community prevention of alcohol problems: science to...

Community Prevention of Alcohol Problems: Science to Practice

Community Prevention of Community Prevention of Alcohol Problems: Alcohol Problems: Science to PracticeScience to Practice

Harold D. HolderHarold D. HolderPrevention Research CenterPrevention Research Center

Berkeley, California USABerkeley, California USA

Building Capacity for ActionEuropean Alcohol Policy Conference

Barcelona, 3-5 April, 2008

Community System of Alcohol Use & Abuse

Formal Regulationand 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 DrinkingSocial Control

and Communication

Public Health Model of PreventionPublic Health Model of Preventionof Alcohol Abuseof Alcohol Abuse

IndividualIndividual(drinker)(drinker)

EnvironmentEnvironment(context)(context)

AgentAgent(alcohol)(alcohol)

Problem Prevention Strategies: Problem Prevention Strategies: Solid EvidenceSolid Evidence

¤¤ Retail price of alcoholRetail price of alcohol¤¤ Minimum drinking/purchase ageMinimum drinking/purchase age——retail retail

compliance checks for alcoholcompliance checks for alcohol

¤¤ Drinking/driving deterrence (RBT)Drinking/driving deterrence (RBT)

¤¤¤¤ Density & location of alcohol outletsDensity & location of alcohol outlets

Lower BAC limits for drivingLower BAC limits for driving

¤¤ Form and style of retail sale, Form and style of retail sale, e.g., hours, e.g., hours, days of retail sale, retail monopoly.days of retail sale, retail monopoly.

¤¤ Responsible Beverage ServiceResponsible Beverage Service——bars, clubsbars, clubs

Retail PriceRetail PriceRetail Price DrinkingDrinkingDrinking

As price increases, drinking declinesAs price increases, drinking declines

Heavy drinkers as well as youth are affected Heavy drinkers as well as youth are affected by price. by price.

Youth who drink weekly up to daily are Youth who drink weekly up to daily are more affected by price.more affected by price.

Responsible Beverage ServiceResponsible Beverage Service

Goal:Goal:Reduce alcohol intoxication in bars and Reduce alcohol intoxication in bars and restaurantsrestaurants

Actions:Actions:

New alcohol serving policies (price promotions, New alcohol serving policies (price promotions, serving sizes, nonserving sizes, non--alcoholic beverages and food)alcoholic beverages and food)Enforcement of no service to underage and Enforcement of no service to underage and obviously intoxicated patronsobviously intoxicated patrons

Server and manager trainingServer and manager training

Unfortunately, there are some problems associated withalcohol outlets

Unfortunately, there are some problems associated withalcohol outlets

ProblemsProblems

-- PedestrianPedestrian Injury Injury CollisionsCollisions

-- Arrests for Arrests for Drunken DrivingDrunken Driving

-- AssaultsAssaults

Alcohol Problem Prevention Strategies:Alcohol Problem Prevention Strategies:Promising Promising ––Replication neededReplication needed

Parent training and mobilizationParent training and mobilization

Auto ignition controlsAuto ignition controls

Curfew laws/Party PatrolsCurfew laws/Party Patrols

Brief intervention in primary health careBrief intervention in primary health care

Alcohol container sizes & keg registrationAlcohol container sizes & keg registrationRestrictions on “sweet” mixed drinksRestrictions on “sweet” mixed drinks

Latest Scientific Advance:Latest Scientific Advance:Mix of evidenceMix of evidence--based prevention based prevention

strategies at local levelstrategies at local level

Community Action Trials which use Community Action Trials which use complimentary alcohol policy complimentary alcohol policy

interventionsinterventions

EXAMPLES OF COMMUNITY ACTIONPROJECTS FROM AROUND THE WORLD PROJECTS FROM AROUND THE WORLD

Western AustraliaWestern Australia

IsraelIsrael

Florence, ItalyFlorence, Italy

LahtiLahti, Finland, Finland

Stockholm, SwedenStockholm, Sweden

Massachusetts, USAMassachusetts, USA

South Carolina, USASouth Carolina, USA

Minnesota, USAMinnesota, USA

California, USACalifornia, USA

MalmoMalmo, Sweden, Sweden....

New ZealandNew ZealandWestern AustraliaWestern AustraliaWestern Australia

IsraelIsraelIsrael

Florence, ItalyFlorence, ItalyFlorence, Italy

LahtiLahtiLahti, Finland,, FinlandFinland

Stockholm, SwedenStockholm, SwedenStockholm, Sweden

Ontario, CanadaOntario, Canada

Massachusetts, USAMassachusetts, USAMassachusetts, USA

South Carolina, USASouth Carolina, USASouth Carolina, USA

Minnesota, USAMinnesota, USAMinnesota, USA

California, USACalifornia, USACalifornia, USA

MalmoMalmoMalmo, Sweden, SwedenSweden....

New ZealandNew ZealandNew ZealandPauliniaPaulinia, Brazil, Brazil

PAKKA, FinlandPAKKA, Finland

6 Community Trial, Sweden6 Community Trial, Sweden

QueenslandQueensland

IrelandIreland

Examples of International Community Examples of International Community Action Projects for Alcohol PreventionAction Projects for Alcohol Prevention

COUNTRYCOUNTRY GOALSGOALS STRATEGIESSTRATEGIES RESULTSRESULTS

•• Public educationPublic education•• Primary health carePrimary health carescreeningscreening

•• Reduce alcoholReduce alcoholaccess access

SwedenSweden Low effects on Low effects on problem indicatorsproblem indicatorsReduce alcohol Reduce alcohol

problemsMalmMalmöö problems Reduced male Reduced male consumption and consumption and problems in (a) problems in (a) screening program screening program and (b) general and (b) general populationpopulation

Modest effect in Modest effect in medium strength medium strength beer sales to youthStockholm Stockholm

CityCity---- STADSTADReduce alcohol Reduce alcohol

and drug and drug problems

••Youth ProgramYouth Program• Secondary prevention • Secondary prevention in health carein health care•Responsible Beverage •Responsible Beverage Service

beer sales to youthproblems Reduction in sales

to intoxicatedpatrons (5% to 47%)ServiceViolent crime down by 29%

Examples of International Community Action Examples of International Community Action Projects for Alcohol PreventionProjects for Alcohol Prevention

COUNTRYCOUNTRY GOALSGOALS STRATEGIESSTRATEGIES RESULTSRESULTSNew Zealand

•• Public awareness Public awareness using local newsusing local news

•• Highly visible Highly visible drink/drive drink/drive enforcementenforcement

••Investigation of onInvestigation of on--license premises license premises based upon based upon ““place of place of last drinklast drink”” data

Reduce Reduce drink/drive drink/drive problems

New ZealandFatal alcohol Fatal alcohol crashes reduced crashes reduced from 22 to 14% from 22 to 14%

Public perception Public perception of risk of being of risk of being caught increasedcaught increased

Waikata RuralDrink/ Drive

Project problems

Alcohol positive Alcohol positive breath checks breath checks decreased.decreased.data

• • Community Forum & Community Forum & alcohol safety auditalcohol safety audit• • Model serving policiesModel serving policies•• Increased enforcement Increased enforcement of alcohol licensed of alcohol licensed premises

Violent events:Violent events:----original siteoriginal site from from

9.8 to 4.79.8 to 4.7

----replication sitesreplication sitesfrom 12.2 to 3.0from 12.2 to 3.0

AustraliaAustralia

premises

Surfers Surfers Paradise Paradise

Safety Action Safety Action Project

Lower Lower alcohol alcohol involved involved violenceviolence

Project

Community Trial to Prevent AlcoholCommunity Trial to Prevent Alcohol--involved Traumainvolved Trauma

OrangeOrangeOceansideOceanside

..

..

..

-

ExperimentalExperimentalComparisonComparison

ModestoModestoSalinasSalinas

FlorenceFlorenceSumterSumter

AlcoholAlcohol--involved Trauma at the Community Level: involved Trauma at the Community Level: Logic Model`````````Logic Model`````````

MOBILIZATIONMOBILIZATIONMOBILIZATION DRINKING AND DRIVINGDRINKING AND DRIVINGDRINKING AND DRIVING

UNDERAGE DRINKINGUNDERAGE DRINKINGUNDERAGE DRINKING

ALCOHOL ACCESSALCOHOL ACCESSALCOHOL ACCESS

RESPONSIBLE BEVERAGE SERVICE

RESPONSIBLE BEVERAGE RESPONSIBLE BEVERAGE SERVICESERVICE

NonNon--Traffic Risk ActivitiesTraffic Risk Activities

Local News about AlcoholLocal News about AlcoholProblems & EnforcementProblems & Enforcement

Retail Alcohol Retail Alcohol AvailabilityAvailability

(On and Off(On and Off--premise)premise)

Alcohol IntoxicationAlcohol Intoxicationor Impairmentor Impairment Alcohol-involved

Injury AlcoholAlcohol--involvedinvolved

Injury Injury

Driving afterDriving afterDrinkingDrinking

Perceived Perceived Risk of ArrestRisk of Arrest

Local LawLocal LawEnforcementEnforcement

Social Access Social Access to Alcoholto Alcohol

Alcohol Alcohol Serving and Serving and

Sales PracticesSales Practices

Local Regulation Local Regulation of Alcoholof Alcohol

(Density, Hours (Density, Hours of Sale)of Sale)

“Mountain of Beer”

Underage Alcohol Purchase SurveyUnderage Alcohol Purchase Survey--Experimental and Comparison CommunitiesExperimental and Comparison Communities--

0

10

20

30

40

50

60

4747 4545

5353

3535

19191616

Comparison ExperimentalNo Training

ExperimentalTraining

Comparison ExperimentalNo Training

ExperimentalTraining

PRETEST PRETEST POSTTESTPOSTTEST

Per

cen

t Se

llin

g

Holder. et al.. Holder. et al.. J. American Medical Association.J. American Medical Association. 20002000

Community Trials Hospitalized Assault CasesCommunity Trials Hospitalized Assault CasesTrend of Experimental vs. Comparison SitesTrend of Experimental vs. Comparison Sites

MONTHMONTH--YEARYEAR

77--909011--9191

77--919111--9292

77--929211--9393

77--939311--9494

77--949411--9595

77--959511--9696

77--9696

LOG

REL

ATI

VE R

ATE

SLO

G R

ELA

TIVE

RA

TES

--1.001.00

--0.750.75

--0.500.50

--0.250.25

0.000.00

0.250.25

0.500.50

0.750.75

1.001.00

Project BeginsProject Begins

ImplementationImplementationCompletedCompleted

Community Trials Final ResultsCommunity Trials Final Results

Driving after “Too much to drink” (Driving after “Too much to drink” (-- 49%)49%)BAC Positive Drivers (BAC Positive Drivers (-- 44%)44%)

Heavy Drinking (Heavy Drinking (--6%)6%)

AssaultsAssaultsNighttime Injury Crashes (Nighttime Injury Crashes (--10%)10%)

---- Hospital Cases (Hospital Cases (--2%)2%)---- Emergency Room Cases (Emergency Room Cases (-- 43%)43%)

Holder. et al. 2000. J. Amer. Medical Assoc.

Total Consumption (+2%)Total Consumption (+2%)

Community Action and PreventionCommunity Action and PreventionLessons from International StudiesLessons from International Studies

Community Mobilization Community Mobilization ----create working groupcreate working group----partnership with researcherspartnership with researchers

----inform population about goalsinform population about goals----be cautious of “self appointed experts”be cautious of “self appointed experts”----Involve police in detailed planningInvolve police in detailed planning----inform and involve alcohol retailersinform and involve alcohol retailers

Community Action and Prevention Community Action and Prevention Lessons from International ProjectsLessons from International Projects

Community MobilizationCommunity Mobilization

ScienceScience--based interventions are essentialbased interventions are essential

Environmental strategies are most effective Environmental strategies are most effective for community level to have public health for community level to have public health effects.effects.

Community Action and PreventionCommunity Action and PreventionPrinciples for SuccessPrinciples for Success

Community MobilizationCommunity MobilizationScienceScience--based interventions are essentialbased interventions are essential

Include & Inform Key Community LeadersElected officials want to be associated with a Elected officials want to be associated with a success & their support is essential. success & their support is essential.

Generate early successGenerate early success——show resultsshow results

Drinking and driving responds quickly to effectiveDrinking and driving responds quickly to effectiveand consistent enforcement and local news coverageand consistent enforcement and local news coverage


Community MobilizationCommunity MobilizationScienceScience--based interventions are essentialbased interventions are essentialInclude & Inform Key Community Leaders

Generate early successGenerate early success——show resultsshow results

Utilize Local NewsUtilize Local News——inform people & inform people & policy makerspolicy makers

Media AdvocacyMedia AdvocacyMedia Advocacy is the strategic use of Media Advocacy is the strategic use of

mass media to advance a social or public mass media to advance a social or public policy initiative.policy initiative.


Community MobilizationCommunity MobilizationScienceScience--based interventions are essentialbased interventions are essentialInclude & Inform Key Community Leaders

Generate early successGenerate early success——show resultsshow resultsUtilize Local NewsUtilize Local News——inform communityinform community

Evaluate projectEvaluate project——determine effectsdetermine effects“Good science and good politics”“Good science and good politics”

Evaluation = Determine if prevention had an effect on targeted community problems

Did it work?

Evaluation = Determine if prevention had an effect on targeted community problems

Did it work?--determine effects -> outcome evaluation--determine effects -> outcome evaluation

Why?—process evaluation

--Improve/learn for future

--avoid mistakes

--Good politics (obtains local support)

--Improve/learn for future

--avoid mistakes

--Good politics (obtains local support)

Elements in Effective Local Alcohol Elements in Effective Local Alcohol Prevention: The top 10Prevention: The top 10

10. Cultural Values Local Cultural 0. Local Cultural Values9. Community as a System

8. Media Advocacy (local news)

7. Enforcement in local action7. Enforcement in local action

6. Partnership of local & nation/state6. Partnership of local & nation/state

4. Central government supporting local action4. Central government supporting local action

5. Community Leadership and Responsibility

3. Local information (evaluation)3. Local information (evaluation)

2. Evidence based strategies2. Evidence based strategies

1. Courage & Passion1. Courage & Passion

AppendicesAppendicesWeb Reference for Community Guides to Underage

Drinking Prevention:

http://www.nhtsa.dot.gov/people/injury/alcohol/Community%20Guides%20HTML/Guides_index.html

Reference:

Babor, T., et al (2003). Alcohol: No Ordinary Commodity: Research and Public Policy. New York: Oxford University Press.

Chapter 16: Alcohol Policies: A Consumer’s Guide

Scientific EvidenceScientific EvidenceDrinking & Driving CountermeasuresDrinking & Driving Countermeasures

EffectivenessEffectiveness Cross Cultural Cross Cultural Testing Testing

Cost/EffectivenessCost/Effectiveness CommentsComments

Random Breath Testing RBTRandom Breath Testing RBT ****** **** **** Requires consistent Requires consistent enforcementenforcement

Sobriety CheckpointsSobriety Checkpoints ** ****** **** Selective/targeted Selective/targeted enforcementenforcement

Lower BAC LevelsLower BAC Levels ****** ****** ****** Population effect, Population effect, requires enforcementrequires enforcement

Administrative License SuspensionAdministrative License Suspension ****** **** **** Effective, requires Effective, requires enforcementenforcement

Graduated Driver LicensingGraduated Driver Licensing **** **** ****** Reduces overall crashesReduces overall crashes

Lower BAC level for youthLower BAC level for youth“Zero Tolerance”“Zero Tolerance”

****** ** ****** Effects depend upon Effects depend upon enforcementenforcement

Designated Driver and Ride ServicesDesignated Driver and Ride Services 00 ** 00 Little evidence of Little evidence of sustained effectsustained effect


Scientific EvidenceScientific EvidenceAlcohol AvailabilityAlcohol Availability



Total BanTotal Ban----ProhibitionProhibition ****** ****** **** Has associated Has associated probemsprobems

Minimum drinking/purchase ageMinimum drinking/purchase age ****** ** **** Effectiveness linked to Effectiveness linked to enforcementenforcement

RationingRationing **** **** ** Specific to one countrySpecific to one country

Government Retail MonopolyGovernment Retail Monopoly ****** ****** ****** Politically challengingPolitically challenging

Hours/Days of SaleHours/Days of Sale ****** ****** ****** Option available to Option available to communitiescommunities

Density of alcohol outletsDensity of alcohol outlets **** ** ****** Option available to Option available to communitiescommunities

Server Server LiabiliyLiabiliy ****** ** ****** Requires publicity of Requires publicity of riskrisk

Low Strength AlcoholLow Strength Alcohol **** **** ****** Effective IF price Effective IF price differencedifference

Alcohol Price/TaxesAlcohol Price/Taxes ****** ****** ****** Strongest evidence, politically challenging


Scientific EvidenceScientific EvidenceAltering theAltering the Drinking Context & PromotionDrinking Context & Promotion



Server Training to reduce over Server Training to reduce over servingserving ****** ****** **** Related to complianceRelated to compliance

Server Training to prevention Server Training to prevention violence & Aggressionviolence & Aggression ** ** **** Effectiveness linked to Effectiveness linked to

enforcementenforcement

Voluntary codes of bar practiceVoluntary codes of bar practice 00 ** 00 Little effect w/o Little effect w/o enforcementenforcement

Enforcement of onEnforcement of on--premise premise regulationsregulations **** **** **** Essential for regulations Essential for regulations

to be effectiveto be effective

Safer bar environment & containersSafer bar environment & containers ?? ** ??

Alcohol Advertising BansAlcohol Advertising Bans ** ** ****** Mixed results on total Mixed results on total advertising bansadvertising bans

Advertising content regulationsAdvertising content regulations ?? 00 ??Alcohol Free ActivitiesAlcohol Free Activities 00 **** 00 No evidence of effects


Scientific EvidenceScientific EvidencePublic Education & TreatmentPublic Education & TreatmentEffectivenessEffectiveness Cross Cultural Cross Cultural

Testing Testing Cost/EffectivenessCost/Effectiveness CommentsComments

Alcohol Education in SchoolsAlcohol Education in Schools ** **** ** Mixed results, only Mixed results, only associated with researchassociated with research

College Student EducationCollege Student Education“Social Marketing”“Social Marketing”

00 ** 00 Education alone is not Education alone is not sufficient sufficient

Public Campaigns, Public Service Public Campaigns, Public Service AdvertisementsAdvertisements 00 ** 00 Little effect on behaviorLittle effect on behavior

Warning Labels about Risk of Warning Labels about Risk of DrinkingDrinking ** ** ** Increased information Increased information

but little behavioral but little behavioral effecteffect

Brief Intervention with Heavy Brief Intervention with Heavy DrinkersDrinkers **** ****** **** Modest effect, targetedModest effect, targeted

Alcoholism TreatmentAlcoholism Treatment ** ** ** Related to level of Related to level of resourcesresources

Mutual Help/Self HelpMutual Help/Self Help“Alcoholics Anonymous”“Alcoholics Anonymous”

** ** ****** Feasible alternative to Feasible alternative to treatmenttreatment

Mandatory Treatment of Repeat Mandatory Treatment of Repeat Drinking/Driving OffendersDrinking/Driving Offenders ** ** ** Targeted to subgroupTargeted to subgroup


community prevention of alcohol problems: science to...

Documents