chapter 3 methodology about alcohol

Presses universitaires de Louvain

Underage drinking.

Chapter 3. Prevention of Alcohol Use and Misuse in Youth: A Comparison of North American and European Approaches

Texte intégral.

1 The current chapter provides a review of the different prevention approaches targeting alcohol use in young people. A number of systematic reviews on this issue are available, particularly through the Cochrane Review library (see Foxcroft & Tsertsvadze, 2011a-c). What these former reviews do not offer is a comparison across the different types of approaches to alcohol prevention. Therefore, we review the theoretical bases of the different approaches to alcohol prevention, and we describe some programmes with the strongest evidence-base and review their efficacy to facilitate comparisons of the evidence across approaches. In reviewing specific programmes, our intent is to be representative rather than comprehensive. Furthermore, special attention is dedicated to the cultural context in which a particular programme or approach has been evaluated to provide policy makers with recommendations on how alcohol prevention might be implemented in new cultural contexts.

KEY FINDINGS

2 • The goals of alcohol prevention programmes often vary according to cultural context. While most U.S.-based programmes have abstinence as their primary goal, most European programmes include reductions in alcohol use as a viable outcome.

3 • Delivering alcohol prevention in the school context captures a larger percentage of youth and yields the most consistent effects, relative to programme delivery within the community or family context. The most effective universal school-based programmes are comprehensive, concurrently addressing normative attitudes about drinking, and teaching generic and alcohol refusal skills.

4 • The most effective family-based programmes for preventing or reducing alcohol use in young people emphasise active parental involvement and work to develop parenting skills to enhance competence and self-regulation in children. Family-based programmes have small effects, but their effects are generally consistent and lasting.

5 • Selective interventions targeted towards at-risk groups (e.g., high personality risk for alcohol use disorders) have been shown to be effective in reducing alcohol use in young people. Such programmes can also delay drinking onset if introduced in early adolescence prior to the onset of alcohol use.

6 • Personalized feedback interventions are designed to correct misperceptions about drinking norms in college and high school students. Such programmes are indicated as a strategy for reducing drinking in those whom have already started drinking, especially those who drink more heavily.

7 Adolescence and young adulthood is a critical period of social and emotional development (Spooner, Mattick, & Noffs, 1996), a time when young people move toward independence and autonomy and decrease dependence on families and schools. For these reasons, this developmental period is also the time when acceptance by peers becomes more important and when risk-taking behaviour is high. It is also a period when individual differences in risk for psychopathology begin to manifest themselves in substance misuse and other psychiatric symptoms. If left untreated, adolescent-onset disorders can become chronic and can cause severe disability (Andrews, Henderson, & Hall, 2001). It is therefore important that prevention programmes be implemented prior to onset of psychiatric symptoms and before social and emotional influences come into full effect. Furthermore, such programmes should be introduced before initial exposure to alcohol, to reduce the adverse impacts of alcohol use on the developing brain. Implementing alcohol prevention programmes early will ensure young people are provided with the knowledge and skills they need to make responsible and informed decisions about drinking (Dielman, 1995) and programmes that can effectively delay onset of drinking, particularly heavy drinking, will ensure that alcohol is not interfering with this critical period of social, cognitive, and neural development.

8 Alcohol prevention can be delivered in the school, to the family, and/or in the community. Prevention programmes can be universal (offered to all members of the population), selective (offered to only those who are at high-risk for the disorder), or indicated (offered only to those who already show signs of the disorder); the latter two types are often collectively referred to as targeted approaches. Approaches to alcohol prevention can vary widely based on the desired end goal of the intervention whether it be abstinence, reduction in drinking quantity, reduced alcohol-related problems, or delayed onset. Desired outcomes may vary across cultural contexts. For example, while most U.S.-based prevention programmes have abstinence as the primary goal, European prevention trials typically are more tolerant and include reductions in alcohol use as a viable treatment outcome. We organise our chapter around the location in which the intervention is delivered (e.g., school-based context), but consider whether the intervention described is universal, selective, or indicated, and what type(s) of alcohol-related outcomes are used to assess efficacy.

SCHOOL-BASED APPROACHES

9 School-based alcohol prevention programmes offer numerous advantages over other prevention approaches because attending school is a mandatory requirement in most Western countries and is where young people spend over a quarter of their waking lives (Cuijpers, 2002). Schools offer a location where educators are able to reach large audiences at one time, keeping costs low and retention relatively high (Botvin, 1999; Botvin, 2000; Cuijpers, 2003; Gottfredson, Gottfredson, & Skroban, 1996; Jones, Sumnall, Burrell, McVeigh, & Bellis, 2006; Shin, 2001; Wenter et al., 2002).

10 School is also where youth experience most peer interaction and influence, which can both positively and negatively influence alcohol-related behaviours and attitudes. It is primarily in the school-age years when drinking behaviours have their onset (Botvin & Griffin, 2003; Sharma, 2006). Alcohol prevention programmes can be easily implemented in the school context (Berkowitz & Begun, 2003) and school research suggests that it is best to deliver prevention in sequential and developmentally-appropriate stages (Ballard, Gillespie, & Irwin, 1994; Dusenbury & Falco, 1995; Meyer & Cahill, 2004). School-based alcohol and drug prevention programmes have been shown to be appealing both to students and educators over and above other types of prevention delivery (Lisnov, Harding, Safer, & Kavanagh, 1998). Other practical and economic advantages to delivering prevention in schools include: being able to capture large numbers of youth at one time, availability of educational resources, and that programmes can be easily tailored and delivered to different development stages (McBride, 2003).

11 Universal prevention addresses the entire population within a particular setting, regardless of their level of risk for alcohol use and aims to delay the onset of alcohol use by equipping individuals with the information and skills that they need to prevent use. In schools, universal programmes focus largely on teaching awareness education (knowledge and harms), normative education, social and drink-refusal skills, and promoting pro-social peer relationships. Universal programmes offer the advantage of being delivered on a large scale and, as such, they have the potential ability to reduce alcohol use and related harms to a greater audience (Jones et al., 2006; Midford, 2008). Importantly, they avoid the risk of stigmatising individuals, given the sensitive nature of alcohol use disorders and risk (Offord, 2000).

12 A recent review of school-based universal prevention has identified some effective programmes (Foxcroft & Tsertsvadze, 2011a). Many effective programmes of this type incorporate a social influence or skill development approach to prevention.

SOCIAL INFLUENCE APPROACH

13 The ‘social influence approach’ to prevention was developed in the 1980s and is based on Bandura’s (1977) social learning theory and McGuire’s (1964, 1968) social inoculation theory. The approach is based on the assumption that young people start to use alcohol as a result of social and psychological pressure from peers, family, and the media (Donaldson et al., 1996). The goal of social influence programmes is to teach young people to avoid using alcohol by resisting external pressure and increasing alcohol-related coping skills (Botvin, 2000). The social influence approach emphasizes three major components: information, normative education, and resistance-skills training (Botvin, 2000). The emphasis in the information component is to highlight short-term rather than long-term consequences of alcohol use since the short-term corresponds to the typical thinking style of young people (Berkowitz & Begun, 2003). The component of normative education is based on findings that heavy drinking adolescents generally overestimate the prevalence of alcohol and other substance use in peers (Perkins, 2007). Therefore, one main component is to correct perceptions by providing students with the most current and accurate data, usually from large and relevant population-based surveys. This approach has been shown to change students’ beliefs about the prevalence and attitudes about acceptability of alcohol use by young people, and delay the onset of alcohol use (Botvin, 2000; Botvin & Griffin, 2007; Cuijpers, 2003; Cuijpers, Jonkers, Weerdt, & Jong, 2002; Hansen & Graham, 1991b; Moskowitz, 1989).

14 The social influence approach also addresses the findings on how pro-alcohol social influences from peers and the media also influence youth drinking by teaching alcohol resistance skills. This generally involves teaching students how to recognise, handle or avoid high-risk situations, increasing students’ awareness of media influences, and training them in drink refusal skills. The inclusion of resistance skills training in school-based prevention has been associated with enhanced effectiveness (e.g., Botvin, 2000). However, in the absence of normative education, resistance skills training has been found to be relatively ineffective and potentially iatrogenic (Hansen et al., 1991b), possibly because the social normative component is necessary to motivate students to utilise peer-resistance strategies.

15 Until recently the most well-documented, school-based alcohol and other drug prevention programme based on the social influence approach was the Drug Abuse Resistance Education (DARE) programme. The DARE programme is typically taught in the fifth grade (10 years of age). What distinguishes the programme from others is that it is taught by police officers. Although some early studies found the programme to impact positively on alcohol and drug-related attitudes, knowledge and behaviour, these studies have since been criticised for their weak or inadequate research methods (Rosenbaum & Hanson, 1998). More recently, studies with stronger designs and analytic methods have shown the DARE programme to have minimal or no impact on reducing alcohol and drug use (Birkeland, Murphy-Graham, & Weiss, 2005; Ennett, Rosenbaum, Flewelling, & Bieler, 1994; Rosenbaum, Flewelling, Bailey, Ringwalt, & Wilkinson, 1994; Rosenbaum & Hanson, 1998). The ineffectiveness of the DARE programme has been suggested to result from the instructional, non-interactive method of delivery by authority figures (Tobler & Stratton, 1997; White & Pitts, 1998).

16 Aside from the DARE programme, a considerable number of studies have examined the efficacy of other social influence programmes in preventing alcohol use when delivered by other members of the community, including teachers. When delivered in this way, the social influence approach has been found to be effective in not only increasing knowledge and attitudes towards alcohol, but importantly in reducing the use of alcohol as reviewed in the evidence section below (e.g., Botvin, Griffin, Paul, & Macaulay, 2003; Cuijpers, 2003; Cuijpers et al., 2002; Faggiano et al., 2008; Hansen, 1992; Midford, 2000; Perry & Kelder, 1992; Roona, Streke, Ochshorn, Marshall, & Palmer, 2000; Shope, Copeland, Marcoux, & Kamp, 1996; Soole, Mazerolle, & Rombouts, 2005; Tobler, Lessard, Marshall, Ochshorn, & Roona, 1999; Tobler et al., 2000).

COMPREHENSIVE APPROACH

17 Social influence programmes generally assume that young people use alcohol as a result of peer influence and a lack of drink refusal skills. However, they fail to take into account other factors which can influence alcohol use such as dealing with low self-esteem, depression, or anxiety. Comprehensive programmes were designed to take such etiological risk factors into account. This approach is also known as the competence enhancement approach to prevention (Botvin, 1999; Botvin et al., 2003), but differs from selective or indicated programmes by promoting generic skills in the general population. Selective programmes, by contrast, promote specific skills in youth identified as lacking these specific skills and/or requiring specific learning conditions.

18 The comprehensive approach is based on Bandura’s (1977) social learning theory and Jessor’s (1977) problem behaviour theory. The approach conceptualises alcohol misuse as a socially learned behaviour that results from the interplay of a variety of social factors (such as modelling and imitation) which influence personal factors (such as beliefs, attitudes, and pro-alcohol cognitions) (Botvin, 2000). Teaching general personal and social skills in the absence of other components of the social influence approach such as drink refusal skills training and normative education has only been found to have a minimal impact on alcohol use (Caplan et al., 1992). However, when elements of the social influence approach are included into the model, effects appear to be more robust (Botvin, 2000). Another essential ingredient of the comprehensive approach to prevention is an interactive delivery style which generally involves class discussions, instruction and demonstration, group feedback and reinforcement, role-plays, and practice (Botvin et al., 2003).

REVIEW OF THE EVIDENCE FOR THE SOCIAL INFLUENCE AND COMPREHENSIVE APPROACHES

19 In a recent Cochrane review of universal alcohol prevention programmes, Foxcroft and Tsertsvadze (2011a) identified 11 alcohol-specific prevention programmes that involved a rigorous randomised controlled trial. Of these, five trials showed no significant differences between their experimental and control groups (Duryea, 1984; Goodstadt & Sheppard, 1983; Newman, Anderson, & Farrell, 1992; Sheehan, Schonfeld, Ballard, & Schofield, 1996; Williams, DiCicco, & Unterberger, 1968) and in the other six trials some significant differences between groups were reported (Dielman, Shope, Butchart, & Campanelli, 1986; McBride, Midford, Farringdon, & Phillips, 2000; Morgenstern, Wiborg, Isensee, & Hanewinkel, 2009; Perry & Grant, 1988; Vogl et al., 2009; Wilhelmsen & Laberg, 1994). These six trials were conducted with children across the world, all living in developed countries, such as Germany, Norway, Switzerland, Australia, and Chile. The programmes all involved in-class alcohol education and drink refusal skills training ranging in duration from four to ten+ sessions. Results showed significant reductions in drinking and binge drinking in intervention groups and effects were observed up to 12 months post-intervention. However, in two of these six trials, effects were limited to subgroups such as girls or those who were not drinkers at baseline. And, as with all systematic reviews, there is the potential lack of inclusion of ‘file drawer’ results (i.e., negative findings that are simply never published and thus not accessible to the reviewers).

20 Alcohol non-specific prevention programmes addressing all substance use outcomes were also evaluated by Foxcroft and Tsertsvadze (2011a) for their effects on youth drinking behaviour. Twenty-four trials showed no significant differences between their experimental and control groups (Allison, Silverman, & Dignam, 1990; Beaulieu & Jason, 1988; Bond et al., 2004; Botvin et al., 2003; Brewer, 1991; Clayton, Cattarello, & Walden, 1991; D’Amico & Fromme, 2002; Durrant, 1986; Ellickson & Bell, 1990; Furr-Holden, Ialango, Anthony, Petras, & Kellam, 2004; Goldberg et al., 2000; Hansen, Johnson, Flay, Graham, & Sobel, 1988; Hansen & Graham, 1991a; Johnson, Shamblen, Ogilvie, Collins, & Saylor, 2009; Koning et al., 2009; Moskowitz, Malvin, Schaeffer, & Schaps, 1984; Perry et al., 2003; Ringwalt, Ennett, & Holt, 1991; Ringwalt, Clark, Hanley, Shamblen, & Flewelling, 2009; Spoth, Redmond, Trudeau, & Shin, 2002; St. Pierre, Osgood, Mincemoyer, Kaltreider, & Kauh, 2005; Sun, Dent, Sussman, & Rohrbach, 2008; Werch, Moore, & DiClemente, 2008; Werch et al., 2010) and 14 trials showed significantly greater reduction in alcohol use when comparing intervention and control groups (Botvin, Baker, Renick, Filazzola, & Botvin, 1984; Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995; Botvin, Griffin, Diaz, & Ifill-Williams, 2001; Caplan et al., 1992; Cook, Lawrence, Morse, & Roehl, 1984; Eisen, Zellman, Massett, & Murray, 2002; Ellickson, McCaffrey, Gosh-Dastidar, & Longshore, 2003; Faggiano, Richardson, Bohrn, & Galanti, EU-Dap Study Group, 2007; Griffin, Holliday, Frazier, & Braithwaite, 2009; Hecht et al., 2003; Kellam et al., 2008; Scaggs, 1985; Schinke, Tepavac, & Cole, 2000; van Lier, Huizink, & Crijnen, 2009). Two studies showed comprehensive programmes to be effective over the medium-long term (Botvin et al., 1995; Scaggs, 1985) and three studies showed this approach to be effective over the longer term (i.e., over three years; Botvin et al., 1995; Schinke et al., 2000; Spoth, Redmond, & Shin, 2001). Most of these studies, with the exception of the European Unplugged programme, were conducted in the U.S.

21 The most popular and most well-evaluated of the comprehensive programmes is the Life Skills Training (LST) model developed by Botvin (1998). The LST was identified in the Foxcroft and Tsertsvadze (2011a) Cochrane Review as having the strongest evidence-base of the comprehensive programmes. This programme emphasises personal and social risks that underpin lifestyle and health behaviours and aims to teach students ways to avoid these risks. This is done by teaching decision making and problem-solving skills, assertiveness training, skills to resist peer and media influences, techniques to communicate effectively and develop healthy personal relationships, ways to enhance one’s self-esteem, and ways to manage stress and anxiety (Botvin, 2000). Various formats of the LST programme have been developed and evaluated, but the most common format consists of 15 lessons in year seven, and ten booster sessions over years eight and nine. Numerous studies testing the efficacy of the LST competence enhancement approach on alcohol use have found the programme to significantly reduce drinking behaviours (e.g., Botvin, 1998; Botvin, Baker, Dusenbury, Tortu, & Botvin, 1990; Botvin et al., 2001; Botvin & Kantor, 2000; Eisen, Zellman, & Murray, 2003; Faggiano et al., 2008; Soole et al., 2005). First tested in primarily white middle class communities in the U.S., the programme was shown to have consistently significant effects. However, these effects were small, accounting for only 10% of the variance in drinking outcomes (e.g., Botvin et al., 1995). More recently, the programme has been evaluated in minority populations, inner-city minority populations, and high-risk youth (i.e., those reporting high-risk characteristics at baseline, such as having peers who have initiated use or low academic achievement). These studies all indicate that the LST programme can be modified to different cultural contexts and is effective, and possibly more effective when delivered to high-risk youth. One study by Botvin et al. (2001) reported over 50% fewer binge drinkers in the intervention group at follow-up relative to the control group when the study sample consisted primarily of inner-city African-American youth. There is also evidence that the LST programme is slightly more effective when it is adapted to the cultural context in which it is delivered (e.g., Botvin et al., 1995) and when delivered in higher risk populations (e.g., Griffin, Botvin, Nichols, & Doyle, 2003).

22 Another important test of the reliability of an intervention effect is when a programme is evaluated by a research team that is independent of the original evaluator (as programme evaluator has been shown to have significant effects on treatment outcome studies). Spoth et al. (2002) evaluated the LST programme against a combined condition that included both LST and a family-based programme or a control condition. Drug initiation outcomes (alcohol, tobacco, and cannabis) were evaluated one year after cluster-randomization in a sample of rural Midwestern American high school students. The LST intervention was found to be effective on a substance initiation index (combining all substances). However, when alcohol initiation was evaluated separately, LST was not shown to significantly prevent onset of drinking in adolescents. Effects of the LST intervention on binge drinking or drunkenness were not reported in this study. The evidence in favour of the LST programme has also been criticised by Gorman (2002) who highlighted problems with the sampling methodology of the most prominent LST effectiveness study. Botvin and colleagues (2000) reported a six-year follow up of a randomised controlled trial of the LST programme but restricted the analysis to only a small subset, namely 7.5% of participants in the study, thus violating the fundamental principles of intent-to-treat analyses (Gorman, 2002). Hence, the longterm effectiveness of the LST programme may be less conclusive than originally thought and caution should be used when making inferences about the robustness of such programmes in producing long-term effects on alcohol and other substance-related behaviour. In addition, a large study in the U.S. was conducted recently to evaluate the effectiveness of the Take Charge of Your Life (TCYL) programme, a comprehensive universal programme delivered by trained police facilitators of the DARE programme. Results from this study found an overall negative effect of the TCYL programme, with intervention students reporting an increase in their use of alcohol and cigarette use, and no differences between groups reported for cannabis use (Sloboda et al., 2009). The authors are actively studying the effect of the intervention on mediators and modifiers in order to explain the reason for these disappointing findings; however, it appears that the more reasonable explanation is that the providers of the intervention were law enforcement officers, and that this could have reduced the possible effect of intervention among at-risk students.

23 More recent evidence for the comprehensive approach comes from the European ‘Unplugged’ Programme, a school-based curriculum against youth alcohol and other substance use which includes components such as normative education and resistance skills (Van Der Kreeft et al., 2009). The programme was packaged into standardised materials and adapted for seven European countries (Belgium, Germany, Spain, Greece, Italy, Austria, and Sweden) and it was evaluated within the frame of the European Drug Addiction Prevention (EU-Dap) study, a randomised controlled community trial, conducted between September 2004 and May 2006. The first follow-up was conducted three months after the end of the delivery and showed that the programme was associated with a reduction of episodes of drunkenness, but not drinking problems, or drinking frequency or quantity (Faggiano et al., 2008). At the 18-month follow-up, the effect on drunkenness survived statistical tests (Faggiano et al., 2010): the intervention was associated with a 20% reduced prevalence of any drunkenness (prevalence odds ratio=0.80) and a 38% reduced prevalence of frequent drunkenness (prevalence odds ratio=0.62). Relative reduction rates for alcohol initiation and weekly drinking were not significant (Faggiano, 2009). This programme has subsequently been shown to be ineffective for students attending schools classified as having medium or high socio-economic status, and more effective for those attending schools classified as having low socioeconomic status. Once this important moderator is considered, this programme was shown to have significant effects on any drinking, weekly drinking, and problem drinking symptoms (Caria, Faggiano, Bellocco, & Galanti, 2011). Finally, another moderator analysis revealed that this programme was more effective in preventing onset of binge drinking in boys, but that the programme was equally effective in preventing progression to regular drunkenness in boys and girls (Vigna-Taglianti et al., 2009). However, it is unclear if this finding is a reflection of how girls drink (progressing more quickly to heavy drinking; see Stewart, Gavric, & Collins, 2009) or of gender-specific effects of the intervention.

24 Another European-based trial of the effectiveness of the LST programme was conducted by Morgenstern et al. (2009). They reported that the intervention significantly reduced risk of lifetime binge drinking at 4 month and 12 month follow-ups with an adjusted odds ratio of 0.56 at four months, suggesting a 44% reduction in binge drinking prevalence, and 0.74 at 12 months, suggesting a 36% reduction in binge drinking prevalence.

25 In summary, the comprehensive approach, particularly the LST programme, can be culturally adapted for new contexts and produces reliable effects on binge drinking, but limited effects on drinking initiation or frequency of drinking. Overall effects on drinking behaviours are small (10%-30% relative reductions), with little support for the effects on drinking initiation, drinking frequency, or drinking problems and stronger support for effects on drunkenness or binge drinking. Furthermore, these reductions have been shown to last up to three years. The programme appears to be effective for both minority populations and majority populations, in both the U.S. and European contexts, and for both girls and boys. There is some evidence suggesting that the more at-risk the population, the greater the effects of the programme (e.g., Botvin et al., 2001; Caria et al., 2011). Another feature identified but not systematically tested as a potential moderator of programme efficacy is the extent of the intervention deliverer’s affiliation with law-enforcement (Sloboda et al., 2009).

PEER-LED INTERVENTION

26 Like drink refusal skills training, peer-led interventions are based on the idea that altering peer influences can have beneficial effects (Velleman, 2009). In the peer-led intervention context, peers are trained to become educators and attitude-formation leaders. The rationale is that peers have the power to influence one another’s attitudes and behaviour if given the information and skills to do so. Moreover, people of the same age feel freer to talk to one another. There is some evidence that peer-led interventions do not always work, however. For example, one study showed no effects of a peer support programme on adolescents’ knowledge, attitudes, or use of alcohol (Webster, Hunter, & Keats, 2002). Interestingly, some research suggests that peer-led interventions may work more for those delivering rather than those receiving the intervention (Sumnall et al., 2006). One study demonstrated the possibility of interactions between peer education and the makeup of the peer network (Valente et al., 2007). Specifically, deleterious effects of the peer-led interventions were found among those with peer networks that support alcohol and drug use.

SELECTIVE VERSUS UNIVERSAL PREVENTION

27 Considering the large literature on childhood risk factors for early onset drinking and problems with alcohol (reviewed in Chapter 2), and the results reviewed above showing possible beneficial effects of universal programmes in higher-risk populations, there is an argument for developing and delivering prevention programmes that target specific populations. Selective interventions have the advantage of allowing the focus of limited resources to be used on those most at need. They also address individual needs of homogeneous at-risk groups and offer an opportunity to tailor interventions to the etiological processes implicated in different risk profiles (Conrod, Castellanos-Ryan, & Strang, 2010; Conrod, Mackie, & Castellanos, 2008; Conrod, Stewart, Comeau, & Maclean, 2006; Thush et al., 2007). Selective prevention programmes are often overlooked due to their practical limitations. It is not only difficult to initially identify those individuals at greatest risk, but finding suitable, cost-effective ways to screen and deliver interventions can also be challenging (Offord, 2000). However, in recent years we have seen the development of selective programmes which are showing that these ethical and practical obstacles can be overcome.

28 One such approach, known as the Personality-Targeted Approach, is a brief, selective programme that presents a novel approach to alcohol and other substance misuse prevention by targeting personality risk factors for early-onset drinking or illicit drug use. It is the first and only school-based alcohol and drug prevention programme that has been shown to prevent growth in alcohol and substance misuse in three separate trials across Canada (Conrod et al., 2006) and the United Kingdom (Conrod et al., 2010; Conrod et al., 2008; Conrod et al., in press; O’Leary-Barrett, Mackie, Castellanos-Ryan, Al-Khudhairy, & Conrod, 2010), through targeting youth with elevated scores on four personality risk factors for early-onset alcohol/drug misuse and other risky behaviours: Hopelessness, Anxiety Sensitivity, Impulsivity, and Sensation-Seeking (Battista, Pencer, McGonnell, Durdle, & Stewart, in press; Krank et al., 2011; Woicik, Stewart, Pihl, & Conrod, 2009). Youth are screened in classroom settings during school hours, and those scoring one standard deviation above the school mean on one of these four personality traits, as measured using the Substance Use Risk Profile Scale (Battista et al., in press; Krank et al., 2011; Woicik et al., 2009), are invited to participate in coping skills workshops. Each of the four personality-specific interventions involve adolescents selected for particular personality profiles to work together over two 90-minute group sessions guided by a trained facilitator and co-facilitator at school. The interventions are manualised and incorporate psycho-educational, motivational enhancement, and cognitive-behavioural components, and include real life ‘scenarios’ shared by high-risk youth in specifically-organised focus groups. A novel component to this intervention approach is that all exercises discuss thoughts, emotions, and behaviours in a personality-specific way.

29 Three separate randomised-controlled trials have shown that this intervention approach is associated with reduced drinking, binge drinking, and problem drinking symptoms in high-risk youth over six months (Conrod et al., 2010; Conrod et al., 2008; Conrod et al., 2006; O’Leary-Barrett et al., 2010), with one of these trials, the Preventure Trial, showing two-year reductions in problem drinking symptoms and illicit drug use in high-risk youth (Conrod et al., 2010; Conrod, Castellanos-Ryan, & Mackie, 2011). A recent cluster-randomised trial, known as the Adventure Trial, replicated the preventative effects of personality-targeted interventions on alcohol use when delivered by trained school-staff (Conrod et al., in press; O’Leary-Barrett et al., 2010), thus suggesting that this intervention approach can operate within an implementation model that has a higher likelihood of being adopted by schools in a sustainable manner. The results of this recent study are central to the development of an effective (as opposed to merely efficacious) intervention. This trial demonstrates that targeted interventions can be successfully delivered by educational staff who have been trained and supervised, and that targeted interventions have the potential to become a sustainable school-based prevention model.

30 Effect sizes for binge drinking from the Adventure trial were similar to those from previous clinician-run personality-targeted intervention trials, with odds ratios between 0.4 and 0.5 across all trials for youth who had already consumed alcohol by 13 years of age (i.e. a particularly high-risk group). These odds ratios correspond to a 50-60% decreased likelihood of binge drinking six months post-intervention. The corresponding odds ratios for a sample including youth who were non-drinkers at baseline were 0.65-0.7, representing a 30-35% decreased likelihood of reporting binge drinking six months later. ‘Numbers Needed to Treat’ across the three trials for baseline alcohol users ranged from four to six, indicating that four to six individuals are required to receive an intervention in order to prevent one case of binge drinking. These effect sizes are remarkable given that the most effective universal alcohol prevention programmes have ‘Numbers Needed to Treat’ values from nine to 30 (Faggiano et al., 2008), which requires targeting at least double the number of adolescents in order to prevent one case of binge drinking. A more recent two-year follow-up of this programme which involved two-part latent growth models to evaluate onset and progression to heavier drinking over time indicated long-term effects of the intervention on drinking rates, binge drinking rates, and growth in binge drinking and problem drinking in high-risk youth, such that high-risk youth showed 43% reduced odds of binge drinking and 29% reduced odds of reporting problem drinking over the course of the trial (42% reduced odds of problem drinking at the two-year follow-up; Conrod et al., in press). High-risk youth were also shown to benefit from the interventions over the 24-month follow-up on drinking quantity, and growth in binge drinking frequency. Furthermore, some herd effects in (untreated) low-risk youth were observed, specifically on drinking rates and growth of binge drinking. In this context, herd effects refer to risk reduction in untreated individuals secondary to reductions in drinking among treated individuals in the population. The idea is that because drinking has been reduced in the high-risk youth through the targeted intervention, this can result in reduced drinking/binge drinking even among untreated low-risk youth by reducing modelling of drinking, and peer pressure and opportunities to drink within students’ social networks. This study reported that the intervention was associated with a 29% reduced odds of drinking over the course of the trial in students attending intervention schools relative to students in control schools which compares favourably to some of the best results from universal comprehensive programmes. Importantly, however, the effect only required intervening upon 45% of the population. There is also an added benefit of this approach: by targeting underlying personality risk factors for alcohol/drug misuse that are also implicated in vulnerability to other mental disorders, this programme also produces benefits in mental health outcomes, such as depression, anxiety, and conduct disorder symptoms (e.g., Castellanos & Conrod, 2006).

31 Another selective programme worth mentioning is one developed in Quebec, Canada which targets high-risk boys with persistent aggressive tendencies in childhood (Tremblay, Pagani-Kurtz, Mâsse, Vitaro, & Pihl 1995; Tremblay & Schaal, 1996). This programme was evaluated within a longitudinal study of primary school children in which 172 boys attending kindergarten in low socio-economic neighbourhoods of Montreal underwent a randomised controlled trial for disruptive behaviour. The intervention was delivered for two years (when the boys were seven to nine years old). It consisted of two main components: a) social and problem-solving skills training for the boys in a group setting, and b) parent training on effective child-rearing skills. Adolescent substance-use, up to eight years post-intervention, was shown to be reduced in those who received the intervention, with effect sizes ranging from.46 to.67, suggesting large effects. More importantly, findings showed that the intervention effect on alcohol-use frequency at 14 years and on growth in number of different drugs used across adolescence (1417 years) were explained, respectively, by reductions in both antisocial behaviours and affiliation with less deviant peers, and by a reduction of impulsivity during pre-adolescence (11 to 13 years; Castellanos-Ryan, Vitaro, Parent, Tremblay, & Seguin, 2012).

32 In summary, the selective personality-based approach to alcohol prevention appears to be highly effective for youth with personality risk factors for early onset alcohol misuse and evidence exists for both the North American and European contexts. There is also preliminary evidence that this approach might also indirectly delay onset and growth of drinking in the general lower-risk population.

INDICATED PROGRAMMES

33 In contrast to selective prevention programmes carried out with groups at-risk for alcohol problems, indicated prevention programmes are those that are carried out with individuals who are already showing signs/symptoms of an alcohol use disorder. Since indicated interventions hold much in common with alcohol use disorder treatment, they are generally beyond the scope of this chapter on alcohol prevention. Nonetheless, there are some school-based indicated programmes that are worthy of mention here. In the next sections, we briefly review the evidence for the efficacy of brief interventions for college students, like the Brief Alcohol Screening and Intervention for College Students (BASICS; Dimeff, Baer, Kivlahan, & Marlatt, 1999), as well as expectancy challenge interventions. It should be noted here that while these interventions are often used as indicated interventions, many are used with volunteers (sometimes heavy drinkers) or universally. In fact, several randomised controlled studies of these approaches deliberately screen out problem drinkers when testing intervention efficacy. Thus, while these interventions are classified as indicated approaches within our review, they do not fit readily within the universal/selective/ indicated organizational framework.

Brief Interventions for College Students

34 Because the legal drinking age in the U.S. is 21, there are many underage drinkers on U.S. college campuses. As U.S. youths transition from high school to college, they often experience significant increases in their prevalence, frequency, and quantity of drinking (Bachman, Wadsworth, O’Malley, Johnston, & Schulenberg, 1997; White, Labouvie, & Papadaratsakis, 2005), especially if they leave their parents’ home (White, McMorris, Catalano, Fleming, Haggerty, & Abbott, 2006). Along with these increases comes a host of alcohol-related negative consequences, including fatal and nonfatal accidents, academic failure, violence and other crime, and unsafe sexual behaviour (Hingson, Zha, & Weitzman, 2009; Presley, Meilman, & Cashin, 1996; Wechsler, Lee, Kuo, & Lee, 2000; Wechsler, Lee, Nelson, & Lee, 2001). Therefore, college campuses have developed numerous prevention programmes to reduce the harms associated with heavy drinking by college students. These programmes target factors associated with student drinking, such as alcohol expectancies and perceived norms for other student drinking and acceptance of drinking (similar to the social norms approach discussed earlier), as well as attempt to increase protective behavioural strategies and motivations to change drinking behaviour (Cronce & Larimer, 2011). Because most of this report focuses on drinking earlier in adolescence, we only briefly discuss these prevention programmes here (for greater detail, see Cronce & Larimer, 2011). Note, however, that some of these programmes could be modified for use with younger adolescents.

35 Larimer and Cronce (2002, 2007), and Cronce and Larimer (2011), reviewed individual-based alcohol prevention programmes for college students. Overall, they found a lack of support for education and awareness programmes, which were solely didactic (instructive) or used values clarification approaches. On the other hand, they found consistent support for the efficacy of brief, personalised, individual motivational feedback interventions, alcohol expectancy challenge interventions (see next section), other types of skills training (e.g., self-monitoring), and stand-alone personal feedback interventions. In addition, there was some limited support for multi-component alcohol education interventions if they included elements of personal feedback (for greater details on these types of interventions, see Cronce & Larimer, 2011).

36 As stated above, one type of brief intervention that has been particularly effective with college students is brief personalised feedback interventions. Personalised feedback interventions provide written and graphical feedback on a student’s drinking pattern relative to other college students (i.e., normative feedback), peak blood alcohol concentration, alcohol-related problems, and personal risk factors (e.g., dependence symptoms, family history of alcoholism) (Cronce & Larimer, 2011; Dimeff et al., 1999). Some feedback sheets also include protective behavioural strategies and/or highlight consequences that are especially salient for students, such as the calories they gain from drinking and the amount of money they spend on alcohol.

37 Although personalized feedback interventions are sometimes used as stand-alone interventions, they are often provided within the context of a brief motivational intervention. Brief motivational interventions, which are usually delivered in one or two sessions, aim to increase the student’s motivation and readiness to change their drinking behaviour. The motivational interview context relies on motivational enhancement techniques to increase students’ readiness for change and to help guide them through the change process (Dimeff et al., 1999). They are also dependent on the student being pre-identified as having experienced a problem related to their alcohol use (e.g., identified in the emergency room, through mass screening, or through university security). Facilitators use a motivational interviewing style, which presents feedback in an empathetic, non-judgmental manner (Miller & Rollnick, 2002). Brief motivational interventions often also include presentation of general alcohol education (e.g., effects at various BACs, cognitive effects of alcohol) as well as a discussion of harm reduction strategies (e.g., how to pace drinks) (Cronce & Larimer, 2011).

38 Overall, evaluations of personalised feedback interventions for college students within the context of a brief motivational intervention and as stand-alone interventions (e.g., written feedback only or web-based feedback), have found them to be more efficacious than educational interventions or assessment-only control conditions (for reviews, see Carey, Scott-Sheldon, Carey, & DeMartini, 2007; Cronce & Larimer, 2011; Larimer & Cronce, 2002, 2007; Walters & Neighbors, 2005; White, 2006). Support for brief personalised feedback and motivational interventions have also been found for students attending Further Education Colleges in the United Kingdom when delivered by trial therapists or trained professionals in the college setting (Grey, McCambridge, & Strang, 2005; McCambridge & Strang, 2004). However, in one study in the U.K., the effects reported for brief interventions were short-lived (McCambridge & Strang, 2004), did not generalise to all drinking outcomes, and were more effective for those reporting greater alcohol use at baseline. Furthermore, according to a more recent trial, there is little evidence that this approach will be effective for universal prevention of alcohol misuse in college students. McCambridge, Hunt, Jenkins, and Strang (2011) recently reported the results of a cluster randomised trial investigating whether brief motivational interviewing could be effective for universal preventions, that is, for students who had not necessarily initiated use or begun to experience problems with alcohol or other substances. This trial which involved 416 students aged 16-19 years old recruited in 12 London Further Education Colleges, and compared the effect of a one-session individualised motivational intervention with a standard practice classroom-delivered Drug Awareness intervention. No group differences in prevalence, initiation, and cessation of alcohol consumption were reported at 3 and 12 months post intervention. On the other hand, findings have been inconsistent in the U.S. as to whether these interventions are better for heavier than lighter drinkers, and some have shown long-term benefits (Mun, White, & Morgan, 2009). More research is needed to: 1) identify the components of feedback that are necessary and sufficient and the best methods for delivery to enhance the preventative effects of brief motivational interventions; 2) evaluate potential mechanisms of intervention efficacy; 3) understand why the intervention is only effective for heavier drinkers; and 4) identify ways to prolong the long-term effects of these interventions (Cronce & Larimer, 2011; Walters & Neighbors, 2005; White, 2006). There is some limited research indicating that personalised feedback interventions may be efficacious with adolescents (e.g., D’Amico & Fromme, 2002). However, much more research is needed to test brief individualised interventions with underage drinkers.

Expectancy-Based Interventions

39 As discussed in Chapter 2, positive alcohol expectancies and motivations to drink are risk factors for drinking among adolescents. One important implication of the notion that alcohol-related cognitions are a central construct in the prediction of drinking in young people, is that they would be a prime target for prevention and early intervention (Goldman, 1999). Indeed, both explicit and implicit alcohol-related cognitions (see Chapter 2) have been targeted in interventions. Expectancies have been targeted using alcohol expectancy-challenge procedures (Darkes & Goldman, 1993; Darkes, Greenbaum, & Goldman, 1998). These procedures involve comparing the actual effects attributable to alcohol to those which an individual expects from drinking alcohol, to make drinkers more aware of the degree to which their drinking behaviours and responses to drinking are impacted by expectancies (Cronce & Larimer, 2011). Because alcohol expectancy challenge procedures often involve actual and perceived alcohol administration, they are rarely used with underage drinkers for legal and ethical reasons. Instead, they have been used mainly with young adults. The alcohol expectancy challenge procedure has been shown to lead to changes in explicit expectancies, but to have minimal impact on implicit cognitions (Wiers, van de Luitgaarden, van den Wildenberg, & Smulders, 2005). Two studies tested whether the change in explicit expectancies ‘mediated’ or helped explain a change in drinking behaviour, with one reporting a positive result (Wiers et al., 2005), and one a negative result (Wood, Capone, Laforge, Erickson, & Brand, 2007). In other targeted prevention programmes, expectancies are also discussed (e.g., BASICS; Dimeff et al., 1999). Motives to drink are a prime target in Motivational Interviewing. Motivational Interviewing has been shown to be a successful intervention in adults (Miller, 1998) and college students (Cronce & Larimer, 2011), but has yielded more mixed results with adolescents (Grenard, Ames, Pentz, & Sussman, 2006). Motivational Interviewing does not appear to affect implicit cognitions (Thush et al., 2009). It is worth noting that some alcohol expectancy challenge studies use videotapes of other people drinking and would, therefore, be amenable for use with underage drinkers (for greater detail, see Darkes et al., 1993, 1998).

40 Recently, researchers have begun to directly target implicit cognitive processes in addiction through cognitive retraining programmes. For example, an attentional bias for alcohol (i.e., the tendency to selectively attend to alcohol-related cues) has been successfully re-trained, with positive results on drinking outcomes in adult problem drinkers (Fadardi & Cox, 2009) and in alcoholic patients (Schoenmakers et al., 2010). Similarly, an approach bias for alcohol (i.e., the automatic tendency to approach alcohol) has been successfully re-trained in hazardous drinking university students (Wiers, Rinck, Kordts, Houben, & Strack, 2010). Positive alcohol associations (i.e., the automatic tendency to associate alcohol cues with positive outcomes) have also been successfully changed through evaluative conditioning procedures, with positive results on drinking in the short-term (Houben, Havermans, & Wiers, 2010). Finally, recent research also indicates that training executive control may be helpful in problem drinkers (Houben, Nederkoorn, Wiers, & Jansen, 2011). Although these results are promising, it should be noted that none of these studies have included adolescents as of yet and none have been shown to prevent either the onset of drinking or harmful drinking.

Effective principles for school-based alcohol prevention

41 Newton, Vogl, Teesson, and Andrews (2011) recently reviewed the principles that have consistently been associated with effective alcohol prevention programmes in schools (Ballard et al., 1994; Cuijpers, 2002; Dusenbury & Falco, 1995; Meyer & Cahill, 2004; Midford, Munro, McBride, Snow, & Ladzinski, 2002). Effective programmes were identified as being: evidence-based and theory driven, targeted to risk factors for substance use and psychopathology, developmentally appropriate, implemented prior to harmful patterns of use being established, part of a comprehensive health education curriculum, based on a skill-building approach (which must include providing resistance skills training, and normative education), immediately relevant to students, interactive, but keeping teacher as the central role, sensitive to the cultural characteristics of the target audience, able to provide adequate initial coverage and continued follow-up in booster sessions; and delivered within an overall framework of harm minimization, rather than being abstinence-based.

Obstacles to effective drug education in schools

42 There are many barriers or ‘obstacles’ which can impede the effectiveness of prevention programmes even when they are evidence-based (Botvin, 2004; Dusenbury & Hansen, 2004; Elliott & Mihalic, 2004; Kaftarian, Robinson, Compton, Davis, & Volkow, 2004). A number of issues, particularly those related to implementation and dissemination of programmes, have been identified as causing the greatest obstacles and interfering with programmes being able to have an impact on behavioural outcomes (Cahill, 2007; Castro, Barrera, & Martinez, 2004; Ennett et al., 2003; Greenberg, 2004; Pentz, 2004; Rohrbach & D’Onofrio, 1996).

43 The dissemination of alcohol prevention programmes into schools is not always entirely successful (Botvin et al., 2003; Cuijpers, 2003), but can be achieved with extensive training and close supervision (O’Leary-Barrett et al., 2010). Two large studies recently reported that less than 15% of schools in the U.S. implemented evidence-based programmes or reported following a programme guide or manual very closely (Ennett et al., 2003; Ringwalt et al., 2003), and one of these studies reported that one-fifth of teachers reported not using a curriculum/ programme guide at all when delivering drug and alcohol prevention. It is well established that programmes delivered with high fidelity lead to superior outcomes for students and programmes delivered with poor fidelity lead to poorer outcomes (e.g., Dane & Schneider, 1998).

44 Internet-based technology offers a practical means of improving implementation fidelity while delivering evidence-based programmes. Computer-based drug prevention programmes have been designed for both universal (Duncan, Duncan, Beauchamp, Wells, & Ary, 2000; Gregor et al., 2003; Gropper, 2002; Schinke, Schwinn, DiNoia, & Cole, 2004; Williams, Griffin, Macaulay, West, & Gronewold, 2005) and targeted populations (Bosworth, Gustafson, & Hawkins, 1994; Schinke, Schwinn, & Ozanian, 2005) and involve youth navigating through simulated real life scenarios (Gregor et al., 2003; Schinke et al., 2004). There is a small literature to suggest that such programmes are both feasible and acceptable (Bosworth et al., 1994; Duncan et al., 2000; Gregor et al., 2003; Schinke et al., 2004; Schinke et al., 2005; Williams et al., 2005).

45 While computerised alcohol prevention programmes are showing promise in terms of affecting behaviours proximal to alcohol use outcomes (e.g., increase alcohol-related knowledge and attitudes; decrease pro-drinking attitudes; Gropper, 2002; Marsch, Bickel, Badger, 2006; Newton, Teesson, Vogl, & Andrews, 2010; Newton, Andrews, Teesson, & Vogl, 2009; Newton, Vogl, Teesson, & Andrews, 2009; Schinke et al., 2004; Williams et al., 2005), the evidence for behavioural change is more limited as most studies have failed to collect behavioural measures (Duncan et al., 2000; Gregor et al., 2003; Gropper, 2002). Of course, this criticism applies to many alcohol prevention programmes delivered in a variety of formats and the lack of behavioural outcome data is not unique to web-based interventions. One Internet-based programme which has demonstrated positive effects in reducing actual alcohol and other drug use is the series of Climate Schools programmes for alcohol and drug prevention specifically designed to overcome factors which typically compromise programme efficacy. The modules are contemporary, cartoon-based, educational programmes based on a social influence approach to prevention, and consistent with the effective harm minimisation framework (McBride, Farringdon, Muleners, & Midford, 2006). Each Climate Schools module consists of six 40-minute lessons. The first half of each lesson is completed individually online where students follow a cartoon storyline of teenagers experiencing real life situations and problems with alcohol and cannabis. The cartoon storylines are used to engage and maintain student interest and involvement over time (Schinke et al., 2004). The second part of each lesson is a predetermined activity delivered by the teacher to reinforce the information learned in the cartoons.

46 The efficacy of the Climate Schools model has been demonstrated for stress reduction (Van Vliet & Andrews, 2009) and alcohol misuse (Newton, Andrews et al., 2009; Vogl et al., 2009). In one study (Newton, Vogl et al., 2009), the Alcohol module of Climate Schools was more effective than usual classes in decreasing average alcohol consumption, frequency of binge drinking (drinking in excess), and alcohol-related harms. A feasibility trial of the Climate Schools programme in the United Kingdom is ongoing and will provide data on the acceptability of this universal programme in the European setting (Newton & Conrod, in preparation).

47 These findings suggest that the Internet offers a promising delivery method for preventing alcohol and other drug use in adolescents. While there is a strong push to adapt programmes for this delivery method, we also caution that this work should be done with careful evaluation of effects on behaviour, considering the results of studies in which small modifications to the implementation of evidence-based prevention programmes led to iatrogenic effects on behaviour.

Family-based prevention programmes

48 Universal prevention programmes have also been delivered in the family setting. These approaches typically aim at supporting the development of parenting skills including parental support, nurturing behaviours, clear communication, establishing and enforcing clear boundaries or rules, and parental monitoring. In addition, universal family-based prevention can include components focused on the adolescent such as the development of social skills, peer resistance skills, and appropriate behavioural norms. However, unlike school-based programmes, the latter skills and norms are instilled indirectly, via parents and family, rather than directly to the adolescents themselves. The underlying assumption of family-based prevention is that if young people have a positive family environment, and develop good peer resistance and social skills, they are more likely to develop and adopt the behavioural norms displayed within their families and to be resilient against external influences such as peer pressure (Foxcroft & Tsertsvadze, 2011b).

49 At least two systematic reviews have assessed the efficacy of various family-based programmes (Foxcroft & Tsertsvadze, 2011b; Petrie, Bunn, & Byrne, 2007). Petrie et al. (2007) conducted a systematic review of controlled studies of parenting programmes to prevent substance abuse in children and adolescents under the age of 18 years. Data were collected on actual or intended use of alcohol and other substances (tobacco and/or other drugs), and associated risk or antecedent behaviours. Twenty studies met their inclusion criteria. Of these, five focused exclusively on alcohol (Loveland-Cherry, Ross, & Kaufman, 1999; Park et al., 2000; Perry et al., 2002; Werch, Owen et al., 2003; Williams, Grechanaia, Romanova, Komro, Perry, & Farbakhsh, 2001), and nine on alcohol and tobacco and/or other drugs (Bauman, Foshee, Emmett, Hicks, & Penberton, 2001; Forman & Brondino, 1990; Hawkins, Catalano, Kosterman, Abbott, & Hill, 1999; Johnson et al., 1990; Lochman & Wells, 2003; Pentz et al., 1989; Spoth et al., 2001; Perry et al., 2003; Spoth et al., 2002). Of these 14 studies focusing on alcohol outcomes, 13 were conducted in the U.S. and the remaining study was conducted in Russia (Williams et al., 2001). None were conducted in Europe. Unqualified statistically significant reductions of alcohol use were found in six of these 14 studies (Lochman & Wells, 2003; Park et al., 2000; Pentz et al., 1989; Perry et al., 2002; Spoth et al., 2001; Spoth et al., 2002). Three others showed significant reductions in alcohol use, but only for certain subgroups (i.e., for boys only, Perry et al., 2003; only in a school where kids were bussed in, Werch, Owen et al., 2003; only for those students with no alcohol use prior to the intervention, Loveland-Cherry et al., 1999). One of the 14 studies showed a statistically significant increase in alcohol use, but only for those young people who had already started drinking by the time of the intervention (Loveland-Cherry et al., 1999). Thus, parent-based prevention programmes can be effective in reducing or preventing alcohol use. This review concluded that the most effective approaches are those that emphasise active parental involvement as well as developing skills in social competence, self-regulation, and parenting (Petrie et al., 2007). However, the authors also noted significant heterogeneity in the methodology of the studies, and stressed that more work is needed to investigate further the long-term effectiveness of parenting programmes.

50 Of the trials included in the Petrie et al. (2007) review, the only non-North American study was conducted in Russia, with materials based on the American ‘Project Northland’ programme (Perry et al., 1996). Although the programme increased parent-child communication and led to increases in students’ knowledge about the negative consequences of underage drinking, there were no changes in adolescents’ actual alcohol use rates by the end of the first year of the three-year programme (Williams et al., 2001). This is in spite of efforts to make the intervention culturally appropriate for the Russian context such as starting a year earlier due to Russian young people’s earlier onset of drinking relative to North American youth (Williams et al., 2001). At first glance, this may appear to suggest that other important cultural differences were neglected in the attempted transfer of this parent-based prevention programme, developed in Minnesota, to a non-North American context. However, the original American ‘Project Northland’ did not achieve changes in students’ alcohol use until the third year of the intervention by which time a multi-component intervention had been implemented in addition to the parent-based programme (Perry et al., 1996). We cover multi-component interventions in a later section.

51 Recently, Foxcroft and Tsertsvadze (2011b) conducted a Cochrane systematic review of evidence on the effectiveness of universal family-based prevention programmes in preventing alcohol misuse in school-aged children and adolescents. Twelve randomised controlled trials evaluating universal family-based prevention programmes and reporting outcomes for alcohol use in students 18 years of age or younger met their criteria and were included in the analysis (Bauman et al., 2002; Brody et al., 2006; Haggerty, Skinner, MacKenzie, & Catalano, 2007; Koning et al., 2009; Loveland-Cherry et al., 1999; O’Donnell, Myint, Duran, & Stueve, 2010; Schinke, Cole & Fang, 2009a; Schinke, Fang, & Cole, 2009b; Schinke, Fang, & Cole, 2009c; Spoth, Lopez Reyes, Redmond, & Shin, 1999; Stevens et al., 2002; Werch et al., 2008). As this review was conducted more recently, only one of the 14 trials covered by Foxcroft and Tsertsvadze (2011b) (i.e., Loveland-Cherry et al., 1999) overlapped with the studies reviewed by Petrie et al. (2007). This review also built upon the review by Petrie et al. (2007) by examining persistence of effects over the longer term in addition to immediate post-treatment outcomes. The authors found that the reporting quality of trials was poor, and that inadequate reporting of the method of randomization and programme allocation concealment was common. Incomplete data was adequately addressed in about half of the trials and this information was unclear for close to one-third of the trials. Due to extensive heterogeneity across interventions, populations, and outcomes, the results were summarised only qualitatively. Eight of the twelve trials showed statistically significant evidence of effectiveness compared to a control or other intervention group, with persistence of effects over the medium and longer-term (i.e., Brody et al., 2006; Loveland-Cherry et al., 1999; O’Donnell et al., 2010; Schinke et al., 2009a; Schinke et al., 2009b; Schinke et al., 2009c; Spoth et al., 1999; Werch et al., 2008). Four of the effective interventions were gender-specific, focusing on young females and (primarily) their mothers (O’Donnell et al., 2010; Schinke et al., 2009a; Schinke et al., 2009b; Schinke et al., 2009c). One study, with a small sample size, showed positive effects that were only marginally significant at p =.10 (Bauman et al., 2002), and three studies with larger sample sizes reported no significant benefits of the family-based intervention for reducing alcohol misuse (Haggerty et al., 2007; Koning et al., 2009; Stevens et al., 2002). In fact, the Stevens et al. (2002) study suggested the intervention resulted in a larger proportion of ‘ever drinkers’ at the three year follow up relative to a control intervention focusing on other safety behaviours (e.g., helmet, seatbelt use). Taken together, these findings led the authors to conclude that the effects of family-based prevention interventions are small but generally consistent, and also persistent into the medium- to longer-term (Foxcroft & Tsertsvadze, 2011b). The authors also noted that although the effects may be small in magnitude, even small effects can be important from a public health perspective (Foxcroft & Tsertsvadze, 2011b).

52 All of the studies included in the Foxcroft and Tsertsvadze (2011b) review, save one, were conducted in the United States. The exception was a single European trial, conducted in the Netherlands, which focused on parental rule-setting around their offspring’s alcohol use (Koning et al., 2009). This parent intervention was modeled after the Swedish ‘Orebro Prevention Programme’ which had been tested previously in a quasi-experimental study and which had been shown to be effective in reducing underage drunkenness in Sweden (Koutakis, Stattin, & Kerr, 2008). Koning et al.’s (2009) objectives were to test this intervention more rigorously (in a randomised controlled design), and to examine the generalizability of the effects of this parental intervention in a context where adolescent drinking is much more prevalent than in Sweden (see Chapter 1). In the Dutch study, the parental intervention was compared to a school-based, youth-focused intervention, each provided alone or in combination in a two by two factorial design. Unlike the Swedish findings (Koutakis et al., 2008), the parental intervention alone had no significant effects on any of the alcohol outcomes (heavy weekly drinking, weekly drinking, drinking frequency) at either 10 or 22 months post-intervention. The results suggest that parental rule setting alone may be less effective in deferring the onset of adolescent drinking in countries with more liberal alcohol policies and lower legal drinking ages (e.g., the legal drinking age in the Netherlands is 16 years and there is weaker enforcement of laws that prohibit selling of alcohol to minors). It would be interesting to see if parental interventions are any less effective in Canada than in the U.S. given the differences between these two North American countries in legal drinking age. Despite the absence of any evidence of efficacy of the parental intervention alone in the Koning et al. (2009) study, there were clear and persisting effects of the combined parent- and child-focused intervention on a variety of alcohol outcomes. The findings of this study are discussed in the next section, and suggest that both parents and children should be targeted simultaneously in multi-component interventions to achieve best results, at least in the Dutch context.

53 Before concluding this section, it is worth reiterating that two of the trials reviewed by Petrie et al. (2007) and Foxcroft and Tsertsvadze (2011b) showed evidence of increases in alcohol use in the experimental group receiving the family-based intervention (i.e., Loveland-Cherry et al., 1999; Stevens et al., 2002). These findings warn of the potential for iatrogenic effects of these interventions in certain cases. But as Foxcroft and Tsertsvadze (2011b) caution, the possibilities that these effects may have arisen by chance, or that they are secondary to differential attrition across groups or to confounding factors, need to be ruled out before we can conclude any iatrogenic effects of particular family-based interventions.

MULTI-COMPONENT PREVENTION PROGRAMMES

54 Multi-component prevention approaches are programmes where the intervention is delivered in multiple different settings. For example, the intervention might occur in both family and school settings, potentially combining a parental intervention with school-based prevention curricula, as described in earlier sections. Thus, in school settings, a multi-component prevention typically takes the form of alcohol awareness education, social and peer resistance skills training, normative feedback, and/or development of behavioural norms, and positive peer affiliations. The family-based component often aims to support the development of parenting skills and parental monitoring, and/or helping parents to establish clear rules around alcohol use (Foxcroft & Tsertsvadze, 2011c). The parent- and child-focused components are most commonly delivered simultaneously.

55 A Cochrane systematic review was recently conducted on universal multi-component programmes in preventing alcohol misuse in school-aged children and adolescents (Foxcroft & Tsertsvadze, 2011c). The authors identified 20 parallel-group randomised controlled trials evaluating prevention programmes where the intervention was delivered in more than one setting and reported outcomes for alcohol use in students up to age 18 years (i.e., Brown, Catalano, Fleming, Haggerty, & Abbott, 2005; Eddy, Reid, & Fetrow, 2000; Furr-Holden et al., 2004; Hawkins et al., 2009; Komro et al., 2006; Koning et al., 2009; Perry et al., 1996; Perry et al., 2003; Reddy et al., 2002; Schinke et al., 2004; Shortt, Hutchinson, Chapman, & Toumbourou, 2007; Simons-Morton, Haynie, Saylor, Crump, & Chen, 2005; Slater et al., 2006; Spoth, Redmond, Trudeau, & Shin, 2002; Spoth et al., 2007; Werch, Pappas et al., 2000; Werch, Moore et al., 2003; Werch, Moore, DiClemente, Bledsoe, & Jobli, 2005a; Werch et al., 2005b; Wu et al., 2003). Of these 20 trials, two were previously reviewed by Petrie et al. (2007) (i.e., Perry et al., 2003; Spoth et al., 2002) and one was previously reviewed by Foxcroft and Tsertsvadze (2011b) (i.e., Koning et al., 2009). As in the previous systematic reviews, the methodological quality of the trials and reporting of study details was noted to be poor, and extensive heterogeneity across interventions, populations, and outcomes was once again found. In 13 of the 20 trials reviewed by Foxcroft and Tsertsvadze (2011c), some evidence of effectiveness was found for the multi-component intervention compared to a control or other intervention group (Brown et al., 2005; Eddy et al., 2000; Hawkins et al., 2009; Koning et al., 2009; Perry et al., 1996; Reddy et al., 2002; Schinke et al., 2004; Slater et al., 2006; Spoth et al., 2002; Werch, Pappas et al., 2000; Werch et al., 2005a; Werch et al., 2005b; Wu et al., 2003). The comparison groups included a no intervention control, educational booklets, face to face interviews, and parent post cards. Four of the 12 effective interventions only assessed immediate post-treatment outcomes (i.e., Brown et al., 2005; Hawkins et al., 2009; Perry et al., 1996; Reddy et al., 2002) while the others assessed and demonstrated durability of effects ranging from three months (Werch et al., 2005b) to three years (Eddy et al., 2000; Schinke et al., 2004) post-treatment.

56 Assessment of the additional benefit of multiple versus single component interventions was possible in seven of the 20 trials reviewed by Foxcroft and Tsertsvadze (2011c). Only one of them clearly showed a benefit of having multiple components. Interestingly, this was the Dutch trial (Koning et al., 2009) discussed earlier in the review of family-based preventions. This trial found the combined, multi-component, student-parent intervention to show substantial and statistically significant effects on heavy weekly drinking, weekly drinking, and frequency of drinking at post-treatment and sustained effects on weekly drinking and frequency of drinking at 22 month follow up. The systematic review by Foxcroft and Tsertsvadze (2011c) thus concluded that there is some evidence that multi-component interventions for alcohol misuse prevention in young people can be effective. They also concluded, however, that there is little evidence that interventions with multiple components are more effective than those with a single component (Foxcroft & Tsertsvadze 2011c).

57 Of the 20 studies reviewed by Foxcroft and Tsertsvadze (2011c), 17 were conducted in the U.S., one in the Netherlands (Koning et al., 2009), one in Australia (Shortt et al., 2007), and one in India (Reddy et al., 2002). Of those conducted outside of the U.S., two showed evidence of efficacy of the multi-component intervention (Koning et al., 2009; Reddy et al., 2002). The Dutch trial has been discussed previously. The Indian trial, conducted in New Delhi, was a school- plus family-based intervention focused on improving children’s cardiovascular health through better nutrition, better diet, and decreased smoking; alcohol use was not a focus of the intervention. The multi-component intervention was compared to the school-based intervention alone and to a no treatment control. The school-based programme was multifaceted and included training in refusing offers to smoke. The family-based intervention consisted of a series of six booklets containing information and family activities focused on improving children’s cardiovascular health. The family booklets were culturally adapted from those used in similar previous work in the U.S. (Luepker et al., 1996; Perry, Luepker, Murray, & Hearn, 1989). Even though the intervention did not focus on alcohol, significant effects of the two interventions were found relative to the control group in terms of reductions in proportion of children reporting ever using alcohol and those intending to drink as adults. The authors speculated that these effects on alcohol outcomes may have been due to the fact that since alcohol and tobacco use are very often co-occurring behaviours, an intervention which is effective in reducing tobacco use may also delay alcohol use (Reddy et al., 2002). There were no differences between the school-based only intervention and the multi-component intervention indicating that there was no additional benefit on alcohol use of sharing the booklets with the families. This may have been due to an insufficient dose of the family-based component, the unsupervised nature of the booklet activities, and/or the lack of interactive intervention with the parents.

58 The Australian trial (Shortt et al., 2007), conducted in Melbourne, examined the outcome of the Resilient Families intervention which involved both school-based and parent-based components. For the school based component, the student curriculum included communication skills, relationship problem solving, emotional awareness training, peer resistance skills building, and conflict resolution skills among the adolescents. The parents were offered both brief and extended training in enhancing parenting skills and encouraging a more positive relationship between parents and their adolescents (Shortt et al., 2007). Although the Resilient Families programme did increase within-family connectedness and problem solving skills as intended, and although it was associated with improvements in both the educational and family environments, intervention effects were not statistically significant predictors of student alcohol use after controlling for other important influences (e.g., peer influences). There are several potential explanations for the lack of significant effects of this multi-component intervention on student alcohol use outcomes. First, the intervention may need to be implemented earlier given the high prevalence of alcohol use in the sample. Second, it is possible that effects still may be observed as this analysis was only for the first year of the intervention. Third, it is certainly possible that the failure to observe effects was due to the lack of interventions focusing specifically on alcohol (e.g., no training for parents in monitoring children’s alcohol use, nor in setting rules about their children’s alcohol use; no specific training for students in drink refusal skills). Finally, not all parents attended the parent sessions. Those who did were already higher in family connectedness, potentially reducing the usefulness of these sessions for these particular families. Future work might examine cross-cultural similarities and differences in the efficacy of multi-component interventions involving both school-and family-based components in preventing, or decreasing (heavy) alcohol use in adolescents.

59 Besides parents and the family, multi-component approaches can also involve a broader community initiative, such as consultation with the police, health professionals, city officials, or local residents, to formulate and support the intervention. Wood, Shakeshaft, Gilmour, and Sanson-Fisher (2006) conducted a systematic review of school-based prevention trials that also involved the community. The authors reviewed 16 studies (Abbey, Pilgrim, Hendrickson, & Buresh, 2000; Aseltine, Dupre, & Lamlein, 2000; Cuijpers et al., 2002; D’Amico & Fromme, 2002; Dedobbeleer & Desjardins, 2001; Dixon & McLearen, 2002; Ellickson et al., 2003; Peleg, Neumann, Friger, Peleg, & Sperber, 2001; Perry et al., 2002; Perry et al., 2003; Schinke et al., 2000; Spoth et al., 2001; Spoth et al., 2002; Werch, Carlson, Pappas, Edgemont, & DiClemente, 2000; Werch, Owen et al., 2003; Williams et al., 2001), 15 of which examined alcohol use outcomes (i.e., all but Abbey et al., 2000). Several of these studies were included in previously discussed systematic reviews (Perry et al., 2002; Perry et al., 2003; Spoth et al., 2001; Spoth et al., 2002; Werch, Owen et al., 2003; Williams et al., 2001). The authors’ goal was to describe and critique the methodologies of multi-component intervention studies that were school-based, but also incorporated a broader community intervention component. Like previous reviews, the authors identified that reviewed studies were often methodologically lacking (Wood et al., 2006). These authors did not conduct a full meta-analysis because of the poor methodological quality of the studies and the heterogeneity in alcohol outcome measures employed. But they did include a brief analysis of effect sizes for the 15 studies that examined alcohol use (i.e., lifetime use, past year use, use in past week or month, initiation into drinking, or binge drinking) as an outcome. In general, limited effectiveness was found, with initial effect sizes that were relatively small in magnitude. However, Wood et al. (2006) noted that most studies used relatively few community components (e.g., only three studies used more than six community components). Thus, they suggested that there is a need for additional studies that attempt to enhance the efficacy of school-based programmes by including broader community components such as media, community services, and alcohol retailer involvement (Wood et al., 2006). In fact, from a more theoretical viewpoint, it has been argued that effective long-term prevention programmes for the reduction of youth drinking require strategies for the wider community and societal change (Wagenaar & Perry, 1994).

60 Of the 15 studies reviewed by Wood et al. (2006), 11 were conducted in the U.S., one was conducted in the Netherlands (Cuijpers et al., 2002), one in Canada (Dedobbeleer & Desjardins, 2001), one in Israel (Peleg et al., 2001), and one in Russia (Williams et al., 2001). The Russian trial was discussed previously. The Israeli study involved randomising grade ten youth to an active intervention or no intervention control. The multi-component intervention involved collaboration between the schools and the community and was put on by school staff and the psychological counseling service in Israel. The intervention took place over three days and included guest lectures by experts as well as adolescent workshops, on topics such as peer pressure, effects of advertising on behaviour, and taking responsibility for one’s actions. Students viewed relevant films and took part in role plays. Efficacy of the intervention was examined at one and two year follow-up. While there was growth in alcohol use in the control group, there was no significant change from baseline in the intervention group over the follow-up, suggesting that the intervention reduced growth in alcohol use over time. The results thus support the efficacy of a multi-component school- plus community-focused intervention in the Israeli context (Peleg et al., 2001).

61 The Dutch study was a quasi-experimental study of the Healthy School and Drugs project (Cuijpers et al., 2002). This programme is run by a coordinating committee (including school and community representatives) and involves parents. The student-focused component involves three lessons about alcohol (information, development of a healthy attitude towards alcohol use, and drink refusal skills). Schools develop clear policies on alcohol use at school and school events, plans for early detection of students with alcohol problems, and provision of support and counseling for identified students. Significant effects of the intervention on alcohol use were found which persisted at two years following the intervention (Cuijpers et al., 2002).

62 The Canadian trial, however, provided less promising results regarding the efficacy of multi-component interventions involving both the school and community in changing adolescent alcohol use. Dedobbeleer and Desjardins (2001) studied the efficacy of the multi-component ‘Coalition for Youth Quality of Life Project’ which was designed to prevent alcohol use and misuse among multi-ethnic youth in Montreal. The intervention was delivered through four channels: schools, community organizations, local government, and families. They targeted sixth and eighth graders who were followed up at 18 and 30 months. Although the programme led to significant effects on several hypothesised mediators (e.g., higher self-esteem and superior peer-resistance skills in the younger students; more leisure alternatives to alcohol and other substance abuse in the older students), the programme had no significant effects on alcohol use. Several possible explanations were considered by the authors including differential attrition across treatment arms, insufficient power, insufficient dose of intervention, and lack of booster sessions (Dedobbeleer & Desjardins, 2001). Since this particular programme has only been assessed in Canada, it is difficult to know to what degree cultural factors might play a role in the failure of this multi-component intervention to exert effects on adolescent drinking behaviour. However, considering the lack of strong cultural effects on other school-based programmes, it is not likely that the cultural context can entirely explain these null findings.

63 There are several contexts in which youth alcohol prevention can be delivered. The school context appears to capture a larger percentage of the target population and yields the most consistent effects relative to other contexts, such as the family context or the community. The school-based programmes that are most effective are comprehensive programmes which concurrently address normative attitudes about drinking and teach generic and alcohol refusal skills. Universal programmes delivered in high schools to students before the normal age of onset of drinking show consistent effects on drinking behaviour, mostly binge drinking, and have been shown to have effects in the North American, European, and Australian contexts. However the effects are small, accounting for only 10% of the variance in drinking behaviour, and there are signs that these programmes might be more effective if delivered to populations at greater risk for early drinking and problem drinking. There is new research from Australia suggesting that the effectiveness of universal, comprehensive programmes might be enhanced with the addition of web-based resources. However, web-based programmes have not been tested in Europe and the U.S. high school context, with a number of pilot studies and ongoing trials suggesting that this modification is feasible and might lead to improved fidelity when implementing evidence-based universal intervention programmes.

64 Effective selective prevention strategies include those that target youth with known individual risk factors for alcohol misuse, including personality risk factors or behavioural problems prior to the onset of alcohol use. These programmes show stronger and long-term effects on drinking onset, binge drinking onset, and problem drinking symptoms in high-risk populations. Two studies show that they might also benefit peers in the broader social network of high-risk youth. Therefore, while these evidence-based selective programmes only target a portion of the adolescent population, they might also have universal effects. The selective approach has been shown to be equally effective in the North American and European contexts and shows some advantages relative to other approaches in that it is also effective in reducing and preventing mental health problems that tend to co-occur with alcohol misuse. Large trials of personality-targeted interventions for high school students are currently being conducted in Canada, the Netherlands, and Australia to address some outstanding questions, such as how does this approach compare to, and combine with, evidence-based universal programmes?

65 While not all indicated prevention programmes were reviewed in this chapter, brief interventions with college students who show early signs of heavy drinking or problem drinking do show promise. Specifically, interventions that include personalised feedback and normative feedback, as well as some brief motivational principles do show some effects on drinking behaviour among college students, and there is some limited research indicating that this approach could be effective with adolescents. There is also some experimental research on expectancy challenges and cognitive control training, but the evidence is limited so far, with more rigorous research needed to support this approach over and above other evidence-based approaches.

66 The family is another context in which prevention programmes are delivered. These are delivered to parents alone or in combination with a child-focused intervention (multi-component). While the family-based approach is less practical and economical to deliver than the school-based approach, one advantage is that it has the potential to address underlying family factors implicated in a number of alcohol and behavioural problems. The evidence in favour of the approach is consistent and suggests small effects that are persistent over the medium to long term. However, the evidence is only positive for the U.S. context and no study has yet shown this approach to be effective outside the U.S. as a single component programme. Finally, comparative studies in the U.S. and Europe suggest that parent training does not offer any incremental effects over an effective school-based comprehensive programme.

67 Several conclusions can also be drawn about the use of multi-component programmes (school plus family; school plus community). First, multi-component interventions can be effective for alcohol misuse prevention in young people. However, generally speaking, interventions with multiple components are no more effective than those with a single component, raising questions as to cost-effectiveness of multi-component programmes. Nonetheless, multi-component programmes may be particularly useful in some cultural contexts. For example, there is some limited evidence that both parents and children should be targeted simultaneously in countries like the Netherlands with more liberal alcohol policies and lower legal drinking ages.

CONCLUSIONS

68 While some comparative research has been conducted to investigate the relative and incremental effects of these approaches, much more research is needed in this regard. It will be important to investigate how universal comprehensive programmes compare and combine with selective prevention approaches to improve outcomes in low- and high-risk adolescents. The Australian Climate Schools and Preventure (CAP) Study (Newton, Teesson, Barrett, Slade, & Conrod, 2012; https://www.capstudy.org.au) is one trial that begins to address these questions. Furthermore, research on the mediators and moderators of these evidence-based programmes will help us better understand how they are having their effects on youth drinking behaviour, which might also lead to more refined and more effective interventions. Another question worthy of further investigation is how web-based materials and resources enhance evidence-based universal and selective approaches. However, as with all preventative interventions, this should be done with careful evaluation, given the potential for negative effects of poorly implemented programmes. Finally, while some experimental research is showing that cognitive and behavioural control training might improve outcomes for alcoholics and problem drinkers, there is a need to investigate how interventions that target some of the implicit and automatic aspects of addiction vulnerability can further improve outcomes for the general adolescent population and those at-risk.

69 To improve implementation of evidence-based alcohol prevention programmes, many jurisdictions have developed and disseminated prevention standards. For example, the Canadian Centre on Substance Abuse (CCSA) has developed a portfolio of Canadian Standards for Youth Substance Abuse Prevention . These consist of three separate documents outlining school-based standards (CCSA, 2010a), family skills-based standards (CCSA, 2010b), and community-based standards (CCSA, 2010c), respectively. Each was developed following a review of the evidence by a panel of experts. A useful future direction would be to create a set of standards that apply to youth alcohol prevention in the international context. Such international standards could include guidelines for adapting alcohol prevention programmes that have been demonstrated effective in one context, for use in new cultural contexts.

RECOMMENDATIONS

70 With the direct and indirect costs of alcohol misuse being somewhere in the range of U.S. $500-$1500 per capita (Rehm, Patra, Gnam, Sarnocinska-Hart, & Popova, 2011), there is clearly an argument for government investment in the evidence-based programmes highlighted in this chapter. Studies involving health economic analyses of alcohol and drug prevention programmes have estimated that for every dollar invested in prevention, five to ten dollars are directly returned (e.g., Spoth, Greenberg, & Turrisi, 2008). Therefore, even programmes that yield small effects can be justified economically and will lead to real public health benefits. Nevertheless, prevention programmes often comprise less than 1% of government alcohol-related costs (Rehm et al., 2006). In addition to more research on the incremental effects of evidence-based interventions, health-economic data on these programmes are needed to help guide policy makers around improving children’s access to these effective intervention programmes. As shown in this chapter, we now have many North American and European programmes that have been demonstrated to be effective in alcohol prevention among youth which now can be disseminated. Further research on these approaches needs to go hand-in-hand with a massive implementation strategy in order for youth to maximally benefit from these programmes.

Bibliographie

Abbey, A., Pilgrim, C., Hendrickson, P., & Buresh, S. (2000). Evaluation of a family-based substance abuse prevention programme targeted for the middle school years. Journal of Drug Education, 30 , 213-228. doi:10.2190/GT8C-ELWH-HY94-ECG9

Allison, K. R., Silverman, G., & Dignam, C. (1990). Effects on students of teacher training in use of a drug education curriculum. Journal of Drug Education , 20 , 31-46. doi:10.2190/HDRV-3RYR-56FY-YM1X

Andrews, G. G., Henderson, S. S., & Hall, W. W. (2001). Prevalence, comorbidity, disability and service utilisation: Overview of the Australian National Mental Health Survey’: Erratum. British Journal of Psychiatry , 179 , 561. doi:10.1192/bjp.179.6.561-b

Aseltine, R. H., Dupre, M., & Lamlein, P. (2000). Mentoring as a drug prevention strategy: An evaluation of Across Ages. Adolescent and Family Health, 1 (1), 11-20.

Bachman, J. G., Wadsworth, K. N., O’Malley, P. M., & Johnston, L. D. (1997). Smoking, drinking, and drug use in young adulthood: The impacts of new freedoms and new responsibilities . Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.

Ballard, R., Gillespie, A., & Irwin, R. (1994). Principles for drug education in schools . Canberra: University of Canberra, Australia.

Bandura, A. (1977). Social learning theory . Oxford England: Prentice-Hall.

Battista, S. R., Pencer, A., McGonnell, M., Durdle, H., & Stewart S. H. (in press). Relations of personality to substance use problems and mental health disorder symptoms in adolescents. International Journal of Mental Health and Addiction .

Bauman, K. E., Ennett, S. T., Foshee, V. A., Pemberton, M., King, T. S., & Koch, G. G. (2002). Influence of a family programme on adolescent smoking and drinking prevalence. Prevention Science , 3 , 35-42. doi:10.1023/A:1014619325968

Bauman, K. E., Foshee, V. A., Ennett, S. T., Hicks, K., & Pemberton, M. (2001). Family matters: A family directed programme designed to prevent adolescent tobacco and alcohol use. Health Promotion Practice, 2 , 81-96. doi: 10.1177/152483990100200112

Beaulieu, M. A., & Jason, L. A. (1988). A drug abuse prevention programme aimed at teaching seventh grade students problem-solving strategies. Children and Youth Services Review , 10 , 131-149. doi:10.1016/0190-7409(88)90033-3

Berkowitz, M. W. & Begun A. L. (2003). Designing prevention programmes: The developmental perspective. In S. Zili & W. J. Bukoski (Eds.), Handbook of drug abuse prevention: Theory, science and practice (pp 327-348). New York, NY: Kluwer Academic/ Plenum Publishers.

Birkeland, S., Murphy-Graham, E., & Weiss, C. (2005). Good reasons for ignoring good evaluation: The case of the Drug Abuse Resistance Education (D.A.R.E.) programme. Evaluation and Programme Planning , 28 , 247-256. doi:10.1016/j.evalprogplan.2005.04.001

Bond, L., Patton, G., Glover, S., Carlin, J. B., Butler, H., Thomas, L., et al. (2004). The Gatehouse Project: Can a multilevel school intervention affect emotional wellbeing and health risk behaviours?. Journal of Epidemiology and Community Health , 58 , 997-1003. doi:10.1136/jech.2003.009449

Bosworth, K., Gustafson, D. H., & Hawkins, R. P. (1994). The BARN system: Use and impact of adolescent health promotion via computer. Computers in Human Behaviour , 10 , 467-482. doi:10.1016/0747-5632(94)90041-8

Botvin, G. J. (1998). Preventing adolescent drug abuse through life skills training: Theory, methods, and effectiveness. In J. Crane (Ed.), Social programmes that work (pp. 225-257). New York, NY: Russell Sage Foundation.

Botvin, G. J. (1999). Prevention in schools. In R. T. Ammerman, P. J. Ott, & R. E. Tarter (Eds.), Prevention and societal impact of drug and alcohol abuse (pp. 281-305). Mahwah, NJ: Lawrence Erlbaum Associates, Inc.

Botvin, G. J. (2000). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors , 25 , 887-897. doi:10.1016/S0306-4603(00)00119-2

Botvin, G. J. (2004). Advancing prevention science and practice: Challenges, critical issues, and future directions. Prevention Science , 5 , 69-72. doi:10.1023/B:PREV.0000013984.83251.8b

Botvin, G. J., Baker, E., Dusenbury, L., Botvin, E. M., & Diaz, T. (1995). Long-term follow-up results of a randomised drug abuse prevention trial in a white middle-class population. The Journal of American Medicine, 273 , 1106-1112. doi:10.1001/jama.1995.03520380042033

Botvin, G. J., Baker, E., Dusenbury, L., Tortu, S., & Botvin, E. M. (1990). 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. doi:10.1037/0022-006X.58.4.437

Botvin, G. J., Baker, E., Renick, N. L., Filazzola, A. D., & Botvin, E. M. (1984). A cognitive-behavioral approach to substance abuse prevention. Addictive Behaviors, 9 , 137-147. doi: 10.1016/0306-4603(84)90051-0

Botvin, G., J., & Griffin, K. (2003). Drug abuse prevention curricula in schools. In Z. Sloboda & W. J. Bukoski (Eds.), Handbook of drug abuse prevention (pp. 45-74). New York, NY: Kluwer Academic/ Plenum Publishers.

Botvin, G. J., & Griffin, K. W. (2007). School-based programmes to prevent alcohol, tobacco, and other drug use. International Review of Psychiatry , 19 , 607-615. doi:10.1080 /09540260701797753

Botvin, G. J., Griffin, K. W., Diaz, T., & Ifill-Williams, M. (2001). Preventing binge drinking during early adolescence: One- and two- year follow-up of a school-based preventive intervention. Psychology of Addictive Behaviors , 15 , 360-365. doi:10.1037/0893-164X.15.4.360

Botvin, G. J., Griffin, K. W., Diaz, T., Schwier, L. M., Williams, C. & Epstein, J. A. (2000). Preventing illicit drug use in adolescents: Long-term follow-up data from a randomised control trial of a school population. Addictive Behaviors, 25 , 769-774. doi: 10.1016/S0306-4603(99)00050-7

Botvin, G. J., Griffin, K. W., Paul, E., & Macaulay, A. P. (2003). Preventing tobacco and alcohol use among elementary school students through life skills training. Journal of Child and Adolescent Substance Abuse , 12 , 1. doi: 10.1300/J029v12n04_01

Botvin, G. J., & Kantor, L. (2000). Preventing alcohol and tobacco use through life skills training. Alcohol Research and Health , 24 (4), 250.

Brewer, L. C. (1991). Social skills training as a deterrent to entry-level drug experimentation among 15 year old adolescents . (Doctoral dissertation). Retrived from PsycARTICLES. (199272895-001).

Brody, G. H., Murry, V., Kogan, S. M., Gerrard, M., Gibbons, F. X., Molgaard, V., et al. (2006). The Strong African-American Families Programme: A cluster-randomised prevention trial of long-term effects and a mediational model. Journal of Consulting and Clinical Psychology, 74 , 356-366. Doi: 10.1037/0022-006X.74.2.356

Brown, E. C., Catalano, R. F., Fleming, C. B., Haggerty, K. P., & Abbott, R. D. (2005). Adolescent substance use outcomes in the Raising Healthy Children Project: A two-part latent growth curve analysis. Journal of Consulting and Clinical Psychology , 73 , 699-710. doi:10.1037/0022-006X.73.4.699

Cahill, H. W. (2007). Challenges in adopting evidence-based school drug education programmes. Drug and Alcohol Review , 26 , 673-679. doi:10.1080/09595230701613593

Canadian Centre on Substance Abuse (2010a). Building on our strengths: Canadian standards for school-based youth substance abuse prevention (Version 2.0). Ottawa, ON:

Canadian Centre on Substance Abuse. Available online at http://www.ccsa.ca/2010%20CCSA%20Documents/ccsa-011815-2010.pdf

Canadian Centre on Substance Abuse (2010b). Strengthening our skills: Canadian guidelines for youth substance abuse prevention family skills programs . Ottawa, ON: Canadian Centre on Substance Abuse. Available online at http://www.ccsa.ca/2010%20CCSA%20Documents/2010_CCSA_Family_skill-based_Guidelines_en.pdf

Canadian Centre on Substance Abuse (2010c). Stronger together: Canadian standards for community-based youth substance abuse prevention . Ottawa, ON: Canadian Centre on Substance Abuse. Available online at http://www.ccsa.ca/2010%20CCSA%20Documents/2010_CCSA_Community-based_Standards_en.pdf

Caplan, M., Weissberg, R. P., Grober, J. S., Sivo, P. J., Grady, K., & Jacoby, C. (1992). Social competence promotion with inner-city and suburban young adolescents: Effects on social adjustment and alcohol use. Journal of Consulting and Clinical Psychology , 60 , 5663. doi:10.1037/0022-006X.60.1.56

Carey, K. B., Scott-Sheldon, L. J., Carey, M. P., & DeMartini, K. S. (2007). Individual-level interventions to reduce college student drinking: A meta-analytic review. Addictive Behaviors , 32 , 2469-2494. doi:10.1016/j.addbeh.2007.05.004

Caria, M., Faggiano, F., Bellocco, R., & Galanti, M. (2011). The influence of socioeconomic environment on the effectiveness of alcohol prevention among European students: A cluster randomised controlled trial. BMC Public Health , 11 , 312-319. doi:10.1186/1471-2458-11-312

Castellanos, C. & Conrod, P. J. (2006). Efficacy of brief personality-targeted cognitive behavioural interventions in reducing and preventing adolescent emotional and behavioural problems. Journal of Mental Health, 15(6) , 1-14.

Castellanos-Ryan, N., Vitaro, F., Parent, S., Tremblay, R. E., & Seguin, J. R. (2012). An intervention for disruptive behaviour in childhood reduces substance use across adolescence . Presented at the biennial meeting of the Life History Research Society, London, UK, October. Abstract published online: http://cms.lifehistory2012.co.uk./index.php/abstracts.

Castro, F., Barrera, M. R., & Martinez, C. R. (2004). The cultural adaptation of prevention interventions: Resolving tensions between fidelity and fit. Prevention Science , 5 , 41-45. doi:10.1023/B:PREV.0000013980.12412.cd

Clayton, R. R., Cattarello, A., & Walden, K. P. (1991). Sensation seeking as a potential mediating variable for school-based prevention intervention: A two-year follow-up of DARE. Health Communication , 3 , 229-239. doi:10.1207/s15327027hc0304_5

Conrod, P. J., Castellanos-Ryan, N., & Mackie, C. (2011). Long-term effects of a personality-targeted intervention to reduce alcohol use in adolescents. Journal of Consulting and Clinical Psychology , 79 , 296-306. doi:10.1037/a0022997

Conrod, P.J., Castellanos-Ryan, N., & Strang, J. (2010). Brief, personality-targeted coping skills interventions prolong survival as a non-drug user over a two-year period during adolescence. Archives of General Psychiatry, 67 , 85-93. doi:10.1001/archgenpsychiatry.2009.173

Conrod, P.J., Mackie, C., & Castellanos, N. (2008). Personality-targeted interventions delay the adolescent onset of drinking and binge drinking. Journal of Child Psychology and Psychiatry, 49 , 181-190. doi:10.1111/j.1469-7610.2007.01826.x

Conrod, P. J., O’Leary-Barrett, M., Newton, N., Topper, L., Castellanos-Ryan, N., Mackie, C., et al. (in press). A cluster randomised trial demonstrates the effectiveness of a selective, personality-targeted prevention programme for adolescent alcohol misuse. Archives of General Psychiatry .

Conrod, P. J., Stewart, S. H., Comeau, N., & Maclean, A. (2006). Efficacy of cognitive-behavioural interventions targeting personality risk factors for youth alcohol misuse. Journal of Clinical Child and Adolescent Psychology , 35(4) , 550-563. doi:10.1207/s15374424jccp3504_6

Cook, R., Lawrence, H., Morse, C., & Roehl, J. (1984). An evaluation of the alternatives approach to drug abuse prevention. International Journal of the Addictions, 19 , 767–787. doi:10.3109/10826088409057222

Cronce, J. M., & Larimer, M. E. (2011). Individual-focused approaches to the prevention of college student drinking. Alcohol Research and Health , 34 (2), 210-221.

Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programmes: A systematic review. Addictive Behaviors , 27 , 1009. doi: 10.1016/S0306-4603(02)00295-2,

Cuijpers, P. (2003). Three decades of drug prevention research. Drugs: Education, Prevention and Policy , 10 , 7-20. doi:10.1080/0968763021000018900

Cuijpers, P., Jonkers, R., De Weerdt, I., & deJong, A. (2002). The effects of drug abuse prevention at school: The ‘Healthy School and Drugs’ project. Addiction, 97 , 67-73.

D’Amico, E. J., & Fromme, K. (2002). Brief prevention for adolescent risk-taking behaviour. Addiction, 97 , 563-574. doi: 10.1046/j.1360-0443.2002.00115.x

Dane, A. V., & Schneider, B. H. (1998). Programme integrity in primary and early secondary intervention: Are implementation effects out of control? Clinical Psychology Review, 18 , 23-45. doi: 10.1016/S0272-7358(97)00043-3

Darkes, J., & Goldman, M. S. (1993). Expectancy challenge and drinking reduction: Experimental evidence for a mediational process. Journal of Consulting and Clinical Psychology , 61 , 344-353. doi:10.1037/0022-006X.61.2.344

Darkes, J., Greenbaum, P. E., & Goldman, M. S. (1998). Sensation seeking--disinhibition and alcohol use: Exploring issues of criterion contamination. Psychological Assessment , 10 , 71. doi:10.1037/1040-3590.10.1.71

Dedobbeleer, N., & Desjardins, S. (2001). Outcomes of an ecological and participatory approach to prevent alcohol and other drug ‘abuse’ among multi-ethnic adolescents. Substance Use and Misuse , 36 , 1959-1991. doi:10.1081/JA-100108434

Dielman, T. E. (1995). School-based research on the prevention of adolescent alcohol use and misuse: Methodological issues and advances. In G. M. Boyd, J. Howard, & R. A. Zucker (Eds.), Alcohol problems among adolescents: Current directions in prevention research (pp. 125-146). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.

Dielman, T. E., Shope, J. T., Butchart, A. T., & Campanelli, P. C. (1986). Prevention of adolescent alcohol misuse: An elementary school programme. Journal of Pediatric Psychology, 11 , 259–282. doi: 10.1093/jpepsy/11.2.259

Dimeff, L., Baer, J., Kivlahan, D., & Marlatt, G. (1999). Brief alcohol screening and intervention for college students (BASICS): A harm reduction approach . New York, NY: Guilford Press.

Dixon, D. J., & McLearen, A. M. (2002). The effectiveness of an alcohol abuse prevention programme among high school students in rural Missouri. Rural Educator, 24(1) , 18-21.

Donaldson, S. I., Sussman, S., MacKinnon, D. P., Severson, H. H., Glynn, T., Murray, D. M., et al.. (1996). Drug abuse prevention programming: Do we know what content works? The American Behavioral Scientist , 39 , 868-883. Retrieved from: http://proquest.umi.com

Duncan, T. E., Duncan, S. C., Beauchamp, N., Wells, J., & Ary, D. V. (2000). Development and evaluation of an interactive CD-ROM refusal skills programme to prevent youth substance use: “Refuse to Use”. Journal of Behavioral Medicine , 23 , 59-72. doi: 10.1023/A:1005420304147

Dusenbury, L., & Falco, M. (1995). Eleven components of effective drug abuse prevention curricula. Journal of School Health , 65 , 420. doi: 10.1111/j.1746-1561.1995.tb08205.x

Dusenbury, L., & Hansen, W. B. (2004). Pursuing the course from research to practice. Prevention Science , 5 , 55-59. doi:10.1023/B:PREV.0000013982.20860.19

Durrant, L. H. (1986). A multi-component approach to prevention of adolescent substance abuse . (Dortoral dissertation). Retrieved from PsycARTICLES. (1987-53849-001).

Duryea, E. (1984). Six-month follow-up results of a preventive alcohol education intervention. Journal of Drug Education , 14 , 97-104. doi:10.2190/5WR2-WTBY-C74F-LEFQ

Eddy, J. M., Reid, J. B., & Fetrow, R. A. (2000). An elementary school-based prevention programme targeting modifiable antecedents of youth delinquency and violence: Linking the interests of families and teachers (LIFT). Journal of Emotional and Behavioral Disorders, 8 , 165-176. doi:10.1177/106342660000800304

Eisen, M., Zellman, G. L., Massett, H. A., & Murray, D. M. (2002). Evaluating the Lions-Quest “Skills for Adolescence” drug education programme: First-year behaviour outcomes. Addictive Behaviors, 27 , 619-632. doi: 10.1016/S0306-4603(01)00197-6

Eisen, M., Zellman, G. L., & Murray, D. M. (2003). Evaluating the Lions–Quest “Skills for Adolescence” drug education programme: Second-year behaviour outcomes. Addictive Behaviors , 28 , 883. doi:10.1016/S0306-4603(01)00292-1

Ellickson, P. L., & Bell, R. M. (1990). Drug prevention in junior high: A multi-site longitudinal test. Science, 247 , 1299-1305. doi: 10.1126/science.2180065

Ellickson, P. L., McCaffrey, D. F., Gosh-Dastidar, B., & Longshore, D. L. (2003). New inroads in preventing adolescent drug use: Results from a large scale trial of project ALERT in middle schools. American Journal of Public Health, 93 , 1830-1836. doi: 10.2105/AJPH.93.11.1830

Elliott, D. S., & Mihalic, S. (2004). Issues in disseminating and replicating effective prevention programmes. Prevention Science , 5 , 47-52. doi:10.1023/B:PREV.0000013981.28071.52

Ennett, S. T., Ringwalt, C. L., Thorne, J., Rohrbach, L., Vincus, A., Simons-Rudolph, A., et al. (2003). A comparison of current practice in school-based substance use prevention programmes with meta-analysis findings. Prevention Science , 4 , 1-14. doi:10.1023/A:1021777109369

Ennett, S. T., Rosenbaum, D. P., Flewelling, R. L., & Bieler, G. S. (1994). Long-term evaluation of Drug Abuse Resistance Education. Addictive Behaviors , 19 , 113-125. doi:10.1016/0306-4603(94)90036-1

Faggiano, F. (2009). Response to “Hypothesis testing and the EU-Dap evaluation of the Unplugged curriculum”. Preventive Medicine , 48 , 606-607. doi:10.1016/j.ypmed.2009.04.005

Faggiano, F., Galanti, M., Bohrn, K., Burkhart, G., Vigna-Taglianti, F., Cuomo, L., et al. (2008). The effectiveness of a school-based substance abuse prevention programme: EU-Dap cluster randomised controlled trial. Preventive Medicine , 47 , 537-543. doi:10.1016/j.ypmed.2008.06.018

Faggiano, F., Richardson, C., Bohrn, K., Galanti, M. R., & the EU-Dap Study Group. (2007). A cluster randomised controlled trial of school-based prevention of tobacco, alcohol, and drug use: The EU-Dap design and study population. Preventive Medicine, 44 , 170-173. doi: 10.1016/j.ypmed.2006.09.010

Faggiano, F., Vigna-Taglianti, F., Burkhart, G., Bohrn, K., Cuomo, L., Gregori, D., et al. & the EU-Dap Study Group. (2010). The effectiveness of a school-based substance abuse prevention programme: 18-Month follow-up of the EU-Dap cluster randomised controlled trial. Drug and Alcohol Dependence, 108 , 56-64. doi: 10.1016/j.drugalcdep.2009.11.018.

Faggiano, F., Vigna-Taglianti, F., Versino, E., Zambon, A., Borraccino, A., & Lemma, P. (2008). School-based prevention for illicit drugs use: A systematic review. Preventive Medicine , 46 , 385-396. doi:10.1016/j.ypmed.2007.11.012

Fadardi, J., & Cox, W. (2009). Reversing the sequence: Reducing alcohol consumption by overcoming alcohol attentional bias. Drug and Alcohol Dependence , 101 , 137-145. doi:10.1016/j.drugalcdep.2008.11.015

Forman, L., & Brondino, M. (1990). Effects of coping skills training on adolescents at risk for substance abuse. Psychology of Addictive Behavior, 4 , 67-76. doi:10.1037/h0080585

Foxcroft, D. R., & Tsertsvadze, A. (2011a). Universal school-based prevention programmes for alcohol misuse in young people. Cochrane Database of Systematic Reviews, issue 5 . doi: 10.1002/14651858.CD009113.

Foxcroft, D. R., & Tsertsvadze, A. (2011b). Universal family-based prevention programmes for alcohol misuse in young people. Cochrane Database of Systematic Reviews, issue 9 . doi: 10.1002/14651858.CD009308

Foxcroft, D. R., & Tsertsvadze, A. (2011c). Universal multi-component prevention programmes for alcohol misuse in young people. Cochrane Database of Systematic Reviews, issue 9 . doi: 10.1002/14651858.CD009307

Furr-Holden, C. D., Ialango, N. S., Anthony, J. C., Petras, H., & Kellam, S. G. (2004). Developmentally inspired drug prevention: Middle school outcomes in a school-based randomised prevention trial. Drug and Alcohol Dependence, 73 , 149-158. doi: 10.1016/j.drugalcdep.2003.10.002

Goldberg, L., MacKinnon, D.P., Elliot, D.L., Moe, E.L., Clarke, G., & Cheong, J. (2000). The Adolescents Training and Learning to Avoid Steroids Programme: Preventing drug use and promoting health behaviors. Archives of Pediatrics and Adolescent Medicine, 154 , 332-338. doi: 10.1001/archpedi.154.4.332

Goldman, M. S. (1999). Risk for substance abuse: Memory as a common etiological pathway. Psychological Science , 10 , 196-198. doi:10.1111/1467-9280.00133

Goodstadt, M. S., & Sheppard, M. A. (1983). Three approaches to alcohol education. Journal of Studies on Alcohol , 44 (2), 362-380.

Gorman, D. M. (2002). The ‘science’ of drug and alcohol prevention: The case of the randomised trial of the Life Skills Training programme. International Journal of Drug Policy , 13 , 21-26. doi:10.1016/S0955-3959(02)00002-6

Gottfredson, D. C., Gottfredson, G. D., & Skroban, S. (1996). A multimodel school-based prevention demonstration. Journal of Adolescent Research , 11 , 97-115. doi:10.1177/0743554896111006

Greenberg, M. T. (2004). Current and future challenges in school-based prevention: The researcher perspective. Prevention Science , 5 , 5-13. doi:10.1023/B:PREV.0000013976.84939.55

Gregor, M. A., Shope, J. T., Blow, F. C., Maio, R. F., Weber, J. E., & Nypaver, M. M. (2003). Feasibility of using an interactive laptop programme in the emergency department to prevent alcohol misuse among adolescents. Annals of Emergency Medicine, 42 , 276-284. doi: 10.1067/mem.2003.265

Grenard, J. L., Ames, S. L., Pentz, M., & Sussman, S. (2006). Motivational interviewing with adolescents and young adults for drug-related problems. International Journal of Adolescent Medicine and Health , 18 , 53-67. doi:10.1515/IJAMH.2006.18.1.53

Grey, E., McCambridge, J., & Strang, J. (2005). The effectiveness of motivational interviewing delivered by youth workers in reducing drinking, cigarette, and cannabis smoking among young people: Quasi-experimental pilot study. Alcohol and Alcoholism, 40(6) , 535-539.

Griffin, K. W., Botvin, G. J., Nichols, T. R., & Doyle, M. M. (2003). Effectiveness of a universal drug abuse prevention approach for youth at high-risk for substance use initiation. Preventive Medicine , 36 , 1-7. doi: 10.1006/pmed.2002.1133

Griffin, J. P., Holliday, R. C., Frazier, E., & Braithwaite, R. L. (2009). The BRAVE (Building Resiliency and Vocational Excellence) programme: Evaluation findings for a career-oriented substance abuse and violence preventive intervention. Journal of Health Care for the Poor and Underserved, 20 , 798–816. doi:10.1353/hpu.0.0174

Gropper, M. (2002). Computer-integrated drug prevention: Combining multi-media and social group work practice to teach inner city Israeli 6th graders how to say no to drugs. Journal of Technology in Human Services , 20 , 49-65. doi:10.1300/J017v20n01_07

Haggerty, K. P., Skinner, M. L., MacKenzie, E. P., & Catalano, R. F. (2007). A randomised trial of Parents Who Care: Effects on key outcome at 24-month follow-up. Prevention Science, 8 , 249-260. doi: 10.1007/s11121-007-0077-2

Hansen, W. B. (1992). School-based substance abuse prevention: A review of the state of the art in curriculum, 1980–1990. Health Education Research , 7 , 403-430. doi:10.1093/her/7.3.403

Hansen, W. B., & Graham, J. W. (1991a). Preventing alcohol, marijuana, and cigarette use among adolescents: Peer pressure resistance training versus establishing conservative norms. Preventative Medicine, 20 , 414-430. doi: 10.1016/0091-7435(91)90039-7

Hansen, W. B., & Graham, J. W. (1991b). Programme integrity as a moderator of prevention programme effectiveness: Results for fifth-grade. Journal of Studies on Alcohol , 52 (6), 568.

Hansen, W. B., Johnson, C. A., Flay, B. R., Graham, J. W., & Sobel, J. (1988). Affective and social influences approaches to the prevention of multiple substance abuse among seventh grade students: Results from project SMART. Preventive Medicine , 17 , 135-154. doi: 10.1016/0091-7435(88)90059-X

Hawkins, J. D., Catalano, R. F., Kosterman, R., Abbott, R., & Hill, K. G. (1999). Preventing adolescent health-risk behaviours by strengthening protection during childhood. Archives of Pediatric and Adolescent Medicine, 153 , 226-234. doi:10.1001/archpedi.153.3.226

Hawkins, J. E., Oesterle, S., Brown, E. C., Arthur, M. W., Abbott, R. D., Fagan, A. A., et al. (2009). Results of a type 2 translational research trial to prevent adolescent drug use and delinquency: A test of communities that care. Archives of Pediatrics and Adolescent Medicine, 163 , 789-798. doi:10.1001/archpediatrics.2009.141

Hecht, M. L., Marsiglia, F. F., Elek, E., Wagstaff, D. A., Kulis, S., Dustman, P., et al. (2003). Culturally grounded substance use prevention: An evaluation of the Keeping’ it R.E.A.L . curriculum. Prevention Science, 4 , 233-248. doi: 10.1023/A:1026016131401

Hingson, R. W., Zha, W. X., & Weitzman, E. R. (2009). Magnitude of and trends in alcohol-related mortality and morbidity among US college students ages 18-24, 1998-2005. Journal of Studies on Alcohol and Drugs Supplement, 16(2) , 12-20.

Houben, K., Havermans, R., & Wiers, R. (2010). Learning to dislike alcohol: Conditioning negative implicit attitudes toward alcohol and its effect on drinking behaviour. Psychopharmacology , 211 , 79-86. doi:10.1007/s00213-010-1872-1

Houben, K., Nederkoorn, C., Wiers, R. W., & Jansen, A. (2011). Resisting temptation: Decreasing alcohol-related affect and drinking behaviour by training response inhibition. Drug and Alcohol Dependence , 116 , 132-136. doi:10.1016/j.drugalcdep.2010.12.011

Jessor, R., & Jessor, S. L. (1977). Problem behaviour and psychosocial development . New York, NY: Academic Press.

Johnson, C. A., Pentz, M. A., Weber, M. D., Dwyer, J. H., Baer, N., MacKinnon, D. P., et al. (1990). Relative effectiveness of comprehensive community programming for drug abuse prevention with high-risk and low-risk adolescents. Journal of Consulting and Clinical Psychology, 58 , 447-456. doi:10.1037/0022-006X.58.4.447

Johnson, K. W., Shamblen, S. R., Ogilvie, K. A., Collins, D., & Saylor, B. (2009). Preventing youths’ use of inhalants and other harmful legal products in frontier Alaskan communities: A randomised trial. Prevention Science , 10 , 298-312. doi:10.1007/s11121-009-0132-2

Jones, L., Sumnall, H., Burrell, K., McVeigh, J., & Bellis, M. A. (2006). Universal drug prevention . Liverpool, UK: National Collaborating Centre for Drug Prevention.

Kaftarian, S., Robinson, E., Compton, W., Davis, B., & Volkow, N. (2004). Blending prevention research and practice in schools: Critical issues and suggestions. Prevention Science , 5 (1), 1-3. doi: 10.1023/B:PREV.0000013975.74774.bc

Kellam, S. G., Hendricks Brown, C. C., Poduska, J. M., Ialongo, N. S., Wang, W., Toyinbo, P., et al. (2008). Effects of a universal classroom behaviour management programme in first and second grades on young adult behavioral, psychiatric, and social outcomes. Drug and Alcohol Dependence , 95 , S5-S28. doi:10.1016/j.drugalcdep.2008.01.004

Komro, K. A., Perry, C. L., Veblen-Mortenson, S., Farbakhsh, K., Kugler, K. C., Alfano, K. A., et al. (2006). Cross-cultural adaptation and evaluation of a home-based programme for alcohol use prevention among urban youth: The “Slick Tracy Home Team Programme”. Journal of Primary Prevention, 27 , 135-154. doi: 10.1007/s10935-005-0029-1

Koning, I. M., Vollebergh, W. A., Smit, F., Vedurmen, J. E., van den Eijnden, R. J., ter Bogt, T. F. M., et al. (2009). Preventing heavy alcohol use in adolescents (PAS): Cluster randomised trial of a parent and student intervention offered separately and simultaneously. Addiction, 104 , 1669-1678. doi:10.1111/j.1360-0443.2009.02677.x

Koutakis, N., Stattin, H., & Kerr, M. (2008). Reducing youth alcohol drinking through a parent-targeted intervention: The Orebro Prevention Programme. Addiction, 103 , 1629-1637. doi: 10.1111/j.1360-0443.2008.02326.x

Krank, M., Stewart, S. H., O’Connor, R., Woicik, P., Wall, A., & Conrod, P. J. (2011). Structural, concurrent, and predictive validity of the Substance Use Risk Profile Scale in early adolescence. Addictive Behaviors , 36 , 37-46. doi:10.1016/j.addbeh.2010.08.010

Larimer, M. E., & Cronce, J. M. (2002). Identification, prevention, and treatment: A review of individual-focused strategies to reduce problematic alcohol consumption by college students. Journal of Studies on Alcohol, Supplement, 14 , 148-163.

Larimer, M. E., & Cronce, J. M. (2007). Identification, prevention, and treatment revisited: Individual-focused college drinking prevention strategies 1999-2006. Addictive Behaviors , 32 , 2439-2468. doi:10.1016/j.addbeh.2007.05.006

Lisnov, L., Harding, C., Safer, L., & Kavanagh, J. (1998). Adolescents’ perceptions of substance abuse prevention strategies. Adolescence , 33(130) , 301.

Lochman, J., & Wells, K. (2003). Effectiveness of the Coping Power Programme and of classroom intervention with aggressive children: Outcomes at a 1-year follow-up. Behaviour Therapy, 34 , 493-515. doi: 10.1016/S0005-7894(03)80032-1

Loveland-Cherry, C., Ross, L., & Kaufman, S. (1999). Effects of a home-based family intervention on adolescent alcohol use and misuse. Journal of Studies on Alcohol , Supplement 13 , 94-102. doi:10.1093/her/cyl061

Luepker, R. V., Rästam, L., Hannan, P. J., Murray, D. M., Gray, C., Baker, W. L., et al. (1996). Community education for cardiovascular disease prevention: Morbidity and mortality results from the Minnesota Heart Health Programme. American Journal of Epidemiology, 144 , 351-362. doi: 10.2105/AJPH.84.9.1383

Marsch, L. A., Bickel, W. K., & Badger, G. J. (2006). Applying computer technology to substance abuse prevention science: Results of a preliminary examination. Journal of Child and Adolescent Substance Abuse , 16 , 69-94. doi: 10.1300/J029v16n02_04

McBride, N. (2003). A systematic review of school drug education. Health Education Research , 18 , 729-742. doi:10.1093/her/cyf050

McBride, N., Farringdon, F., Muleners., L., & Midford, R. (2006). School Health and Alcohol Harm Reduction Project: Details of intervention development and research procedures . Perth, Australia National Drug Research Institute, Curtin University of Technology.

McBride, N., Midford, R., Farringdon, F., & Phillips, M. (2000). Early results from a school alcohol harm minimization study: The School Health and Alcohol Harm Reduction Project. Addiction , 95 , 1021. doi: 10.1046/j.1360-0443.2000.95710215.x

McCambridge, J., Hunt, C., Jenkins, R. J., & Strang, J. (2011). Cluster randomised trial of the effectiveness of motivational interviewing for universal prevention. Drug and Alcohol Dependence, 114(2-3) , 177-184.

McCambridge, J., & Strang, J. (2004). The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: Results from a multi-site cluster randomized trial. Addiction, 99 , 39-52.

McGuire, W. J. (1964). Inducing resistance to persuasion: Some contemporary approaches. In L. Berkowitz (Ed.), Advances in experimental social psychology (Vol. 1, pp. 191-229). New York, NY: Academic Press.

McGuire, W. J. (1968). Personality and susceptibility to social influence. In E. F. Borgatta & W. W. Lambert (Eds.), Handbook of personality theory and research . Chicago, IL: Rand McNally.

Meyer L., & Cahill H. (2004). Principles for school drug education . Canberra, Australia: Australian Government Department of Education Science and Training

Midford, R. (2000). Does drug education work?. Drug and Alcohol Review , 19 , 441-446. doi:10.1080/713659427

Midford, R. (2008). Is this the path to effective prevention? Addiction , 103 , 1169-1170. doi:10.1111/j.1360-0443.2008.02224.x

Midford, R., Munro, G., McBride, N., Snow, P., & Ladzinski, U. (2002). Princicples that underpin effective school-based drug education. Journal of Drug Education , 32 (4), 363-386.

Miller, W. R. (1998). Enhancing motivation for change. In W. R. Miller, & N. Heather (Eds.), Treating addictive behaviors (2nd ed.) (pp. 121-132). New York, NY: Plenum Press.

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.) . New York, NY: Guilford Press.

Morgenstern, M., Wiborg, G., Isensee, B., & Hanewinkel, R. (2009). School-based alcohol education: Results of a cluster-randomised controlled trial. Addiction, 104 , 402-412. doi:10.1111/j.1360-0443.2008.02471.x

Moskowitz, J. M. (1989). The primary prevention of alcohol problems: A critical review of the research literature. Journal of Studies on Alcohol , 50 (1), 54-88.

Moskowitz, J. M., Malvin, J. H., Schaeffer, G. A., & Schaps, E. (1984). An experimental evaluation of a drug education course. Journal of Drug Education , 14 , 9-22. doi:10.2190/R977-NCC7-9ET5-3PLX

Mun, E. Y., White, H. R., & Morgan, T. J. (2009). Individual and situational factors that influence the efficacy of personal feedback substance use interventions for college students. Journal of Consulting and Clinical Psychology, 77 , 88-102. PMCID: PMC2818838.

Newman, I. M., Anderson, C. S., & Farrell, K. A. (1992). Role rehearsal and efficacy: Two 15-month evaluations of a ninth-grade alcohol education programme. Journal of Drug Education , 22 , 55-67. doi:10.2190/QQWE-PFJ5-PVKY-FQQK

Newton, N. C., & Conrod, P. J. (2012). Climate Schools – UK: A feasibility study . Manuscript in preparation.

Newton, N. C., Andrews, G., Teesson, M., & Vogl, L. E. (2009). Delivering prevention for alcohol and cannabis using the Internet: A cluster randomised controlled trial. Preventive Medicine, 48 , 579-584. doi:10.1016/j.ypmed.2009.04.009

Newton, N. C., Teeson, M., Barrett, E. L., Slade, T., & Conrod, P. J. (2012). The CAP study, evaluation of integrated universal and selective prevention strategies for youth alcohol misuse: Study protocol of a cluster randomised controlled trial. BMC Psychiatry, 12(1) , 118. [Epub ahead of print] PMID: 22906138 [PubMed – as supplied by publisher]

Newton, N. C., Vogl, L. E., Teesson, M., & Andrews, G. (2009). Climate Schools alcohol module: Cross-validation of a school-based prevention programme for alcohol misuse. Australian and New Zealand Journal of Psychiatry , 43 , 201-207. doi:10.1080/00048670802653364

Newton, N. C., Vogl, L., Teesson, M., & Andrews, G. (2011). Developing the Climate Schools alcohol and cannabis module: A harm-minimization, universal drug prevention programme facilitated by the internet. Substance Use and Misuse , 46 , 1651-1663. doi:10.3109/10826084.2011.613441

Newton, N. C., Teesson, M., Vogl, L. E., & Andrews, G. (2010). Internet-based prevention for alcohol and cannabis use: Final results of the Climate Schools course. Addiction , 105 , 749-759. doi:10.1111/j.1360-0443.2009.02853.x

O’Donnell, L., Myint-U, A., Duran, R., & Stueve, A. (2010). Especially for daughters: Parent education to address alcohol and sex-related risk taking among urban young adolescent girls. Health Promotion Practice , 11 , 70S-78S. doi:10.1177/1524839909355517

O’Leary-Barrett, M., Mackie, C.J., Castellanos-Ryan, N., Al-Khudhairy, N., & Conrod, P.J. (2010). Personality-targeted interventions delay uptake of drinking and decrease risk of alcohol-related problems when delivered by teachers. Journal of the American Academy of Child and Adolescent Psychiatry, 49 , 954-963. doi:10.1016/j.jaac.2010.04.011

Offord, D. R. (2000). Selection levels of prevention. Addictive Behaviors , 25 , 833-842. doi:10.1016/S0306-4603(00)00132-5

Park, M., Kosterman, R., Hawkins, J. D., Haggerty, K P., Duncan, T. E., Duncan, S. C., et al. (2000). Effects of the ‘Preparing for the Drug Free Years’ curriculum on growth in alcohol use and risk for alcohol use in early adolescence. Prevention Sciences, 1 , 125-138. doi:10.1023/A:1010021205638

Peleg, A., Neumann, L., Friger, M., Peleg, R., & Sperber, A. D. (2001). Outcomes of a brief alcohol abuse prevention programme for Israeli high school students. Journal of Adolescent Health, 28 , 263-269. doi:10.1016/S1054-139X(00)00216-0

Pentz, M. (2004). Form follows function: Designs for prevention effectiveness and diffusion research. Prevention Science , 5 , 23-29. doi:10.1023/B:PREV.0000013978.00943.30

Pentz, M. A., Johnson, A., Dwyer, J. H., MacKinnon, D. M., Hansen, W. B., et al. (1989). A comprehensive community approach to adolescent drug abuse prevention: Effects on cardiovascular disease risk behaviours. Annals of Medicine, 21 , 219-222. doi: 10.3109/07853898909149937

Perkins, H. W. (2007). Misperceptions of peer drinking norms in Canada: Another look at the ‘reign of error’ and its consequences among college students. Addictive Behaviors, 32 , 2645-2656. doi:10.1016/j.addbeh.2007.07.00

Perry, C.L., & Grant, M. (1988). Comparing peer-led to teacher-led youth alcohol education in four countries (Australia, Chile, Norway and Swaziland). Alcohol Health and Research World, 12 , 322-326.

Perry, C. L., Komro, K., Veblen-Mortenson, S., Bosma, L. M., Farbakhsh, K., Munson, K. A., et al. (2003). A randomised controlled trial of the middle and junior high school DARE and DARE PLUS programmes. Archives of Paediatric Adolescent Medicine, 157 , 178-184. doi:10.1001/archpedi.157.2.178

Perry, C. L., & Kelder, S. H. (1992). Models for effective prevention. Journal of Adolescent Health , 13 , 355-363. doi:10.1016/1054-139X(92)90028-A

Perry, C. L., Luepker, R. V., Murray, D. M., & Hearn, M. D. (1989). Parent involvement with children’s health promotion: A one-year follow-up of the Minnesota Home Team. Health Education Quarterly , 16 , 171-180. doi:10.1177/109019818901600203

Perry, C. L., Williams, C. L., Komro, K. A., Veblen-Mortenson, S., Stigler, M. H., Munson, K. A., et al. (2002). Project Northland: Long-term outcomes of community action to reduce adolescent alcohol use. Health Education Research, 17 , 117-132. doi: 10.1093/her/17.1.117

Perry, C. L., Williams, C. L., Veblen-Mortenson, S., Toomey, T. L., Komro, K. A., Anstine, P. S., et al. (1996). Outcomes of a community-wide alcohol use prevention programme during early adolescence: Project Northland. American Journal of Public Health, 86(7) , 956-965.

Petrie, J., Bunn, F., & Byrne, G. (2007). Parenting programmes for preventing tobacco, alcohol, or drug misuse in children under 18: A systematic review. Health Education Research, 22 , 177-191. doi: 10.1093/her/cyl061

Presley, C. A., Meilman, P. W., & Cashin, J. R. (1996). Alcohol and drugs on American college campuses: Use, consequences, and perceptions of the campus environment. National Criminal Justice Reference Service, 3 , 1991-1993.

Reddy, K. S., Arora, M., Perry, C. L., Nair, B., Kohli, A., Lytle, L. A., et al. (2002). Tobacco and alcohol use outcomes of a school based intervention in New Delhi. American Journal of Health Behaviour, 26 , 173-181. doi: 10.5993/AJHB.26.3.2

Rehm, J,. Baliunas, D., Brochu, S., Fischer, B., Gnam, W., Patra, J., et al. (2006). The costs of substance abuse in Canada, 2002 . Ottawa, Canada: Canadian Centre on Substance Abuse (CCSA).

Rehm, J., Patra, J., Gnam, W. H., Sarnocinska-Hart, A., & Popova, S. (2011). Avoidable cost of alcohol abuse in Canada. European Addiction Research , 17 , 72-79. doi:10.1159/000321463

Ringwalt, C. L., Clark, H., Hanley, S., Shamblen, S. R, & Flewelling, R. L. (2009). Project ALERT: A cluster randomised trial. Archives of Pediatrics & Adolescent Medicine, 163 , 625-632. doi:10.1001/archpediatrics.2009.88

Ringwalt, C. L., Ennett, S. T., & Holt, K. D. (1991). An outcome evaluation of Project DARE (Drug Abuse Resistance Education). Health Education Research , 6 , 327-337. doi:10.1093/her/6.3.327

Ringwalt, C. L., Ennett, S. T., Johnson, R., Rohrbach, L., Simons-Rudolph, A., Vincus, A., et al. (2003). Factors associated with fidelity to substance use prevention curriculum guides in the nation’s middle schools. Health Education and Behaviour , 30 (3), 375-391. doi:10.1177/1090198103030003010

Rohrbach, L., & D’Onofrio, C. N. (1996). Diffusion of school-based substance abuse prevention programmes. American Behavioural Scientist , 39 , 919. doi: 1 0.1177/0002764296039007012

Roona, M. R., Streke, A. V., Ochshorn, P., Marshall, D. M., & Palmer, A. P. (2000). Identifying effective school-based substance abuse prevention interventions: Background paper for Prevention 2000 Summit . Albany, NY: Social Capital Development Corporation.

Rosenbaum, D. P., Flewelling, R. L., Bailey, S. L., Ringwalt, C. L., & Wilkinson, D. L. (1994). Cops in the classroom: A longitudinal evaluation of Drug Abuse Resistance Education (DARE). Journal of Research in Crime and Delinquency , 31 , 3-31. doi: 10.1177/0022427894031001001

Rosenbaum, D. P., & Hanson, G. S. (1998). Assessing the effects of school-based drug education: A six-year multilevel analysis of project DARE. Journal of Research in Crime and Delinquency , 35(4) , 381-412.

Scaggs, L. S. (1985). A substance abuse awareness prevention programme: Knowledge, attitudes, and behaviours . (Unpublished doctoral dissertation). Colombus, OH: Ohio State University.

Schinke, S. P., Cole, K. C., & Fang, L. (2009a). Gender-specific intervention to reduce underage drinking among early adolescent girls: A test of a computer-mediated, mother-daughter programme. Alcohol and Drugs, 70(1) , 70-77.

Schinke, S. P., Fang, L., & Cole, K. C. (2009b). Computer-delivered, parent-involvement intervention to prevent substance use among adolescent girls. Preventive Medicine, 49 , 429-435. doi:10.1016/j.ypmed.2009.08.001

Schinke, S. P., Fang, L., & Cole, K. C. (2009c). Preventing substance use among adolescent girls: One-year outcomes of a computerised mother-daughter programme. Addictive Behaviors, 34 , 1060-1064. doi:10.1016/j.addbeh.2009.06.007

Schinke, S. P., Schwinn, T. M., di Noia, J., & Cole, K. C. (2004). Reducing the risks of alcohol use among urban youth: Three-year effects of a computer-based intervention with and without parent involvement. Journal of Studies on Alcohol, 65 (4), 443-449.

Schinke, S. P., Tepavac, L., & Cole, C. K. (2000). Preventing substance abuse among Native American youth: Three-year results. Addictive Behaviors, 25 , 387-397. doi: 10.1016/S0306-4603(99)00071-4

Schinke, S. P., Schwinn, T. M., & Ozanian, A. J. (2005). Alcohol abuse prevention among high-risk youth: Computer-based intervention. Journal of Prevention and Intervention in the Community , 29 , 117-130. doi:10.1300/J005v29n01_08

Schoenmakers, T. M., de Bruin, M., Lux, I. M., Goertz, A. G., Van Kerkhof, D. T., et al. (2010). Clinical effectiveness of attentional bias modification training in abstinent alcoholic patients. Drug and Alcohol Dependence , 109 , 30-36. doi:10.1016/j.drugalcdep.2009.11.022

Sharma, M. (2006). Editorial: Making effective alcohol education interventions for high schools. Journal of Alcohol and Drug Education , 50 (2), 1-4.

Sheehan, M., Schonfeld, C., Ballard, R., & Schofield, F. (1996). A three year outcome evaluation of a theory-based drunk driving education programme. Journal of Drug Education , 26 , 295-312. doi:10.2190/RPRV-7GP1-XH7F-3LHN

Shin, C. (2001). A review of school-based drug prevention progamme evaluations in the 1990’s. American Journal of Health Education, 32 (3), 139-147.

Shope, J. T., Copeland, L. A., Marcoux, B. C., & Kamp, M. E. (1996). Effectiveness of a school-based substance abuse prevention programme. Journal of Drug Education , 26 , 323-337. doi:10.2190/E9HH-PBUH-802D-XD6U

Shortt, A. L., Hutchinson, D. M., Chapman, R., & Toumbourou, J. W. (2007). Family, school, peer, and individual influences on early adolescent alcohol use: First-year impact of the Resilient Families Programme. Drug and Alcohol Review, 26 , 625-634. doi:10.1080/09595230701613817

Simons-Morton, B., Haynie, D., Saylor, K., Crump, A. D., & Chen, R. (2005). The effects of the Going Places programme on early adolescent substance use and antisocial behaviour. Prevention Science, 6 , 187-197. doi: 10.1007/s11121-005-0005-2

Slater, M. D., Kelly, K. J., Edwards, R. W., Thurman, P. J., Plested, B. A., Keefe, T. J., et al. (2006). Combining in-school and community-based media efforts: Reducing marijuana and alcohol uptake among younger adolescents. Health Education Research, 21 , 157-167. doi:10.1093/her/cyh056

Sloboda, Z., Stephens, R. C., Stephens, P. C., Grey, S. F., Teasdale, B., Hawthorne, R. D., et al. (2009). The Adolescent Substance Abuse Prevention Study: A randomised field trial of a universal substance abuse prevention programme. Drug and Alcohol Dependence , 102 , 1-10. doi:10.1016/j.drugalcdep.2009.01.015

Soole, D. W., Mazerolle, L. & Rombouts, S. (2005). School based drug prevention: A systematic review of the effectiveness on illicit drug use. Monograph No. 07 DPMP Monograph Series . Fitzroy, Australia: Turning Point Alcohol and Drug Centre.

Spooner, C., Mattick R., & Noffs, W. (1996). The nature and treatment of adolescent substance abuse. Monograph No. 26 . Sydney, Australia: National Drug and Alcohol Research Centre.

Spoth, R., Greenberg, M., & Turrisi, R. (2008). Preventive interventions addressing underage drinking: State of the evidence and steps toward public health impact. Pediatrics , 121 , 311-336. doi:10.1542/peds.2007-2243E

Spoth, R., Lopez Reyes, M., Redmond, C., & Shin, C. (1999). Assessing a public health approach to delay onset and progression of adolescent substance use: Latent transition and log-linear analyses of longitudinal family preventive intervention outcomes. Journal of Consulting and Clinical Psychology , 67 , 619-630. doi:10.1037/0022-006X.67.5.619

Spoth, R. L., Redmond, C., & Shin, C. (2001). Randomised trial of brief family interventions for general populations: Adolescent substance use outcomes four years following baseline. Journal of Consulting and Clinical Psychology, 69 , 627-642. doi:10.1037/0022-006X.69.4.627

Spoth, R. L., Redmond, C., Trudeau, L., & Shin, C. (2002). Longitudinal substance initiation outcomes for a universal preventive intervention combining family and school programmes. Psychology of Addictive Behaviour, 16 , 129-134. doi:10.1037/0893-164X.16.2.129

Spoth, R., Redmond, C., Shin, C., Greenberg, M., Clair, S., & Feinberg, M. (2007). Substance use outcomes at 18 months past baseline: The PROSPER community-university partnership trial. American Journal of Preventive Medicine, 32 , 395-402. doi:10.1016/j.amepre.2007.01.014

St. Pierre, T. L., Osgood, D., Mincemoyer, C. C., Kaltreider, D., & Kauh, T. J. (2005). Results of an independent evaluation of project ALERT delivered in schools by cooperative extension. Prevention Science , 6 , 305-317. doi:10.1007/s11121-005-0015-0

Stevens, M. M., Olson, A. L., Gaffney, C. A., Tosteson, T. D., Mott, L. A., & Starr, P. (2002). A paediatric, practice-based randomised trial of drinking and smoking prevention and bicycle, helmet, gun and seatbelt safety promotion. Paediatrics, 109 , 490-497. doi: 10.1542/peds.109.3.490)

Stewart, S. H., Gavric, D., & Collins, P. (2009). Women, girls and alcohol. In K. Brady, S. Back, & S. Greenfield (Eds.), Women and alcohol: A comprehensive handbook . (pp. 341-359). New York, NY: Guilford Press.

Sumnall, H., McGrath, Y., McVeigh, J., Burrell, K., Wilkinson, L., & Bellis, M. (2006). Drug use prevention among young people: Evidence into practice briefing February 2006 . London, UK: National Institute for Health and Clinical Excellence.

Sun, P., Dent, C. W., Sussman, S., & Rohrbach, L. A. (2008). One-year follow-up evaluation of Project Towards No Drug Abuse (TND4). Preventative Medicine, 47 , 438-442. doi: 10.1016/j.ypmed.2008.07.003

Thush, C. C., Wiers, R. W., Moerbeek, M., Ames, S. L., Grenard, J. L., Sussman, S., et al. (2009). Influence of motivational interviewing on explicit and implicit alcohol-related cognition and alcohol use in at-risk adolescents. Psychology of Addictive Behaviors , 23 , 146-151. doi:10.1037/a0013789

Thush, C. C., Wiers, R. W., Theunissen, N. N., Van den Bosch, J. J., Opdenacker, J. J., van Empelen, P. P., et al. (2007). A randomised clinical trial of a targeted intervention to moderate alcohol use and alcohol-related problems in at-risk adolescents. Pharmacology, Biochemistry and Behavior , 86 , 368-376. doi:10.1016/j.pbb.2006.07.023

Tobler, N. S., Roona, M. R., Ochshorn, P., Marshall, D. G., Streke, A. V., & Stackpole, K. M. (2000). School-based adolescent drug prevention programmes: 1998 meta-analysis. The Journal of Primary Prevention , 20 , 275-336. doi:10.1023/A:1021314704811

Tobler, N. S., Lessard, T., Marshall, D., Ochshorn, P., & Roona, M. (1999). Effectiveness of school-based drug prevention programmes for marijuana use. School Psychology International , 20 , 105-137. doi:10.1177/0143034399201008

Tobler, N. S., & Stratton, H. H. (1997). Effectiveness of school-based drug prevention programmes: A meta-analysis of the research. The Journal of Primary Prevention , 18 , 71128. doi:10.1023/A:1024630205999

Tremblay, R. E., Pagani-Kurtz, L., Mâsse, L. C., Vitaro, F., & Pihl, R. O. (1995). A bimodal preventive intervention for disruptive kindergarten boys: Its impact through mid-adolescence. Journal of Consulting and Clinical Psychology , 63 , 560-568. doi:10.1037/0022-006X.63.4.560

Tremblay, R. E., & Schaal, B. (1996). Physically aggressive boys from age 6 to 12 years Their biopsychosocial status at puberty. Annals of the New York Academy of Sciences, 794 , 192–207. doi: 10.1111/j.1749-6632.1996.tb32521.x

Valente, T. W., Ritt-Olson, A., Stacy, A., Unger, J. B., Okamoto, J., & Sussman, S. (2007). Peer acceleration: Effects of a social network tailored substance abuse prevention programme among high-risk adolescents. Addiction , 102 , 1804-1815. doi:10.1111/j.1360-0443.2007.01992.x

Van Der Kreeft, P., Wiborg, G., Galanti, M., Siliquini, R., Bohrn, K., Scatigna, M., et al. & the EU-Dap Study Group (2009). ‘Unplugged’: A new European school programme against substance abuse. Drugs: Education, Prevention and Policy , 16 , 167-181. doi:10.1080/09687630701731189

van Lier, P. C., Huizink, A., & Crijnen, A. (2009). Impact of a preventive intervention targeting childhood disruptive behaviour problems on tobacco and alcohol initiation from age 10 to 13 years. Drug and Alcohol Dependence , 100 , 228-233. doi:10.1016/j.drugalcdep.2008.10.004

Van Vliet, H., & Andrews, G. (2009). Internet-based course for the management of stress for junior high schools. Australian and New Zealand Journal of Psychiatry , 43 , 305-309. doi:10.1080/00048670902721145

Velleman, R. (2009). Swimming with crocodiles: The culture of extreme drinking. Journal of Addictive Diseases , 28 , 83-85. doi:10.1080/10550880802545283

Vigna-Taglianti, F. F., Vadrucci, S. S., Faggiano, F. F., Burkhart, G. G., Siliquini, R. R., Galanti, M. R., & the EU-Dap Study Group. (2009). Is universal prevention against youths’ substance misuse really universal? Gender-specific effects in the EU-Dap school-based prevention trial. Journal of Epidemiology and Community Health , 63 , 722-728. doi:10.1136/jech.2008.081513

Vogl, L., Teesson, M., Andrews, G., Bird, K., Steadman, B., & Dillon, P. (2009). A computerised harm minimization prevention program for alcohol misuse and related harms: Randomised controlled trial. Addiction , 104 , 564-575. doi:10.1111/j.1360-0443.2009.02510.x

Wagenaar, A. C., & Perry, C. L. (1994). Community strategies for the reduction of youth drinking: Theory and application. Journal of Research on Adolescence, 4 , 319-345.

Walters, S. T., & Neighbors, C. (2005). Feedback interventions for college alcohol misuse: What, why and for whom? Addictive Behaviors , 30 , 1168-1182. doi:10.1016/j.addbeh.2004.12.005

Webster, R. A., Hunter, M., & Keats, J. A. (2002). Evaluating the effects of a peer support programme on adolescents’ knowledge, attitudes and use of alcohol and tobacco. Drug and Alcohol Review , 21 , 7-16. doi:10.1080/09595230220119282

Wechsler, H., Lee, J., Kuo, M., & Lee, H. (2000). College binge drinking in the 1990s: A continuing problem: Results of the Harvard School of Public Health 1999 college alcohol study. Journal of American College Health , 48 , 199-210. doi: 10.1080/07448480009599305

Wechsler, H., Lee, J., Nelson, T. F., & Lee, H. (2001). Drinking levels, alcohol problems and secondhand effects in substance-free college residences: Results of a national study. Journal of Studies on Alcohol , 62 (1), 23-31.

Wenter, D. L., Ennett, S. T., Ribisl, K. M., Vincus, A. A., Rohrbach, L., Ringwalt, C. L., et al. (2002). Comprehensiveness of substance use prevention programmes in U.S. middle schools. Journal of Adolescent Health , 30, 455-462. doi: 10.1016/S1054-139X(02)00346-4

Werch, C., Bian, H., DiClemente, C. C., Moore, M. J., Thombs, D., Ames, S. C., et al. (2010). A brief image-based prevention intervention for adolescents. Psychology of Addictive Behaviors , 24 , 170-175. doi:10.1037/a0017997

Werch, C. E., Hui, B., Moore, M. J., Ames, S. C., DiClemente, C. C., Thombs, D., et al. (2008). Brief multiple behaviour health interventions for older adolescents. American Journal of Health Promotion , 23 , 92-96. doi: 10.4278/ajhp.07040533

Werch, C. C., Moore, M. J., & DiClemente, C. C. (2008). Brief image-based health behaviour messages for adolescents and their families . Journal of Child and Adolescent Substance Abuse, 17 , 19-40. doi: 10.1080/15470650802231887

Werch, C. C., Moore, M. J., DiClemente, C. C., Bledsoe, R., & Jobli, E. (2005a). A multi-health behaviour intervention integrating physical activity and substance use prevention for adolescents. Prevention Science, 6 , 213-226. doi: 10.1007/s11121-005-0012-3

Werch, C. C., Moore, M. J., DiClemente, C. C., Owen, D. M., Carlson, J. M., & Jobli, E. (2005b). Single vs. multiple drug prevention: Is more always better? A pilot study. Substance Use and Misuse, 40 (8), 1085-1101.

Werch, C. C., Moore, M. J., DiClemente, C. C., Owen, D. M., Jobli, E., & Bledsoe, R. (2003a). A sport-based intervention for preventing alcohol use and promoting physical activity among adolescents. Journal of School Health, 73 , 380-388. doi: 10.1111/j.1746-1561.2003.tb04181.x

Werch, C. C., Owen, D., Carlson, J., DiClemente, C. C., Edgemon, P., & Moore, M. J. (2003b). One-year follow up results of the STARS for Families alcohol prevention programme. Health Education Research, 18 , 74-87. doi: 10.1093/her/18.1.74

Werch, C. C., Pappas, D., Carlson, J., Edgemont, P., Sinder, J., & DiClemente, C. (2000a). Evaluation of a brief alcohol prevention programme for urban school youth. American Journal of Health Behaviour, 24 , 120-131. doi: http://dx.doi.org/10.5993/AJHB.24.2.5

Werch, C. E., Carlson, J. M., Pappas, D. M., Edgemont, P., & DiClemente, C. C. (2000b). Effects of a brief alcohol preventive programme for youth attending school sports physical examinations. Substance Use and Misuse, 35(3) , 421-432.

White, D., & Pitts, M. (1998). Educating young people about drugs: A systematic review. Addiction , 93 , 1475-1487. doi:10.1046/j.1360-0443.1998.931014754.x

White, H. R. (2006). Reduction of alcohol-related harm on United States college campuses: The use of personal feedback interventions. International Journal of Drug Policy, 17 , 310-319.

White, H. R., Labouvie, E. W., & Papadaratsakis, V. (2005). Changes in substance use during the transition to adulthood: A comparison of college students and their non-college age peers. Journal of Drug Issues , 35 (2), 281-305.

White, H. R., McMorris, B., Catalano, R. F., Fleming, C. B., Haggerty, K. P., & Abbott, R. W. (2006). Increases in alcohol and marijuana use during the transition out of high school into emerging adulthood: The effects of leaving home, going to college, and high school protective factors. Journal of Studies on Alcohol , 67 , 810-822.

Wiers, R. W., Rinck, M., Kordts, R., Houben, K., & Strack, F. (2010). Retraining automatic action-tendencies to approach alcohol in hazardous drinkers. Addiction , 105 , 279-287. doi:10.1111/j.1360-0443.2009.02775.x

Wiers, R. W., Van de Luitgaarden, J., van den Wildenberg, E., & Smulders, F. T. Y. (2005). Challenging implicit and explicit alcohol-related cognitions in young heavy drinkers. Addiction , 100 , 806-819. doi: 10.1111/j.1360-0443.2005.01064.x

Wilhelmsen, B., & Laberg, J. (1994). Evaluation of two student and teacher involved alcohol prevention programmes. Addiction , 89 , 1157-1165. doi: 10.1111/j.1360-0443.1994.tb02792.x

Williams, A. F., DiCicco, L. M., & Unterberger, H. (1968). Philosophy and evaluation of an alcohol education programme. Quarterly Journal of Studies on Alcohol , 29 (3-A), 685-702.

Williams, C. L., Grechanaia, T., Romanova, O., Komro, K. A., Perry, C. L., & Farbakhsh, K. (2001). Russian-American partners for prevention: Adaptation of a school-based parent-child programme for alcohol use prevention. European Journal of Public Health, 11 , 314-321. doi: 10.1093/eurpub/11.3.314

Williams, C., Griffin, K., Macaulay, A., West, T., & Gronewold, E. (2005). Efficacy of a Drug Prevention CD-ROM Intervention for Adolescents. Substance Use and Misuse , 40 , 869-877. doi:10.1081/JA-200042219

Woicik, P. A., Stewart, S. H., Pihl, R. O., & Conrod, P. J. (2009). The Substance Use Risk Profile Scale: A scale measuring traits linked to reinforcement-specific substance use profiles. Addictive Behaviors , 34 , 1042-1055. doi: 10.1016/j.addbeh.2009.07.001

Wood, M. D., Capone, C., Laforge, R., Erickson, D. J., & Brand, N. H. (2007). Brief motivational intervention and alcohol expectancy challenge with heavy drinking college students: A randomised factorial study. Addictive Behaviors , 32 , 2509-2528. doi:10.1016/j.addbeh.2007.06.018

Wood, E., Shakeshaft, A., Gilmour, S., & Sanson-Fisher, R. (2006). A systematic review of school-based studies involving alcohol and the community. Australian and New Zealand Journal of Public Health, 30 , 542-549. doi: 10.1111/j.1467-842X.2006.tb00783.x

Wu, Y., Stanton, B. R., Galbraith, J., Kaljee, L., Cottrell, L., Li, X., et al. (2003). Sustaining and broadening intervention impact: A longitudinal randomised trial of three adolescent risk reduction interventions. P aediatrics, 111 , e32-38. doi: 10.1542/peds.111.1.e32

Ph.D ., Professor of Psychiatry and Psychology Psychology Department Dalhousie University, 1355 Oxford Street CA – Halifax, Nova Scotia [email protected]

Du même auteur

• Recommendations in Underage Drinking , , 2012

Ph.D., Senior Lecturer and Consultant Clinical Psychologist Department of Psychological Medicine and Psychiatry Institute of Psychiatry King’s College London 4 Windsor Walk, Denmark Hill UK – London, SE5 8BB [email protected] Ph.D., OPQ, Chercheure Agrégée, Psychiatrie Centre de recherche du CHU Ste-Justine Université de Montréal, Bureau 1551 3175 Chemin de la Côte Sainte-Catherine CA – Montreal, H3T 1C5 [email protected]

Ph.D . Department of Public Health Hjelt InstituteUniversity of Helsinki FI – 00014 Helsinki and Department of Mental Health and Substance Abuse Services National Institute for Health and Welfare FI – 00271 Helsinki [email protected]

• Chapter 2. Risk and Protective Factors for Underage Drinking in Underage Drinking , , 2012

Ph.D ., Professor Addiction, Development, and Psychopathology (Adapt) Department of Psychology University of Amsterdam Weesperplein 4 Nl – 1018 XA Amsterdam [email protected]

Ph.D ., Professor II Center of Alcohol Studies Rutgers University 607 Allison Road, Piscataway USA – New Jersey 08854-8001 [email protected]

• Chapter 1. Underage Drinking in Europe and North America in Underage Drinking , , 2012

Le texte et les autres éléments (illustrations, fichiers annexes importés) sont sous Licence OpenEdition Books , sauf mention contraire.

A Report on Drinking in the Second Decade of Life in Europe and North America

Vérifiez si votre institution a déjà acquis ce livre : authentifiez-vous à OpenEdition Freemium for Books. Vous pouvez suggérer à votre bibliothèque/établissement d’acquérir un ou plusieurs livres publié(s) sur OpenEdition Books. N'hésitez pas à lui indiquer nos coordonnées : OpenEdition - Service Freemium [email protected] 22 rue John Maynard Keynes Bat. C - 13013 Marseille France Vous pouvez également nous indiquer à l'aide du formulaire suivant les coordonnées de votre institution ou de votre bibliothèque afin que nous les contactions pour leur suggérer l’achat de ce livre.

Merci, nous transmettrons rapidement votre demande à votre bibliothèque.

Volume papier

Référence électronique du chapitre, référence électronique du livre, collez le code html suivant pour intégrer ce livre sur votre site..

OpenEdition est un portail de ressources électroniques en sciences humaines et sociales.

• OpenEdition Journals
• OpenEdition Books
• OpenEdition Freemium
• Mentions légales
• Politique de confidentialité
• Gestion des cookies
• Signaler un problème

Vous allez être redirigé vers OpenEdition Search

An official website of the United States government

Here’s how you know

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Methodology.

Download the Source and Accuracy Statement PDF 863 KB

niaaa.nih.gov

An official website of the National Institutes of Health and the National Institute on Alcohol Abuse and Alcoholism

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

THE EFFECT OF ALCOHOLISM TOWARD ACADEMIC PERFORMANCE

Drinking habit of civil engineering student of Samar state university.

Related Papers

Archives of Clinical Psychiatry (São Paulo)

Vilma Aparecida da Silva Fonseca

International journal of preventive medicine

Claire D. Mills

We assessed associations between educational achievement and alcohol consumption. We employed five alcohol consumption measures (length of time of and amount consumed during most recent drinking occasion, frequency of alcohol consumption, heavy episodic drinking, problem drinking); and three educational achievement indicators (students' subjective importance of achieving good grades, students' appraisal of their academic performance in comparison with peers, students' actual module mark). Males were positively associated with all five alcohol consumption measures. Age was negatively associated with three alcohol consumption measures. While students´ importance of good grades was negatively associated with three alcohol consumption measures, academic performance in comparison with peers was negatively associated with heavy episodic drinking. Actual module mark was not associated with any alcohol consumption measure. Alcohol consumption showed negative associations with mo...

Journal of Adolescent Health

Bert Aertgeerts

Journal of College Student Development

Tricia Seifert , Kathleen Goodman

Mediterranean Journal of Social Sciences

Veronica A K W E N A B U A Y E Undelikwo

Alcohol abuse cut-short the academic vision of colleges and universities and may undermine their aspiration of molding future citizens. In Nigeria, alcohol consumption has found its way among undergraduate students, who are normally seen in bars and restaurants including other secluded areas some metres away from the school consuming alcohol. The study examined the effects of alcohol abuse on the academic performance of Social Science Students of the University of Calabar, Nigeria. Data was obtained through the administration of 120 copies of questionnaires to students of the faculty of Social Sciences of University of Calabar, Nigeria. The Participants were approached at their lecture rooms and popular hang-outs within the faculty. Their ages ranged from 15 to 35 years and above. The result revealed that majority of the participants were within the age group of 15 – 35 years, which indeed is the age of risky behaviour characterized by substances use and abuse. For fun, stay wake (n...

Sharyn Burns

Jurnal Pendidikan Jasmani dan Olahraga

Arvin Andacao

Alcohol is widely used in the world. Either for happiness or resolving problems, college students continue to have interaction with alcoholic drinks. This paper was aimed to examine the connection between alcohol intake and scholastic performance of second-year college students who took Physical Education subject in Davao Oriental State College of Science and Technology. The authors employed descriptive-correlational design with 115 students as samples out of 377 participated respondents. One set of adopted, contextualized, and tested 15-items of types of drinker instrument gaining excellent Cronbach’s alpha was used. Academic grades had been acquired and generated from an electronic database school system for academic records of the students. The findings discovered that the general level of alcohol consumption of the students was moderate, while the overall educational performance score was generally determined as satisfactory. The students aged 15 to 17 years gained f value 6758...

Brian Yatich

RELATED PAPERS

muhammad munawar

Annalen der Physik

Christoph Strunk

Journal of the Brazilian Chemical Society

RENATO ZANELLA

Progress in biomaterials

Anita Margret

Leigh Symonds

2021 IEEE 8th International Workshop on Metrology for AeroSpace (MetroAeroSpace)

Annarita Tedesco

Research in International Business and Finance

Dr Fouad Jamaani

Brain : a journal of neurology

Mena Abdelsayed

Media Gizi Indonesia

ERWIN ASTHA TRIYONO

Artie in Friuli Arte in Trieste

Janez Höfler Hoefler

Íconos - Revista de Ciencias Sociales

Stefan Ortiz Przychodzka

[Universitatea din București], București, 1978

Persian Studies Cluj-Napoca

arXiv (Cornell University)

Transplantation Proceedings

Cüneyt Aytekin

Buy Verified Cash App Accounts

Natural Hazards and Earth System Sciences

Delta Silva

Surgery for Obesity and Related Diseases

maryam Biglari Abhari

Transport Reviews

Sergio Jara-Diaz

Journal of Applied Cognitive Neuroscience

Ricardo Allegri

Journal of emerging technologies and innovative research

Dr Preeti Pareek

Chanakyapuri

Ashish Delhi

Journal of Pain Research

Joseph Cappelleri

Sohal Ismail

See More Documents Like This

RELATED TOPICS

•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2024

The Palgrave Handbook of Psychological Perspectives on Alcohol Consumption pp 1–22 Cite as

Psychological Perspectives on Alcohol Consumption

• Richard Cooke 8 , 9 ,
• Dominic Conroy 10 ,
• Emma Louise Davies 11 ,
• Martin S. Hagger 12 , 13 &
• Richard O. de Visser 14  
• First Online: 11 May 2021

940 Accesses

1 Citations

6 Altmetric

This chapter provides an introduction to the Handbook, setting the scene for the subsequent chapters by covering several key topics in psychological research on alcohol consumption, such as why do people drink alcohol, how drinking patterns are defined (e.g., heavy episodic drinking, low-risk drinking), and how do governments and health agencies encourage performance of low-risk drinking. The chapter goes on to discuss issues of definition and measurement of alcohol consumption in psychological research studies, beginning with a focus on limitations with self-report measures used in most studies, before a brief discussion of alternative (biological measures, observation) methods to measure consumption. The chapter ends by introducing the five sections that comprise the book.

This is a preview of subscription content, log in via an institution .

Buying options

• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

A UK unit equals 8 g or 10 ml of pure alcohol and is the same as a single (25 ml) shot of spirits, approximately half a 175 ml glass of wine and approximately half a pint (568 ml) of beer, 1 cider, or lager.

Anderson, P., Chisholm, D., & Fuhr, D. C. (2009). Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet (London, England), 373 (9682), 2234–2246. https://doi.org/10.1016/S0140-6736(09)60744-3

Article   PubMed   Google Scholar  

Babor, T. (Ed.). (2010). Alcohol: No ordinary commodity: Research and public policy . Oxford, UK: Oxford University Press.

Google Scholar  

Barratt, M. J., Ferris, J. A., Zahnow, R., Palamar, J. J., Maier, L. J., & Winstock, A. R. (2017). Moving on from representativeness: Testing the utility of the global drug survey. Substance Abuse: Research and Treatment, 11 , 117822181771639. https://doi.org/10.1177/1178221817716391

Article   Google Scholar  

Beccaria, F., Petrilli, E., & Rolando, S. (2015). Binge drinking vs. drunkenness. The questionable threshold of excess for young Italians. Journal of Youth Studies, 18 (7), 823–838. https://doi.org/10.1080/13676261.2014.992321

Bowring, A. L., Gold, J., Dietze, P., Gouillou, M., Van Gemert, C., & Hellard, M. E. (2012). Know your limits: Awareness of the 2009 Australian alcohol guidelines among young people: Alcohol guidelines: Awareness and risk. Drug and Alcohol Review, 31 (2), 213–223. https://doi.org/10.1111/j.1465-3362.2011.00409.x

Burgess, M., Cooke, R., & Davies, E. L. (2019). My own personal hell : Approaching and exceeding thresholds of too much alcohol. Psychology & Health , 34 , 1451–1469. https://doi.org/10.1080/08870446.2019.1616087

Ceballos, N., & Babor, T. F. (2017). Editor’s corner: Binge drinking and the evolving language of alcohol research. Journal of Studies on Alcohol and Drugs, 78 (4), 488–490. https://doi.org/10.15288/jsad.2017.78.488

Centers for Disease Control and Prevention. (2011). Fact sheets: Binge drinking . http://www.cdc.gov/alcohol/fact-sheets/bingedrinking.htm

Clapp, J. D., Holmes, M. R., Reed, M. B., Shillington, A. M., Freisthler, B., & Lange, J. E. (2007). Measuring college students’ alcohol consumption in natural drinking environments: Field methodologies for bars and parties. Evaluation Review, 31 (5), 469–489. https://doi.org/10.1177/0193841X07303582

Conroy, D., & Measham, F. (2020). Young adult drinking styles: Current perspectives on research, policy and practice . Palgrave Macmillan US: https://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=5987650

Cooke, R., French, D. P., & Sniehotta, F. F. (2010). Wide variation in understanding about what constitutes ‘binge-drinking’. Drugs: Education, Prevention and Policy, 17 (6), 762–775. https://doi.org/10.3109/09687630903246457

Cooper, M. L., Kuntsche, E., Levitt, A., Barber, L. L., & Wolf, S. (2015). Motivational models of substance use: A review of theory and research on motives for using alcohol, marijuana, and tobacco. In K. J. Sher (Ed.), The Oxford handbook of substance use disorders (Vol. 1). Oxford, UK: Oxford University Press. https://doi.org/10.1093/oxfordhb/9780199381678.013.017

Chapter   Google Scholar  

Cox, W. M., & Klinger, E. (1988). A motivational model of alcohol use. Journal of Abnormal Psychology, 97 (2), 168–180.

Crawford, J., Jones, A., Rose, A., & Cooke, R. (2020). ‘You see the pictures the morning after and you’re like I wish I was in them’: an interpretative phenomenological analysis of university student’s alcohol-related regrets. Psychology & Health . https://doi.org/10.1080/08870446.2020.1867728

Davies, E. L., Cooke, R., Maier, L. J., Winstock, A. R., & Ferris, J. A. (2020). Drinking to excess and the tipping point: An international study of alcohol intoxication in 61,000 people. International Journal of Drug Policy, 83 , 102867. https://doi.org/10.1016/j.drugpo.2020.102867

Davies, E. L., Puljevic, C., Connolly, D., Zhuparris, A., Ferris, J. A., & Winstock, A. R. (2020). The world’s favourite drug: What we have Learned about alcohol from over 500,000 respondents to the global drug survey. In D. Frings & I. P. Albery (Eds.), Alcohol handbook: From synapse to society . Cambridge, MA: Academic Press.

Davis, P., Patton, R., & Jackson, S. (Eds.). (2017). Addiction: Psychology and treatment . Hoboken, NJ: John Wiley & Sons.

de Beukelaar, M. F., Janse, M. L., Sierksma, A., Feskens, E. J., & de Vries, J. H. (2019). How full is your glass? Portion sizes of wine, fortified wine and straight spirits at home in the Netherlands. Public Health Nutrition, 22 (10), 1727–1734. https://doi.org/10.1017/S1368980019000442

de Visser, R., Brown, C., Cooke, R., Cooper, G., & Memon, A. (2017). Using alcohol unit-marked glasses enhances capacity to monitor intake: Evidence from a mixed-method intervention trial. Alcohol and Alcoholism, 52 , 206–212. https://doi.org/10.1093/alcalc/agw084

de Visser, R. O., & Birch, J. D. (2012). My cup runneth over: Young people’s lack of knowledge of low-risk drinking guidelines: Young people’s knowledge of alcohol guidelines. Drug and Alcohol Review, 31 (2), 206–212. https://doi.org/10.1111/j.1465-3362.2011.00371.x

de Visser, R. O., Hart, A., Abraham, C., Memon, A., Graber, R., & Scanlon, T. (2014). Which alcohol control strategies do young people think are effective?: Alcohol policies. Drug and Alcohol Review, 33 (2), 144–151. https://doi.org/10.1111/dar.12109

de Visser, R. O., & Nicholls, J. (2020). Temporary abstinence during Dry January: Predictors of success; impact on well-being and self-efficacy. Psychology & Health , 35 , 1293–1305. https://doi.org/10.1080/08870446.2020.1743840

Department of Health. (2016). UK chief medical officers’ alcohol guidelines review summary of the proposed new guidelines. https://www.gov.uk/government/uploads/sys-tem/uploads/attachment_data/file/489795/summary.pdf

Furtwaengler, N. A. F. F., & de Visser, R. O. (2013). Lack of international consensus in low-risk drinking guidelines. Drug and Alcohol Review, 32 (1), 11–18. https://doi.org/10.1111/j.1465-3362.2012.00475.x

Graber, R., de Visser, R., Abraham, C., Memon, A., Hart, A., & Hunt, K. (2016). Staying in the ‘sweet spot’: A resilience-based analysis of the lived experience of low-risk drinking and abstention among British youth. Psychology & Health, 31 (1), 79–99. https://doi.org/10.1080/08870446.2015.1070852

Heather, N., Partington, S., Partington, E., Longstaff, F., Allsop, S., Jankowski, M., … St Clair Gibson, A. (2011). Alcohol use disorders and hazardous drinking among undergraduates at English universities. Alcohol and Alcoholism (Oxford, Oxfordshire), 46 (3), 270–277. https://doi.org/10.1093/alcalc/agr024

Holmes, J., Brown, J., Meier, P., Beard, E., Michie, S., & Buykx, P. (2016). Short-term effects of announcing revised lower risk national drinking guidelines on related awareness and knowledge: A trend analysis of monthly survey data in England. BMJ Open, 6 (12), e013804. https://doi.org/10.1136/bmjopen-2016-013804

Article   PubMed   PubMed Central   Google Scholar  

Jones, L., Bellis, M. A., Dedman, D., Sumnall, H., & Tocque, K. (2008). Alcohol attributable fractions for England: Alcohol attributable mortality and hospital admissions . North West Public Health Observatory and Department of Health.

Kuntsche, E., Kuntsche, S., Thrul, J., & Gmel, G. (2017). Bing drinking: Health impact, prevalence, correlates and interventions. Psychology & Health, 32 , 976–1017. https://doi.org/10.1080/08870446.2017.1325889

Kuntsche, E., Stewart, S. H., & Cooper, M. L. (2008). How stable is the motive–alcohol use link? A cross-national validation of the drinking motives questionnaire revised among adolescents from Switzerland, Canada, and the United States. Journal of Studies on Alcohol and Drugs, 69 (3), 388–396. https://doi.org/10.15288/jsad.2008.69.388

Livingston, M. (2012). Perceptions of low-risk drinking levels among Australians during a period of change in the official drinking guidelines: Perceptions of low-risk drinking. Drug and Alcohol Review, 31 (2), 224–230. https://doi.org/10.1111/j.1465-3362.2011.00414.x

Lovatt, M., Eadie, D., Meier, P. S., Li, J., Bauld, L., Hastings, G., & Holmes, J. (2015). Lay epidemiology and the interpretation of low-risk drinking guidelines by adults in the United Kingdom: Lay epidemiology and the interpretation of low-risk drinking guidelines. Addiction, 110 (12), 1912–1919. https://doi.org/10.1111/add.13072

McCambridge, J., & Day, M. (2008). Randomized controlled trial of the effects of completing the Alcohol Use Disorders Identification Test questionnaire on self-reported hazardous drinking. Addiction, 103 (2), 241–248. https://doi.org/10.1111/j.1360-0443.2007.02080.x

McKenna, H., Treanor, C., O’Reilly, D., & Donnelly, M. (2018). Evaluation of the psychometric properties of self-reported measures of alcohol consumption: A COSMIN systematic review. Substance Abuse Treatment, Prevention, and Policy, 13 (1), 6. https://doi.org/10.1186/s13011-018-0143-8

Moss, A. C., & Dyer, K. R. (2010). Psychology of addictive behaviour . Basingstoke, UK: Palgrave Macmillan.

Book   Google Scholar  

National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2004). NIAAA approves definition of binge drinking. NIAAA Newsletter, 3 (Winter) https://pubs.niaaa.nih.gov/publications/Newsletter/winter2004/Newsletter_Number3.pdf

Piano, M. R., Mazzuco, A., Kang, M., & Phillips, S. A. (2017). Binge drinking episodes in young adults: How should we measure them in a research setting? Journal of Studies on Alcohol and Drugs, 78 (4), 502–511. https://doi.org/10.15288/jsad.2017.78.502

Radaev, V. (2019). Making sense of alcohol consumption among Russian young adults in the context of post-2009 policy initiatives. In D. Conroy & F. Measham (Eds.), Young adult drinking styles (pp. 313–332). Cham, Switzerland: Palgrave Macmillan.

Riordan, B. C., Flett, J. A. M., Cody, L. M., Conner, T. S., & Scarf, D. (2019). The Fear of Missing Out (FoMO) and event-specific drinking: The relationship between FoMO and alcohol use, harm and breath alcohol concentration during orientation week. Current Psychology . https://doi.org/10.1007/s12144-019-00318-6

Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption--II. Addiction (Abingdon, England), 88 (6), 791–804.

Sobell, L. C., & Sobell, M. B. (1992). Timeline follow-back: A technique for assessing self-reported alcohol consumption. In R. Z. Litten & J. P. Allen (Eds.), Measuring alcohol consumption (pp. 41–72). Totowa, NJ: Humana Press.

Svanberg, J. (2018). The psychology of addiction . London/Washington, DC: Routledge/Taylor & Francis Group.

van der Sar, R., Storvoll, E. E., Brouwers, E. P. M., van de Goor, L. A. M., Rise, J., & Garretsen, H. F. L. (2012). Dutch and Norwegian support of alcohol policy measures to prevent young people from problematic drinking: A cross-national comparison. Alcohol and Alcoholism, 47 (4), 479–485. https://doi.org/10.1093/alcalc/ags032

van Egmond, K., J.C Wright, Livingston, M., & Kuntsche, E. (2020). Wearable transdermal alcohol monitors: A systematic review of detection validity, relationship between transdermal and breath alcohol concentration and influencing factors. Alcoholism: Clinical and Experimental Research , acer.14432. doi: https://doi.org/10.1111/acer.14432

World Health Organization. (2018). Global status report on alcohol and health 2018 . Geneva, Switzerland: World Health Organization.

Download references

Author information

Authors and affiliations.

Department of Psychology, University of Liverpool, Liverpool, UK

Richard Cooke

Liverpool Centre for Alcohol Research, Liverpool, UK

School of Psychology, University of East London, London, UK

Dominic Conroy

Department of Psychology, Health and Professional Development, Oxford Brookes University, Oxford, UK

Emma Louise Davies

Department of Psychological Sciences, University of California, Merced, Merced, CA, USA

Martin S. Hagger

Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland

Brighton and Sussex Medical School, University of Sussex, Falmer, UK

Richard O. de Visser

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Richard Cooke .

Editor information

Editors and affiliations, rights and permissions.

Reprints and permissions

Copyright information

© 2021 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Cite this chapter.

Cooke, R., Conroy, D., Davies, E.L., Hagger, M.S., de Visser, R.O. (2021). Psychological Perspectives on Alcohol Consumption. In: Cooke, R., Conroy, D., Davies, E.L., Hagger, M.S., de Visser, R.O. (eds) The Palgrave Handbook of Psychological Perspectives on Alcohol Consumption. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-66941-6_1

Download citation

DOI : https://doi.org/10.1007/978-3-030-66941-6_1

Published : 11 May 2021

Publisher Name : Palgrave Macmillan, Cham

Print ISBN : 978-3-030-66940-9

Online ISBN : 978-3-030-66941-6

eBook Packages : Behavioral Science and Psychology Behavioral Science and Psychology (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

Prevention and Treatment of Alcohol Problems: Research Opportunities (1990)

Chapter: 6 methodological issues in alcohol prevention research: conclusions and recommendations.

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

6 METHODOLOGICAL ISSUES IN ALCOHOL PREVENTION RESEARCH: CONCLUSIONS AND RECOMMENDATIONS No single set of research designs or analytical strategies has characterized research on the prevention of alcohol problems. A variety of approaches can be used depending on the goals of the research, the setting or opportunity afforded, the amount and type of variation one wishes to control or explain, and the generalizability of the findings. One of the difficulties in prevention research--particularly the kind of research that is most relevant to public policy deliberations--is the need to conduct such research outside the laboratory setting. ~Real-world" research, however, is difficult to undertake, often expensive to conduct, and difficult to analyze. It is less precise than laboratory work because researchers do not have the opportunity to manipulate variables as they would in laboratory experimentation. It also raises questions of ascertainment and of the validity of self-reports and other measures that are commonly used to assess the efficacy of a preventive intervention. On the other hand, because of the controlled or "hothouse" conditions used in laboratory settings, the extent to which prevention research undertaken in the laboratory can be generalized to the real world is not known. In recent years, alcohol prevention research has made use of a variety of qualitative and quantitative methods. For example, ethnographic methods and the observation of behavior in natural settings have been employed. Ethnographers gather data through semistructured interviews and through traditional participant-observer techniques. Examples of ethnographic/observational studies in prevention include studies of blue-collar workers and family drinking (Ames and Janes, 1987), of public drinking and drinking contexts (Rosenbluth, Nathan, and Lawson, 1978; Storm and Cutler, 1981; Harford et al., 1983; Single and Storm, 1985; Geller, Russ, and Altomari, 1986), and of the work site (Ames, 1987~. In many respects, the social and health problems that are associated with alcohol need to be viewed in a historical context. Historical analysis, by using both U.S. and international data sources, offers promising opportunities for prevention research. For example, it has been reported that between 1830 and 1850 there was a dramatic decline in per capita consumption in the United States (Rorabaugh, 1976) and that the temperance movement and government policies contributed to this decline and to a concomitant decrease in alcohol problems (Popham, 1978; Moore and Gerstein, 1981; Pendergast, 1987~. Historical analysis could provide a method to discover potential "lessons" that might be useful in the modern alcohol problem prevention arena. Community, school, and work site prevention trials have begun to reflect the use of combinations of several relevant theories (learning, organization, communication, behavior change, health education, and social marketing) in their design. Interest in such designs has been stimulated by the success in health promotion programs to reduce heart disease that are discussed in Chapter 5 (Farquhar et al., 1984; Puska et al., 1985~. These approaches have been used in studies of community interventions for alcohol problems at schools (see the review by Moskowitz, 1989), local availability of alcohol (Wittman and Hilton, 1987), and the influence of the mass media (Hewitt and Blane, 1984~. Because of the difficulty of random assignment in field studies, quasi-experimental designs have been used (Cook and Campbell, 1979~. These designs are often employed in the policy analysis -128

of Naturals experiments, such as changes in alcohol availability. One useful statistical tool Is the interrupted time-series analysis (Box and Tiao, 1975; Box and Jenkins, 1976), which has more power than conventional least-squares regression to deal with problems of autoregression, seasonali~, and trending (Skim lo Wanennar 19~ Rln.ce ~nr1 Mn1~1f~.r 1987; Holder and Those, 1987a). O ~=, , ~-, _ _, ~^ ~,, Quasi~xperimental designs are also used to address problems related to nonequivalent control conditions or groups (Cook and Campbell, 1979~. These designs frequently employ multivariate analysis techniques to increase statistical power. Examples include evaluations of server intervention (Saltz, 1987), happy-hour bans (Smart and Adlaf, 1986), college prevention programs (Mills et al., 1983), cross-cultural drinking behavior (Moskowitz, 1989), alcohol taxes (Cook and Tauchen, 1982), and changes in driving-under-the-influence sanctions and enforcement in Maine (Hingson et al., 1987~. The multifaceted and dynamic nature of the social, cultural, and economic systems in which prevention occurs requires techniques that can deal with such complexity. One approach that has been used is computer modeling. This tool is used in astronomy, physics, and business and economic research and has particular utility for prevention research because it provides the ability to predict potential outcomes prior to expensive field implementation (Katzper, Ryback, and Hertzman, 1976; Holder and Those, 1987b). For example, complex statistical modeling has been used to examine the sensitivity of drinking and alcohol problems to changes in price levels. Examples include studies by Grossman, Coate, and Arluck (1987) and by Levy and Sheflin (1983~. RESEARCH DESIGN FOR FUTURE ALCOHOL PREVENTION RESEARCH PROGRAMS There are several primary issues relevant to the design of prevention research in the alcohol field. Three of these issues are discussed below: (1) the importance of using theory as a basis for design, (2) the need for both laboratory and field research, and (3) the practical as well as the statistical significance of research findings. The Importance of Theory A truly comprehensive theory for prevention research must encompass complex and dynamically changing biobehavioral mechanisms, individual and group behaviors, organizational influences, and cultural patterns. It is particularly important to incorporate the dimension of time into theoretical models in order to take account of life-span or developmental milestones. Theory is required to establish priorities, to develop and test hypotheses about mediating mechanisms, and to develop or select appropriate interventions, program evaluation, and intermediate and longer term outcome measures. When used for these purposes, theory can help prevention researchers identify the active ingredients in prevention programs and anticipate and account for intervention effects. Theory-driven programmatic research could then be undertaken by using combinations of methodologies including laboratory-based randomized trials, analogue studies, ethnographic and other naturalistic data collection methods, and complex model building. Such research can be undertaken within and between different levels of the social structure ranging from the individual to the community. -129

In other public health efforts that have utilized community, school, or work site as the base in prevention trials, combinations of several relevant theories (learning, organizational, communication, behavior change, health education, media, social marketing) have been used to guide intervention and evaluation (Flay, 1984; Farquhar et al., 1985; Abrams et al., 1986~. This diversity in approach is illustrated by the Stanford, Minnesota, and Pawtucket heart disease prevention trials discussed in the preceding chapter (Maccoby et al., 1977; Blackburn et al., 1984; Lasater et al., 1984; Farquhar et al., 1985~. Crucial to developing effective and adequate strategies of prevention intervention is the use of formative research, program evaluation, process tracking, and assessment of program impact and potential problems. A varietr of research approaches can be used in which the design of programs results from an interactive process, combining theoretical and scientific input with practical input from the community and individual consumers. These approaches include ethnographic methods derived from anthropology, unobtrusive or naturalistic observation, the use of focus groups, random-digit rapid telephone surveys, and the use of small-scale randomized designs in the field or laboratory. ~ -' - -' O ouch eva~uauon methods are crucial for developing effective interventions, for making early or midcourse corrections in a program, and for evaluating whether, in fact, the manipulation of independent variables did occur at a sufficiently strong level (dosage) and with the intended impact on the target variables, mediating mechanisms, or processes. In community prevention programs, interactive and synergistic effects sometimes occur or are intentionally encouraged, making it necessary to consider the question of contamination and to measure impact in areas other than the direct intervention targets. For example, do single-focus, school-based smoking prevention programs actually reduce (or increase) alcohol and other drug use? Are multifocus programs more or less effective? Unlike traditional research in which one variable is manipulated whereas all other factors are controlled, the use of multiple criteria (including factors such as cost-effectiveness) may be more appropriate in program evaluation or prevention research (e.g., Warner and Luce, 1982; Altman et al., 1987~. In some cases, the spillover effects that result from such multifocused, synergistic processes as changing social norms and social network interactions in a school, work site, or other system are regarded as beneficial. They are viewed as an intentional part of the intervention and evaluation process rather than ~contamination." However, it is crucial to decide what is acceptable synergism and what is contamination, especially with respect to the unit of analysis, the questions being asked, and the comparison groups and settings being used. Need for Both Laboratory and Field Prevention Research The term laboratory research is used here to mean research conducted under conditions that permit the direct manipulation of the variables under investigation. Studies conducted within a controlled environment to allow the manipulation of variables have the advantage of providing better opportunities to assign subjects randomly to treatment and no-treatment conditions. Laboratory studies permit the examination of particular variables and the determination of whether specific experimental factors may play a role in a prevention program or policy. For example, the potential role of retail price in alcohol use can be demonstrated in a laboratory experiment that simulates an actual retail drinking situation in which the subjects' drinking is measured as the price of alcohol is manipulated. Such analogue studies can demonstrate (or fail to demonstrate) that retail price (or the economic accessibility of alcohol) affects drinking behavior. Such studies cannot tell, however, -130

whether price is actually a significant variable in the natural setting, given the number of other factors at work. Prevention research also requires studies that are conducted in the field or in naturalistic environments in which physical manipulation of the situation may be difficult or impossible. Such studies can be more generalizable, but they lack the convenience or appropriateness of random assignment for controlling variance in extraneous factors; however, multivariate statistical tools are available as the means for control. Both laboratory and field studies are needed in prevention research because they have complementary strengths. In particular, the validity of conclusions is strengthened when consistency is demonstrated between the two approaches. In recent years, empirically minded social scientists have become increasingly concerned with the problem of inferring individual-level behavior from aggregate data (Lanbein and Lichtman, 1978~. (The term ecological fallacy has been used to describe an incorrect inference about individual behavior based on proud data.) By far the most obvious intervening variable in need of disaggregation is the consumption history of the drinker. Many authors who have written about the policy implications of economic variables have lamented the fact that current models have been unable to differentiate among alcohol-dependent persons, heavy drinkers, and moderate consumers. Although there has never been a systematic program of experimental research designed to investigate the interaction between environmental variables and alcohol consumption, a number of studies have been conducted to investigate the important policy questions raised by economic and epidemiological studies. For example, several studies have investigated the relative impact of economic variables on the behavior of alcohol abusers (Mello, 1968; Cohen et al., 1971; Bigelow and Liebson, 1972; Engle and Williams, 1972; Marlatt, Demming, and Reid, 1973~. The findings in these studies suggest that the strengths of both experimental and quasi-experimental research designs can be combined in complementary studies that move from laboratory analogues to more complicated natural settings. One question of interest in prevention research concerns whether persons with alcohol problems differ from persons without alcohol problems in their responsiveness to economic incentives for drinking or abstinence. Babor and colleagues (1978) demonstrated that heavy drinkers were as responsive as casual drinkers to the afternoon price manipulation known as the happy hour. Indeed, one of the most encouraging findings of the happy-hour studies was the extent to which the discount drink policy was associated with similar alterations in drinking behavior in both laboratory and natural settings (Babor et al., 1980~. Laboratory analogue research was also combined with naturalistic observation in the studies of Langenbucher and Nathan (1983~. Three experiments were used to test the ability of social dnnkers, bartenders, and police officers to estimate sobriety. This study has important implications for public policy regarding alcohol sale or use and the legal penalties for purveyors who knowingly or unknowingly serve alcohol to intoxicated persons. Naturalistic studies have the advantage of being heuristic, realistic, and relevant to important social problems when they include three important dimensions: natural behavior (e.g., drinking), natural settings (e.g., a tavern or bar), and natural treatment (e.g., price variations). -131

The Practical Significance of Prevention Research In addition to the concern that no false conclusions be drawn from data, the prevention researcher must also consider the practical significance of any finding. A statistical change may be too small to justifier the operational costs of a prevention strategy. Alternatively, the level of statistical significance may be set so high by the researcher, or the variable selected for measurement may occur so infrequently, that a finding of practical significance is overlooked. In selecting a research design, the variables to be studied, and the statistical approach, researchers should be aware that prevention research must accommodate both substantive and statistical significance. DIRECTION AND DESIGN OF FUTURE ALCOHOL PREVENTION RESEARCH PROGRAMS: CONCLUSIONS AND RECOMMENDATIONS The conclusions discussed below constitute the committee's recommendations for future directions in research designed to reduce alcohol-related problems. · Attempts should be made to integrate findings from biomedical research (e.g., biobehavioral vulnerability) with theories on individual, social, educational, and economic variables that influence alcohol use and abuse. Integrated models can then be used to guide the development of prevention interventions and the matching of at-risk subgroups with appropriate intervention strategies. · It is important to ensure that theory drives the research, which can be achieved by borrowing theory-based analogues from studies in other health fields. Although such theories as social learning approaches have helped in understanding behavior change in individuals, there is little assurance that an adequate theoretical framework is available for the fields of community organization, regulatory and polipy-based interventions, environmental change strategies, and interventions that depend on changing the organizations themselves. · Life-span considerations and developmental factors over time should be incorporated into comprehensive theories. If it can be anticipated that a specific interaction between individual characteristics (e.g., social skills deficits) and environmental/cultural demands (e.g., peer pressure to conform during early puberty) is likely to produce a large at-risk group, then such predictions can be used to plan both individual and community prevention programs. In this manner, findings from biological, psychological, and cultural areas can be used to plan prevention strategies for use during an earlier developmental phase so as to ~inoculate" a vulnerable population prior to exposure. Research should also be undertaken to shed light on the determinants of social norms regarding alcohol use. Such research should include creative methods to determine the effects of corporate policies, advertising, and the popular mass media on the nation's attitudes regarding the use of alcohol. · Multidisciplinary collaboration in theory development should be encouraged from such diverse fields as the biomedical sciences, econometrics, education, psychology, sociology, clinical epidemiology, anthropology, and other relevant disciplines. The development of theories that examine the interaction.s amen ~ varinhles rl~.riv~1 from adherent levels or analysis or olllerent olsclpllnes should be particularly encouraged, especially if the theories can be used to guide the selection of intervention components and evaluation approaches. The use of new methodologies for formal theory development and model building should also be encouraged. Such methods as structural modeling and path-analytic procedures, computer simulation, and other multivariate approaches to causal . . ana yses appear promising. -132

· Program planning and implementation should be integrated with evaluation. The use of formative research, one of the main components of social marketing, should be increased to ensure success in pilot studies of untested components of programs. Researchers are often unable to obtain sufficient funding to implement programs they may want to evaluate, and program personnel often do not have the funds to support a full evaluation of their programs. The result is that major prevention programs are ~evaluated" after the fact and only in a descriptive or cursory manner. A mechanism needs to be found to facilitate a coherent demonstration evaluation plan whereby program and research designs are fully integrated. Until then, program evaluations, particularly at the community level, will remain piecemeal, inconsistent, and generally inadequate. (One of the great barriers to community prevention research is the enormous cost of collecting the data necessary for measuring whether an intervention has had an effect. NIAAA may want to consider ways to encourage local and county agencies to develop information management systems that can sense as existing data bases for measuring changes within the community. As local agencies begin to see the value of such data bases, they would undoubtedly expand their range to incorporate community and environmental variables that at first may seem remote to their needs. Ideally, such a system might include regular spot surveys of the alcohol-related concerns, knowledge, consumption, and problems of the community.) · Community trials of prevention strategies should be instituted. One essential prevention research finding derived from heart disease and cancer prevention studies is the value of long-term community trials, such as those reported in Chapter 5. Such approaches have rarely been undertaken in efforts to prevent or reduce alcohol problems or to conduct alcohol problem prevention research. Tested research components should be combined into comprehensive, integrated, and reasonably long-term community-based projects to test the hypothesis that synergistic effects occur and that significant reductions in alcohol-related problems may be demonstrated. Effective community trials are long-term investments in the health and well-being of community members. They represent an opportunity to carefully monitor changes or the absence of change in targeted behaviors and situations. Prevention efforts to reduce alcohol problems have matured to a stage at which cost-effective longitudinal research projects could be undertaken. Such community prevention research trials will require (a) a long-term funding commitment for project development, implementation, and evaluation; (b) an effective partnership between prevention program specialists and prevention researchers; and (c) application of the latest research findings to identify behaviors and situations that can be effectively targeted for change. · Prevention research should be used in policy development. The interests of researchers, prevention policymakers, and program planners are similar but not identical. Polipymakers and planners are interested not merely in understanding the general effects of a particular strategy or documenting its past impact but also in anticipating its future impact in a specific situation. Conventional research and evaluation studies do not by themselves Drovide the tvDes of "Drosnective" information that nolicvmakers require. ~ ~ or-- -- r---r~ ~~ ~~~~~ a---- ~~-~- ~~~- Although traditional research methods are often the most effective approach for examining a small number of variables in isolation from other factors, the policymaker must deal with the considerable Messiness" of detail contained in the real world. Tools are needed to assist policymakers and planners in making the best use of available resources, which would enable them to bring empirical and theoretical knowledge to bear on (a) understanding the complex network of factors that surround a set of alcohol problems and (b) estimating the likely impact of interventions in specific situations. Prevention research must develop the methods and techniques needed to assist prevention planners in estimating potential effects based on the best available research. One potentially valuable area of research is computer simulation, which permits perturbation (nwhat ifs) experiments to be undertaken to examine changes in a complex system. In such research, the computer is programmed to act like -133

the system under study and changes are made to represent the analogous changes expected with a planned prevention policy or program. This type of computer-based experiment is intended to provide policymakers and researchers with data about likely or possible long-term results or outcomes of a set of potential prevention actions. · Cost factors must be considered in prevention research. Much of prevention research is still in a formative stage and thus basic in nature. However, some areas of prevention research have developed beyond this stage to a point at which public policy and programs to prevent or reduce alcohol problems have already been based on such research. In these cases, both program costs and effects should be part of the evaluation; that is, what does it cost to undertake this program or policy given its effect in comparison with other strategies? As has been learned in other public health prevention efforts, cost/effect considerations aid in the selection of the best mix of programs and policies for reducing problems. All prevention approaches do not have similar costs or similar effects. To date, most prevention research has addressed contributory and risk factors and the potential effects of specific prevention strategies. Such research has not addressed the cost to implement or create programs based on research findings. Prevention research should include cost as a part of the outcome measures when such research has moved beyond the formative and developmental stages to a point at which programs can be based on this research. Together, these recommendations present an ambitious program for the coming years. Considerable financial resources and a commitment from researchers in the field will be required to realize the progress called for in this report. Yet the benefits to be gained from reductions in the human and economic tolls of alcohol-related problems will most certainly justify the needed investments of money and intellectual energy. REFERENCES Abrams, D. B., J. Elder, T. Lasater et al. A comprehensive framework for conceptualizing and planning organizational health promotion programs. In M. Cataldo and T. Coates, eds. Behavioral Medicine in Industry. New York: John Wiley and Sons, 1986. Altman, D., T. Flora, S. Fortmann et al. The cost effectiveness of three smoking cessation programs. Am. J. Public Health 77~2~:162-165, 1987. Ames, G. Environmental factors can create a drinking culture at worksite. Business and Health 5:44-45, 1987. Ames, G., and C. R. Janes. Heavy and problem drinking in an American blue collar population: Implications for prevention. Soc. Sci. Med. 25:949-960, 1987. Babor, T., J. Mendelson, I. Greenberg et al. Experimental analysis of the happy hour: Effects of purchase price on alcohol consumption. Psychopharmacology 58:35-41, 1978. Babor, T., J. Mendelson, I. Greenberg et al. Drinking patterns in experimental and barroom settings. J. Stud. Alcohol 41~7~:635-651, 1980. Bigelow, G., and I. Liebson. Cost factors controlling alcohol drinking. Psychol. Rec. 22:305-314, 1972. -134

Blackburn, H., R. Luepker, F. Kline et al. The Minnesota Heart Health Program: A research and demonstration project in cardiovascular disease prevention. Pp. 1171-1178 in J. D. Matarazzo, N. E. Miller, S. M. Weiss et al., eds. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: John Wiley and Sons, 1984. Those, J. O., and H. Holder. Liquor-by-the-drink and alcohol-related traffic crashes: A natural experiment using time-series analysis. J. Stud. Alcohol 48:52-60, 1987. Box, G. E., and G. M. Jenkins. Time Series Analysis: Forecasting and Control. San Francisco: Holden-Day, 1976. Box, G. E., and G. C. Tiao. Intervention analysis with applications to economic and environmental problems. J. Am. Statist. Assoc. 70:70-79, 1975. Cohen, M., I. ~ Liebson, L. ~ Faillace et al. Alcoholism: Controlled drinking and incentives for abstinence. Psychol. Reports 28:575-580, 1971. Cook, P. J., and G. Tauchen. The effect of liquor taxes on heavy drinking. Bell J. Economics 13~2~:379-390, 1982. Cook, T. D., and D. T. Campbell. Quasi-Experimentation: Design and Analysis Issues for Field Settings. Boston: Houghton-Mifflin, 1979. Engle, K B., and T. K Williams. Effects of an ounce of vodka on alcoholics' desire for alcohol. Q. J. Stud. Alcohol 33:1099-1105, 1972. Farquhar, J., S. Fortmann, N. Maccoby et al. lathe Stanford Five City Project: An overview. Pp. 1154-1165 in J. D. Matarazzo, N. E. Miller, S. M. Weiss et al., eds. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: John Wiley and Sons, 1984. Farquhar, J., S. Fortmann, I. Flora et al. The Stanford Five City Project: Designs and methods. Am. J. Epidemiol. 122:323-343, 1985. Flay, B. R. What do we know about the social influences approach to smoking prevention? Review and recommendations. Pp. 67-112 in C. S. Bell and R. Battles, eds. Prevention Research: Deterring Drug Abuse Among Children and Adolescents. NIDA Research Monograph No. 63. USDHHS Publ. No. (A13M)85-1334. Rockville, MD: National Institute on Drug Abluse, 1984. Geller, E. S., N. W. Russ, and M. G. Altomari. Naturalistic observations of beer drinking among college students. J. Appl. Behav. Anal. 19:391-396, 1986. Grossman, M., D. Coate, and G. M. Arluck. Price sensitivity of alcoholic beverages in the United States: Youth alcohol consumption. Pp. 169-198 in H. D. Holder, ed. Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. Greenwich, CI: JAI Press, 1987. Harford, T., S. Feinhandler, J. O'Leary et al. Drinking in bars: An observational study of companion status and drinking behavior. Inter. J. Addict. 18:937-950, 1983. -135

Hewitt, L. W., and H. T. Blane. Prevention through mass media communication. Pp. 281-323 in P. M. Miller and T. D. Nirenberg, eds. Prevention of Alcohol Abuse. New York: Plenum Press, 1984. Hingson, R., T. Heeren, D. Kovenock et al. Effects of Maine's 1981 and Massachusetts' 1982 D.U.I. legislation. Am. J. Public Health 77:593-597, 1987. Holder, H., and J. Those. Impact of changes in distilled spirits availability on apparent consumption: A time series analysis of liquor-by-the-glass. Br. J. Addict. 82:623-631, 1987a. Holder, H., and J. Those. The reduction of community alcohol problems: Computer simulation experiments in three counties. J. Stud. Alcohol 48~2~:124-135, 1987b. Katzper, M., R. Ryback, and M. Hertzman. Preliminary Aspects of Modeling and Simulation for Understanding Alcohol Utilization and the Effects of Regulatory Policies. Report submitted to the National Institute on Alcoholism, September 1976. Kellam, S., C. Brown, B. Rubin et al. Paths leading to teenage psychiatric symptoms and substance use: Developmental epidemiological studies in Woodlawn. Pp. 17-51 in S. Guze, F. Earls, and J. Barrett, eds. Childhood Psychopathology and Development. New York: Raven Press, 1983. Lanbein, L. J., and ~ J. Lichtman. Ecological Inference. London: Sage Publications, 1978. Langenbucher, J. W., and P. E. Nathan. Psychology, public policy and the evidence for alcohol intoxication. Am. Psychologist 383~10~:1070-1077, 1983. Lasater, T., D. Abrams, L. Artz et al. Lay volunteers of a community- based cardiovascular risk factor change program: The Pawtucket Experiment. Pp. 1171-1178 in J. D. Matarazzo, N. E. Miller, S. M. Weiss et al., eds. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: John Wiley and Sons, 1984. Levy, D., and N. Sheflin. New evidence on controlling alcohol through price. J. Stud. Alcohol 44:929-937, 1983. Maccoby, N., J. Farquhar, P. Wood et al. Reducing the risk of cardiovascular disease: Effects of a community-based campaign on knowledge and behavior. J. Community Health 23:100-114, 1977. Marlatt, G. A., B. Demming, and J. B. Reid. Loss of control drinking in alcoholics: An experimental analog. J. Abnormal Psychol. 81:223-241, 1973. Mello, N. K Some aspects of the behavioral pharmacology of alcohol. Pp. 787-809 in D. H. Efrow, ed. Psychopharmacology: A Review of Progress, 1957-1967. Public Health Se~vice Publ. No. 1836. Washington, DC: Government Printing Office, 1968. -136

Mills, K, D. McCarty, J. Ward et al. A residence hall tavern as a collegiate alcohol abuse prevention activity. Addict. Behav. 8:105-108, 1983. Moore, M. H., and D. R. Gerstein. Alcohol and Public Polipy: Beyond the Shadow of Prohibition. Washington, DC: National Academy Press, 1981. Moskowitz, J. M. The primary prevention of alcohol problems: A critical review of the research literature. J. Stud. Alcohol, 50~1~:54-88, 1989. Pendergast, M. L. A history of alcohol problem prevention efforts in the United States. Pp. 25-52 in H. Holder, ed. Advances in Substance Abuse, vol. 1, Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. Greenwich, CI: JAl Press, 1987. Popham, R. The social history of the tavern. Pp. 225-302 in Y. Israel et al., eds. Research Advances in Alcohol and Ding Problems, vol. 4. New York: Plenum Press, 1978. Pu~ska, P., ~ Nissinen, J. Tuomilehto et al. The community-based strategy to prevent coronary heart disease: Conclusions from the ten years of the North Karelia Project. Ann. Rev. Public Health 6:147-193, 1985. Rorabaugh, W. Estimated U.S. alcoholic beverage consumption, 1790 - 1860. J. Stud. Alcohol 37:357-364, 1976. Rosenbluth, J., P. E. Nathan, and D. M. Lawson. Environmental influences on drinking by college students in a college pub: Behavioral observation in the natural setting environment. Addict. Behav. 3:117-121, 1978. Saltz, R. The role of bars and restaurants in preventing alcohol- impaired driving: An evaluation of server intervention. Evaluation and the Health Professions 10:5-27, 1987. Single, E.,-and T. Storm, eds. Public drinking and public policy. Proceedings of a Symposium on Observation Studies held at Banff, Alberta, Canada, April 26-28, 1984. Toronto: Addiction Research Foundation, 1985. Skog, O. Trends in alcohol consumption and violent deaths. Br. J. Addict. 81:365-379, 1986. Smart, R. G., and E. M. Adlaf. Banning happy hours: The impact on drinking and impaired-driving charges in Ontario, Canada. J. Stud. Alcohol, 46~3~:256-258, 1986. Storm, T., and R. Cutler. Observations of drinking in natural settings: Vancouver beer parlors and cocktail lounges. J. Stud. Alcohol 42:972-997, 1981. Wagenaar, ~ Preventing highway crashes by raising the legal minimum age for drinking: The Michigan experience six years later. J. Safety Res. 17:101-109, 1986. -137

Warner, K E., and B. R. Luce. Cost Benefit and Cost Effectiveness Analysis in Health Care: Principles, Practice and Potential. Ann Arbor, MI: Health Administration Press, 1982. Wittman, F., and M. Hilton. Local regulation of alcohol availability: Uses of planning and zoning ordinances to regulate alcohol outlets in California cities. In H. Holder, ed. Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. Greenwich, CI': JAI Press, 1987. -138

II RESEARCH OPPORTUNITIES IN THE TREATMENT OF ALCOHOL-RELATED PROBLEMS -139

INTRODUCTION Within the framework of universal, selected, and indicated interventions noted in Chapter 1 of this report, treatment can be said to be an indicated intervention; its focus is on persons with already evident problems rather than on the preventions of problems in unaffected individuals. Given the heterogeneity of persons with alcohol problems-- and the wide range of such problems--reflected in the concept espoused by the committee of a continuum of severity, it should be no surprise to find that a variety of treatment methods and modalities have arisen in response. These numerous approaches testify to the vigorous interest of treatment providers and researchers and offer numerous opportunities for continued development and research on treatment efficacy and effectiveness. In response to its charge, the committee conducted an extensive review of recent treatment research with a view toward identifying promising avenues of inquiry for future studies. Chapters 7 though 14 summarize its findings, necessarily presenting illustrative as opposed to comprehensive considerations of the various topics. Chapter 7 describes the social and historical context of alcohol treatment research, noting the past extent of federal support as well as emerging trends in service delivery and demographics that may affect future funding and research interests. Chapter 8 deals with issues of assessment, methodology, and research design. It describes some of the notable achievements in treatment evaluation in recent years (e.g., conceptual advances, new measurement techniques) and discusses a number of the major unresolved research issues. Many of the available treatment approaches have not been systematically or rigorously evaluated. Nevertheless, Chapter 9 surveys outcome evaluation research since 1980 on several treatment modalities (e.g., pharmacotherapies, psychotherapy and counseling, mutual help groups) and also considers recent process evaluation research. Chapters 10 and 11 discuss research on two recent trends that appear to offer promise for impairing treatment outcome--namely, early identification of persons with alcohol problems and patient-treatment matching. Both of these areas hold promise for improving treatment outcome. Chapter 12 highlights selected findings from treatment studies of other psychoactive substance-use disorders that may be applicable to research on the treatment of alcohol problems; Chapter 13 discusses treatment of health consequences of heavy alcohol use or dependence; and Chapter 14 considers recent research on some of the public policy implications of alcohol treatment, particularly those related to costs and efficiency. In all of these chapters, the committee reviews research directions that have already been pursued and highlights potentially fruitful opportunities for further progress in identifying effective treatment approaches for alcohol problems. -140

A thorough examination of nearly everything known about the prevention and treatment of alcohol problems, this volume is directed particularly at people interested in conducting research and at agencies supporting research into the phenomenon of drinking. The book essentially is two volumes in one. The first covers progress and potential in the prevention of alcohol problems, ranging from the predispositions of the individual to the temptations posed by the environment. The second contains a history and appraisal of treatment methods and their costs, including the health consequences of alcohol abuse. A concluding section describes the funding and research policy emphases believed to be necessary for various aspects of research into prevention and treatment.

READ FREE ONLINE

Welcome to OpenBook!

You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

Do you want to take a quick tour of the OpenBook's features?

Show this book's table of contents , where you can jump to any chapter by name.

...or use these buttons to go back to the previous chapter or skip to the next one.

Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

To search the entire text of this book, type in your search term here and press Enter .

Share a link to this book page on your preferred social network or via email.

View our suggested citation for this chapter.

Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

Get Email Updates

Do you enjoy reading reports from the Academies online for free ? Sign up for email notifications and we'll let you know about new publications in your areas of interest when they're released.

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Substance Abuse and Mental Health Services Administration (US); Office of the Surgeon General (US). Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health [Internet]. Washington (DC): US Department of Health and Human Services; 2016 Nov.

Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health [Internet].

Chapter 3 prevention programs and policies.

• Chapter 3 Preview

As discussed in earlier chapters, the misuse of alcohol and drugs and substance use disorders has a huge impact on public health in the United States. In 2014, over 43,000 people died from a drug overdose, more than in any previous year on record 2 and alcohol misuse accounts for about 88,000 deaths in the United States each year (including 1 in 10 total deaths among working-age adults). 4 The yearly economic impact of alcohol misuse and alcohol use disorders is estimated at $249 billion ($2.05 per drink) in 2010 6 and the impact of illicit drug use and drug use disorders is estimated at $193 billion-figures that include both direct and indirect costs related to crime, health, and lost productivity. 7 Over half of these alcohol-related deaths and three-quarters of the alcohol-related economic costs were due to binge drinking. In addition, alcohol is involved in about 20 percent of the overdose deaths related to prescription opioid pain relievers. 6

Substance misuse is also associated with a wide range of health and social problems, including heart disease, stroke, high blood pressure, various cancers (e.g., breast cancer), mental disorders, neonatal abstinence syndrome (NAS), driving under the influence (DUI) and other transportation-related injuries, 8 , 9 sexual assault and rape, 10 , 11 unintended pregnancy, sexually transmitted infections, 12 intentional and unintentional injuries, 13 and property crimes. 14

Given the impact of substance misuse on public health and the increased risk for long-term medical consequences, including substance use disorders, it is critical to prevent substance misuse from starting and to identify those who have already begun to misuse substances and intervene early. Evidence-based prevention interventions, carried out before the need for treatment, are critical because they can delay early use and stop the progression from use to problematic use or to a substance use disorder (including its severest form, addiction), all of which are associated with costly individual, social, and public health consequences. 6 , 15 - 17 This chapter will demonstrate that prevention can markedly reduce the burden of disease and related costs. The good news is that there is strong scientific evidence supporting the effectiveness of prevention programs and policies.

FOR MORE ON THIS TOPIC

See Chapter 4 - Early Intervention , Treatment, and Management of Substance Use Disorders .

This chapter uses the term evidence-based interventions (EBIs) to refer to programs and policies supported by research. The chapter discusses the predictors of substance use initiation early in life and substance misuse throughout the lifespan, called risk factors, as well as factors that can mitigate those risks, called protective factors. The chapter also includes a system of categorizing prevention strategies defined by the Institute of Medicine (IOM). 18 This discussion is followed by a review of rigorous research on substance use initiation and misuse prevention programs that have demonstrated evidence of effectiveness. The chapter continues with a review of the rigorous research on the effectiveness and population impact of prevention policies, most of which are associated with alcohol misuse, as there is limited scientific literature on policy interventions for other drugs. Detailed reviews of these programs and policies are in Appendix B - Evidence-Based Prevention Programs and Policies. The chapter then describes how communities can build the capacity to implement effective programs and policies community wide to prevent substance use and related harms, and concludes with research recommendations.

KEY FINDINGS *

• Well-supported scientific evidence exists for robust predictors (risk and protective factors) of substance use and misuse from birth through adulthood. These predictors show much consistency across gender, race and ethnicity, and income.
• Well-supported scientific evidence demonstrates that a variety of prevention programs and alcohol policies that address these predictors prevent substance initiation, harmful use, and substance use-related problems, and many have been found to be cost-effective. These programs and policies are effective at different stages of the lifespan, from infancy to adulthood, suggesting that it is never too early and never too late to prevent substance misuse and related problems.
• Communities and populations have different levels of risk, protection, and substance use. Well-supported scientific evidence shows that communities are an important organizing force for bringing effective EBIs to scale. To build effective, sustainable prevention across age groups and populations, communities should build cross-sector community coalitions which assess and prioritize local levels of risk and protective factors and substance misuse problems and select and implement evidence-based interventions matched to local priorities.
• Well-supported scientific evidence shows that federal, state, and community-level policies designed to reduce alcohol availability and increase the costs of alcohol have immediate, positive benefits in reducing drinking and binge drinking, as well as the resulting harms from alcohol misuse, such as motor vehicle crashes and fatalities.
• There is well-supported scientific evidence that laws targeting alcohol-impaired driving, such as administrative license revocation and lower per se legal blood alcohol limits for adults and persons under the legal drinking age, have helped cut alcohol-related traffic deaths per 100,000 in half since the early 1980s.
• As yet, insufficient evidence exists of the effects of state policies to reduce inappropriate prescribing of opioid pain medications.

The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence as: “Well-supported”: when evidence is derived from multiple controlled trials or large-scale population studies; “Supported”: when evidence is derived from rigorous but fewer or smaller trials; and “Promising”: when evidence is derived from a practical or clinical sense and is widely practiced. 5

• Why We Should Care About Prevention

Beginning in the twentieth century, the major illnesses leading to death shifted from infectious diseases, such as tuberculosis and infections in newborns, to noncommunicable diseases, such as heart disease, diabetes, and cancer. This shift was a result of effective public health interventions, such as improved sanitation and immunizations that reduced the rate of infectious diseases, as well as increased rates of unhealthy behaviors and lifestyles, including smoking, poor nutrition, physical inactivity, and substance misuse. In fact, behavioral health problems such as substance use, violence, risky driving, mental health problems, and risky sexual activity are now the leading causes of death for those aged 15 to 24. 19

To effectively prevent substance misuse, it is important to understand the nature of the problem, including age of onset. Although people generally start using and misusing substances during adolescence, misuse can begin at any age and can continue to be a problem across the lifespan. As seen in Figure 3.1 , likelihood of substance use escalates dramatically across adolescence, peaks in a person's twenties, and declines thereafter. For example, the highest prevalence of past month binge drinking and marijuana use occurs at ages 21 and 20, respectively. Other drugs follow similar trajectories, although their use typically begins at a later age. 20 Early substance misuse, including alcohol misuse, is associated with a greater likelihood of developing a substance use disorder later in life. 21 , 22 Of those who begin using a substance, the percentage of those who develop a substance use disorder, and the rate at which they develop it, varies by substance.

Past-Month Alcohol Use, Binge Alcohol Use, and Marijuana Use, by Age: Percentages, 2015 National Survey on Drug and Health (NSDUH). Note: Binge alcohol use is defined as drinking five or more drinks (for males) or four or more drinks (for females) on (more...)

It is important to note that the vast majority of people in the United States who misuse substances do not have substance use disorders. 20 , 23 Nonetheless, substance misuse can put individual users and others around them at risk of harm, whether or not they have a disorder. Also, early initiation, substance misuse, and substance use disorders are associated with a variety of negative consequences, including deteriorating relationships, poor school performance, loss of employment, diminished mental health, and increases in sickness and death (e.g., motor vehicle crashes, poisoning, violence, or accidents). 15 - 17 It is therefore critical to prevent the full spectrum of substance misuse problems in addition to treating those with substance use disorders.

Preventing or reducing early substance use initiation, substance misuse, and the harms related to misuse requires the implementation of effective programs and policies that address substance misuse across the lifespan. The prevention science reviewed in this chapter demonstrates that effective prevention programs and policies exist, and if implemented well, they can markedly reduce substance misuse and related threats to the health of the population. However, evidence-based programs and policies are underutilized. For example, studies have found that many schools and communities are using prevention programs and strategies that have little or no evidence of effectiveness. 24 , 25 In fact, underuse of effective prevention programs and policies was the impetus for the creation of Communities That Care (CTC), a prevention service delivery system that promotes healthy youth development, improves youth outcomes, and reduces substance use and other problem behavior. 26

At the policy level, research shows that higher alcohol prices reduce alcohol misuse and related harms (e.g., alcohol-related motor vehicle crashes), 27 - 31 and taxes are one component of price. As of January 1, 2015, 42 states had a beer excise tax of less than $0.50 per gallon, while only four states had an excise tax more than $1.00 per gallon ( Table 3.4 ). 32 , 33

Status of Selected Evidence-Based Strategies in States for Preventing Alcohol Misuse and Related Harms.

• Risk and Protective Factors

Longitudinal research has identified predictors of substance use and other behavioral health problems that are targets for preventive interventions. 34 - 36 Risk and protective factors influence the likelihood that a person will use a substance and whether they will develop a substance use disorder.

Risk factors. Factors that increase the likelihood of beginning substance use, of regular and harmful use, and of other behavioral health problems associated with use.

Protective factors. Factors that directly decrease the likelihood of substance use and behavioral health problems or reduce the impact of risk factors on behavioral health problems.

Risk and protective factors become influential at different times during development, and they often relate to physiological changes that occur over the course of development or to factors in a person's environment—for example, biological transitions such as puberty or social transitions such as attending a new school, parental divorce or military deployment, or graduation. 37 These factors can be influenced by programs and policies at multiple levels, including the federal, state, community, family, school, and individual levels. 38 - 41 Targeted programs implemented at the family, school, and individual levels can complement the broader population-level policy interventions, and assist in reducing specific risk factors ( Table 3.1 ) and promoting protective factors ( Table 3.2 ). Although there are exceptions, most risk and protective factors associated with substance use also predict other problems affecting youth, including delinquency, psychiatric conditions, violence, and school dropout. Therefore, programs and policies addressing those common or overlapping predictors of problems have the potential to simultaneously prevent substance misuse as well as other undesired outcomes. 42 - 44

Risk Factors for Adolescent and Young Adult Substance Use.

Protective Factors for Adolescent and Young Adult Substance Use.

Some risk and protective factors appear to have consistent effects across cultural and gender groups, although low-income and disadvantaged populations are generally exposed to more risk factors, including risk factors within the environment, and to fewer protective factors than are other groups in the population. However, research has shown that binge drinking is more common among individuals in higher income households as compared to lower income households. 45 This has implications for the types of prevention programs and policies that might be most successful with disadvantaged populations. Despite the similarities in many identified risk factors across groups, it is important to examine whether there are subpopulation differences in the exposure of groups to risk factors.

• Types of Prevention Interventions

The IOM has described three categories of prevention interventions: universal, selective, and indicated. 18 Universal interventions are aimed at all members of a given population (for instance, all children of a certain age); selective interventions are aimed at a subgroup determined to be at high-risk for substance use (for instance, justice-involved youth); indicated interventions are targeted to individuals who are already using substances but have not developed a substance use disorder. Communities must choose from these three types of preventive interventions, but research has not yet been able to suggest an optimal mix. Communities may think it is best to direct services only to those with the highest risk and lowest protection or to those already misusing substances. 100 However, a relatively high percentage of substance misuse-related problems come from people at lower risk, because they are a much larger group within the total population than are people at high-risk. This follows what is known as the Prevention Paradox: “a large number of people at a small risk may give rise to more cases of disease than the small number who are at a high risk.” 1 By this logic, providing prevention interventions to everyone (i.e., universal interventions) rather than only to those at highest risk is likely to have greater benefits. 3

One advantage of a properly implemented universal prevention intervention is that it is likely to reach most or all of the population (for example, school-based interventions are likely to reach all students). Targeted (selective and indicated) approaches are likely to miss a large percentage of their targets, but they provide more intensive services to those who are reached. Because the best mix of interventions has not yet been determined, it is prudent for communities to provide a mix of universal, selective, and indicated preventive interventions.

Universal Prevention Interventions

Universal interventions attempt to reduce specific health problems across all people in a particular population by reducing a variety of risk factors and promoting a broad range of protective factors. Examples of universal interventions include policies—such as the setting of a minimum legal drinking age (MLDA) or reducing the availability of substances in a community—and school-based programs that promote social and emotional competencies to reduce stress, express emotion appropriately, and resist negative social influences. Because they focus on the entire population, universal interventions tend to have the greatest overall impact on substance misuse and related harms relative to interventions focused on individuals alone. 18

Selective Interventions

Selective interventions are delivered to particular communities, families, or children who, due to their exposure to risk factors, are at increased risk of substance misuse problems. Target audiences for selective interventions may include families living in poverty, the children of depressed or substance-using parents, or children who have difficulties with social skills. Selective interventions typically deliver specialized prevention services to individuals with the goal of reducing identified risk factors, increasing protective factors, or both. Selective programs focus effort and resources on interventions that are intentionally designed for a specific high-risk group. 101 Selective programs have an advantage in that they focus effort and resources on those who are at higher risk for developing behavioral health problems. In so doing, they allow planners to create interventions that are more specifically designed for that audience. However, they are typically not population-based and therefore, compared to population-level interventions, they have more limited reach.

Indicated Interventions

Indicated prevention interventions are directed to those who are already involved in a risky behavior, such as substance misuse, or are beginning to have problems, but who have not yet developed a substance use disorder. Such programs are often intensive and expensive but may still be cost-effective, given the high likelihood of an ensuing expensive disorder or other costly negative consequences in the future. 102

• Evidence-based Prevention Programs

This section identifies universal, selective, and indicated prevention programs that have been shown to successfully reduce the number of people who start using alcohol or drugs or who progress to harmful use. Inclusion of the programs here was based on an extensive review of published research studies. Of the 600 programs considered, 42 met criteria to be included in this Report. Studies on programs that included people who already had a substance use or related disorder were excluded. The review used standard literature search procedures which are summarized in detail in Appendix A - Review Process for Prevention Programs.

The vast majority of prevention studies have been conducted on children, adolescents, and young adults, but prevention trials of older populations meeting the criteria were also included. Programs that met the criteria are categorized as follows: Programs for children younger than age 10 (or their families); programs for adolescents aged 10 to 18; programs for individuals ages 18 years and older; and programs coordinated by community coalitions. Due to the number of programs that have proven effective, the following sections highlight just a few of the effective programs from the more comprehensive tables in Appendix B - Evidence-Based Prevention Programs and Policies, which describe the outcomes of all the effective prevention programs. Representative programs highlighted here were chosen for each age group, domain, and level of intervention, and with attention to coverage of specific populations and culturally based population subgroups. It is important to note that screening and brief intervention (SBI) and electronic SBI for reducing alcohol misuse have been recognized as effective strategies for identifying and reducing substance misuse among adults, but these are discussed in detail in Chapter 4 -Early Intervention , Treatment, and Management of Substance Use Disorders as effective early intervention strategies. 103 - 106

Interventions for Youth Aged 0 to 10

Few substance use prevention programs for children under the age of 10 have been evaluated for their effect on substance misuse and related problems. Such studies are rare because they require expensive long-term follow-up tracking and assessment to demonstrate an impact on substance initiation or misuse years or decades into the future. Consistent with general strategies to increase protective factors and decrease risk factors, universal prevention interventions for infants, preschoolers, and elementary school students have primarily focused on building healthy parent-child relationships, decreasing aggressive behavior, and building children's social, emotional, and cognitive competence for the transition to school. Both universal and selective programs have shown reductions in child aggression and improvements in social competence and relations with peers and adults (generally predictive of favorable longer-term outcomes), but only a few have studied longer-term effects on substance use. 107 , 108 Select programs showing positive effects are described below.

Nurse-Family Partnership

Only one program that focused on children younger than age 5—the Nurse-Family Partnership —has shown significant reductions in the use of alcohol in the teen years compared with those who did not receive the intervention. 109 , 110 This selective prevention program uses trained nurses to provide an intensive home visitation intervention for at-risk, first-time mothers during pregnancy. This intervention provides ongoing education and support to improve pregnancy outcomes and infant health and development while strengthening parenting skills.

The Good Behavior Game and Classroom-Centered Intervention

One universal elementary school-based prevention program has shown long-term preventive effects on substance use among a high-risk subgroup, males with high levels of aggression. The Good Behavior Game is a classroom behavior management program that rewards children for acting appropriately during instructional times through a team-based award system. Implemented by Grade 1 and 2 teachers, this program significantly lowered rates of alcohol, other substance use, and substance use disorders when the children reached the ages of 19 to 21. 111 The Classroom-Centered Intervention , which combined the Good Behavior Game with additional models of teacher instruction, also reduced rates of cocaine and heroin use in middle and high school, but it had no preventive effects on alcohol or marijuana initiation. 112 , 113

Raising Healthy Children

A number of multicomponent, universal, elementary school programs involving both schools and parents are effective in preventing substance misuse. 114 , 115 One example is the Raising Healthy Children program (also known as Seattle Social Development Project) which targets Grades 1 through 6 and combines social and emotional learning, classroom instruction and management training for teachers, and training for parents conducted by school-home coordinators, who work with the children in school and the parents at home, focusing on in-home problem solving and similar workshops. Studies of this program showed reductions in heavy drinking at age 18 (6 years after the intervention) 114 , 115 and in rates of alcohol and marijuana use. 115

The Fast Track Program

Two multicomponent selective and universal prevention programs were effective. An example is the Fast Track Program, an intensive 10-year intervention that was implemented in four United States locations for children with high rates of aggression in Grade 1. The program includes universal and selective components to improve social competence at school, early reading tutoring, and home visits as well as parenting support groups through Grade 10. Follow-up at age 25 showed that individuals who received the intervention as adolescents decreased alcohol and other substance misuse, with the exception of marijuana use. 116

Interventions for Adolescents Aged 10 to 18

A variety of universal interventions focused on youth aged 10 to 18 have been shown to affect either the initiation or escalation of substance use. 117 - 124 In general, school-based programs share a focus on building social, emotional, cognitive, and substance refusal skills and provide children accurate information on rates and amounts of peer substance use. 119 , 120 , 124

School-based Programs

One well-researched and widely used program is LifeSkills Training, a school-based program delivered over 3 years. 117 Research has shown that this training delayed early use of alcohol, tobacco, and other substances and reduced rates of use of all substances up to 5 years after the intervention ended. A multicultural model, keepin'it REAL, uses student-developed videos and narratives and has shown positive effects on substance use among Mexican American youth in the Southwestern United States. 121 Another example is Project Toward No Drug Abuse, which focuses on youth who are at high risk for drug use and violence. It is designed for youth who are attending alternative high schools but can be delivered in traditional high schools as well. The twelve 40-minute interactive sessions have shown positive effects on alcohol and drug misuse. 125

Family-based Programs

A number of family-focused, universal prevention interventions show substantial preventive effects on substance use. 126 - 130 For example, Strengthening Families Program: For Parents and Youth 10-14 (SFP) is a widely used seven-session universal, family-focused program that enhances parenting skills—specifically nurturing, setting limits, and communicating—as well as adolescent substance refusal skills. Across multiple studies conducted in rural United States communities, SFP showed reductions in tobacco, alcohol, and drug use up to 9 years after the intervention (i.e., to age 21) compared with youth who were not assigned to the SFP. 126 , 130 SFP also shows reductions in prescription drug misuse up to 13 years after the intervention (i.e., to age 25), both on its own and when paired with effective skills-focused school-based prevention. 131 , 132 Strong African American Families, a cultural adaptation of SFP, shows reductions in early initiation and rate of alcohol use for Black or African American rural youth. 127 - 129

Three selective programs focus on interventions with families. 133 - 135 An example is Familias Unidas, a family-based intervention for Hispanic or Latino youth. It includes both multi-parent groups (eight weekly 2-hour sessions) and four to ten 1-hour individual family visits and has been shown to lower substance use or delay the start of substance use among adolescents. 133

A number of selective and indicated interventions successfully prevent substance misuse when delivered to youth aged 10 to 18. 125 , 136 - 142 Most of these interventions target students who show early aggressive behavior, delinquency, or early substance use, as these are risk factors for later substance misuse, and some offer both a youth component in the classroom setting and a parent component. An example is Coping Power, a 16-month program for children in Grades 5 and 6 who were identified with early aggression. The program, which is designed to build problem-solving and self-regulation skills, has both a parent and a child component and reduces early substance use. 136

Internet-based Programs

A number of computer- and Internet-based interventions also show positive effects on preventing substance use. 143 - 146 An example is I Hear What You're Saying, which involves nine 45-minute sessions to improve communication, establish family rules, and manage conflict. Specifically focused on mothers and daughters, follow-up results showed lower rates of substance use in an ethnically diverse sample. 143 - 145 Additionally, Project Chill, a brief intervention (30 to 45 minutes) delivered in primary care settings through either a computer or a therapist, reduced the number of youth who started using marijuana. 146

Programs for Young Adults

Young adulthood is a key developmental period, when individuals are exposed to new social contexts with greater freedom and less social control than they experienced during their high school years. Social roles are changing at the same time that social safety net supports are weakening. 147 In addition, many young adults are undergoing transitions, such as leaving home, leaving the compulsory educational system, beginning college, entering the workforce, and forming families. As a result of all these forces, young adulthood is typically associated with increases in substance use, misuse, and misuse-related consequences.

Numerous studies have examined the effectiveness of brief alcohol interventions for adolescents and young adults. One review examined 185 such experimental studies among adolescents aged 11 to 18 and adults aged 19 to 30. Overall, brief alcohol interventions were associated with significant reductions in alcohol consumption and alcohol-related problems in both adults and adolescents, and in some studies, effects persisted up to one year. 148 The United States Preventive Services Task Force has recommended screening and brief intervention for reducing alcohol misuse among adults, as discussed in Chapter 4 - Early Intervention , Treatment, and Management Of Substance Use Disorders , and the American Academy of Pediatrics recommends that screening and brief interventions for alcohol misuse or use disorders be implemented for adolescent patients as well. 149

Programs for College Students

Many interventions have been developed to reduce alcohol and marijuana misuse among college students. Several literature reviews of alcohol screening and brief interventions in this population have reported that these interventions reduce college student drinking, 150 - 154 and several other interventions for college students have shown longer term reductions in substance misuse. 155 - 165 One analysis reviewed 41 studies with 62 individual or group interventions and found that recipients of interventions experienced reduced alcohol use and fewer alcohol related problems up to four years post intervention. 166 Effective intervention components were personalized feedback, protective strategies to moderate drinking, setting alcohol-related goals, and challenging alcohol expectancies. Interventions with four or more components were most effective. Two example interventions for college students are described below.

Brief Alcohol Screening and Intervention for College Students (BASICS) is an example of a brief motivational intervention for which results have been positive. BASICS is designed to help students reduce alcohol misuse and the negative consequences of their drinking. It consists of two 1-hour interviews, with a brief online assessment after the first session. The first interview gathers information about alcohol consumption patterns and personal beliefs about alcohol, while providing instructions for self-monitoring drinking between sessions. The second interview uses data from the online assessment to develop personalized, normative feedback that reviews negative consequences and risk factors, clarifies perceived risks and benefits of drinking, and provides options for reducing alcohol use and its consequences. Follow-up studies of students who used BASICS have shown reductions in drinking quantity in the general college population, among fraternity members, with heavy drinkers who volunteered to use BASICS, and among those who were mandated to engage in the program from college disciplinary bodies. 106 , 162 , 164

A second intervention, the Parent Handbook, focuses on teaching parents how and when to intervene during the critical time between high school graduation and college entry to disrupt the escalation of heavy drinking during the first year of college. The Parent Handbook is distributed during the summer before college, and parents receive a booster call to encourage them to read the materials. Research has found that the timing for the Parent Handbook is critical. If parents received it during the summer before college, it reduced the odds of students becoming heavy drinkers, but this intervention was not effective if used after the transition to college. 167 One study showed the combination of BASICS, and the Parent Handbook significantly reduced alcohol consumption among incoming college students who showed heavy rates of high school drinking. 168

Many other interventions have been developed for this population that have not shown effects beyond 3 or 6 months after the intervention, and most positive effects are not maintained by 12-month follow-up. 155 - 159 For example, even though brief motivational interviewing (BMI) interventions have appeared promising, a recent analysis of 17 randomized trials demonstrated little effectiveness among college-aged individuals. 160

A Resource: The National Institute on Alcohol Abuse and Alcoholism's (NIAAA's) CollegeAIM: Alcohol Intervention Matrix

In an effort to inform colleges and universities of the rapidly growing evidence base of programs and policies that can reduce harmful and underage drinking and related harms by college students, NIAAA has published CollegeAIM-the College Alcohol Intervention Matrix.

CollegeAIM reviews nearly 60 interventions, including both individual-level strategies and environmental-level policy strategies. The strategies are ranked by effectiveness (higher, moderate, lower, not effective, and too few studies to evaluate). Implementation costs (lower, mid-range, and higher) and implementation barriers (higher, moderate, and lower) are also ranked, as is public health reach (broad or focused). 169

Programs in Adult Workplaces

Two programs met this Report's criteria for workplace or clinic-based prevention programs; 170 - 172 others have not shown significant preventive effects longer than 6 months. 173 The successful programs, Team Awareness and Team Resilience, were delivered in three 2-hour sessions to restaurant workers and led to decreases in heavy drinking and work-related problems. These programs reached approximately 30,000 workers in diverse settings, including military, tribal, and government settings, and with ex-offenders, young restaurant workers, and more. 170 , 172

Programs for Older Adults

Only two studies showed preventive effects on alcohol use in older adults. 174 , 175 One is Project Share, which showed reductions in heavy drinking among those aged 60 and older. Project Share provided personalized feedback to at-risk older drinkers, which included a personalized patient report, discussion with a physician, and three phone calls from a health educator. 174 A second study, the Computerized Alcohol-Related Problems Survey (CARPS) assessed personalized reports of drinking risks and benefits accompanied with education for physicians and patients aged 65 and older. The study found a significant decrease in alcohol misuse, including reductions in the quantity and frequency that older individuals reported drinking. 175

Economics of Prevention

The Washington State Institute for Public Policy developed a standardized model using scientifically rigorous standards to estimate the costs and benefits associated with various prevention programs. Benefit-per-dollar cost ratios for EBIs ranged from small returns per dollar invested to more than $64 for every dollar invested. These estimates are illustrated below in Table 3.3 .

Cost-Benefit of EBIs Reviewed by the Washington State Institute for Public Policy, 2016.

• Evidence-based Community Coalition-based Prevention Models

Community-based prevention programs can be effective in helping to address major challenges raised by substance misuse and its consequences. Such programs are often coordinated by local community coalitions composed of representatives from multiple community sectors or organizations (e.g., government, law enforcement, health, education) within a community, as well as private citizens.

These coalitions work to change community-level risk and protective factors and achieve community-wide reductions in substance use by planning and implementing one or more prevention strategies in multiple sectors simultaneously, with the goal of reaching as many members of the community as possible with accurate, consistent messages. For example, interventions may be implemented in family, educational, workplace, health care, law enforcement, and other settings, and they may involve policy interventions and publicly funded social and traditional media campaigns. 28 , 74 , 177 - 179

A common feature of successful community programs is their reliance on local coalitions to select effective interventions and implement them with fidelity. An important requirement is that coalitions receive proactive training and technical assistance on prevention science and the use of EBIs and that they have clear goals and guidelines. Technical assistance can be provided by independent organizations such as Community Anti-Drug Coalitions of America (CADCA), academic institutions, the program developers, or others with expertise in the substance misuse prevention field. Three examples of effective community-based coalition models are provided below.

Communities That Care

Communities That Care (CTC) creates a broad-based community coalition to assess and prioritize risk and protective factors and substance use rates, using a school survey of all students in Grades 6, 8, 10, and 12. The coalition then chooses and implements EBIs that address their chosen priorities. CTC was tested in a 24-community trial, where 12 communities were randomly assigned to receive the CTC intervention.

Among a panel of students in Grade 5 who were enrolled in the study before the intervention, those in the CTC communities who were compared to the prevention as usual communities had lower rates of alcohol and tobacco initiation at Grades 10 and 12. 26 , 180 - 182

PROmoting School-community-university Partnerships to Enhance Resilience

The PROmoting School-community-university Partnerships to Enhance Resilience (PROSPER) delivery system focuses on community-based collaboration and capacity building that links the land-grant university Cooperative Extension System with the public school system. Local teams select and implement family-focused EBIs in Grade 6 and a school-based EBI in Grade 7. PROSPER has shown reductions through Grade 12 in marijuana, methamphetamine, and inhalant use, and lifetime prescription opioid misuse and prescription drug misuse. Analysis showed greater intervention benefits for youth at higher versus lower risk for most substances. 183 , 184

Prescription drug misuse. Use of a drug in any way a doctor did not direct an individual to use it.

Communities That Care - 24 Community Randomized Trials in Colorado, Illinois, Kansas, Maine, Oregon, Utah, and Washington

I think one of the biggest advantages of Communities That Care is that it has really brought together the entire community. When I preach and prepare, and if I'm speaking specifically to something that bears upon the teen culture and teen population, the fact is [with CTC assessment data from the community], I'm able to speak with greater clarity with greater directness and with greater understanding of what they are facing. – Adam Kohlstrom, Pastor, Camden, ME

Agency or Organization

University of Washington Center for Communities That Care

This evidence-based system provides communities with strategic consultation, training and research-based tools for prevention planning. The CTC system engages entire communities (e.g. youth, parents, elected officials, law enforcement, schools, businesses, etc.) and is tailored to the risks and needs of each defined community population.

• Promote positive development and healthy behaviors for all children and youth.
• Prevent problem behaviors, including substance use, delinquency, teen pregnancy, school drop-out, and violence.

33 percent less likely to begin smoking;

32 percent less likely to begin using alcohol;

33 percent less likely to begin using smokeless tobacco; and

25 percent less likely to initiate delinquent behavior (itself a risk factor for future substance use).

Communities Mobilizing for Change on Alcohol

Community coalition-driven environmental models attempt to reduce substance use by changing the macro-level physical, social, and economic risk and protective factors that influence these behaviors. Most research on environmental interventions has focused on alcohol misuse and related problems, including DUI, injuries, and alcohol use by minors. 185 - 187 For example, Communities Mobilizing for Change on Alcohol (CMCA) implemented coalition-led policy changes aimed at reducing youth access to alcohol, including training for alcohol retailers to reduce sales to minors, increased enforcement of underage drinking laws, measures to reduce availability of alcohol at community events, and media campaigns emphasizing that underage drinking is not acceptable. 188 , 189 In a randomized trial comparing seven communities in Minnesota and Wisconsin using CMCA with eight communities in states not implementing CMCA, significant reductions in alcohol-related problem behaviors were shown among young adults aged 18 to 20 from the beginning of the initiative to 2.5 years after coalition activities began. The proportion of young adults aged 19 to 20 who reported providing alcohol to other minors declined by 17 percent, 188 and arrests for DUI decreased more for this age group in the intervention compared to the control sites. 189

• Evidence-based Prevention Policies

This section primarily discusses the evidence of effectiveness for policies to reduce alcohol misuse, as well as the more limited body of scientific literature on the effectiveness of policies to prevent the misuse of prescription medications, including pain relievers, tranquilizers, stimulants, and sedatives.

Policies to Reduce Alcohol Misuse and Related Problems

Research has shown that policies focused on reducing alcohol misuse for the general population can effectively reduce alcohol consumption among adults as well as youth, and they can reduce alcohol-related problems including alcohol-impaired driving. 190 , 191 In addition to discussing a number of effective population-level alcohol policies, this section will also describe policies designed specifically to reduce drinking and driving and underage drinking.

Price and Tax Policies

Evidence indicates that higher prices on alcoholic beverages are associated with reductions in alcohol consumption and alcohol-related problems, including alcohol-impaired driving. Several systematic reviews have linked higher alcohol taxes and prices with reduction in alcohol misuse, including both underage and binge drinking. 28 , 31 , 72 , 192 - 197 One 2009 review examined 1,003 separate estimates from 112 studies. 72 The authors concluded, “We know of no other prevention intervention to reduce drinking that has the numbers of studies and consistency of effects seen in the literature on alcohol taxes and prices.” Similarly, a 2010 review of 73 taxation studies found “consistent evidence that higher alcohol prices and alcohol taxes are associated with reductions in both alcohol misuse and related, subsequent harms.” 31 For example, a study found that the price elasticity of binge drinking among individuals aged 18 to 21 was -0.95 for men and -3.54 for women, meaning that a 10.0 percent increase in the price of alcohol is expected to decrease binge drinking by 9.5 percent among men and 35.4 percent among women in that age group. 198

The effectiveness of increasing alcohol taxes as a strategy for reducing alcohol misuse and related problems has also been acknowledged outside the United States. 28 For example, a 2009 World Health Organization (WHO) review stated that “when other factors are held constant, such as income and the price of other goods, a rise in alcohol prices leads to less alcohol consumption” and “[p]olicies that increase alcohol prices delay the time when young people start to drink, slow their progression towards drinking larger amounts, and reduce their heavy drinking and the volume of alcohol drunk on each occasion.” 192 Additionally, studies have found that increasing alcohol taxes is not only cost effective but can result in a net cost savings (i.e., the savings outweigh the costs of the intervention).

Policies that Affect Access to and Availability of Alcohol

Policies affecting alcohol outlet density.

Research suggests that an increase in the number of retail alcohol outlets in an area—called higher alcohol outlet density—is associated with an increase in alcohol-related problems in that area, such as violence, crime, and injuries. 177 , 199 , 200 Four longitudinal studies of communities that reduced the number of alcohol outlets showed consistent and significant reductions in alcohol-related crimes, relative to comparison communities that had not reduced alcohol outlet density. 199 , 201 - 203 Although no studies have explicitly analyzed the cost-benefit ratio of this intervention, research suggests that the costs of limiting the number of alcohol outlets is expected to be much smaller than the societal costs of alcohol misuse. 177

Commercial Host (Dram Shop) Liability Policies

Commercial host (dram shop) liability allows alcohol retailers—such as the owner or server(s) at a bar, restaurant, or other retail alcohol outlet—to be held legally liable for harms resulting from illegal beverage service to intoxicated or underage customers. 204 In a systematic review, 11 studies assessed the association between dram shop laws and alcohol-related health outcomes. 205 The review found a median reduction of 6.4 percent (range was 3.7 percent to 11.3 percent) in alcohol-related motor vehicle fatalities associated with these policies. Two studies on the effects of these laws did not find reductions in binge drinking.

Policies to Reduce Days and Hours of Alcohol Sales

A review of 11 studies of changing days of sale (both at on-premise alcohol outlets such as restaurants and bars, and off-premise outlets such as grocery, liquor, and convenience stores) indicated that increasing the number of days alcohol could be sold was associated with increases in alcohol misuse and alcohol-related harms, while reducing days alcohol is sold was associated with decreases in alcohol-related harms. 206 Similarly, a review of 10 studies (none conducted in the United States) found that increasing hours of sale by two or more hours increased alcohol-related harms, while policies decreasing hours of sale by at least two hours reduced alcohol-related harms. 207 One study found that lifting a ban on Sunday sales of alcohol led to an estimated 41.6 percent increase in alcohol-related fatalities on Sundays during the period from 1995 to 2000, equating to an additional cost of more than $6 million in medical care and lost productivity per year in one state. 208 Banning sales of alcohol on Sundays has been recognized as a cost-effective strategy.

State Policies to Privatize Alcohol Sales

The privatization of alcohol sales involves changing from direct governmental control over the retail sales of one or more types of alcohol, and allowing private, commercial entities to obtain alcohol licenses, typically to sell liquor in convenience, grocery, or other off-premise locations. A systematic review of studies evaluating the impact of privatizing retail alcohol sales found that such policies increased per capita alcohol sales in privatized states by a median of 44.4 percent. Studies show that per capita alcohol sales is known to be a proxy for alcohol misuse. 209 , 210

Policies to Reduce Drinking and Driving

Since the early 1980s, alcohol-related traffic deaths in the United States have been cut by more than half ( Figure 3.2 ). It has been estimated that reductions in driving after drinking prevented more than 300,000 deaths during this time period. 211 In fact, declines in traffic deaths due to reductions in drinking and driving have exceeded declines from the combined effects of increased use of seat belts, airbags, and motorcycle and bicycle helmets. 212 From 1982 to 2013, alcohol-related traffic deaths decreased by 67 percent, whereas non-alcohol-related traffic deaths decreased by only 14 percent. 213

Alcohol- Versus Non-alcohol-related Traffic Deaths, Rate per 100,000, All Ages, United States, 1982-2013. Source: Adapted from Hingson and White, (2014).

Several policies and law enforcement approaches have been found to reduce rates of drinking and driving and related traffic crashes, injuries, and deaths within the general population, among both youth and adults. These DUI policies and enforcement approaches create deterrence by increasing the public's awareness of the consequences of drinking and driving, including the possibility of arrest. Some of these strategies include:

• 0.08 percent criminal per se legal blood alcohol content (BAC) limits, meaning that no further evidence of intoxication beyond a BAC of 0.08 percent is needed for a DUI case; 214 - 221 and
• Sobriety checkpoints. 222 - 224

Other proven DUI prevention strategies fall under the rubric of indicated interventions as they target drivers who have been convicted of DUI to reduce recidivism: 223

• Lower legal blood alcohol limits for people convicted of DUI; 217 , 223
• Mandatory ignition interlock laws for all convicted offenders, including first offenders; 223 , 225 , 226
• Mandatory assessment and treatment of persons convicted of DUI; 223
• DUI courts; 223
• Continuous 24/7 alcohol monitoring of persons with one or multiple DUI charges; 223 and
• Vehicle impoundment or immobilization. 223

The Implications of Drinking-Oriented and Driving-Oriented Policies to Reduce Harms

An examination of state-level data on 29 alcohol control policies in all 50 states from 2001-2009 227 divided those policies into two mutually exclusive groups: (1) drinking-oriented policies, intended to regulate alcohol production, sales, and consumption, raise alcohol taxes, and prevent sales to minors; and (2) driving-oriented policies, which are intended to prevent an already intoxicated person from driving. State data on impaired driving from more than 12 million adults during the even years of 2002 through 2010 were evaluated, and four results were reported, two of which are presented here:

• First, the review found that drinking-oriented policies were slightly more effective in reducing impaired driving than driving-oriented policies, though both types of policy changes were independently associated with lower levels of impaired driving.
• Second, drinking-oriented policies appeared to exert their effects by reducing binge drinking, which in turn was associated with a lower likelihood of impaired driving. The authors concluded that most states may have a greater opportunity for adopting and aggressively implementing drinking-oriented policies to reduce overall harms, although there is a need to strengthen driving-oriented policies as well.

Overall, these findings support the importance of implementing a comprehensive range of alcohol policies to effectively reduce alcohol misuse and related harms, including strengthening both drinking-oriented policies and driving-oriented policies.

Policies to Reduce Underage Drinking

Raising the minimum legal drinking age.

Before 1984, only 22 states had a MLDA of 21. To reduce DUIs, Congress passed the National Minimum Drinking Age Act, which threatened to withhold a portion of states' federal highway construction funds if states made the purchase or public possession of alcoholic beverages legal for those under the age of 21. By 1988, all states had adopted age 21 as the MLDA. In the 1982 Monitoring the Future annual national survey of middle and high school students, 71.2 percent of high school seniors reported that they drank in the past 30 days and 42 percent reported binge drinking in the past 2 weeks. 228 In 2014, these same statistics were 37.4 percent and 19 percent respectively ( Figure 3.3 ). 213 These declines may be partially attributable to the MLDA 214 along with other policy and behavior-change interventions occurring at the same time.

Trends in 2-Week Prevalence of 5 or More Drinks in a Row among 12th Graders, 1980-2015. Note: The first vertical bar indicates institution of the MLDA 21 policy change in 7 states in 1984. The second vertical bar indicates federal passage of the MLDA (more...)

Many studies have shown the benefits of raising the MLDA. A Community Guide review found that raising the MLDA reduced crashes among drivers aged 18 to 20 by a median of 16 percent: 215 A finding replicated in a prospective analysis of the National Highway Traffic Safety Administration's (NHTSA's) Fatality Analysis Reporting System (FARS) examining the ratio of drinking to non-drinking drivers aged 20 and younger. The analysis statistically adjusted for zero tolerance laws, graduated licensing restrictions (e.g., provisional licenses for new drivers that include restrictions on driving at night or with any measurable alcohol in their systems), use/lose laws, administrative license revocation, 0.08% BAC per se laws, per capita beer consumption, unemployment rate, vehicle miles traveled, frequency of sobriety check points, number of licensed drivers, and the ratio of drinking to non-drinking drivers in fatal crashes ages 26 and older. 214 An additional analysis examined national alcohol-related fatal traffic crash data before and after states raised the MLDA to 21. Before those laws were instituted, 61 percent of drivers aged 16 to 20 had a positive BAC compared with 33 percent following institution of those laws. 229 These analyses showed general declines in alcohol-related fatal crashes across age groups, but the declines were highest for drivers aged 16 to 20. Comparing the declines across ages is useful because these older drivers were not the main focus of the MLDA changes.

An extensive review concluded that raising the MLDA to 21 has been directly associated with less frequent drinking, less heavy drinking, and fewer alcohol-related traffic fatalities in the age groups targeted by the law. 178 More specifically, NHTSA estimates that raising the MLDA to 21 may have prevented 30,323 traffic deaths since 1975. 230

MLDA Compliance Checks

As a complement to the MLDA laws, research has shown the importance of repeated compliance check surveys on alcohol sales to people younger than age 21. These compliance check surveys monitor the percentage of attempts to buy alcohol that result in a sale to a person appearing to be younger than age 21. Alcohol outlet owners are informed in writing whether or not they were observed selling alcohol to underage-appearing individuals, told about the penalties for selling to minors, which can include fines or license suspension, and informed that the surveys will be repeated. A review identified several studies that found these compliance check surveys reduce the percentage of underage alcohol buying attempts and sales of alcohol to youthful-looking decoys by more than 40 percent. 187 This strategy is an effective way to reduce alcohol consumption by minors and can be implemented in conjunction with population level alcohol policies.

Zero Tolerance Laws

All 50 states have passed laws making it illegal for persons younger than age 21 to drive with any measurable BAC. These laws, called zero tolerance laws, were instituted because of the higher fatal crash risk among drivers younger than age 21 215 , 231 and because of studies showing that lowering the drinking age below age 21 was related to increases in fatal crashes. 232 Another study examined the first eight states to implement zero tolerance laws, comparing each with a nearby state that did not enact such a law. 233 Examining an equal number of years before and after these laws changed, researchers found 20 percent fewer alcohol-related traffic crash deaths in the targeted age groups within the zero tolerance states compared to nearby states without these laws. Similarly, a more recent examination of Monitoring the Future survey data for high school seniors in 30 states before and after adoption of zero tolerance laws found that after the laws were enacted, a 19 percent decline in driving after drinking occurred as well as a 23 percent decline in driving after five or more drinks. 234

Use/Lose Laws

Use/lose laws allow states to suspend a person's driver's license for underage alcohol violations. An examination of the Youth Risk Behavior Surveillance System survey data by state (statistically adjusted to account for state differences in age, gender, race, ethnicity, and other factors) from 1999 to 2009 found past-month drinking declined after use/lose laws were instituted. 235 The study also found that after these laws were instituted, survey respondents were half as likely to report driving after drinking compared with before the laws were instituted.

Criminal Social Host Liability Laws

Criminal state social host liability laws require law enforcement to prove intent to provide alcohol to underage guests. Specifically, “social host” refers to adults who knowingly or unknowingly host underage drinking parties on property that they own, lease, or otherwise control. With social host ordinances, law enforcement can hold adults accountable for underage drinking through fines and potentially criminal charges. More than 30 states have some form of social host liability laws. To see the effect of these laws, researchers examined rates of alcohol consumption, binge drinking, and DUI between 1984 and 2004 from the annual Behavioral Risk Factor Surveillance System. They also looked at data from the FARS from 1975 to 2005 on alcohol-related versus non-alcohol-related fatal traffic deaths among those aged 18 to 20. After controlling for the state's legal drinking age, several drinking laws, and socioeconomic factors, social host liability laws were independently associated with declines in binge drinking (3 percent), driving after drinking (1.7 percent), and alcohol-related traffic deaths (9 percent). 236

Civil Social Host Liability Laws

In contrast to state-level criminal social host ordinances, city- or county-level civil liability ordinances allow for a lower burden of proof but still deter underage drinking parties. Through civil social host liability laws, adults can be held responsible for underage drinking parties held on their property, regardless of whether they directly provided alcohol to minors. To date, more than 150 cities or counties have social host liability ordinances in place. The research on this strategy is still emerging, but findings currently show that social host liability reduces alcohol-related motor vehicle crashes as well as other alcohol-related problems. 28 , 237

Proposals for Reductions in Alcohol Advertising

Although evidence of a causal relationship is lacking, research has found an association between increased exposure to marketing and increased alcohol consumption among youth. 77 For example, one study found that for every additional advertisement seen by youth per month, they drank one percent more, while for every additional dollar per capita spent on alcohol advertising in a youth's media market, they drank three percent more. 238 Typically, these studies have not controlled for other factors known to influence underage drinking, such as parental attitudes and drinking by peers. Further, studies have yet to determine whether reducing alcohol marketing leads to reductions in youth drinking. One study estimated that a 28 percent decrease in alcohol marketing in the United States could lead to a decrease in the monthly prevalence of adolescent drinking from 25 percent to between 21 and 24 percent. 239 A separate study of alcohol advertising bans concluded that “there is a lack of robust evidence for or against recommending the implementation of alcohol advertising restrictions.” 240

Many Policy Interventions Are Not Consistently Implemented

Despite the evidence discussed in this section, many policies are not consistently implemented in states or communities. For example, commercial host (dram shop) liability laws, which permit alcohol retail establishments to be held responsible for injuries or harms caused by service to intoxicated or underage patrons have not been implemented consistently, have been changed over time, or both. Consequently, as of January 1, 2015, only 20 states had dram shop liability laws with no major limitations; 25 states had these laws but with major limitations (e.g., restrictions on who this liability applied to and the evidence required to determine liability); and six states have no dram shop liability laws at all. 241 These numbers have not changed since 2013 ( Table 3.4 ). 242

Policies related to the regulation of alcohol outlet density have changed over time. For example, as of 2013, only 18 states had exclusive local or joint state/local alcohol retail licensing authority, and eight states allowed no local control over alcohol retail licensing.

Additionally, one study analyzed FARS from 1982-2012. The authors compared the ratio of drinking drivers in fatal crashes to non-drinking drivers in fatal crashes among drivers aged 20 and younger and those 26 and older. Using advanced statistical analyses that adjusted for state DUI laws, safety belt laws, economic strength, driving exposure, and beer consumption, the authors identified nine laws designed to reduce underage drinking and driving whose implementation was prospectively, independently, and significantly associated with decreases in the ratio of drinking to non-drinking drivers under age 21 in fatal crashes, including laws prohibiting underage possession and purchase of alcohol; use alcohol lose your license (use/lose) laws; zero tolerance laws; laws requiring bartenders to be aged 21 or older; state responsible beverage/server programs; fake identification state support services for retailers; dram shop liability; and social host civil liability. Those nine laws were estimated to save approximately 1,135 lives annually, yet only five states have enacted all nine laws. The authors estimated that if all states adopted these laws an additional 210 lives could be saved every year. 243

These data suggest that effective alcohol control policies are not being widely implemented in the United States despite the well-documented, scientific evidence on the effectiveness of such policies for reducing alcohol misuse and related harms. To have maximum public health impact, it is critical to implement effective policy interventions that address alcohol misuse and related harms, and that recognize the widespread nature of the problem and the strong relationship between alcohol misuse, particularly binge drinking, and related harms among adults and youth in states. 190 , 191 , 244

Policies to Reduce Other Substance Misuse and Related Problems

Preventing prescription drug misuse.

Policies to prevent prescription drug misuse and related harms have only begun to receive research attention. However, some studies have begun to examine the impact of prescription drug monitoring programs (PDMPs) on misuse of prescription medications. 245 These state-initiated policies are designed to curb the rate of inappropriate prescribing of opioid pain relievers through various methods. Data from the U.S. Drug Enforcement Administration's (DEA's) Automation of Reports and Consolidated Orders System (ARCOS) 246 showed little impact of these monitoring systems, perhaps because of the variability of the policies controlling different state systems. The ARCOS is an automated, comprehensive drug reporting system which monitors the movement of controlled substances from where they are manufactured through distribution at the retail level, such as hospitals, pharmacies, and practitioners.

Some studies associate state PDMPs with lower rates of prescription drug misuse and altered prescribing practices, although evidence is mixed and inconclusive. 247 One reason for inconsistent findings may be low and variable prescriber utilization of PDMPs. Because mandates are relatively new, their efficacy in increasing PDMP utilization has not been formally studied. However, preliminary data suggest that in some states mandates have contributed to a rapid increase in provider enrollment and utilization of PDMPs and subsequent decreases in prescribing of controlled substances and the number of patients who visit multiple providers seeking the same or similar drugs. 248 Data from Kentucky, Tennessee, New York and Ohio—early adopters of comprehensive PDMP use mandates—indicate substantial increases in queries, reductions in opioid prescribing, and declines in multiple provider episodes (doctor shopping) following implementation. 249 In one of the most rigorous studies to date, Florida's simultaneous institution of a prescription drug monitoring system and “pill mill” control policies was compared to Georgia, a state without either policy. This study demonstrated “modest reductions in total opioid volume, mean morphine milligram equivalent per transaction, and total number of opioid prescriptions dispensed, but no effect on duration of treatment. These reductions were generally limited to patients and prescribers with the highest baseline opioid use and prescribing.” 250

A 2016 study found that the implementation of a PDMP was associated with 1.12 fewer opioid-related overdose deaths per 100,000 people in the year immediately after the program was implemented, and if every state in the United States had a robust PDMP, there would be an estimated 600 fewer overdose deaths per year. 251 However, another study analyzed eight types of laws that restricted the prescribing and dispensing of opioids (including PDMP laws but not including prescriber mandate laws) and found no relationship between the laws and opioid-related outcomes among disabled Medicare beneficiaries, who accounted for nearly 25 percent of opioid overdose deaths in 2008. 252

Collectively, these early results suggest the potential influence of PDMPs to reduce unsafe controlled substance prescribing and rates of misuse and diversion, but there is a need to conduct additional research on the effectiveness of specific strategies for implementation and use of PDMPs. Multiple efforts to address prescription drug misuse within states occurring in concert with mandatory PDMP legislation may limit the ability to draw causal conclusions about the effectiveness of mandatory use of PDMPs.

The CDC has developed the CDC Guideline for Prescribing Opioids for Chronic Pain, which provides research-based recommendations for the prescribing of opioids for pain in patients aged 18 and older in primary care settings. The guideline includes a discussion of when to start opioids for chronic pain, how to select the right opioid and dosage, and how to assess risks and address harms from opioid use. 253 This guideline can help providers reduce opioid misuse and related harms among those with chronic pain.

Adolescent Use of Marijuana

Marijuana use, in adolescents in particular, can cause negative neurological effects. Long-term, regular use starting in the young adult years may impair brain development and functioning. The main chemical in marijuana is delta-9-tetrahydrocannabinol (THC), which, when smoked, quickly passes from the lungs into the bloodstream, which then carries it to organs throughout the body, including the brain. 254 THC disrupts the brain's normal functioning and can lead to problems studying, learning new things, and recalling recent events. 255 One study followed people from age 13 to 38 and found that those who began marijuana use in their teens and developed a persistent cannabis use disorder had up to an eight point drop in IQ, even if they stopped using in adulthood. 256 Frequent marijuana use has also been linked to increased risk of psychosis in individuals with specific pre-existing genetic vulnerabilities. 257 , 258 And marijuana use—particularly long-term, chronic use or use starting at a young age—can also lead to dependence and addiction.

These effects highlight the importance of prevention. To prevent marijuana use before it starts, or to intervene when use has already begun, parents and other caregivers as well as those with relationships with young people—such as teachers, coaches, and others—should be informed about marijuana's effects in order to provide relevant and accurate information on the dangers and misconceptions of marijuana use. Comprehensive prevention programs focusing on risk and protective factors have shown success preventing marijuana use. 259 , 260 Evidence-based strategies or best practices in community level prevention efforts can be used to assess, build capacity, plan, implement, and evaluate initiatives. 261

• Prevention Interventions for Specific Populations

An important consideration in any assessment of the overall effectiveness of EBIs is whether and to what extent they work with specific populations, such as Blacks or African Americans, Hispanics or Latino/as, Asians, American Indians or Alaska Natives, Native Hawaiians or Other Pacific Islanders, veterans, or lesbian, gay, bisexual, and transgender (LGBT) populations. The EBIs described in this chapter have been purposely selected because many have been implemented, tested, and found to be effective in diverse populations. It should be noted that while prevention policies have shown impacts for the entire population, and a number of prevention programs at each developmental period have shown positive outcomes with a mix of populations, most studies have not specifically examined their differential effects on racial and ethnic subpopulations. Studies finding significant prevention effects across multiple population subgroups include LifeSkills Training, keepin' it Real, Nurse Family Partnership, Raising Healthy Children, Good Behavior Game, Classroom-Centered Intervention , Fast Track, SODAs City, I Hear What You're Saying, Project Chill, Positive Family Support, Coping Power, Project Towards No Drug Abuse, Communities That Care, Project Northland, and Project STAR.

See Appendix A - Review Process for Prevention Programs and Appendix B - Evidence-Based Prevention Programs and Policies.

The following programs were found to be equally effective in White and specific racial and ethnic minority populations: Fast Track, which is equally effective for White and Black or African American adolescents, LifeSkills Training, which is equally effective with White and Black or African American and Hispanic or Latino adolescents, and keepin' it REAL, which is equally effective with White and Hispanic or Latino adolescents. In addition, some interventions developed for specific populations have been shown to be effective in those populations, i.e., Strong African American Families, Familas Unidas for Hispanics or Latinos, Bicultural Competence for American Indian or Alaska Natives, and PROSPER for rural communities.

Adaptation of EBIs in Diverse Communities

A goal of prevention and public health professionals is to broadly disseminate all tested-and-effective EBIs, thus making them readily available to communities and consumers. 262 Achieving population-level exposure of an EBI to all population groups—or “going to scale”—raises critical issues of “fit” of the EBI's contents and the needs and preferences of local community residents. 263 Often, some form of local adaptation is necessary when a certain feature of the selected EBI fails to engage a specific group within a local community. However, not all EBIs may work with all community subgroups. 264 , 265 The sometimes delicate balance that needs to be struck between fidelity to the program as originally designed and tested and the need for adapting it to the needs of specific subgroups is an important issue and requires sophisticated methodology to address. Currently, several cultural adaptations of an original EBI have been developed and tested. 266

Fidelity . The extent to which an intervention is delivered as it was designed and intended to be delivered.

Issues regarding the cultural adaptation of EBIs have been reviewed extensively within the past two decades. 266 - 268 Early studies examined the utility of developing a culturally-focused version of the EBI LifeSkills Training to fit the needs of racially and ethnically diverse adolescents living in the New York City area. 269 In general, the challenge involves the viability of implementing an EBI with total fidelity to its protocol, versus adapting it by making adjustments so the EBI is more relevant and responsive to the needs of local community residents. 270 Producing an adapted version of an established EBI may not generalize well enough to create the same effects when implemented with a culturally different group from that used to validate the original intervention. Such limited generalizability might occur if the intervention is insufficiently sensitive, culturally or otherwise, to the unique stressors, resources, cultural traditions, family practices, and other prevailing sociocultural factors that govern the lives of residents from that community. 265

It is worth noting that the major racial and ethnic populations in the United States—Hispanics or Latinos, Blacks or African Americans, Asians, and American Indians or Alaska Natives—also exhibit significant within-population variations in important sociocultural characteristics. 271 Beyond differential EBI efficacy that may appear by racial or ethnic status—Black or African American versus White, for example—differential efficacy may also be observed by one of several demographic or clinical variables that define any one racial or ethnic group. These variables include gender (male vs. female), age group (younger vs. older), grade level (Grade 8 vs. Grade 10), sexual and gender identity, neighborhood status (problem vs. non-problem), problem severity (moderate vs. high), level of education (middle school vs. high school or greater), level of acculturation (low acculturation, bicultural, high acculturation). It can also include sociocultural needs and preferences that can be incorporated into the culturally adapted prevention intervention.

Given the multiple sources of within-group variation, one dissenting view is that it is impractical to develop many different versions of an original EBI in efforts to respond to the needs of various groups. A contrasting view is that a few selective and directed adaptations may be sufficient to respond to the sociocultural needs of many of these groups “to ensure fit with diverse consumer populations.” 265 Clusters of these groups may share common life experiences, such as their identity and identification as a person of color, experiences with discrimination and disempowerment, or the need for cultural validation. 264

All of these issues create a “ Fidelity -Adaptation Dilemma:” How to make necessary local or cultural adaptations that are responsive to the needs of a growing diversity of cultural groups in the United States, while also not compromising the fundamental science-based components or “active ingredients” that drive the effectiveness of the original EBI. As originally formulated, the Fidelity-Adaptation Dilemma framed fidelity and adaptation as diametrically opposed approaches in the implementation of an EBI. 267 , 268 After more than a decade of analysis and research, this conceptualization appears no longer productive, given that both fidelity and adaptation are now recognized as important for the effective implementation of an EBI, especially when delivered within diverse racial and ethnic communities. The dual aim for resolving the Fidelity-Adaptation Dilemma is to adhere with fidelity to the intervention's theory, principles, goals, and mechanisms of effect for attaining the EBI's intended outcomes, while also making well-reasoned “cultural adaptations” that remedy emerging problems with the EBI's contents and/or activities. 272 , 273 A partnership between intervention developers, persons delivering the intervention, and potential program participants who can represent the group's concerns, is recommended for developing well-reasoned solutions to remedy specific features of the original EBI that are not working as intended. 121 , 274 The ultimate aim is to craft needed adaptive adjustments that aptly remedy these emerging problems and that also enhance the efficacy of the intervention in attaining the intended outcomes with local community residents.

Several adaptations use a social participatory approach 274 - 276 with a community advisory committee that is composed of local leaders who know the local community well. 274 These individuals offer “insider” observations and recommendations that inform substantive deep-structure modifications that can make the original EBI more culturally responsive. 267 , 277

Although sufficient evidence has not yet accrued to inform a single best approach for addressing this Fidelity -Adaptation Dilemma, a review of the EBI adaptation literature shows a convergence of specifically prescribed steps for adapting an original EBI. 266 Several models describe these steps in the cultural adaptation and testing of an original EBI. 266 Other approaches have introduced the concept of “adaptive interventions” that aim to tailor the intervention individually based on empirically-developed decision rules. 278 , 279

A future goal for effective cultural adaptation would be to identify robust principles and guidelines that can inform and guide the development of cultural adaptations. One emerging principle involves avoiding adaptations that produce detrimental changes, termed “misadaptations,” that erode the original EBI's established efficacy for changing intended outcomes. 263 A second emerging principle is to conduct adaptations that enhance consumer engagement based on curriculum activities that are culturally responsive to the needs and preferences of the local community of consumers. Additional research is needed to establish the robustness of these or other emerging principles and to generate clear and functional guidelines that can inform intervention design and implementation to promote both fidelity and adaptive fit. The aim of this adaptation is to maximize intervention effect when delivered to diverse groups of consumers.

EBI adaptation that is based on evidence-based outcomes data constitutes an empirically-based methodology to correct, refine, and enhance an original EBI. From this perspective, these adaptations or modifications transcend fidelity-adaptation issues, advance toward EBI refinement that is conducted systematically, increase efficacy as well as generalizability, and reach and benefit a greater number of those who are most in need of EBIs.

• Maximizing Prevention Program and Policy Effectiveness

Although a variety of prevention policies and programs have been shown to reduce substance misuse and consequences of use, many are underutilized. Additionally, many programs are not currently being implemented with sufficient quality to effectively improve public health. For example, although it is difficult to collect data on this issue, research suggests that few family-serving agencies are using EBIs to address child behavioral and emotional problems, 280 , 281 and surveys of school administrators indicate that only 8 to 10 percent report using EBIs to prevent substance misuse. 282 , 283 Additionally, research has shown that untested or ineffective prevention programs are used more often than EBIs, 282 , 283 and, when they are used, EBIs are often poorly implemented, do not serve large numbers of participants, and are not sustained. 284 , 285 For example, family-based EBIs are often delivered with less intensity and/or to different types of participants than specified by program developers. 286 School officials have reported low rates of implementation fidelity, including failure to deliver all required lessons, content, and activities; to use the required materials; to employ the recommended instructional strategies; to target the appropriate students with lessons; and/or to ensure that all teachers receive training. 24 , 283 , 284 , 287 , 288 EBIs that are poorly implemented tend to have weak or no effects on participants. 272 , 289 - 296 For example, in one study, the LifeSkills Training program delivered in middle and junior high schools has shown significant, long-term effects on Grade 12 students' alcohol and marijuana use only among students whose teachers delivered at least 60 percent of the required material. 292

Research demonstrates that building prevention infrastructure; activating federal, state, local, and tribal stakeholders; ensuring collaboration; and helping communities select, implement, and sustain EBIs 297 is possible and can be done effectively. For example, one large-scale study provided schools and various human service agencies with training and technical assistance to replicate nine EBIs rated as “Model” by the Blueprints for Healthy Youth Development. 268 That study indicated that when provided with ongoing support, 74 percent of sites successfully implemented these systems. 298 Evaluations of PROSPER and CTC, which provide community coalitions with prevention infrastructure to choose EBIs that addressed their needs and to implement the chosen EBIs with fidelity, have shown that communities using these delivery systems implement EBIs with high fidelity and sustain them over time. 299 - 304 In addition, evaluations showed that CTC communities reached more participants with more EBIs compared with communities that did not use this prevention infrastructure support system. 302 , 303 These and other studies indicate that prevention infrastructure can be generated by taking the actions discussed in the section on Improving the Dissemination and Implementation of Evidence-based Programs later in this chapter.

Additionally, strengthening state and local public health capacity will help to increase the surveillance and monitoring of risk and protective factors and substance misuse by adolescents and adults in the general population, including persons who drink to excess but are not dependent on alcohol. It is important to educate and raise awareness about the public health burden of substance misuse and effective program and policy interventions for preventing and reducing substance use across the population.

The History of Substance Use and Misuse Policy Formation and Implementation

The dissemination and implementation of evidence-based prevention programs have been studied extensively; less research has been conducted on evidence-based policy formation and implementation. This section describes three organizations or activities focusing on federal, state, and local policy to reduce substance misuse: Mothers Against Drunk Driving (MADD), CADCA, and the Congressional Sober Truth on Preventing Underage Drinking (STOP) Act.

In the early 1980s, President Ronald Reagan established a bipartisan presidential commission to reduce drunk driving. The commission's first recommended action was to raise the MLDA to 21. In 1984 and with strong support from the newly founded MADD, Congress passed legislation to withhold federal highway construction funds from states that did not raise the MLDA to 21. MADD was also instrumental in supporting the passage of legislation in 1996 to withhold federal highway construction funds from states that did not have zero tolerance laws. They were a key player in 2000 legislation to withhold construction funds from states that did not lower the legal blood alcohol limit to 0.08 percent for adult drivers. Since the early 1980s, more than 2,000 other state laws have been passed to reduce driving after drinking, and MADD has been a major citizen activist force encouraging the passage of many of those laws.

MADD also has prepared and published periodic state and national “report cards” rating each state and the nation's efforts to reduce alcohol-impaired driving. 319 States have been rated on how many of the more than 30 laws scientifically demonstrated to reduce impaired driving had been passed and how many were passed since the previous report card. In one study, these state report cards were found to clearly predict the percent of respondents in each state who reported driving after drinking in the past month. 320 Although the impact of the report cards in accelerating passage of the laws has never been empirically tested, media monitoring of news stories derived from the report cards indicated that at least one third of the United States population has been exposed to media coverage about the report cards.

One study compared characteristics of MADD chapters that had early success in raising the MLDA to 21 to chapters in states that did not raise the age. The analysis found that having chapters headed by people who lost immediate family members through drinking and driving crashes and those with higher percentages of such victim members were the most successful in early passage of MLDA laws. Of note, the size of chapters' financial budget did not predict the passage of these laws. 321

Although MADD has helped to foster passage of more than 2,000 state-level laws, implementation of those laws is accomplished at the community level. This often requires the existence of trained coalitions focusing on substance use. One such collaboration, CADCA, has played a critical role in training local coalitions in implementing laws, particularly the MLDA law in all 50 states. CADCA's membership includes more than 5,000 community coalitions nationwide that seek to reduce underage drinking and drug use. CADCA has partnered with MADD and federal organizations to develop a manual on how to reduce drinking and driving and underage drinking in communities. 322 CADCA holds its annual leadership meeting in Washington, D.C so that its members can also meet with congressional representatives to explore better ways to reduce alcohol and drug misuse and underage drinking.

In 2004, the IOM released Reducing Underage Drinking: A Collective Responsibility, a report on underage drinking in the United States. 323 Partly in response to this report, Congress passed the STOP Act, which:

• Provided supplemental funding to community programs that were already addressing substance use so that they could also address underage drinking;
• Called on all states to test the BAC in anyone younger than age 21 who died from an injury or overdose;
• Encouraged every state to develop an interagency task force of officials from multiple state governmental departments and private citizens and organizations to develop strategic plans to reduce underage drinking (38 states have established task forces and strategic plans);
• Required the federal government to establish the Interagency Coordinating Committee for the Prevention of Underage Drinking (ICCPUD), comprising the following departments and agencies: Departments of Education, Health and Human Services, Transportation, and Defense; and the Federal Trade Commission. The Committee meets monthly to coordinate federal efforts to reduce underage drinking; and
• Required the federal government through ICCPUD and SAMHSA to provide annual reports to Congress on the magnitude of underage drinking and related problems and what the federal and state governments are doing to prevent and reduce underage drinking.
• Improving the Dissemination and Implementation of Evidence-based Programs

The emerging field of dissemination and implementation research seeks to identify ways to increase the use and high-quality implementation of evidence-based programs and address challenges to implementation. This research indicates that the key to achieving significant gains in public health, including reductions in substance use initiation and substance misuse, is to build prevention infrastructure at the local level. 305 - 307 This means increasing awareness of EBIs among community leaders, service providers, and local citizens. It also means providing tools to help communities select and use EBIs that will be feasible to implement and relevant for their populations. 308 - 310 When agencies and staff are unaware of, do not support, or lack the ability to select and implement appropriate EBIs with quality, then dissemination, implementation, and sustainability will be hindered. 285 , 311 - 313 In contrast, when local systems and agencies learn more about the effectiveness of prevention interventions, have a culture and climate that supports innovation and the use of EBIs, and have the budget and skills needed to plan for and monitor the implementation of EBIs, then effective dissemination and implementation will be fostered. 294 , 311 , 312 , 314 - 318

Dissemination . The active distribution of EBIs to specific audiences, with the goal of increasing their adoption.

Implementation . A specified set of activities designed to put policies and programs into practice.

Coalition-based systems have been developed to assist communities in building these capacities, and when tested in randomized trials, these systems have been shown to improve community capacity for effective prevention; increase dissemination, implementation, and sustainability of EBIs; and produce community-wide reductions in youth substance use. 324 An important feature of these systems is the provision of community coalitions with multiple training workshops and ongoing technical assistance. Just as organizations require technical assistance to ensure high-quality implementation of specific EBIs, coalitions need technical assistance to support and develop their prevention capacities. 325 - 328 Each community model has different steps that outline their process; the following four steps are one example of how to build broader implementation of evidence-based prevention.

Step 1. Form Diverse, Representative, Cross-Sector Community Coalitions

Coalitions, or groups of stakeholders working together to achieve a common goal, are a useful mechanism for building and maintaining local prevention infrastructure and capacity. 25 , 34 , 324 , 325 , 329 - 331 The first step in building a coalition is to decide on the “community” to be involved in prevention activities, including the geographic area in which services will be delivered, and to identify the organizations, agencies, groups, and individuals whose participation is necessary for success. The more the coalitions represent the community in terms of demographic diversity, organizations expected to deliver services, and groups or individuals expected to receive services, the more likely they are to ensure that EBIs will be supported. 329 , 332 , 333 Similarly, such coalitions will be better equipped to implement multiple EBIs across diverse contexts and to a larger percentage of the population, all of which should make population-level improvements more likely. 329 In addition, by sharing information and resources, community coalitions can help minimize duplication of efforts and potentially offer more cost-effective services that are better implemented and more likely to be sustained. 25 , 334 - 337

Step 2. Conduct a Needs Assessment and a Fit Assessment

Needs and fit assessments help coalitions select the right EBIs for their community. The right EBIs are those that address the highest-priority local risk and protective factors the coalition identifies (e.g., the risk factors that are most elevated and the protective factors that are most depressed in the community) and the groups or individuals most in need of services. 330 , 338 Coalitions conduct needs assessments by gathering data on risk and protective factors, substance misuse, and related problems. For example, in the CTC system, needs assessments rely primarily on data reported by adolescents on school-based, anonymous surveys. These data are reviewed by coalition members and risk factors that are consistently elevated and protective factors that are consistently depressed are identified as targets that need to be addressed by EBIs. 334 The priorities may vary by neighborhood in larger cities or by specific subpopulations (e.g., gender or racial and ethnic groups). 334

To select the best-fitting EBIs, coalitions need to be familiar with the list of possible interventions that can address their needs, and must consider whether or not they can meet all the implementation requirements of the EBIs. 294 , 312 , 339 Consulting a registry of EBIs, such as the National Registry of Evidence-based Programs and Practices (NREPP) 340 and the Blueprints for Healthy Youth Development 341 or NIAAA's Alcohol Policy Information System 342 for alcohol policies, can assist in creating the list of EBIs that meet community needs. These databases compile information about programs that have met rigorous evaluation criteria in a user-friendly format, which makes it easy for communities to learn about and compare intervention costs and requirements. 343 , 344 The databases also describe the intervention methods and population(s) with which the interventions were tested to help coalitions determine whether the EBI is culturally relevant and compatible with the norms, values, and needs of the local community.

Step 3. Enhance Implementation Fidelity and Implementers' Capacity

Some research suggests that EBIs can never be perfectly replicated in communities and that changes or adaptations to the EBI's content, activities, materials, or methods of delivery will be necessary given the differences between well-controlled research trials and real-world settings. 263 , 270 , 345 - 347 However, research has shown that when EBIs are implemented with fidelity, programs achieve expected results. While culturally relevant adaptations can be expected to increase the relevance of the material, better engage participants, and improve effectiveness, it is clear that poor or inappropriate adaptation can reduce effectiveness. 268 , 295 For example, an evaluation showed that the effectiveness of the Nurse-Family Partnership program was significantly reduced when paraprofessionals rather than registered nurses delivered services in communities that lack registered nurses. 348 These types of inappropriate adaptations emphasize the need for communities to learn as much as they can about EBIs during the fit assessment and select only those interventions that are considered feasible given resources.

Steps to Build Prevention Infrastructure for Effective Community-based Prevention

Conduct a local needs assessment:

• Collect data on levels of substance use;
• Collect data on risk and protective factors related to substance use; and
• Identify and prioritize elevated risk factors and depressed protective factors.

Conduct a resource assessment:

• Assess current prevention programming, including the risk and protective factors addressed by current services, numbers and types of populations served, effectiveness, and implementation quality; and
• Identify potential new services using EBI and policy registries.

Assess the fit of new EBIs with the local community:

• Determine whether or not each potential EBI addresses the identified substance misuse problems and priority risk and protective factors; and
• Assess the degree to which the new EBI is culturally relevant for the local population.

Assess local readiness and capacity to implement EBIs:

• Identify the organization(s) that will deliver each new EBI;
• Assess levels of support for each new EBI among all key personnel; and
• Identify the financial and human resources and all other requirements necessary to implement each EBI.

Select the intervention(s) that is the best fit for the community: The ones that are most likely to be fully supported meet prioritized needs, are culturally relevant, can be well implemented, and can be sustained over the long-term.

Ensure high quality implementation of each new EBI:

• Create a detailed implementation plan;
• Specify participant eligibility criteria, participation goals, and recruitment procedures;
• Create teams to oversee implementation;
• Hire all necessary staff and administrators;
• Ensure that all staff are trained and regularly supervised; and
• Seek regular technical assistance from intervention developers.

Evaluate the impact of the selected interventions: It is critical to systematically collect and analyze information about program activities, participant characteristics, and outcomes.

• Collect data on all aspects of implementation; and
• Regularly review implementation and outcomes data and improve procedures as needed.

In addition to appropriate cultural adaptations, staff competency is critical to successful delivery of EBIs, and coalition members can support local agencies to ensure that they hire staff who have the credentials and experience recommended by developers, and that they receive training in each EBI's theory, content, and methods of delivery. 142 , 294 , 312 , 339 , 349 Training is an important ingredient in ensuring greater levels of implementation fidelity, especially because the content, activities, and methods of delivery may be new to practitioners. 24 , 294 , 295 In general, relatively few professionals responsible for implementing EBIs (including mental health counselors, teachers, psychologists, and social workers) receive training in substance misuse prevention, including knowledge of risk and protective factors that impact alcohol and drug use, the knowledge of EBIs that target these factors, or the importance of implementation fidelity when delivering interventions. 18 , 350 These topics should be incorporated into undergraduate, graduate, and in-service professional training programs. 351 In the meantime, staff should be supervised and receive coaching and corrective feedback to ensure they are implementing EBIs with quality. 294 , 295 , 349 , 352

Technical assistance from EBI developers can assist local agencies in staff supervision, and most EBIs offer support in how to monitor implementation activities, overcome challenges when they arise, and integrate EBIs into agency operations. 294 , 295 , 353 Although experimental studies are lacking, observational studies have reported that technical assistance, implementation monitoring, and staff feedback help ensure the high-quality delivery and sustainability of EBIs. 268 , 285 , 294 , 312 , 314 , 354 , 355

Step 4. Plan for Long-Term Sustainability

A lack of funding is a significant barrier to the long-term sustainability of EBIs, 294 , 308 , 311 , 356 - 359 and it is critical that, even before implementation, agencies and communities consider how each EBI will be integrated into existing systems and funded over time. 304 , 360 Considering how a new EBI will address local needs can be useful in gaining support. 361

• Recommendations for Research

Although much has been learned in prevention research over the past four decades, much remains to be understood. Future research should develop and evaluate new prevention interventions, both programs and policies, and continue to assess the effectiveness of existing interventions about which little is known. This research will help guide the field toward strategies with the greatest potential for reducing substance misuse and related problems.

Research also is needed to examine the effectiveness of screening and brief interventions for alcohol use in adolescents and for drug use in adolescents and adults; the combinations of evidence-based alcohol policies that most effectively reduce alcohol misuse and related harms; the public health impact of policies to reduce drug misuse; and the effectiveness of strategies to reduce marijuana misuse, driving after drug use, and simultaneous use of alcohol and drugs. In addition, the public health impact of marijuana decriminalization, legalization of medical marijuana, and legalization of recreational marijuana on marijuana, alcohol, and other drug use, as well as policies to reduce prescription drug misuse, should be monitored closely.

Research is needed to develop and test new prevention interventions, both policies and programs, to fill gaps in existing EBIs and to meet emerging public health needs across the lifecourse.

Given that racial and ethnic minority communities are often disproportionately affected by the adverse consequences of substance misuse, culturally-informed research should be conducted to examine ways to increase the cultural relevance, engagement, and effectiveness of prevention interventions for diverse communities. Additionally, studies of these interventions should be replicated and examined to determine the impact of prevention interventions for different cultural groups and contexts.

Consistent standards for evaluating interventions, conducting replication trials, and reporting the results should be developed. Examples of such standards have been developed by the Society for Prevention Research and the United Nations Office on Drugs and Crime. 26 , 357 , 362 - 368 Studies evaluating the effectiveness of interventions for reducing substance misuse should collect data over extended periods of time to track the long-term effects of these interventions on persons of all ages. The impact of environmental interventions on substance misuse should also be followed for at least a year beyond the end of the period of intervention support. The field needs to develop a consensus on standardization of methods of cost-benefit analysis, and increase research on cost-effectiveness evaluations of prevention EBIs.

Evidence is also needed to develop improved strategies for intervention in primary health care settings to prevent the initiation and escalation of adolescent substance use. More research is also needed on linking screening with personalized interventions, improved strategies for effective referral to specialty treatment, and interventions for adolescents that use social media and capitalize on current technologies. Research should also consider the optimal conditions for bringing effective prevention interventions to scale, develop consensus on standardization of methods for cost-benefit analysis, and increase research on cost-effectiveness evaluations of prevention EBIs.

Surveillance of risky drinking, drug use, and related problems needs to be improved. All drivers in fatal crashes should have their blood alcohol content tested and be tested for drug use. All unintentional and intentional injury deaths, including overdoses, should be tested for both alcohol and drugs. Surveillance surveys need to add questions about simultaneous alcohol and drug use and questions about the maximum quantities consumed in a day and frequency of consumption at those levels. Efforts are needed to increase surveillance of the second-hand effects of alcohol and drug use, such as assaults, sexual assaults, motor vehicle crashes, homicides and suicides, and effects of substance use on academic and work performance. Efforts are needed to expand surveillance beyond national and state levels to the level of local communities.

• Cite this Page Substance Abuse and Mental Health Services Administration (US); Office of the Surgeon General (US). Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health [Internet]. Washington (DC): US Department of Health and Human Services; 2016 Nov. CHAPTER 3, PREVENTION PROGRAMS AND POLICIES.
• PDF version of this title (12M)
• Disable Glossary Links

In this Page

Other titles in these collections.

• Reports of the Surgeon General
• Health Services/Technology Assessment Texts (HSTAT)

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

Recent Activity

• PREVENTION PROGRAMS AND POLICIES - Facing Addiction in America PREVENTION PROGRAMS AND POLICIES - Facing Addiction in America

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

3.7 Alcohol

Alcohol facts and statistics, alcohol use in the united states:.

• Prevalence of Drinking:  According to the 2015 National Survey on Drug Use and Health (NSDUH), 86.4 percent of people ages 18 or older reported that they drank alcohol at some point in their lifetime; 70.1 percent reported that they drank in the past year; 56.0 percent reported that they drank in the past month. 1
• Prevalence of Binge Drinking and Heavy Alcohol Use:  In 2015, 26.9 percent of people ages 18 or older reported that they engaged in binge drinking in the past month; 7.0 percent reported that they engaged in heavy alcohol use in the past month. 2  (See “Definitions” box for definitions of binge drinking and heavy alcohol use.)

Alcohol Use Disorder (AUD) in the United States:

• About 6.7 percent of adults who had AUD in the past year received treatment. This includes 7.4 percent of males and 5.4 percent of females with AUD in this age group. 5
• Youth (ages 12–17):  According to the 2015 NSDUH, an estimated 623,000 adolescents ages 12–17 6  (2.5 percent of this age group 7 ) had AUD. This number includes 298,000 males 6  (2.3 percent of males in this age group 7 ) and 325,000 females 6  (2.7 percent of females in this age group 7 ).
• About 5.2 percent of youth who had AUD in the past year received treatment. This includes 5.1 percent of males and 5.3 percent of females with AUD in this age group. 5

Alcohol-Related Deaths:

• An estimated 88,000 8  people (approximately 62,000 men and 26,000 women 8 ) die from alcohol-related causes annually, making alcohol the third leading preventable cause of death in the United States. The first is tobacco, and the second is poor diet and physical inactivity. 9
• In 2014, alcohol-impaired driving fatalities accounted for 9,967 deaths (31 percent of overall driving fatalities). 10

Economic Burden:

• In 2010, alcohol misuse cost the United States $249.0 billion. 11
• Three-quarters of the total cost of alcohol misuse are related to binge drinking. 11

Global Burden:

• In 2012, 3.3 million deaths, or 5.9 percent of all global deaths (7.6 percent for men and 4.1 percent for women), were attributable to alcohol consumption. 12
• In 2014, the World Health Organization reported that alcohol contributed to more than 200 diseases and injury-related health conditions, most notably DSM–IV alcohol dependence (see sidebar), liver cirrhosis, cancers, and injuries. 13  In 2012, 5.1 percent of the burden of disease and injury worldwide (139 million disability-adjusted life-years) was attributable to alcohol consumption. 12
• Globally, alcohol misuse was the fifth leading risk factor for premature death and disability in 2010. Among people between the ages of 15 and 49, it is the first. 14  In the age group 20–39 years, approximately 25 percent of the total deaths are alcohol-attributable. 15

Family Consequences:

• More than 10 percent of U.S. children live with a parent with alcohol problems, according to a 2012 study. 16

Underage Drinking:

• Prevalence of Drinking:  According to the 2015 NSDUH, 33.1 percent of 15-year-olds report that they have had at least 1 drink in their lives. 17  About 7.7 million people ages 12–20 18  (20.3 percent of this age group 19 ) reported drinking alcohol in the past month (19.8 percent of males and 20.8 percent of females 19 ).
• Prevalence of Binge Drinking:  According to the 2015 NSDUH, approximately 5.1 million people 18 (about 13.4 percent 19 ) ages 12–20 (13.4 percent of males and 13.3 percent of females 19 ) reported binge drinking in the past month.
• Prevalence of Heavy Alcohol Use:  According to the 2015 NSDUH, approximately 1.3 million people 18 (about 3.3 percent 19 ) ages 12–20 (3.6 percent of males and 3.0 percent of females 19 ) reported heavy alcohol use in the past month.
• Research indicates that alcohol use during the teenage years could interfere with normal adolescent brain development and increase the risk of developing AUD. In addition, underage drinking contributes to a range of acute consequences, including injuries, sexual assaults, and even deaths—including those from car crashes. 20

Alcohol and College Students:

• Prevalence of Drinking:  According to the 2015 NSDUH, 58.0 percent of full-time college students ages 18–22 drank alcohol in the past month compared with 48.2 percent of other persons of the same age. 21
• Prevalence of Binge Drinking:  According to the 2015 NSDUH, 37.9 percent of college students ages 18–22 reported binge drinking in the past month compared with 32.6 percent of other persons of the same age. 21
• Prevalence of Heavy Alcohol Use:  According to the 2015 NSDUH, 12.5 percent of college students ages 18–22 reported heavy alcohol use in the past month compared with 8.5 percent of other persons of the same age. 21
• 1,825 college students between the ages of 18 and 24 die from alcohol-related unintentional injuries, including motor-vehicle crashes. 22
• 696,000 students between the ages of 18 and 24 are assaulted by another student who has been drinking. 23
• 97,000 students between the ages of 18 and 24 report experiencing alcohol-related sexual assault or date rape. 23
• Roughly 20 percent of college students meet the criteria for AUD. 24
• About 1 in 4 college students report academic consequences from drinking, including missing class, falling behind in class, doing poorly on exams or papers, and receiving lower grades overall. 25

Alcohol and Pregnancy:

• The prevalence of Fetal Alcohol Syndrome (FAS) in the United States was estimated by the Institute of Medicine in 1996 to be between 0.5 and 3.0 cases per 1,000. 26
• More recent reports from specific U.S. sites report the prevalence of FAS to be 2 to 7 cases per 1,000, and the prevalence of Fetal Alcohol Spectrum Disorders (FASD) to be as high as 20 to 50 cases per 1,000. 27,28

Alcohol and the Human Body:

• In 2015, of the 78,529 liver disease deaths among individuals ages 12 and older, 47.0 percent involved alcohol. Among males, 49,695 liver disease deaths occurred and 49.5 percent involved alcohol. Among females, 28,834 liver disease deaths occurred and 43.5 percent involved alcohol. 29
• Among all cirrhosis deaths in 2013, 47.9 percent were alcohol-related. The proportion of alcohol-related cirrhosis was highest (76.5 percent) among deaths of persons ages 25–34, followed by deaths of persons ages 35–44, at 70.0 percent. 30
• In 2009, alcohol-related liver disease was the primary cause of almost 1 in 3 liver transplants in the United States. 31
• Drinking alcohol increases the risk of cancers of the mouth, esophagus, pharynx, larynx, liver, and breast. 32

Definitions

Alcohol Use Disorder (AUD):  AUD is a chronic relapsing brain disease characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. AUD can range from mild to severe, and recovery is possible regardless of severity. The fourth edition of the  Diagnostic and Statistical Manual  (DSM-IV), published by the American Psychiatric Association, described two distinct disorders—alcohol abuse and alcohol dependence—with specific criteria for each. The fifth edition, DSM-5, integrates the two DSM-IV disorders, alcohol abuse, and alcohol dependence, into a single disorder called alcohol use disorder, or AUD, with mild, moderate, and severe subclassifications.

Binge Drinking:

• NIAAA defines binge drinking as a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL. This typically occurs after 4 drinks for women and 5 drinks for men—in about 2 hours. 33
• The Substance Abuse and Mental Health Services Administration (SAMHSA), which conducts the annual National Survey on Drug Use and Health (NSDUH), defines binge drinking as 5 or more alcoholic drinks for males or 4 or more alcoholic drinks for females on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past month. 34

Heavy Alcohol Use:   SAMHSA defines heavy alcohol use as binge drinking on 5 or more days in the past month.

Moderate alcohol consumption:  According to the  “Dietary Guidelines for Americans 2015-2020,” U.S. Department of Health and Human Services and U.S. Department of Agriculture , moderate drinking is up to 1 drink per day for women and up to 2 drinks per day for men.

NIAAA’s Definition of Drinking at Low Risk for Developing AUD:  For women, low-risk drinking is defined as no more than 3 drinks on any single day and no more than 7 drinks per week. For men, it is defined as no more than 4 drinks on any single day and no more than 14 drinks per week. NIAAA research shows that only about 2 in 100 people who drink within these limits have AUD.

Alcohol-Impaired-Driving Fatality:  A fatality in a crash involving a driver or motorcycle rider (operator) with a BAC of 0.08 g/dL or greater.

Disability-Adjusted Life-Years (DALYs):  A measure of years of life lost or lived in less than full health.

Underage Drinking:  Alcohol use by anyone under the age of 21. In the United States, the legal drinking age is 21.

What Is A Standard Drink?

• Regular beer: 5% alcohol content
• Some light beers: 4.2% alcohol content

That’s why it’s important to know how much alcohol your drink contains.  In the United States, one “standard” drink contains roughly 14 grams of pure alcohol, which is found in:

• 12 ounces of regular beer, which is usually about 5% alcohol
• 5 ounces of wine, which is typically about 12% alcohol
• 1.5 ounces of distilled spirits, which is about 40% alcohol

How do you know how much alcohol is in your drink?

Even though they come in different sizes, the drinks below are examples of  one standard drink :

Each beverage portrayed above represents one standard drink of “pure” alcohol, defined in the United States as 0.6 fl oz or 14 grams. The percent of pure alcohol, expressed here as alcohol by volume (alc/vol), varies within and across beverage types. Although the standard drink amounts are helpful for following health guidelines, they may not reflect customary serving sizes.

Visit the following websites for information on alcohol

• Rethinking Drinking
• Link to alcohol fact sheets from drugabuse.gov
• WebMD slideshow on How Alcohol Affects Your Body

Drugs, Health & Behavior Copyright © 2018 by Jacqueline Schwab and Denise Salters is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

Share This Book