Preventing Alcohol Problems: What Works

A Case Study of the U.S.

XVII Annual Conference Brazilian Association for Drug and Alcohol Studies Ouro Preto, Brazil September 1, 2005

Robert I. Reynolds, Director Alcohol Policy Initiatives Pacific Institute for Research and Evaluation Shepherdstown, West Virginia, USA

Alcohol is a drug which is:

1.

Mind altering 2. Tolerance producing 3. Addictive These basic facts are not changed by alcohol industry advertising.

Drug “Capture” Rate

Percent of Users Who Become Clinically Dependent Tobacco Heroin Cocaine Alcohol Stimulants Marijuana

Source: National Comorbidity Survey Anthony, Warner, and Kessler

31.9% 23.1% 16.7% 15.4% 11.2% 9.1%

WARNING: U.S. experiences may be hazardous to Brazil!

Global Burden of Disease (Disability-Adjusted Life Years) Worldwide North America South America Tobacco Attribution Alcohol Illicit Drugs 4.1% 4.0% 0.8% 8 - 15.9% 4 - 7.9% 2 - 3.9% 2 - 3.9% 8 - 15.9% 1 - 1.9% Source: World Health Report 2002 World Health Organization

Global Market – Alcohol Spirits Sales Exceed 2 Billion Cases Annually Country Case Volume China Russia India

Brazil

Japan

United States

Korea Thailand Germany France 725 million cases 350 249

195

176

135

79 76 60 37 Source: Mark Brown, President Sazerac Company, Inc. March 4, 2003

Product Categories – Alcohol Spirits Product Category Baijiu Vodka Whisky Cachaca Rum Brandy Shochu Soju Liqueurs Case Volume 725 million cases 400 205 200 115 82 70 70 51 Source: Mark Brown, President Sazerac Company, Inc. March 4, 2003

U.S. Prevention Strategies and U.S. Per Capita Alcohol Consumption

Term Prevention Strategy Per Capita Consumption % Change Term % Change from 1919 1919 1.96

1920-1935 Prohibition 1.20

-39% -39% 1935-1960 1960-1970 1970-1980 1980-1990 1990-2000 Benign Neglect Education Education Control Policies Control Policies Source: NIAAA 2.07

2.52

2.76

2.45

2.18

+73% +22% +10% -11% -11% +6% +29% +41% +25% +11%

U.S. Economic Costs of ATOD Use, 1995 Total Costs = $415 Billion 27% 33% 40% Alcohol-$167 Billion Tobacco-$138 Billion Illicit Drugs-$110 Billion

Sources: Harwood, Fountain, & Livermore, NIDA & NIAAA, 1998 Rice (unpublished) Institute for Health and Aging, UCSF, 1995

Most U.S. adults do not drink or drink infrequently.

Frequency of Drinking Among U.S. Adults 21 and Older, 2002 (past 30 days) 60% 46% 40% 26% 20% 13% 9% 6% 0% 0 1 to 4 5 to 10 11 to 21 Number of Drinking Days 21+

Source: NSDUH, 2002

Most U.S. adults do not drink at a hazardous level.

Drinking Patterns among U.S. Adults 21 and Older, 2002 (past 30 days) 16% 7% 31% 46% Nondrinker Nonbingers Infrequent Bingers Frequent Bingers

Source: NSDUH, 2002

Binge drinkers are 23% of the population, but consume 76% of the alcohol. 100% U.S. Binge Drinkers, 2002 76% 80% 60% 40% 20% 23% 0%

Source: NSDUH, 2002

Population Alcohol

Most young people do not drink.

Drinking Among Youth, 2002 (past 30 days) 15- to 17-year-olds 10% 18% 0 Drinking occasions 1 to 4 5 or more 72%

Among the 28% of 15-17 year olds who drink, 65% drank heavily at least once in the past month.

Source: NSDUH, 2002

What prevention strategies were effective in reducing U.S. per capita alcohol consumption by 21% between 1980 and 2000?

Strategy Options:

1. Personal change strategies – change people 2. Alcohol control strategies – control alcohol availability

Personal Change Strategies

The U.S. has spent a fortune trying to “change people” through programs for adults, youth and children to: 1. Provide alcohol education 2. Change attitudes about drinking 3. Provide early intervention and treatment services for individuals with alcohol problems, and for their families

Research Evidence of Effectiveness: Personal Change Strategies 1. With few exceptions, these programs have not been effective in preventing societal alcohol problems.

2. As for the exceptions, these programs are too expensive to be implemented across society.

3. Despite this evidence, programs implementing personal change strategies are the most popular, most prevalent, and best funded prevention efforts in the U.S.

Alcohol Control Strategies: Essential Components

•

changes in social norms

•

policy interventions

•

deterrence and enforcement

Alcohol Control Strategies: The Role of Public Health Education in Changing Social Norms

1. Raise societal awareness and concern about alcohol problems.

2. Educate the society that these problems can be prevented.

3. Inform the society about specific policy controls and deterrence strategies that are effective.

4. Publicize successes.

If You're Not in the News - You Don't Exist

Alcohol Control Strategies: Effective Public Health Education Strategies for Changing Social Norms

1. Rely on research epidemiology.

2. Develop a strategic plan to educate society incrementally and sequentially.

3. Stay on message.

4. Utilize mass media.

Media Advocacy

Media Advocacy is the strategic use of mass media to advance a social or public policy initiative.

Sequence of U.S. Public Awareness of Alcohol Problems

Pre 1960 1960-1970 1970-1980 1980-1990 Duh – what problems?

Addiction, public drunkenness, social disorder Youth drinking Drinking and driving, fetal alcohol effects 1990-2000 2000 Alcohol industry behavior Violence and crime?

Alcohol Control Strategies Policy Interventions

• To prevent alcohol problems, policy interventions must focus on the

Availability

of alcohol.

• Effective policies address the –

Price

–

Place

–

Product

–

Promotion… …of alcohol products

02-0 0 PIRE NATL ALC POL TRAINING

02-0 0 PIRE NATL ALC POL TRAINING

Percent of U.S. Population (18+ years of age) favoring alcohol policies designed to reduce alcohol problems among youth Proposed Policy Favor Strongly Favor Somewhat Oppose Somewhat Oppose Strongly 16.8

5.7

12.6

Increase alcohol tax by 5 cents to fund prevention programs Restrict alcohol ads to make drinking less appealing to youth Conduct compliance checks to reduce illegal sales to minors Require registration of beer kegs Source: Harwood, et al, 1998 65.0

52.6

46.5

39.9

26.0

19.0

21.3

10.5

9.5

15.3

10.8

25.0

23.5

Parks Percent of U.S. Population (18+ years of age) favoring restrictions on drinking in public locations Public location Ban drinking By permit only No restrictions 63.0

27.3

9.8

Concerts Beaches Stadiums/arenas 51.2

53.1

47.8

34.1

28.7

29.6

14.6

18.2

22.6

Source: Harwood, et al, 1998

Alcohol Control Strategies Deterrence and Enforcement

• Effective deterrence requires the

perception

of • • •

Certainty Swiftness Severity

• Active enforcement is a requirement for effective deterrence.

45 40 35 30 25 19 77 19 79 Impact of enforcement on alcohol-related traffic fatalities Percentage traffic fatalities related to alcohol (1977-1999) 19 81 19 83 19 85 19 87 19 89 19 91 19 93 Percent alcohol-related 19 95 19 97 19 99

Essential Elements of Effective Prevention of Alcohol Problems

Policies and Laws Prevention Enforcement Public Support

Implementing Alcohol Control Strategies in Brazil

A. Strengthen alcohol surveillance systems

1. Epidemiologic surveys: household, school, roadside, emergency room, special events, alcohol sales and service practices, industry marketing, etc.

2. Increase expertise in behavioral health research methods and analysis.

3. Create and staff a Brazilian alcohol research center and develop an integrative and multi disciplinary research strategy.

Every Ounce of Alcohol Sold in the United States Generates $2.25 in Public Sector Costs Alcohol Problem Cost per Ounce

Alcohol – Related Violence Drinking Driving Problems Other Costs $1.00

.85

.40

$2.25

Total Societal Costs, including Public Sector Costs: $6.00/ounce

Source: Ted Miller, Ph.D.

PIRE

Societal Costs – Alcohol Sales

Sales Unit Beer – Six Pack Wine – Fifth Bottle Spirits – Fifth Bottle Public Sector Costs $7.30

$7.50

$23.00

Total Societal Costs $19.45

$20.00

$61.45

Source: Ted Miller, Ph.D.

PIRE

Challenges Confronting the Community Prevention Coordinator

A.

Provide “translation” services between: 1. Researchers 2. Public health professionals 3. Community organizers 4. Policy makers 5. Alcohol industry B.

6. Alcohol law enforcement Provide “honest broker” services for each of the above groups.

C. Keep a low profile!

Implementing Alcohol Control Strategies

B. Establish a Brazilian technical assistance center for implementation of alcohol control strategies

1. Organize services by problems, not by control policies (violence, youth drinking, traffic safety, noise and neighborhood disruption, etc.).

2. Local communities are the first priority for services.

3. Develop and implement a public health education strategy to change social norms.

4.

Respond quickly to “unscheduled opportunities”.

Implementing Alcohol Control Strategies

C. Increase enforcement of existing alcohol control policies.

1. Public health and law enforcement are not traditional allies – build relationships!

2. Support creation of law enforcement units which specialize in enforcement of alcohol laws.

3. Document, and then acknowledge publicly, the results of alcohol law enforcement.

Community Prevention Case Studies

1. Paulinia: alcohol price controls



Price/Enforcement 2. Salinas: alcohol control at special events



Place/Social Norms 3. Salinas: reducing alcohol outlet density



Place 4. Diadema: limiting alcohol sales



Place, Social Norms, Enforcement

Case Studies: Alcohol Prevention Research in Brazil Presentation Outline 1. What was your research interest?

2. What were your fears and concerns beginning your research?

3. What was the major difficulty you faced in conducting your research?

4. What was the biggest assistance you received in conducting your research?

5.

What was the biggest unexpected “surprise” you encountered?

6. What is your advice to those who come along next in conducting research in your area?

• • • • • •

Alcohol Prevention Research in Brazil

Research Topic Bar surveys and underage buyer surveys Municipal school surveys Collaboration with municipal officials Utilizing municipal records for evaluation, and roadside driver surveys Local and national household surveys, and emergency room surveys Alcohol industry structure and marketing practices

• • • • • •

Researcher Marcos Romano Denise Vieira Nino Meloni Sergio Duailibi Ronaldo Laranjeira Illana Pinsky

Never doubt that a small, committed group of people with a good idea can change the world. Indeed, it is the only thing that ever has . - Margaret Meade