"Prevention of Substance "Prevention of Substance Abuse: What science tells Abuse: What science tells

us”us”

Harold D. Holder, Ph.D.Harold D. Holder, Ph.D.Senior ScientistSenior Scientist

Prevention Research CenterPrevention Research CenterPacific Institute for Research and Pacific Institute for Research and

Evaluation Evaluation Berkeley, CABerkeley, CA

Tucson, ArizonaTucson, Arizona

"Prevention of Substance "Prevention of Substance Abuse: What science tells Abuse: What science tells

us”us”

Harold D. Holder, Ph.D.Harold D. Holder, Ph.D.Senior ScientistSenior Scientist

Prevention Research CenterPrevention Research CenterPacific Institute for Research and Pacific Institute for Research and

Evaluation Evaluation Berkeley, CABerkeley, CA

Tucson, ArizonaTucson, Arizona

December 13, 2005December 13, 2005

More local problems are More local problems are caused by heavy drinking caused by heavy drinking

than by alcoholics.than by alcoholics.

Prevention Paradox:

0

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30

40

50

60

70

Alcoh

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Inhal

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Hallu

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Cocai

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Students Who Reported Using Alcohol, Students Who Reported Using Alcohol, Tobacco, and Other Drugs in Past 30 DaysTobacco, and Other Drugs in Past 30 Days

63%63%

46%46%

25%25%

11.4%11.4% 10.8%10.8%6.1%6.1% 4.5%4.5% 3.5%3.5% 4.5%4.5%

Experimentation and Established Smoking by Age

Source: 1996 CTS

Past Month Illicit Drug Use—any drug

Just what Just what isis prevention, anyway?prevention, anyway?

Goals of ATOD preventionGoals of ATOD prevention

Prevent health and safety problems related to Prevent health and safety problems related to substance use, e.g., traffic crashes, violence, substance use, e.g., traffic crashes, violence, lung cancer, overdose.lung cancer, overdose.

Prevent Prevent allall use of tobacco and illicit substances use of tobacco and illicit substances for everyone, for everyone, regardlessregardless of age. 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 Delay adolescent initiation of substances that are licit for adults (e.g., tobacco and alcohol).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 behavioralchange leading to demand reduction

Community/state system or population change leading to both demand and supply reduction

TargetIndividual, 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 FactorsSubstance Abuse Influences and Factors

(3) Economic - (3) Economic - Cost of alcohol, drugs, tobacco; Cost of alcohol, drugs, tobacco; geography of availability geography of availability

(3) Economic - (3) Economic - Cost of alcohol, drugs, tobacco; Cost of alcohol, drugs, tobacco; geography of availability geography of availability

(1)(1)Physical - Physical - Proximity of alcohol & Proximity of alcohol & tobacco outlets and drugtobacco outlets and drugsupplies, places of public usesupplies, places of public use

(1)(1)Physical - Physical - Proximity of alcohol & Proximity of alcohol & tobacco outlets and drugtobacco outlets and drugsupplies, places of public usesupplies, places of public use

(2) Social - (2) Social - Family, peers and larger Family, peers and larger social networks, norms, social networks, norms,

mass mediamass media

(2) Social - (2) Social - Family, peers and larger Family, peers and larger social networks, norms, social networks, norms,

mass mediamass media

For Example, Youth DrinkingFor Example, Youth DrinkingFor Example, Youth DrinkingFor Example, Youth Drinking

AlcoholAlcoholAvailabilityAvailability

DrinkingDrinkingBy PeersBy Peers

RetailRetailPricePrice

Alcohol purchases by other youthAlcohol purchases by other youth

EconomicEconomicSocialSocial

Cost &Cost &availabilityavailability to youthto youth

Availability of Availability of alcohol to & alcohol to & from peersfrom peers

PhysicalPhysical

Public Health Model of PreventionPublic Health Model of Prevention

IndividualIndividual

EnvironmentEnvironment AgentAgent

Public Health Model of Substance Public Health Model of Substance Abuse Problem PreventionAbuse Problem Prevention

IndividualIndividual(User)(User)

EnvironmentEnvironment(Context)(Context)

AgentAgent(Substance)(Substance)

Individual ApproachesIndividual Approaches

3.3.

4.4.

1.1.

2.2.

School-Based EducationSchool-Based Education

Mass Communication and Public Mass Communication and Public EducationEducation

Family Education/counselingFamily Education/counseling

Alcohol and Tobacco Warning labelsAlcohol and Tobacco Warning labels

DeterrenceDeterrence: : Possession or sale of drugs, Possession or sale of drugs, Drinking and driving Laws, Sale of tobacco or Drinking and driving Laws, Sale of tobacco or alcohol to minors.alcohol to minors.

5.5.

Brief Intervention in health care or workplace6.

Public Health Model of Substance Use Public Health Model of Substance Use PreventionPrevention

EnvironmentEnvironment(Context)(Context)

IndividualIndividual(User)(User)

AgentAgent(Substance)(Substance)

Environmental ApproachesEnvironmental Approaches

1.1.

2.2.

3.3.

Retail Access to substances, e.g., Retail Access to substances, e.g., price, outlet locations, minimum price, outlet locations, minimum purchase laws, parental restrictions on purchase laws, parental restrictions on youth.youth.

Restrictions or constraints on the Restrictions or constraints on the Drinker’s or Smokers Behavior, Drinker’s or Smokers Behavior, e.g., e.g., drinking & smoking locations, drink drivedrinking & smoking locations, drink drive

Reduce Risk or Problem SeverityReduce Risk or Problem Severity

Public Health Model of Substance Use Public Health Model of Substance Use PreventionPrevention

AgentAgent(Substance)(Substance)

IndividualIndividual(User)(User)

EnvironmentEnvironment(Context)(Context)

Agent ApproachesAgent Approaches

1.1.

2.2.

3.3.

Low or No Alcohol Beverages or lower Low or No Alcohol Beverages or lower tar tobacco productstar tobacco products

Alcohol container size or Alcohol container size or tobacco package restrictions tobacco package restrictions

Restrictions on Product Restrictions on Product AdvertisingAdvertising

Standards of EvidenceStandards of Evidence

1.1.

2.2.

3.3.

Achieves significant effects (actually Achieves significant effects (actually reduces ATOD problems) under scientific reduces ATOD problems) under scientific standards.standards.

Replicated across two or more studies Replicated across two or more studies under diverse community or national under diverse community or national conditions.conditions.

Has practical applicability and can affect Has practical applicability and can affect the total community, not only target the total community, not only target groups, i.e., groups, i.e., has public health importhas public health import..

Problem Prevention Strategies: Problem Prevention Strategies: Solid EvidenceSolid Evidence

¤¤

¤¤

¤¤

¤¤

¤¤

¤¤

Retail price of alcohol or tobaccoRetail price of alcohol or tobacco

Density & location of alcohol outletsDensity & location of alcohol outlets

Lower BAC limits for drivingLower BAC limits for driving

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

Graduated licenses & “zero tolerance Graduated licenses & “zero tolerance for Youthfor Youth

Minimum drinking/purchase ageMinimum drinking/purchase age—retail —retail compliance checks for alcohol and tobaccocompliance checks for alcohol and tobacco

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

As price increases, smoking and heavy As price increases, smoking and heavy drinking declines (Chaloupka, 1993)drinking declines (Chaloupka, 1993)

Heavy drinkers/smokers as well as youth are Heavy drinkers/smokers as well as youth are affected by price. (Coate and Grossman, affected by price. (Coate and Grossman, 1988)1988)

Retail PriceRetail PriceRetail PriceRetail Price Drinking & Drinking & smokingsmokingDrinking & Drinking & smokingsmoking

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

Underage DrinkingUnderage Drinking

Increase community awareness of underageIncrease community awareness of underagedrinkingdrinking

Reduce physical availability of alcohol to minorsReduce physical availability of alcohol to minors

GoalGoal::Decrease underage drinkingDecrease underage drinking

Increase awareness of retail establishments andIncrease awareness of retail establishments andadults of the legal and social risks of providingadults of the legal and social risks of providingalcohol to minorsalcohol to minors

ActionActions:s:

Alcohol Use (30-day mean) Before and After Alcohol Use (30-day mean) Before and After Minimum Drinking Age (MDA) was Raised--United StatesMinimum Drinking Age (MDA) was Raised--United States

Alcohol Use (30-day mean) Before and After Alcohol Use (30-day mean) Before and After Minimum Drinking Age (MDA) was Raised--United StatesMinimum Drinking Age (MDA) was Raised--United States

Years Before and After MDA was Years Before and After MDA was RaisedRaised

2.2

2.4

2.6

2.8

3

3.2

-3 -2 -1 1 2 3Me

an

30

-Da

y A

lco

ho

l M

ea

n 3

0-D

ay

Alc

oh

ol

Us

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se

Source: O’Malley & Wagenaar (1991)

13% Decline13% Decline

Environment Environment Environment Environment Person ActivitiesPerson ActivitiesPerson ActivitiesPerson Activities

Drinking and DrivingDrinking and Driving

Increase law enforcement efficiencyIncrease law enforcement efficiency

Increase perceived risk of DWI detectionIncrease perceived risk of DWI detection

Increase community support of DWI Increase community support of DWI enforcementenforcement

GoalGoal::Reduce the number of community drinking and Reduce the number of community drinking and driving eventsdriving events

ActionsActions::

Access InterventionAccess Intervention

GoalGoal: : Decreased physical availability of SubstancesDecreased physical availability of Substances

ActionsActions::

Changes in planning and zoning lawsChanges in planning and zoning laws

License challengesLicense challenges

Reduction in outlet densities and sales to minorsReduction in outlet densities and sales to minors

Problem Prevention Strategies:Problem Prevention Strategies:Positive Evidence – Need ReplicationPositive Evidence – Need Replication

Responsible beverage service – Policy & server trainingResponsible beverage service – Policy & server training

Primary health care interventionsPrimary health care interventions

Liability for sales or serving alcoholLiability for sales or serving alcohol

Alcohol & tobacco warning labelsAlcohol & tobacco warning labels

Administrative driver license suspensionAdministrative driver license suspension

School education alone & w/ community School education alone & w/ community interventiointerventionnss

Community Prevention Trials utilizing local policy

School EducationSchool Education

Effective programs:Effective programs: Values and norms clarificationValues and norms clarification Decision-makingDecision-making Life skillsLife skills Use interactive teaching methodsUse interactive teaching methods

Ineffective programs:Ineffective programs: Target self-esteemTarget self-esteem Increase knowledgeIncrease knowledge Use scare tacticsUse scare tactics Use didactic methodsUse didactic methods

Individual: Individual: School-based EducationSchool-based Education

Popular prevention strategy--mostly US studiesPopular prevention strategy--mostly US studies

Information only – no effectInformation only – no effect

Mixed results across studies and substances & Mixed results across studies and substances & onlyonly in controlled research studies in controlled research studies

Most effective with some combination of:Most effective with some combination of:1. Normative beliefs1. Normative beliefs2. Personal commitment2. Personal commitment3. Information3. Information4. Resistance skills4. Resistance skills

Responsible Beverage ServiceResponsible Beverage Service

Goal:Goal: Reduce alcohol intoxication or impairment for Reduce alcohol intoxication or impairment for patrons of bars and restaurantspatrons of bars and restaurants

Actions:Actions:

New alcohol serving policies (price promotions, New alcohol serving policies (price promotions, serving sizes, non-alcoholic beverages and food)serving sizes, non-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

Problem Prevention Strategies:Problem Prevention Strategies:Promising -- Too early to tellPromising -- Too early to tell

Workplace interventions—workplace policyWorkplace interventions—workplace policy

Genetics and alcohol drug dependency riskGenetics and alcohol drug dependency risk

Alcohol sales to intoxicated personsAlcohol sales to intoxicated persons

Auto ignition controlsAuto ignition controls

Curfew lawsCurfew laws

Parent training and mobilizationParent training and mobilization

Restrictions on drinking & smoking locationRestrictions on drinking & smoking location

Low or no alcoholic beverages; low tar tobaccoLow or no alcoholic beverages; low tar tobacco

Alcohol container and tobacco product sizesAlcohol container and tobacco product sizes

Alcohol Problem Prevention Strategies:Alcohol Problem Prevention Strategies:Mixed Findings -- Uncertain ImplicationsMixed Findings -- Uncertain Implications

Mass communication and public education aloneMass communication and public education alone

School-based education aloneSchool-based education alone

Restrictions on AdvertisingRestrictions on Advertising

Examples of media programsExamples of media programs

ONDCP Anti-drug media campaignONDCP Anti-drug media campaign Partnership for a Drug-Free AmericaPartnership for a Drug-Free America

Individual: Individual: Mass Communication Mass Communication and Public Education and Public Education

Increases awarenessIncreases awareness

Produces little behavioral changeProduces little behavioral change

Reinforces environmental strategiesReinforces environmental strategies

Latest Scientific Advance:Latest Scientific Advance: Comprehensive Mix of Comprehensive Mix of

evidence-based prevention evidence-based prevention strategies at local levelstrategies at local level

Community Action Trials which use Community Action Trials which use complimentary interventionscomplimentary interventions

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

Community System of Alcohol Use & Abuse

National Community Trial to Prevent National Community Trial to Prevent Alcohol-involved TraumaAlcohol-involved Trauma

OrangeOrange

OceansideOceanside..

..

..

-

ExperimentalExperimentalComparisonComparison

ModestoModesto

SalinasSalinas

FlorenceFlorence

SumterSumter

Alcohol-involved Trauma at the Community Level: Alcohol-involved Trauma at the Community Level: Conceptual Model`````````Conceptual Model`````````

MOBILIZATIONMOBILIZATIONMOBILIZATIONMOBILIZATION DRINKING AND DRIVINGDRINKING AND DRIVINGDRINKING AND DRIVINGDRINKING AND DRIVING

UNDERAGE DRINKINGUNDERAGE DRINKINGUNDERAGE DRINKINGUNDERAGE DRINKING

ALCOHOL ACCESSALCOHOL ACCESSALCOHOL ACCESSALCOHOL ACCESS

RESPONSIBLE BEVERAGE RESPONSIBLE BEVERAGE SERVICESERVICE

RESPONSIBLE BEVERAGE RESPONSIBLE BEVERAGE SERVICESERVICE

Non-Traffic Risk ActivitiesNon-Traffic Risk Activities

Local News about AlcoholLocal News about AlcoholProblems & EnforcementProblems & Enforcement

Retail Alcohol Retail Alcohol AvailabilityAvailability

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

Alcohol IntoxicationAlcohol Intoxication or Impairmentor Impairment Alcohol-involvedAlcohol-involved

Injury Injury

Alcohol-involvedAlcohol-involvedInjury 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)

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

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Perc

en

t S

ellin

g

4747 4545

5353

3535

19191616

Comparison

ExperimentalNo Training

ExperimentalTraining

Comparison

ExperimentalNo Training

ExperimentalTraining

PRETEST PRETEST POSTTESTPOSTTEST

Holder, et al., Holder, et al., J. American Medical Association,J. American Medical Association, 2000 2000

Community Trials Final ResultsCommunity Trials Final Results

Driving after “Too much to drink” (- 49%)Driving after “Too much to drink” (- 49%)

BAC Positive Drivers (- 44%)BAC Positive Drivers (- 44%)

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

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

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

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

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

Similarities across Similarities across allall effective prevention effective prevention strategiesstrategies

Comprehensive and multi-componentComprehensive and multi-component Targets specific causal variables which have Targets specific causal variables which have

been shown to affect total local population as been shown to affect total local population as well as the environmentwell as the environment

Based on methodologically sound, Based on methodologically sound, independently replicated evaluations under independently replicated evaluations under “real world” conditions“real world” conditions

Community System StrategiesCommunity System Strategies

Impact both heavy & moderate drinkers/usersImpact both heavy & moderate drinkers/users

Yield longevity of effectsYield longevity of effects

Effectiveness at population levelEffectiveness at population level

Do not target subgroups--non discriminatingDo not target subgroups--non discriminatingHave lower costsHave lower costs

-No case-finding-No case-finding

--Individual services NOT requiredIndividual services NOT required

-NO continued costs to sustain effects-NO continued costs to sustain effects