Prevention of Alcohol Harm in the Community--I What Can International Research Teach Us? Harold D. Holder Prevention Research Center Berkeley, California USA Associação Brasileira de Estudos de Álcool e Outras Drogas, Sao Paulo September 4, 2003

Underage Drinking 11% of 6th grade students reported binge drinking (Kelder, Murray, et al., 2001) 21% of 8th graders reported having been drunk at least once (Johnson, 2002b) About 30% of 12th graders engaged in binge drinking (Johnson, 2002a)

Prevalence of Lifetime Alcohol Dependence by Age at Drinking Onset

Binge Drinking Across the Life Span 50% of students who drink engage in binge drinking; 20% do so frequently (twice or more every 3 weeks) More than 2/3 of binge drinking episodes in the U.S. occur among adults age 26 and older (Naimi, 2003) Half of all binge drinking episodes occur among otherwise moderate drinkers (White et al., 2002)

Public Health Model of Alcohol Problem Prevention Individual(Drinker) Environment (Drinking Context) Agent (Alcohol)

Environmental Influence & Youth Drinking Physical - Proximity of alcohol outlets, places of public drinking (2) Social - Family, peers and larger social networks (3) Economic - Cost of alcohol; economic geography of availability

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

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

Environmental Approaches 1. Retail Access to Alcoholic Beverages, e.g., price, outlet locations, minimum drinking laws. 2. Restrictions or Constraints on the Drinker’s Behavior, e.g., drinking locations, drink drive 3. Reduce Risk or Problem Severity

Agent Approaches 1. Low or No Alcohol Beverages 2. Container Size 3. Restrictions on Advertising

Youth Alcohol Problem Prevention Strategies: Solid Evidence ¤ Retail price of alcohol ¤ Minimum drinking age ¤ “Zero tolerance” for Youth ¤ Drinking/driving deterrence ¤ Lower BAC limits for driving ¤ Graduated Licenses

Third Party alcohol sales/”Shoulder Taps” Youth Alcohol Problem Prevention Strategies: Promising –Replication needed  Tort Liability for sales/service of alcohol to youth  Genetics, alcohol dependency risk, & treatment  Third Party alcohol sales/”Shoulder Taps”  Auto ignition controls  Curfew laws/Party Patrols  Parent training and mobilization  Restrictions on drinking location & outlet density  Low or no alcoholic beverages  Alcohol container sizes & keg registration

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

LOCATIONS OF COMMUNITY ACTION PROJECTS FROM AROUND THE WORLD Western Australia Israel Florence, Italy Lahti , Finland Stockholm, Sweden Aarhus , Denmark Ontario, Canada Massachusetts, USA South Carolina, USA Minnesota, USA California, USA Malmo , Sweden .. New Zealand Paulinia, Brazil

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS Canada Ontario (6 Projects) Reduce alcohol problems • Alcohol serving practices & policies • Municipal policies • DUI enforcement  Reduced public drinking  Lower heavy drinking in bars and restaurants  Modest effects on overall drinking Finland Lathi Reduce heavy drinking • Primary health care • Community education • News  Reductions in heavy drinking  Greater news coverage Sweden Reduce heavy drinking and youth drinking • School education  Modest effect on heavy drinking Stockholm--Kungsholmen •Public education

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS Australia COMPARI Project Reduce alcohol injury and death • Local coalitions • Health education • Local alcohol policy concerning public alcohol sale  Modest effect on injury Australia Surfers Paradise Safety Action Project • Community Forum & alcohol safety audit • Model House Policies • Increased enforcement of alcohol licensed premises  Violent events: --original site from 9.8 to 4.7 --replication sites from 12.2 to 3.0 Lower alcohol involved violence

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS New Zealand Reduce drink/drive problems • Public awareness using local news • Highly visible drink/drive enforcement •Investigation of on-license premises based upon “place of last drink” data  Fatal alcohol crashes reduced from 22 to 14% Waikata Rural Drink/ Drive Project  Public perception of risk of being caught increased  Alcohol positive breath checks decreased by 600% • Local coordinating committee • Review of alcohol availability • Local alcohol advertising limits New Zealand Six City Project Increase local alcohol policy  Greater news coverage  Increased public support of local policy

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS Sweden Stockholm City--STAD Reduce alcohol and drug problems •Youth Program • Secondary prevention in health care •Responsible Beverage Service  Modest effect in medium strength beer sales to youth  Reduction in sales to intoxicated patrons (5% to 47%) Violent crime down by 29%   Reduced Sales to Youth in 2 target sites (81% to 25% & 48% to 42%) Stockholm City (18 Districts) & Stockholm County Targets • Local work committees • Develop Alcohol Plan • Decrease sales of folk beer to youth Increase local alcohol policy  Increased interest in local policy

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS Sweden Low effects on problem indicators • Public education • Primary health care screening • Reduce alcohol access  Reduce alcohol problems Malmö  Reduced male consumption and problems in (a) screening program and (b) general population  Program adopted by city

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS United States California/ South Carolina Reduce alcohol injury and death • DUI enforcement • Alcohol service • News coverage • Underage sales • Alcohol outlets  10% reduction in alcohol crashes  43% reduction in violence  Lower alcohol sales to youth Lower alcohol sales to youth Reduced traffic crashes  Minnesota Reduce youth drinking • Local sales policies and enforcement  Massachusetts Reduce alcohol crashes • News coverage • DUI enforcement • Alcohol outlet surveillance  25% reduction in fatal crashes

Community Action and Prevention Lessons from International Projects  Community Mobilization

Community Mobilization Goal: Community Awareness of Alcohol Problems and Support for Local Policy Actions Community Organizing Local News (Media Advocacy)

Community Action and Prevention Lessons from International Projects Community Mobilization   Science-based interventions are essential  Utilize Local News

Friday, December 10, 1993

Community Action and Prevention Lessons from International Projects Science-based interventions are essential Utilize local news media Community Mobilization   Value of Evaluation—determine effects  Environmental strategies are most effective

Elements in Effective Local Alcohol Prevention: The top 10 10. Cultural Values Local Cultural 0. Local Cultural Values   9. Community as a System  8. Media Advocacy (local news)  7. Enforcement in local action  6. Partnership of local & nation/state  5. Community Leadership and Responsibility  4. Central government supporting local action  3. Local information (evaluation)  2. Evidence based strategies  1. Courage & Passion