National Institute on Alcohol Abuse and Alcoholism No. 34 PH 370 October 1996

Preventing Alcohol Abuse and Related Problems

Prevention measures aim to reduce alcohol abuse and its consequences. Such measures include policies regulating alcohol-related behavior on the one hand and community and educational interventions seeking to influence drinking behavior on the other. Researchers use scientific methods, such as randomized controlled trials, time-series analysis, and computer simulation, to determine the effectiveness of prevention initiatives. The resulting data may both inform policy and guide community and educational prevention efforts. This Alcohol Alert summarizes research on the effectiveness of selected initiatives in each of these areas.

Policy Interventions

Alcohol Taxes. Researchers find that alcohol taxes and prices affect alcohol consumption and associated consequences (1). Studies demonstrate that increased beer prices lead to reductions in the levels and frequency of drinking and heavy drinking among youth (2,3). Higher taxes on beer are associated with lower traffic crash fatality rates, especially among young drivers (4,5), and with reduced incidence of some types of crime (6). Research suggests that the heaviest-drinking 5 percent of drinkers do not reduce their consumption significantly in response to price increases, unlike drinkers who consume alcohol at lower levels (7). In one study, heavy drinkers who were unaware of the adverse health consequences of their drinking were less responsive to price changes than either moderate drinkers or better informed heavy drinkers (8).

Raising the Minimum Legal Drinking Age (MLDA). MLDA legislation is intended to reduce alcohol use among those under 21, to prevent traffic deaths, and to avoid other negative outcomes (9-11). Raising the MLDA has been accompanied by reduced alcohol consumption, traffic crashes, and related fatalities among those under 21 (11,12). A nationwide study found a significant decline in single-vehicle nighttime (SVN) fatal crashes--those most likely to involve alcohol--among drivers under 21 following increases in the MLDA (9).

Zero-Tolerance Laws. The National Highway Systems Act provides incentives for all States to adopt "zero-tolerance laws" that set maximum blood alcohol concentration (BAC) limits for drivers under 21 to 0.02 percent or lower beginning October 1, 1998 (13). An analysis of the effect of zero-tolerance laws in the first 12 States enacting them found a 20-percent relative reduction in the proportion of SVN fatal crashes among drivers under 21, compared with nearby States that did not pass zero-tolerance laws (12,14).

Other BAC Laws. Fourteen States have lowered BAC limits from 0.10 to 0.08 percent to reduce alcohol-related fatal motor vehicle crashes. One study found that States with the reduced limit experienced a 16-percent decline in the proportion of fatal crashes involving fatally injured drivers whose BAC's were 0.08 percent or higher, compared with nearby States that did not reduce their BAC limit. In a separate analysis, this study found that States that lowered their BAC limit also experienced an 18-percent decline in the proportion of fatal crashes involving fatally injured drivers whose BAC's were 0.15 or higher, relative to comparison States (15).

Administrative License Revocation Laws. Laws permitting the withdrawal of driving privileges without court action have been adopted by 38 States to prevent traffic crashes caused by unsafe driving practices, including driving with a BAC over the legal limit (16). These laws were associated with a 5-percent decline in nighttime fatal crashes in some studies (17,18). Other studies observed six- to nine-percent reductions in nighttime fatal crashes following their adoption (17).

Server Liability. Alcohol servers are increasingly held liable for injuries and deaths from traffic crashes following the irresponsible selling and serving of alcohol. Researchers assessed the effect of potential server liability on the rates of alcohol-related fatal crashes in Texas (19). SVN fatal traffic crashes decreased 6.5 percent after the filing of a major server-liability court case in 1983 and decreased an additional 5.3 percent after a 1984 case was filed. However, before concluding that server liability is effective, these results need replication (19).

Warning Labels. The mandated warning label on containers of alcoholic beverages aims to inform and remind drinkers that alcohol consumption can result in birth defects, impaired ability to drive a car or operate machinery, and health problems. Research indicates that public support for warning labels is extremely high; that awareness of the label's content has increased substantially over time (20); that perception of the described risks was high before the label appeared and has not generally increased (21); and that the label has not had important effects on hazardous behavior, although certain effects may be indicative of the early stages of behavioral change (20). One study of pregnant women found that after the label appeared, alcohol consumption declined among lighter drinkers but not among those who drank more heavily (22).

Community and Educational Interventions

The Saving Lives Program. The Saving Lives Program in six communities in Massachusetts was designed to reduce drinking and driving and to promote safe driving practices. Saving Lives involved the media, businesses, schools and colleges, citizens' advocacy groups, and the police in activities such as high school peer-led education, college prevention programs, increased liquor-outlet surveillance, and other efforts. Participating communities reduced fatal crashes by 25 percent during the program years compared with the rest of Massachusetts. The decline in alcohol-related fatal crashes was 42 percent greater in Saving Lives communities than in comparison cities during the program years. The proportion of drivers under 21 who reported driving after drinking in the month before being interviewed also declined in participating communities (17).

Life Skills Training (LST). LST teaches students in grades seven to nine skills to resist social influences to use alcohol and other drugs and to enhance general competence and self-esteem. LST has been found to increase students' knowledge of the negative consequences of drinking and to promote realistic, not inflated, perceptions of drinking prevalence (23). A study of LST's long-term effects among 12th grade students who had received a relatively complete version of the program showed significantly lower rates of weekly drinking, heavy drinking, and getting drunk than did control students. The full sample exposed to the program also showed significantly lower rates of drunkenness than did the controls (24).

Project Northland. Project Northland is a multicomponent, school- and community-based intervention to delay, prevent, and reduce alcohol use and related problems among adolescents. It includes social-behavioral curricula, peer leadership, parental involvement/education, and communitywide task force activities (25,26). The first 3 years of intervention, conducted in grades six through eight, resulted in significantly lower prevalence of past-month and past-week alcohol use among students in intervention communities compared with controls. These beneficial effects were particularly notable among students who had not yet begun experimenting with alcohol when the program began (27).

Alcohol Misuse Prevention Study (AMPS). The AMPS curriculum, for students in grades five through eight, focuses primarily on teaching peer-resistance skills and on clarifying students' misperceptions of their peers' alcohol use. Among adolescents at greatest risk for escalating alcohol misuse--those who engaged in early unsupervised use of alcohol--the AMPS intervention had a modest, but lasting, statistically significant effect of slowing the increase in alcohol misuse through grade 8 (28,29) and into grade 12 (30). Replication of this research again showed a significant effect for the highest risk subgroup (29).

Project STAR. Project STAR--involving schools, mass media, parents, community organizations, and health policy components in two sites in the Midwest--attempts to delay the onset and decrease the prevalence of alcohol and other drug use among students beginning in sixth grade. Project STAR teaches skills to resist alcohol use and educates students about the actual, as opposed to the perceived, prevalence of alcohol use among their peers. Early followup studies showed that the program had little effect on alcohol use (31,32). However, in a 6-year followup in Kansas City, students in program schools showed lower rates of increase in alcohol use and episodes of drunkenness over time than did students in control schools. Similar but smaller effects were observed at 3.5-year followup in Indianapolis (33).

Drug Abuse Resistance Education (DARE). DARE, typically taught to 10- and 11-year-old students in grades five and six by police officers, aims to inform about alcohol and other drugs and to teach social and decisionmaking skills to help students resist their use. Studies have found that DARE essentially has no impact on alcohol use (34-36).

Informational Programs. Programs attempting to persuade students not to use alcohol by arousing fear do not work to change behavior (30,37). Emphasizing the dangers of alcohol may attract those who tend to be risk-takers. Programs providing information about the pharmacological effects of alcohol may arouse curiosity and lead to drinking (37).

Server Training. Server training, mandatory in some States, educates alcohol servers to alter their serving practices, particularly with underage customers and those who show obvious signs of intoxication. Server training explains the effects of alcohol, applicable laws, how to refuse service to obviously intoxicated patrons, and how to assist customers in obtaining transportation as an alternative to driving. Some, but not all, studies report more interventions with customers after server training than before. One evaluation of the effects of Oregon's mandatory server-training policy indicates that it had a statistically significant effect on reducing the incidence of SVN traffic crashes in that State (38).

Preventing Alcohol Abuse and Related Problems--
A Commentary by NIAAA Director Enoch Gordis, M.D.

Prevention encompasses activities or actions ranging from those affecting the whole population through social and regulatory controls to those affecting specific groups, such as adolescents, or the individual. Many of these activities overlap. For example, health warning labels, a product of legislation (social and regulatory control), also are educational. In this Alcohol Alert, we have tried to give a "flavor" of this broad spectrum; the prevention areas described are by no means exhaustive, and some areas described in one category could well be in others.

The good news is that, using contemporary tools of science, prevention can be rigorously studied. Currently, research evidence shows that some prevention efforts are effective and others have little or no effect. This knowledge will help local communities, the States, and others who have made significant investments in prevention activities develop or refine existing programs to achieve their desired objectives.

References

(1) Leung, S.-F., & Phelps, C.E. "My kingdom for a drink . . . ?" A review of the estimates of the price sensitivity of demand for alcoholic beverages. In: Hilton, M.E., & Bloss, G., eds. Economics and the Prevention of Alcohol-Related Problems. National Institute on Alcohol Abuse and Alcoholism Research Monograph No. 25. NIH Pub. No. 93-3513. Rockville, MD: the Institute, 1993. pp. 1-31. (2) Coate, D., & Grossman, M. The effects of alcoholic beverage prices and legal drinking ages on youth alcohol use. Journal of Law and Economics 31(1):145-171, 1988. (3) Grossman, M.; Coate, D.; & Arluck, G.M. Price sensitivity of alcoholic beverages in the United States: Youth alcohol consumption. In: Holder, H., ed. Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. Greenwich, CT: JAI Press, 1987. pp. 169-198. (4) Ruhm, C.J. Alcohol policies and highway vehicle fatalities. Journal of Health Economics, in press. (5) Saffer, H., & Grossman, M. Beer taxes, the legal drinking age, and youth motor vehicle fatalities. Journal of Legal Studies 16(2):351-374, 1987. (6) Cook, P.J., & Moore, M.J. Economic perspectives on reducing alcohol-related violence. In: Martin, S.E., ed. Alcohol and Interpersonal Violence: Fostering Multidisciplinary Perspectives. National Institute on Alcohol Abuse and Alcoholism Research Monograph No. 24. NIH Pub. No. 93-3496. Rockville, MD: the Institute, 1993. pp. 193-212. (7) Manning, W.G.; Blumberg, L.; & Moulton, L.H. The demand for alcohol: The differential response to price. Journal of Health Economics 14(2):123-148, 1995. (8) Kenkel, D.S. New estimates of the optimal tax on alcohol. Economic Inquiry XXIV(2):296-319, 1996. (9) O'Malley, P.M., & Wagenaar, A.C. Effects of minimum drinking age laws on alcohol use, related behaviors and traffic crash involvement among American youth: 1976-1987. Journal of Studies on Alcohol 52(5):478-491, 1991. (10) Klitzner, M.; Stewart, K.; & Fisher, D. Reducing underage drinking and its consequences. Alcohol Health & Research World 17(1):12-18, 1993. (11) Wagenaar, A.C. Minimum drinking age and alcohol availability to youth: Issues and research needs. In: Hilton, M.E., & Bloss, G., eds. Economics and the Prevention of Alcohol-Related Problems. National Institute on Alcohol Abuse and Alcoholism Research Monograph No. 25. NIH Pub. No. 93-3513. Rockville, MD: the Institute, 1993. pp. 175-200. (12) Hingson, R.; Heeren, T.; & Winter, M. Lower legal blood alcohol limits for young drivers. Public Health Reports 109(6):738-744, 1994. (13) National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert No. 31: Drinking and Driving. PH 362. Bethesda, MD: the Institute, 1996. (14) Martin, S.E.; Voas, R.; & Hingson, R. Zero tolerance laws: Effective public policy? Alcoholism: Clinical and Experimental Research, in press. (15) Hingson, R.; Heeren, T.; & Winter, M. Lowering state legal blood alcohol limits to 0.08 %: The effect on fatal motor vehicle crashes. American Journal of Public Health 86(9):1297-1299, 1996a. (16) Hingson, R.; McGovern, T.; Howland, J.; et al. Reducing alcohol-impaired driving in Massachusetts: The Saving Lives Program. American Journal of Public Health 86(6):791-797, 1996b. (17) Hingson, R. Prevention of alcohol-impaired driving. Alcohol Health & Research World 17(1):28-34, 1993. (18) Zador, P.L.; Lund, A.K.; Fields, M.; et al. Fatal Crash Involvement and Laws Against Alcohol Impaired Driving. Arlington, VA: Institute for Highway Safety, 1989. (19) Wagenaar, A.C., & Holder, H.D. Effects of alcoholic beverage server liability on traffic crash injuries. Alcoholism: Clinical and Experimental Research 15(6):942-947, 1991. (20) MacKinn on, D.P. Review of the effects of the alcohol warning label. In: Watson, R.R., ed. Alcohol, Cocaine, and Accidents. Totowa, NJ: Humana Press, 1995. (21) Hilton, M.E. An overview of recent findings on alcoholic beverage warning labels. Journal of Public Policy & Marketing 12(1):1-9, 1993. (22) Hankin, J.R.; Firestone, J.I.; Sloan, J.J.; et al. The impact of the alcohol warning label on drinking during pregnancy. Journal of Public Policy & Marketing 12(1):10-18, 1993. (23) Botvin, G.J.; Baker, E.; Dusenbury, L.; et al. Preventing adolescent drug abuse through a multimodal cognitive-behavioral approach: Results of a 3-year study. Journal of Consulting and Clinical Psychology 58:437-446, 1990. (24) Botvin, G.J.; Baker, E.; Dusenbury, L.; et al. Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population. JAMA 273(14):1106-1112, 1995. (25) Perry, C.L.; Williams, C.L.; Forster, J.L.; et al. Background, conceptualization and design of a community-wide research program on adolescent alcohol use: Project Northland. Health Education Research: Theory & Practice 8(1):125-136, 1993. (26) Williams, C.L.; Perry, C.L.; Dudovitz, B.; et al. A home-based prevention program for sixth-grade alcohol use: Results from Project Northland. The Journal of Primary Prevention 16(2):125-147, 1995. (27) Perry, C.L.; Williams, C.L.; Veblen-Mortenson, S.; et al. Project Northland: Outcomes of a communitywide alcohol use prevention program during early adolescence. American Journal of Public Health 86(7):956-965, 1996. (28) Dielman, T.E.; Shope, J.T.; Leech, S.L.; et al. Differential effectiveness of an elementary school-based alcohol misuse prevention program. Journal of School Health 59(6):255-263, 1989. (29) Shope, J.T.; Kloska, D.D.; Dielman, T.E.; et al. Longitudinal evaluation of an enhanced Alcohol Misuse Prevention Study (AMPS) curriculum for grades six through eight. Journal of School Health 64:160-166, 1994. (30) Dielman, T.E. School-based research on the prevention of adolescent alcohol use and misuse: Methodological issues and advances. In: Boyd, G.; Howard, J.; & Zucker, R.A., eds. Alcohol Problems Among Adolescents: Current Directions in Prevention Research. Hillsdale, NJ: Lawrence Erlbaum Associates, 1995. (31) Johnson, C.A.; Pentz, M.A.; Weber, M.D.; et al. Relative effectiveness of comprehensive community programming for drug abuse prevention with high-risk and low-risk adolescents. Journal of Consulting and Clinical Psychology 58(4):47-56, 1990. (32) Pentz, M.A.; Dwyer, J.H.; MacKinnon, D.P.; et al. A multicommunity trial for primary prevention of adolescent drug abuse: Effects on drug abuse prevalence. JAMA 261(22):3259-3266, 1989. (33) Pentz, M.A. Preventing drug abuse through the community: Multicomponent programs make the difference. In: David, S., et al., eds. Drug Abuse Prevention Research. Rockville, MD: National Institute on Drug Abuse, in press. (34) Rosenbaum, D.P.; Flewelling, R.L.; Bailey, S.L.; et al. Cops in the classroom: A longitudinal evaluation of drug abuse resistance education (DARE). Journal of Research in Crime and Delinquency 31(1):3-31, 1994. (35) Ringwalt, C.L.; Ennett, S.T.; & Holt, K.D. An outcome evaluation of Project DARE. Health Education Research: Theory and Practice 6:327-337, 1991. (36) Ennett, S.T.; Tobler, N.S.; Ringwalt, C.L.; et al. How effective is drug abuse resistance education? A meta-analysis of Project DARE outcome evaluations. American Journal of Public Health 84(9):1394-1401, 1994. (37) Botvin, G.J. Principles of prevention. In: Coombs, R.H., & Ziedonis, D.M., eds. Handbook on Drug Abuse Prevention: A Comprehensive Strategy to Prevent the Abuse of Alcohol and Other Drugs. Boston: Allyn and Bacon, 1995. (38) Holder, H.D., & Wag enaar, A.C. Mandated server training and reduced alcohol-involved traffic crashes: A time series analysis of the Oregon experience. Accident Analysis and Prevention 26(1):89-97, 1994.

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The National Institute on Alcohol Abuse and Alcoholism (NIAAA) was deeply saddened by the death of Harold Everett Hughes, former Iowa Governor and U.S. Senator. He was the force behind the passage of landmark legislation, the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (Public Law 91-616), which established NIAAA. A recovering alcoholic with more than 40 years of sobriety, Governor Hughes, who died on October 23, 1996, at his retirement home in Glendale, Arizona, was a highly visible and much-loved and -respected force in the alcoholism and drug abuse fields for close to half a century.

Born in Ida Grove, Iowa, into a poor farming family, Governor Hughes returned from service in World War II "a drinking but functioning alcoholic." A truck driver at the time, he continued to drink, trying to quit but succumbing to relapse, time and again. After contemplating suicide in 1952, he experienced, in his own words, a "deep spiritual experience" that led to his eventual recovery from alcoholism. He went on to win three terms as Governor of Iowa, followed by election to the U.S. Senate, where he served from 1968 to 1974. After retiring from the Senate, Governor Hughes continued to work on behalf of alcoholics and other addicted persons, founding four Harold Hughes Recovery Centers for alcoholism treatment, among his other accomplishments. Noted for his eloquent and forceful oratorical style, Governor Hughes lectured nationally on alcohol and other drug abuse issues, particularly on the need to develop a lay constituency for problems of addiction, and eventually founded the Society of Americans for Recovery.

Often referred to as the "father" of NIAAA, Governor Hughes shunned the title; instead, he deferred to the many people who had been instrumental in the passage of Public Law 91-616 as the "fathers" of NIAAA. In a 1988 article in Alcohol Health & Research World, Governor Hughes wrote:

Thinking about all those fellow "fathers" who laid the groundwork for the creation of NIAAA takes me back to the day of my arrival in Washington in 1969. I had been elected to the U.S. Senate only 17 years after admitting that I was an alcoholic and reaching out for help. As my plane landed, I thought of the hundreds of thousands of men, women, and children who had never found help, many of whom lived as derelicts or had died tragically. I asked myself if one of the reasons I had been brought to Washington as U.S. Senator was to represent those still suffering from addiction to alcohol and other drugs.

And represent them he did. As a result of his own recovery, Governor Hughes understood that many alcoholics were hidden within society, and he knew that they could be helped. More important, Governor Hughes strongly believed that alcoholics and drug addicts should be helped. Thus began his quest in 1969 to focus national attention on alcohol abuse and alcoholism. His three terms as Governor of Iowa gave him the political wherewithal to work within the U.S. Senate to gain sponsors and support for creating a national alcoholism institute. In addition, Governor Hughes' associations with researchers, clinicians, and recovered alcoholics in prominent national positions helped him to convene an extraordinary coalition of individuals to request that the Congress take action. His political acumen and his personal tenacity in achieving and maintaining recovery helped him to convince a reluctant public, who largely viewed alcoholism as a sin or sign of moral weakness, that the actions of Congress were sound. Governor Hughes' efforts resulted not only in the passage of Public Law 91-616, but also, 4 years later, in the creation of the National Institute on Drug Abuse and the former Alcohol, Drug Abuse, and Mental Health Administration.

Today's alcohol research programs, which provide hope for people at risk for and affected by alcohol-related problems, were born of Governor Hughes' vision for the future. According to an article written about him in the May 1990 issue of Sober Times, Governor Hughes' motto was "All things are possible." As his achievements attest, this was a motto of deed as well as of thought. Many alcoholics have recovered, and many more have a chance for recovery, because one man believed that "all things are possible."

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service * National Institutes of Health