"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.
Download ReportTranscript "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.
Slide 1
"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
Slide 2
Prevention Paradox:
More local problems are caused
by heavy drinking than by
alcoholics.
Slide 3
Students Who Reported Using Alcohol,
Tobacco, and Other Drugs in Past 30 Days
70
63%
60
50
46%
40
30
20
10
25%
11.4%
10.8%
6.1% 4.5% 3.5%
4.5%
A
lc
oh
ol
To
ba
cc
o
M
ar
iju
an
a
In
ha
H
la
al
nt
lu
s
ci
no
ge
Tr
an
ns
qu
A
ili
m
ze
ph
rs
et
am
in
es
C
oc
ai
ne
N
ar
co
tic
s
0
Slide 4
Experimentation and Established Smoking by Age
Source: 1996 CTS
Slide 5
Past Month Illicit Drug Use—any drug
Slide 6
Just what is
prevention, anyway?
Slide 7
Goals of ATOD prevention
Prevent health and safety problems related to
substance use, e.g., traffic crashes, violence,
lung cancer, overdose.
Prevent all use of tobacco and illicit substances
for everyone, regardless of age.
Prevent heavy and high risk use of substances.
Delay adolescent initiation of substances that are
licit for adults (e.g., tobacco and alcohol).
Slide 8
Approaches to the reduction of
ATOD use and resulting problems
Orientation
Individual change
approaches
Goal
Individual behavioral
change leading to
demand reduction
Target
Individual, directly
or through others
(e.g., family, peers)
Environmental
change approaches
Community/state system or
population change leading
to both demand and supply
reduction
Social, economic and
physical environment
But lots of hybrid , multi-component models
Slide 9
Substance Abuse Influences and Factors
(1)Physical -
Proximity of alcohol &
tobacco outlets and drug
supplies, places of public use
(2) Social -
Family, peers and larger
social networks, norms,
mass media
(3) Economic - Cost of alcohol, drugs, tobacco;
geography of availability
Slide 10
For Example, Youth Drinking
Availability of
alcohol to &
from peers
Physical
Cost &
availability
to youth
Alcohol
Availability
Social
Drinking
By Peers
Retail
Price
Economic
Alcohol purchases by other youth
Slide 11
Public Health Model of Prevention
Individual
Environment
Agent
Slide 12
Public Health Model of Substance
Abuse Problem Prevention
Individual
(User)
Environment
(Context)
Agent
(Substance)
Slide 13
Individual Approaches
1.
School-Based Education
2.
Mass Communication and Public
Education
3.
Family Education/counseling
4.
Alcohol and Tobacco Warning labels
5.
Deterrence: Possession or sale of drugs, Drinking
and driving Laws, Sale of tobacco or alcohol to
minors.
6.
Brief Intervention in health care or workplace
Slide 14
Public Health Model of Substance Use
Prevention
Individual
(User)
Environment
(Context)
Agent
(Substance)
Slide 15
Environmental Approaches
1. Retail Access to substances, e.g.,
price, outlet locations, minimum
purchase laws, parental restrictions on
youth.
2. Restrictions or constraints on the
Drinker’s or Smokers Behavior, e.g.,
drinking & smoking locations, drink drive
3. Reduce Risk or Problem Severity
Slide 16
Public Health Model of Substance Use
Prevention
Individual
(User)
Environment
(Context)
Agent
(Substance)
Slide 17
Agent Approaches
1.
Low or No Alcohol Beverages or lower
tar tobacco products
2.
Alcohol container size or
tobacco package restrictions
3.
Restrictions on Product
Advertising
Slide 18
Slide 19
Standards of Evidence
1.
2.
3.
Achieves significant effects (actually
reduces ATOD problems) under scientific
standards.
Replicated across two or more studies
under diverse community or national
conditions.
Has practical applicability and can affect
the total community, not only target
groups, i.e., has public health import.
Slide 20
Problem Prevention Strategies:
Solid Evidence
¤
Retail price of alcohol or tobacco
¤
Minimum drinking/purchase age—retail
compliance checks for alcohol and tobacco
¤
¤
¤
¤
¤
Graduated licenses & “zero tolerance for Youth
Drinking/driving deterrence (RBT)
Lower BAC limits for driving
Density & location of alcohol outlets
Form and style of retail sale, e.g., hours
and days of retail sale.
Slide 21
Retail Price
Drinking &
smoking
As price increases, smoking and heavy
drinking declines (Chaloupka, 1993)
Heavy drinkers/smokers as well as youth are
affected by price. (Coate and Grossman,
1988)
Youth who drink weekly up to daily are
more affected by price (Grossman, et al.,
1991; Coate and Grossman, 1988)
Slide 22
Underage Drinking
Goal:
Decrease underage drinking
Actions:
Increase community awareness of underage
drinking
Reduce physical availability of alcohol to minors
Increase awareness of retail establishments and
adults of the legal and social risks of providing
alcohol to minors
Slide 23
Environment
Person Activities
Alcohol Use (30-day mean) Before and After
Minimum Drinking Age (MDA) was Raised--United States
3.2
3
2.8
2.6
13% Decline
2.4
2.2
-3
-2
-1
1
2
3
Years Before and After MDA was
Source: O’Malley & Wagenaar
Raised
(1991)
Slide 24
Drinking and Driving
Goal:
Reduce the number of community drinking and
driving events
Actions:
Increase law enforcement efficiency
Increase perceived risk of DWI detection
Increase community support of DWI
enforcement
Slide 25
Access Intervention
Goal:
Decreased physical availability of Substances
Actions:
Reduction in outlet densities and sales to minors
Changes in planning and zoning laws
License challenges
Slide 26
Problem Prevention Strategies:
Positive Evidence – Need Replication
Responsible beverage service – Policy & server training
Community Prevention Trials utilizing local policy
Primary health care interventions
Liability for sales or serving alcohol
Alcohol & tobacco warning labels
Administrative driver license suspension
School education alone & w/ community
interventions
Slide 27
School Education
Effective programs:
Values and norms clarification
Decision-making
Life skills
Use interactive teaching methods
Ineffective programs:
Target self-esteem
Increase knowledge
Use scare tactics
Use didactic methods
Slide 28
Individual: School-based Education
Popular prevention strategy--mostly US studies
Information only – no effect
Mixed results across studies and substances &
only in controlled research studies
Most effective with some combination of:
1. Normative beliefs
2. Personal commitment
3. Information
4. Resistance skills
Slide 29
Responsible Beverage Service
Goal:
Reduce alcohol intoxication or impairment for
patrons of bars and restaurants
Actions:
Server and manager training
New alcohol serving policies (price promotions,
serving sizes, non-alcoholic beverages and food)
Enforcement of no service to underage and
obviously intoxicated patrons
Slide 30
Problem Prevention Strategies:
Promising -- Too early to tell
Workplace interventions—workplace policy
Genetics and alcohol drug dependency risk
Alcohol sales to intoxicated persons
Auto ignition controls
Curfew laws
Parent training and mobilization
Restrictions on drinking & smoking location
Low or no alcoholic beverages; low tar tobacco
Alcohol container and tobacco product sizes
Slide 31
Alcohol Problem Prevention Strategies:
Mixed Findings -- Uncertain Implications
Mass communication and public education alone
School-based education alone
Restrictions on Advertising
Slide 32
Examples of media programs
ONDCP Anti-drug media campaign
Partnership for a Drug-Free America
Slide 33
Individual: Mass Communication
and Public Education
Increases awareness
Produces little behavioral change
Reinforces environmental strategies
Slide 34
Latest Scientific Advance:
Comprehensive Mix of
evidence-based prevention strategies at
local level
Community Action Trials which use
complimentary interventions
Slide 35
Community System of Alcohol Use & Abuse
Legal Action
about Drinking
Social Control
and
Communication
Alcohol-involved
Mortality &
Morbidity
CONSUMPTION
Formal Regulation
and Control of
Alcohol Sales
Retail Sales by
Average Type
Social, Health,
and Economic
Consequences
Social and
Health Services
Alcohol Production,
Marketing and
Distribution
Community
Economic Sector
Slide 36
National Community Trial to Prevent
Alcohol-involved Trauma
-
Modesto
Salinas
Orange
Oceanside
. .
.
..
.
Florence
Sumter
Experimental
Comparison
Slide 37
Alcohol-involved Trauma at the Community Level:
Conceptual Model`````````
MOBILIZATION
Local News about Alcohol
Problems & Enforcement
DRINKING AND DRIVING
Perceived
Risk of Arrest
Local Law
Enforcement
RESPONSIBLE BEVERAGE
SERVICE
Social Access
to Alcohol
Driving after
Drinking
Alcohol
Serving and
Sales Practices
UNDERAGE DRINKING
Local Regulation
of Alcohol
(Density, Hours
of Sale)
Retail Alcohol
Availability
(On and Off-premise)
ALCOHOL ACCESS
Alcohol Intoxication
or Impairment
Alcohol-involved
Injury
Non-Traffic Risk Activities
Slide 38
Underage Alcohol Purchase Survey
-Experimental and Comparison Communities-
60
Percent Selling
50
PRETEST
POSTTEST
53
40 47
45
35
30
20
19
10
16
0
Comparison
Experimental
No Training
Experimental
Training
Comparison
Experimental
No Training
Experimental
Training
Holder, et al., J. American Medical Association, 2000
Slide 39
Slide 40
Slide 41
Community Trials Final Results
Holder, et al. 2000. J. Amer. Medical Assoc.
Total Consumption (+2%)
Heavy Drinking (-6%)
Driving after “Too much to drink” (- 49%)
BAC Positive Drivers (- 44%)
Nighttime Injury Crashes (-10%)
Assaults
-- Hospital Cases (-2%)
-- Emergency Room Cases (- 43%)
Slide 42
Similarities across all effective prevention
strategies
Comprehensive and multi-component
Targets specific causal variables which have
been shown to affect total local population as
well as the environment
Based on methodologically sound,
independently replicated evaluations under
“real world” conditions
Slide 43
Community System Strategies
Effectiveness at population level
Impact both heavy & moderate drinkers/users
Yield longevity of effects
Do not target subgroups--non discriminating
Have lower costs
-No case-finding
-Individual services NOT required
-NO continued costs to sustain effects
"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
Slide 2
Prevention Paradox:
More local problems are caused
by heavy drinking than by
alcoholics.
Slide 3
Students Who Reported Using Alcohol,
Tobacco, and Other Drugs in Past 30 Days
70
63%
60
50
46%
40
30
20
10
25%
11.4%
10.8%
6.1% 4.5% 3.5%
4.5%
A
lc
oh
ol
To
ba
cc
o
M
ar
iju
an
a
In
ha
H
la
al
nt
lu
s
ci
no
ge
Tr
an
ns
qu
A
ili
m
ze
ph
rs
et
am
in
es
C
oc
ai
ne
N
ar
co
tic
s
0
Slide 4
Experimentation and Established Smoking by Age
Source: 1996 CTS
Slide 5
Past Month Illicit Drug Use—any drug
Slide 6
Just what is
prevention, anyway?
Slide 7
Goals of ATOD prevention
Prevent health and safety problems related to
substance use, e.g., traffic crashes, violence,
lung cancer, overdose.
Prevent all use of tobacco and illicit substances
for everyone, regardless of age.
Prevent heavy and high risk use of substances.
Delay adolescent initiation of substances that are
licit for adults (e.g., tobacco and alcohol).
Slide 8
Approaches to the reduction of
ATOD use and resulting problems
Orientation
Individual change
approaches
Goal
Individual behavioral
change leading to
demand reduction
Target
Individual, directly
or through others
(e.g., family, peers)
Environmental
change approaches
Community/state system or
population change leading
to both demand and supply
reduction
Social, economic and
physical environment
But lots of hybrid , multi-component models
Slide 9
Substance Abuse Influences and Factors
(1)Physical -
Proximity of alcohol &
tobacco outlets and drug
supplies, places of public use
(2) Social -
Family, peers and larger
social networks, norms,
mass media
(3) Economic - Cost of alcohol, drugs, tobacco;
geography of availability
Slide 10
For Example, Youth Drinking
Availability of
alcohol to &
from peers
Physical
Cost &
availability
to youth
Alcohol
Availability
Social
Drinking
By Peers
Retail
Price
Economic
Alcohol purchases by other youth
Slide 11
Public Health Model of Prevention
Individual
Environment
Agent
Slide 12
Public Health Model of Substance
Abuse Problem Prevention
Individual
(User)
Environment
(Context)
Agent
(Substance)
Slide 13
Individual Approaches
1.
School-Based Education
2.
Mass Communication and Public
Education
3.
Family Education/counseling
4.
Alcohol and Tobacco Warning labels
5.
Deterrence: Possession or sale of drugs, Drinking
and driving Laws, Sale of tobacco or alcohol to
minors.
6.
Brief Intervention in health care or workplace
Slide 14
Public Health Model of Substance Use
Prevention
Individual
(User)
Environment
(Context)
Agent
(Substance)
Slide 15
Environmental Approaches
1. Retail Access to substances, e.g.,
price, outlet locations, minimum
purchase laws, parental restrictions on
youth.
2. Restrictions or constraints on the
Drinker’s or Smokers Behavior, e.g.,
drinking & smoking locations, drink drive
3. Reduce Risk or Problem Severity
Slide 16
Public Health Model of Substance Use
Prevention
Individual
(User)
Environment
(Context)
Agent
(Substance)
Slide 17
Agent Approaches
1.
Low or No Alcohol Beverages or lower
tar tobacco products
2.
Alcohol container size or
tobacco package restrictions
3.
Restrictions on Product
Advertising
Slide 18
Slide 19
Standards of Evidence
1.
2.
3.
Achieves significant effects (actually
reduces ATOD problems) under scientific
standards.
Replicated across two or more studies
under diverse community or national
conditions.
Has practical applicability and can affect
the total community, not only target
groups, i.e., has public health import.
Slide 20
Problem Prevention Strategies:
Solid Evidence
¤
Retail price of alcohol or tobacco
¤
Minimum drinking/purchase age—retail
compliance checks for alcohol and tobacco
¤
¤
¤
¤
¤
Graduated licenses & “zero tolerance for Youth
Drinking/driving deterrence (RBT)
Lower BAC limits for driving
Density & location of alcohol outlets
Form and style of retail sale, e.g., hours
and days of retail sale.
Slide 21
Retail Price
Drinking &
smoking
As price increases, smoking and heavy
drinking declines (Chaloupka, 1993)
Heavy drinkers/smokers as well as youth are
affected by price. (Coate and Grossman,
1988)
Youth who drink weekly up to daily are
more affected by price (Grossman, et al.,
1991; Coate and Grossman, 1988)
Slide 22
Underage Drinking
Goal:
Decrease underage drinking
Actions:
Increase community awareness of underage
drinking
Reduce physical availability of alcohol to minors
Increase awareness of retail establishments and
adults of the legal and social risks of providing
alcohol to minors
Slide 23
Environment
Person Activities
Alcohol Use (30-day mean) Before and After
Minimum Drinking Age (MDA) was Raised--United States
3.2
3
2.8
2.6
13% Decline
2.4
2.2
-3
-2
-1
1
2
3
Years Before and After MDA was
Source: O’Malley & Wagenaar
Raised
(1991)
Slide 24
Drinking and Driving
Goal:
Reduce the number of community drinking and
driving events
Actions:
Increase law enforcement efficiency
Increase perceived risk of DWI detection
Increase community support of DWI
enforcement
Slide 25
Access Intervention
Goal:
Decreased physical availability of Substances
Actions:
Reduction in outlet densities and sales to minors
Changes in planning and zoning laws
License challenges
Slide 26
Problem Prevention Strategies:
Positive Evidence – Need Replication
Responsible beverage service – Policy & server training
Community Prevention Trials utilizing local policy
Primary health care interventions
Liability for sales or serving alcohol
Alcohol & tobacco warning labels
Administrative driver license suspension
School education alone & w/ community
interventions
Slide 27
School Education
Effective programs:
Values and norms clarification
Decision-making
Life skills
Use interactive teaching methods
Ineffective programs:
Target self-esteem
Increase knowledge
Use scare tactics
Use didactic methods
Slide 28
Individual: School-based Education
Popular prevention strategy--mostly US studies
Information only – no effect
Mixed results across studies and substances &
only in controlled research studies
Most effective with some combination of:
1. Normative beliefs
2. Personal commitment
3. Information
4. Resistance skills
Slide 29
Responsible Beverage Service
Goal:
Reduce alcohol intoxication or impairment for
patrons of bars and restaurants
Actions:
Server and manager training
New alcohol serving policies (price promotions,
serving sizes, non-alcoholic beverages and food)
Enforcement of no service to underage and
obviously intoxicated patrons
Slide 30
Problem Prevention Strategies:
Promising -- Too early to tell
Workplace interventions—workplace policy
Genetics and alcohol drug dependency risk
Alcohol sales to intoxicated persons
Auto ignition controls
Curfew laws
Parent training and mobilization
Restrictions on drinking & smoking location
Low or no alcoholic beverages; low tar tobacco
Alcohol container and tobacco product sizes
Slide 31
Alcohol Problem Prevention Strategies:
Mixed Findings -- Uncertain Implications
Mass communication and public education alone
School-based education alone
Restrictions on Advertising
Slide 32
Examples of media programs
ONDCP Anti-drug media campaign
Partnership for a Drug-Free America
Slide 33
Individual: Mass Communication
and Public Education
Increases awareness
Produces little behavioral change
Reinforces environmental strategies
Slide 34
Latest Scientific Advance:
Comprehensive Mix of
evidence-based prevention strategies at
local level
Community Action Trials which use
complimentary interventions
Slide 35
Community System of Alcohol Use & Abuse
Legal Action
about Drinking
Social Control
and
Communication
Alcohol-involved
Mortality &
Morbidity
CONSUMPTION
Formal Regulation
and Control of
Alcohol Sales
Retail Sales by
Average Type
Social, Health,
and Economic
Consequences
Social and
Health Services
Alcohol Production,
Marketing and
Distribution
Community
Economic Sector
Slide 36
National Community Trial to Prevent
Alcohol-involved Trauma
-
Modesto
Salinas
Orange
Oceanside
. .
.
..
.
Florence
Sumter
Experimental
Comparison
Slide 37
Alcohol-involved Trauma at the Community Level:
Conceptual Model`````````
MOBILIZATION
Local News about Alcohol
Problems & Enforcement
DRINKING AND DRIVING
Perceived
Risk of Arrest
Local Law
Enforcement
RESPONSIBLE BEVERAGE
SERVICE
Social Access
to Alcohol
Driving after
Drinking
Alcohol
Serving and
Sales Practices
UNDERAGE DRINKING
Local Regulation
of Alcohol
(Density, Hours
of Sale)
Retail Alcohol
Availability
(On and Off-premise)
ALCOHOL ACCESS
Alcohol Intoxication
or Impairment
Alcohol-involved
Injury
Non-Traffic Risk Activities
Slide 38
Underage Alcohol Purchase Survey
-Experimental and Comparison Communities-
60
Percent Selling
50
PRETEST
POSTTEST
53
40 47
45
35
30
20
19
10
16
0
Comparison
Experimental
No Training
Experimental
Training
Comparison
Experimental
No Training
Experimental
Training
Holder, et al., J. American Medical Association, 2000
Slide 39
Slide 40
Slide 41
Community Trials Final Results
Holder, et al. 2000. J. Amer. Medical Assoc.
Total Consumption (+2%)
Heavy Drinking (-6%)
Driving after “Too much to drink” (- 49%)
BAC Positive Drivers (- 44%)
Nighttime Injury Crashes (-10%)
Assaults
-- Hospital Cases (-2%)
-- Emergency Room Cases (- 43%)
Slide 42
Similarities across all effective prevention
strategies
Comprehensive and multi-component
Targets specific causal variables which have
been shown to affect total local population as
well as the environment
Based on methodologically sound,
independently replicated evaluations under
“real world” conditions
Slide 43
Community System Strategies
Effectiveness at population level
Impact both heavy & moderate drinkers/users
Yield longevity of effects
Do not target subgroups--non discriminating
Have lower costs
-No case-finding
-Individual services NOT required
-NO continued costs to sustain effects