1. The purpose of
this report is to look at prevention from an
environmental perspective and on that basis make
recommendations which will continue to contribute and
strengthen the many ongoing efforts at drug
prevention now being made in this country at a
national and local level. It is the individual who is
the ultimate agent who does or does not make the
personal decision to misuse drugs and their capacity
to make sensible and healthy choices will be weakened
or supported by the world which surrounds them.
4. When setting up
drug prevention policies consideration will often
need at the same time to given to the place of
alcohol, tobacco and volatile substances in the
scheme of things. Drug prevention policies which
ignore licit drugs lack credibility.
5. Family, school,
work and leisure environments, and peer group
influences are part of the environment. So too are
cultural beliefs, expectations and attitudes.
8. Cannabis is the
drug which has been most used. The total number to
have ever taken cannabis is about 7 million.
9. The use of
tobacco, alcohol and solvents are predictors of the
later use of illicit drugs.
49. When it comes to
drug misuse and values we think there is a complexity
which must not be overlooked. Some values may appear
insulting and unattainable for some people. The aim
should be to adopt practices and foster an
environment which enables individuals to attain the
values which make them a part of society.
50. If society
intends to provide young people with an environment
which helps them not to take illicit drugs, or to
reduce the harms which they do, the climate of
awareness and beliefs on alcohol and tobacco must be
seen as part of that context.
58. We question
whether it is sensible to confine drug prevention
messages to the health consequences of taking drugs.
We give some examples of other approaches, involving
social unacceptability, which might be considered.
91. In accordance
with ACMD's report on Police, Drug Misusers and the
Community (1994) action against drugs markets should
be taken in the wider context of community safety.
93. Any intervention
directed at a market will lead to benefits and harms
which should as far as possible be foreseen and
94. Not to take
action against blatant dealing must have a symbolic
importance which should not be disregarded. It
suggests a "don't care" attitude which can
only affect the climate of beliefs adversely.
105. Deprivation is
today in Britain likely often to make a significant
causal contribution to the cause, complications and
intractability of damaging kinds of drug misuse.
112. We want now and
in the future to see deprivation given its full and
proper place in all considerations of drug prevention
policy, at both local and strategic levels, and not
let slip from sight.
118. Drug misuse is
a problem with linked personal and social origins.
Our contention in this report is that while the
individual has personal responsibility for healthy
decision making, there is a social responsibility to
construct and keep in repair a social, psychological
and physical environment surround which supports the
individual's capacity to stay away from drug misuse
and the harms of drug misuse and helps them pull out
of damaging drug misuse.
aims of the report
prevention approach is concerned with the totality of
drugs covered by the Misuse of Drugs Act (and has
also embraced volatile substance abuse). When setting
up drug prevention policies consideration will often
need at the same time to given to the place of
alcohol and tobacco in the scheme of things. By way
of analogy in its report on drug education in schools
ACMD (1993) took the view that health education
should embrace use of both licit and illicit
should be concerned to relieve the harm done not only
to the drug misuser him or herself but to other
people besides. Such harm may for instance be done to
the family who are bearing the brunt of a young
person's behaviour, to the children of adult drug
misusers, to the person's sexual partner whom the
drug misuser infects with hepatitis or HIV, to the
victim of drug-related crime, or to the community at
large by damage to comfort and amenities.
1.17 The environment
can encourage or oppose drug use partly through
greater or lesser physical access to drugs, the
presence of drug markets and knowledge of them, the
number of dealers and the level of enforcement. In
addition, the environment comprises prevalent,
normative attitudes towards drugs which make these
drugs more or less attractive and acceptable to the
The nature and extent of illicit drug use in the UK
2.27 In focusing
attention upon young people it is important to also
look at the use of tobacco, alcohol, and solvents,
since early use of these drugs has been shown to
predict later use of illicit drugs. A survey of 758
schoolchildren aged between 11 to 16 in Dundee,
Scotland, found that just over half (52.6%) had ever
2.28 In the Dundee
study 43.7% of schoolchildren reported having been
drunk in the past. Most recently there has been
concern over the availability of a number of
alcoholic drinks, which in aspects of their
marketing, and in some cases their sweet taste, may
appeal particularly to young people - these drinks
include a variety of white ciders and fruit wines. It
has been shown that many of these drinks are being
widely consumed by those under 16.
2.29 Over 6% of
deaths of 15-16 year olds in 1991 were attributable
2.30 Over 40% of 15
and 16 year olds report past experience of having
used an illicit drug.
2.45 In 1995 there
were a total of 602 deaths attributable to drug
2.64 Drug use or
misuse is not, however, the same as drug dependence.
Our best estimate of the extent of drug dependence in
England and Wales in 1992 places that figure in the
region of three quarters of a million people; our
best estimate of the number of people who have ever
used cannabis in England and Wales places the figure
in the region of 6.5 million people. The difference
between these figures gives some indication of the
fact that use of an illegal drug does not lead
inevitably to drug dependence.
2.67 Is the blanket
term "drug misuse" really satisfactory for
the policy analysis? ... we would like to see greater
investment in studies which determine, partition and
quantitatively estimate the relative contributions
made to the causes of any type or intensity of drug
misuse by, say, environmental factors, personal
factors and the drugs supply and availability of
Environmental factors and drug misuse
3.6 Access to any
substance is a fundamental and necessary requirement
of an individual's external environment. Where licit
drugs such as alcohol and tobacco are concerned,
access can be significantly influenced by such
factors as price, taxation, licensing regulations,
3.7 Access to
illicit drugs is most likely at the initial stage to
be provided by friends. This is well-researched and
well-evidenced. In the light of the decisive role of
friendship networks in disseminating drugs, it is
difficult to conceive of any effective form of
conventionally conceived drug enforcement policy to
control access at this level - quite simply, how
might one be expected to police friendship?
3.10 Drug choices
will be influenced as much by fashion as by
pharmacology, and fashions can and do change.
3.15 For drug use to
continue beyond experimentation, access to the
substance must be maintained. Moreover, it must be
maintained at an 'effective price', that is not only
in terms of monetary price but also in terms of costs
such as 'search time' and other potential forms of
inconvenience. Raising the effective price
(particularly in terms of search time) is potentially
one of the most useful ways of erecting barriers
between initiation and regular use.
3.16 Another form of
non-monetary 'cost' to the individual would be if the
form of drug consumption contemplated or undertaken
were to be highly socially stigmatised or to be
associated with highly stigmatised groups of people
or other socially stigmatised experiences.
3.17 A review of
environmental influences will necessarily lean in the
direction of an emphasis on the role of friendship
networks; neighbourhood and family life; the ways in
which drugs are found to be compatible or
incompatible with daily routines and lifestyle;
whether or not an effective means of access to the
drug can be maintained or is regarded as desirable;
the extent to which drug use is condoned or
stigmatised within a person's social circle. And none
of this is to contradict the fact that different
drugs are in a pharmacological sense different, with
differing properties for reward and reinforcement.
[alcohol] is a dominant feature of European and North
3.34 The emphasis on
friendship as 'peer pressure' reflects a major
difficulty in so much of the social discourse around
drug-related issues - namely the absence of any
notion of volition or desire. Health education
discourses in particular have often been cleansed of
any reference to the possibility that people might
use drugs because they find them pleasurable.
Reflecting the same tendency to view the drug user as
a passive victim of circumstance, there is a constant
resort to the use of the term 'pusher' which does not
accurately describe the dynamics of consensual drug
markets, or to the alleged involvement of foreign and
alien influences in drug-dealing networks.
3.40 Low levels of
bonding to the conventional social order (i.e.
involvement with family and school, and attachment to
conventional norms and aspirations) did not in
themselves predict either delinquency or drug use.
However, where there was both involvement with
delinquent peers and a low level of
conventional bonding, this was highly predictive -
even when controlling for prior involvement in
delinquency or drugs.
3.45 High levels of
parental monitoring could discourage both boys and
girls from beginning to use drugs, help reduce levels
of consumption among heavy using boys, and encourage
girl experimenters to quit. Once young people had
begun to use drugs, however, peer influences seemed
more influential than parental behaviour.
3.47 Some North
American research has noted an association between
modest cannabis and/or cocaine use and increased
productivity levels and wages levels.
3.54 Britain first
came to experience widespread and serious problems of
drug misuse amidst the economic downturn of the early
1980s which devastated the local economies of many
industrial working class communities.
3.62 It is commonly
assumed that drug misuse causes crime although
research has repeatedly demonstrated that a person's
involvement in crime often precedes their involvement
3.64 The vast
research effort on the still disputed drugs-crime
connection in the USA, conducted over more than
thirty years and including some highly sophisticated
methodological work, suggests that questions of
causality should be regarded as difficulties and
confusions to be lived with rather than resolved.
Current community-based drug prevention strategies:
evidence and review
4.62 The ultimate
aim must always be to assess the impact of drugs
prevention programmes on drug use.
4.64 While the
overall conclusion must therefore be that we know
very little for sure, there are nevertheless strong
suggestions from the research of the types of
approaches that are likely to prove most useful.
Given the way that drug use (both legal drug use and
perhaps increasingly, illicit drug use) are part of
our culture, there has been a growing awareness of
the need to tackle drug use in a multi-faceted,
Local drug projects and local preventive action
Drug prevention and the environment of awareness and
What people and
communities believe about drugs is as much part of
the environment as is the physical surround. We argue
that attitudes to tobacco and alcohol are part of
this context of ideas and that DATs should consider
the merit of dealing with all substances together.
The media as well as intentional health education are
among the factors which shape the relevant climate.
6.1 The choices
people make about drugs, or anything else, are
governed by awareness and beliefs - what they feel
6.2 Our thesis is
that how people value themselves, whether they think
they can control their destiny, how they think they
fit in with society and so on will influence whether
they take drugs.
6.4 It is very
difficult to say how values of an individual are
formed ... but the greater influence probably comes
from family and friends and to some extent from the
society in which the individual lives.
6.5 We think it is a
reasonable expectation on the part of the individual
that he or she should not be excluded from being a
neighbour, having respect of others and respecting
themself - that is, being part of society. Those who
feel let down by society and see no means of
improving their lot may well feel that society has
one set of values for the well off and one for them.
They would regard it as insulting if you suggested
they should aspire to those general values.
6.6 Some values may
appear insulting and unattainable for some people. On
the other hand we think that at a general level
values remain important as a touchstone of a
civilised society. The aim should be to adopt
practises and foster an environment which enables
individuals to attain the values which make them a
part of society.
6.7 It is not
society's role to dictate what an individual's
beliefs should be but we do believe that the
environment of awareness and beliefs should be
sufficiently strong to enable an individual to make
healthy and informed choices. In this chapter in
common with previous ACMD reports we have adopted the
word "misuse" to cover harmful and
experimental, or occasional use, unless the context
makes it plain otherwise rather than adopt the
convention of regarding harmful taking as
"misuse" and other taking as
6.9 We see awareness
and beliefs operating at several levels, or in
6.10 First there is
the layer of what the large society around us
believes. Its beliefs are not uniform but
contradictory and varied. Some parts want to see drug
misusers punished rather than treated while other
parts would like to see drugs legalised, arguing that
resultant crime would reduce. And there are sections
of society which regard their drug taking as use
rather than misuse - that is, as a normal and not
anti-social activity. Parliament and policy makers'
views will be at odds with some part of society's but
it will be theirs which at the official level will
prevail. Second, there is the layer of neighbourhood.
Third, there is the layer of the family. And
fourthly, there are the beliefs of individuals
6.11 This report is
only concerned with United Kingdom society, but the
United Kingdom is not isolated from the rest of the
world and is inevitably influenced in its attitudes
and beliefs towards drugs by the international
community. This is well illustrated by the United
Nations Drugs Conventions which control certain drugs
and to which the United Kingdom and many other
countries are signatories. It is from these
Conventions that the UK laws on drugs derive, and
these, of course, set the tone and the embodiment of
society's attitude toward drug misuse.
6.12 it is society
at large, with policy makers as its agents, who
determine how the misuse of drugs should be regarded.
There will be conflicts of ideas within society and
those ideas are likely to vary with time.
6.13 We believe that
there are steps which can be taken to change, to some
extent, society's larger "awareness and
beliefs" environment in the cause of drug
6.14 It is sometimes
suggested that drug taking in this country is a
normalised activity. That as a general proposition is
misleading. Nationally among young people (16-29)
around 45% have taken a prohibited drug some time in
6.15 For many young
people alcohol, tobacco and illicit drugs inhabit one
and the same world rather than constituting separate
domains. The possible influence of their illicit
drug-taking behaviour which is exerted by the climate
of ideas on licit drugs needs therefore to be
considered. The majority of people who have used
illicit drugs have previously used tobacco and
alcohol. Alcohol and cigarette smoking have been
found to be the most powerful predictors of marijuana
6.20 Alcohol is as
much a "dance drug" as ecstasy or
amphetamines. Young people live in a society which
heavily advertises alcohol and tobacco, and where
they are readily and lawfully accessible, and the
advertising of 'alcopops' has on occasion seemingly
been targeted at young people and has at times veered
towards open encouragement of drunkenness. To
establish causal connections between use of one type
of psychoactive substance and another is notoriously
difficult, but our conclusion is that if society
intends to provide young people which an environment
which helps them not to take illicit drugs (or to
abuse volatile substances), or to reduce the harms
which they do, the climate of awareness and beliefs
on alcohol and tobacco must be seen as part of the
6.21 To reduce
illicit drug misuse we believe that individuals need
to be engaged in the decisions which they take. By
this we mean that individuals need to feel there is a
purpose to the decisions which they take and that
they are realisable. The aim is for society to alter
the climate in which those decisions are made so as
to make the misuse of drugs less acceptable and thus
influence individuals away from them. That climate is
more likely to be engendered where people are truly
informed, not just of the facts but also the values -
valuing themselves, valuing the community and valuing
other people. In recent years drinking and driving
has become much less acceptable than it was which we
see as an interesting parallel in terms of change of
attitude with what we are proposing should be the aim
of society's attitude toward drug misuse.
6.33 Young people,
while being part of larger society, belong to a
society of their own. Their attitudes on drugs are
quite likely to be at variance with older people's
and generally less condemnatory. They are more likely
than adults to regard drugs as an accepted part of
life even if they do not misuse them themselves.
6.42 Sport is also
very much part of young people's existence and there
is a ready acceptance of alcohol consumption with
some sports and indeed prominent sponsorship of some
sports by drinks companies. This very open acceptance
of alcohol is part of the wider drugs, alcohol and
tobacco context to which we referred in paragraph
6.20. The bodies which are responsible for governing
them have anti-drug policies, which cover bot
psychoactive drugs and performance enhancing drugs
such as anabolic steroids, but reports of drug-taking
among sportsmen still appear. Sometimes the offender
is sacked and other times he is taken back into the
fold on the basis that he will undertake treatment
and become abstinent - there is an inconsistency in
these two approaches which the young may find
difficult to make sense of.
6.44 In short, young
people live in a society which acknowledges and
accepts drugs to some extent, a state of affairs
which arises from environmental factors.
attempts need to be made with more emphasis being put
on distinguishing between non-users, misusers and
polydrug users, and even between problematic and
non-problematic misusers. Given the links between
drug misuse and alcohol consumption, pubs,
off-licences, clubs and the like would appear to be
obvious locations for targeting.
6.59 The credibility
of messages is enormously important if the awareness
and beliefs of individuals are going to be
influenced. Another aspect of the messages which we
should like to mention is the balance to be struck
between the desired feelings generated by taking the
drug and the undesirable health consequences. For
those who misuse the drug in question and know its
effects absence of any mention of the desirable
effects is likely to reduce the credibility of the
6.61 We live in a
society which makes the production, supply and
possession of these substances unlawful on the basis
that they cause social problems so why shouldn't the
messages also say that drug taking is socially
unacceptable as well as unhealthy? Any drug
transaction involves illegality and is not subject to
the safeguards which apply to most consumer goods and
you cannot be sure what you're getting.
significant at the local level is the attitude which
is taken toward the use of alcohol. It is part of the
spectrum of misused substances.
6.76 Most families,
most of the time, will act as bulwarks against drug
misuse. They achieve this through the parents
adopting an approach which includes listening and
responding to their children, acting consistently,
defining boundaries and supervising them well.
Conversely, harsh and erratic discipline, parental
conflict, and lack of parental interest or time, will
tend to work the other way.
6.81 The young
person today is in a society where the acceptability
of the use of drugs and the availability of them has
changed markedly in recent years.
Drug prevention and housing
within some communities of open, concentrated drug
markets may both facilitate dissemination of drugs
and become a public nuisance. We believe that it is
in the public interest to take planned action against
8.8 Occasional users
may be deterred from use if search costs are high.
The "price" paid for any drug includes not
just the money which changes hands but also the time
taken to find a supplier, the risk of being ripped
off, the risk of poor quality drugs and the risk of
being caught by the police.
8.13 The ability of
drug users to purchase and how much they can purchase
of a particular drug will depend on: price; price of
substitutes; availability of income; search or other
8.14 Even where the
price change is small it may nonetheless have an
effect on consumption.
intervention directed at a market should, in
assessing the overall outcome, take account of the
fact that markets respond to change quickly and
sometimes unexpectedly. The intervention will lead to
benefits and harms which should as far as possible be
foreseen and always evaluated. Complete elimination
of an established market is probably an unrealistic
8.19 Intervening at
the point of production or some other point of major
transaction unfortunately now seems to have little,
if any, effect on the drugs market. That is not to
say that we think it is useless intervening at these
points - such actions are necessary in order to stop
the market mushrooming.
8.26 There can be no
sympathy for regular dealers primarily motivated by
8.29 In deciding
what can be done care will need to be taken to ensure
that there are no unacceptable consequences.
8.34 In relation to
pubs we are aware that the licenced trade has, with
assistance fom the police, taken steps to reduce
dealing on their premises. Broad approaches in
partnership, of the sort which these pub schemes
exemplify, seem to us to be the right way to tackle
drug dealing in semi-public places.
Drugs and social deprivation
significantly and causally related to problematic
9.4 The experience
of deprivation may have within it a number of
constituents such as poverty, inadequate housing,
educational disadvantage, and lack of job
opportunities. Unemployment and low or relatively low
income are often key factors.
9.5 It is important
to realise that what we are talking about here is a
condition which at the same time will often exist as
a potent, corrosive, subjective and personal
experience. The mix of feelings are likely to include
worthlessness and a sense of failure, powerless and
the feeling of not being in control, alienation and
apathy and loss of any role as stakeholder, the sense
of lacking any hope of a personal way out or up and
of there being no better future in sight for one's
9.6 There is
evidence to show that it is sometimes relative rather
than absolute deprivation which is associated with
adverse health consequences: people feel bad about
themselves when they feel disadvantaged in comparison
9.8 In Britain
between 1982 and 1996, there was a rise from 10% to
19% in those whose income was at a level below half
the national mean. The poorest fifth of the British
population have less spending power than equivalent
strata in other major Western countries. Poverty
levels in Britain had been decreasing up to the early
1980s, but since then we are the only major Western
nation to have experienced a significant increase in
9.19 At the
beginning of the 1990s, cigarette smoking had in this
country become a strongly class-related drug
behaviour. The less privileged have thus far found it
significantly more difficult to give up smoking than
have the more privileged sectors. Cigarettes in
Britain are moving toward becoming a poverty drug.
Alcohol consumption in Britain is greater among the
richer than among the poorer segments of society.
9.24 A recent
ecological study of cocaine and opiate overdose in
New York City over the years 1990-1992 showed that
poverty accounted for 69% of the variance in overdose
9.25 Alcohol was
undoubtedly in this country the major substance
problem for [the 19th] century and there is vivid
contemporary testimony as to the appaling social
consequences of slum drinking which were embedded in
social deprivation of an extent and intensity which
is today fortunately long since gone.
9.28 The evidence is
persuasive that major drug problems during the 1980s
became increasingly associated with social
9.32 Although VSA
[volatile substance abuse] is not covered by the
Misuse of Drugs Act, ACMD has taken the position that
VSA is an integral part of the national drug problem
and has published a report which deals specifically
with this topic.
9.37 An analysis of
persons admitted to hospital for drug-related
emergencies ... found a very strong correlation
across postcode sectors between rates for drug
related and alcohol related admissions (correlation
coefficient 0.94 or p less than 0.001).
9.43 Drug use per se
probably shows a different relationship with
deprivation than VSA related deaths, problematic use
which has reached clinical significance or
relates statistically to types and intensities of
drug use which are problematic.
gives rise to personal distress and psychological
discomfort of a kind which can result in depressive
illness as well as lesser and more amorphous types of
mood disturbance. In such circumstances mind-acting
drugs (including illicit drugs) can be used as
self-medication to relieve distress or as a
substitute source of excitement and good feelings.
9.54 What we are
suggesting here is fully in accord with more general
policies on inequalities in health and with wider
health service concern with targeting areas of social
macro-level social and economic policies
significantly fail and social deprivation, structural
unemployment and poverty become rife, one of the
prices which will have to be paid is the added cost
and tragedy of deprivation-related drug misuse.
The resources available to support community action