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Preventing Alcohol Problems In Young People

Popular Approaches Are Ineffective, Effective Approaches Are Politically Impossible
By Robin Room, Centre for Social Research on Alcohol and Drugs, Stockholm University, 2000.
In my presentation today I set out to answer a number of questions. The questions are the following:


1.  Why do young people drink and get drunk?
2.  What are we trying to prevent with prevention programs in the alcohol field?
3.  What are the different strategies of prevention?
4.  What is the evidence of their effectiveness?
5.  What strategies are most politically popular, and how do they relate to those which are most effective?
6.  What conclusions can we draw for future programs and initiatives?

Why do young people drink and get drunk?

First, why do young people drink? More importantly, from the point of view of harm, why do young people get drunk? Because most of the problems related to young people's drinking are from intoxication, not just from taking a sip or one drink.


Though all of us were teenagers once, and thus know something about the experience of being young, formal empirical knowledge about what impels children and teenagers to get drunk, and what meaning it holds for them, is rather limited. The experience of intoxication is eventually spread widely enough among teenagers that it has to be seen and interpreted not only in pathological but also in normalizing terms -- as part of the process of growing up.


In this framing, adolescence is seen as a period of experimentation and identity formation. Part of this developmental process includes seeking new sensations and taking at least some risks, with a particular focus on behaviours which are supposed to be for adults and thus serve as markers of adulthood. Thus adolescents learn about and experiment with new behaviours as various as sexuality and driving an automobile, including experimenting near or at the edge of the various dangers that may accompany these "adult" behaviours.


Motives for experimenting with drinking and intoxication -- as also with other psychoactive substances -- vary. Motives which are commonly mentioned in the literature include rebellion, sensation-seeking, providing pleasure, alleviating boredom, satisfying curiosity, facilitating social bonding, attaining peer status, or as an escape/coping mechanism (Amos et al., 1997; Arnett, 1992; Banwell & Young, 1993; Franzkowiak, 1987; Igra & Irwin, 1996; Wilks, 1992). In terms of some of these motivations, drinking is thus a functional behaviour.


However, drinking is also a behaviour heavily weighted with symbolic significance. Youthful drinking is often a performance in front of an audience of associates and others, staking a claim to a valued identity, and expressing solidarity in a group or marking off social boundaries (Room, 1994). Choices about drinking B which type of beverage and which brand-name, as well as when and how much to drink --- are potent ways of identifying with a cultural style (Polhemus, 1994), of marking a symbolic distinction from those who are outside the circle or "too young", and of performing for an audience of other youth


The prevention literature pays too little attention to the collective and symbolic aspects of drinking and intoxication. Drinking is predominantly done in groups, and is often incidental to another social activity, such as dancing, clubbing, partying, or following a particular style of music (Thornton, 1995). "Peer influence" is often more a matter of the attraction of a particular social group for the teenager than it is a matter of pressure from anyone specifically to drink or become intoxicated.


During the slow transition into adulthood, then, drinking at all and drinking to intoxication can symbolize freedom and autonomy, providing youth with a seemingly adult status (Jessor, 1992; Jessor & Jessor, 1977). Positive lifestyle advertisements and sponsorships contribute to general favourable associations and expectancies (Wyllie et al., 1998b).


Messages about not drinking "until you are old enough" have a double edge, reinforcing the status of drinking or smoking as claims on adult status. In the context of the social acceptance of drinking among adults, youth see messages that they should behave differently as hypocritical and, thus, are likely to reject them (D=Emidio-Caston & Brown, 1998).


Though it may be normative, youthful drinking nevertheless carries with it considerable social, health and casualty problems. These may include a start on patterns which lead later in life to alcohol dependence or to chronic physical and mental health problems.


But foremost among the problems are the relatively immediate consequences, particularly, as we have noted, adverse consequences of intoxication. These include substantial numbers of deaths and permanent disabilities among youth due to accidents or violence related to drinking.


In the WHO estimates of the global burden of disease and disability, alcohol accounts for 5.1% of the years of life prematurely lost and 15.6% of the burden of disability (years lived with disability) in the Established Market Economies (Murray and Lopez, 1996:313). Much of this devastation results from casualties among youth. Though we do not have equivalent estimates of the burden in these areas, youthful intoxication can also leave behind a trail of personal suffering and interpersonal and social problems.


What are we trying to prevent?


I turn now to the question, what are we trying to prevent? My primary argument is for a focus on the immediate; in this the situation for alcohol differs from that for tobacco. While the longer term must be kept in mind, there are several good reasons for putting the greatest weight in youth alcohol problems prevention work on the more immediate potential harms.


First, preventing a proximal harm is inherently an easier task than preventing a distal harm. Most commonly, the effects of any intervention decays over time: in the long run, there is just too much "noise" from the intervening activities and events of everyday life. For instance, a youth prevention program has a much better chance of preventing a tragedy from driving home drunk after an upcoming high-school prom than it has of preventing a death from liver cirrhosis in a 50-year-old.


Secondly, a youth audience will be more open to prevention messages about immediate problems in their lives than to messages about how to prevent problems which may or may not occur when they are in their 60s (USDHHS, 1994).


Thirdly, more strategies are available for preventing harms related to the immediate drug use event or pattern than are available for preventing long-term chronic conditions (Room, 1974). While the main way of preventing liver cirrhosis is by affecting the person=s cumulative amount of drinking, preventing a drinking-driving casualty can be accomplished not only by affecting the driver=s drinking, but also by such means as providing an alternative driver or transport, relocating the prom, or even by seat-belts and airbags.


My second argument concerns the issue of the target behaviour. A youth prevention program focussed on alcohol can aim to prevent or postpose drinking at all; to prevent or postpone risky drinking such as intoxication; or to prevent or postpone harms from drinking or intoxication. The aims of such programs are to a considerable degree conditioned by the society=s expectations about youth drinking. If the legal drinking age is high, then it is likely that programs aimed at youth in their early or middle teens will aim to prevent or postpone drinking at all. Harm reduction strategies may run into political difficulty in this environment, since they are predicated on a recognition that many youths are already drinking.


A difficulty with the literature evaluating the effectiveness of youth prevention programs on alcohol issues is that much of it has been produced in exactly this societal environment. The uniform minimum legal drinking age in the United States, where much of the literature has been produced, has been 21 since the mid-1980s.


On the other hand, the average age of actually starting drinking in the U.S. is about the same as in many other developed societies B the early teens. Much of the evaluation literature available for reviewing thus evaluates programs which might be seen as starting with one hand tied behind their back, in assuming that the target audience is not already drinking. This handicap must be kept in mind as we review the often negative tenor of findings from the evaluation literature.


What are the different strategies, and what is the evidence on their effectiveness?


Let us now turn to strategies of alcohol prevention, and evidence on their effectiveness. Simplifying somewhat, there are seven main strategies to minimize alcohol problems. One strategy is to educate or persuade people not to use or about ways to use so as to limit harm. A second strategy, a kind of negative persuasion, is to deter drinking-related behaviour with the threat of penalties.


A third strategy, operating in the positive direction, is to provide alternatives to drinking or to drink-connected activities. A fourth strategy is in one way or another to insulate the use from harm. A fifth strategy is to regulate availability of the drug or the conditions of its use. Prohibition of supply may be regarded as a special case of such regulation.


A sixth strategy is to work with social or religious movements oriented to reducing alcohol problems. And a seventh strategy is to treat or otherwise help people who are in trouble with their drinking.


In recent decades, there have been efforts to form partnerships, often involving both official agencies and grassroots groups to work on alcohol problems, at the level of the local community. These community action projects typically use one or more of the strategies outlined above and discussed below. In the present terms, then, community action is not itself a strategy, but rather is a mode of working which uses one or more of the prevention strategies.


As we have already heard exemplified, the tradition of evaluated community action projects (Giesbrecht et al., 1990; Greenfield and Zimmerman, 1993; Holmila, 1997; Holder 1998) is able to show a modest record of success, depending in part on the strategies adopted. Although the community often wants the project oriented specifically to affecting patterns among youth, there is a good argument, as discussed below, for embedding any youth program in a broader effort not limited to youth.


We will consider in turn the seven strategies and the evidence on their effectiveness.


Education and persuasion


In principle, education can be offered in a variety of venues, but it is usually education in schools which first comes to mind in the prevention of alcohol problems, particularly among youth. Community-based prevention programs also may include an educational component.


Education offers new information or ways of thinking about information, and leaves it to the listener to draw conclusions concerning beliefs and behaviour. However, most alcohol education programs go beyond this. A commonplace of the North American evaluative literature on alcohol education is that "knowledge-only" approaches do not result in changes in behaviour (Botvin, 1995). School-based alcohol education has thus usually had a persuasional element along with the information provision, aiming to influence students in a particular direction.


Persuasion is directly concerned with changing beliefs or behaviours, and may or may not also offer information. Mass-media campaigns aimed at persuasion have been a very common component of prevention programs for alcohol-related problems, but persuasion can be pursued also through other media and modalities. Most such campaigns are aimed at the drinker, but some are aimed at those around or responding to the drinker. Prototypical examples are campaigns with the theme, "friends don=t let friends drive drunk".


In most societies, public-health-oriented persuasion about alcohol must compete with a variety of other persuasional messages, including those intended to sell alcoholic beverages. The evidence that alcohol advertising influences teenagers and young adults towards increased drinking and problematic drinking is becoming stronger (Wyllie et al., 1998a; 1998b). Even where alcohol advertising is not allowed on the mass media, these messages are conveyed to consumers and potential consumers in a variety of other ways.


Evidence on effectiveness As we have noted, the literature on effectiveness of educational approaches is dominated by school-based studies from the United States. In general, despite the best efforts of a generation of researchers, this literature has had difficulty showing substantial and lasting effects (Paglia and Room, 1999). There is a good argument from general principles for alcohol education in the context of consumer and health education, but there is little evidence from the formal evaluation literature at this point of its effectiveness beyond the short term.


Persuasional media campaigns have also been a favourite modality in many places in recent decades for the prevention of alcohol problems. In general, evaluations of such campaigns have been able to demonstrate impacts on knowledge and awareness about alcohol, but can show only modest success in affecting attitudes and behaviours . As with school education approaches, there are hints in the literature that success may come more from influencing the community environment around the drinker -- in terms of attitudes of significant others, or popular support for alcohol policy measures -- than from directly persuading the drinker him/herself.


Thus, media messages can be effective as agenda-setting mechanisms in the community, increasing or sustaining public support for other preventive strategies (Casswell et al., 1989).


There is now new experience to bring to bear here, though, from the state-financed anti-smoking campaigns in California and in Florida. These have been very hard-hitting, often directly attacking the tobacco industry, with message such as "the tobacco industry is not in business for your health". The government doing this offered an unusual spectacle, one which apparently attracted the attention of teenagers; there have been notieceable affects on teenage smoking rates, at least in the short term.


But by the same token, the campaigns have proved very difficult to sustain politically -- under pressure from the tobacco industry, the Florida campaign=s teeth were pulled by the governor, and a former California governor tried to do the same.


Deterrence


In its broadest sense, deterrence means simply the threat of negative sanctions or incentives for behavior -- a form of negative persuasion. Criminal laws deter in two ways: by general deterrence, which is the effect of the law in preventing a prohibited behavior in the population as a whole, and specific deterrence, which is the effect of the law in discouraging those who have been caught from doing it again (Ross, 1982). A law tends to have a greater preventive effect and to be cheaper to administer to the extent it has a strong general deterrence effect.


Prohibitions on driving after drinking more than a specified amount are now in effect in most nations (Hurst et al., 1997, pp. 555-556). In many societies, there have also been laws against public drunkenness (being in a public place while intoxicated), and against obnoxious behavior while intoxicated. Other common prohibitions are concerned with producing or selling alcoholic beverages outside state-regulated channels, and with drinking and public and other aspects of drinking under a specified minimum age.


Evidence on effectiveness Drinking-driving legislation, such as "per-se" laws outlawing driving while at or above a defined blood-alcohol level, has been shown to be effective in changing drivers= behavior and reducing rates of alcohol-related problems (Ross, 1982; Edwards et al., 1994, pp. 153-159; Hingson, 1996). The effect is through both general and specific deterrence. The quickness and certainty of punishment, as well as its severity, are important in the deterrent value (too much severity tends to undercut its quickness and certainty). Drinking-driving is an ideal area for applying general deterrence, since the gains from breaking the law are limited, and automobile drivers typically have something to lose by being caught.


However, we are now approaching the limit of what can be accomplished with general deterrence of drinking driving. Nearly every countermeasure which our cultures will allow has already been taken.


Many English-speaking and Scandinavian countries have had a tradition of criminalizing drinking in public places or public drunkenness as such, but the trend has been to decriminalize public drunkenness. Though there are few specific studies, criminalizing public drunkenness may not be very effective in changing the behavior of those who have little to lose.


This principle may also apply to laws deterring aspects of youthful drinking, although there is little in the alcohol literature on deterrence with teenage populations. Deterrence works best on those with more to lose.


Providing and encouraging alternative activities


Another strategy, in principle involving positive incentives, is to provide and seek to encourage activities which are an alternative to drinking or to activities closely associated with drinking. This includes such initiatives as making soft drinks available as an alternative to alcoholic beverages, providing locations for sociability as an alternative to taverns, and providing and encouraging recreational activities as an alternative to leisure activities involving drinking. Job-creation and skill development programs are other examples. Providing alternative activities such as sports and recreational programs has been a particularly common strategy with youth populations.


Evidence on effectiveness "Boredom" and "because there's nothing else to do" are certainly among the reasons that are quite often given for drinking. And there are often good reasons of general social policy for providing and encouraging alternative activities.


But Klaus M?kel? once noted, the problem with alternatives to drinking is that drinking combines so well with so many of them. Soft drinks are indeed an alternative to alcoholic beverages for quenching thirst, but they may also serve as a mixer in an alcoholic drink. Involvement in sports may go along with drinking as well as replace it.


Historically, there are some clear substitutions, for instance of coffee for alcohol in the classic temperance era in Norway (Skog, 1985). But in the modern era such effects are hard to find. The few evaluation studies of providing alternative activities, again from a restricted range of societies, have generally not shown lasting effects on drinking behavior (Moskowitz et al., 1983; Norman et al., 1997), though they undoubtedly often serve a general social purpose in broadening opportunities for the disadvantaged (Carmona and Stewart, 1996).


Insulating use from harm


A major social strategy for reducing alcohol-related problems in many societies has been measures to separate the drinking, and particularly heavy drinking, from potential harm -- making the world safe for (and from) drunks, as it has sometimes been put. This separation can be physical (in terms of distance or walls), it can be temporal, or it can be cultural (e.g., defining the drinking occasion as "time out" from normal responsibilities). These "harm reduction" strategies, as they are called in the context of illicit drugs, are often built into cultural arrangements around drinking, but can also be the object of purposive programs and policies (Moore and Gerstein, 1981, pp. 100-111 ).


A variety of modifications of the driving environment affect casualties associated with drinking and driving, along with other casualties. These include mandatory use of seat belts, airbags, and improvements in the safety of road vehicles and roads. Many other practical measures to separate intoxication episodes from casualties and other adverse consequences have been put into practice, though usually without formal evaluation.


Other harm-reduction projects have aimed to reduce potential casualties and other harms associated with drinking in bars and nightclubs. Often these projects have been aimed particularly at youth-oriented drinking places. Australian and Canadian community projects have worked with bar and nightclub owners and staff to reform serving practices to reduce rates of drinking-related violence (Graham and Homel, 1997; Hauritz et al., 1998; Wells et al., 1998).


Harm reduction approaches can be politically sensitive, particularly when they are aimed at underaged youth, since they involve accepting facts which are unwanted and not admitted.


Evidence on effectiveness Drinking-driving countermeasures are a prime example of an approach in terms of insulating drinking behavior from harm, since they seek to reduce alcohol-related traffic casualties without necessarily stopping or reducing alcohol use (Evans, 1991). There is substantial evidence of the success of a range of such countermeasures, including environmental change approaches as well as deterrence (Forsyth, 1996; Zajac, 1997). Some environmental measures which reduce road casualties in general -- e.g., requiring wearing of seat-belts in cars, providing sidewalks separated from the road -- may prevent casualties associated with intoxication even more than other casualties.


The first results from the projects aiming at reducing alcohol-related violence in youth-oriented bars have been positive (Hauritz et al, 1998), although the Australian experiences raise the question of how the early gains of such projects can be continued and institutionalized. The server intervention training literature suggests that this is effective only when backed up by enforcement and potential sanctions if servers ignore the training.


Regulating the availability and conditions of use


In terms of the substantial harms to health and public order they can cause, alcoholic beverages are not ordinary commodities. Governments have thus often actively intervened in the markets for such beverages, far beyond usual levels of state intervention in markets for commodities.


Total prohibition can be viewed as an extreme form of regulation of the market. In this circumstance, where noone is licensed to sell alcohol, the state has no formal control over the conditions of the sales which nevertheless occur, and there are no legal sales interests, controlled through licensing, to cooperate with the state in the market's regulation.


With a general prohibition, typically the consumption of alcohol does fall in the population, and there are declines also in the rates of the direct consequences of drinking such as cirrhosis or alcohol-related mental disorders (e.g., Teasley, 1992; Moore and Gerstein, 1981). But prohibition also brings with it characteristic negative consequences, including the emergence and growth of an illicit market, and the crime associated with this. Partly for this reason, prohibition for adults is not now a live option in any developed society, although it is in some other societies. However, a minimum drinking age can be regarded as a form of prohibition specifically for youth.


Alcohol controls are typically enforced through control or licensing of the sellers, not of the drinkers. This makes them potentially relatively cheap and effective to implement. The features of alcohol control regimes, regulating the legal market in alcohol, vary greatly.


Special taxes on alcohol are very common, imposed often as much for revenue as for public health considerations. In addition to minimum age limits forbidding sales to underage customers, many jurisdictions forbid sales to the already intoxicated. Often the regulations include limiting the number of sales outlets, restricting hours and days of sale, and limiting sales to special stores or drinking-places. Rationing of alcohol purchases -- limiting the amount individuals can buy in a given time-period -- has also been used as a means of regulating availability.


Regulations restricting or forbidding advertising of alcoholic beverages attempt to limit or channel efforts by private interests to increase demand for particular alcoholic beverage products. Such regulations potentially complement education and persuasion efforts. State monopolization of sales of some or all alcoholic beverages at the retail and/or wholesale level has also been commonly been used as a mechanism to minimize alcohol-related harm (Room, 1993).


The countries north of the Baltic Sea, of course, have had relatively strong alcohol control systems for many years. But they exemplify how difficult it has become in the present era to retain such a level of control. Difficulties exist at both ideological and practical levels. The doctrine of consumer sovereignty -- the idea that we should be able to purchase whatever we like, whenever we like, as long as we have money in our pocket -- is very strong. Trade agreements and dispute resolution mechanisms limit the ability of nations and localities to use alcohol control regulations.


For instance, the European Union single market commissioner is currently pressing France to withdraw the Loi ??vin, which outlaws alcohol advertising (Financial Times, 2000). Lower alcohol taxes elsewhere create pressures to reduce taxes. And as new private interests enter the market, they become a political constituency for the "ratchet mechanism" (M?kel? et al., 1981) of market liberalizations.


The effectiveness of specific types of regulation of availability. The last 25 years have seen the development of a burgeoning literature on the effects of alcohol control measures. Specific types of regulation of the alcohol market, and the evidence on their effectiveness, are discussed below.


Minimum age limits: As noted above, a minimum age limit is a partial prohibition, applied to one segment of the population. There is a strong evaluation literature showing the effectiveness of establishing and enforcing minimum-age limits in reducing alcohol-related problems (Edwards et al., 1994, pp. 138-139). However, this literature is North America-based, focuses mostly on youthful driving casualties, and mostly evaluates reduction from and increases to age 21 as the limit, a higher minimum-age limit than in most societies. The applicability of the literature=s findings in other societies and where youth cultures are less automobile-focused has been little tested.