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"Prevention of Substance Abuse: What science tells us” Harold D. Holder, Ph.D. Senior Scientist Prevention Research Center Pacific Institute for Research and Evaluation Berkeley, CA Tucson, Arizona. December 13, 2005. Prevention Paradox:. - PowerPoint PPT Presentation
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"Prevention of Substance "Prevention of Substance Abuse: What science tells Abuse: What science tells
us”us”
Harold D. Holder, Ph.D.Harold D. Holder, Ph.D.Senior ScientistSenior Scientist
Prevention Research CenterPrevention Research CenterPacific Institute for Research and Pacific Institute for Research and
Evaluation Evaluation Berkeley, CABerkeley, CA
Tucson, ArizonaTucson, Arizona
"Prevention of Substance "Prevention of Substance Abuse: What science tells Abuse: What science tells
us”us”
Harold D. Holder, Ph.D.Harold D. Holder, Ph.D.Senior ScientistSenior Scientist
Prevention Research CenterPrevention Research CenterPacific Institute for Research and Pacific Institute for Research and
Evaluation Evaluation Berkeley, CABerkeley, CA
Tucson, ArizonaTucson, Arizona
December 13, 2005December 13, 2005
More local problems are More local problems are caused by heavy drinking caused by heavy drinking
than by alcoholics.than by alcoholics.
Prevention Paradox:
0
10
20
30
40
50
60
70
Alcoh
ol
Tobac
co
Mar
ijuan
a
Inhal
ants
Hallu
cinoge
ns
Tranq
uiliz
ers
Amph
etam
ines
Cocai
ne
Narco
tics
Students Who Reported Using Alcohol, Students Who Reported Using Alcohol, Tobacco, and Other Drugs in Past 30 DaysTobacco, and Other Drugs in Past 30 Days
63%63%
46%46%
25%25%
11.4%11.4% 10.8%10.8%6.1%6.1% 4.5%4.5% 3.5%3.5% 4.5%4.5%
Experimentation and Established Smoking by Age
Source: 1996 CTS
Past Month Illicit Drug Use—any drug
Just what Just what isis prevention, anyway?prevention, anyway?
Goals of ATOD preventionGoals of ATOD prevention
Prevent health and safety problems related to Prevent health and safety problems related to substance use, e.g., traffic crashes, violence, substance use, e.g., traffic crashes, violence, lung cancer, overdose.lung cancer, overdose.
Prevent Prevent allall use of tobacco and illicit substances use of tobacco and illicit substances for everyone, for everyone, regardlessregardless of age. of age.
Prevent heavy and high risk use of substances.Prevent heavy and high risk use of substances.
Delay adolescent initiation of substances that are Delay adolescent initiation of substances that are licit for adults (e.g., tobacco and alcohol).licit for adults (e.g., tobacco and alcohol).
Approaches to the reduction of ATOD use and resulting problems
Individual change Environmental approaches change approaches
Goal
Individual behavioralchange leading to demand reduction
Community/state system or population change leading to both demand and supply reduction
TargetIndividual, directly or through others (e.g., family, peers)
Social, economic and physical environment
Orientation
But lots of hybrid , multi-component models
Substance Abuse Influences and FactorsSubstance Abuse Influences and Factors
(3) Economic - (3) Economic - Cost of alcohol, drugs, tobacco; Cost of alcohol, drugs, tobacco; geography of availability geography of availability
(3) Economic - (3) Economic - Cost of alcohol, drugs, tobacco; Cost of alcohol, drugs, tobacco; geography of availability geography of availability
(1)(1)Physical - Physical - Proximity of alcohol & Proximity of alcohol & tobacco outlets and drugtobacco outlets and drugsupplies, places of public usesupplies, places of public use
(1)(1)Physical - Physical - Proximity of alcohol & Proximity of alcohol & tobacco outlets and drugtobacco outlets and drugsupplies, places of public usesupplies, places of public use
(2) Social - (2) Social - Family, peers and larger Family, peers and larger social networks, norms, social networks, norms,
mass mediamass media
(2) Social - (2) Social - Family, peers and larger Family, peers and larger social networks, norms, social networks, norms,
mass mediamass media
For Example, Youth DrinkingFor Example, Youth DrinkingFor Example, Youth DrinkingFor Example, Youth Drinking
AlcoholAlcoholAvailabilityAvailability
DrinkingDrinkingBy PeersBy Peers
RetailRetailPricePrice
Alcohol purchases by other youthAlcohol purchases by other youth
EconomicEconomicSocialSocial
Cost &Cost &availabilityavailability to youthto youth
Availability of Availability of alcohol to & alcohol to & from peersfrom peers
PhysicalPhysical
Public Health Model of PreventionPublic Health Model of Prevention
IndividualIndividual
EnvironmentEnvironment AgentAgent
Public Health Model of Substance Public Health Model of Substance Abuse Problem PreventionAbuse Problem Prevention
IndividualIndividual(User)(User)
EnvironmentEnvironment(Context)(Context)
AgentAgent(Substance)(Substance)
Individual ApproachesIndividual Approaches
3.3.
4.4.
1.1.
2.2.
School-Based EducationSchool-Based Education
Mass Communication and Public Mass Communication and Public EducationEducation
Family Education/counselingFamily Education/counseling
Alcohol and Tobacco Warning labelsAlcohol and Tobacco Warning labels
DeterrenceDeterrence: : Possession or sale of drugs, Possession or sale of drugs, Drinking and driving Laws, Sale of tobacco or Drinking and driving Laws, Sale of tobacco or alcohol to minors.alcohol to minors.
5.5.
Brief Intervention in health care or workplace6.
Public Health Model of Substance Use Public Health Model of Substance Use PreventionPrevention
EnvironmentEnvironment(Context)(Context)
IndividualIndividual(User)(User)
AgentAgent(Substance)(Substance)
Environmental ApproachesEnvironmental Approaches
1.1.
2.2.
3.3.
Retail Access to substances, e.g., Retail Access to substances, e.g., price, outlet locations, minimum price, outlet locations, minimum purchase laws, parental restrictions on purchase laws, parental restrictions on youth.youth.
Restrictions or constraints on the Restrictions or constraints on the Drinker’s or Smokers Behavior, Drinker’s or Smokers Behavior, e.g., e.g., drinking & smoking locations, drink drivedrinking & smoking locations, drink drive
Reduce Risk or Problem SeverityReduce Risk or Problem Severity
Public Health Model of Substance Use Public Health Model of Substance Use PreventionPrevention
AgentAgent(Substance)(Substance)
IndividualIndividual(User)(User)
EnvironmentEnvironment(Context)(Context)
Agent ApproachesAgent Approaches
1.1.
2.2.
3.3.
Low or No Alcohol Beverages or lower Low or No Alcohol Beverages or lower tar tobacco productstar tobacco products
Alcohol container size or Alcohol container size or tobacco package restrictions tobacco package restrictions
Restrictions on Product Restrictions on Product AdvertisingAdvertising
Standards of EvidenceStandards of Evidence
1.1.
2.2.
3.3.
Achieves significant effects (actually Achieves significant effects (actually reduces ATOD problems) under scientific reduces ATOD problems) under scientific standards.standards.
Replicated across two or more studies Replicated across two or more studies under diverse community or national under diverse community or national conditions.conditions.
Has practical applicability and can affect Has practical applicability and can affect the total community, not only target the total community, not only target groups, i.e., groups, i.e., has public health importhas public health import..
Problem Prevention Strategies: Problem Prevention Strategies: Solid EvidenceSolid Evidence
¤¤
¤¤
¤¤
¤¤
¤¤
¤¤
Retail price of alcohol or tobaccoRetail price of alcohol or tobacco
Density & location of alcohol outletsDensity & location of alcohol outlets
Lower BAC limits for drivingLower BAC limits for driving
Drinking/driving deterrence (RBT)Drinking/driving deterrence (RBT)
Graduated licenses & “zero tolerance Graduated licenses & “zero tolerance for Youthfor Youth
Minimum drinking/purchase ageMinimum drinking/purchase age—retail —retail compliance checks for alcohol and tobaccocompliance checks for alcohol and tobacco
¤¤ Form and style of retail sale, Form and style of retail sale, e.g., hours and days of retail e.g., hours and days of retail sale.sale.
As price increases, smoking and heavy As price increases, smoking and heavy drinking declines (Chaloupka, 1993)drinking declines (Chaloupka, 1993)
Heavy drinkers/smokers as well as youth are Heavy drinkers/smokers as well as youth are affected by price. (Coate and Grossman, affected by price. (Coate and Grossman, 1988)1988)
Retail PriceRetail PriceRetail PriceRetail Price Drinking & Drinking & smokingsmokingDrinking & Drinking & smokingsmoking
Youth who drink weekly up to daily are Youth who drink weekly up to daily are more affected by price (Grossman, et al., more affected by price (Grossman, et al., 1991; Coate and Grossman, 1988)1991; Coate and Grossman, 1988)
Underage DrinkingUnderage Drinking
Increase community awareness of underageIncrease community awareness of underagedrinkingdrinking
Reduce physical availability of alcohol to minorsReduce physical availability of alcohol to minors
GoalGoal::Decrease underage drinkingDecrease underage drinking
Increase awareness of retail establishments andIncrease awareness of retail establishments andadults of the legal and social risks of providingadults of the legal and social risks of providingalcohol to minorsalcohol to minors
ActionActions:s:
Alcohol Use (30-day mean) Before and After Alcohol Use (30-day mean) Before and After Minimum Drinking Age (MDA) was Raised--United StatesMinimum Drinking Age (MDA) was Raised--United States
Alcohol Use (30-day mean) Before and After Alcohol Use (30-day mean) Before and After Minimum Drinking Age (MDA) was Raised--United StatesMinimum Drinking Age (MDA) was Raised--United States
Years Before and After MDA was Years Before and After MDA was RaisedRaised
2.2
2.4
2.6
2.8
3
3.2
-3 -2 -1 1 2 3Me
an
30
-Da
y A
lco
ho
l M
ea
n 3
0-D
ay
Alc
oh
ol
Us
eU
se
Source: O’Malley & Wagenaar (1991)
13% Decline13% Decline
Environment Environment Environment Environment Person ActivitiesPerson ActivitiesPerson ActivitiesPerson Activities
Drinking and DrivingDrinking and Driving
Increase law enforcement efficiencyIncrease law enforcement efficiency
Increase perceived risk of DWI detectionIncrease perceived risk of DWI detection
Increase community support of DWI Increase community support of DWI enforcementenforcement
GoalGoal::Reduce the number of community drinking and Reduce the number of community drinking and driving eventsdriving events
ActionsActions::
Access InterventionAccess Intervention
GoalGoal: : Decreased physical availability of SubstancesDecreased physical availability of Substances
ActionsActions::
Changes in planning and zoning lawsChanges in planning and zoning laws
License challengesLicense challenges
Reduction in outlet densities and sales to minorsReduction in outlet densities and sales to minors
Problem Prevention Strategies:Problem Prevention Strategies:Positive Evidence – Need ReplicationPositive Evidence – Need Replication
Responsible beverage service – Policy & server trainingResponsible beverage service – Policy & server training
Primary health care interventionsPrimary health care interventions
Liability for sales or serving alcoholLiability for sales or serving alcohol
Alcohol & tobacco warning labelsAlcohol & tobacco warning labels
Administrative driver license suspensionAdministrative driver license suspension
School education alone & w/ community School education alone & w/ community interventiointerventionnss
Community Prevention Trials utilizing local policy
School EducationSchool Education
Effective programs:Effective programs: Values and norms clarificationValues and norms clarification Decision-makingDecision-making Life skillsLife skills Use interactive teaching methodsUse interactive teaching methods
Ineffective programs:Ineffective programs: Target self-esteemTarget self-esteem Increase knowledgeIncrease knowledge Use scare tacticsUse scare tactics Use didactic methodsUse didactic methods
Individual: Individual: School-based EducationSchool-based Education
Popular prevention strategy--mostly US studiesPopular prevention strategy--mostly US studies
Information only – no effectInformation only – no effect
Mixed results across studies and substances & Mixed results across studies and substances & onlyonly in controlled research studies in controlled research studies
Most effective with some combination of:Most effective with some combination of:1. Normative beliefs1. Normative beliefs2. Personal commitment2. Personal commitment3. Information3. Information4. Resistance skills4. Resistance skills
Responsible Beverage ServiceResponsible Beverage Service
Goal:Goal: Reduce alcohol intoxication or impairment for Reduce alcohol intoxication or impairment for patrons of bars and restaurantspatrons of bars and restaurants
Actions:Actions:
New alcohol serving policies (price promotions, New alcohol serving policies (price promotions, serving sizes, non-alcoholic beverages and food)serving sizes, non-alcoholic beverages and food)
Enforcement of no service to underage and Enforcement of no service to underage and obviously intoxicated patronsobviously intoxicated patrons
Server and manager trainingServer and manager training
Problem Prevention Strategies:Problem Prevention Strategies:Promising -- Too early to tellPromising -- Too early to tell
Workplace interventions—workplace policyWorkplace interventions—workplace policy
Genetics and alcohol drug dependency riskGenetics and alcohol drug dependency risk
Alcohol sales to intoxicated personsAlcohol sales to intoxicated persons
Auto ignition controlsAuto ignition controls
Curfew lawsCurfew laws
Parent training and mobilizationParent training and mobilization
Restrictions on drinking & smoking locationRestrictions on drinking & smoking location
Low or no alcoholic beverages; low tar tobaccoLow or no alcoholic beverages; low tar tobacco
Alcohol container and tobacco product sizesAlcohol container and tobacco product sizes
Alcohol Problem Prevention Strategies:Alcohol Problem Prevention Strategies:Mixed Findings -- Uncertain ImplicationsMixed Findings -- Uncertain Implications
Mass communication and public education aloneMass communication and public education alone
School-based education aloneSchool-based education alone
Restrictions on AdvertisingRestrictions on Advertising
Examples of media programsExamples of media programs
ONDCP Anti-drug media campaignONDCP Anti-drug media campaign Partnership for a Drug-Free AmericaPartnership for a Drug-Free America
Individual: Individual: Mass Communication Mass Communication and Public Education and Public Education
Increases awarenessIncreases awareness
Produces little behavioral changeProduces little behavioral change
Reinforces environmental strategiesReinforces environmental strategies
Latest Scientific Advance:Latest Scientific Advance: Comprehensive Mix of Comprehensive Mix of
evidence-based prevention evidence-based prevention strategies at local levelstrategies at local level
Community Action Trials which use Community Action Trials which use complimentary interventionscomplimentary interventions
Formal Regulationand Control of Alcohol Sales
CONSUMPTION
Alcohol Production, Marketing and
Distribution
Social, Health, and Economic Consequences
Retail Sales by Average Type
Alcohol-involved Mortality & Morbidity
Community Economic Sector
Social and Health Services
Legal Action about DrinkingSocial Control
and Communication
Community System of Alcohol Use & Abuse
National Community Trial to Prevent National Community Trial to Prevent Alcohol-involved TraumaAlcohol-involved Trauma
OrangeOrange
OceansideOceanside..
..
..
-
ExperimentalExperimentalComparisonComparison
ModestoModesto
SalinasSalinas
FlorenceFlorence
SumterSumter
Alcohol-involved Trauma at the Community Level: Alcohol-involved Trauma at the Community Level: Conceptual Model`````````Conceptual Model`````````
MOBILIZATIONMOBILIZATIONMOBILIZATIONMOBILIZATION DRINKING AND DRIVINGDRINKING AND DRIVINGDRINKING AND DRIVINGDRINKING AND DRIVING
UNDERAGE DRINKINGUNDERAGE DRINKINGUNDERAGE DRINKINGUNDERAGE DRINKING
ALCOHOL ACCESSALCOHOL ACCESSALCOHOL ACCESSALCOHOL ACCESS
RESPONSIBLE BEVERAGE RESPONSIBLE BEVERAGE SERVICESERVICE
RESPONSIBLE BEVERAGE RESPONSIBLE BEVERAGE SERVICESERVICE
Non-Traffic Risk ActivitiesNon-Traffic Risk Activities
Local News about AlcoholLocal News about AlcoholProblems & EnforcementProblems & Enforcement
Retail Alcohol Retail Alcohol AvailabilityAvailability
(On and Off-premise)(On and Off-premise)
Alcohol IntoxicationAlcohol Intoxication or Impairmentor Impairment Alcohol-involvedAlcohol-involved
Injury Injury
Alcohol-involvedAlcohol-involvedInjury Injury
Driving afterDriving afterDrinkingDrinking
Perceived Perceived Risk of ArrestRisk of Arrest
Local LawLocal LawEnforcementEnforcement
Social Access Social Access to Alcoholto Alcohol
Alcohol Alcohol Serving and Serving and
Sales PracticesSales Practices
Local Regulation Local Regulation of Alcoholof Alcohol
(Density, Hours (Density, Hours of Sale)of Sale)
Underage Alcohol Purchase SurveyUnderage Alcohol Purchase Survey-Experimental and Comparison Communities--Experimental and Comparison Communities-
0
10
20
30
40
50
60
Perc
en
t S
ellin
g
4747 4545
5353
3535
19191616
Comparison
ExperimentalNo Training
ExperimentalTraining
Comparison
ExperimentalNo Training
ExperimentalTraining
PRETEST PRETEST POSTTESTPOSTTEST
Holder, et al., Holder, et al., J. American Medical Association,J. American Medical Association, 2000 2000
Community Trials Final ResultsCommunity Trials Final Results
Driving after “Too much to drink” (- 49%)Driving after “Too much to drink” (- 49%)
BAC Positive Drivers (- 44%)BAC Positive Drivers (- 44%)
Heavy Drinking (-6%)Heavy Drinking (-6%)
AssaultsAssaultsNighttime Injury Crashes (-10%)Nighttime Injury Crashes (-10%)
-- Hospital Cases (-2%)-- Hospital Cases (-2%) -- Emergency Room Cases (- 43%)-- Emergency Room Cases (- 43%)
Holder, et al. 2000. J. Amer. Medical Assoc.
Total Consumption Total Consumption (+2%)(+2%)
Similarities across Similarities across allall effective prevention effective prevention strategiesstrategies
Comprehensive and multi-componentComprehensive and multi-component Targets specific causal variables which have Targets specific causal variables which have
been shown to affect total local population as been shown to affect total local population as well as the environmentwell as the environment
Based on methodologically sound, Based on methodologically sound, independently replicated evaluations under independently replicated evaluations under “real world” conditions“real world” conditions
Community System StrategiesCommunity System Strategies
Impact both heavy & moderate drinkers/usersImpact both heavy & moderate drinkers/users
Yield longevity of effectsYield longevity of effects
Effectiveness at population levelEffectiveness at population level
Do not target subgroups--non discriminatingDo not target subgroups--non discriminatingHave lower costsHave lower costs
-No case-finding-No case-finding
--Individual services NOT requiredIndividual services NOT required
-NO continued costs to sustain effects-NO continued costs to sustain effects