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Reframing the science and policy of nicotine, illegal drugs and alcohol – conclusions of the ALICE RAP Project

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DOI: 10.12688/f1000research.10860.1
In 2013, illegal drug use was responsible for 1.8% of years of life lost in the European Union, alcohol was responsible for 8.2% and tobacco for 18.2%, imposing economic burdens in excess of 2.5% of GDP. No single European country has optimal governance structures for reducing the harm done by nicotine, illegal drugs and alcohol, and existing ones are poorly designed, fragmented, and sometimes cause harm. Reporting the main science and policy conclusions of a transdisciplinary five-year analysis of the place of addictions in Europe, researchers from 67 scientific institutions addressed these problems by reframing an understanding of addictions. A new paradigm needs to account for evolutionary evidence which suggests that humans are biologically predisposed to seek out drugs, and that, today, individuals face availability of high drug doses, consequently increasing the risk of harm. New definitions need to acknowledge that the defining element of addictive drugs is ‘heavy use over time’, a concept that could replace the diagnostic artefact captured by the clinical term ‘substance use disorder’, thus opening the door for new substances to be considered such as sugar. Tools of quantitative risk assessment that recognize drugs as toxins could be further deployed to assess regulatory approaches to reducing harm. Re-designed governance of drugs requires embedding policy within a comprehensive societal well-being frame that encompasses a range of domains of well-being, including quality of life, material living conditions and sustainability over time; such a frame adds arguments to the inappropriateness of policies that criminalize individuals for using drugs and that continue to categorize certain drugs as illegal. A health footprint, modelled on the carbon footprint, and using quantitative measures such as years of life lost due to death or disability, could serve as the accountability tool that apportions responsibility for who and what causes drug-related harm.
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Reframing the science and policy of nicotine, illegal drugs and
alcohol – conclusions of the ALICE RAP Project [version 1;
referees: awaiting peer review]
PeterAnderson , VirginiaBerridge , PatriciaConrod , RobertDudley ,
MatildaHellman , DirkLachenmeier , AnneLingford-Hughes , DavidMiller ,
JürgenRehm , RobinRoom , LauraSchmidt , RogerSullivan ,
TamykoYsa , AntoniGual20,21
1-3 4 5 6
7,8 9,10 11 12
3,9,13,14 15,16 17 18
19 20,21
Referee Status: AWAITING PEER
17Mar2017, :289(doi: )First published: 6 10.12688/f1000research.10860.1
17Mar2017, :289(doi: )Latest published: 6 10.12688/f1000research.10860.1
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F1000Research 2017, 6:289 Last updated: 17 MAR 2017
PeterAnderson( )Corresponding author:
AndersonP,BerridgeV,ConrodP How to cite this article: et al. Reframing the science and policy of nicotine, illegal drugs and alcohol –
2017, :289(doi:conclusions of the ALICE RAP Project [version 1; referees: awaiting peer review] F1000Research 6
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TheresearchleadingtothebasisofthispaperhasreceivedfundingfromtheEuropeanCommission'sSeventhFrameworkGrant information:
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Competing interests: PAandAGcoordinatedtheALICERAPproject.VB,PC,MH,DWL,AL-H,DM,JR,RR,LS,andTYundertookvarious
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A consortium of 67 scientific institutions from 24 European coun-
tries and beyond, covering over thirty scientific disciplines rang-
ing from anthropology to toxicology, responded to an invitation
by the European Commission to study the place of addictions in
contemporary European society. The resulting five-year endeavour,
the Addictions and Lifestyles in Contemporary Europe - Reframing
Addictions Project (ALICE RAP,, went beyond
this. It reframed our understanding of addictions and formulated a
blueprint for re-designing the governance of addictions. This paper
summarizes the project’s conclusions, pointing to new understand-
ings of the science and policy of nicotine, illegal drugs and alcohol,
hereafter collectively referred to as ‘drugs’16. Although this paper
does not cover process addictions (e.g., gambling3), much of what
is said applies to addictions beyond drugs.
The paper starts by discussing why we need to re-think addictions.
It contrasts two powerful pieces of evidence: the harm done by
drugs, versus the poorly structured existing governance approaches
designed to manage such harm. The paper continues by consider-
ing three bases for re-thinking the addiction concept in ways that
could lead to improved strategies across different jurisdictions: rec-
ognition that there is a biological predisposition for people to seek
out and ingest drugs; that heavy use over time becomes a replace-
ment concept and descriptor for the term substance use disorder;
and that quantitative risk assessment can be used to standardize
harm across different drugs, based on drug potency and expo-
sure. The paper finishes by proposing two approaches that could
strengthen addictions governance: embedding governance within a
well-being frame, and adopting an accountability system—a health
footprint that apportions responsibility for who and what causes
drug-related harm.
Why do we need to re-think addictions?
The need to re-think addictions is exemplified by the extent of
harm caused by the drugs themselves, and by the fact that no single
country, at least in Europe, has fully overcome poorly managed and
fragmented governance structures.
Harm done by drugs
A standard way to document and describe the interference that
drugs have on human biology and functioning is to use years of
life lost to premature mortality (YLL) and disability adjusted life
years (DALYs). DALYs are a measure of health that sum up YLL
and years or life lost due to disability and detriments in functioning
(YLD). In 2013, illegal drug use was responsible for 1.8% of YLL
in the European Union (EU), alcohol was responsible for 8.2% and
tobacco for 18.2% (Table 1), imposing economic burdens in excess
of 2.5% of GDP7.
The data in Table 1 represents harm to the drug user. However, drug
use also harms the health of others. For instance, operating machin-
ery under the impact of illegal drugs can cause injury to others8,9.
Although decreasing globally, second-hand smoking was estimated
to kill more than 330 thousand people worldwide in 2013, and
caused about 7% of the burden of disease in DALYs attributable to
tobacco smoking10. The extent of harm to others caused by alcohol
consumption is estimated to be proportionally even larger, mainly
due to traffic accidents, violence, including homicide, and foetal
alcohol spectrum disorders11.
Dataset 1. Source data underlying the results presented in Table 1
The data was based on the IHME Global burden of diseases,
injuries and risk factors study (
Fragmented governance structures
Governance is defined as the processes and structures of public
policy decision making and management that engage people across
the boundaries of public agencies, levels of government, and public,
private and civic spheres to carry out a public purpose that cannot be
Table 1. Burden of disease caused by drug exposure in the European Union (EU) in 2013.
Source: own calculations based on IHME Global burden of diseases, injuries and risk factors study
Risk factor Sex YLLs in
YLLs per
% of all
in 1,000
DALYs per
% of all
Illegal drug use Men 1,069.8 428.5 2.5% 1,749.2 700.7 2.3%
Women 292.7 111.9 0.9% 580.5 222.0 0.8%
Total 1,362.5 266.6 1.8% 2,329.7 455.8 1.6%
Alcohol use Men 4,558.7 1,826.1 10.4% 5,981.4 2,396.0 7.9%
Women 1,584.0 605.8 5.1% 2,019.8 772.5 2.9%
Total 6,142.8 1,201.9 8.2% 8,001.2 1,565.5 5.5%
Tobacco use Men 10,036.4 4,020.3 23.0% 11,280.0 4,518.5 14.9%
Women 3,552.2 1,358.6 11.5% 4,405.0 1,684.7 6.4%
Total 13,588.6 2,658.6 18.2% 15,685.0 3,068.8 10.9%
YLL: Years of life lost due to premature mortality
DALYs: Disability adjusted life years
Source data available in Dataset 1102.
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F1000Research 2017, 6:289 Last updated: 17 MAR 2017
accomplished by any one sector alone12. The involvement of mul-
tiple stakeholders in governance is not without risk. The exclusive
use of top-down bureaucratic approaches cannot maximize societal
benefits when dealing with ‘wicked problems’ that are highly resist-
ant to resolution13 (for definition of wicked problems, see ‘The New
Governance of Addictive Substances and Behaviours by Anderson
et al6). An analysis of 28 European countries found that no sin-
gle country had a comprehensive policy for all drugs (including
nicotine, illegal drugs and alcohol) within a broad societal well-
being approach. For more detail, see ‘Governance of Addictions:
European Public Policies’, by Albareda A et al1.
There are at least three reasons for ineffective and poorly inte-
grated governance. Firstly, the same harm done by drugs is defined
and understood in different ways in different countries and state
systems1416. Seen from a trans-national comparative perspective,
there is a lack of a common understanding of appropriate poli-
cies, and responses are often constrained by approaches that are
tied to assumptions that are not evidence-based4. Ways of thinking
about the harm done by drugs vary enormously, with considerable
heterogeneity between different drugs, and between international,
national and local levels of governance. For detail, see ‘Concepts
of Addictive Substances and Behaviours across Time and Place, by
Hellman et al4.
Secondly, a multitude of commercial, political and public stake-
holders are active in addictions governance on national and
international levels. In any given society, stakeholders that have
power, means and influence are likely to achieve an advantageous
influential position. The concepts of addiction are also shaped
by popular constructs promulgated by the mass media and cus-
toms in the general population. Stakeholder positions and percep-
tions of drug problems also vary over time and by area4, implying
that sustainable approaches must be interwoven into societal and
governance structures.
Thirdly, corporate power17, through multiple channels of influence,
can hinder evidence-based policy decisions5. Corporate strategies
often include attempts to influence civil society, science and the
media, as part of a wider aim to manage and, if possible, capture
institutions that set policy. Transparency is insufficient given that
the multiplicity of channels with corporate power is poorly
acknowledged and understood by policy makers. Therefore, the
rules in place to ensure level playing fields for discussions and
equitable decision-making across all factors are inadequate6.
Reframing addictions
The consensus reached under ALICE RAP was that there are at
least three ways to reframe addictions that could lead to improved
strategies across different jurisdictions. These include:
1) Recognition that humans have a biological predisposition for
seeking out and ingesting drugs;
2) Recognition that ‘heavy use over time’ should replace the con-
cept and term ‘substance use disorder’;
3) Recognition that a quantitative risk assessment accounting for
drug potency and drug exposure, can standardize measures of harm
across different drugs.
Evolutionary evidence for biological predisposition
The idea that human exposure to drugs did not occur until late in
human evolution—thus leaving our species inexperienced—is often
posited as one of the reasons that these substances cause so much
harm18. However, multidisciplinary scientific evidence suggests
otherwise. Many substances consumed today are not evolutionary
novelties18,19. In the story of terrestrial life over the last 400 mil-
lion years or so, one ongoing theme has been the “battle” between
plants and the animals that eat them. Of the many defence mecha-
nisms in existence, plants produce numerous chemicals, including
tetrahydrocannabinol, cocaine, nicotine, and opiates, all of which
are potent neurotoxins that deter consumption of plant tissue by
animals18. From an evolutionary perspective, we thus find natu-
ral selection for compounds that discourage consumption of the
plant via punishment of potential consumers. By contrast, there
has been no natural selection for expression of psychoactive
compounds which encourage consumption (i.e., via consumer
reward), which has also been predicted by neurobiological and
behavioural psychology theories of reward and reinforcement for
contemporary drugs20.
Counterbalancing the development of plant neurotoxins, plant-
eating animals have evolved to counter-exploit plants’ pro-
duction of drugs, for instance by exploiting the anti-parasitic
properties of some of them18. Many species of invertebrates and
vertebrates engage in pharmacophagy, the deliberate consumption
and sequestration of plant toxins, to dissuade parasites and preda-
tors. In a human context, present day examples of pharmacophagy
may be seen with Congo basin hunter gatherers, amongst whom the
quantity of cannabis21 and nicotine22 consumed is titrated against
intestinal worm burden - the higher the intake, the lower the worm
burden. In individuals treated with the anti-worm drug abendazole,
the number of nicotine-containing cigarettes smoked is reduced22.
Although parasite-host co-evolution is recognized as a potent selec-
tive force in nature, other, subtler evolutionary dynamics may affect
human and animal interactions with plant-based drugs, including
that they may buffer against nutritional and energetic constraints on
signalling in the central nervous system23. Ethnographic research
reveals that many indigenous groups classify “drugs” as food,
rather than psychoactive entities, and that they are perceived as
having food-like effects, most notably for increasing tolerance
for fatigue, hunger and thermal stress in nutritionally-constrained
environments23. The causes of these perceived effects have not
been a research question, but there are clues that the “food” clas-
sification may be literal rather than allegorical. Common plant
toxins not only mimic mammalian neurotransmitters, they are also
synthesized from the same nutritionally-constrained amino acid
precursors, such as tyrosine and tryptophan. In harsh environ-
ments, toxic plants could function as a “famine food” providing
essential dietary building blocks, or, may function as a direct
substitute for nutritionally-constrained endogenous neurotrans-
mitters. There is some evidence to support this hypothesis in
animal research; for example, wood rats in cold environments
reduce thermoregulatory costs by modulating body temperature
with plant toxins consumed from the juniper plant24.
In the case of ethanol, its presence within ripe fruit suggests
low-level but chronic dietary exposure for all fruit-eating animals,
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with volatilized alcohols potentially serving in olfactory localiza-
tion of nutritional resources (i.e., animals can use the smell of alco-
hol to locate food over long distances)19. Molecular evolutionary
studies indicate that an oral digestive enzyme capable of rapidly
metabolizing ethanol was modified in human ancestors near the
time that they began extensively using the forest floor, about 10
million years ago25; humans have retained the fast-acting enzyme to
this day. By contrast, the same alcohol dehydrogenase in our more
ancient and mostly tree-dwelling ancestors did not oxidize etha-
nol as efficiently. This evolutionary switch suggests that exposure
to dietary sources of ethanol became more common as hominids
adapted to bipedal life on the ground. Ripe fruits accumulating on
the forest floor could provide substantially more ethanol cues and
result in greater caloric gain relative to fruits ripening within the
forest canopy, and our contemporary patterns of alcohol consump-
tion and excessive use may accordingly reflect millions of years of
natural dietary exposure19.
This evolutionary evidence does not imply that humans also evolved
to specifically consume nicotine, for example, or that nicotine use is
beneficial in the modern world. What is novel in the modern world
is the high degree of availability, and high concentration of psy-
choactive agents and routes of consumption that promote intoxica-
tion. What is different with alcohol in the modern world is novel
availability through fermentative technology, enabling humans to
consume it as a beverage, devoid of food bulk, with higher ethanol
content, and artificially higher salience than that which character-
izes fruit fermenting in the wild. The evolutionary evidence has two
implications: firstly, policies that prohibit the use of drugs are likely
to fail because people have a biological predisposition to seek out
chemicals with varying nutritional and pharmacological properties;
and secondly, in present-day society, drug delivery systems have
been developed that are beyond what is reflected in the natural envi-
ronment, particularly with respect to levels of potency, availability
and taste, which could be argued as being the more central driv-
ers of harm. Potency is largely determined by producer organisa-
tions operating in markets, which, from the perspective of overall
societal well-being, are inadequately managed26. Better regulation
of potency can become a major opportunity for additional policy
interventions - for example with alcohol, see ‘Evidence of reducing
ethanol content in beverages to reduce harmful use of alcohol’ by
Rehm et al.27.
Heavy use over time
To better understand the interference of drugs in human biology
and functioning, the consensus reached in ALICE RAP was that the
concept and term ‘heavy use over time’ should be proposed as the
replacement for ‘substance use disorder’. In medical settings and
indeed often in academic and lay settings, heavy users of drugs are
commonly dichotomized into those with a ‘substance use disorder’
or not. ‘Substance use disorder’ is a clinical construct that is often
used as a shorthand to identify individuals who might benefit from
advice or treatment. But as a condition in itself, it is a medical arte-
fact which occurs in all grades of severity, with no natural distinc-
tion between ‘health’ and ‘disease’28,29.
This is illustrated with alcohol. The associated chronic organ dam-
age (e.g., liver cirrhosis, cancers) exponentially increases in risk as
alcohol consumption accumulates over time30,31. Unmanaged heavy
drinking is associated with subsequent heavy drinking, often culmi-
nating in brain damage32, itself a consequence of heavy drinking33,34
but also a driver of future behaviour.
Alcohol consumption itself is close to log-normally distributed in
drinking populations, skewed towards heavy drinking35. There is
no natural cut-off point above which “alcohol use disorder” defini-
tively exists and below which it does not. “Alcohol use disorder” is
clinically defined as a score on a checklist of symptoms, and there
is a smooth line exponential relationship between levels of alco-
hol consumption and the score on the checklist29,36. Heavy drink-
ing is a cause of the items on the checklist, including compulsion
to drink more, which can also be a consequence of brain damage,
itself caused by heavy drinking. Thus, “alcohol use disorder” is a
diagnostic artefact. No more is needed to consider what is called
“alcohol use disorder” other than heavy use over time28,29.
For alcohol (and other drugs as well), this approach does not imply
that heavy use over time is the only cause of harm. There are other
factors involved that that drive heavy alcohol use and harm3 that
are independent of, or in interaction with, molecular and cellular
levels (e.g., alcohol dehydrogenase polymorphisms37), individual
levels (e.g., income38 and personality39) and environmental levels
(e.g., stigma)
There is an ongoing discussion as to whether or not sugar is an
‘addictive’ substance that should be captured in the same category
as drugs26. Framing the problem as one of heavy use over time
provides insight into this debate. As with alcohol and high blood
pressure40, chronic disease risk associated with plasma glu-
cose levels has a continuous exponential relationship with sugar
consumption41. The distribution of blood glucose levels is close
to log-normally distributed in populations and skewed towards
high consumption levels42. There is no natural cut-off point above
which diabetes (or any other disease manifestation) linked to sugar
definitively exists and below which it does not. Similar to the alco-
hol model where heavy use of alcohol over time leads to further
heavy use of alcohol from the resulting brain damage, heavy use of
sugar over time damages hippocampal function43, which leads to
further heavy use of sugar over time44. Thus, in the ‘heavy use over
time’ frame, sugar can be placed in the same category as alcohol
and other drugs, and managed with similar governance approaches
that promote public health.
Quantitative risk assessment
A core way to document the interference of drugs in human biol-
ogy and functioning is to use quantitative risk assessment (QRA).
QRA is a method applied in regulatory toxicology, for example, to
evaluate water contaminants, and before safety approvals for food
additives or pesticides. QRA has not been widely applied to drugs.
Previous approaches for ranking harm have mostly been based on
expert judgements45,46 which have been criticized as being arbitrary
and biased47.
The advantage of QRA is that it provides a formal scientific method
to rank the harm-potential of drugs, making optimum use of avail-
able data48. There are several approaches for QRA available, with
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F1000Research 2017, 6:289 Last updated: 17 MAR 2017
Margin of Exposure (MOE) suggested by WHO49 as being most
suitable for prioritizing risk management. In the alcohol field, MOE
has been applied to evaluate the liver cirrhosis risk of ethanol, which
is the single most important chronic disease condition attributable
to alcohol globally50. MOE results have replicated those behind
existing guidelines for low-risk drinking51. In a detailed study of the
components in alcoholic beverages, ethanol was confirmed as the
compound with highest risk52. In a detailed comparison between
ethanol and non-metabolically produced acetaldehyde contained
in beverages, it was also judged that the risk of ethanol comprises
more than 99% of the total risk53. It can be concluded that the risk
of alcoholic beverages can be evaluated by looking at the effects
of ethanol alone. The situation is less clear for tobacco, for which
some industry MOE studies find toxicants other than nicotine54,55.
An MOE analysis of electronic cigarette liquids indicated that nico-
tine is the compound posing the highest risk56.
MOEs are calculated as the ratio of a toxic dose of the drug (usu-
ally the benchmark dose BMDL10, the lowest dose which is 95%
certain to cause no more than a 10% negative outcome incidence)
with the dose consumed either individually or on a population
scale47. The higher the MOE, the lower the level of risk, with low
risk not implying safety. An MOE of 100 means that the drug is
being consumed at one hundredth of the benchmark dose; an MOE
of 1 means that the drug is being consumed at this toxic dose. The
MOE for drugs can be calculated taking into account a range of
hazard outcomes in health and other well-being domains, as long as
suitable dose-response data are available (which is not the case for
most drugs and many well-being indicators). Therefore, analyses
to date are primarily restricted to lethal outcomes based on animal
studies. Results for European adults are summarized in Figure 1.
The low MOE for alcohol (and thus high risk) is due to the high
levels of consumption by European adults. The MOE results are
consistent with the consensus of expert rankings in which cannabis
is ranked with lower risk and alcohol with higher risk than current
policies assume45,46. The MOE is inherent to the drug itself; it does
not account for the harms that arise from drug delivery systems,
for example, smoked tobacco, or from secondary effects such as
unclean syringes used for heroin intake.
Of course, MOE, as presented here, focuses on the physical body
of the adult user as the locus of harm. It does not take into account
the sex and age of the user, or harm to individuals other than the
user or at collective levels, which are a primary source of social dif-
ferentiation between drugs. It also focuses on mortality, rather than
intoxication in the moment. Differences between the intoxicating
power of substances in the moment, and in the behavioural con-
sequences of taking them, are primary reasons why, for example,
societies have treated alcohol differently to tobacco. Nevertheless,
we believe that MOE should be applied at the current stage even
when the underlying toxicological data are incomplete, to provide
a better alignment of prioritization of policy to the drugs associated
with higher risks, which in this case are nicotine, cocaine, heroin
and alcohol.
Towards better governance
We have described three harmonizing approaches to reframe our
understanding of addictions: biological predisposition to seek out
psychoactive substances; heavy use over time as a fruitful charac-
terisation; and quantitative risk assessment. Here, we propose two
Figure 1. Margin of exposure for daily drug use estimated using probabilistic analysis. Source: Lachenmeier & Rehm (2015)47.
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Figure 2. Well-being framework, reproduced with permission from the OECD Better Life Index initiative. Source: OECD. (2011), How’s
Life?: Measuring Well-being, OECD Publishing, Paris. DOI:
underlying pillars for a re-design of the governance of drug con-
trols: embedding drugs governance within a comprehensive model
of societal well-being; and creating a health footprint which, mod-
elled on the carbon footprint, promotes accountability by identify-
ing who causes what harm to whom from drugs.
Societal well-being
We propose that societal well-being should be our overarching
frame for a more integrated governance and monitoring of drug
control policies. Societal well-being, as captured by OECD57,
includes quality of life (health, education and skills, social connec-
tions, civic engagement, and personal security), material conditions
(income, employment and housing) and sustainability over time
(see Figure 2). Gross domestic product (GDP) is included as a sep-
arate domain, recognizing that, while economic well-being is an
important component of societal well-being, GDP has significant
limitations. GDP excludes, for example, non-market household
activity such as parenting, and activities such as conservation of
natural resources. GDP also includes activities which do not con-
tribute to well-being, such as pollution and crime, termed regret-
tables that are depicted within GDP but outside well-being. The use
of and harm done by drugs are affected by and affect all well-being
Well-being analyses have found that, whilst some illegal drug poli-
cies may reduce health harms, they often come with adverse side
effects including criminalization, social stigma and social exclusion,
all of which exacerbate health harms59. Humans are hard-wired to be
social animals60, with social networks strongly influencing tobacco
use61 and alcohol intake62. Punitive drug policies bring about the
opposite: social exclusion due to stigma and social isolation6365.
Engagement with illegal drugs conveys especially strong social
meanings and can lead to stigma of marginalized heavy users, as
opposed to the supposedly more responsible mainstream users66.
This can lead to punitive societal responses. Meanwhile, exclusion
from the mainstream may allow harms to continue unchecked. If a
user is caught using drugs in a country with “zero tolerance” to ille-
gal drugs, the ensuing criminal sanctions will impede civic engage-
ment and any improvements in quality of life and material living
conditions. For more detail, see ‘Well-being as a frame for under-
standing addictive substances’ by Stoll & Anderson58. Changes in
life expectancy in Mexico illustrate the negative consequences of
criminalization67. After six decades of gains in life expectancy in
Mexico, the trend stagnated after 2000 for both men and women,
and for men was reversed after 200568. This was largely due to an
unprecedented rise in homicide rates, mostly as a result of drug
policies promoting ‘gang wars’ and conflicts between gangs, the
police and army69.
A well-being frame calls for whole-of-society approaches that pro-
gressively legalize illegal drugs to reduce violence and personal
insecurity, while focusing on substances as drivers of harm6,70. It
balances the complex factors impacting drug use and related harm
through the continuous monitoring of policy effects in a proactive
way, with regulations embedded in international coordination. It
calls for whole-of-society approaches that avoid criminalization
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F1000Research 2017, 6:289 Last updated: 17 MAR 2017
where possible and where costs of addressing the problem are
equally distributed across society. Governance strategies manage
nicotine, illegal drugs and alcohol as a whole to avoid overlaps,
contradictions, gaps and inequalities1. The concern should be
focused on harms, both to the user and to others, including family
and friends, communities and society as a whole. The structures
to support the strategies should be coordinated and multi-sectoral,
involving high-level coordination of health, social welfare, and jus-
tice agencies in the context of international treaties, and, impor-
tantly, equitable across the lifespan, between genders and cultural
groups. To increase the pace of policy change, regional and local
public policies can create policy communities and networks within
a common international framework.
Managing ‘wicked problems’ requires clear rules of private sector
engagement in policy making, particularly when private interests
go against societal well-being6. An evolved governance system
must include measures to avoid industry co-optation, through trans-
parency, checks and balances. Private sector stakeholders should
operate within established rules.
The ongoing monitoring of outcomes within a well-being framework
would promote accountability. Modelled on the carbon footprint, we
propose a health footprint as the accountability tool. Footprints were
developed in the ecological field as a measure of human demand on
ecosystems71, including water footprints72 and carbon footprints that
apportion greenhouse gas emissions to certain activities, products
and populations73. The central reason for estimating a carbon foot-
print is to help reduce the risk of climate change through enabling
targeted and effective reductions in greenhouse gas emissions74.
The health footprint can be considered a measure of the total
amount of risk factor attributable disability adjusted life years
(DALYs)75 of a defined population, sector or action within a spatial
(e.g., jurisdiction) or temporal boundary (e.g. one year). It can be
calculated using standard risk factor-related YLL and DALY meth-
odologies of the Global Burden of Disease Study10 and of the World
Health Organization75. Health footprints are a starting point. To
be accountable, we ultimately need to understand what drives the
health footprint (Figure 3).
Structural drivers
Above the health footprint of Figure 3 are the structural driv-
ers of harm that directly influence the size of the health footprint.
Biological attributes and functions include, for example, the bio-
logical pre-disposition to seek out and use drugs. Genetic vari-
ants, for example, could be those that affect the function of alcohol
dehydrogenase, influencing consumption levels and harm8,76.
Changes in global population size and structure can increase
absolute numbers of drug-related DALYs, even though rates per
person can decrease over the same time7. As sociodemographic
status improves in lower income countries, so do drug-related
DALYs10; yet, for the same amount of drug use, people with lower
incomes suffer more drug-related DALYs than people with higher
Figure 3. Drivers of harm done by drugs and addictive behaviour.
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F1000Research 2017, 6:289 Last updated: 17 MAR 2017
Circumstantial drivers
Above the structural drivers are the circumstantial drivers, those
that can change. Related to drug potency and exposure, an MOE
target for all drugs no greater than 10 has been argued6. Policies
could achieve such a result by either reducing drug exposure or
by reducing the potency of the drug. Technological developments
have led to electronic nicotine delivery systems (widely known as
e-cigarettes) as widespread alternatives to smoked tobacco, with
current best estimates showing e-cigarettes to be considerably less
harmful to health than smoked cigarettes7880. It may be that once
e-cigarettes are heavily produced and marketed by the tobacco
industry, that society will see cigarette-like levels of sustained
heavy use of nicotine. However, e-cigarette’s harm quotient
should stay low, provided they are properly regulated in terms
of their components, including nicotine. Social influences and
attitudes drive harm through stigma, social exclusion and social
marginalization; these are often side-effects of drug policies, which
can bring more harm than drug use itself81,82.
Policies and measures
Policies that reduce exposure to drugs are essentially those that
limit availability by increasing the price and reducing physical
availability59,83,84. The absence of such evidence-based policies is
an important driver of harm. Limits to availability bring a range of
co-benefits to educational achievement and productivity, for exam-
ple, but they can also bring adverse effects – for example, the well-
documented violence, corruption and loss of public income
associated with some existing ‘illegal’ drug policies58,85. Individual
choices and behaviour that drive harm from drug use are determined
by the environment in which those choices and behaviours operate86.
Banning commercial communications, increasing price and
reducing availability are all incentives that impact individual behav-
iour. Research and development can be promoted to reduce the
potency of existing drugs87 and their drug delivery packages27,56,78.
Unfortunately, there remain enormous gaps between the supply
and demand of evidence-based prevention, advice and treatment
programmes8892. Called for by United Nations Sustainable Devel-
opment Goal 3.593, their supply can bring many co-benefits to soci-
ety, including reduced social costs and increased productivity94. The
harm driven by the gaps is due in large part to insufficient resources
and insufficient implementation of effective evidence-based pre-
vention and treatment programmes95. Currently these programmes
represents less than 1% of all costs incurred to society by drugs96.
Similar to medicines agencies (such as the European Medicines
Agency) that assess and approve drugs, prevention agencies could
be created95. Compounding the gap between supply and demand is
the fact that often, considerable marginalization and stigmatization
happens in the path to treatment, and this is then further exacer-
bated by the treatment itself82. The use of pharmacotherapy as an
adjunct may be further limited due to ideological stances, poorly
implemented guidelines, lack of appropriate medication, and even a
perceived lack of effect, if the drug is available97.
The private sector is a core driver of harm, through commercial
communications which include all actions undertaken by produc-
ers of drugs to persuade consumers to buy and consume more98.
There are international models encouraging better control of
commercial communications in the public health interest, the most
notable being the Framework Convention on Tobacco Control83. In
addition to commercial communications, the private sector drives
harm through shaping drug policies, leading to more drug-related
deaths5. Governance structures thus need to have the capability and
expertise to supervise industry movements that shape drug-related
legislation and regulations, including regulating and restricting
political lobbying. One of the difficulties here is that politically
driven change in difficult areas, such as drug policies, is highly
dependent on collective decisions99 and influenced by what has
been termed specular interaction100, in which a politician’s actions
may be less determined by their own conviction, and more by their
evaluation of beliefs of their rivals and friends.
The health footprint is the accountability system for who and what
causes drug-related harm. Jurisdictional entities can be ranked
according to their overall health footprint, in order to identify the
countries that contribute most to drug attributable ill-health and pre-
mature death, and where the most health gain could be achieved
at country level. Jurisdictional footprints could include ‘policy
attributable health footprints’ which estimate the health footprint
between current policy and ideal health policy. This would address
the question: ‘what would be the improvement in the health foot-
print compared to present policies, were the country to implement
strengthened or new policies?’ Conversely, the health footprint can
provide accountability for when such evidence-based policy is not
implemented correctly.
A range of sectors are involved in nicotine and alcohol related risk
factors. These include producer and retail organizations such as
large supermarket chains, and service provider companies such as
advertising and marketing industries. There is considerable overlap
between sectors, and estimates will need to determine appropri-
ate boundaries for health footprint calculations. Companies could
report their health footprints and choose to commit to reducing them
by a specified amount over a five to ten-year time frame. Direct
examples of producer action could include switching from higher to
lower alcohol concentration products27, and switching from smoked
tobacco cigarettes to e-cigarettes80.
The points stated above underscore the need to redesign the gov-
ernance of drugs; in Europe, and globally. Margins of exposure
estimates for four drugs (nicotine, cocaine, heroin and alcohol) are
exceedingly high and thus call for determined action. Drugs are
responsible for a high proportion of years of life lost in the Euro-
pean Union; tobacco accounted for 18.2% of life years lost, illegal
drugs for 1.8%, and alcohol for 8.2% in 2013. There are many side
effects of existing policies, such as stigma, social exclusion, lack of
personal security, civil unrest and homicide58.
Under the auspices of ALICE RAP, a large, multidisciplinary
team of addiction scientists put forward a range of arguments for
moving progressively towards regulated legalization of certain
illegal drugs, proposing a well-being frame that calls for whole-
of-society approaches and continuously monitors and accounts
for adverse side effects of drug policy. Humans have a biological
pre-disposition to seek out a range of drugs, so prohibitionist
Page 9 of 13
F1000Research 2017, 6:289 Last updated: 17 MAR 2017
policies are likely to run into difficulty - and they have. Legaliza-
tion does not imply that drug governance is left to market forces
alone - the experience of nicotine and alcohol demonstrates that this
is not possible. Instead, drug governance requires comprehensive
regulation, with adequate and transparent rules of the game for
stakeholder involvement, and appropriate international regulatory
frameworks. With a health footprint, it can be documented who
causes what harm from nicotine, illegal drugs and alcohol in the
public and private sectors. Public bodies and private companies
should be required to publish their health footprints on an annual
basis, and indicate their plans for reducing the health footprint.
The consensus that ALICE RAP reached will not come without
push-back. Without input from evolutionary theory, neurobiol-
ogy will continue to maintain that human drug use is initiated
and sustained by reward and reinforcement at both biological and
behavioural levels, compounded by mistaken views that the human
encounter with drugs is a relatively new evolutionary experience,
and human vulnerability to drugs in moral, behavioural, and bio-
logical dimensions. Disease classification systems are based not
only on measurement, but on qualification, and thus payment, for
treatment. The concept heavy use over time does not prevent the use
of qualification definitions for treatments. Threshold consumption
levels determining treatment can be defined as levels above which
advice and treatment have been shown to reduce the development
or progression of end-organ damage. Extending margin of exposure
analyses for a range of outcomes beyond mortality will overcome
concern of one metric for drug policy - its strength is that it allows
standard comparison across drugs and indicates options for chang-
ing both dose and exposure.
Whilst measuring societal well-being as a whole has gained
support, the implications for drug policy that favour regulated
legalization will meet resistance from those who favour prohibi-
tion, particularly as prohibition is based more on a moral than an
evidence-based standpoint, as has been the case with alcohol101.
The footprint implies responsibility, which is often difficult for
both public and private sectors to accept, in particular for producer
companies whose vested interests might be challenged.
What we propose in this paper are large adjustments to our under-
standing of addictions and to what needs to be done to effectively
reduce the widespread harms done by drugs. We hope that what
we have written might start a process for better drug policy for the
good of the public.
Data availability
Dataset 1: Source data underlying the results presented in Table 1.
The data was based on the IHME Global burden of diseases,
injuries and risk factors study (
DOI, 10.5256/f1000research.10860.d154573102
Author contributions
and AG drafted sections of the text and read the final manuscript,
for which consensus was agreed. PA coordinated the drafting and
edited the text.
Competing interests
PA and AG coordinated the ALICE RAP project. VB, PC, MH,
DWL, AL-H, DM, JR, RR, LS, and TY undertook various aspects
of research for the ALICE RAP project. PA reports receipt of fees
for public health comment to AB InBev’s goals to reduce the harm-
ful use of alcohol, outside the submitted work. PC reports having
served as a technical advisor to ABInBev Global Health Founda-
tion, outside the submitted work. AG reports grants and personal
fees from Lundbeck, grants and personal fees from D&A Pharma,
personal fees from AbbVie, outside the submitted work. AL-H
reports grants and personal fees from Lundbeck, outside the
submitted work. JR reports grants, personal and other fees from
Lundbeck, outside the submitted work. All other authors report
no conflicts of interest. The views expressed here reflect only the
authors’ and the European Union is not liable for any use that may
be made of the information contained therein. No funds were used
to prepare the paper.
Grant information
The research leading to the basis of this paper has received
funding from the European Commission’s Seventh Framework
Programme (FP7) 2007–2013, under Grant Agreement nº 266813
- Addictions and Lifestyle in Contemporary Europe Reframing
Addictions Project (ALICE RAP –
The funders had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.
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Alcohol-related harm is a major social order issue which requires evidence-based policy. This project capitalises on a unique window of policy adoption within Queensland to investigate the introduc…" [more]
The main aims of this project were to study the alcohol and drug treatment system both at the level of treatment agencies and at the level of clients coming into the system. We studied the populati…" [more]
Bryggan City: Gästerna, deras nätverk, problem, behov och resurser. The aim of this one-year study, funded by Mobilisering mot narkotika (MOB) (the Swedish National Drug Policy Coordinator), is to…" [more]
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