimate of
the social cost of drugs.
The second striking fact is that a sig-
nificantly smaller share of the Helsinki
population personally knows a drug user
with a worrisome consumption. If we are
to believe the numbers and take them as
indicators of the size of the drug problem,
this deviation needs an explanation. One
way of examining whether the pattern in
the table is accurate, is to compare the re-
sults with prevalence numbers (Table 3).
The survey results are mostly consistent
with drug use prevalence. Denmark has
both the highest drug prevalence as well
as the largest share of people who person-
ally know and feel concern for a drug user.
Finnish prevalence rates are significantly
lower than those in Denmark, but the dif-
ference between Finland and the other
Nordic countries in terms of lifetime can-
nabis prevalence is not very large and can-
not explain the differences in the share of
respondents who know and worry about
another person’s drug use. To do so, one
might focus more on the consumption
of hard drugs since this is often a cause
of more concern. In agreement with the
pattern of know/worry, the prevalence is
higher in Norway and Demark and lower
in Sweden and Finland. Thus, the general
direction of the answers is in agreement
with prevalence numbers, but size of the
difference between Finland and some of
the other countries is still large. A partial
explanation could be that the number of
heavy drug users has historically been
higher in Sweden than in Finland (Olsson
Table 3. Life time prevalence of drug use in the Nordic countries
Country Year Age range all
adults
Sample size
all adults
Cannabis Cocaine Amphetamines Ecstasy LSD
Denmark 2005 16–64 13310 36.5 % 4.0 % 6.9 % 1.8 % 1.7 %
Finland 2006 15–64 2802 14.3 % 1.1 % 2.2 % 1.6 % 1.1 %
Norway 2004 15–64 2669 16.2 % 2.7 % 3.6 % 1.8 % 1.1 %
Sweden 2000 16–64 1750 12.5 % 0.7 % 1.9 % 0.2 % 0.3 %
Source: EMCDDA (http://www.emcdda.europa.eu/stats08/gpstab1a)
110 NORDIC STUDIES ON ALCOHOL AND DRUGS VO L. 2 8. 2011 . 2
et al. 1997). Historically, drug use in Hel-
sinki was lower than in the other Nordic
capitals and only changed in the second
half of 1990s, a fact that may be reflected
in the lifetime figures of knowing and wor-
rying (Hakkarainen et al. 2007).
Affected in what way?
In all capitals more than 20% of respond-
ents answered that during their lifetime
they had experienced fear of violence from
a drug user they knew personally, with be-
tween 5% and 9% having experienced this
during the past 12 months (see Table 4).
Approximately 10% had sought profes-
sional help for themselves as a result of
their relationship with the drug user, and
3% had done so during the last year. With
the exception of Finland few had called
the police because of the illegal drug use
of somebody they knew personally – be-
tween 3% and 11% had ever done so and
between 1% and 3% had done so during
the last year.
One of the interesting facts about the
results in Table 4, is that despite having
the lowest prevalence and lowest share of
people who know and worry about a drug
user, Helsinki ranks highest on several in-
dicators on how severely affected those
who know drug users are. In Helsinki,
those who know drug users have a higher
fear of violence and a much higher tenden-
cy to call the police. This is internally con-
sistent in the sense that fear of violence is
expected to be correlated with contacting
the police. It is less obvious why the Hel-
sinki respondents should respond more
to this than the respondents in the other
capitals given that they know fewer drug
users. One possible explanation for this
could be that the less common drug use is,
the more frightening it is for those who are
close to a drug user. Moreover, the smaller
the group, the more marginalized they may
be. Denmark, for instance, has traditional-
ly de-mystified drug use and although the
prevalence numbers are high, they score
low in terms of how severely people are
affected. On the other hand, until the end
of the 1990s drug policy in Finland was
based mainly on police control, and it is
possible that people still relied on police
authorities as their first reaction (Tammi
2007). However, it is also possible that the
measured categories do not capture all of
the main dimensions of harm to others. A
broader measure of harm is addressed in
the next question, which encouraged the
respondents to reflect on the overall im-
pact they had experienced as a result of
knowing a drug user.
Table 4. ”Have you ever feared violence/sought professional help/called the police because of
the use of drugs among somebody you know personally?” (Percent of respondents answering
yes)
Feared violence Sought professional help Called police
Life Last 12 months Life Last 12 months Life Last 12 months
Copenhagen 21 5 8 2 3 1
Helsinki 30 9 12 4 11 3
Oslo 20 5 10 4 4 1
Stockholm 23 7 13 3 6 1
111
NORDIC STUDIES ON ALCOHOL AND DRUGS V OL . 28. 201 1 . 2
When those who knew drug users were
asked to what extent the drug use had af-
fected them on a scale from 0 (no harm)
to 10 (”it has ruined my life”), the aver-
age answer was between 2 and 2.6 in a
life perspective and slightly higher than
1 during the past year in all capitals (see
Table 5). This time the respondents in
Helsinki reported the lowest average, in-
dicating that this question captured the
different dimensions of harm better than
the one-dimensional questions about fear
of violence, calling the police and seeking
professional help.
A total score of 1 or 2 may not seem
like a large harm on a scale of 10, but the
average conceals a minority who report
higher harms. Figure 1 shows the share
of respondents who report a harm of 5 or
higher. In Copenhagen and Oslo more than
20% of those who have known drug us-
ers for a longer time reported a harm of 5
Table 5. ”If you know somebody who use drugs regularly, how
would you say it has it affected you on a scale from 0 to 10 (0 is ”no
negative effect” and 10 is “it has ruined my life”)
Life perspective Last 12
months
Expected (if friend
started to use)
Copenhagen 2,6 1,2 3,9
Helsinki 2,0 1,1 5,7
Oslo 2,6 1,4 6,1
Stockholm 2,5 1,2 6,2
6
0,0
5,0
10,0
15,0
20,0
25,0
Copenhagen Helsinki Oslo Stockholm
Whole life
Last 12 months
Figure 1. ì How has it affected you during the last 12 months?î Percentage responding with 5
or more on a scale where 0 is no negative effect and 10 is ì it has ruined my lifeî
Figure 1. ”How has it affected you during the last 12 months?” Percentage responding with 5
or more on a scale where 0 is no negative effect and 10 is ”it has ruined my life”
Percentages
112 NORDIC STUDIES ON ALCOHOL AND DRUGS VO L. 2 8. 2011 . 2
or higher. In Stockholm the corresponding
rate was close to 20%, while it in Helsinki
was about 15%. Even when limiting the
period to the past year, almost 10% re-
ported a harm of 5 or higher. This gives
some indication that although the aver-
age impact may be low, and most people
who know drug users are only moderately
affected, there is a significant minority –
about 10% – who report a harm of 5 or
higher on a scale from 0 to 10.
The answers about harm also contain a
significant gender imbalance. As illustrated
in Figure 2, females reported more negative
harm as a result of knowing drug users than
males. The tendency was the same in all
the capitals and it shows a gender dimen-
sion of human harm that estimates of social
costs often overlook. When using reported
harm as an indicator of drug problems, it
7
0,00
0,50
1,00
1,50
2,00
2,50
3,00
3,50
Male Female Male Female Male Female Male Female Male Female
Copenhagen Helsinki Oslo Stockholm Total
Figure 2. Gender differences in harm. If you know somebody who use drugs regularly, how
would you say it has it affected your life on a scale from 0 to 10 (0 is no negative
consequences and 10 is ì it has ruined my lifeî )
Figure 2. Gender differences in harm. If you know somebody who use drugs regularly, how
would you say it has it affected your life on a scale from 0 to 10 (0 is no negative consequences
and 10 is ”it has ruined my life”)
Levels of harms
Table 6. ”If you know somebody who uses drugs regularly, how would you say it has it affected
you on a scale from 0 to 10 (0 is ”no negative consequences” and 10 is ”it has ruined my
life”)
Life perspective Last 12 months
Close family member Other relations Close family member Other relations
Copenhagen 3.7 2.3 2.3 1.0
Helsinki 2.0 1.0 4.2 1.8
Oslo 3.6 2.4 2.4 1.2
Stockholm 3.8 2.2 2.2 1.0
113
NORDIC STUDIES ON ALCOHOL AND DRUGS V OL . 28. 201 1 . 2
is easy to identify groups that suffer more
than others and to quantify exactly how
much more they are affected.
Finally, the nature of the relationship
to the drug user is of great importance. As
expected, persons who have drug users as
close family members report on average
the highest levels of harms while those
with other acquaintances such as friends,
neighbours or colleagues report signifi-
cantly less harm (Table 6).
To measure the relative contribution of
the various factors that could influence
the amount of harm, we use multiple re-
gression. Since the dependent variable –
reported harm – is a count variable with
many zero values, ordinary least squares
may give misleading results and a hurdle
model is more appropriate. The first stage
is a logistic regression in which we investi-
gate the association between reporting any
harm at all and the independent variables.
The second stage consists of a regression
that measures the extent to which the vari-
ables can explain the size of the reported
harm. As shown in Table 7, being female,
on average, increased the probability of re-
porting harm from other’s drug use by 0.13
and being a close family member of the drug
user increased it by 0.19. Age and having a
university education were not important,
while the number of drug users known was
positively associated with increased harm.
The differences between the countries are
also evident in the regression results, with
”Living in Helsinki” leading to a score that
is lower on the subjective harm index com-
pared to the benchmark country (Sweden).
The regression results confirm that the pat-
terns found when examining one factor at
a time in a cross-table also hold when we
consider the factors collectively.
Table 7. Regression results, Factors associated with reporting of harm (during life-course)
Factors affecting whether harm is
reported (Logistic regression)
Factors affecting the extent of reported
harm (Poisson model)
Variable Coefficient
Standard
error
Marginal
effect Coefficient
Standard
error
Marginal
effect
Female 0.88 *** 0.14 0.13 0.30 *** 0.04 0.96
Age 0.04 0.03 0.01 0.00 0.01 0.01
Age squared 0.00 0.00 0.00 0.00 0.00 0.00
Tertiary education 0.04 0.14 0.01 0.01 0.04 0.05
How many drug users
they know (log) 0.23 *** 0.08 0.03 0.06 *** 0.02 0.19
Is the drug user a family
member? 1.02 *** 0.16 0.19 0.23 *** 0.04 0.79
Live in Oslo 0.15 0.18 0.02 0.04 0.05 0.12
Live in Copenhagen 0.18 0.18 0.03 0.02 0.05 0.06
Live in Helsinki -0.20 0.22 -0.03 -0.22 *** 0.07 -0.63
Constant -3.56 *** 0.72 0.72 *** 0.19
*** Statistically significant at the 1% level.
R-squared is 0.14
The results assume that the reported answers are valid and that the reported harm can be treated as a count
variable.
114 NORDIC STUDIES ON ALCOHOL AND DRUGS VO L. 2 8. 2011 . 2
In order to better understand the harms
reported on the harm scale the respond-
ents were also asked to rank some other
illnesses and situations on a scale from 0
to 10 (Figure 3). In this way one may find
a reference point for how bad a harm of 2
or 5 is interpreted to be. For instance, the
respondents indicated, with a harm score
of about 7.5 that for a young adult becom-
ing addicted to drugs was about as bad as
turning blind. Becoming paralyzed or get-
ting lymph cancer was ranked as slightly
worse than drug addiction while having
diabetes or asthma was given a value of
about half that of becoming a drug addict.
Although the numbers are interesting,
one needs to be careful when interpret-
ing these results. In addition to the un-
avoidable problem of how different people
interpret ”becoming addicted to drugs”,
”cancer” and so on, there is a problem
of determining the validity of the scores.
People who have not experienced some-
thing themselves often have misconcep-
tions about how bad or good something is.
This means that one should not simply use
the results to argue, ”becoming addicted to
drugs is about as bad as turning blind.” Or
that ”people reporting 4 on the harm scale
when asked about how they have been af-
fected by drug use among friends means
that they suffer a harm equivalent to get-
ting diabetes.”
The problem is well illustrated by com-
paring answers about experienced level of
harm among those who know drug users
to expected level of harm among those
who do not know drug users (Table 5).
Those who do not personally know a drug
user believe they would experience very
high levels of harm if they had a friend
who used drugs. The expected harm was
more than twice as large as the experi-
enced harm reported among those who ac-
tually knew a drug user. This shows that it
is difficult to use expected harm to assess
the actual level of harm. It also suggests
that an important part of the harm of drugs
is related to fear and that the fear itself
is not well founded. Finally, since fear is
reduced by experience and closeness, the
results imply that one important element
in the overall cost of drug use – social fear
– may fall if drug use becomes more com-
mon in a society.
The fact that there are several problems
with the ability of people to give answers
to the question of how much harm they
believe drug addiction or illnesses would
cause does not imply that the answers have
no meaning. If the answers were random,
we would not expect the pattern to vary
systematically. In fact, Figure 3 illustrates
that the answers about harm caused by
various illnesses and situations are similar
across countries. This is consistent with the
interpretation that the question captures a
stable perception and that the question of
experienced harm on a scale between 0
and 10 provides useful information.
The information could be useful, for
example, in providing an indication on
how drug use affects the quality of life for
relatives. This is a policy relevant mea-
sure since health officials sometimes use
quality adjusted life years as an aid when
allocating funds. Previous surveys have
reported that diabetes is associated with a
relative loss of between 12% and 20% on
a quality of life health scale from 0 to 1
(depending on age, see van Praag & Ferrer-
i-Carbonell 2001). Diabetes corresponds to
a harm of four in the survey in this paper.
If one extrapolates based on this, it implies
115
NORDIC STUDIES ON ALCOHOL AND DRUGS V OL . 28. 201 1 . 2
that those reporting harm of five or more
as a result of being close to an illicit drug
user, experience a harm that is higher than
having diabetes and that the loss can be
quantified as larger than 12% in terms of
life quality. This extrapolation is based
on only one disease and it assumes that
both conditions are measured accurately.
As noted above there are many practical
problems associated with this, but the ex-
ample still illustrates how reported harm
in principle can be transformed into Qual-
ity Adjusted Life Years which can be used
in policy formulation. Decisions about the
allocation of resources to drug treatment
could then be based on a more accurate
measurement of benefits which includes
the change in the quality of life of relatives
(Davidson & Levin 2010).
Harm measured in money?
Social costs are often measured in money.
Is it possible to quantify the harm suffered
by friends and family in monetary terms
in order to include it in the overall meas-
ure of the social cost of drugs? One way
of doing so would be to explore individu-
als’ willingness to pay for the treatment of
drug addicts, but the willingness to pay
is a problematic question (Smith 2003). It
is, for instance, difficult to know whether
the answers reveal a true willingness or if
they are influenced by the wording of the
question or if there are other mechanisms
that may distort the answer. In order to ex-
amine the effect of this, we asked several
questions. Firstly, we asked about willing-
ness to pay for a friend. Secondly, we asked
about willingness to pay for treatment for a
drug addict in general by way of increasing
taxes. Thirdly, we asked more open ended
10
0,00
1,00
2,00
3,00
4,00
5,00
6,00
7,00
8,00
9,00
10,00
Blind
Paralyzed
Diabetes
Death
Cancer
Drug addict
Asthma
Alcohol addict
Severe burn
Copenhagen
Helsinki
Oslo
Stockholm
Figure 3. On a scale from 0 to 10, how bad is the following for a young adult Ö
Figure 3. On a scale from 0 to 10, how bad is the following for a young adult
116 NORDIC STUDIES ON ALCOHOL AND DRUGS VO L. 2 8. 2011 . 2
questions in which the respondents could
state the amount of money they were will-
ing to pay for treatment of their children,
their spouses, and their friends.
The results in Figure 4, show that in Nor-
way and Denmark there was a small ma-
jority in favour of a tax increase of about
100 euro per taxpayer to finance the treat-
ment of 800 additional addicts each year,
while the corresponding rate in Sweden
and Finland was about 40%. When asked
whether they would contribute about 500
euro to help finance treatment for a friend,
the respondents gave slightly more ame-
nable answers in all countries, with the
exception of Sweden where there was a
significantly higher positive response (an
increase of 12 percentage points to 52%).
These questions reveal some of the same
problems and patterns discussed in Zar-
kin et al. (2000). Willingness to pay was
relatively insensitive to the sums used in
the question. For instance, 100 euro per
taxpayer for 800 treatments represent a
different willingness to pay for each treat-
ment in the different countries because
the sum is larger in the country with the
highest population. Despite this, there is
a high correspondence between the tax
question and the friend question (with the
exception of Sweden) and this suggests
that the answers reveal an underlying at-
titude of supporting more treatment rather
than a precise consideration of the costs
and benefits. This observed insensitivity
underlines the problems related to using
monetary measures when researching this
particular field.
The results concerning willingness to
pay for the treatment of individuals are
highly dependent on the nature of the rela-
tionships (see Table 8). There is also a large
11
0,0
10,0
20,0
30,0
40,0
50,0
60,0
Copenhagen Helsinki Oslo Stockholm
Agree to tax
Pay for friend
Figure 4. Willingness to accept tax increased to pay for more treatment vs. willingness to
contribute financially to the treatment of a friend
Figure 4. Willingness to accept tax increased to pay for more treatment vs. willingness to
contribute financially to the treatment of a friend
117
NORDIC STUDIES ON ALCOHOL AND DRUGS V OL . 28. 201 1 . 2
degree of variation between the respond-
ents, with some individuals reporting very
high sums. To avoid presenting averages
that are heavily influenced by a few ex-
treme observations, the table presents the
median response.
In all capitals the highest median will-
ingness to pay was observed for respond-
ents’ children, followed by spouses, sib-
lings and, lastly, friends. For friends and
siblings, the answers are very similar in
the different capitals with willingness to
pay for friends being about half of the will-
ingness to pay for siblings. In Helsinki, the
absolute willingness to pay for spouses
and children was substantially smaller
than in the other countries, but the relative
willingness to pay for children compared
to spouses was highest in Helsinki.
When interpreting the responses it is im-
portant to keep in mind that the respond-
ents were specifically asked about willing-
ness to pay for treatment as opposed to
”successful treatment” which was used
in Zarkin’s pilot study. This means that
the results can be interpreted as willing-
ness to pay for treatment in general, even
when the outcome is uncertain. It should
also be noted that willingness to pay for
treatment may be motivated by concerns
other than to reduce the harm on family
and friends. For this reason, adding it to
already estimated external costs may lead
to double-counting. The size of this prob-
lem depends on the wording of the ques-
tion. The more focused the question is on
close personal relationships, the more the
respondent is likely to focus on personal
harm as opposed to reducing crime in
society in general and other motives that
may inspire a willingness to pay for treat-
ment. Because of this, the questions about
willingness to pay for treatment in general
or to accept a tax increase should not be
interpreted as a measure of personal harm
alone. The questions about willingness
to pay for friends and family will capture
more of this personal aspect.
Human harm compared to other
cost categories
By combining the information in the vari-
ous questions it is possible to get a picture
of the human harm on friends and fam-
ily caused by drug use compared to other
costs commonly associated with drug use.
Using Kleiman’s (1999) suggestion about
measuring harm by the willingness of
friends to pay for treatment, we first ex-
amine the number of respondents who
have drug-using friends and are willing to
pay at least 450 euro for the treatment of a
friend. For instance, in Oslo 14% of the re-
spondents fulfilled these two conditions. If
14% of the adult population in Norway are
willing to pay at least 450 euro, this means
Table 8. ”About how much of your own money do you think you would be
willing to pay for the treatment of your own…” (median answers converted
to Euro)
Friend Brother/sister Child Spouse
Copenhagen 678 1 356 13 563 6 782
Helsinki 500 1 000 5 000 2 000
Oslo 575 1 149 11 494 5 747
Stockholm 505 1 009 7 569 5 046
118 NORDIC STUDIES ON ALCOHOL AND DRUGS VO L. 2 8. 2011 . 2
that human harm associated with drugs is
at least 236 million euro or about 50 euro
per capita. As a comparison, about 30%
of jail inmates in Norway are convicted
of drug offences and the cost of prison for
this group amounts to about 17 euro per
Norwegian each year. This illustrates that
human harm represents a large component
of the cost of drugs and that ignoring it can
produce misleading estimates.
Contrary to the conclusion above, one
might argue actual willingness to pay is
often lower than the reported willingness.
Moreover, the capital may have a dispro-
portionate number of drug users. Both
arguments are valid, but it should also be
noted that the estimate above is conserva-
tive for several reasons: Many of the re-
spondents reported that they were willing
to pay much more than the sum listed in
the question and used in the calculation
(450 euro), some have more than one friend
for whom they would be willing to pay,
the estimate does not include the much
higher willingness to pay for spouses and
children, and as shown in the tax question
many are willing to pay for treatment even
when they do not personally know people
who use drugs. Taking into account all of
these factors would most likely give larger
estimated burden. However, to establish
the importance of human harm compared
to other cost categories, it is not necessary
to make more complicated calculations.
Even when conservatively estimated, hu-
man harm in monetary units is larger than
the cost of prison, which is one of the oth-
er major cost components in traditional
analysis of social costs of drugs.
The experience with using monetary
questions was mixed. While the medians
and averages seemed to be quite stable
and similar in different countries, some re-
spondents were clearly unfamiliar and un-
comfortable with these questions. Approxi-
mately ten Norwegian respondents took a
very negative stand to the questions in the
open comments area of the survey. This
provides an important lesson of how one
should go about measuring human harm
in the future. Direct monetary questions
about valuation may give some results that
are useful on average or as a conservative
estimate using the most reliable answers,
but questions about harm on a scale from
0 to 10 do not create similar emotional re-
actions and provide more stable answers
that are even more easily interpreted.
Extensions and limitations
Illicit drug use is sometimes accompanied
by the use of other substances such as alco-
hol. In this case it is difficult to distinguish
between the harm caused by alcohol and
the harm caused by the illicit drug. This
is unavoidable given the nature of the
consumption pattern. The survey also did
not have an option in which respondents
could report that the drug use of a friend or
a relative had had an overall positive influ-
ence. At best the respondents could select
the option ”No negative impact” so to the
extent a positive impact was present, the
survey does not measure this. If drugs have
positive impacts, such as reduced level of
violence compared to the use of alcohol,
the survey did not capture this aspect. The
questions also specifically asked about
”regular” drug use, not about whether
the respondents knew individuals who
were addicted. In this sense the survey
measures the burden of drug use as felt by
friends and relatives, not the cost of addic-
tion. Finally the question about monetary
119
NORDIC STUDIES ON ALCOHOL AND DRUGS V OL . 28. 201 1 . 2
valuation could be improved by a more
detailed description of the nature of the
good (the extent to which treatment would
work and for how long) as well as distin-
guishing between several different types of
reasons for willingness to pay (see Smith
2007; 2008). This was avoided in the cur-
rent survey in order to keep it simple for
the respondents. For the same reasons the
survey did not distinguish between differ-
ent types of drugs. Future work in this area
could explore these extensions.
Conclusions
Our results show that it is important to in-
clude human harm to get a more accurate
picture of the overall cost of drugs in so-
ciety. Even very conservatively measured,
the cost of human harm among relatives
outweighs other large costs that are often
included when estimating the cost of drug
use, such as the prison cost for drug of-
fences. Ignoring human harm could lead to
underestimation of the total costs, which
in turn could result in under-prioritization
of drug-related problems. For example, the
results of the study suggest that there may
not be enough support services for fami-
lies and friends of drug users in the Nordic
societies.
The survey also indicates that it may
be more stable and useful not to measure
harm in monetary terms since respondents
often have difficulties answering these
questions. Instead, simple questions about
knowledge and harm on a 0–10 scale
seemed to give more meaningful answers.
These results show that every year about
25% of the population of the capital cities
know and worry about drug users and that
about 10% of those knowing drug users
report a harm of more than 5. Finally, the
results highlight the unequal distribution
of the costs. The main costs were not born
by the state or society at large, but by the
females who were close to the drug user.
Although the direction of this effect is
not surprising, the results still document
the surprisingly large difference between
harm reported by males and friends on the
one hand, and harm reported by females
and relatives on the other.
Declaration of interest None.
Hans Olav Melberg, researcher
SIRUS & University of Oslo, Norway
E-mail: hans.melberg@gmail.com
Pekka Hakkarainen, researcher
THL, Helsinki, Finland
E-mail: Pekka.hakkarainen@thl.fi
Esben Houborg, researcher
Center for alcohol and drug research
Aarhus University, Denmark
E-mail: eh@crf.au.dk
Marke Jääskeläinen, researcher
THL, Helsinki, Finland
E-mail: marke.jaaskelainen@thl.fi
Astrid Skretting, researcher
SIRUS, Oslo, Norway
E-mail: as@sirus.no
Mats Ramstedt, researcher
SoRAD, Stockholm University
Stockholm, Sweden
E-mail: mats.ramstedt@sorad.su.se
Pia Rosenqvist, head of unit
Nordic Center for Welfare and Social Issues
Helsinki, Finland
E-mail: pia.rosenqvist@nordicwelfare.org
120 NORDIC STUDIES ON ALCOHOL AND DRUGS VO L. 2 8. 2011 . 2
REFERENCES
Braunsberger, K. & Wybenga, H. & Gates, R.
(2007): A comparison of reliability between
telephone and web-based surveys, Journal
of Business Research 60: 758–764
Couper, M.P. (2000): Web Surveys: A review
of issues and approaches, Public Opinion
Quarterly 64: 464–494
Culyer, A. & Eaton, G. & Godfrey, C. & Kou-
stolioutsos, H. & McDougall, C. (2002):
Economics & Social cost of substance
misuse in the United Kingdom: Review of
the methodological and empirical studies
of the economic and social costs of illicit
drugs. York, University of York, Centre for
Criminal Justice, Economics, and Psycho-
logy
Davidson, T. & Levin, L-Å. (2010): Is the
Societal Approach Wide Enough to Include
Relatives? Incorporating Relatives’ Costs
and Effects in a Cost-Effectiveness Analy-
sis, Applied Health Economics & Health
Policy 8 (1): 25–35
Diener, A. & O’Brien, B. & Gafni, A. (1998):
Health care contingent valuation studies: A
review and classification of the literature,
Health Economics 7 (4): 313–326
French, M.T.P. & Martin, R.B.B. (1996): The
Costs of Drugs Abuse Consequences: A
summary of Research Findings. Journal of
Substance Abuse Treatment 13: 453–466
Hakkarainen, P. & Tigerstedt, C. & Tammi, T.
(2007): Dual-track drug policy: Normaliza-
tion of the drug problem in Finland. Drugs:
education, prevention and policy 14:
543–558
Harwood, H. & Fountain, D. & Livermore, G.
(1998): The Economic Cost of Alcohol and
Drug Abuse in the United States, 1992.
National Institute on Drug Abuse and the
National Institute on Alcohol Abuse and
Alcoholism, National Institute on Health,
U.S. Department of Health and Human
Services. NIH Pub. No. 98-4327. Rockville.
MD: National Institute on Drug Abuse
Jones, A. (2007): Applied Econometrics for
Health Economists: A Practical Guide,
Radcliffe Publishing
Kleiman, M.A.R. (1999): Economic cost’
measurements, damage minimization and
drug abuse control policy, Addiction 94 (5):
638–641
Klose, T. (1999): The contingent valuation
method in health care, Health Policy 47 (2):
97–123
MacDonald, Z. & Tinsley, L. & Collingwood, J.
& Jamieson, P. & Pudney, S. (2005): Measur-
ing the harm from illegal drugs using the
drug harm index. United Kingdom Home
Office. Available: http://www.homeoffice.
gov.uk/rds/pdfs05/rdsolr2405.pdf
McFadden, M. (2006): The Australian Federal
Police drug harm index: A new methodo-
logy for quantifying success in combating
drug use. Australian Journal of Public
Administration 65: 68–81
Melberg, H.O. (2010): Conceptual problems
with studies of the social cost of alcohol
and drug use. Nordic Studies on Alcohol
and Drugs 27 (4): 287–304
Moore, T.J. & Caulkins, J.P. (2006): How cost-
of-illness studies can be made more useful
for illicit drug policy analysis. Applied
Health Economics and Health Policy 5 (2):
75–85
Nutt, D.J. & King, L.A. Phillips, L.D. (2010):
Drug Harms in the UK: A multicirteria de-
cision analysis. The Lancet 376:1558-65
Olsson, B. & Stymme, A. & Hakkarainen, P.
& Schmidt, D. & Skretting, A. & Valsson,
K. (1997): The Nordic drug scene in the
1990s – Recent trends. Nordisk alkohol- &
narkotikatidskrift 14 (English Supplement):
64–82
Praag, B. & Ferrer-i-Carbonell, A. (2001): Age-
differentiated QALY losses, IZA Discussion
Paper no 314, Bonn, Germany
Ritter, A. (2007): Comparing Alcohol Policies
Between Countries: Science or Silliness?
PLoS Medicine 4 (4): e153. doi:10.1371/
journal.pmed.0040153
Reuter, P. (1999): Are calculations of the eco-
nomic costs of drug abuse either possible or
useful? Addiction 94: 635–638
Single, E. & Robson, L. & Xie, X. & Rehm, J.
(1998): The Economic costs of alcohol,
tobacco, and illicit drugs in Canada, 1992.
Addiction 93: 991–1006
Smith, R. (2003): Construction of the con-
121
NORDIC STUDIES ON ALCOHOL AND DRUGS V OL . 28. 201 1 . 2
tingent valuation market in health care: a
critical assessment. Health Economics 12:
609–628
Smith, R. (2007): Use, option and externality
values: are contingent valuation studies in
health care mis-specified? Health Econom-
ics 16: 861–869
Smith, R. (2008): Contingent valuation in
health care: does it matter how the ‘good’
is described? Health Economics 17 (5):
607–617
Tammi, T. (2007): Medicalising prohibition.
Harm reduction in Finnish and interna-
tional drug policy. Helsinki: Stakes
Zarkin, G.A. & Cates, S.C. & Bala M.V. (2000):
Estimating the willingness to pay for drug
abuse treatment: a pilot study. Journal of
substance abuse treatment 18 (2):149–159.
