Strategies to Reduce High-Risk Drinking

September 30, 2008 Macomb, County.

Presentation

         1. Environmental Strategies Defined 2. Environmental Strategies Contrasted with Traditional Approaches 3. Environmental Strategies in World Context 4. Two Studies Presented in Detail (The Community Trials Project and the Sacramento Neighborhood Alcohol Prevention Project) 5) Introduce Two New Studies (The Border and Safer College Studies) 6) Basic Questions Regarding Mobilization in These Studies a) How are they different?

b) How are they similar?

c) How does mobilization work across these studies?

d) What is the role of data in these studies?

Alcohol Environmental Interventions Defined

Strategies used to reduce problems associated with the use of alcohol through alterations in the physical, social, legal or economic alcohol environment.

Illustrations of Environmental Interventions

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Physical —Restrictions on Densities of Outlets

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Legal —Minimum Drinking Age Laws

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Social —Parental Efforts to Monitor Alcohol Availability to Youth within the Home

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Economic —Taxes on Alcohol Sales

Approaches to the Reduction of Alcohol Problems Goal Use of Media Target Community Role General Approach Traditional Approaches Environmental Approaches Individual Behavioral Change Individual Influence Individuals At-Risk Information Receivers and Disseminators Demand-Oriented Community System Change Policy Maker Influence Alcohol Environment Provides Energy for Policy Change Supply-Oriented

Targets of Environmental Prevention Efforts

Whole populations of geographic areas (e.g., states, communities) Selected sub-populations particularly at risk (e.g., drinkers at bars) Small geographic areas containing select subgroups (e.g., community neighborhoods)

Prevention Paradox and Public Health

 Higher risk individuals -- more problems personally  Lower risk individuals -- more people and, thus, produce more aggregate problems for a community For example: Drinkers x Risk Rate = Problem Events 100 x 10% = 10 5,000 x 1% = 50

Prevention Paradox and Public Health

 Higher risk individuals -- more problems personally

Policy and Environmental Strategies

 Policy as defined here consists of those effort to deliberately alter economic, social, physical, and legal dimensions of the alcohol environment.

Alcohol Policy

a view from history

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Alcohol policy---often applied at the national level. Communities are often passive recipients.

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Policy approaches with greatest effectiveness seek to alter the environment

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Communities have primarily used program rather than policy strategies.

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, Sweden Aarhus , Denmark

6 Community Trial, Sweden PAKKA, Finland

Lahti , Finland Paulinia, Brazil Diadema, Brazil

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS

United States

California/ South Carolina Reduce alcohol injury and death • DUI enforcement • Alcohol service • News coverage • Underage sales • Alcohol outlets

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10% reduction in alcohol crashes

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43% reduction in violence

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Lower alcohol sales to youth Minnesota Massachusetts Reduce youth drinking Reduce alcohol crashes

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• Local sales policies and enforcement

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Lower alcohol sales to youth Reduced traffic crashes • News coverage • DUI enforcement • Alcohol outlet surveillance

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25% reduction in fatal crashes

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS

New Zealand Waikata Rural Drink/ Drive Project

Reduce drink/drive problems • Public awareness using local news • Highly visible drink/drive enforcement •Investigation of on license premises based upon “place of last drink” data

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Fatal alcohol crashes reduced from 22 to 14%

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Public perception of risk of being caught increased

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Alcohol positive breath checks decreased by 600%

New Zealand Six City Project

Increase local alcohol policy • Local coordinating committee • Review of alcohol availability • Local alcohol advertising limits

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Greater news coverage

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Increased public support of local policy

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS

Canada

Ontario (6 Projects) Reduce alcohol problems • Alcohol serving practices & policies • Municipal policies • DUI enforcement

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Reduced public drinking

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Lower heavy drinking in bars and restaurants

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Modest effects on overall drinking

Finland Lathi

Reduce heavy drinking • Primary health care • Community education • News

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Reductions in heavy drinking Greater news coverage

Sweden

Stockholm- Kungsholmen Reduce heavy drinking and youth drinking • School education •Public education

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Modest effect on heavy drinking

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS

Sweden

Stockholm Reduce alcohol •Youth Program

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Modest effect in City--STAD and drug medium strength problems beer sales to youth • Secondary

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Reduction in sales prevention in health to intoxicated care patrons (5% to 47%) •Responsible Beverage Service

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Violent crime down by 29% Stockholm City (18 Districts) & Stockholm County Targets Increase local alcohol policy • Local work committees • Develop Alcohol Plan • Decrease sales of folk

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beer to youth

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Reduced Sales to Youth in 2 target sites (81% to 25% & 48% to 42%) Increased interest in local policy

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS

Sweden

Malm ö Reduce alcohol problems • Public education • Primary health care screening • Reduce alcohol access

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Low effects on problem indicators

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Reduced male consumption and problems in (a) screening program and (b) general population

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Program adopted by city

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS

Australia

COMPARI Project Reduce alcohol injury and death • Local coalitions • Health education • Local alcohol policy concerning public alcohol sale

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Modest effect on injury

Australia

Surfers Paradise Safety Action Project Lower alcohol involved violence alcohol safety audit • Model House Policies • Increased enforcement of alcohol licensed premises Violent events: --original site from 9.8 to 4.7

- replication sites from 12.2 to 3.0

Examples of International Community Action Projects for Alcohol Prevention COUNTRY GOALS STRATEGIES RESULTS Australia

Partysafe project

Carnarvon, Western Australia Reduce harm from private drinking (males 25-45 years) • local media • peer cartoon character • server training

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Heightened local awareness of alcohol issues

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Unknown effects on drinking

Community System of Alcohol & Drug Use & Abuse Social Control and Communication Legal Action about use/abuse CONSUMPTION Alcohol & Drug involved Mortality & Morbidity Formal Regulation and Control of Sales Retail Sales Social, Health, and Economic Consequences Production, Marketing and Distribution Social and Health Services Community Economic Sector

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Community Action and Prevention Lessons from International Projects

Community Mobilization

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Science-based interventions are essential

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Utilize local news media Value of Evaluation —

determine effects

Environmental strategies are most effective

COMMUNITY TRIALS TO PREVENT ALCOHOL-INVOLVED TRAUMA 1991-1997 Prevention Research Center Berkeley, CA

Sponsors: National Institute on Alcohol Abuse and Alcoholism & Center for Substance Abuse Prevention

National Community Trial to Prevent Alcohol-Involved Trauma

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Overall Project Goal: Reduce Alcohol-involved Trauma

Traffic Crashes Unintentional Injuries Violence

Five Prevention Components

1.

2.

3.

4.

5.

Community Mobilization Responsible Beverage Service Risk of Drinking and Driving Underage Drinking Alcohol Access

General Timeline of Program Implementation Community Trials Project 1991 - 1996

1991 1992 1993 1994 1995 1996 Funding Secured Evaluation Data Collection Mobilization & Media Advocacy Component Drinking and Driving Component Responsible Beverage Service Component Underage Drinking Component Access Component

Community Mobilization

Goal: Provide support for other project interventions

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Actions: Increase general community awareness and concern about alcohol-involved unintentional trauma

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Increase community support for environmental prevention

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Mobilize community to support specific interventions

Responsible Beverage Service

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

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Server and manager training New alcohol serving policies (price promotions, reduce serving sizes, promote non-alcoholic beverages and food)

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Enforcement of no service to underage and obviously intoxicated patrons

Drinking and Driving

Goal: Reduce the number of community drinking and driving events Actions:

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Increase law enforcement efficiency

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Increase perceived risk of DWI detection

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Increase community support of DWI enforcement

Underage Drinking

Goal: Decrease underage drinking Actions:

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Increase community awareness of underage drinking

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Reduce physical availability of alcohol to minors

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Increase awareness of retail establishments and adults of the legal and social risks of providing alcohol to minors

Access Intervention

Goal: Decreased physical availability of alcohol Actions:

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Reduction in outlet densities

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Changes in planning and zoning laws

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License challenges

THE SUCCESSION OF ALCOHOL OUTLETS . . . Chronic Outcomes [ Alcohol Dependence Cirrhosis Drinking Levels Population Growth Outlet Growth Alcohol Sales Drinking Contexts Acute Outcomes

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Drunken Driving Alcohol-Related Crashes Drowning, Burns, and Falls Alcohol-Related Violence

. . . THE COMMUNITY TRIALS INTERVENTIONS Chronic Outcomes Alcohol Dependence Cirrhosis Population Growth Access Component (Availability) Outlet Growth Youth Component (Sales to Youth) Alcohol Sales Drinking Levels Responsible Beverage Service Component Drinking Contexts Media Component Acute Outcomes Drinking and Driving Component

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Drunken Driving Alcohol-Related Crashes Drowning, Burns, and Falls Alcohol-Related Violence

COMMUNITY TRIALS OUTCOME DECLINES

49% -- self- reported over-consumption 51% -- self-reported driving over limit 10% -- nighttime injury crashes 6% -- self-reported drinking per occasion 6% -- crashes involving drinking drivers 43% -- assault injures in emergency rooms Source: Holder, H.D., Gruenewald, P.J., Ponicki, W.R., Treno, A.J., Grube, J.G., Saltz, R.F., Voas, R.B., Reynolds, R., Davis, J., Sanchez, J., Gaumont, G., and Roeper, P. Effect of Community-Based Interventions on High-Risk Drinking and Alcohol-Related Injuries, Journal of the American Medical Association. 2000; 18:2341-2347.

The Follow-up

 Community Trials Project was awarded “model program status” by the Center for Substance Abuse Prevention.  Communities across the country are adopting this program and receiving federal support under the State Incentive Grants program.

Sacramento Neighborhood Alcohol Prevention Project (SNAPP)

2000-2003

La Familia Counseling Center Stanford Settlement House Prevention Research Center

Funded by the National Institute on Alcohol Abuse and Alcoholism, the Center for Substance Abuse Prevention, and The California Endowment

Project Goals

Reduce:  Youth and young adult drinking  Youth access to alcohol  Drinking- related problems (i.e., crime, automobile crashes, and alcohol-involved injuries).

The intervention components was phased in over a 4 year period: 1. A neighborhood in the southern part of the city, and 2. In a similar neighborhood in the northern part, 2 years later.

Sacramento Study Area and City Boundaries Study areas North (N) South (S) 4 N 4 City limit and police sectors 1 - 4 3 1 S 2 American River

Project Interventions

1. Community mobilization increases neighborhood support for all components.

2. Community awareness disseminates information about youth and young adult alcohol access and use.

Project Interventions

3. Responsible Beverage Service program focuses on service to minors and intoxicated patrons 4. Underage Access Component supports increased police enforcement of underage sales laws and laws regarding provision of alcohol to minors by social hosts

Project Interventions

5. Enforcement component regulating sales to intoxicated persons in alcohol establishments and at special events

Types of Evaluation

   Process: What happened and when, i.e. dosage Intermediary Measures: What effect did it have?

Outcomes: Did it reduce problems?

Sources of Evaluation Information

Data Collection Instrument: Telephone Survey On-Premise Survey Pseudo-Drunken Patron Survey Off-Premise Survey Underage Decoy Purchase Survey Traffic Crashes Violent Crimes Property Crimes Hospital Discharge Trauma Deaths Temporal Specificity : Years 1, 3 and 5 Years 1, 3 and 5 Years 1, 3 and 5 Years 1, 3 and 5 Years 1, 3 and 5 Daily by time of day Daily Daily Daily Daily Daily Geographic Specificity : Nearest Cross-Streets (Residence) Street Address (Outlet) Street Address (Outlet) Street Address (Outlet) Street Address (Outlet) Street Address (Event) Street Address (Event) Street Address (Event) Zip Code (Residence) Street Address (Event) Zip Code (Residence)

Timeline of Intervention Activities ( South)

Purchase/Service Rates for Waves 1 and 2

Pre Underage Survey Post Post – Pre Pseudo-Intoxicated Patron Survey Pre Post Post – Pre South North At Large .49

.20

.38

.32

.61

.47

-.17

+.41

+.09

.68

.80

.63

.86

.87

.92

+.18

+.07

+.29

South North At Large

Purchase/Service Rates for Waves 2 and 3

Underage Survey Pre Post Post – Pre Pseudo-Intoxicated Patron Survey Pre Post Post – Pre .32

.61

.47

.23

.25

.11

-.09

-.36

-.36

.86

.87

.92

.83

.82

.76

-.03

-.05

-.16

SNAPP OUTCOMES

Overall Statistical Assessment of Impacts of South and North Interventions corrected for seasonal effects and temporal autocorrelated error (Seemingly Unrelated Regression Equations)

Outcome: Police Calls Assault Public Drunkenness Emergency Medical Services Aggregate Outcomes Assault Motor Vehicle Accidents Alcohol and Other Drugs Suicide Overall Effects (4 df): X 2 : p: Effect Size * : X 2 : South Site (2 df): p: Effect Size * : X 2 : North Site (2 df): p: Effect Size * : 27.09 7.25 14.72 <.001 n.s. .005 -.475 --- -.695 10.10 4.07 10.79 .011 n.s. .005 -.412 --- -.761 18.05 4.43 4.35 .002 n.s. n.s. -.837 --- --- 11.82 10.92 9.16 4.81 .019 .028 n.s. n.s. -.571 -.548 --- --- 3.15 10.11 6.77 1.23 n.s. .006 .034 n.s. --- -.740 -.466 --- 8.98 1.48 4.84 4.11 .011 n.s. n.s. n.s. -.833 --- --- ---

SNAPP OUTCOMES

Relative differences in rates of problem outcomes by South and North sites (significant effects only).

Outcome: Police Calls Assault Emergency Medical Services: Aggregate Outcomes Assault Motor Vehicle Accidents Alcohol and Other Drugs Annual Rate * : 8.796 12.864 4.428 6.864 1.056 South Site: Percent Change: Savings ** : -3.9% *** .34 -33.7% --- -33.4% -47.7% 4.34 --- 2.29 .50 North Site: Percent Change: Savings ** : -36.5% 3.21 --- -37.4% --- --- --- 1.66 --- ---

SNAPP OUTCOMES

 Given an estimated 35,000 persons per neighborhood, these effects represent reductions of 1,150 problem events in the two communities.

The Border Project

Preventing alcohol-related problems at the US/Mexico Border

Current sites

    San Diego -Tijuana El Paso – Juarez Laredo –Nuevo Laredo Brownsville - Matamoros

The Problem

  Mexico’s drinking age is 18 Some border towns provided plentiful, cheap sources of alcohol

The Problem

    Mexico’s drinking age is 18 Some border towns provided plentiful, cheap sources of alcohol Young people traveled to Mexico to drink Beverage service not always “responsible”

The Problem

      Mexico’s drinking age is 18 Some border towns provided plentiful, cheap sources of alcohol Young people traveled to Mexico to drink Beverage service not always “responsible” Heavy drinking occurred Sometimes resulted in problems in Mexico

The Problem

      Mexico’s drinking age is 18 Some border towns provided plentiful, cheap sources of alcohol Young people traveled to Mexico to drink Beverage service not always “responsible” Heavy drinking occurred Sometimes resulted in problems in Mexico Impaired young people drove home

The Research Strategy

 PIRE studied drinking behavior of young US residents crossing into Mexico  Documented the extent of heavy drinking  Shed light on motivations and behavior of border crossers

The Implementation Strategy

 The nature and scope of the problem were explained to groups and agencies on both sides of the border  Media advocacy brought the problem to the attention of the public through compelling news coverage

The Change Strategies

    Earlier bar closings Stepped up DUI enforcement efforts on the US side of the border Highly publicized enforcement of laws against crossing by youth under 18 New restrictions on Marines from Camp Pendleton

The Results

 Dramatic decline in number of nighttime crossings by young people  Reduction in nighttime crashes involving drivers under 18  90% reduction in number of Marines driving back from the border

Safer California Universities: A risk management approach to college student drinking problems Robert F. Saltz, Ph.D.

Principal Investigator Prevention Research Center, Pacific Institute for Research and Evaluation Funded by the National Institute on Alcohol Abuse and Alcoholism

Safer California Universities Project Goal

To evaluate the efficacy of a “Risk Management” approach to alcohol problem prevention

Risk Management

 Risk Reduction – interventions aimed at reducing alcohol related problems  Risk Assessment – using data to identify intervention targets (settings, events)  Risk Monitoring – using data to assess intervention effectiveness and modify

Risk Assessment and Monitoring Data Sources

 Brief interviews with key personnel  Archival data sources  Student survey data

What are we trying to prevent?

 Intoxication at particular settings/events  Harm related to intoxication at particular settings/events

Selecting A Problem Setting

Using assessment data to target prevention efforts

Web-based Student Survey, Fall 2003

   Administered to ~14,000 students at 14 California universities Established baseline levels of student drinking and alcohol-related problems Identified settings where the majority of alcohol-related problems are occurring

Survey Modules for Specific Settings

      Residence hall parties Greek parties Campus events (e.g., concerts, sporting events) Off-campus parties (houses, apartments) Bars/restaurants Outdoor settings (e.g., parks, beaches)

Questions About Each Setting

     Frequency of going to setting during semester Frequency of alcohol use Frequency of intoxication Frequency of alcohol-related problems Last time at setting: – How long at setting – How much alcohol consumed before, during, after – Number of people, underage drinking, system for preventing underage drinking

Prevalence of Student Intoxication Last Time at Each Setting

70 60 50 40 30 20 10 0 Dorm party Greek party Campus event Off-campus party Bar/restaurant Outdoor setting

Source: Safer CA Univerisities Fall 2003 Survey

Drinking Problems in Past Semester/Quarter

RWDD DUI Got Sick Did Poorly on Test Got Hurt or Injured Damaged Property Not Used Protection Had Unplanned Sex Taken Advatage of Sexually Got Behind in Work Missed Class Hangover 0 4 6 9 10 12 10 17 23 26 21 24 38 20 30 Percentage 40 51 50 60

Source: Safer California Universities Survey, 2003

Secondary Drinking Problems in Past Semester

Sexual Assault Found Vomit Unwanted Sexual Advance Studies or Sleep Disrupted Take Care of Other Property Damaged Physical Violence Pushed, Hit, Assaulted Argument Harassed Insulted 1 2 0 4 6 9 12 13 12 26 34 10 15 20 Percentage 30 40

Source: Safer California Universities Survey, 2003

Percentage of Alcohol Problems by Setting Fall 2003 Outdoor s ettings .8% Bars /res taurants 5.6% Off cam pus parties 57.2% Dorm parties 18.0% Cam pus events 3.7% Greek parties 14.6%

Why Off-Campus Parties are Causing the Most Problems

  Over 9,000 students in survey sample went to at least one off-campus party, 3-4 times as many as other settings Statistical analyses indicate that off campus parties carry a higher risk for frequent intoxication and alcohol related problems than other settings

Effects of Survey Data on Decision Making

   Consensus among members of campus-community task forces to target interventions to off-campus settings (e.g., house parties) Strong support for initiation and long term implementation of interventions Great interest in continuing surveys to assess intervention effects

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Interventions for Off-Campus Settings

Educational campaign that helps students and others host safe social gatherings and to know their responsibility as a host for the safety and well-being of their guests and neighbors; Fair but firm enforcement of existing laws that protect the community from alcohol-related harm: – DUI enforcement – Party patrols to disperse dangerous crowds – Enforce laws prohibiting alcohol sales or informal provision of alcohol to minors Placing the burden of costs to those who repeatedly require community or police response – a “response cost” ordinance.

Summary

   Student survey, archival and key informant data provide an assessment of where and when alcohol-related problems are occurring These data can be used to help college prevention specialists, administrators, campus police and others to focus intervention efforts on a particular setting and sustain those efforts Data can also be used to monitor the

Environmental Strategies: Myths & Mistakes

2 1 Effects take a long time to demonstrate….

Environmental strategies are “programs”… 3

All prevention programs are “environmental”….

4

Only youth are targeted….

Questions---Summary

¤ ¤ ¤ ¤ What are minimum factors for success?

What partnerships are necessary between community coalitions and researchers?

What works? Which combinations of strategies are most cost-effective?

How can coalitions demonstrate that their “home grown” efforts are effective, e.g., in 1-3 years?

Similarities Across Programs

     Comprehensive and Multi-component Address the Specifics of the Local Alcohol Environment Research Based Rely Largely on Local Energies for Implementation Evaluation Addressing Process, Intermediary Environmental Conditions, and Outcomes

Differences between Programs

   Tailored to the Specific Needs and Conditions of their Respective “Communities” Targeting Different Outcomes Differing Instruments Used to Evaluate Based on these Needs and Conditions

Mobilization Across Programs

  Existing Groups are Key Mobilization is Used in Support of Environmental Change

Role Played by Research Across Programs

   Development of Specific Targets and Strategies To Mobilize Communities by Increasing Awareness and Concern, Acceptance of the Environmental Approach For Purposes of Program Evaluation