Lancet Book Review: Our Changing Attitudes to Alcohol, Tobacco, and Drugs

" Those who cannot remember the past are condemned to repeat it." George Santayana

I was surprised that Virginia Berridge didn't mention the above quote in her impressive book, Demons, because it succinctly covers the key message. Berridge explores the history of alcohol, tobacco, and drugs, particularly opioids but she also covers to some extent cannabis and cocaine. The book highlights how almost all issues that are currently being debated in relation to drugs have been discussed in the past few centuries and many of the policy approaches have been tried before. This is not surprising since the moral issues and attitudes relating to drug use are to some extent unchanging, although the scientific aspects of how drugs work and how they may lead to addiction have moved on greatly.

What is clear from Berridge's historical analysis is that logic and evidence of harm play only a minor part compared with political and business interests and how fashionable drugs are in different elements of society. This explains why some drugs, notably alcohol and tobacco, are still legal when less harmful substances such as cannabis are forcibly controlled. Berridge argues that in reality the only significant "scientific" impact on the whole field has been in the purification of drugs such as cocaine and opioids. Much more important has been the development of technologies that make drugs more rapidly active or easily available, such as the hypodermic syringe and the mass production of cigarettes through machine rolling.

The book details how changing attitudes to drug use and addiction are cyclical, with many of the lessons of the past being relevant today. For example, during the 1850s the Swedish city of Gothenburg had a state-controlled system of access to alcohol that looked remarkably like the Dutch coffee shop model for cannabis today. The use of low-dose opioid preparations such as laudanum in the 1800s across the western world was for a range of symptoms, including work stress and insomnia, rather like cannabis is used by some people today. The banning of these preparations at the turn of the 19th century was driven by similarly exaggerated claims of harms that are used to justify current politically motivated punitive approaches to cannabis in the UK. The reason cannabis was not banned at the same time as laudanum preparations was that it was seen as relatively safe and was even thought to have benefits for mental health.

Alcohol has always had a special role because of its long use in western society: for many centuries it was one of the only safe liquids to drink because water was so often polluted. In the 19th century with the rise of industrial production the alcohol industry became one of the most powerful industrial blocs in the UK with enormous political clout; indeed, Berridge documents how it was particularly supportive of Conservative policies at that time-much as it seems to be today. However, history tells us that government policies to restrict use and access-such as the introduction of licensing times during World War 1 in the UK and the French ban on absinthe-did reduce use and health harms.

The profound and widespread impact of the USA on international policy is very evident. This began with the first opium conventions that were designed to break the UK and Dutch stranglehold on the far-eastern opium markets, so allowing the USA greater trade and influence. Subsequently the USA has been the driver for the current punitive approaches to many drugs, particularly cocaine and cannabis. The UK having tried and failed to prevent this US hegemony of policy in the early 20th century has now largely fallen into line; only its refusal to comply with the ban on heroin showed any clear evidence of independent thought in relation to the UN conventions. The internal UK approach to prescribing heroin treatment that ran from the 1930s to the 1970s is well documented. This "English" approach was generally regarded as one of the most successful medical interventions for drug users; it maintained stability and by obviating their need to become drug dealers in order to obtain their supply kept a cap on new users. It's a pity that the current UK Government with its obsession with abstinence-based "recovery" programmes seems to have forgotten (or never learned) this lesson of history.

Inevitably in a field that is going through a period of major policy change, as drugs are at present, some of the more recent facts Berridge makes have since changed-for instance, the US National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism have not fused; Uruguay now has a state cannabis monopoly. However, Berridge would undoubtedly point out that these are mere blips in the historical narrative-and this informative book contains plenty of proof of that.

Demons: Our Changing Attitudes to Alcohol, Tobacco, and Drugs

Virginia Berridge

Oxford University Press, 2013

Pp 304. ISBN-9780199604982

David Nutt is the author of Drugs Without the Hot Air (UIT Cambridge Ltd, 2012) and the author of two Lancet papers on the relative harms of drugs, which are all mentioned by Virginia Berridge in Demons.

Reference: Nutt D. Drug policy over the centuries: what's health got to do with it? Lancet. 2014;383(9915):401. Link to article.

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