"Prevention of Substance Abuse: What science tells us” Harold D. Holder, Ph.D. Senior Scientist Prevention Research Center Pacific Institute for Research and Evaluation Berkeley, CA Tucson, Arizona December 13, 2005

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

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%

Experimentation and Established Smoking by Age Source: 1996 CTS

Past Month Illicit Drug Use—any drug

Just what is prevention, anyway?

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

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

Substance Abuse Influences and Factors (3) Economic - Cost of alcohol, drugs, tobacco; geography of availability (1)Physical - Proximity of alcohol & tobacco outlets and drug supplies, places of public use (1)Physical - Proximity of alcohol & tobacco outlets and drug supplies, places of public use (2) Social - Family, peers and larger social networks, norms, mass media

For Example, Youth Drinking AlcoholAvailability Drinking By Peers RetailPrice Alcohol purchases by other youth EconomicSocial Cost & availability to youth to youth Availability of alcohol to & from peers Physical

Public Health Model of Prevention Individual EnvironmentAgent

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

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

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

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

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

Agent Approaches Low or No Alcohol Beverages or lower tar tobacco products Alcohol container size or tobacco package restrictions Restrictions on Product Advertising

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

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

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)   Retail Price Drinking & smoking Youth who drink weekly up to daily are more affected by price (Grossman, et al., 1991; Coate and Grossman, 1988) 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

National Community Trial to Prevent Alcohol-involved Trauma

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

Underage Alcohol Purchase Survey -Experimental and Comparison Communities Percent Selling ComparisonExperimental No Training Experimental Training ComparisonExperimental No Training Experimental Training PRETEST PRETEST POSTTEST POSTTEST Holder, et al., J. American Medical Association, 2000

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

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

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