Preventing Alcohol Problems: What Works A Case Study of the U.S.

1. Preventing Alcohol Problems: What WorksA Case Study of the U.S. XVII Annual Conference Brazilian Association for Drug and Alcohol Studies Ouro Preto, Brazil September 1, 2005 Robert I. Reynolds, Director Alcohol Policy Initiatives Pacific Institute for Research and Evaluation Shepherdstown, West Virginia, USA

2. Alcohol is a drug which is: • Mind altering • Tolerance producing • Addictive These basic facts are not changed by alcohol industry advertising.

3. Drug “Capture” Rate Percent of Users Who Become Clinically Dependent Tobacco 31.9% Heroin 23.1% Cocaine 16.7% Alcohol 15.4% Stimulants 11.2% Marijuana 9.1% Source: National Comorbidity Survey Anthony, Warner, and Kessler

4. WARNING: U.S. experiences may be hazardous to Brazil!

5. Global Burden of Disease(Disability-Adjusted Life Years) Attribution Tobacco Alcohol Illicit Drugs Worldwide 4.1% 4.0% 0.8% North America 8 - 15.9% 4 - 7.9% 2 - 3.9% South America 8 - 15.9% 2 - 3.9% 1 - 1.9% Source: World Health Report 2002 World Health Organization

6. Country Case Volume China 725 million cases Russia 350 India 249 Brazil 195 Japan 176 United States 135 Korea 79 Thailand 76 Germany 60 France 37 Source: Mark Brown, President Sazerac Company, Inc. March 4, 2003 Global Market – Alcohol SpiritsSales Exceed 2 Billion Cases Annually

7. Product Categories – Alcohol Spirits Product Category Case Volume Baijiu 725 million cases Vodka 400 Whisky 205 Cachaca 200 Rum 115 Brandy 82 Shochu 70 Soju 70 Liqueurs 51 Source: Mark Brown, President Sazerac Company, Inc. March 4, 2003

8. U.S. Prevention Strategies and U.S. Per Capita Alcohol Consumption Source: NIAAA

9. U.S. Economic Costs of ATOD Use, 1995 Total Costs = $415 Billion Sources: Harwood, Fountain, & Livermore, NIDA & NIAAA, 1998 Rice (unpublished) Institute for Health and Aging, UCSF, 1995

10. Most U.S. adults do not drink or drink infrequently. Frequency of Drinking Among U.S. Adults 21 and Older, 2002 (past 30 days) Number of Drinking Days Source: NSDUH, 2002

11. Most U.S. adults do not drink at a hazardous level. Drinking Patterns among U.S. Adults 21 and Older, 2002(past 30 days) Source: NSDUH, 2002

12. Binge drinkers are 23% of the population, but consume 76% of the alcohol. U.S. Binge Drinkers, 2002 Source: NSDUH, 2002

13. Most young people do not drink. Drinking Among Youth, 2002 (past 30 days) 15- to 17-year-olds 10% Drinking occasions 18% 0 1 to 4 5 or more 72% Among the 28% of 15-17 year olds who drink, 65% drank heavily at least once in the past month. Source: NSDUH, 2002

14. What prevention strategies were effective in reducing U.S. per capita alcohol consumption by 21% between 1980 and 2000?

15. Strategy Options: • Personal change strategies – change people • Alcohol control strategies – control alcohol availability

16. Personal Change Strategies The U.S. has spent a fortune trying to “change people” through programs for adults, youth and children to: • Provide alcohol education • Change attitudes about drinking • Provide early intervention and treatment services for individuals with alcohol problems, and for their families

17. Research Evidence of Effectiveness:Personal Change Strategies • With few exceptions, these programs have not been effective in preventing societal alcohol problems. • As for the exceptions, these programs are too expensive to be implemented across society. • Despite this evidence, programs implementing personal change strategies are the most popular, most prevalent, and best funded prevention efforts in the U.S.

18. Alcohol Control Strategies: Essential Components • changes in social norms • policy interventions • deterrence and enforcement

19. Alcohol Control Strategies:The Role of Public Health Education in Changing Social Norms • Raise societal awareness and concern about alcohol problems. • Educate the society that these problems can be prevented. • Inform the society about specific policy controls and deterrence strategies that are effective. • Publicize successes.

20. If You're Not in the News - You Don't Exist

21. Alcohol Control Strategies: Effective Public Health Education Strategiesfor Changing Social Norms • Rely on research epidemiology. • Develop a strategic plan to educate society incrementally and sequentially. • Stay on message. • Utilize mass media.

22. Media Advocacy is the strategic use of mass media to advance a social or public policy initiative. Media Advocacy

23. Pre 1960 1960-1970 1970-1980 1980-1990 1990-2000 2000- Duh – what problems? Addiction, public drunkenness, social disorder Youth drinking Drinking and driving, fetal alcohol effects Alcohol industry behavior Violence and crime? Sequence of U.S. Public Awareness of Alcohol Problems

24. Alcohol Control StrategiesPolicy Interventions • To prevent alcohol problems, policy interventions must focus on the Availability of alcohol. • Effective policies address the • Price • Place • Product • Promotion… …of alcohol products

28. Percent of U.S. Population (18+ years of age) favoring alcohol policies designed to reduce alcohol problems among youth Source: Harwood, et al, 1998

29. Percent of U.S. Population (18+ years of age) favoring restrictions on drinking in public locations Source: Harwood, et al, 1998

30. Alcohol Control StrategiesDeterrence and Enforcement • Effective deterrence requires the perception of • Certainty • Swiftness • Severity • Active enforcement is a requirement for effective deterrence.

31. Impact of enforcement on alcohol-related traffic fatalities Percentage traffic fatalities related to alcohol(1977-1999)

32. Essential Elements of Effective Prevention of Alcohol Problems Policies and Laws Enforcement Prevention Public Support

33. Implementing Alcohol Control Strategies in Brazil • Strengthen alcohol surveillance systems • Epidemiologic surveys: household, school, roadside, emergency room, special events, alcohol sales and service practices, industry marketing, etc. • Increase expertise in behavioral health research methods and analysis. • Create and staff a Brazilian alcohol research center and develop an integrative and multi-disciplinary research strategy.

34. Every Ounce of Alcohol Sold in the United States Generates $2.25 in Public Sector Costs Alcohol – Related Violence $1.00 Drinking Driving Problems .85 Other Costs .40 $2.25 Alcohol Problem Cost per Ounce Total Societal Costs, including Public Sector Costs: $6.00/ounce Source: Ted Miller, Ph.D. PIRE

35. Sales Unit Public Sector Costs Total Societal Costs Societal Costs – Alcohol Sales Source: Ted Miller, Ph.D. PIRE Beer – Six Pack $7.30 $19.45 Wine – Fifth Bottle $7.50 $20.00 Spirits – Fifth Bottle $23.00 $61.45

36. Challenges Confronting the Community Prevention Coordinator • Provide “translation” services between: • Researchers • Public health professionals • Community organizers • Policy makers • Alcohol industry • Alcohol law enforcement • Provide “honest broker” services for each of the above groups. • Keep a low profile!

37. Implementing Alcohol Control Strategies • Establish a Brazilian technical assistance center for implementation of alcohol control strategies • Organize services by problems, not by control policies (violence, youth drinking, traffic safety, noise and neighborhood disruption, etc.). • Local communities are the first priority for services. • Develop and implement a public health education strategy to change social norms. • Respond quickly to “unscheduled opportunities”.

38. Implementing Alcohol Control Strategies • Increase enforcement of existing alcohol control policies. • Public health and law enforcement are not traditional allies – build relationships! • Support creation of law enforcement units which specialize in enforcement of alcohol laws. • Document, and then acknowledge publicly, the results of alcohol law enforcement.

39. Community Prevention Case Studies • Paulinia: alcohol price controls • Price/Enforcement • Salinas: alcohol control at special events • Place/Social Norms • Salinas: reducing alcohol outlet density • Place • Diadema: limiting alcohol sales • Place, Social Norms, Enforcement

40. Case Studies:Alcohol Prevention Research in BrazilPresentation Outline • What was your research interest? • What were your fears and concerns beginning your research? • What was the major difficulty you faced in conducting your research? • What was the biggest assistance you received in conducting your research? • What was the biggest unexpected “surprise” you encountered? • What is your advice to those who come along next in conducting research in your area?

41. Research Topic Bar surveys and underage buyer surveys Municipal school surveys Collaboration with municipal officials Utilizing municipal records for evaluation, and roadside driver surveys Local and national household surveys, and emergency room surveys Alcohol industry structure and marketing practices Researcher Marcos Romano Denise Vieira Nino Meloni Sergio Duailibi Ronaldo Laranjeira Illana Pinsky Alcohol Prevention Research in Brazil

42. Never doubt that a small, committed group of people with a good idea can change the world. Indeed, it is the only thing that ever has. - Margaret Meade