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THE EFFECT OF ALCOHOLISM TOWARD ACADEMIC PERFORMANCE

Profile image of Villegas Genevie

Drinking habit of civil engineering student of Samar state university.

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Underage drinking.

Chapter 3. Prevention of Alcohol Use and Misuse in Youth: A Comparison of North American and European Approaches

Chapter 3. Prevention of Alcohol Use and Misuse in Youth: A Comparison of North American and European Approaches

Texte intégral.

1 The current chapter provides a review of the different prevention approaches targeting alcohol use in young people. A number of systematic reviews on this issue are available, particularly through the Cochrane Review library (see Foxcroft & Tsertsvadze, 2011a-c). What these former reviews do not offer is a comparison across the different types of approaches to alcohol prevention. Therefore, we review the theoretical bases of the different approaches to alcohol prevention, and we describe some programmes with the strongest evidence-base and review their efficacy to facilitate comparisons of the evidence across approaches. In reviewing specific programmes, our intent is to be representative rather than comprehensive. Furthermore, special attention is dedicated to the cultural context in which a particular programme or approach has been evaluated to provide policy makers with recommendations on how alcohol prevention might be implemented in new cultural contexts.

KEY FINDINGS

2 • The goals of alcohol prevention programmes often vary according to cultural context. While most U.S.-based programmes have abstinence as their primary goal, most European programmes include reductions in alcohol use as a viable outcome.

3 • Delivering alcohol prevention in the school context captures a larger percentage of youth and yields the most consistent effects, relative to programme delivery within the community or family context. The most effective universal school-based programmes are comprehensive, concurrently addressing normative attitudes about drinking, and teaching generic and alcohol refusal skills.

4 • The most effective family-based programmes for preventing or reducing alcohol use in young people emphasise active parental involvement and work to develop parenting skills to enhance competence and self-regulation in children. Family-based programmes have small effects, but their effects are generally consistent and lasting.

5 • Selective interventions targeted towards at-risk groups (e.g., high personality risk for alcohol use disorders) have been shown to be effective in reducing alcohol use in young people. Such programmes can also delay drinking onset if introduced in early adolescence prior to the onset of alcohol use.

6 • Personalized feedback interventions are designed to correct misperceptions about drinking norms in college and high school students. Such programmes are indicated as a strategy for reducing drinking in those whom have already started drinking, especially those who drink more heavily.

7 Adolescence and young adulthood is a critical period of social and emotional development (Spooner, Mattick, & Noffs, 1996), a time when young people move toward independence and autonomy and decrease dependence on families and schools. For these reasons, this developmental period is also the time when acceptance by peers becomes more important and when risk-taking behaviour is high. It is also a period when individual differences in risk for psychopathology begin to manifest themselves in substance misuse and other psychiatric symptoms. If left untreated, adolescent-onset disorders can become chronic and can cause severe disability (Andrews, Henderson, & Hall, 2001). It is therefore important that prevention programmes be implemented prior to onset of psychiatric symptoms and before social and emotional influences come into full effect. Furthermore, such programmes should be introduced before initial exposure to alcohol, to reduce the adverse impacts of alcohol use on the developing brain. Implementing alcohol prevention programmes early will ensure young people are provided with the knowledge and skills they need to make responsible and informed decisions about drinking (Dielman, 1995) and programmes that can effectively delay onset of drinking, particularly heavy drinking, will ensure that alcohol is not interfering with this critical period of social, cognitive, and neural development.

8 Alcohol prevention can be delivered in the school, to the family, and/or in the community. Prevention programmes can be universal (offered to all members of the population), selective (offered to only those who are at high-risk for the disorder), or indicated (offered only to those who already show signs of the disorder); the latter two types are often collectively referred to as targeted approaches. Approaches to alcohol prevention can vary widely based on the desired end goal of the intervention whether it be abstinence, reduction in drinking quantity, reduced alcohol-related problems, or delayed onset. Desired outcomes may vary across cultural contexts. For example, while most U.S.-based prevention programmes have abstinence as the primary goal, European prevention trials typically are more tolerant and include reductions in alcohol use as a viable treatment outcome. We organise our chapter around the location in which the intervention is delivered (e.g., school-based context), but consider whether the intervention described is universal, selective, or indicated, and what type(s) of alcohol-related outcomes are used to assess efficacy.

SCHOOL-BASED APPROACHES

9 School-based alcohol prevention programmes offer numerous advantages over other prevention approaches because attending school is a mandatory requirement in most Western countries and is where young people spend over a quarter of their waking lives (Cuijpers, 2002). Schools offer a location where educators are able to reach large audiences at one time, keeping costs low and retention relatively high (Botvin, 1999; Botvin, 2000; Cuijpers, 2003; Gottfredson, Gottfredson, & Skroban, 1996; Jones, Sumnall, Burrell, McVeigh, & Bellis, 2006; Shin, 2001; Wenter et al., 2002).

10 School is also where youth experience most peer interaction and influence, which can both positively and negatively influence alcohol-related behaviours and attitudes. It is primarily in the school-age years when drinking behaviours have their onset (Botvin & Griffin, 2003; Sharma, 2006). Alcohol prevention programmes can be easily implemented in the school context (Berkowitz & Begun, 2003) and school research suggests that it is best to deliver prevention in sequential and developmentally-appropriate stages (Ballard, Gillespie, & Irwin, 1994; Dusenbury & Falco, 1995; Meyer & Cahill, 2004). School-based alcohol and drug prevention programmes have been shown to be appealing both to students and educators over and above other types of prevention delivery (Lisnov, Harding, Safer, & Kavanagh, 1998). Other practical and economic advantages to delivering prevention in schools include: being able to capture large numbers of youth at one time, availability of educational resources, and that programmes can be easily tailored and delivered to different development stages (McBride, 2003).

11 Universal prevention addresses the entire population within a particular setting, regardless of their level of risk for alcohol use and aims to delay the onset of alcohol use by equipping individuals with the information and skills that they need to prevent use. In schools, universal programmes focus largely on teaching awareness education (knowledge and harms), normative education, social and drink-refusal skills, and promoting pro-social peer relationships. Universal programmes offer the advantage of being delivered on a large scale and, as such, they have the potential ability to reduce alcohol use and related harms to a greater audience (Jones et al., 2006; Midford, 2008). Importantly, they avoid the risk of stigmatising individuals, given the sensitive nature of alcohol use disorders and risk (Offord, 2000).

12 A recent review of school-based universal prevention has identified some effective programmes (Foxcroft & Tsertsvadze, 2011a). Many effective programmes of this type incorporate a social influence or skill development approach to prevention.

SOCIAL INFLUENCE APPROACH

13 The ‘social influence approach’ to prevention was developed in the 1980s and is based on Bandura’s (1977) social learning theory and McGuire’s (1964, 1968) social inoculation theory. The approach is based on the assumption that young people start to use alcohol as a result of social and psychological pressure from peers, family, and the media (Donaldson et al., 1996). The goal of social influence programmes is to teach young people to avoid using alcohol by resisting external pressure and increasing alcohol-related coping skills (Botvin, 2000). The social influence approach emphasizes three major components: information, normative education, and resistance-skills training (Botvin, 2000). The emphasis in the information component is to highlight short-term rather than long-term consequences of alcohol use since the short-term corresponds to the typical thinking style of young people (Berkowitz & Begun, 2003). The component of normative education is based on findings that heavy drinking adolescents generally overestimate the prevalence of alcohol and other substance use in peers (Perkins, 2007). Therefore, one main component is to correct perceptions by providing students with the most current and accurate data, usually from large and relevant population-based surveys. This approach has been shown to change students’ beliefs about the prevalence and attitudes about acceptability of alcohol use by young people, and delay the onset of alcohol use (Botvin, 2000; Botvin & Griffin, 2007; Cuijpers, 2003; Cuijpers, Jonkers, Weerdt, & Jong, 2002; Hansen & Graham, 1991b; Moskowitz, 1989).

14 The social influence approach also addresses the findings on how pro-alcohol social influences from peers and the media also influence youth drinking by teaching alcohol resistance skills. This generally involves teaching students how to recognise, handle or avoid high-risk situations, increasing students’ awareness of media influences, and training them in drink refusal skills. The inclusion of resistance skills training in school-based prevention has been associated with enhanced effectiveness (e.g., Botvin, 2000). However, in the absence of normative education, resistance skills training has been found to be relatively ineffective and potentially iatrogenic (Hansen et al., 1991b), possibly because the social normative component is necessary to motivate students to utilise peer-resistance strategies.

15 Until recently the most well-documented, school-based alcohol and other drug prevention programme based on the social influence approach was the Drug Abuse Resistance Education (DARE) programme. The DARE programme is typically taught in the fifth grade (10 years of age). What distinguishes the programme from others is that it is taught by police officers. Although some early studies found the programme to impact positively on alcohol and drug-related attitudes, knowledge and behaviour, these studies have since been criticised for their weak or inadequate research methods (Rosenbaum & Hanson, 1998). More recently, studies with stronger designs and analytic methods have shown the DARE programme to have minimal or no impact on reducing alcohol and drug use (Birkeland, Murphy-Graham, & Weiss, 2005; Ennett, Rosenbaum, Flewelling, & Bieler, 1994; Rosenbaum, Flewelling, Bailey, Ringwalt, & Wilkinson, 1994; Rosenbaum & Hanson, 1998). The ineffectiveness of the DARE programme has been suggested to result from the instructional, non-interactive method of delivery by authority figures (Tobler & Stratton, 1997; White & Pitts, 1998).

16 Aside from the DARE programme, a considerable number of studies have examined the efficacy of other social influence programmes in preventing alcohol use when delivered by other members of the community, including teachers. When delivered in this way, the social influence approach has been found to be effective in not only increasing knowledge and attitudes towards alcohol, but importantly in reducing the use of alcohol as reviewed in the evidence section below (e.g., Botvin, Griffin, Paul, & Macaulay, 2003; Cuijpers, 2003; Cuijpers et al., 2002; Faggiano et al., 2008; Hansen, 1992; Midford, 2000; Perry & Kelder, 1992; Roona, Streke, Ochshorn, Marshall, & Palmer, 2000; Shope, Copeland, Marcoux, & Kamp, 1996; Soole, Mazerolle, & Rombouts, 2005; Tobler, Lessard, Marshall, Ochshorn, & Roona, 1999; Tobler et al., 2000).

COMPREHENSIVE APPROACH

17 Social influence programmes generally assume that young people use alcohol as a result of peer influence and a lack of drink refusal skills. However, they fail to take into account other factors which can influence alcohol use such as dealing with low self-esteem, depression, or anxiety. Comprehensive programmes were designed to take such etiological risk factors into account. This approach is also known as the competence enhancement approach to prevention (Botvin, 1999; Botvin et al., 2003), but differs from selective or indicated programmes by promoting generic skills in the general population. Selective programmes, by contrast, promote specific skills in youth identified as lacking these specific skills and/or requiring specific learning conditions.

18 The comprehensive approach is based on Bandura’s (1977) social learning theory and Jessor’s (1977) problem behaviour theory. The approach conceptualises alcohol misuse as a socially learned behaviour that results from the interplay of a variety of social factors (such as modelling and imitation) which influence personal factors (such as beliefs, attitudes, and pro-alcohol cognitions) (Botvin, 2000). Teaching general personal and social skills in the absence of other components of the social influence approach such as drink refusal skills training and normative education has only been found to have a minimal impact on alcohol use (Caplan et al., 1992). However, when elements of the social influence approach are included into the model, effects appear to be more robust (Botvin, 2000). Another essential ingredient of the comprehensive approach to prevention is an interactive delivery style which generally involves class discussions, instruction and demonstration, group feedback and reinforcement, role-plays, and practice (Botvin et al., 2003).

REVIEW OF THE EVIDENCE FOR THE SOCIAL INFLUENCE AND COMPREHENSIVE APPROACHES

19 In a recent Cochrane review of universal alcohol prevention programmes, Foxcroft and Tsertsvadze (2011a) identified 11 alcohol-specific prevention programmes that involved a rigorous randomised controlled trial. Of these, five trials showed no significant differences between their experimental and control groups (Duryea, 1984; Goodstadt & Sheppard, 1983; Newman, Anderson, & Farrell, 1992; Sheehan, Schonfeld, Ballard, & Schofield, 1996; Williams, DiCicco, & Unterberger, 1968) and in the other six trials some significant differences between groups were reported (Dielman, Shope, Butchart, & Campanelli, 1986; McBride, Midford, Farringdon, & Phillips, 2000; Morgenstern, Wiborg, Isensee, & Hanewinkel, 2009; Perry & Grant, 1988; Vogl et al., 2009; Wilhelmsen & Laberg, 1994). These six trials were conducted with children across the world, all living in developed countries, such as Germany, Norway, Switzerland, Australia, and Chile. The programmes all involved in-class alcohol education and drink refusal skills training ranging in duration from four to ten+ sessions. Results showed significant reductions in drinking and binge drinking in intervention groups and effects were observed up to 12 months post-intervention. However, in two of these six trials, effects were limited to subgroups such as girls or those who were not drinkers at baseline. And, as with all systematic reviews, there is the potential lack of inclusion of ‘file drawer’ results (i.e., negative findings that are simply never published and thus not accessible to the reviewers).

20 Alcohol non-specific prevention programmes addressing all substance use outcomes were also evaluated by Foxcroft and Tsertsvadze (2011a) for their effects on youth drinking behaviour. Twenty-four trials showed no significant differences between their experimental and control groups (Allison, Silverman, & Dignam, 1990; Beaulieu & Jason, 1988; Bond et al., 2004; Botvin et al., 2003; Brewer, 1991; Clayton, Cattarello, & Walden, 1991; D’Amico & Fromme, 2002; Durrant, 1986; Ellickson & Bell, 1990; Furr-Holden, Ialango, Anthony, Petras, & Kellam, 2004; Goldberg et al., 2000; Hansen, Johnson, Flay, Graham, & Sobel, 1988; Hansen & Graham, 1991a; Johnson, Shamblen, Ogilvie, Collins, & Saylor, 2009; Koning et al., 2009; Moskowitz, Malvin, Schaeffer, & Schaps, 1984; Perry et al., 2003; Ringwalt, Ennett, & Holt, 1991; Ringwalt, Clark, Hanley, Shamblen, & Flewelling, 2009; Spoth, Redmond, Trudeau, & Shin, 2002; St. Pierre, Osgood, Mincemoyer, Kaltreider, & Kauh, 2005; Sun, Dent, Sussman, & Rohrbach, 2008; Werch, Moore, & DiClemente, 2008; Werch et al., 2010) and 14 trials showed significantly greater reduction in alcohol use when comparing intervention and control groups (Botvin, Baker, Renick, Filazzola, & Botvin, 1984; Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995; Botvin, Griffin, Diaz, & Ifill-Williams, 2001; Caplan et al., 1992; Cook, Lawrence, Morse, & Roehl, 1984; Eisen, Zellman, Massett, & Murray, 2002; Ellickson, McCaffrey, Gosh-Dastidar, & Longshore, 2003; Faggiano, Richardson, Bohrn, & Galanti, EU-Dap Study Group, 2007; Griffin, Holliday, Frazier, & Braithwaite, 2009; Hecht et al., 2003; Kellam et al., 2008; Scaggs, 1985; Schinke, Tepavac, & Cole, 2000; van Lier, Huizink, & Crijnen, 2009). Two studies showed comprehensive programmes to be effective over the medium-long term (Botvin et al., 1995; Scaggs, 1985) and three studies showed this approach to be effective over the longer term (i.e., over three years; Botvin et al., 1995; Schinke et al., 2000; Spoth, Redmond, & Shin, 2001). Most of these studies, with the exception of the European Unplugged programme, were conducted in the U.S.

21 The most popular and most well-evaluated of the comprehensive programmes is the Life Skills Training (LST) model developed by Botvin (1998). The LST was identified in the Foxcroft and Tsertsvadze (2011a) Cochrane Review as having the strongest evidence-base of the comprehensive programmes. This programme emphasises personal and social risks that underpin lifestyle and health behaviours and aims to teach students ways to avoid these risks. This is done by teaching decision making and problem-solving skills, assertiveness training, skills to resist peer and media influences, techniques to communicate effectively and develop healthy personal relationships, ways to enhance one’s self-esteem, and ways to manage stress and anxiety (Botvin, 2000). Various formats of the LST programme have been developed and evaluated, but the most common format consists of 15 lessons in year seven, and ten booster sessions over years eight and nine. Numerous studies testing the efficacy of the LST competence enhancement approach on alcohol use have found the programme to significantly reduce drinking behaviours (e.g., Botvin, 1998; Botvin, Baker, Dusenbury, Tortu, & Botvin, 1990; Botvin et al., 2001; Botvin & Kantor, 2000; Eisen, Zellman, & Murray, 2003; Faggiano et al., 2008; Soole et al., 2005). First tested in primarily white middle class communities in the U.S., the programme was shown to have consistently significant effects. However, these effects were small, accounting for only 10% of the variance in drinking outcomes (e.g., Botvin et al., 1995). More recently, the programme has been evaluated in minority populations, inner-city minority populations, and high-risk youth (i.e., those reporting high-risk characteristics at baseline, such as having peers who have initiated use or low academic achievement). These studies all indicate that the LST programme can be modified to different cultural contexts and is effective, and possibly more effective when delivered to high-risk youth. One study by Botvin et al. (2001) reported over 50% fewer binge drinkers in the intervention group at follow-up relative to the control group when the study sample consisted primarily of inner-city African-American youth. There is also evidence that the LST programme is slightly more effective when it is adapted to the cultural context in which it is delivered (e.g., Botvin et al., 1995) and when delivered in higher risk populations (e.g., Griffin, Botvin, Nichols, & Doyle, 2003).

22 Another important test of the reliability of an intervention effect is when a programme is evaluated by a research team that is independent of the original evaluator (as programme evaluator has been shown to have significant effects on treatment outcome studies). Spoth et al. (2002) evaluated the LST programme against a combined condition that included both LST and a family-based programme or a control condition. Drug initiation outcomes (alcohol, tobacco, and cannabis) were evaluated one year after cluster-randomization in a sample of rural Midwestern American high school students. The LST intervention was found to be effective on a substance initiation index (combining all substances). However, when alcohol initiation was evaluated separately, LST was not shown to significantly prevent onset of drinking in adolescents. Effects of the LST intervention on binge drinking or drunkenness were not reported in this study. The evidence in favour of the LST programme has also been criticised by Gorman (2002) who highlighted problems with the sampling methodology of the most prominent LST effectiveness study. Botvin and colleagues (2000) reported a six-year follow up of a randomised controlled trial of the LST programme but restricted the analysis to only a small subset, namely 7.5% of participants in the study, thus violating the fundamental principles of intent-to-treat analyses (Gorman, 2002). Hence, the longterm effectiveness of the LST programme may be less conclusive than originally thought and caution should be used when making inferences about the robustness of such programmes in producing long-term effects on alcohol and other substance-related behaviour. In addition, a large study in the U.S. was conducted recently to evaluate the effectiveness of the Take Charge of Your Life (TCYL) programme, a comprehensive universal programme delivered by trained police facilitators of the DARE programme. Results from this study found an overall negative effect of the TCYL programme, with intervention students reporting an increase in their use of alcohol and cigarette use, and no differences between groups reported for cannabis use (Sloboda et al., 2009). The authors are actively studying the effect of the intervention on mediators and modifiers in order to explain the reason for these disappointing findings; however, it appears that the more reasonable explanation is that the providers of the intervention were law enforcement officers, and that this could have reduced the possible effect of intervention among at-risk students.

23 More recent evidence for the comprehensive approach comes from the European ‘Unplugged’ Programme, a school-based curriculum against youth alcohol and other substance use which includes components such as normative education and resistance skills (Van Der Kreeft et al., 2009). The programme was packaged into standardised materials and adapted for seven European countries (Belgium, Germany, Spain, Greece, Italy, Austria, and Sweden) and it was evaluated within the frame of the European Drug Addiction Prevention (EU-Dap) study, a randomised controlled community trial, conducted between September 2004 and May 2006. The first follow-up was conducted three months after the end of the delivery and showed that the programme was associated with a reduction of episodes of drunkenness, but not drinking problems, or drinking frequency or quantity (Faggiano et al., 2008). At the 18-month follow-up, the effect on drunkenness survived statistical tests (Faggiano et al., 2010): the intervention was associated with a 20% reduced prevalence of any drunkenness (prevalence odds ratio=0.80) and a 38% reduced prevalence of frequent drunkenness (prevalence odds ratio=0.62). Relative reduction rates for alcohol initiation and weekly drinking were not significant (Faggiano, 2009). This programme has subsequently been shown to be ineffective for students attending schools classified as having medium or high socio-economic status, and more effective for those attending schools classified as having low socioeconomic status. Once this important moderator is considered, this programme was shown to have significant effects on any drinking, weekly drinking, and problem drinking symptoms (Caria, Faggiano, Bellocco, & Galanti, 2011). Finally, another moderator analysis revealed that this programme was more effective in preventing onset of binge drinking in boys, but that the programme was equally effective in preventing progression to regular drunkenness in boys and girls (Vigna-Taglianti et al., 2009). However, it is unclear if this finding is a reflection of how girls drink (progressing more quickly to heavy drinking; see Stewart, Gavric, & Collins, 2009) or of gender-specific effects of the intervention.

24 Another European-based trial of the effectiveness of the LST programme was conducted by Morgenstern et al. (2009). They reported that the intervention significantly reduced risk of lifetime binge drinking at 4 month and 12 month follow-ups with an adjusted odds ratio of 0.56 at four months, suggesting a 44% reduction in binge drinking prevalence, and 0.74 at 12 months, suggesting a 36% reduction in binge drinking prevalence.

25 In summary, the comprehensive approach, particularly the LST programme, can be culturally adapted for new contexts and produces reliable effects on binge drinking, but limited effects on drinking initiation or frequency of drinking. Overall effects on drinking behaviours are small (10%-30% relative reductions), with little support for the effects on drinking initiation, drinking frequency, or drinking problems and stronger support for effects on drunkenness or binge drinking. Furthermore, these reductions have been shown to last up to three years. The programme appears to be effective for both minority populations and majority populations, in both the U.S. and European contexts, and for both girls and boys. There is some evidence suggesting that the more at-risk the population, the greater the effects of the programme (e.g., Botvin et al., 2001; Caria et al., 2011). Another feature identified but not systematically tested as a potential moderator of programme efficacy is the extent of the intervention deliverer’s affiliation with law-enforcement (Sloboda et al., 2009).

PEER-LED INTERVENTION

26 Like drink refusal skills training, peer-led interventions are based on the idea that altering peer influences can have beneficial effects (Velleman, 2009). In the peer-led intervention context, peers are trained to become educators and attitude-formation leaders. The rationale is that peers have the power to influence one another’s attitudes and behaviour if given the information and skills to do so. Moreover, people of the same age feel freer to talk to one another. There is some evidence that peer-led interventions do not always work, however. For example, one study showed no effects of a peer support programme on adolescents’ knowledge, attitudes, or use of alcohol (Webster, Hunter, & Keats, 2002). Interestingly, some research suggests that peer-led interventions may work more for those delivering rather than those receiving the intervention (Sumnall et al., 2006). One study demonstrated the possibility of interactions between peer education and the makeup of the peer network (Valente et al., 2007). Specifically, deleterious effects of the peer-led interventions were found among those with peer networks that support alcohol and drug use.

SELECTIVE VERSUS UNIVERSAL PREVENTION

27 Considering the large literature on childhood risk factors for early onset drinking and problems with alcohol (reviewed in Chapter 2), and the results reviewed above showing possible beneficial effects of universal programmes in higher-risk populations, there is an argument for developing and delivering prevention programmes that target specific populations. Selective interventions have the advantage of allowing the focus of limited resources to be used on those most at need. They also address individual needs of homogeneous at-risk groups and offer an opportunity to tailor interventions to the etiological processes implicated in different risk profiles (Conrod, Castellanos-Ryan, & Strang, 2010; Conrod, Mackie, & Castellanos, 2008; Conrod, Stewart, Comeau, & Maclean, 2006; Thush et al., 2007). Selective prevention programmes are often overlooked due to their practical limitations. It is not only difficult to initially identify those individuals at greatest risk, but finding suitable, cost-effective ways to screen and deliver interventions can also be challenging (Offord, 2000). However, in recent years we have seen the development of selective programmes which are showing that these ethical and practical obstacles can be overcome.

28 One such approach, known as the Personality-Targeted Approach, is a brief, selective programme that presents a novel approach to alcohol and other substance misuse prevention by targeting personality risk factors for early-onset drinking or illicit drug use. It is the first and only school-based alcohol and drug prevention programme that has been shown to prevent growth in alcohol and substance misuse in three separate trials across Canada (Conrod et al., 2006) and the United Kingdom (Conrod et al., 2010; Conrod et al., 2008; Conrod et al., in press; O’Leary-Barrett, Mackie, Castellanos-Ryan, Al-Khudhairy, & Conrod, 2010), through targeting youth with elevated scores on four personality risk factors for early-onset alcohol/drug misuse and other risky behaviours: Hopelessness, Anxiety Sensitivity, Impulsivity, and Sensation-Seeking (Battista, Pencer, McGonnell, Durdle, & Stewart, in press; Krank et al., 2011; Woicik, Stewart, Pihl, & Conrod, 2009). Youth are screened in classroom settings during school hours, and those scoring one standard deviation above the school mean on one of these four personality traits, as measured using the Substance Use Risk Profile Scale (Battista et al., in press; Krank et al., 2011; Woicik et al., 2009), are invited to participate in coping skills workshops. Each of the four personality-specific interventions involve adolescents selected for particular personality profiles to work together over two 90-minute group sessions guided by a trained facilitator and co-facilitator at school. The interventions are manualised and incorporate psycho-educational, motivational enhancement, and cognitive-behavioural components, and include real life ‘scenarios’ shared by high-risk youth in specifically-organised focus groups. A novel component to this intervention approach is that all exercises discuss thoughts, emotions, and behaviours in a personality-specific way.

29 Three separate randomised-controlled trials have shown that this intervention approach is associated with reduced drinking, binge drinking, and problem drinking symptoms in high-risk youth over six months (Conrod et al., 2010; Conrod et al., 2008; Conrod et al., 2006; O’Leary-Barrett et al., 2010), with one of these trials, the Preventure Trial, showing two-year reductions in problem drinking symptoms and illicit drug use in high-risk youth (Conrod et al., 2010; Conrod, Castellanos-Ryan, & Mackie, 2011). A recent cluster-randomised trial, known as the Adventure Trial, replicated the preventative effects of personality-targeted interventions on alcohol use when delivered by trained school-staff (Conrod et al., in press; O’Leary-Barrett et al., 2010), thus suggesting that this intervention approach can operate within an implementation model that has a higher likelihood of being adopted by schools in a sustainable manner. The results of this recent study are central to the development of an effective (as opposed to merely efficacious) intervention. This trial demonstrates that targeted interventions can be successfully delivered by educational staff who have been trained and supervised, and that targeted interventions have the potential to become a sustainable school-based prevention model.

30 Effect sizes for binge drinking from the Adventure trial were similar to those from previous clinician-run personality-targeted intervention trials, with odds ratios between 0.4 and 0.5 across all trials for youth who had already consumed alcohol by 13 years of age (i.e. a particularly high-risk group). These odds ratios correspond to a 50-60% decreased likelihood of binge drinking six months post-intervention. The corresponding odds ratios for a sample including youth who were non-drinkers at baseline were 0.65-0.7, representing a 30-35% decreased likelihood of reporting binge drinking six months later. ‘Numbers Needed to Treat’ across the three trials for baseline alcohol users ranged from four to six, indicating that four to six individuals are required to receive an intervention in order to prevent one case of binge drinking. These effect sizes are remarkable given that the most effective universal alcohol prevention programmes have ‘Numbers Needed to Treat’ values from nine to 30 (Faggiano et al., 2008), which requires targeting at least double the number of adolescents in order to prevent one case of binge drinking. A more recent two-year follow-up of this programme which involved two-part latent growth models to evaluate onset and progression to heavier drinking over time indicated long-term effects of the intervention on drinking rates, binge drinking rates, and growth in binge drinking and problem drinking in high-risk youth, such that high-risk youth showed 43% reduced odds of binge drinking and 29% reduced odds of reporting problem drinking over the course of the trial (42% reduced odds of problem drinking at the two-year follow-up; Conrod et al., in press). High-risk youth were also shown to benefit from the interventions over the 24-month follow-up on drinking quantity, and growth in binge drinking frequency. Furthermore, some herd effects in (untreated) low-risk youth were observed, specifically on drinking rates and growth of binge drinking. In this context, herd effects refer to risk reduction in untreated individuals secondary to reductions in drinking among treated individuals in the population. The idea is that because drinking has been reduced in the high-risk youth through the targeted intervention, this can result in reduced drinking/binge drinking even among untreated low-risk youth by reducing modelling of drinking, and peer pressure and opportunities to drink within students’ social networks. This study reported that the intervention was associated with a 29% reduced odds of drinking over the course of the trial in students attending intervention schools relative to students in control schools which compares favourably to some of the best results from universal comprehensive programmes. Importantly, however, the effect only required intervening upon 45% of the population. There is also an added benefit of this approach: by targeting underlying personality risk factors for alcohol/drug misuse that are also implicated in vulnerability to other mental disorders, this programme also produces benefits in mental health outcomes, such as depression, anxiety, and conduct disorder symptoms (e.g., Castellanos & Conrod, 2006).

31 Another selective programme worth mentioning is one developed in Quebec, Canada which targets high-risk boys with persistent aggressive tendencies in childhood (Tremblay, Pagani-Kurtz, Mâsse, Vitaro, & Pihl 1995; Tremblay & Schaal, 1996). This programme was evaluated within a longitudinal study of primary school children in which 172 boys attending kindergarten in low socio-economic neighbourhoods of Montreal underwent a randomised controlled trial for disruptive behaviour. The intervention was delivered for two years (when the boys were seven to nine years old). It consisted of two main components: a) social and problem-solving skills training for the boys in a group setting, and b) parent training on effective child-rearing skills. Adolescent substance-use, up to eight years post-intervention, was shown to be reduced in those who received the intervention, with effect sizes ranging from.46 to.67, suggesting large effects. More importantly, findings showed that the intervention effect on alcohol-use frequency at 14 years and on growth in number of different drugs used across adolescence (1417 years) were explained, respectively, by reductions in both antisocial behaviours and affiliation with less deviant peers, and by a reduction of impulsivity during pre-adolescence (11 to 13 years; Castellanos-Ryan, Vitaro, Parent, Tremblay, & Seguin, 2012).

32 In summary, the selective personality-based approach to alcohol prevention appears to be highly effective for youth with personality risk factors for early onset alcohol misuse and evidence exists for both the North American and European contexts. There is also preliminary evidence that this approach might also indirectly delay onset and growth of drinking in the general lower-risk population.

INDICATED PROGRAMMES

33 In contrast to selective prevention programmes carried out with groups at-risk for alcohol problems, indicated prevention programmes are those that are carried out with individuals who are already showing signs/symptoms of an alcohol use disorder. Since indicated interventions hold much in common with alcohol use disorder treatment, they are generally beyond the scope of this chapter on alcohol prevention. Nonetheless, there are some school-based indicated programmes that are worthy of mention here. In the next sections, we briefly review the evidence for the efficacy of brief interventions for college students, like the Brief Alcohol Screening and Intervention for College Students (BASICS; Dimeff, Baer, Kivlahan, & Marlatt, 1999), as well as expectancy challenge interventions. It should be noted here that while these interventions are often used as indicated interventions, many are used with volunteers (sometimes heavy drinkers) or universally. In fact, several randomised controlled studies of these approaches deliberately screen out problem drinkers when testing intervention efficacy. Thus, while these interventions are classified as indicated approaches within our review, they do not fit readily within the universal/selective/ indicated organizational framework.

Brief Interventions for College Students

34 Because the legal drinking age in the U.S. is 21, there are many underage drinkers on U.S. college campuses. As U.S. youths transition from high school to college, they often experience significant increases in their prevalence, frequency, and quantity of drinking (Bachman, Wadsworth, O’Malley, Johnston, & Schulenberg, 1997; White, Labouvie, & Papadaratsakis, 2005), especially if they leave their parents’ home (White, McMorris, Catalano, Fleming, Haggerty, & Abbott, 2006). Along with these increases comes a host of alcohol-related negative consequences, including fatal and nonfatal accidents, academic failure, violence and other crime, and unsafe sexual behaviour (Hingson, Zha, & Weitzman, 2009; Presley, Meilman, & Cashin, 1996; Wechsler, Lee, Kuo, & Lee, 2000; Wechsler, Lee, Nelson, & Lee, 2001). Therefore, college campuses have developed numerous prevention programmes to reduce the harms associated with heavy drinking by college students. These programmes target factors associated with student drinking, such as alcohol expectancies and perceived norms for other student drinking and acceptance of drinking (similar to the social norms approach discussed earlier), as well as attempt to increase protective behavioural strategies and motivations to change drinking behaviour (Cronce & Larimer, 2011). Because most of this report focuses on drinking earlier in adolescence, we only briefly discuss these prevention programmes here (for greater detail, see Cronce & Larimer, 2011). Note, however, that some of these programmes could be modified for use with younger adolescents.

35 Larimer and Cronce (2002, 2007), and Cronce and Larimer (2011), reviewed individual-based alcohol prevention programmes for college students. Overall, they found a lack of support for education and awareness programmes, which were solely didactic (instructive) or used values clarification approaches. On the other hand, they found consistent support for the efficacy of brief, personalised, individual motivational feedback interventions, alcohol expectancy challenge interventions (see next section), other types of skills training (e.g., self-monitoring), and stand-alone personal feedback interventions. In addition, there was some limited support for multi-component alcohol education interventions if they included elements of personal feedback (for greater details on these types of interventions, see Cronce & Larimer, 2011).

36 As stated above, one type of brief intervention that has been particularly effective with college students is brief personalised feedback interventions. Personalised feedback interventions provide written and graphical feedback on a student’s drinking pattern relative to other college students (i.e., normative feedback), peak blood alcohol concentration, alcohol-related problems, and personal risk factors (e.g., dependence symptoms, family history of alcoholism) (Cronce & Larimer, 2011; Dimeff et al., 1999). Some feedback sheets also include protective behavioural strategies and/or highlight consequences that are especially salient for students, such as the calories they gain from drinking and the amount of money they spend on alcohol.

37 Although personalized feedback interventions are sometimes used as stand-alone interventions, they are often provided within the context of a brief motivational intervention. Brief motivational interventions, which are usually delivered in one or two sessions, aim to increase the student’s motivation and readiness to change their drinking behaviour. The motivational interview context relies on motivational enhancement techniques to increase students’ readiness for change and to help guide them through the change process (Dimeff et al., 1999). They are also dependent on the student being pre-identified as having experienced a problem related to their alcohol use (e.g., identified in the emergency room, through mass screening, or through university security). Facilitators use a motivational interviewing style, which presents feedback in an empathetic, non-judgmental manner (Miller & Rollnick, 2002). Brief motivational interventions often also include presentation of general alcohol education (e.g., effects at various BACs, cognitive effects of alcohol) as well as a discussion of harm reduction strategies (e.g., how to pace drinks) (Cronce & Larimer, 2011).

38 Overall, evaluations of personalised feedback interventions for college students within the context of a brief motivational intervention and as stand-alone interventions (e.g., written feedback only or web-based feedback), have found them to be more efficacious than educational interventions or assessment-only control conditions (for reviews, see Carey, Scott-Sheldon, Carey, & DeMartini, 2007; Cronce & Larimer, 2011; Larimer & Cronce, 2002, 2007; Walters & Neighbors, 2005; White, 2006). Support for brief personalised feedback and motivational interventions have also been found for students attending Further Education Colleges in the United Kingdom when delivered by trial therapists or trained professionals in the college setting (Grey, McCambridge, & Strang, 2005; McCambridge & Strang, 2004). However, in one study in the U.K., the effects reported for brief interventions were short-lived (McCambridge & Strang, 2004), did not generalise to all drinking outcomes, and were more effective for those reporting greater alcohol use at baseline. Furthermore, according to a more recent trial, there is little evidence that this approach will be effective for universal prevention of alcohol misuse in college students. McCambridge, Hunt, Jenkins, and Strang (2011) recently reported the results of a cluster randomised trial investigating whether brief motivational interviewing could be effective for universal preventions, that is, for students who had not necessarily initiated use or begun to experience problems with alcohol or other substances. This trial which involved 416 students aged 16-19 years old recruited in 12 London Further Education Colleges, and compared the effect of a one-session individualised motivational intervention with a standard practice classroom-delivered Drug Awareness intervention. No group differences in prevalence, initiation, and cessation of alcohol consumption were reported at 3 and 12 months post intervention. On the other hand, findings have been inconsistent in the U.S. as to whether these interventions are better for heavier than lighter drinkers, and some have shown long-term benefits (Mun, White, & Morgan, 2009). More research is needed to: 1) identify the components of feedback that are necessary and sufficient and the best methods for delivery to enhance the preventative effects of brief motivational interventions; 2) evaluate potential mechanisms of intervention efficacy; 3) understand why the intervention is only effective for heavier drinkers; and 4) identify ways to prolong the long-term effects of these interventions (Cronce & Larimer, 2011; Walters & Neighbors, 2005; White, 2006). There is some limited research indicating that personalised feedback interventions may be efficacious with adolescents (e.g., D’Amico & Fromme, 2002). However, much more research is needed to test brief individualised interventions with underage drinkers.

Expectancy-Based Interventions

39 As discussed in Chapter 2, positive alcohol expectancies and motivations to drink are risk factors for drinking among adolescents. One important implication of the notion that alcohol-related cognitions are a central construct in the prediction of drinking in young people, is that they would be a prime target for prevention and early intervention (Goldman, 1999). Indeed, both explicit and implicit alcohol-related cognitions (see Chapter 2) have been targeted in interventions. Expectancies have been targeted using alcohol expectancy-challenge procedures (Darkes & Goldman, 1993; Darkes, Greenbaum, & Goldman, 1998). These procedures involve comparing the actual effects attributable to alcohol to those which an individual expects from drinking alcohol, to make drinkers more aware of the degree to which their drinking behaviours and responses to drinking are impacted by expectancies (Cronce & Larimer, 2011). Because alcohol expectancy challenge procedures often involve actual and perceived alcohol administration, they are rarely used with underage drinkers for legal and ethical reasons. Instead, they have been used mainly with young adults. The alcohol expectancy challenge procedure has been shown to lead to changes in explicit expectancies, but to have minimal impact on implicit cognitions (Wiers, van de Luitgaarden, van den Wildenberg, & Smulders, 2005). Two studies tested whether the change in explicit expectancies ‘mediated’ or helped explain a change in drinking behaviour, with one reporting a positive result (Wiers et al., 2005), and one a negative result (Wood, Capone, Laforge, Erickson, & Brand, 2007). In other targeted prevention programmes, expectancies are also discussed (e.g., BASICS; Dimeff et al., 1999). Motives to drink are a prime target in Motivational Interviewing. Motivational Interviewing has been shown to be a successful intervention in adults (Miller, 1998) and college students (Cronce & Larimer, 2011), but has yielded more mixed results with adolescents (Grenard, Ames, Pentz, & Sussman, 2006). Motivational Interviewing does not appear to affect implicit cognitions (Thush et al., 2009). It is worth noting that some alcohol expectancy challenge studies use videotapes of other people drinking and would, therefore, be amenable for use with underage drinkers (for greater detail, see Darkes et al., 1993, 1998).

40 Recently, researchers have begun to directly target implicit cognitive processes in addiction through cognitive retraining programmes. For example, an attentional bias for alcohol (i.e., the tendency to selectively attend to alcohol-related cues) has been successfully re-trained, with positive results on drinking outcomes in adult problem drinkers (Fadardi & Cox, 2009) and in alcoholic patients (Schoenmakers et al., 2010). Similarly, an approach bias for alcohol (i.e., the automatic tendency to approach alcohol) has been successfully re-trained in hazardous drinking university students (Wiers, Rinck, Kordts, Houben, & Strack, 2010). Positive alcohol associations (i.e., the automatic tendency to associate alcohol cues with positive outcomes) have also been successfully changed through evaluative conditioning procedures, with positive results on drinking in the short-term (Houben, Havermans, & Wiers, 2010). Finally, recent research also indicates that training executive control may be helpful in problem drinkers (Houben, Nederkoorn, Wiers, & Jansen, 2011). Although these results are promising, it should be noted that none of these studies have included adolescents as of yet and none have been shown to prevent either the onset of drinking or harmful drinking.

Effective principles for school-based alcohol prevention

41 Newton, Vogl, Teesson, and Andrews (2011) recently reviewed the principles that have consistently been associated with effective alcohol prevention programmes in schools (Ballard et al., 1994; Cuijpers, 2002; Dusenbury & Falco, 1995; Meyer & Cahill, 2004; Midford, Munro, McBride, Snow, & Ladzinski, 2002). Effective programmes were identified as being: evidence-based and theory driven, targeted to risk factors for substance use and psychopathology, developmentally appropriate, implemented prior to harmful patterns of use being established, part of a comprehensive health education curriculum, based on a skill-building approach (which must include providing resistance skills training, and normative education), immediately relevant to students, interactive, but keeping teacher as the central role, sensitive to the cultural characteristics of the target audience, able to provide adequate initial coverage and continued follow-up in booster sessions; and delivered within an overall framework of harm minimization, rather than being abstinence-based.

Obstacles to effective drug education in schools

42 There are many barriers or ‘obstacles’ which can impede the effectiveness of prevention programmes even when they are evidence-based (Botvin, 2004; Dusenbury & Hansen, 2004; Elliott & Mihalic, 2004; Kaftarian, Robinson, Compton, Davis, & Volkow, 2004). A number of issues, particularly those related to implementation and dissemination of programmes, have been identified as causing the greatest obstacles and interfering with programmes being able to have an impact on behavioural outcomes (Cahill, 2007; Castro, Barrera, & Martinez, 2004; Ennett et al., 2003; Greenberg, 2004; Pentz, 2004; Rohrbach & D’Onofrio, 1996).

43 The dissemination of alcohol prevention programmes into schools is not always entirely successful (Botvin et al., 2003; Cuijpers, 2003), but can be achieved with extensive training and close supervision (O’Leary-Barrett et al., 2010). Two large studies recently reported that less than 15% of schools in the U.S. implemented evidence-based programmes or reported following a programme guide or manual very closely (Ennett et al., 2003; Ringwalt et al., 2003), and one of these studies reported that one-fifth of teachers reported not using a curriculum/ programme guide at all when delivering drug and alcohol prevention. It is well established that programmes delivered with high fidelity lead to superior outcomes for students and programmes delivered with poor fidelity lead to poorer outcomes (e.g., Dane & Schneider, 1998).

44 Internet-based technology offers a practical means of improving implementation fidelity while delivering evidence-based programmes. Computer-based drug prevention programmes have been designed for both universal (Duncan, Duncan, Beauchamp, Wells, & Ary, 2000; Gregor et al., 2003; Gropper, 2002; Schinke, Schwinn, DiNoia, & Cole, 2004; Williams, Griffin, Macaulay, West, & Gronewold, 2005) and targeted populations (Bosworth, Gustafson, & Hawkins, 1994; Schinke, Schwinn, & Ozanian, 2005) and involve youth navigating through simulated real life scenarios (Gregor et al., 2003; Schinke et al., 2004). There is a small literature to suggest that such programmes are both feasible and acceptable (Bosworth et al., 1994; Duncan et al., 2000; Gregor et al., 2003; Schinke et al., 2004; Schinke et al., 2005; Williams et al., 2005).

45 While computerised alcohol prevention programmes are showing promise in terms of affecting behaviours proximal to alcohol use outcomes (e.g., increase alcohol-related knowledge and attitudes; decrease pro-drinking attitudes; Gropper, 2002; Marsch, Bickel, Badger, 2006; Newton, Teesson, Vogl, & Andrews, 2010; Newton, Andrews, Teesson, & Vogl, 2009; Newton, Vogl, Teesson, & Andrews, 2009; Schinke et al., 2004; Williams et al., 2005), the evidence for behavioural change is more limited as most studies have failed to collect behavioural measures (Duncan et al., 2000; Gregor et al., 2003; Gropper, 2002). Of course, this criticism applies to many alcohol prevention programmes delivered in a variety of formats and the lack of behavioural outcome data is not unique to web-based interventions. One Internet-based programme which has demonstrated positive effects in reducing actual alcohol and other drug use is the series of Climate Schools programmes for alcohol and drug prevention specifically designed to overcome factors which typically compromise programme efficacy. The modules are contemporary, cartoon-based, educational programmes based on a social influence approach to prevention, and consistent with the effective harm minimisation framework (McBride, Farringdon, Muleners, & Midford, 2006). Each Climate Schools module consists of six 40-minute lessons. The first half of each lesson is completed individually online where students follow a cartoon storyline of teenagers experiencing real life situations and problems with alcohol and cannabis. The cartoon storylines are used to engage and maintain student interest and involvement over time (Schinke et al., 2004). The second part of each lesson is a predetermined activity delivered by the teacher to reinforce the information learned in the cartoons.

46 The efficacy of the Climate Schools model has been demonstrated for stress reduction (Van Vliet & Andrews, 2009) and alcohol misuse (Newton, Andrews et al., 2009; Vogl et al., 2009). In one study (Newton, Vogl et al., 2009), the Alcohol module of Climate Schools was more effective than usual classes in decreasing average alcohol consumption, frequency of binge drinking (drinking in excess), and alcohol-related harms. A feasibility trial of the Climate Schools programme in the United Kingdom is ongoing and will provide data on the acceptability of this universal programme in the European setting (Newton & Conrod, in preparation).

47 These findings suggest that the Internet offers a promising delivery method for preventing alcohol and other drug use in adolescents. While there is a strong push to adapt programmes for this delivery method, we also caution that this work should be done with careful evaluation of effects on behaviour, considering the results of studies in which small modifications to the implementation of evidence-based prevention programmes led to iatrogenic effects on behaviour.

Family-based prevention programmes

48 Universal prevention programmes have also been delivered in the family setting. These approaches typically aim at supporting the development of parenting skills including parental support, nurturing behaviours, clear communication, establishing and enforcing clear boundaries or rules, and parental monitoring. In addition, universal family-based prevention can include components focused on the adolescent such as the development of social skills, peer resistance skills, and appropriate behavioural norms. However, unlike school-based programmes, the latter skills and norms are instilled indirectly, via parents and family, rather than directly to the adolescents themselves. The underlying assumption of family-based prevention is that if young people have a positive family environment, and develop good peer resistance and social skills, they are more likely to develop and adopt the behavioural norms displayed within their families and to be resilient against external influences such as peer pressure (Foxcroft & Tsertsvadze, 2011b).

49 At least two systematic reviews have assessed the efficacy of various family-based programmes (Foxcroft & Tsertsvadze, 2011b; Petrie, Bunn, & Byrne, 2007). Petrie et al. (2007) conducted a systematic review of controlled studies of parenting programmes to prevent substance abuse in children and adolescents under the age of 18 years. Data were collected on actual or intended use of alcohol and other substances (tobacco and/or other drugs), and associated risk or antecedent behaviours. Twenty studies met their inclusion criteria. Of these, five focused exclusively on alcohol (Loveland-Cherry, Ross, & Kaufman, 1999; Park et al., 2000; Perry et al., 2002; Werch, Owen et al., 2003; Williams, Grechanaia, Romanova, Komro, Perry, & Farbakhsh, 2001), and nine on alcohol and tobacco and/or other drugs (Bauman, Foshee, Emmett, Hicks, & Penberton, 2001; Forman & Brondino, 1990; Hawkins, Catalano, Kosterman, Abbott, & Hill, 1999; Johnson et al., 1990; Lochman & Wells, 2003; Pentz et al., 1989; Spoth et al., 2001; Perry et al., 2003; Spoth et al., 2002). Of these 14 studies focusing on alcohol outcomes, 13 were conducted in the U.S. and the remaining study was conducted in Russia (Williams et al., 2001). None were conducted in Europe. Unqualified statistically significant reductions of alcohol use were found in six of these 14 studies (Lochman & Wells, 2003; Park et al., 2000; Pentz et al., 1989; Perry et al., 2002; Spoth et al., 2001; Spoth et al., 2002). Three others showed significant reductions in alcohol use, but only for certain subgroups (i.e., for boys only, Perry et al., 2003; only in a school where kids were bussed in, Werch, Owen et al., 2003; only for those students with no alcohol use prior to the intervention, Loveland-Cherry et al., 1999). One of the 14 studies showed a statistically significant increase in alcohol use, but only for those young people who had already started drinking by the time of the intervention (Loveland-Cherry et al., 1999). Thus, parent-based prevention programmes can be effective in reducing or preventing alcohol use. This review concluded that the most effective approaches are those that emphasise active parental involvement as well as developing skills in social competence, self-regulation, and parenting (Petrie et al., 2007). However, the authors also noted significant heterogeneity in the methodology of the studies, and stressed that more work is needed to investigate further the long-term effectiveness of parenting programmes.

50 Of the trials included in the Petrie et al. (2007) review, the only non-North American study was conducted in Russia, with materials based on the American ‘Project Northland’ programme (Perry et al., 1996). Although the programme increased parent-child communication and led to increases in students’ knowledge about the negative consequences of underage drinking, there were no changes in adolescents’ actual alcohol use rates by the end of the first year of the three-year programme (Williams et al., 2001). This is in spite of efforts to make the intervention culturally appropriate for the Russian context such as starting a year earlier due to Russian young people’s earlier onset of drinking relative to North American youth (Williams et al., 2001). At first glance, this may appear to suggest that other important cultural differences were neglected in the attempted transfer of this parent-based prevention programme, developed in Minnesota, to a non-North American context. However, the original American ‘Project Northland’ did not achieve changes in students’ alcohol use until the third year of the intervention by which time a multi-component intervention had been implemented in addition to the parent-based programme (Perry et al., 1996). We cover multi-component interventions in a later section.

51 Recently, Foxcroft and Tsertsvadze (2011b) conducted a Cochrane systematic review of evidence on the effectiveness of universal family-based prevention programmes in preventing alcohol misuse in school-aged children and adolescents. Twelve randomised controlled trials evaluating universal family-based prevention programmes and reporting outcomes for alcohol use in students 18 years of age or younger met their criteria and were included in the analysis (Bauman et al., 2002; Brody et al., 2006; Haggerty, Skinner, MacKenzie, & Catalano, 2007; Koning et al., 2009; Loveland-Cherry et al., 1999; O’Donnell, Myint, Duran, & Stueve, 2010; Schinke, Cole & Fang, 2009a; Schinke, Fang, & Cole, 2009b; Schinke, Fang, & Cole, 2009c; Spoth, Lopez Reyes, Redmond, & Shin, 1999; Stevens et al., 2002; Werch et al., 2008). As this review was conducted more recently, only one of the 14 trials covered by Foxcroft and Tsertsvadze (2011b) (i.e., Loveland-Cherry et al., 1999) overlapped with the studies reviewed by Petrie et al. (2007). This review also built upon the review by Petrie et al. (2007) by examining persistence of effects over the longer term in addition to immediate post-treatment outcomes. The authors found that the reporting quality of trials was poor, and that inadequate reporting of the method of randomization and programme allocation concealment was common. Incomplete data was adequately addressed in about half of the trials and this information was unclear for close to one-third of the trials. Due to extensive heterogeneity across interventions, populations, and outcomes, the results were summarised only qualitatively. Eight of the twelve trials showed statistically significant evidence of effectiveness compared to a control or other intervention group, with persistence of effects over the medium and longer-term (i.e., Brody et al., 2006; Loveland-Cherry et al., 1999; O’Donnell et al., 2010; Schinke et al., 2009a; Schinke et al., 2009b; Schinke et al., 2009c; Spoth et al., 1999; Werch et al., 2008). Four of the effective interventions were gender-specific, focusing on young females and (primarily) their mothers (O’Donnell et al., 2010; Schinke et al., 2009a; Schinke et al., 2009b; Schinke et al., 2009c). One study, with a small sample size, showed positive effects that were only marginally significant at p =.10 (Bauman et al., 2002), and three studies with larger sample sizes reported no significant benefits of the family-based intervention for reducing alcohol misuse (Haggerty et al., 2007; Koning et al., 2009; Stevens et al., 2002). In fact, the Stevens et al. (2002) study suggested the intervention resulted in a larger proportion of ‘ever drinkers’ at the three year follow up relative to a control intervention focusing on other safety behaviours (e.g., helmet, seatbelt use). Taken together, these findings led the authors to conclude that the effects of family-based prevention interventions are small but generally consistent, and also persistent into the medium- to longer-term (Foxcroft & Tsertsvadze, 2011b). The authors also noted that although the effects may be small in magnitude, even small effects can be important from a public health perspective (Foxcroft & Tsertsvadze, 2011b).

52 All of the studies included in the Foxcroft and Tsertsvadze (2011b) review, save one, were conducted in the United States. The exception was a single European trial, conducted in the Netherlands, which focused on parental rule-setting around their offspring’s alcohol use (Koning et al., 2009). This parent intervention was modeled after the Swedish ‘Orebro Prevention Programme’ which had been tested previously in a quasi-experimental study and which had been shown to be effective in reducing underage drunkenness in Sweden (Koutakis, Stattin, & Kerr, 2008). Koning et al.’s (2009) objectives were to test this intervention more rigorously (in a randomised controlled design), and to examine the generalizability of the effects of this parental intervention in a context where adolescent drinking is much more prevalent than in Sweden (see Chapter 1). In the Dutch study, the parental intervention was compared to a school-based, youth-focused intervention, each provided alone or in combination in a two by two factorial design. Unlike the Swedish findings (Koutakis et al., 2008), the parental intervention alone had no significant effects on any of the alcohol outcomes (heavy weekly drinking, weekly drinking, drinking frequency) at either 10 or 22 months post-intervention. The results suggest that parental rule setting alone may be less effective in deferring the onset of adolescent drinking in countries with more liberal alcohol policies and lower legal drinking ages (e.g., the legal drinking age in the Netherlands is 16 years and there is weaker enforcement of laws that prohibit selling of alcohol to minors). It would be interesting to see if parental interventions are any less effective in Canada than in the U.S. given the differences between these two North American countries in legal drinking age. Despite the absence of any evidence of efficacy of the parental intervention alone in the Koning et al. (2009) study, there were clear and persisting effects of the combined parent- and child-focused intervention on a variety of alcohol outcomes. The findings of this study are discussed in the next section, and suggest that both parents and children should be targeted simultaneously in multi-component interventions to achieve best results, at least in the Dutch context.

53 Before concluding this section, it is worth reiterating that two of the trials reviewed by Petrie et al. (2007) and Foxcroft and Tsertsvadze (2011b) showed evidence of increases in alcohol use in the experimental group receiving the family-based intervention (i.e., Loveland-Cherry et al., 1999; Stevens et al., 2002). These findings warn of the potential for iatrogenic effects of these interventions in certain cases. But as Foxcroft and Tsertsvadze (2011b) caution, the possibilities that these effects may have arisen by chance, or that they are secondary to differential attrition across groups or to confounding factors, need to be ruled out before we can conclude any iatrogenic effects of particular family-based interventions.

MULTI-COMPONENT PREVENTION PROGRAMMES

54 Multi-component prevention approaches are programmes where the intervention is delivered in multiple different settings. For example, the intervention might occur in both family and school settings, potentially combining a parental intervention with school-based prevention curricula, as described in earlier sections. Thus, in school settings, a multi-component prevention typically takes the form of alcohol awareness education, social and peer resistance skills training, normative feedback, and/or development of behavioural norms, and positive peer affiliations. The family-based component often aims to support the development of parenting skills and parental monitoring, and/or helping parents to establish clear rules around alcohol use (Foxcroft & Tsertsvadze, 2011c). The parent- and child-focused components are most commonly delivered simultaneously.

55 A Cochrane systematic review was recently conducted on universal multi-component programmes in preventing alcohol misuse in school-aged children and adolescents (Foxcroft & Tsertsvadze, 2011c). The authors identified 20 parallel-group randomised controlled trials evaluating prevention programmes where the intervention was delivered in more than one setting and reported outcomes for alcohol use in students up to age 18 years (i.e., Brown, Catalano, Fleming, Haggerty, & Abbott, 2005; Eddy, Reid, & Fetrow, 2000; Furr-Holden et al., 2004; Hawkins et al., 2009; Komro et al., 2006; Koning et al., 2009; Perry et al., 1996; Perry et al., 2003; Reddy et al., 2002; Schinke et al., 2004; Shortt, Hutchinson, Chapman, & Toumbourou, 2007; Simons-Morton, Haynie, Saylor, Crump, & Chen, 2005; Slater et al., 2006; Spoth, Redmond, Trudeau, & Shin, 2002; Spoth et al., 2007; Werch, Pappas et al., 2000; Werch, Moore et al., 2003; Werch, Moore, DiClemente, Bledsoe, & Jobli, 2005a; Werch et al., 2005b; Wu et al., 2003). Of these 20 trials, two were previously reviewed by Petrie et al. (2007) (i.e., Perry et al., 2003; Spoth et al., 2002) and one was previously reviewed by Foxcroft and Tsertsvadze (2011b) (i.e., Koning et al., 2009). As in the previous systematic reviews, the methodological quality of the trials and reporting of study details was noted to be poor, and extensive heterogeneity across interventions, populations, and outcomes was once again found. In 13 of the 20 trials reviewed by Foxcroft and Tsertsvadze (2011c), some evidence of effectiveness was found for the multi-component intervention compared to a control or other intervention group (Brown et al., 2005; Eddy et al., 2000; Hawkins et al., 2009; Koning et al., 2009; Perry et al., 1996; Reddy et al., 2002; Schinke et al., 2004; Slater et al., 2006; Spoth et al., 2002; Werch, Pappas et al., 2000; Werch et al., 2005a; Werch et al., 2005b; Wu et al., 2003). The comparison groups included a no intervention control, educational booklets, face to face interviews, and parent post cards. Four of the 12 effective interventions only assessed immediate post-treatment outcomes (i.e., Brown et al., 2005; Hawkins et al., 2009; Perry et al., 1996; Reddy et al., 2002) while the others assessed and demonstrated durability of effects ranging from three months (Werch et al., 2005b) to three years (Eddy et al., 2000; Schinke et al., 2004) post-treatment.

56 Assessment of the additional benefit of multiple versus single component interventions was possible in seven of the 20 trials reviewed by Foxcroft and Tsertsvadze (2011c). Only one of them clearly showed a benefit of having multiple components. Interestingly, this was the Dutch trial (Koning et al., 2009) discussed earlier in the review of family-based preventions. This trial found the combined, multi-component, student-parent intervention to show substantial and statistically significant effects on heavy weekly drinking, weekly drinking, and frequency of drinking at post-treatment and sustained effects on weekly drinking and frequency of drinking at 22 month follow up. The systematic review by Foxcroft and Tsertsvadze (2011c) thus concluded that there is some evidence that multi-component interventions for alcohol misuse prevention in young people can be effective. They also concluded, however, that there is little evidence that interventions with multiple components are more effective than those with a single component (Foxcroft & Tsertsvadze 2011c).

57 Of the 20 studies reviewed by Foxcroft and Tsertsvadze (2011c), 17 were conducted in the U.S., one in the Netherlands (Koning et al., 2009), one in Australia (Shortt et al., 2007), and one in India (Reddy et al., 2002). Of those conducted outside of the U.S., two showed evidence of efficacy of the multi-component intervention (Koning et al., 2009; Reddy et al., 2002). The Dutch trial has been discussed previously. The Indian trial, conducted in New Delhi, was a school- plus family-based intervention focused on improving children’s cardiovascular health through better nutrition, better diet, and decreased smoking; alcohol use was not a focus of the intervention. The multi-component intervention was compared to the school-based intervention alone and to a no treatment control. The school-based programme was multifaceted and included training in refusing offers to smoke. The family-based intervention consisted of a series of six booklets containing information and family activities focused on improving children’s cardiovascular health. The family booklets were culturally adapted from those used in similar previous work in the U.S. (Luepker et al., 1996; Perry, Luepker, Murray, & Hearn, 1989). Even though the intervention did not focus on alcohol, significant effects of the two interventions were found relative to the control group in terms of reductions in proportion of children reporting ever using alcohol and those intending to drink as adults. The authors speculated that these effects on alcohol outcomes may have been due to the fact that since alcohol and tobacco use are very often co-occurring behaviours, an intervention which is effective in reducing tobacco use may also delay alcohol use (Reddy et al., 2002). There were no differences between the school-based only intervention and the multi-component intervention indicating that there was no additional benefit on alcohol use of sharing the booklets with the families. This may have been due to an insufficient dose of the family-based component, the unsupervised nature of the booklet activities, and/or the lack of interactive intervention with the parents.

58 The Australian trial (Shortt et al., 2007), conducted in Melbourne, examined the outcome of the Resilient Families intervention which involved both school-based and parent-based components. For the school based component, the student curriculum included communication skills, relationship problem solving, emotional awareness training, peer resistance skills building, and conflict resolution skills among the adolescents. The parents were offered both brief and extended training in enhancing parenting skills and encouraging a more positive relationship between parents and their adolescents (Shortt et al., 2007). Although the Resilient Families programme did increase within-family connectedness and problem solving skills as intended, and although it was associated with improvements in both the educational and family environments, intervention effects were not statistically significant predictors of student alcohol use after controlling for other important influences (e.g., peer influences). There are several potential explanations for the lack of significant effects of this multi-component intervention on student alcohol use outcomes. First, the intervention may need to be implemented earlier given the high prevalence of alcohol use in the sample. Second, it is possible that effects still may be observed as this analysis was only for the first year of the intervention. Third, it is certainly possible that the failure to observe effects was due to the lack of interventions focusing specifically on alcohol (e.g., no training for parents in monitoring children’s alcohol use, nor in setting rules about their children’s alcohol use; no specific training for students in drink refusal skills). Finally, not all parents attended the parent sessions. Those who did were already higher in family connectedness, potentially reducing the usefulness of these sessions for these particular families. Future work might examine cross-cultural similarities and differences in the efficacy of multi-component interventions involving both school-and family-based components in preventing, or decreasing (heavy) alcohol use in adolescents.

59 Besides parents and the family, multi-component approaches can also involve a broader community initiative, such as consultation with the police, health professionals, city officials, or local residents, to formulate and support the intervention. Wood, Shakeshaft, Gilmour, and Sanson-Fisher (2006) conducted a systematic review of school-based prevention trials that also involved the community. The authors reviewed 16 studies (Abbey, Pilgrim, Hendrickson, & Buresh, 2000; Aseltine, Dupre, & Lamlein, 2000; Cuijpers et al., 2002; D’Amico & Fromme, 2002; Dedobbeleer & Desjardins, 2001; Dixon & McLearen, 2002; Ellickson et al., 2003; Peleg, Neumann, Friger, Peleg, & Sperber, 2001; Perry et al., 2002; Perry et al., 2003; Schinke et al., 2000; Spoth et al., 2001; Spoth et al., 2002; Werch, Carlson, Pappas, Edgemont, & DiClemente, 2000; Werch, Owen et al., 2003; Williams et al., 2001), 15 of which examined alcohol use outcomes (i.e., all but Abbey et al., 2000). Several of these studies were included in previously discussed systematic reviews (Perry et al., 2002; Perry et al., 2003; Spoth et al., 2001; Spoth et al., 2002; Werch, Owen et al., 2003; Williams et al., 2001). The authors’ goal was to describe and critique the methodologies of multi-component intervention studies that were school-based, but also incorporated a broader community intervention component. Like previous reviews, the authors identified that reviewed studies were often methodologically lacking (Wood et al., 2006). These authors did not conduct a full meta-analysis because of the poor methodological quality of the studies and the heterogeneity in alcohol outcome measures employed. But they did include a brief analysis of effect sizes for the 15 studies that examined alcohol use (i.e., lifetime use, past year use, use in past week or month, initiation into drinking, or binge drinking) as an outcome. In general, limited effectiveness was found, with initial effect sizes that were relatively small in magnitude. However, Wood et al. (2006) noted that most studies used relatively few community components (e.g., only three studies used more than six community components). Thus, they suggested that there is a need for additional studies that attempt to enhance the efficacy of school-based programmes by including broader community components such as media, community services, and alcohol retailer involvement (Wood et al., 2006). In fact, from a more theoretical viewpoint, it has been argued that effective long-term prevention programmes for the reduction of youth drinking require strategies for the wider community and societal change (Wagenaar & Perry, 1994).

60 Of the 15 studies reviewed by Wood et al. (2006), 11 were conducted in the U.S., one was conducted in the Netherlands (Cuijpers et al., 2002), one in Canada (Dedobbeleer & Desjardins, 2001), one in Israel (Peleg et al., 2001), and one in Russia (Williams et al., 2001). The Russian trial was discussed previously. The Israeli study involved randomising grade ten youth to an active intervention or no intervention control. The multi-component intervention involved collaboration between the schools and the community and was put on by school staff and the psychological counseling service in Israel. The intervention took place over three days and included guest lectures by experts as well as adolescent workshops, on topics such as peer pressure, effects of advertising on behaviour, and taking responsibility for one’s actions. Students viewed relevant films and took part in role plays. Efficacy of the intervention was examined at one and two year follow-up. While there was growth in alcohol use in the control group, there was no significant change from baseline in the intervention group over the follow-up, suggesting that the intervention reduced growth in alcohol use over time. The results thus support the efficacy of a multi-component school- plus community-focused intervention in the Israeli context (Peleg et al., 2001).

61 The Dutch study was a quasi-experimental study of the Healthy School and Drugs project (Cuijpers et al., 2002). This programme is run by a coordinating committee (including school and community representatives) and involves parents. The student-focused component involves three lessons about alcohol (information, development of a healthy attitude towards alcohol use, and drink refusal skills). Schools develop clear policies on alcohol use at school and school events, plans for early detection of students with alcohol problems, and provision of support and counseling for identified students. Significant effects of the intervention on alcohol use were found which persisted at two years following the intervention (Cuijpers et al., 2002).

62 The Canadian trial, however, provided less promising results regarding the efficacy of multi-component interventions involving both the school and community in changing adolescent alcohol use. Dedobbeleer and Desjardins (2001) studied the efficacy of the multi-component ‘Coalition for Youth Quality of Life Project’ which was designed to prevent alcohol use and misuse among multi-ethnic youth in Montreal. The intervention was delivered through four channels: schools, community organizations, local government, and families. They targeted sixth and eighth graders who were followed up at 18 and 30 months. Although the programme led to significant effects on several hypothesised mediators (e.g., higher self-esteem and superior peer-resistance skills in the younger students; more leisure alternatives to alcohol and other substance abuse in the older students), the programme had no significant effects on alcohol use. Several possible explanations were considered by the authors including differential attrition across treatment arms, insufficient power, insufficient dose of intervention, and lack of booster sessions (Dedobbeleer & Desjardins, 2001). Since this particular programme has only been assessed in Canada, it is difficult to know to what degree cultural factors might play a role in the failure of this multi-component intervention to exert effects on adolescent drinking behaviour. However, considering the lack of strong cultural effects on other school-based programmes, it is not likely that the cultural context can entirely explain these null findings.

63 There are several contexts in which youth alcohol prevention can be delivered. The school context appears to capture a larger percentage of the target population and yields the most consistent effects relative to other contexts, such as the family context or the community. The school-based programmes that are most effective are comprehensive programmes which concurrently address normative attitudes about drinking and teach generic and alcohol refusal skills. Universal programmes delivered in high schools to students before the normal age of onset of drinking show consistent effects on drinking behaviour, mostly binge drinking, and have been shown to have effects in the North American, European, and Australian contexts. However the effects are small, accounting for only 10% of the variance in drinking behaviour, and there are signs that these programmes might be more effective if delivered to populations at greater risk for early drinking and problem drinking. There is new research from Australia suggesting that the effectiveness of universal, comprehensive programmes might be enhanced with the addition of web-based resources. However, web-based programmes have not been tested in Europe and the U.S. high school context, with a number of pilot studies and ongoing trials suggesting that this modification is feasible and might lead to improved fidelity when implementing evidence-based universal intervention programmes.

64 Effective selective prevention strategies include those that target youth with known individual risk factors for alcohol misuse, including personality risk factors or behavioural problems prior to the onset of alcohol use. These programmes show stronger and long-term effects on drinking onset, binge drinking onset, and problem drinking symptoms in high-risk populations. Two studies show that they might also benefit peers in the broader social network of high-risk youth. Therefore, while these evidence-based selective programmes only target a portion of the adolescent population, they might also have universal effects. The selective approach has been shown to be equally effective in the North American and European contexts and shows some advantages relative to other approaches in that it is also effective in reducing and preventing mental health problems that tend to co-occur with alcohol misuse. Large trials of personality-targeted interventions for high school students are currently being conducted in Canada, the Netherlands, and Australia to address some outstanding questions, such as how does this approach compare to, and combine with, evidence-based universal programmes?

65 While not all indicated prevention programmes were reviewed in this chapter, brief interventions with college students who show early signs of heavy drinking or problem drinking do show promise. Specifically, interventions that include personalised feedback and normative feedback, as well as some brief motivational principles do show some effects on drinking behaviour among college students, and there is some limited research indicating that this approach could be effective with adolescents. There is also some experimental research on expectancy challenges and cognitive control training, but the evidence is limited so far, with more rigorous research needed to support this approach over and above other evidence-based approaches.

66 The family is another context in which prevention programmes are delivered. These are delivered to parents alone or in combination with a child-focused intervention (multi-component). While the family-based approach is less practical and economical to deliver than the school-based approach, one advantage is that it has the potential to address underlying family factors implicated in a number of alcohol and behavioural problems. The evidence in favour of the approach is consistent and suggests small effects that are persistent over the medium to long term. However, the evidence is only positive for the U.S. context and no study has yet shown this approach to be effective outside the U.S. as a single component programme. Finally, comparative studies in the U.S. and Europe suggest that parent training does not offer any incremental effects over an effective school-based comprehensive programme.

67 Several conclusions can also be drawn about the use of multi-component programmes (school plus family; school plus community). First, multi-component interventions can be effective for alcohol misuse prevention in young people. However, generally speaking, interventions with multiple components are no more effective than those with a single component, raising questions as to cost-effectiveness of multi-component programmes. Nonetheless, multi-component programmes may be particularly useful in some cultural contexts. For example, there is some limited evidence that both parents and children should be targeted simultaneously in countries like the Netherlands with more liberal alcohol policies and lower legal drinking ages.

CONCLUSIONS

68 While some comparative research has been conducted to investigate the relative and incremental effects of these approaches, much more research is needed in this regard. It will be important to investigate how universal comprehensive programmes compare and combine with selective prevention approaches to improve outcomes in low- and high-risk adolescents. The Australian Climate Schools and Preventure (CAP) Study (Newton, Teesson, Barrett, Slade, & Conrod, 2012; https://www.capstudy.org.au) is one trial that begins to address these questions. Furthermore, research on the mediators and moderators of these evidence-based programmes will help us better understand how they are having their effects on youth drinking behaviour, which might also lead to more refined and more effective interventions. Another question worthy of further investigation is how web-based materials and resources enhance evidence-based universal and selective approaches. However, as with all preventative interventions, this should be done with careful evaluation, given the potential for negative effects of poorly implemented programmes. Finally, while some experimental research is showing that cognitive and behavioural control training might improve outcomes for alcoholics and problem drinkers, there is a need to investigate how interventions that target some of the implicit and automatic aspects of addiction vulnerability can further improve outcomes for the general adolescent population and those at-risk.

69 To improve implementation of evidence-based alcohol prevention programmes, many jurisdictions have developed and disseminated prevention standards. For example, the Canadian Centre on Substance Abuse (CCSA) has developed a portfolio of Canadian Standards for Youth Substance Abuse Prevention . These consist of three separate documents outlining school-based standards (CCSA, 2010a), family skills-based standards (CCSA, 2010b), and community-based standards (CCSA, 2010c), respectively. Each was developed following a review of the evidence by a panel of experts. A useful future direction would be to create a set of standards that apply to youth alcohol prevention in the international context. Such international standards could include guidelines for adapting alcohol prevention programmes that have been demonstrated effective in one context, for use in new cultural contexts.

RECOMMENDATIONS

70 With the direct and indirect costs of alcohol misuse being somewhere in the range of U.S. $500-$1500 per capita (Rehm, Patra, Gnam, Sarnocinska-Hart, & Popova, 2011), there is clearly an argument for government investment in the evidence-based programmes highlighted in this chapter. Studies involving health economic analyses of alcohol and drug prevention programmes have estimated that for every dollar invested in prevention, five to ten dollars are directly returned (e.g., Spoth, Greenberg, & Turrisi, 2008). Therefore, even programmes that yield small effects can be justified economically and will lead to real public health benefits. Nevertheless, prevention programmes often comprise less than 1% of government alcohol-related costs (Rehm et al., 2006). In addition to more research on the incremental effects of evidence-based interventions, health-economic data on these programmes are needed to help guide policy makers around improving children’s access to these effective intervention programmes. As shown in this chapter, we now have many North American and European programmes that have been demonstrated to be effective in alcohol prevention among youth which now can be disseminated. Further research on these approaches needs to go hand-in-hand with a massive implementation strategy in order for youth to maximally benefit from these programmes.

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Ph.D ., Professor of Psychiatry and Psychology Psychology Department Dalhousie University, 1355 Oxford Street CA – Halifax, Nova Scotia [email protected]

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Ph.D., Senior Lecturer and Consultant Clinical Psychologist Department of Psychological Medicine and Psychiatry Institute of Psychiatry King’s College London 4 Windsor Walk, Denmark Hill UK – London, SE5 8BB [email protected] Ph.D., OPQ, Chercheure Agrégée, Psychiatrie Centre de recherche du CHU Ste-Justine Université de Montréal, Bureau 1551 3175 Chemin de la Côte Sainte-Catherine CA – Montreal, H3T 1C5 [email protected]

Ph.D . Department of Public Health Hjelt InstituteUniversity of Helsinki FI – 00014 Helsinki and Department of Mental Health and Substance Abuse Services National Institute for Health and Welfare FI – 00271 Helsinki [email protected]

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Chapter 3. Prevention of Alcohol Use and Misuse in Youth: A Comparison of North American and European Approaches

A Report on Drinking in the Second Decade of Life in Europe and North America

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The Palgrave Handbook of Psychological Perspectives on Alcohol Consumption pp 1–22 Cite as

Psychological Perspectives on Alcohol Consumption

  • Richard Cooke 8 , 9 ,
  • Dominic Conroy 10 ,
  • Emma Louise Davies 11 ,
  • Martin S. Hagger 12 , 13 &
  • Richard O. de Visser 14  
  • First Online: 11 May 2021

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This chapter provides an introduction to the Handbook, setting the scene for the subsequent chapters by covering several key topics in psychological research on alcohol consumption, such as why do people drink alcohol, how drinking patterns are defined (e.g., heavy episodic drinking, low-risk drinking), and how do governments and health agencies encourage performance of low-risk drinking. The chapter goes on to discuss issues of definition and measurement of alcohol consumption in psychological research studies, beginning with a focus on limitations with self-report measures used in most studies, before a brief discussion of alternative (biological measures, observation) methods to measure consumption. The chapter ends by introducing the five sections that comprise the book.

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A UK unit equals 8 g or 10 ml of pure alcohol and is the same as a single (25 ml) shot of spirits, approximately half a 175 ml glass of wine and approximately half a pint (568 ml) of beer, 1 cider, or lager.

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Richard Cooke

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Cooke, R., Conroy, D., Davies, E.L., Hagger, M.S., de Visser, R.O. (2021). Psychological Perspectives on Alcohol Consumption. In: Cooke, R., Conroy, D., Davies, E.L., Hagger, M.S., de Visser, R.O. (eds) The Palgrave Handbook of Psychological Perspectives on Alcohol Consumption. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-66941-6_1

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National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Introduction.

Alcohol is part of our society. People use it to celebrate, socialize, relax, and enhance the enjoyment of meals. Nearly 90 percent of adults in the United States report that they drank alcohol at some point in their lifetime, and more than half report drinking in the last month. 1  Although most people drink in moderation, nearly 40 percent of U.S. adults drink in excess of the low-risk guidelines established by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). 2  (See “ Drinking Patterns and Their Definitions .”)

Alcohol misuse has wide-ranging adverse consequences. In the United States, nearly 88,000 people per year die from alcohol-related causes; 3  globally, alcohol accounts for 3.3 million deaths—5.9 percent of all deaths—each year. 4  Alcohol misuse also contributes to poor performance at school and work; family problems; unprotected sex and sexually transmitted diseases; violence; memory blackouts; unintentional injuries, accidents, and overdoses; and organ damage and disease. It can lead to alcohol use disorder (AUD), a serious chronic condition that affects nearly 16 million people in the United States. 5  (See “ What Is Alcohol Use Disorder? ”) The Centers for Disease Control and Prevention estimates that alcohol misuse, including AUD, costs the United States $249 billion per year due to health care expenses, lost workplace productivity, crime, property damage, and other outcomes. 6

NIAAA, a component of the National Institutes of Health (NIH), is the largest funder of alcohol research in the world. For nearly five decades, NIAAA’s extramural research program has supported a diverse portfolio of innovative investigator-initiated research to elucidate the effects of alcohol on health and reduce the burden of alcohol misuse for individuals at all stages of life. This work is complemented by a robust intramural research program that leverages the state-of-the-art resources available at NIH to advance high-risk, high-reward studies in key areas of alcohol science. In addition, through the Collaborative Research on Addiction at NIH (CRAN) initiative, NIAAA is partnering with the National Institute on Drug Abuse and the National Cancer Institute to integrate resources and expertise across NIH to develop a comprehensive, well integrated understanding of substance use, misuse, and addiction that considers the common and distinctive features of addictive substances and substance use disorders (SUDs).

Research supported by NIAAA has spurred tremendous progress in identifying the factors that contribute to alcohol-related problems and the fundamental biological and behavioral mechanisms by which they develop, and it has paved the way for innovative preventive and treatment interventions. Once viewed as a moral failing or character flaw, AUD is now widely regarded as a chronic but treatable brain disease that develops through complex, dynamic interactions among biological, environmental, and developmental factors. This shift in perspective, bolstered by decades of research on the neurobiology of addiction, has helped reduce the stigma associated with AUD and has underscored the need for a multipronged approach to preventing and treating alcohol-related problems, with interventions designed for individuals, families, communities, and society at large.

This strategic plan serves as a roadmap for catalyzing continued progress across the spectrum of alcohol research and translating these advances for the benefit of the public. It highlights NIAAA’s research goals in five key areas:

  • Goal 1: Identify Mechanisms of Alcohol Action, Alcohol-Related Pathology, and Recovery  
  • Goal 2: Improve Diagnosis and Tracking of Alcohol Misuse, Alcohol Use Disorder, and Alcohol-Related Consequences  
  • Goal 3: Develop and Improve Strategies To Prevent Alcohol Misuse, Alcohol Use Disorder, and Alcohol-Related Consequences  
  • Goal 4: Develop and Improve Treatments for Alcohol Misuse, Alcohol Use Disorder, Co-Occurring Conditions, and Alcohol-Related Consequences  
  • Goal 5: Enhance the Public Health Impact of NIAAA-Supported Research

Along with the goals outlined above, NIAAA has identified several cross-cutting research themes, which are woven throughout this strategic plan.

Address Alcohol Misuse Across the Lifespan

Human biology and behavior change throughout life; these changes affect drinking patterns and risks for alcohol-related injury and disease. NIAAA has adopted a “lifespan approach” to alcohol research that considers how the emergence and progression of drinking behavior and related outcomes interact with developmental changes and environmental inputs across the lifespan, from the embryonic and fetal stages of development into older adulthood. This perspective guides the identification of life-stage–appropriate strategies for preventing, treating, and facilitating recovery from alcohol problems, as well as tailoring resources to the needs of individuals of all ages.

Address Co-Occurring Conditions

AUD frequently co-occurs with other SUDs and mental health conditions, including major depressive disorder, anxiety disorders, bipolar disorder, antisocial and borderline personality disorders, and post-traumatic stress disorder (PTSD). Individuals suffering from psychiatric comorbidity tend to have a poorer prognosis, higher risk for treatment dropout, less support for sobriety from their families and in the workplace, and a higher risk for suicide. Alcohol misuse also contributes to more than 200 diseases and injury-related health conditions, 9  including alcoholic liver disease. In fact, alcohol is involved in nearly half of all liver disease deaths in the United States each year. 10  Alcohol misuse frequently co-occurs with human immunodeficiency virus (HIV), contributes to HIV transmission, reduces HIV screening, makes it difficult to follow complex HIV medication regimens, and contributes to or exacerbates other health conditions in HIV-infected individuals. NIAAA will continue to support research to investigate the relationships between AUD and co-occurring conditions and to develop interventions to prevent and treat them.

Reduce Health Disparities

Some groups of people may be more vulnerable to alcohol problems than others. For example, although Native Americans are less likely to drink than white Americans, those who do drink are more likely to binge drink, 11  have a higher rate of past-year AUD compared with other racial and ethnic groups, 12  and are approximately twice as likely to die from alcohol-related causes than the general American public. 13  In addition, Hispanics and blacks who drink are more likely to binge drink than whites who drink, 11  but Hispanics with AUD are less likely than whites with AUD to receive alcohol treatment at a specialty facility. 14  The lesbian, gay, bisexual, and transgender communities are also important subpopulations to consider. Lesbian and bisexual women are about seven times more likely than heterosexual women to meet criteria for AUD. 15  Although rates of alcohol use and AUD among men who have sex with men (MSM) are comparable to rates in the general population, alcohol misuse among MSM is an important public health problem. Alcohol misuse is a known risk factor for HIV, and MSM account for more than half of all new HIV infections each year in the United States. 16  NIAAA is committed to ensuring that all people benefit from alcohol research advances and will support studies to better understand health disparities and develop interventions for at-risk groups.

Advance Precision Medicine

Studies investigating how individual variability in genes, environment, and lifestyle contribute to disease are bringing us closer to developing individually tailored interventions for alcohol-related conditions. NIAAA will continue to support research on the factors that contribute to individual variation in alcohol misuse, AUD, and alcohol-related outcomes. The Institute will use that information to guide the development and validation of prognostic and diagnostic biomarkers and personalized interventions for these conditions. These efforts will be aided by the recent expansion of electronic medical records and the development of mobile health technologies, which have the potential to improve the quality and collection of patient data and to provide comprehensive, personalized health care services where and when patients need them.

Strengthen the Biomedical Workforce

Cultivating a talented and diverse research workforce is essential to advancing the frontiers of scientific knowledge and to translating research findings into practice. NIAAA promotes alcohol research training through individual pre- and postdoctoral fellowships, institutional training grants, and career development awards that span the breadth of NIAAA’s research portfolio. Diverse research teams broaden the scope of scientific inquiry, bring creative solutions to bear on complex scientific problems, and encourage research relevant to the health care needs of underserved populations. Programs to identify, recruit, and train scientists from diverse populations, especially those underrepresented in health research, are an important component of NIAAA’s training portfolio.

Serve as a Responsible Steward of Our Nation’s Research Resources

Underpinning NIAAA’s ability to advance innovative science is an unwavering commitment to responsible research stewardship. NIAAA supports efforts to enhance the rigor and reproducibility of research, including ensuring that sex is incorporated as a biological variable into the design, analysis, and scientific reporting of the studies it funds. This is a critical step toward ensuring that everyone, regardless of sex or gender, benefits from alcohol research advances. NIAAA maximizes the use of research resources by forging strategic partnerships with other NIH Institutes, Centers, and Offices; other Federal agencies; academia; industry; and not-for-profit organizations. Such partnerships provide opportunities to share resources and expertise, and to broaden the dissemination of alcohol research findings. Moreover, by encouraging the use of common research metrics and protocols, as well as the sharing, aggregation, and secondary analysis of data, NIAAA hopes to improve the efficiency of alcohol research and stimulate new insight into preventing and treating alcohol-related conditions.

Drinking Patterns and Their Definitions  

What Is a Standard Drink?

Many people are surprised to learn what counts as a drink. The amount of liquid in your glass, can, or bottle does not necessarily match how much alcohol is in your drink. Different types of beer, wine, or malt liquor can have very different amounts of alcohol. For example, many light beers have almost as much alcohol as regular beer—about 85 percent as much.

What is a standard drink? 12 fluid ounces of regular beer equals 8 to 9 fluid ounces of malt liquor showing in a 12 ounce glass, equals 5 fluid ounces of table wine, equals 1.5 fluid ounces of distilled spirits. Each beverage portrayed above represents one standard drink (or one alcohol drink equivalent), defined in the United States as any beverage containing .6 fluid ounces or 14 grams of pure alcohol.

Moderate Alcohol Consumption

According to the Dietary Guidelines for Americans, 7  which are intended to help individuals improve and maintain overall health and reduce the risk of chronic disease, moderate drinking is up to one drink per day for women and up to two drinks per day for men.

Low-Risk Drinking for Developing Alcohol Use Disorder

As defined by NIAAA, for women, low-risk drinking is no more than three drinks on any single day and no more than seven drinks per week. For men, it is defined as no more than 4 drinks on any single day and no more than 14 drinks per week. NIAAA research shows that only about 2 in 100 people who drink within these limits have alcohol use disorder. Even within these limits, you can have problems if you drink too quickly or have other health issues.

Alcohol Misuse

Alcohol misuse refers to drinking in a manner, situation, amount, or frequency that could cause harm to the users or to those around them. For individuals younger than the legal drinking age of 21, or for pregnant women, any alcohol use constitutes misuse.

Binge Drinking

NIAAA defines binge drinking as a pattern of drinking that brings blood alcohol concentration levels to 0.08 g/dL (0.08 percent) or higher. This typically occurs after a woman consumes four drinks or a man consumes five drinks in a 2-hour time frame.

The Substance Abuse and Mental Health Services Administration (SAMHSA), which conducts the annual National Survey on Drug Use and Health (NSDUH), defines binge drinking for men as drinking five or more alcoholic drinks on the same occasion on at least 1 day in the past 30 days. SAMHSA defines binge drinking for women as drinking four or more alcoholic drinks on the same occasion on at least 1 day in the past 30 days.

Extreme Binge Drinking

Extreme binge drinking, also known as high-intensity drinking, refers to drinking at levels far beyond the binge threshold, resulting in high peak blood alcohol concentrations. Though definitions vary, some studies define extreme binge drinking as 2 or more times the gender-specific binge drinking thresholds (i.e., 10 or more standard drinks for men; 8 or more for women); other studies use a higher threshold that may or may not be gender specific.

Heavy Drinking

SAMHSA defines heavy drinking as binge drinking (based on the SAMHSA binge drinking thresholds described above for men and women) on 5 or more days in the past 30 days.

Certain people should avoid alcohol completely, including those who:

  • Are younger than the minimum legal drinking age of 21.
  • Are pregnant or trying to become pregnant.
  • Have a medical condition that alcohol can aggravate.
  • Take medications that interact with alcohol.
  • Are driving a vehicle or operating machinery (or plan to do so shortly after drinking).

What Is Alcohol Use Disorder?  

woman drinking wine by the window

Alcohol use disorder (AUD) is a medical condition that doctors diagnose when a patient’s drinking causes distress or harm. It ranges from mild to severe and is characterized by clinically significant impairments in health and social function. To be diagnosed with AUD, a person must meet certain diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM).8 The current DSM (DSM-5) integrates the two DSM–IV disorders, alcohol abuse and alcohol dependence, into a single disorder called AUD. Under DSM-5, anyone meeting any 2 of the 11 criteria during the same 12-month period is diagnosed with AUD. The severity of AUD is based on the number of criteria a person meets—mild (2–3), moderate (4–5), or severe (6 or more).

To assess whether someone has AUD, a health care provider may ask him or her some questions. For example, in the past year, have you:

  • Had times when you ended up drinking more, or longer, than you intended?
  • More than once wanted to cut down or stop drinking, or tried to, but couldn’t
  • Spent a lot of time drinking? Or being sick or getting over the aftereffects?
  • Experienced craving—a strong need, or urge, to drink?
  • Found that drinking—or being sick from drinking—often interfered with taking care of your home or family? Or caused job troubles? Or school problems?
  • Continued to drink even though it was causing trouble with your family or friends?
  • Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink?
  • More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)?
  • Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout (i.e., forgetting, after drinking, where you were or what you did while drinking)?
  • Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?
  • Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, irritability, anxiety, dysphoria, depression, restlessness, nausea, or sweating? Or sensed things that were not there?

Any of these symptoms may be a cause for concern. The more symptoms one has, the more urgent the need for change.

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3.7 Alcohol

Alcohol facts and statistics, alcohol use in the united states:.

  • Prevalence of Drinking:  According to the 2015 National Survey on Drug Use and Health (NSDUH), 86.4 percent of people ages 18 or older reported that they drank alcohol at some point in their lifetime; 70.1 percent reported that they drank in the past year; 56.0 percent reported that they drank in the past month. 1
  • Prevalence of Binge Drinking and Heavy Alcohol Use:  In 2015, 26.9 percent of people ages 18 or older reported that they engaged in binge drinking in the past month; 7.0 percent reported that they engaged in heavy alcohol use in the past month. 2  (See “Definitions” box for definitions of binge drinking and heavy alcohol use.)

Alcohol Use Disorder (AUD) in the United States:

  • About 6.7 percent of adults who had AUD in the past year received treatment. This includes 7.4 percent of males and 5.4 percent of females with AUD in this age group. 5
  • Youth (ages 12–17):  According to the 2015 NSDUH, an estimated 623,000 adolescents ages 12–17 6  (2.5 percent of this age group 7 ) had AUD. This number includes 298,000 males 6  (2.3 percent of males in this age group 7 ) and 325,000 females 6  (2.7 percent of females in this age group 7 ).
  • About 5.2 percent of youth who had AUD in the past year received treatment. This includes 5.1 percent of males and 5.3 percent of females with AUD in this age group. 5

Alcohol-Related Deaths:

  • An estimated 88,000 8  people (approximately 62,000 men and 26,000 women 8 ) die from alcohol-related causes annually, making alcohol the third leading preventable cause of death in the United States. The first is tobacco, and the second is poor diet and physical inactivity. 9
  • In 2014, alcohol-impaired driving fatalities accounted for 9,967 deaths (31 percent of overall driving fatalities). 10

Economic Burden:

  • In 2010, alcohol misuse cost the United States $249.0 billion. 11
  • Three-quarters of the total cost of alcohol misuse are related to binge drinking. 11

Global Burden:

  • In 2012, 3.3 million deaths, or 5.9 percent of all global deaths (7.6 percent for men and 4.1 percent for women), were attributable to alcohol consumption. 12
  • In 2014, the World Health Organization reported that alcohol contributed to more than 200 diseases and injury-related health conditions, most notably DSM–IV alcohol dependence (see sidebar), liver cirrhosis, cancers, and injuries. 13  In 2012, 5.1 percent of the burden of disease and injury worldwide (139 million disability-adjusted life-years) was attributable to alcohol consumption. 12
  • Globally, alcohol misuse was the fifth leading risk factor for premature death and disability in 2010. Among people between the ages of 15 and 49, it is the first. 14  In the age group 20–39 years, approximately 25 percent of the total deaths are alcohol-attributable. 15

Family Consequences:

  • More than 10 percent of U.S. children live with a parent with alcohol problems, according to a 2012 study. 16

Underage Drinking:

  • Prevalence of Drinking:  According to the 2015 NSDUH, 33.1 percent of 15-year-olds report that they have had at least 1 drink in their lives. 17  About 7.7 million people ages 12–20 18  (20.3 percent of this age group 19 ) reported drinking alcohol in the past month (19.8 percent of males and 20.8 percent of females 19 ).
  • Prevalence of Binge Drinking:  According to the 2015 NSDUH, approximately 5.1 million people 18 (about 13.4 percent 19 ) ages 12–20 (13.4 percent of males and 13.3 percent of females 19 ) reported binge drinking in the past month.
  • Prevalence of Heavy Alcohol Use:  According to the 2015 NSDUH, approximately 1.3 million people 18 (about 3.3 percent 19 ) ages 12–20 (3.6 percent of males and 3.0 percent of females 19 ) reported heavy alcohol use in the past month.
  • Research indicates that alcohol use during the teenage years could interfere with normal adolescent brain development and increase the risk of developing AUD. In addition, underage drinking contributes to a range of acute consequences, including injuries, sexual assaults, and even deaths—including those from car crashes. 20

Alcohol and College Students:

  • Prevalence of Drinking:  According to the 2015 NSDUH, 58.0 percent of full-time college students ages 18–22 drank alcohol in the past month compared with 48.2 percent of other persons of the same age. 21
  • Prevalence of Binge Drinking:  According to the 2015 NSDUH, 37.9 percent of college students ages 18–22 reported binge drinking in the past month compared with 32.6 percent of other persons of the same age. 21
  • Prevalence of Heavy Alcohol Use:  According to the 2015 NSDUH, 12.5 percent of college students ages 18–22 reported heavy alcohol use in the past month compared with 8.5 percent of other persons of the same age. 21
  • 1,825 college students between the ages of 18 and 24 die from alcohol-related unintentional injuries, including motor-vehicle crashes. 22
  • 696,000 students between the ages of 18 and 24 are assaulted by another student who has been drinking. 23
  • 97,000 students between the ages of 18 and 24 report experiencing alcohol-related sexual assault or date rape. 23
  • Roughly 20 percent of college students meet the criteria for AUD. 24
  • About 1 in 4 college students report academic consequences from drinking, including missing class, falling behind in class, doing poorly on exams or papers, and receiving lower grades overall. 25

Alcohol and Pregnancy:

  • The prevalence of Fetal Alcohol Syndrome (FAS) in the United States was estimated by the Institute of Medicine in 1996 to be between 0.5 and 3.0 cases per 1,000. 26
  • More recent reports from specific U.S. sites report the prevalence of FAS to be 2 to 7 cases per 1,000, and the prevalence of Fetal Alcohol Spectrum Disorders (FASD) to be as high as 20 to 50 cases per 1,000. 27,28

Alcohol and the Human Body:

  • In 2015, of the 78,529 liver disease deaths among individuals ages 12 and older, 47.0 percent involved alcohol. Among males, 49,695 liver disease deaths occurred and 49.5 percent involved alcohol. Among females, 28,834 liver disease deaths occurred and 43.5 percent involved alcohol. 29
  • Among all cirrhosis deaths in 2013, 47.9 percent were alcohol-related. The proportion of alcohol-related cirrhosis was highest (76.5 percent) among deaths of persons ages 25–34, followed by deaths of persons ages 35–44, at 70.0 percent. 30
  • In 2009, alcohol-related liver disease was the primary cause of almost 1 in 3 liver transplants in the United States. 31
  • Drinking alcohol increases the risk of cancers of the mouth, esophagus, pharynx, larynx, liver, and breast. 32

Definitions

Alcohol Use Disorder (AUD):  AUD is a chronic relapsing brain disease characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. AUD can range from mild to severe, and recovery is possible regardless of severity. The fourth edition of the  Diagnostic and Statistical Manual  (DSM-IV), published by the American Psychiatric Association, described two distinct disorders—alcohol abuse and alcohol dependence—with specific criteria for each. The fifth edition, DSM-5, integrates the two DSM-IV disorders, alcohol abuse, and alcohol dependence, into a single disorder called alcohol use disorder, or AUD, with mild, moderate, and severe subclassifications.

Binge Drinking:

  • NIAAA defines binge drinking as a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL. This typically occurs after 4 drinks for women and 5 drinks for men—in about 2 hours. 33
  • The Substance Abuse and Mental Health Services Administration (SAMHSA), which conducts the annual National Survey on Drug Use and Health (NSDUH), defines binge drinking as 5 or more alcoholic drinks for males or 4 or more alcoholic drinks for females on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past month. 34

Heavy Alcohol Use:   SAMHSA defines heavy alcohol use as binge drinking on 5 or more days in the past month.

Moderate alcohol consumption:  According to the  “Dietary Guidelines for Americans 2015-2020,” U.S. Department of Health and Human Services and U.S. Department of Agriculture , moderate drinking is up to 1 drink per day for women and up to 2 drinks per day for men.

NIAAA’s Definition of Drinking at Low Risk for Developing AUD:  For women, low-risk drinking is defined as no more than 3 drinks on any single day and no more than 7 drinks per week. For men, it is defined as no more than 4 drinks on any single day and no more than 14 drinks per week. NIAAA research shows that only about 2 in 100 people who drink within these limits have AUD.

Alcohol-Impaired-Driving Fatality:  A fatality in a crash involving a driver or motorcycle rider (operator) with a BAC of 0.08 g/dL or greater.

Disability-Adjusted Life-Years (DALYs):  A measure of years of life lost or lived in less than full health.

Underage Drinking:  Alcohol use by anyone under the age of 21. In the United States, the legal drinking age is 21.

What Is A Standard Drink?

  • Regular beer: 5% alcohol content
  • Some light beers: 4.2% alcohol content

That’s why it’s important to know how much alcohol your drink contains.  In the United States, one “standard” drink contains roughly 14 grams of pure alcohol, which is found in:

  • 12 ounces of regular beer, which is usually about 5% alcohol
  • 5 ounces of wine, which is typically about 12% alcohol
  • 1.5 ounces of distilled spirits, which is about 40% alcohol

How do you know how much alcohol is in your drink?

Even though they come in different sizes, the drinks below are examples of  one standard drink :

The same amount of alcohol is contained in 12 fluid ounces of regular beer, 8 to 9 fluid ounces of malt liquor, 5 fluid ounces of table wine, or a 1.5 fluid ounce shot of 80-proof spirits (“hard liquor” such as whiskey, gin, etc.) The percent of ‘pure’ alcohol varies by beverage.

Each beverage portrayed above represents one standard drink of “pure” alcohol, defined in the United States as 0.6 fl oz or 14 grams. The percent of pure alcohol, expressed here as alcohol by volume (alc/vol), varies within and across beverage types. Although the standard drink amounts are helpful for following health guidelines, they may not reflect customary serving sizes.

Visit the following websites for information on alcohol

  • Rethinking Drinking
  • Link to alcohol fact sheets from drugabuse.gov
  • WebMD slideshow on How Alcohol Affects Your Body

Drugs, Health & Behavior Copyright © 2018 by Jacqueline Schwab and Denise Salters is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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National Academies Press: OpenBook

Prevention and Treatment of Alcohol Problems: Research Opportunities (1990)

Chapter: 6 methodological issues in alcohol prevention research: conclusions and recommendations.

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6 METHODOLOGICAL ISSUES IN ALCOHOL PREVENTION RESEARCH: CONCLUSIONS AND RECOMMENDATIONS No single set of research designs or analytical strategies has characterized research on the prevention of alcohol problems. A variety of approaches can be used depending on the goals of the research, the setting or opportunity afforded, the amount and type of variation one wishes to control or explain, and the generalizability of the findings. One of the difficulties in prevention research--particularly the kind of research that is most relevant to public policy deliberations--is the need to conduct such research outside the laboratory setting. ~Real-world" research, however, is difficult to undertake, often expensive to conduct, and difficult to analyze. It is less precise than laboratory work because researchers do not have the opportunity to manipulate variables as they would in laboratory experimentation. It also raises questions of ascertainment and of the validity of self-reports and other measures that are commonly used to assess the efficacy of a preventive intervention. On the other hand, because of the controlled or "hothouse" conditions used in laboratory settings, the extent to which prevention research undertaken in the laboratory can be generalized to the real world is not known. In recent years, alcohol prevention research has made use of a variety of qualitative and quantitative methods. For example, ethnographic methods and the observation of behavior in natural settings have been employed. Ethnographers gather data through semistructured interviews and through traditional participant-observer techniques. Examples of ethnographic/observational studies in prevention include studies of blue-collar workers and family drinking (Ames and Janes, 1987), of public drinking and drinking contexts (Rosenbluth, Nathan, and Lawson, 1978; Storm and Cutler, 1981; Harford et al., 1983; Single and Storm, 1985; Geller, Russ, and Altomari, 1986), and of the work site (Ames, 1987~. In many respects, the social and health problems that are associated with alcohol need to be viewed in a historical context. Historical analysis, by using both U.S. and international data sources, offers promising opportunities for prevention research. For example, it has been reported that between 1830 and 1850 there was a dramatic decline in per capita consumption in the United States (Rorabaugh, 1976) and that the temperance movement and government policies contributed to this decline and to a concomitant decrease in alcohol problems (Popham, 1978; Moore and Gerstein, 1981; Pendergast, 1987~. Historical analysis could provide a method to discover potential "lessons" that might be useful in the modern alcohol problem prevention arena. Community, school, and work site prevention trials have begun to reflect the use of combinations of several relevant theories (learning, organization, communication, behavior change, health education, and social marketing) in their design. Interest in such designs has been stimulated by the success in health promotion programs to reduce heart disease that are discussed in Chapter 5 (Farquhar et al., 1984; Puska et al., 1985~. These approaches have been used in studies of community interventions for alcohol problems at schools (see the review by Moskowitz, 1989), local availability of alcohol (Wittman and Hilton, 1987), and the influence of the mass media (Hewitt and Blane, 1984~. Because of the difficulty of random assignment in field studies, quasi-experimental designs have been used (Cook and Campbell, 1979~. These designs are often employed in the policy analysis -128

of Naturals experiments, such as changes in alcohol availability. One useful statistical tool Is the interrupted time-series analysis (Box and Tiao, 1975; Box and Jenkins, 1976), which has more power than conventional least-squares regression to deal with problems of autoregression, seasonali~, and trending (Skim lo Wanennar 19~ Rln.ce ~nr1 Mn1~1f~.r 1987; Holder and Those, 1987a). O ~=, , ~-, _ _, ~^ ~,, Quasi~xperimental designs are also used to address problems related to nonequivalent control conditions or groups (Cook and Campbell, 1979~. These designs frequently employ multivariate analysis techniques to increase statistical power. Examples include evaluations of server intervention (Saltz, 1987), happy-hour bans (Smart and Adlaf, 1986), college prevention programs (Mills et al., 1983), cross-cultural drinking behavior (Moskowitz, 1989), alcohol taxes (Cook and Tauchen, 1982), and changes in driving-under-the-influence sanctions and enforcement in Maine (Hingson et al., 1987~. The multifaceted and dynamic nature of the social, cultural, and economic systems in which prevention occurs requires techniques that can deal with such complexity. One approach that has been used is computer modeling. This tool is used in astronomy, physics, and business and economic research and has particular utility for prevention research because it provides the ability to predict potential outcomes prior to expensive field implementation (Katzper, Ryback, and Hertzman, 1976; Holder and Those, 1987b). For example, complex statistical modeling has been used to examine the sensitivity of drinking and alcohol problems to changes in price levels. Examples include studies by Grossman, Coate, and Arluck (1987) and by Levy and Sheflin (1983~. RESEARCH DESIGN FOR FUTURE ALCOHOL PREVENTION RESEARCH PROGRAMS There are several primary issues relevant to the design of prevention research in the alcohol field. Three of these issues are discussed below: (1) the importance of using theory as a basis for design, (2) the need for both laboratory and field research, and (3) the practical as well as the statistical significance of research findings. The Importance of Theory A truly comprehensive theory for prevention research must encompass complex and dynamically changing biobehavioral mechanisms, individual and group behaviors, organizational influences, and cultural patterns. It is particularly important to incorporate the dimension of time into theoretical models in order to take account of life-span or developmental milestones. Theory is required to establish priorities, to develop and test hypotheses about mediating mechanisms, and to develop or select appropriate interventions, program evaluation, and intermediate and longer term outcome measures. When used for these purposes, theory can help prevention researchers identify the active ingredients in prevention programs and anticipate and account for intervention effects. Theory-driven programmatic research could then be undertaken by using combinations of methodologies including laboratory-based randomized trials, analogue studies, ethnographic and other naturalistic data collection methods, and complex model building. Such research can be undertaken within and between different levels of the social structure ranging from the individual to the community. -129

In other public health efforts that have utilized community, school, or work site as the base in prevention trials, combinations of several relevant theories (learning, organizational, communication, behavior change, health education, media, social marketing) have been used to guide intervention and evaluation (Flay, 1984; Farquhar et al., 1985; Abrams et al., 1986~. This diversity in approach is illustrated by the Stanford, Minnesota, and Pawtucket heart disease prevention trials discussed in the preceding chapter (Maccoby et al., 1977; Blackburn et al., 1984; Lasater et al., 1984; Farquhar et al., 1985~. Crucial to developing effective and adequate strategies of prevention intervention is the use of formative research, program evaluation, process tracking, and assessment of program impact and potential problems. A varietr of research approaches can be used in which the design of programs results from an interactive process, combining theoretical and scientific input with practical input from the community and individual consumers. These approaches include ethnographic methods derived from anthropology, unobtrusive or naturalistic observation, the use of focus groups, random-digit rapid telephone surveys, and the use of small-scale randomized designs in the field or laboratory. ~ -' - -' O ouch eva~uauon methods are crucial for developing effective interventions, for making early or midcourse corrections in a program, and for evaluating whether, in fact, the manipulation of independent variables did occur at a sufficiently strong level (dosage) and with the intended impact on the target variables, mediating mechanisms, or processes. In community prevention programs, interactive and synergistic effects sometimes occur or are intentionally encouraged, making it necessary to consider the question of contamination and to measure impact in areas other than the direct intervention targets. For example, do single-focus, school-based smoking prevention programs actually reduce (or increase) alcohol and other drug use? Are multifocus programs more or less effective? Unlike traditional research in which one variable is manipulated whereas all other factors are controlled, the use of multiple criteria (including factors such as cost-effectiveness) may be more appropriate in program evaluation or prevention research (e.g., Warner and Luce, 1982; Altman et al., 1987~. In some cases, the spillover effects that result from such multifocused, synergistic processes as changing social norms and social network interactions in a school, work site, or other system are regarded as beneficial. They are viewed as an intentional part of the intervention and evaluation process rather than ~contamination." However, it is crucial to decide what is acceptable synergism and what is contamination, especially with respect to the unit of analysis, the questions being asked, and the comparison groups and settings being used. Need for Both Laboratory and Field Prevention Research The term laboratory research is used here to mean research conducted under conditions that permit the direct manipulation of the variables under investigation. Studies conducted within a controlled environment to allow the manipulation of variables have the advantage of providing better opportunities to assign subjects randomly to treatment and no-treatment conditions. Laboratory studies permit the examination of particular variables and the determination of whether specific experimental factors may play a role in a prevention program or policy. For example, the potential role of retail price in alcohol use can be demonstrated in a laboratory experiment that simulates an actual retail drinking situation in which the subjects' drinking is measured as the price of alcohol is manipulated. Such analogue studies can demonstrate (or fail to demonstrate) that retail price (or the economic accessibility of alcohol) affects drinking behavior. Such studies cannot tell, however, -130

whether price is actually a significant variable in the natural setting, given the number of other factors at work. Prevention research also requires studies that are conducted in the field or in naturalistic environments in which physical manipulation of the situation may be difficult or impossible. Such studies can be more generalizable, but they lack the convenience or appropriateness of random assignment for controlling variance in extraneous factors; however, multivariate statistical tools are available as the means for control. Both laboratory and field studies are needed in prevention research because they have complementary strengths. In particular, the validity of conclusions is strengthened when consistency is demonstrated between the two approaches. In recent years, empirically minded social scientists have become increasingly concerned with the problem of inferring individual-level behavior from aggregate data (Lanbein and Lichtman, 1978~. (The term ecological fallacy has been used to describe an incorrect inference about individual behavior based on proud data.) By far the most obvious intervening variable in need of disaggregation is the consumption history of the drinker. Many authors who have written about the policy implications of economic variables have lamented the fact that current models have been unable to differentiate among alcohol-dependent persons, heavy drinkers, and moderate consumers. Although there has never been a systematic program of experimental research designed to investigate the interaction between environmental variables and alcohol consumption, a number of studies have been conducted to investigate the important policy questions raised by economic and epidemiological studies. For example, several studies have investigated the relative impact of economic variables on the behavior of alcohol abusers (Mello, 1968; Cohen et al., 1971; Bigelow and Liebson, 1972; Engle and Williams, 1972; Marlatt, Demming, and Reid, 1973~. The findings in these studies suggest that the strengths of both experimental and quasi-experimental research designs can be combined in complementary studies that move from laboratory analogues to more complicated natural settings. One question of interest in prevention research concerns whether persons with alcohol problems differ from persons without alcohol problems in their responsiveness to economic incentives for drinking or abstinence. Babor and colleagues (1978) demonstrated that heavy drinkers were as responsive as casual drinkers to the afternoon price manipulation known as the happy hour. Indeed, one of the most encouraging findings of the happy-hour studies was the extent to which the discount drink policy was associated with similar alterations in drinking behavior in both laboratory and natural settings (Babor et al., 1980~. Laboratory analogue research was also combined with naturalistic observation in the studies of Langenbucher and Nathan (1983~. Three experiments were used to test the ability of social dnnkers, bartenders, and police officers to estimate sobriety. This study has important implications for public policy regarding alcohol sale or use and the legal penalties for purveyors who knowingly or unknowingly serve alcohol to intoxicated persons. Naturalistic studies have the advantage of being heuristic, realistic, and relevant to important social problems when they include three important dimensions: natural behavior (e.g., drinking), natural settings (e.g., a tavern or bar), and natural treatment (e.g., price variations). -131

The Practical Significance of Prevention Research In addition to the concern that no false conclusions be drawn from data, the prevention researcher must also consider the practical significance of any finding. A statistical change may be too small to justifier the operational costs of a prevention strategy. Alternatively, the level of statistical significance may be set so high by the researcher, or the variable selected for measurement may occur so infrequently, that a finding of practical significance is overlooked. In selecting a research design, the variables to be studied, and the statistical approach, researchers should be aware that prevention research must accommodate both substantive and statistical significance. DIRECTION AND DESIGN OF FUTURE ALCOHOL PREVENTION RESEARCH PROGRAMS: CONCLUSIONS AND RECOMMENDATIONS The conclusions discussed below constitute the committee's recommendations for future directions in research designed to reduce alcohol-related problems. · Attempts should be made to integrate findings from biomedical research (e.g., biobehavioral vulnerability) with theories on individual, social, educational, and economic variables that influence alcohol use and abuse. Integrated models can then be used to guide the development of prevention interventions and the matching of at-risk subgroups with appropriate intervention strategies. · It is important to ensure that theory drives the research, which can be achieved by borrowing theory-based analogues from studies in other health fields. Although such theories as social learning approaches have helped in understanding behavior change in individuals, there is little assurance that an adequate theoretical framework is available for the fields of community organization, regulatory and polipy-based interventions, environmental change strategies, and interventions that depend on changing the organizations themselves. · Life-span considerations and developmental factors over time should be incorporated into comprehensive theories. If it can be anticipated that a specific interaction between individual characteristics (e.g., social skills deficits) and environmental/cultural demands (e.g., peer pressure to conform during early puberty) is likely to produce a large at-risk group, then such predictions can be used to plan both individual and community prevention programs. In this manner, findings from biological, psychological, and cultural areas can be used to plan prevention strategies for use during an earlier developmental phase so as to ~inoculate" a vulnerable population prior to exposure. Research should also be undertaken to shed light on the determinants of social norms regarding alcohol use. Such research should include creative methods to determine the effects of corporate policies, advertising, and the popular mass media on the nation's attitudes regarding the use of alcohol. · Multidisciplinary collaboration in theory development should be encouraged from such diverse fields as the biomedical sciences, econometrics, education, psychology, sociology, clinical epidemiology, anthropology, and other relevant disciplines. The development of theories that examine the interaction.s amen ~ varinhles rl~.riv~1 from adherent levels or analysis or olllerent olsclpllnes should be particularly encouraged, especially if the theories can be used to guide the selection of intervention components and evaluation approaches. The use of new methodologies for formal theory development and model building should also be encouraged. Such methods as structural modeling and path-analytic procedures, computer simulation, and other multivariate approaches to causal . . ana yses appear promising. -132

· Program planning and implementation should be integrated with evaluation. The use of formative research, one of the main components of social marketing, should be increased to ensure success in pilot studies of untested components of programs. Researchers are often unable to obtain sufficient funding to implement programs they may want to evaluate, and program personnel often do not have the funds to support a full evaluation of their programs. The result is that major prevention programs are ~evaluated" after the fact and only in a descriptive or cursory manner. A mechanism needs to be found to facilitate a coherent demonstration evaluation plan whereby program and research designs are fully integrated. Until then, program evaluations, particularly at the community level, will remain piecemeal, inconsistent, and generally inadequate. (One of the great barriers to community prevention research is the enormous cost of collecting the data necessary for measuring whether an intervention has had an effect. NIAAA may want to consider ways to encourage local and county agencies to develop information management systems that can sense as existing data bases for measuring changes within the community. As local agencies begin to see the value of such data bases, they would undoubtedly expand their range to incorporate community and environmental variables that at first may seem remote to their needs. Ideally, such a system might include regular spot surveys of the alcohol-related concerns, knowledge, consumption, and problems of the community.) · Community trials of prevention strategies should be instituted. One essential prevention research finding derived from heart disease and cancer prevention studies is the value of long-term community trials, such as those reported in Chapter 5. Such approaches have rarely been undertaken in efforts to prevent or reduce alcohol problems or to conduct alcohol problem prevention research. Tested research components should be combined into comprehensive, integrated, and reasonably long-term community-based projects to test the hypothesis that synergistic effects occur and that significant reductions in alcohol-related problems may be demonstrated. Effective community trials are long-term investments in the health and well-being of community members. They represent an opportunity to carefully monitor changes or the absence of change in targeted behaviors and situations. Prevention efforts to reduce alcohol problems have matured to a stage at which cost-effective longitudinal research projects could be undertaken. Such community prevention research trials will require (a) a long-term funding commitment for project development, implementation, and evaluation; (b) an effective partnership between prevention program specialists and prevention researchers; and (c) application of the latest research findings to identify behaviors and situations that can be effectively targeted for change. · Prevention research should be used in policy development. The interests of researchers, prevention policymakers, and program planners are similar but not identical. Polipymakers and planners are interested not merely in understanding the general effects of a particular strategy or documenting its past impact but also in anticipating its future impact in a specific situation. Conventional research and evaluation studies do not by themselves Drovide the tvDes of "Drosnective" information that nolicvmakers require. ~ ~ or-- -- r---r~ ~~ ~~~~~ a---- ~~-~- ~~~- Although traditional research methods are often the most effective approach for examining a small number of variables in isolation from other factors, the policymaker must deal with the considerable Messiness" of detail contained in the real world. Tools are needed to assist policymakers and planners in making the best use of available resources, which would enable them to bring empirical and theoretical knowledge to bear on (a) understanding the complex network of factors that surround a set of alcohol problems and (b) estimating the likely impact of interventions in specific situations. Prevention research must develop the methods and techniques needed to assist prevention planners in estimating potential effects based on the best available research. One potentially valuable area of research is computer simulation, which permits perturbation (nwhat ifs) experiments to be undertaken to examine changes in a complex system. In such research, the computer is programmed to act like -133

the system under study and changes are made to represent the analogous changes expected with a planned prevention policy or program. This type of computer-based experiment is intended to provide policymakers and researchers with data about likely or possible long-term results or outcomes of a set of potential prevention actions. · Cost factors must be considered in prevention research. Much of prevention research is still in a formative stage and thus basic in nature. However, some areas of prevention research have developed beyond this stage to a point at which public policy and programs to prevent or reduce alcohol problems have already been based on such research. In these cases, both program costs and effects should be part of the evaluation; that is, what does it cost to undertake this program or policy given its effect in comparison with other strategies? As has been learned in other public health prevention efforts, cost/effect considerations aid in the selection of the best mix of programs and policies for reducing problems. All prevention approaches do not have similar costs or similar effects. To date, most prevention research has addressed contributory and risk factors and the potential effects of specific prevention strategies. Such research has not addressed the cost to implement or create programs based on research findings. Prevention research should include cost as a part of the outcome measures when such research has moved beyond the formative and developmental stages to a point at which programs can be based on this research. Together, these recommendations present an ambitious program for the coming years. Considerable financial resources and a commitment from researchers in the field will be required to realize the progress called for in this report. Yet the benefits to be gained from reductions in the human and economic tolls of alcohol-related problems will most certainly justify the needed investments of money and intellectual energy. REFERENCES Abrams, D. B., J. Elder, T. Lasater et al. A comprehensive framework for conceptualizing and planning organizational health promotion programs. In M. Cataldo and T. Coates, eds. Behavioral Medicine in Industry. New York: John Wiley and Sons, 1986. Altman, D., T. Flora, S. Fortmann et al. The cost effectiveness of three smoking cessation programs. Am. J. Public Health 77~2~:162-165, 1987. Ames, G. Environmental factors can create a drinking culture at worksite. Business and Health 5:44-45, 1987. Ames, G., and C. R. Janes. Heavy and problem drinking in an American blue collar population: Implications for prevention. Soc. Sci. Med. 25:949-960, 1987. Babor, T., J. Mendelson, I. Greenberg et al. Experimental analysis of the happy hour: Effects of purchase price on alcohol consumption. Psychopharmacology 58:35-41, 1978. Babor, T., J. Mendelson, I. Greenberg et al. Drinking patterns in experimental and barroom settings. J. Stud. Alcohol 41~7~:635-651, 1980. Bigelow, G., and I. Liebson. Cost factors controlling alcohol drinking. Psychol. Rec. 22:305-314, 1972. -134

Blackburn, H., R. Luepker, F. Kline et al. The Minnesota Heart Health Program: A research and demonstration project in cardiovascular disease prevention. Pp. 1171-1178 in J. D. Matarazzo, N. E. Miller, S. M. Weiss et al., eds. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: John Wiley and Sons, 1984. Those, J. O., and H. Holder. Liquor-by-the-drink and alcohol-related traffic crashes: A natural experiment using time-series analysis. J. Stud. Alcohol 48:52-60, 1987. Box, G. E., and G. M. Jenkins. Time Series Analysis: Forecasting and Control. San Francisco: Holden-Day, 1976. Box, G. E., and G. C. Tiao. Intervention analysis with applications to economic and environmental problems. J. Am. Statist. Assoc. 70:70-79, 1975. Cohen, M., I. ~ Liebson, L. ~ Faillace et al. Alcoholism: Controlled drinking and incentives for abstinence. Psychol. Reports 28:575-580, 1971. Cook, P. J., and G. Tauchen. The effect of liquor taxes on heavy drinking. Bell J. Economics 13~2~:379-390, 1982. Cook, T. D., and D. T. Campbell. Quasi-Experimentation: Design and Analysis Issues for Field Settings. Boston: Houghton-Mifflin, 1979. Engle, K B., and T. K Williams. Effects of an ounce of vodka on alcoholics' desire for alcohol. Q. J. Stud. Alcohol 33:1099-1105, 1972. Farquhar, J., S. Fortmann, N. Maccoby et al. lathe Stanford Five City Project: An overview. Pp. 1154-1165 in J. D. Matarazzo, N. E. Miller, S. M. Weiss et al., eds. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: John Wiley and Sons, 1984. Farquhar, J., S. Fortmann, I. Flora et al. The Stanford Five City Project: Designs and methods. Am. J. Epidemiol. 122:323-343, 1985. Flay, B. R. What do we know about the social influences approach to smoking prevention? Review and recommendations. Pp. 67-112 in C. S. Bell and R. Battles, eds. Prevention Research: Deterring Drug Abuse Among Children and Adolescents. NIDA Research Monograph No. 63. USDHHS Publ. No. (A13M)85-1334. Rockville, MD: National Institute on Drug Abluse, 1984. Geller, E. S., N. W. Russ, and M. G. Altomari. Naturalistic observations of beer drinking among college students. J. Appl. Behav. Anal. 19:391-396, 1986. Grossman, M., D. Coate, and G. M. Arluck. Price sensitivity of alcoholic beverages in the United States: Youth alcohol consumption. Pp. 169-198 in H. D. Holder, ed. Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. Greenwich, CI: JAI Press, 1987. Harford, T., S. Feinhandler, J. O'Leary et al. Drinking in bars: An observational study of companion status and drinking behavior. Inter. J. Addict. 18:937-950, 1983. -135

Hewitt, L. W., and H. T. Blane. Prevention through mass media communication. Pp. 281-323 in P. M. Miller and T. D. Nirenberg, eds. Prevention of Alcohol Abuse. New York: Plenum Press, 1984. Hingson, R., T. Heeren, D. Kovenock et al. Effects of Maine's 1981 and Massachusetts' 1982 D.U.I. legislation. Am. J. Public Health 77:593-597, 1987. Holder, H., and J. Those. Impact of changes in distilled spirits availability on apparent consumption: A time series analysis of liquor-by-the-glass. Br. J. Addict. 82:623-631, 1987a. Holder, H., and J. Those. The reduction of community alcohol problems: Computer simulation experiments in three counties. J. Stud. Alcohol 48~2~:124-135, 1987b. Katzper, M., R. Ryback, and M. Hertzman. Preliminary Aspects of Modeling and Simulation for Understanding Alcohol Utilization and the Effects of Regulatory Policies. Report submitted to the National Institute on Alcoholism, September 1976. Kellam, S., C. Brown, B. Rubin et al. Paths leading to teenage psychiatric symptoms and substance use: Developmental epidemiological studies in Woodlawn. Pp. 17-51 in S. Guze, F. Earls, and J. Barrett, eds. Childhood Psychopathology and Development. New York: Raven Press, 1983. Lanbein, L. J., and ~ J. Lichtman. Ecological Inference. London: Sage Publications, 1978. Langenbucher, J. W., and P. E. Nathan. Psychology, public policy and the evidence for alcohol intoxication. Am. Psychologist 383~10~:1070-1077, 1983. Lasater, T., D. Abrams, L. Artz et al. Lay volunteers of a community- based cardiovascular risk factor change program: The Pawtucket Experiment. Pp. 1171-1178 in J. D. Matarazzo, N. E. Miller, S. M. Weiss et al., eds. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: John Wiley and Sons, 1984. Levy, D., and N. Sheflin. New evidence on controlling alcohol through price. J. Stud. Alcohol 44:929-937, 1983. Maccoby, N., J. Farquhar, P. Wood et al. Reducing the risk of cardiovascular disease: Effects of a community-based campaign on knowledge and behavior. J. Community Health 23:100-114, 1977. Marlatt, G. A., B. Demming, and J. B. Reid. Loss of control drinking in alcoholics: An experimental analog. J. Abnormal Psychol. 81:223-241, 1973. Mello, N. K Some aspects of the behavioral pharmacology of alcohol. Pp. 787-809 in D. H. Efrow, ed. Psychopharmacology: A Review of Progress, 1957-1967. Public Health Se~vice Publ. No. 1836. Washington, DC: Government Printing Office, 1968. -136

Mills, K, D. McCarty, J. Ward et al. A residence hall tavern as a collegiate alcohol abuse prevention activity. Addict. Behav. 8:105-108, 1983. Moore, M. H., and D. R. Gerstein. Alcohol and Public Polipy: Beyond the Shadow of Prohibition. Washington, DC: National Academy Press, 1981. Moskowitz, J. M. The primary prevention of alcohol problems: A critical review of the research literature. J. Stud. Alcohol, 50~1~:54-88, 1989. Pendergast, M. L. A history of alcohol problem prevention efforts in the United States. Pp. 25-52 in H. Holder, ed. Advances in Substance Abuse, vol. 1, Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. Greenwich, CI: JAl Press, 1987. Popham, R. The social history of the tavern. Pp. 225-302 in Y. Israel et al., eds. Research Advances in Alcohol and Ding Problems, vol. 4. New York: Plenum Press, 1978. Pu~ska, P., ~ Nissinen, J. Tuomilehto et al. The community-based strategy to prevent coronary heart disease: Conclusions from the ten years of the North Karelia Project. Ann. Rev. Public Health 6:147-193, 1985. Rorabaugh, W. Estimated U.S. alcoholic beverage consumption, 1790 - 1860. J. Stud. Alcohol 37:357-364, 1976. Rosenbluth, J., P. E. Nathan, and D. M. Lawson. Environmental influences on drinking by college students in a college pub: Behavioral observation in the natural setting environment. Addict. Behav. 3:117-121, 1978. Saltz, R. The role of bars and restaurants in preventing alcohol- impaired driving: An evaluation of server intervention. Evaluation and the Health Professions 10:5-27, 1987. Single, E.,-and T. Storm, eds. Public drinking and public policy. Proceedings of a Symposium on Observation Studies held at Banff, Alberta, Canada, April 26-28, 1984. Toronto: Addiction Research Foundation, 1985. Skog, O. Trends in alcohol consumption and violent deaths. Br. J. Addict. 81:365-379, 1986. Smart, R. G., and E. M. Adlaf. Banning happy hours: The impact on drinking and impaired-driving charges in Ontario, Canada. J. Stud. Alcohol, 46~3~:256-258, 1986. Storm, T., and R. Cutler. Observations of drinking in natural settings: Vancouver beer parlors and cocktail lounges. J. Stud. Alcohol 42:972-997, 1981. Wagenaar, ~ Preventing highway crashes by raising the legal minimum age for drinking: The Michigan experience six years later. J. Safety Res. 17:101-109, 1986. -137

Warner, K E., and B. R. Luce. Cost Benefit and Cost Effectiveness Analysis in Health Care: Principles, Practice and Potential. Ann Arbor, MI: Health Administration Press, 1982. Wittman, F., and M. Hilton. Local regulation of alcohol availability: Uses of planning and zoning ordinances to regulate alcohol outlets in California cities. In H. Holder, ed. Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. Greenwich, CI': JAI Press, 1987. -138

II RESEARCH OPPORTUNITIES IN THE TREATMENT OF ALCOHOL-RELATED PROBLEMS -139

INTRODUCTION Within the framework of universal, selected, and indicated interventions noted in Chapter 1 of this report, treatment can be said to be an indicated intervention; its focus is on persons with already evident problems rather than on the preventions of problems in unaffected individuals. Given the heterogeneity of persons with alcohol problems-- and the wide range of such problems--reflected in the concept espoused by the committee of a continuum of severity, it should be no surprise to find that a variety of treatment methods and modalities have arisen in response. These numerous approaches testify to the vigorous interest of treatment providers and researchers and offer numerous opportunities for continued development and research on treatment efficacy and effectiveness. In response to its charge, the committee conducted an extensive review of recent treatment research with a view toward identifying promising avenues of inquiry for future studies. Chapters 7 though 14 summarize its findings, necessarily presenting illustrative as opposed to comprehensive considerations of the various topics. Chapter 7 describes the social and historical context of alcohol treatment research, noting the past extent of federal support as well as emerging trends in service delivery and demographics that may affect future funding and research interests. Chapter 8 deals with issues of assessment, methodology, and research design. It describes some of the notable achievements in treatment evaluation in recent years (e.g., conceptual advances, new measurement techniques) and discusses a number of the major unresolved research issues. Many of the available treatment approaches have not been systematically or rigorously evaluated. Nevertheless, Chapter 9 surveys outcome evaluation research since 1980 on several treatment modalities (e.g., pharmacotherapies, psychotherapy and counseling, mutual help groups) and also considers recent process evaluation research. Chapters 10 and 11 discuss research on two recent trends that appear to offer promise for impairing treatment outcome--namely, early identification of persons with alcohol problems and patient-treatment matching. Both of these areas hold promise for improving treatment outcome. Chapter 12 highlights selected findings from treatment studies of other psychoactive substance-use disorders that may be applicable to research on the treatment of alcohol problems; Chapter 13 discusses treatment of health consequences of heavy alcohol use or dependence; and Chapter 14 considers recent research on some of the public policy implications of alcohol treatment, particularly those related to costs and efficiency. In all of these chapters, the committee reviews research directions that have already been pursued and highlights potentially fruitful opportunities for further progress in identifying effective treatment approaches for alcohol problems. -140

A thorough examination of nearly everything known about the prevention and treatment of alcohol problems, this volume is directed particularly at people interested in conducting research and at agencies supporting research into the phenomenon of drinking. The book essentially is two volumes in one. The first covers progress and potential in the prevention of alcohol problems, ranging from the predispositions of the individual to the temptations posed by the environment. The second contains a history and appraisal of treatment methods and their costs, including the health consequences of alcohol abuse. A concluding section describes the funding and research policy emphases believed to be necessary for various aspects of research into prevention and treatment.

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National Research Council (US) and Institute of Medicine (US) Committee on Drug Use in the Workplace; Normand J, Lempert RO, O'Brien CP, editors. Under the Influence? Drugs and the American Work Force. Washington (DC): National Academies Press (US); 1994.

Cover of Under the Influence?

Under the Influence? Drugs and the American Work Force.

  • Hardcopy Version at National Academies Press

2 Etiology of Alcohol and Other Drug Use: An Overview of Potential Causes

The underlying causes of alcohol and other drug use and abuse are many, varied, and not well understood. Hundreds of variables have been studied as potential predictors of the onset of alcohol and other drug use. While most alcohol and other drug use initiation occurs with friends or peers who are also using drugs, the stage for this event has been set much earlier by parents, the community, and society.

This chapter provides some insight into the causes of alcohol and other drug use and proceeds to focus on the potentially different causes of off-and on-the-job alcohol and other drug use. Finally, it examines the potential influence of environmental factors on workers' alcohol and other drug use.

The individual and social influences that have been investigated can be classified into four categories: (1) the cultural/societal environment, (2) the immediate community, (3) interpersonal forces such as school, peers, and family, and (4) individual factors, including genetics, personality, and attitudes. An individual can be considered ''at risk" because of factors or forces within each of these areas. Considerable theoretical and empirical attention has been devoted to each of these possible influences (e.g., Glantz and Pickens, 1992; Galizio and Maisto, 1985; Lettieri, 1985; Lettieri et al., 1980). Hawkins et al. (1992) reviewed the possible risk factors for youth ful alcohol and other drug use and identified 20 potential causes reflecting the 4 general areas listed above (see Table 2.1 ). Cultural/societal factors include laws and norms favorable to drug use, the availability of drugs, extreme economic deprivation, and neighborhood disorganization. Interpersonal factors include family alcohol and drug use behavior and attitudes, poor and inconsistent family management practices, family conflict, peer rejection in elementary grades, and association with drug-using peers. Psychobehavioral influences include early and persistent problem behaviors, academic failure, a low degree of commitment to school, alienation and rebelliousness, attitudes favorable to drug use, and early onset of drug use. And biogenetic factors include the possible heritability of a vulnerability to drug abuse and a psychophysiological susceptibility to the effects of drugs. In a comprehensive review of the "risk factor" literature, Clayton (1992) provides a tabulation of the primary topologies and concludes that there is an emergent consensus on the most important risk factors for drug use and abuse.

TABLE 2.1. Summary of Risk Factors for Drug Use.

Summary of Risk Factors for Drug Use.

Within the behavioral sciences it is often stated that the best predictor of future behavior is past behavior. The study of alcohol and other drug use behavior is no exception to this rule. For any given individual, the strongest predictor of current use is past use. Other potential predictors are relatively more important in predicting the initiation of use or the progression of alcohol and other drug abuse. If, however, the question is whether a particular individual is likely to use or abuse drugs in the future, the individual's past history of use and abuse will tell us more about future prospects than the incremental contributions of other variables related to alcohol and other drug use.

The risk for initiating alcohol and other drug use increases for most drugs to a peak during mid-to late adolescence and decreases thereafter (Kandel and Logan, 1984). Tobacco has the youngest age of highest vulnerability, usually in early adolescence. Increased likelihood for beginning alcohol, marijuana, and psychedelics typically occurs in mid-adolescence. Interestingly, the most hazardous age for experimenting with cocaine has typically been young adulthood—about the mid-twenties; however, this pattern for cocaine may be changing due to the emergence of crack, the inexpensive and smokable form of cocaine, which may be more available and alluring to teenagers.

Some types of alcohol and other drug abuse appear to have a genetic component (Cadoret, 1992; Merikangas et al., 1992; Vaillant and Milofsky, 1982), although environmental, social, and psychological factors have received primary attention as causes of the initiation of alcohol and other drug use and progression to abuse (e.g., Sadava, 1987; Zucker and Gomberg, 1986). Attention to the latter factors is appropriate, for biogenetic influences are shaped and modified by personal attributes and environmental conditions (e.g., Marlatt et al., 1988). An important question concerns what precisely is inherited if there is a genetic influence for alcoholism or other drug abuse. Research evidence, primarily but not exclusively based on animal models, suggests at least two mechanisms (e.g., Bardo and Risner, 1985). Those at genetic risk for alcohol and other drug abuse may inherit a biological vulnerability to the hedonic effects of the drug, so for them drug effects are more attractive than for others. They may also not experience the withdrawal effects as severely as those not at risk (i.e., less likelihood of hangover). However, these proposed mechanisms and perhaps others (e.g., inherited behavioral traits; Tarter, 1988) must be evaluated more conclusively in further research (Schuckit, 1987).

Some have suggested that involvement with alcohol and other drugs progresses in a fixed sequence, moving from licit drugs to illicit substances (e.g., Kandel, 1975; Kandel and Faust, 1975). An individual's drug-using career might start with beer, wine, or cigarettes, move to hard liquor, then to marijuana, and subsequently to other illicit drugs, such as amphetamines, cocaine, and heroin. Desistance may occur at any point (O'Donnell and Clayton, 1982), meaning that involvement at one stage does not necessarily lead to involvement at the next stage, but rather that involvement at the next stage is unlikely without prior involvement in the previous stage. Results in various cross-sectional and longitudinal studies have generally confirmed the stage hypothesis with some variations (e.g., Hays et al., 1987; Mills and Noyes, 1984; Newcomb and Bentler, 1986a). Donovan and Jessor (1983), for example, found that problem drinking occurred higher in the progression than general alcohol use, and Newcomb and Bentler (1986a) found that, when the role of cigarettes and nonprescription medications was included, several mini-sequences accounted for drug involvement from early adolescence to young adulthood.

Social factors that determine the availability and the attractiveness of alcohol and other drugs to particular individuals are important to this progression, and highly addictive drugs, such as crack cocaine, may alter this sequence of drug progression. Thus it may be that the severe addictive potential and wide and inexpensive availability of crack may lead to its being used earlier in the sequence than other less addictive illicit drugs or even licit drugs. There are, however, few data currently available to test this notion. The mechanism that drives staging, such as availability, anxiety reduction, peer groups norms, and physiological vulnerability, are not known, but these factors may not be the same at all stages. Peer group norms, for example, might be of vital importance to initiation, while individual psychopathology may figure more in shifts toward the end of the involvement sequence.

Some research suggests that the reasons people begin using alcohol and other drugs are different from the reasons they continue or escalate their use, which is to say, the factors that influence initiation are different from those that influence progression to more serious use. Several researchers have found that initiation is often strongly tied to social and peer influences, whereas biological and psychological processes appear to be associated with abuse (Carman, 1979; Kandel et al., 1978; Newcomb and Bentler, 1990; Paton et al., 1977). Even though data may as yet be too sparse to establish firmly that the causes of use are different from the causes of abuse, the evidence consistent with this hypothesis is accumulating (Glantz and Pickens, 1992).

A wide range of correlates with the initiation of alcohol and other drug use have been identified. They tend to overlap substantially with predictors of general problem behavior or deviance, which is not surprising given the correlation of other problem behaviors with alcohol and other drug use. The primary mechanism for establishing unique predictors of alcohol and other drug use has been longitudinal studies, controlling statistically for other deviant behaviors and attitudes using structural equation modeling methods (Bentler, 1980; Newcomb, 1990). These studies suggest that peer influences (such as modeling use, providing drugs, and encouraging use) are the most consistent and strongest predictors. In addition to the role of prior behavioral experience with alcohol and other drugs and peer influences, other factors associated with initial involvement with drugs include social structural variables, such as socioeconomic status (with heavier use among more disadvantaged groups), family role and socialization variables (with greater use in families with adult drug users, dysfunctional family structures), educational variables (with poor school attachment and performance associated with greater drug use), psychological variables (such as a high need for stimulation), attitudinal variables such as tolerance for deviance (with nontraditionalism associated with greater drug use), behavioral variables such as deviant behaviors and low law abidance (implying greater substance use), emotional variables (such as anxiety and need for excitement), psychopathology (with greater depression and antisocial personality related to higher drug use), temperament and exposure to stressful life events (see Hawkins et al., 1992; Clayton, 1992).

While influences like these have been related to involvement with alcohol and other drug use or abuse, none has ever been found to be a single primary factor that causes alcohol and other drug use or abuse. Indeed, it seems highly unlikely that any one factor or even a few factors will ever be found to account fully for all variations in drug involvement. Because the range of variables leading to initial involvement in alcohol and other drug use is so large, recent views of this phenomenon have emphasized the risk factor notion that is often used in medical epidemiology (Bry et al., 1982; Schreier and Newcomb, 1991a,b). Risk factors include environmental, behavioral, psychological, and social attributes.

Viewing alcohol and other drug involvement as multiply determined suggests that the more risk factors someone is exposed to that encourage use, the more likely he or she is to use or abuse alcohol and other drugs. Exposure to a greater numbers of risk factors is not only a reliable correlate of use, but it also influences the increase in alcohol and other drug use over time, implying a true causal role for those variables that together make for increased risk (Schreier and Newcomb, 1991b). It appears from this approach that the presence of particular factors that can encourage drug use are not as important as the accumulation and interaction of such factors in a person's life.

Protective factors, in contrast to risk factors for alcohol and other drug use, reduce the likelihood and level of drug use and abuse. Protective factors are those psychosocial influences that limit or reduce drug involvement (Newcomb, 1992). Only recently has the risk factors approach to drug use and abuse been expanded to test for multiple protective factors as well (Newcomb, 1992; Newcomb and Felix-Ortiz, 1992). Protective factors may operate through mechanisms other than simply by a direct reduction of alcohol and drug involvement. For example, protective factors have been shown to buffer or moderate the association between risk factors and drug use and abuse (Brook et al., 1992). Recent examples of protective factors that have been found to mitigate the risk of alcohol and other drug use or abuse involve aspects of the environment (e.g., maternal affection—Brook et al., 1989) and the individual (e.g., introversion or self-acceptance—Stacy et al., 1992).

  • Alcohol And Other Drug Use On The Job

As we discussed in Chapter 1 , the definition of terms can significantly shape the problem under study. More specifically, with respect to on-the-job versus off-the-job drug use, Chapter 1 indicates the importance of such a distinction in the study of alcohol and other drug use by the work force. The term on-the-job drug use is ambiguous and can mean different things in different studies. Taken literally, the phrase refers only to drugs used at the work site while work is or should be going on. By this definition, a three-martini lunch or a two-joint break would not be considered drug use on the job. Yet many drugs affect work performance for hours, if not days, after consumption. Several self-report measures of workplace drug use ask respondents whether they have used a particular drug on the job. It is unclear whether employees interpret this question to include alcohol and other drugs used just before work, during breaks, or at lunch. Alcohol and other drugs used at these times could lead to workplace impairment even though they do not involve "drug use on the job" if the term is taken literally. The more relevant question might be whether employees have ever been drunk, high, or stoned at work, but this is rarely asked. It is well known that small differences in question wording or even question order can affect survey responses, and attention should be paid to this dynamic in future surveys of workplace drug use.

Patterns of Alcohol and Other Drug Use on the Job

Employers have often been plagued by the occasional alcoholic employee who is frequently absent or tardy or may drink or be drunk on the job. Some employers believe that such behavior is increasing and extends to drugs other than alcohol. However, no large-scale surveys of adult workers exist to substantiate such conclusions.

Alcohol is believed to be the most frequently used drug in the workplace (apart from nicotine and caffeine), but precise comparisons with other drugs and evaluations of their relationship to alcohol cannot be made (Cohen, 1984, 1986). The few surveys that attempt to assess the prevalence of alcohol and other drug use in the work site typically report estimates from management or union sources rather than from employees (e.g., Schreier, 1987; Steele, 1981). Such surveys report the perceptions of knowledgeable observers who are close to the problem, but as a measure of actual alcohol and other drug use they are obviously flawed.

Nevertheless, as discussed in more detail in Chapter 3 , a few studies designed specifically to estimate rates of alcohol and other drug use on the job provide tentative estimates of work force alcohol and other drug use. Those studies vary greatly in terms of methods used to assess alcohol and other drug use and when similar methods are used, they often define their measures of alcohol and other drug use differently (e.g., on-the-job drug use).

Although these studies do not provide precise estimates of the rate of alcohol and other drug use by the work force, they do, however, provide information concerning which members of the work force are more likely to use drugs and what drugs are most likely to be used. Rates of self-reported alcohol and other drug use on the job vary according to occupation, age, gender, and ethnicity. Excluding tobacco and caffeine, most surveys find that fewer than 10 percent of workers report having used alcohol or other drugs while on the job during the prior year. Some studies, however, report significantly higher use rates. Much of the difference in the rates reported appears attributable to differences in samples surveyed and questions asked.

It appears that a sizable number of people use alcohol or other drugs regularly, but not at work; others use alcohol or other drugs both at work and away from work. Some use alcohol or other drugs only when they are away from the workplace, and others use alcohol or other drugs only when they are at work. There may also be a group of individuals who use one drug at work and other drugs at home or away from the work site. Researchers have only begun to confront the degree of correspondence between a general proclivity to use alcohol and other drugs and the use of alcohol or other drugs on the job. Often implicit is the yet unproven assumption that the association is quite high, if not perfect. For instance, many discussions of on-the-job drug use cite statistics of general drug use of various populations and argue that alcohol and other drug use in the workplace must be rampant (e.g., Backer, 1987). Since people can choose where to use alcohol and other drugs and what drugs to use, heavy off-the-job use of specific drugs does not mean that those drugs will be used at work. The "weekend drunk" is an example. It is, however, reasonable to assume that at least some general drug use must precede on-the-job use for most people.

Newcomb (1988) found that alcohol and other drug use at work and general alcohol and other drug use were highly, but not perfectly, related (i.e., high general use of drugs did not mean drugs would necessarily be used in the workplace, but the two were clearly associated). In most cases, knowing the extent of general alcohol and other drug use among a sample of individuals predicted less than 50 percent of the variance of on-the-job alcohol and other drug use. Thus the propensity to use alcohol and other drugs on the job varied with the degree of off-the-job alcohol and other drug involvement, but the relationship was not so strong as to justify treating overall alcohol and other drug use prevalence rates as indicators of the likely extent of different types of drug use on the job.

The association that Newcomb found between the use of drugs at and away from work varied by drug combination. For instance, those who reported using marijuana off the job were twice as likely to use alcohol and seven time more likely to use cocaine on the job than those who did not report off-the-job marijuana use (Newcomb, 1988:72-73). Similarly, cigarette smokers were twice as likely to use alcohol on the job and over three times as likely to use marijuana, cocaine, or other hard drugs on the job, as those who did not smoke cigarettes.

Moreover, previous research has revealed that a person's drug use is typically not limited to one specific substance, but often involves the use of various drugs, sometimes more or less simultaneously. This is particularly true for teenagers and for those who use illicit drugs (i.e., marijuana, cocaine), but it has been documented among young adults (Newcomb and Bentler, 1998a,b) and adults (Newcomb, 1992) as well. Clayton and Ritter (1985:83), after examining many studies, concluded that "more often than not, the persons who are using drugs frequently are multiple drug users." Cocaine users, for example, reported significantly higher rates of use for all other types of drugs, including cigarettes, alcohol, marijuana, over-the-counter medications, hypnotics, stimulants, psychedelics, inhalants, narcotics, and PCP, compared with those who had never used cocaine. These large differences were found for both men and women and were prevalent during adolescence as well as young adulthood (e.g., Newcomb and Bentler, 1986b). The association between various types of drug use is so high that common underlying constructs of general polydrug use (Newcomb and Bentler, 1986b) and polydrug use in the workplace (Newcomb, 1988; Stein et al., 1988) have been distinctly and reliably identified.

In an extensive series of analyses of alcohol and other drug use, one of the overriding conclusions reached by Newcomb (1988) was that alcohol and other drug use in the workplace was not typically restricted to single drugs but was highly related to the use of other drugs of both similar and different types. Thus someone caught using marijuana at work is more likely than a random worker to have also used alcohol on the job and far more likely to have used harder drugs. Indeed, Newcomb's study suggests that substance use in the workplace is best characterized as polydrug use at work. The use of one substance at work increases the likelihood of using other drugs in that context.

As we already noted, it appears that alcohol and other drug involvement progresses by stages (Kandel, 1975; Kandel and Faust, 1975). Newcomb (1988) reports data suggesting that using alcohol and other drugs at work reflects a relatively high level of drug involvement. Newcomb's data indicate that using drugs at work is located after both alcohol and marijuana use on the drug involvement continuum for men and subsequent to cocaine use for women. Thus it appears that workplace alcohol and other drug use implies a degree of drug involvement somewhere between that implied by marijuana and cocaine use, on one hand, and cocaine and harder drug use, on the other. The different scaling results for men and women suggest that using alcohol and other drugs at work occurs earlier in the sequence of drug involvement for men than women. This may help explain the gender differences in the prevalence of alcohol and other drug use in the workplace that is reported in Chapter 3 . The polydrug use concept is consistent with the view of drug involvement as a staged process defined in large measure by the types of drugs used (e.g., Newcomb and Bentler, 1986b). Those who have tried drugs high in the progression of drug involvement may also continue to use the drugs that do not by themselves characterize high involvement. Indeed, a more elaborate stage model might identify certain configurations of polydrug use as separate stages in the progression of drug involvement.

Predictors of Alcohol and Other Drug Use on the Job

Evidence of social-environmental influences on drug use have led many to believe that job conditions constitute important risk or protective factors with respect to alcohol and other drug use. Among the characteristics of the work environment that have been posited to influence employee alcohol and other drug use are organizational frustration and job stress (Milbourn, 1984), distancing forces, attractions, and constraints (Gupta and Jenkins, 1984), occupational and coworker norms (Shore, 1986), and alcohol and other drug use "enabling" aspects of the work environment (Ames, 1990; Roman et al., 1992).

In empirical tests of these expectations, the primary focus has been on correlates with alcohol and other drug use in general and not specifically with alcohol and other drug use on the job. Markowitz (1984), for example, found that indicators of general alcohol misuse were significantly correlated with less responsibility and autonomy in the workplace. Martin et al. (1992) found that some form of alcohol use was significantly associated with more pressure and fewer extrinsic rewards, although demographic factors (divorced and urban residence) were far more important than these job characteristics.

A few studies have directly examined the relationship of job characteristics as they relate to actual alcohol and other drug use on the job. Lehman and Simpson (1992) found that alcohol and other drug use at work was directly correlated with male gender, depression, not working in an office, job dissatisfaction, job tension, accidents, and absences; it was inversely correlated with age, education, faith in management, job involvement, and organizational commitment. Some of these correlations appear to be causally related to alcohol and other drug use (e.g., age); others are the likely results of use (e.g., accidents); and for still others the relationship is likely to be bidirectional (e.g., organizational involvement). In a different analysis of this data set, Lehman et al. (1991) found seven significant predictors of alcohol and other drug use at work: (1) not being married, (2) having been arrested, (3) low self-esteem, (4) high peer drug use, (5) working alone or in a small group, (6) having a high-risk job, and (7) low job involvement.

Mensch and Kandel (1988) examined various job dimensions as possible correlates of on-the-job marijuana use for men and women. They found eight small, but significant correlates of using marijuana at work among men: (1) low skill discretion, (2) low decision authority, (3) high job insecurity, (4) low supervisor support, (5) high physical demands, (6) high hazardous exposure, (7) low substantive complexity, and (8) high motor skills. Among women, marijuana use on the job was significantly correlated with five job characteristics: (1) low skill discretion, (2) low decision authority, (3) high coworker support, (4) low substantive complexity, and (5) high physical demands.

Mangione and Quinn (1975) examined relationships between alcohol and other drug use on the job and job satisfaction among men and women above and below age 30. There were no significant correlations between alcohol and other drug use in the workplace and job satisfaction for either group of women. The only significant correlation was found for men 30 years or older—but it was small (r = –.12).

Using ethnographic methods, Ames (1990) found that certain aspects of the work environment, as well as ambiguous or conflicting responsibilities of supervisors, encouraged drinking on the job. They characterized these aspects of the working environment as enabling influences for on-the-job alcohol use.

Newcomb (1988) has presented a comprehensive set of both cross-sectional and prospective survey findings on the correlates and predictors of alcohol and other drug use in the workplace. He examined many personal, social, and work-related factors in terms of their associations with using alcohol and other drugs on the job. Demographically, Newcomb found that those most likely to use alcohol and other drugs in the workplace were male, either black (for use of marijuana) or white (for use of other drugs), had few educational plans, had cohabited sometime in their life, had no children, and were not currently married. Higher income was related to greater use of cocaine and harder drugs. A wide range of personality, emotional functioning, social support, and problem variables were examined as possible correlates of alcohol and other drug use in the workplace. Several small, but significant, effects were found. Using alcohol or other drugs at work was slightly but significantly related to relationship and family problems and emotional distress. Alcohol and other drug use at work was most highly related to having drug and alcohol problems, being low in law abidance, being liberal, feeling powerless, and lacking fear of injury. In other words, alcohol and other drug use in the workplace typically does not appear to result from life problems or general unhappiness (although a few small associations in these variables were found). It was most related to general nonconformity, low fearfulness, having some trouble with an intimate relationship, off-the-job drug or alcohol problems, and feeling powerless.

Workplace alcohol and other drug use was not highly related to such work-related variables as income, collecting public assistance, hours worked, and support for work problems. It was most strongly related to job instability (frequently being fired), committing vandalism at work, and somewhat less strongly to job dissatisfaction. Alcohol and other drug use in the workplace was only slightly but significantly related to problems and unhappiness in the workplace.

To summarize, Newcomb's studies indicate that alcohol and other drug use in the workplace appears to be more a function of the personal qualities of individuals, rather than functions of their work environments. Alcohol and other drug use on the job is strongly related to such personality characteristics as rebelliousness, nonconformity, deviance, and perhaps acting out; the prospective studies reveal that people with such traits are more likely than others to use alcohol and other drugs at work at later points in time. Based on Newcomb's studies, it appears that alcohol and other drug use on the job is neither largely nor generally situationally determined, but is a manifestation of a general syndrome of problem behaviors, both related to and separate from alcohol and other drug use. But some of the other studies reviewed by the committee do show small but not always consistent workplace environment effects.

Several reviews of the literature reach conclusions similar to those of Newcomb. For instance, Harris and Heft (1992:241) concluded that ''though statistically significant in some cases, the relationship between work conditions and drug/alcohol consumption appears to be quite small." Over a decade earlier, Herold and Conlon (1981:337) reached the same conclusion regarding the association between work factors and alcohol abuse, stating that "unequivocal evidence of such linkages is scarce."

There are, however, problems with this general conclusion, which mean that the work environment cannot be ruled out as a contributing or interactive factor for generating alcohol and other drug use among workers or protecting them from it. All the studies that find that personality variables dwarf work environment variables are biased by an imbalance in the use of individual and job condition and attitude measures. Some studies measure many individual traits but have relatively few measures of job conditions; in a few others, the imbalance is reversed. One might expect that the more variables used to measure a domain, the greater the amount of variance attributable to a domain and the more likely some significant relationships will be revealed. These complexities are confounded by the fact that no existing study has been designed to test directly and explicitly whether alcohol and other drug use on the job is associated more or less with personal qualities (i.e., traits) or job characteristics (e.g., role ambiguity, stress, shift work) when appropriate and thorough measures of both domains have been gathered.

Moreover, most existing studies employ models that assume only direct or main effects of work environment on alcohol and other drug use. This perspective is too narrow. As several reviews have noted, the associations between work environment and on-or off-the-job alcohol and other drug use are likely to be far more complex (e.g., Martin et al., 1992). They may involve intervening variables (e.g., Violanti et al., 1983), generalization processes (e.g., Martin et al., 1992), influence by individual differences (Conway et al., 1981), as well as interactions or moderated relationships between personal characteristics and job conditions (e.g., Brief and Folger, 1992). For example, a poor work environment may lead to family stresses that promote alcohol and other drug use, or those with low self-esteem may be prone to use alcohol and other drugs on the job, but only on those jobs in which supervisors are authoritarian and seldom give positive feedback. Because of possibilities like these and the shortcomings of the extant research, we cannot conclude that the work environment does not affect worker alcohol and other drug use both on and off the job to an important extent. More comprehensive analyses and tests of more realistic theories are necessary to sort out the relative impact of work environment and individual traits on worker alcohol and other drug use and the ways in which variables in these domains relate to each other.

Nature Versus Nurture in Alcohol and Other Drug Use on the Job

Data on different levels of alcohol and other drug use across occupations that are discussed in Chapter 3 raise an important issue. that is, are these occupational differences explained in part by the social dynamics of particular occupations, or are they the result of the individual characteristics of those who gravitate toward certain occupations? Okinuora (1984) and Plant (1981) identified several risk factors that were related to the connection between occupation and alcoholism. These included the availability of alcohol at work, social pressure to drink on the job, separation from normal social relationships, freedom from supervision, very high or very low income, collusion by colleagues, strains, stresses, and hazards, and self-selection for high-risk occupations.

The association between job type and alcohol or other drug use may be because those with a propensity to use drugs are attracted to particular positions/occupations (e.g., alcoholics may find brewery jobs enticing), because particular job conditions are conducive to drug use (e.g., brewery workers may find it hard to resist social pressures to drink), or to some combination of causal possibilities. Plant (1978, 1979) attempted to tease apart these possibilities by studying new recruits to the liquor or brewery trade (a very high-risk occupation) and comparing them with those applying for jobs at low risk for alcohol problems. He found that those who sought liquor and brewery jobs had poorer employment records and were heavier drinkers prior to their employment than were applicants to lower-risk occupations. This supports the self-selection hypothesis. He also found, however, that those in the liquor industry increased their drinking behavior (including on-the-job drinking) in conformity to perceived social norms. Thus it appears that self-selection and environmental pressures combine to account for the high rates of alcoholism that are found in the alcoholic beverage industry.

In a study of prevalence rates for lifetime cocaine use (Trinkoff et al., 1990) reported that among 6 job categories studied, the skilled labor category had the highest level of lifetime cocaine use (12 percent) followed by management professionals (8 percent), technical/sales/support (8 percent), service (7 percent), farm/forest/fishing (7 percent), and unskilled labor with the lowest rate of 6 percent. The authors point out that such rates were strongly related to education level and varied substantially across age groups with the highest reported rates observed among respondents below age 35. In another prevalence study Trinkoff et al. (1991) analyzed a different subset of data from the Epidemiologic Catchment Area Program to estimate rate of alcohol and other drug use among nurses and compared those rates to a matched control group of employed non-nurses. Their results showed that nurses were no more likely to have engaged in illicit drug use than non-nurses. However nurses were found to be less likely to have experienced problems with alcohol abuse than non-nurses. Unfortunately, prevalence estimates on specific drug types, other than alcohol, were unstable with large confidence intervals due to the missing data and the small size of the samples studied.

Cosper (1979) and Cosper and Hughes (1982) challenged the notion that occupations associated with heavy drinking are disproportionately characterized by alcohol abuse or alcoholism. They suggested that the frequency, but not the quantity, of drinking is higher in certain occupations, and that the frequency of drinking may not reflect problem levels. They suggest that conformity to the unique norms of an occupation may generate differences in drinking behavior and thus may not indicate deviance or low social conformity. Although this may be true in certain jobs (they studied naval officers and journalists), it does not account for the differential treatment rates for alcohol and other drugs nor for mortality differences observed in other studies.

Alcohol and Other Drug Use by Occupation and Context

Several recent studies have identified industries or job categories that have different risks for on-the-job alcohol and other drug use. Lehman et al. (1990) found the highest rates of alcohol and other drug use in the workplace for skilled, technical, paraprofessional, and service occupations (ranging from 3 to 4 percent) and the lowest for professional and clerical positions (from 0 to 1 percent). Mensch and Kandel (1988), in exploring similar occupations, found interactions between job sector, drug type, and gender. Among men, the recreation, entertainment, and construction industries were associated with the highest rates of alcohol, marijuana, and cocaine use on the job. Among women, alcohol use at work was most likely in the agriculture, forestry, and fishery industries; marijuana use on the job most often occurred in construction jobs, and cocaine was most prevalent on the job in the transportation sector. Gleason et al. (1991) found that the highest prevalence rates of drug use on the job were in the construction and entertainment/recreation industries, whereas the lowest rates were found in the professional services and public administration industries.

Results from the High School Senior survey presented in detail in Chapter 3 indicate that military and protective services occupational groups (e.g., police, fire fighters) had very low rates of use at work. Reported alcohol use at work (at least once in the previous 12 months) was highest for men in professional, skilled, and managerial or semiskilled jobs. Women were only slightly lower than men in their rate of using alcohol. The High School Senior follow-up survey revealed greater variation in marijuana use at work. Between 9 and 10 percent of skilled and semiskilled male workers had smoked marijuana at work, compared with less than 5 percent in any of the other gender-occupation categories. Skilled and semiskilled male workers were also more likely to report having used cocaine at work; 2 to 4 percent said they had done so. The situation was different for the nonmedical use of psychotherapeutic drugs. Amphetamine use was highest among female skilled workers, with prevalence rates of 4 percent, while male and female semiskilled workers and men in the military had rates of around 3 percent. About 3 percent of female skilled workers had taken tranquilizers at work; no other group much exceeded 1 percent.

  • Conclusions And Recommendations
  • The most vulnerable age and primary risk factors associated with drug use initiation typically precede an individual's entry into the work force. This fact has important implications for work-related prevention interventions designed to prevent the onset of drug use. This means that workplace interventions may have only limited effects on preventing initiation into most categories of drug use.
  • Most alcohol and other drug users do not develop patterns of clinically defined abuse or dependence. The progression from use to abuse and dependence varies with drug type as well as with factors that are specific to individuals and their environments. It is not possible, however, to predict with great accuracy which alcohol and other drug users will become abusers or will eventually need treatment.
  • If use and abuse have different causes, it follows that they are likely to benefit from different types of interventions, so it is important to further explore the hypothesis that any type of drug or alcohol use at the work site in fact reflects abuse.
  • Among illicit drug users, polydrug use, most often including the use of alcohol and tobacco, is the norm rather than the exception.

Recommendation: In evaluating the impact of alcohol and other drug use on behavior, specific attention should be paid to the actions of drugs in combination.

• Based on the sparse empirical evidence accumulated to date, alcohol and other drug use by the work force appears to be more a function of the personal qualities of individuals than of their work environments. However, most studies of why workers use alcohol and other drugs have serious methodological flaws. Hence, the work environment cannot be ruled out as a contributing or interactive factor in generating use among workers or protecting them from it.

Recommendation: Research is still needed to sort out the relative impact of the work environment and individual traits on workers' alcohol and other drug use. This research should test realistic theories involving such potential critical variables such as drug availability, local norms, and work stress and attending to such complexities as interaction effects can reverse causation.

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  • Cite this Page National Research Council (US) and Institute of Medicine (US) Committee on Drug Use in the Workplace; Normand J, Lempert RO, O'Brien CP, editors. Under the Influence? Drugs and the American Work Force. Washington (DC): National Academies Press (US); 1994. 2, Etiology of Alcohol and Other Drug Use: An Overview of Potential Causes.
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  1. 45 Infographics about Alcohol That You Should Know

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  2. Chapter 11 Lesson 2: Alcohol Use and Abuse by

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  3. Different People, Different Options

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  4. AA ------ Chapter 3 ~ MORE ABOUT ALCOHOLISM

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  1. PDF Chapter 3

    Here are some of the methods we have tried: Drink-ing beer only, limiting the number of drinks, never drinking alone, never drinking in the morning, drink-ing only at home, never having it in the house, never drinking during business hours, drinking only at parties, switching from scotch to brandy, drinking only natural wines, agreeing to resign...

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    Chapter 3 of the dissertation presents the research design and the specific procedures used in conducting your study. A research design includes various interrelated elements that reflect its sequential nature.

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  4. Underage Drinking

    KEY FINDINGS 2 • The goals of alcohol prevention programmes often vary according to cultural context. While most U.S.-based programmes have abstinence as their primary goal, most European programmes include reductions in alcohol use as a viable outcome.

  5. Methodology

    Methodology. Download the Source and Accuracy Statement PDF 863 KB. In this Section. NESARC-III Data Access. Human Subjects Protection. NIAAA Data Use Agreement. Questionnaire. Flashcard Booklet. Methodology.

  6. Methodological Issues in Alcohol Prevention Research: Conclusions and

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  7. Alcohol consumption and social harm: quantitative research methodology

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  8. Chapter 3—Motivational Interviewing as a Counseling Style

    Chapter 3 explores specific MI strategies you can use to help clients who misuse substances or who have substance use disorders (SUDs) strengthen their motivation and commitment to change their substance use behaviors. This chapter examines what's new in MI, the spirit of MI, the concept of ambivalence, core counseling skills, and the four processes of MI, as well as the effectiveness of MI in ...

  9. Issues of Assessment, Methodology, and Research Design

    A third advance in conceptualization concerns new developments in the way treatment evaluation is viewed. Interest in treatment evaluation research has been increasing within the alcohol field over the past 20 years. The dominant approach in both clinical practice and treatment evaluation research has been to ask: Is treatment effective?

  10. PDF Chapter 3: Method (Phenomenological Study)

    Chapter 3: Method (Phenomenological Study) This workbook is intended to help you to write Chapter 3 of your dissertation proposal. Each ... Describes the specific research methodology chosen and how it derives logically from the statement of problem and the research questions. Introduction 5. Suggested Resources for Enrichment

  11. PDF Chapter 3 MORE ABOUT ALCOHOLISM

    Here are some of the methods we have tried: Drinking beer only, limiting the number of drinks, never drinking alone, never drinking in the morning, drinking only at home, never having it in the house, never drinking during business hours, drinking only at parties, switching from scotch to brandy, drinking only natural wines, agreeing to resign i...

  12. Psychological Perspectives on Alcohol Consumption

    A 'binge' is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gram percent or above. For the typical adult, this pattern corresponds to consuming 5 or more drinks (male), or 4 or more drinks (female), in about 2 hours. Binge drinking is clearly dangerous for the drinker and society.

  13. Chapter 3

    Points Scale Verbal Interpretation 4 3 - 4 Strongly Agree 3 2 - 3 Agree 2 1 - 2 Disagree 1 1 - 1 Strongly Disagree. Formula Used in Treating the data gathered: x̅ =N∑ M,X + W 2 X + W 3 X + W 4 X + W 5 X. Where: x̅ = weighted mean. x = total number pf respondents per question. N = total number of respondents. W = respective legend point (4 ...

  14. Chapter 3

    Chapter 3 - Free download as PDF File (.pdf), Text File (.txt) or read online for free. sfwe

  15. National Institute on Alcohol Abuse and Alcoholism (NIAAA)

    Introduction. Alcohol is part of our society. People use it to celebrate, socialize, relax, and enhance the enjoyment of meals. Nearly 90 percent of adults in the United States report that they drank alcohol at some point in their lifetime, and more than half report drinking in the last month. 1 Although most people drink in moderation, nearly ...

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    Figure 1 Analytic framework. Go to: LITERATURE SEARCH AND SCREENING PLAN Inclusion and exclusion criteria Table 3 provides the inclusion and exclusion criteria for the systematic review.

  17. 3.7 Alcohol

    In 2010, alcohol misuse cost the United States $249.0 billion. 11; Three-quarters of the total cost of alcohol misuse are related to binge drinking. 11; Global Burden: In 2012, 3.3 million deaths, or 5.9 percent of all global deaths (7.6 percent for men and 4.1 percent for women), were attributable to alcohol consumption. 12

  18. A Quantitative Examination of Alcohol Consumption Motivation Between

    MOTIVATION TO CONSUME ALCOHOL AMONG FRESHMEN MALES 1 CHAPTER I Introduction On average, there are 1,825 deaths related to alcohol consumption among college students each year in the United States (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2014). Alcohol is a common substance that is used among college

  19. Read "Prevention and Treatment of Alcohol Problems: Research

    Chapter 7 describes the social and historical context of alcohol treatment research, noting the past extent of federal support as well as emerging trends in service delivery and demographics that may affect future funding and research interests. Chapter 8 deals with issues of assessment, methodology, and research design.

  20. PDF Chapter 3 Methodology

    This chapter of this study describes research methodological approaches to test. the brief cognitive-support treatment in comparison to usual care. The topics consist. of research design, population and sample, settings, instrumentation, protection of. human subjects' rights, data collection and intervention procedures, strategies to.

  21. PDF Chapter 3

    Here are some of the methods we have tried: Drinking beer only, limiting the number of drinks, never drinking alone, never drinking in the morning, drinking only at home, never having it in the house, never drinking during business hours, drinking only at parties, switching from scotch to brandy, drinking only natural wines, agreeing to resign i...

  22. CHAPTER 3 METHODOLOGY 1. INTRODUCTION

    2. RESEARCH DESIGN. This research is exploratory in nature as it attempts to explore the experiences of mothers of incest survivors. Their subjective perceptions formed the core data of the study; hence it needed the method that would deal with the topic in an exploratory nature. For the purpose of this study, the research paradigm that was ...

  23. Etiology of Alcohol and Other Drug Use: An Overview of Potential Causes

    Nevertheless, as discussed in more detail in Chapter 3, a few studies designed specifically to estimate rates of alcohol and other drug use on the job provide tentative estimates of work force alcohol and other drug use. Those studies vary greatly in terms of methods used to assess alcohol and other drug use and when similar methods are used ...