December 13, 2005

1. "Prevention of Substance Abuse: What science tells us”Harold D. Holder, Ph.D.Senior ScientistPrevention Research CenterPacific Institute for Research and Evaluation Berkeley, CATucson, Arizona December 13, 2005

2. Prevention Paradox: More local problems are caused by heavy drinking than by alcoholics.

3. Students Who Reported Using Alcohol, Tobacco, and Other Drugs in Past 30 Days 63% 46% 25% 11.4% 10.8% 6.1% 4.5% 3.5% 4.5%

4. Experimentation and Established Smoking by Age Source: 1996 CTS

5. Past Month Illicit Drug Use—any drug

6. Just what is prevention, anyway?

7. Goals of ATOD prevention • Prevent health and safety problems related to substance use, e.g., traffic crashes, violence, lung cancer, overdose. • Prevent all use of tobacco and illicit substances for everyone, regardless of age. • Prevent heavy and high risk use of substances. • Delay adolescent initiation of substances that are licit for adults (e.g., tobacco and alcohol).

8. Approaches to the reduction of ATOD use and resulting problems IndividualchangeEnvironmental approacheschange approaches Orientation Individualbehavioralchange leading to demand reduction Community/state system or population change leading to both demand and supply reduction Goal Individual, directly or through others (e.g., family, peers) Target Social, economic and physical environment But lots of hybrid , multi-component models

9. Substance Abuse Influences and Factors • Physical - Proximity of alcohol & tobacco outlets and drug • supplies, places of public use (2) Social - Family, peers and larger social networks, norms, mass media (3) Economic - Cost of alcohol, drugs, tobacco; geography of availability

10. Alcohol Availability Drinking By Peers Retail Price For Example, Youth Drinking Physical Cost & availability to youth Availability of alcohol to & from peers Social Economic Alcohol purchases by other youth

11. Public Health Model of Prevention Individual Environment Agent

12. Environment(Context) Agent(Substance) Public Health Model of Substance Abuse Problem Prevention Individual (User)

13. Individual Approaches 1. School-Based Education 2. Mass Communication and Public Education 3. Family Education/counseling 4. Alcohol and Tobacco Warning labels 5. Deterrence: Possession or sale of drugs, Drinking and driving Laws, Sale of tobacco or alcohol to minors. 6. Brief Intervention in health care or workplace

14. Individual(User) Agent(Substance) Public Health Model of Substance Use Prevention Environment(Context)

15. Environmental Approaches 1. Retail Access to substances, e.g., price, outlet locations, minimum purchase laws, parental restrictions on youth. 2. Restrictions or constraints on the Drinker’s or Smokers Behavior, e.g., drinking & smoking locations, drink drive 3. Reduce Risk or Problem Severity

16. Individual(User) Environment(Context) Public Health Model of Substance Use Prevention Agent(Substance)

17. Agent Approaches 1. Low or No Alcohol Beverages or lower tar tobacco products 2. Alcohol container size or tobacco package restrictions 3. Restrictions on Product Advertising

18. Scientific Evidence about Prevention What works?

19. Standards of Evidence 1. Achieves significant effects (actually reduces ATOD problems) under scientific standards. 2. Replicated across two or more studies under diverse community or national conditions. 3. Has practical applicability and can affect the total community, not only target groups, i.e., has public health import.

20. Problem Prevention Strategies: Solid Evidence ¤ Retail price of alcohol or tobacco ¤ Minimum drinking/purchase age—retail compliance checks for alcohol and tobacco ¤ Graduated licenses & “zero tolerance for Youth ¤ Drinking/driving deterrence (RBT) ¤ Lower BAC limits for driving ¤ Density & location of alcohol outlets ¤ Form and style of retail sale, e.g., hours and days of retail sale.

21. Retail Price Drinking & smoking As price increases, smoking and heavy drinking declines (Chaloupka, 1993)  Heavy drinkers/smokers as well as youth are affected by price. (Coate and Grossman, 1988)  Youth who drink weekly up to daily are more affected by price (Grossman, et al., 1991; Coate and Grossman, 1988) 

22. Underage Drinking Goal:Decrease underage drinking Actions:  Increase community awareness of underage drinking  Reduce physical availability of alcohol to minors  Increase awareness of retail establishments and adults of the legal and social risks of providing alcohol to minors

23. Environment Person Activities Mean 30-Day Alcohol Use Years Before and After MDA was Raised Source: O’Malley & Wagenaar (1991) Alcohol Use (30-day mean) Before and After Minimum Drinking Age (MDA) was Raised--United States 13% Decline

24. Drinking and Driving Goal:Reduce the number of community drinking and driving events Actions:  Increase law enforcement efficiency  Increase perceived risk of DWI detection  Increase community support of DWI enforcement

25. Access Intervention Goal: Decreased physical availability of Substances Actions:  Reduction in outlet densities and sales to minors  Changes in planning and zoning laws  License challenges

26. Problem Prevention Strategies:Positive Evidence – Need Replication  Responsible beverage service – Policy & server training  Community Prevention Trials utilizing local policy  Primary health care interventions  Liability for sales or serving alcohol  Alcohol & tobacco warning labels  Administrative driver license suspension  School education alone & w/ community interventions

27. School Education • Effective programs: • Values and norms clarification • Decision-making • Life skills • Use interactive teaching methods • Ineffective programs: • Target self-esteem • Increase knowledge • Use scare tactics • Use didactic methods

28. Individual: School-based Education  Popular prevention strategy--mostly US studies  Information only – no effect  Mixed results across studies and substances & only in controlled research studies  Most effective with some combination of: 1. Normative beliefs 2. Personal commitment 3. Information 4. Resistance skills

29. Actions:  Server and manager training  New alcohol serving policies (price promotions, serving sizes, non-alcoholic beverages and food)  Enforcement of no service to underage and obviously intoxicated patrons Responsible Beverage Service Goal: Reduce alcohol intoxication or impairment for patrons of bars and restaurants

30. Problem Prevention Strategies:Promising -- Too early to tell  Workplace interventions—workplace policy  Genetics and alcohol drug dependency risk  Alcohol sales to intoxicated persons  Auto ignition controls  Curfew laws  Parent training and mobilization  Restrictions on drinking & smoking location  Low or no alcoholic beverages; low tar tobacco  Alcohol container and tobacco product sizes

31. Alcohol Problem Prevention Strategies:Mixed Findings -- Uncertain Implications  Mass communication and public education alone  School-based education alone  Restrictions on Advertising

32. Examples of media programs • ONDCP Anti-drug media campaign • Partnership for a Drug-Free America

33. Individual: Mass Communication and Public Education Increases awareness  Produces little behavioral change  Reinforces environmental strategies 

34. Latest Scientific Advance:Comprehensive Mix of evidence-based prevention strategies at local level Community Action Trials which use complimentary interventions

35. Legal Action about Drinking Social Control and Communication Alcohol-involved Mortality & Morbidity CONSUMPTION Social, Health, and Economic Consequences Formal Regulationand Control of Alcohol Sales Retail Sales by Average Type Social and Health Services Alcohol Production, Marketing and Distribution Community Economic Sector Community System of Alcohol Use & Abuse

36. - Modesto Modesto . . Salinas Salinas . . Orange Orange . Florence Florence . Oceanside Oceanside Sumter Sumter Experimental Experimental Comparison Comparison National Community Trial to Prevent Alcohol-involved Trauma

37. Alcohol-involved Trauma at the Community Level: Conceptual Model````````` MOBILIZATION DRINKING AND DRIVING Local News about AlcoholProblems & Enforcement Perceived Risk of Arrest Local Law Enforcement RESPONSIBLE BEVERAGE SERVICE Social Access to Alcohol Driving after Drinking Alcohol Serving and Sales Practices UNDERAGE DRINKING Local Regulation of Alcohol (Density, Hours of Sale) Alcohol-involved Injury Retail Alcohol Availability (On and Off-premise) Alcohol Intoxication or Impairment ALCOHOL ACCESS Non-Traffic Risk Activities

38. PRETEST POSTTEST 53 47 45 35 19 16 Comparison ExperimentalNo Training ExperimentalTraining Comparison ExperimentalNo Training ExperimentalTraining Underage Alcohol Purchase Survey-Experimental and Comparison Communities- 60 50 40 Percent Selling 30 20 10 0 Holder, et al., J. American Medical Association, 2000

41. Community Trials Final Results Holder, et al. 2000. J. Amer. Medical Assoc.  Total Consumption (+2%)  Heavy Drinking (-6%)  Driving after “Too much to drink” (- 49%)  BAC Positive Drivers (- 44%)  Nighttime Injury Crashes (-10%)  Assaults -- Hospital Cases (-2%) -- Emergency Room Cases (- 43%)

42. Similarities across all effective prevention strategies • Comprehensive and multi-component • Targets specific causal variables which have been shown to affect total local population as well as the environment • Based on methodologically sound, independently replicated evaluations under “real world” conditions

43. Community System Strategies  Effectiveness at population level  Impact both heavy & moderate drinkers/users  Yield longevity of effects  Do not target subgroups--non discriminating  Have lower costs -No case-finding -Individual services NOT required -NO continued costs to sustain effects