What are the most effective strategies to prevent alcohol problems among young people?

What are the most effective strategies to prevent alcohol problems among young people? Tim Stockwell Centre for Addictions Research of BC, University of Victoria, British Columbia, Canada Presentation to MEAS Alcohol and Young People Conference, Dublin, 14th October 2004

Australian Alcohol Indicators Project Statistical Bulletins 1. Mortality 2. Road injuries 3. Patterns of 4. Per capita 5. Violence and morbidity and fatalities drinking consumption National Drug Research Institute and Turning Point Alcohol and Drug Centre Inc. (www.ndri.curtin.edu.au) Funded by the National Drug Strategy

Australian Alcohol Indicators Project Download at: www.ndri.curtin.edu.au

The National Drug Research Institute and the Centre for Adolescent Health The Prevention of Substance Use, Risk and Harm in Australia: A review of the evidence (download: www.carbc.uvic.ca) Funded by the Australian Government Department of Health and Ageing

A Broad View of Prevention A Risk and Protection approach to the prevention of harmful drug use across the whole life span….

Prevention is about more than just persuading kids not to get off their heads….

Prevention needs to be about harm reduction as well as use and supply reduction…

Prevention is about regulation and law enforcement, not just education and persuasion

A Broad View of Prevention • Risk and Protection factors across the life span • All types of psychoactive drugs • Prevention of risky drug use and harm at the population level • Common developmental and social determinants • Multiple levels of intervention from individual to international

Prevention Principle 1: The health and economic benefits of government prevention policies will reflect the extent to which the most prevalent patterns of harmful drug use have been addressed.

Global Burden of Disease in 2000 Taking account of deaths, life years lost and extent of disabilities caused, tobacco contributes 4.1% of preventable death/disability, alcohol 4.0% and illicit drugs 0.8% ie legal drugs cause more than 90% of population level harm from drugs. (Rehm and Room, in press)

Young adults contribute disproportionately to the global burden of disease from alcohol, mainly from the acute consequences of drinking

Australian National Drinking Guidelines (www.nhmrc.health.gov.au) On an average day: Women 2 standard drinks Men 4 standard drinks On an occasional day: Women 4 standard drinks Men 6 standard drinks (1 drink=10g alcohol)

% Alcohol drunk in Australia at risk levels for acute and/or chronic harm, 18-24 yr olds Low Risk High Risk Risky 30% • NDS Household Survey, 1998 (n= 10,030)

Most national surveys estimates of alcohol consumption rely on the concept of the standard drink…..

Harms caused by alcohol in 15-29 year old Australians, 1992 to 2001 Of 4,365 deaths & 143,464 hospital episodes due to alcohol: Intoxication caused 96% deaths 90% hospital episodes 40% young adults at risk, at least monthly Regular use caused 4% deaths 10% hospital episodes 15% at risk Dependence* caused ? Source: National Alcohol Indicators Project, 2003.

Prevention Principle 2: Governments will achieve the most enduring benefits by addressing both the distal causes of substance use problems (social and developmental factors) as well as the immediate causes (patterns and settings of use)

Social and developmental risk factors for adolescent drug problems • Community:physical and economic availability, norms favourable to drug use, low attachment • School: low grades, truancy, conduct problems • Family: parental conflict, drug use, poor discipline and management • Individual/peer:aggressive, thrill-seeking, hyperactive, early drug use, drug using peers, antisocial behaviour Williams et al (2000)

Social and developmental protectionagainst drug use and other problems • Religious involvement, social skills, belief in social order • Attachment to family, school and community plus opportunities and rewards for pro-social involvement in each Williams et al (2000)

Victorian Adolescent Health and Wellbeing Study 9,000 Victorian high school children from 194 schools. 2,500 year II students included (age 15 or 16 years). Risk and Protection Scale (Arthur et al., 2002) Lifetime and recent drug use (tobacco, alcohol, cannabis, other illicits).

Elevated risk factors for recent substance use, Victorian School-aged children (n=9,000) 80 70 60 50 alcohol cigarettes 40 % marijuana 30 other drugs 20 10 0 0-1 2-3 4-6 7-9 >=10 Risk factors Victorian Department of Human Services, 1999

Social and developmental Risk Status of 2,510 15/16 year olds who ‘binged’ at least once per week (= 5or more drinks on one occasion) Low Risk High Risk Average Risk 59% • Victorian Survey of Adolescent Health and Wellbeing(Bond et al, 2000)

Not just the socially and developmentally disadvantaged • Risky drinking engaged in by the affluent and well-adjusted as well as the socially and developmentally disadvantaged.

Prevention Principle 3: The population level impact of government policy will be determined by the extent to which investment is made in prevention strategies with the strongest evidence-base

Interventions evaluated Illicit Drugs 42 All drug types 13 Alcohol 38 Cannabis 9 Broad-based 31 Pharmaceuticals 6 Tobacco 20 TOTAL 159

Ratings of Evidence • O Limited investigation, inconclusive data • Evidence is contra-indicative •  Warrants further research • pEvidence for implementation. p Proportion of studies with positive effects •  Evidence for outcome effectiveness •  Evidence for effective dissemination

 High priority for implementation and maintenance • Alcohol taxation: hypothecation, lower rates for lower alcohol content drinks • Random Breath Testing: visible, high rate • Brief interventions for tobacco and alcohol • Treatment Programs

The Living With Alcohol Program In April 1992 the NT Government charged a levy on alcoholic drinks which raised $18.4 million over 4 years for the prevention and treatment of alcohol problems.

Health and economic benefits associated with the NT’s Living With Alcohol program, 1992/3 to 1996/7 • 129 fewer alcohol-caused deaths • 1394 fewer alcohol-caused road crash injuries requiring medical treatment • 1277 fewer hospital admissions for other alcohol-caused conditions • Savings of $124.3 million over four years.

Health and economic impact of the NT’s Living With Alcohol program Postscript: In August 1997 the Living With Alcohol levy was removed and alcohol became cheaper . The program was funded federally until 2002. A forthcoming paper shows that acute alcohol-caused deaths increased after 1997 compared with adjacent regions of Queensland and Western Australia.

 High priority for wide implementation with evaluation (1) • Ignition interlocks • Thiamine supplementation • Responsible Alcohol Service and Accords WITH law enforcement • Limits on liquor outlet trading hours

 High priority for wide implementation with evaluation (2) • Community action for structural alcohol policy reform • Liquor restrictions in isolated communities • Restrict price discounting schemes (tobacco and alcohol)

 Recommended with caveats • Labelling of alcohol containers to support drinking guidelines • Social marketing for alcohol – providing supports other effective strategies • Workplace alcohol and other drug testing – high risk settings only, ethical issues • Plastic glasses • Food service • Harm reduction education in schools

School Health and Alcohol Harm Reduction Project McBride, N. et al (2004) Harm minimization in school drug education: final results of the School Health and Alcohol Harm Reduction Project (SHAHRP), Addiction National Drug Research Institute Perth, Western Australia

RESULTS 2,300 students from 14 schools allocated to control or intervention programs, 76% follow-up at 32 months. At follow-up SHAHRP students had: • 10% greater alcohol related knowledge • consumed 31% less alcohol • experienced 23% less harm associated with their own use of alcohol • experienced 10% less harm associated with other peoples use of alcohol than did the control group. Cost: $24 per student over two years.

 Recommended for future research and development • Restrict alcohol promotions • Restrict liquor outlet density • Night patrols • Sobering up shelters

 NOT Recommended • Responsible alcohol service WITHOUT supporting law enforcement • Licensees codes of conduct WITHOUT law enforcement • Staggered closing times which create later trading

Prevention Principle 4: Governments can harness existing community support for some effective strategies – and can lead public opinion on others. ie Prevention can be popular as well as effective.

%Support for alcohol policies in Australia 2001 NDS Household Survey (n=26,744) • Low alcohol beer at sports events 64% • Strict control of late night venues 73% • Strict laws against serving intoxicated 85% Other Australian surveys • Alcohol Harm Reduction Levy 70-90% • Less tax for low alcohol content drinks 75%

Conclusions • Harm reduction strategies can work and should be implemented more widely, some in partnership with industry groups • Well-designed demand reduction, educational strategies can make a contribution. Industry can help. • Modern regulatory controls on economic and physical availability are the most effective – community education and political leadership needed. Public interest not vested interests should be served.

What are the most effective strategies to prevent alcohol problems among young people?