Click for next page ( 24


The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 23
A PUBLIC HEALTH PERSPECTIVE ON THE PREVENTION OF ALCOHOL PROBLEMS Alcohol use is involved in nearly 100,000 deaths annually, and it plays a major role in numerous medical and social problems in the United States. A contributor to deaths from liver disease and certain cancers, it is also a demonstrated risk factor for vehicular injuries (Haddon et al., 1961; McCarroll and Haddon, 1962~. Indeed, drinking is involved in nearly half the deaths from car crashes in this country (U.S. Department of Transportation, 1986~. Alcohol use has also been associated with injuries resulting from falls (Honkanen et al., 1983; Hingson and Howland, 1987) and probably contributes to other intentional (Collins, 1981; Merrigan, 1988) and unintentional injuries as well (Howland and Hingson, 1987, 1988~. In 1980 the costs from absenteeism, property damage, medical care, and other services that could be attributed to alcohol use were approximately $89.5 billion (NIAAA, 1987). The amount and frequency of drinking combined with the characteristics of the social and physical environment can either increase or decrease the risks of drinking (Moore and Gerstein, 1981~. For example, a very intoxicated person would be at greater risk for an alcohol-related problem outcome in a dangerous activity and environment (e.g., when operating machinery) and at lower risk in a safer pursuit and environment (e.~.. at home watching television). ~A, Because the level of intoxication of an individual who is drinking interacts with environmental factors to determine the risks of drinking, alcohol-related problems are not limited to heavy drinkers. Moderate drinkers who drink occasionally but in an unsafe environment are also at risk for an alcohol-related problem. Therefore, everyone who drinks can be at risk, and even people who do not drink are often the innocent victims of the effects of such alcohol-related problems as violent crimes and car crashes. Drinking problems can be aligned along a continuum from none to moderate to severe alcohol dependence (see IOM, 1987, pp. 16-17~. It is estimated that 10 percent of the adult U.S. population has a serious drinking problem or are alcohol dependent. Another 30 percent does not drink at all. The remaining 60 percent is classified as light to moderate drinkers (IOM, 1987~. Although heavy drinkers may suffer from the most severe effects of drinking and experience a greater concentration of problems, they do not account for the full range of alcohol problems. Surprisingly, the greatest proportion of problems can be attributed to moderate drinkers because the number of people in this group is larger than the number of alcohol-dependent persons. Despite the severe and far-reaching consequences of alcohol use, success in preventing these problems has been limited. The purpose of this chapter is to describe a public health model of prevention, which the committee has used as a framework to organize its discussion of promising avenues of prevention research. The model's emphasis on the interaction of factors related to problems with alcohol, as well as its ability to encompass a wide variety of intervention approaches, seems particularly useful. -23

OCR for page 23
As described in the National Research Council (NRC) report Alcohol and Public Policy: Beyond the Shadow of Prohibition (Moore and Gerstein, 1981), as well as in the Institute of Medicine report Causes and Consequences of Alcohol Problems (IOM, 1987), research in the field of alcohol abuse has expanded from the focus on clinical alcoholism to a broader interest in alcohol-related problems. There is now a relatively large body of literature for such a new field, and within the last 10 years there has been a rapid expansion in the number and type of studies that have been completed. The scope and distribution of alcohol problems throughout the population have profound implications for prevention. It has been persuasively argued (Moore and Gerstein, 1981; Room, 1981) that the goal of prevention should be expanded to that of reducing the occurrence of alcohol-related problems rather than merely lowering the prevalence of clinical alcoholism. Even if it were possible to identify and treat everyone with a severe drinking problem, environmental factors guarantee that there would still be alcohol-related problems associated with moderate drinking. This expanded concept, however, changes the focus of prevention efforts from an exclusive emphasis on drinking behavior to one that seeks to prevent the medical, personal, and social consequences of alcohol use. Heretofore, much of the discussion of prevention has tended to focus on intoxication as the sole cause of alcohol problems and has not adequately included the contributory role of the environment. This report assumes that the goal of prevention is to reduce the incidence of alcohol-related problems and that efforts to induce widespread change in social norms and behavior are components of a larger strategy to reduce all of these problems, including clinical alcoholism. A PUBLIC HEALTH MODEL OF ALCOHOL-RELATED PROBLEMS As outlined in Causes and Consequences of Alcohol Problems (IOM, 1987), the growing body of epidemiological data and the corresponding increase in understanding have led us to see that alcohol problems arise through a complex interaction of individual, interpersonal, and social factors. It is no longer suggested that these problems stem from a single determining mechanism such as inherited susceptibility to alcohol dependence or the availability of alcoholic beverages. To gain a perspective on the interaction of multiple factors, prevention specialists have adopted an epidemiological or public health model of alcohol-related problems (Figure 1- 1~. The model shows three major elements that act together either to produce or attenuate specific problems: 1. the agent--alcoholic beverages or ethanol itself; 2. the individual (host)--traits that affect a person's susceptibility or vulnerability to the effects of alcoholic beverages; and 3. the environment--the physical, interpersonal, or social milieu surrounding the use of alcohol that either regulates the individual's exposure to the agent or mediates the risk that the agent poses to the individual. This concept includes both macro- and microenvironments, such as the legal environment (alcoholic beverage control [ABC] laws, laws regarding driving under the influence of alcohol, minimum purchase age laws, zoning); the economic environment (pricing, the excise tax rate, promotions); the normative environment (general attitudes and beliefs regarding alcohol, mass media effects); and the physical aspects of the drinker's immediate environment. -24

OCR for page 23
As the model suggests, a specific alcohol-related problem does not result from only one or the other of these sources. Rather, the model emphasizes the interaction of sometimes subtle forces that shape the type and magnitude of problematic outcomes. The etiology of the specific problem--whether it be intoxication, dependence, or driving after drinking--can often be understood best from a public health perspective by isolating the relevant individual, agent, and environmental variables that are contributing influences. The preventive trial offers one method for determining the influence of a particular variable and its implications for subsequent interventions to prevent problem outcomes. A preventive trial refers to an intervention that is targeted to a well population in which a presumed risk factor is modified or eliminated in hopes of detecting a reduced incidence of disorder in those who receive the intervention. The goal of a preventive trial is to provide the rationale for large-scale public health prevention programs that have the capaan,r because an incidence rate in a large population. Preventive teals can provide researchers with an experimental capacity in that an experimental manipulation that modifies a causal risk factor in a population enables a Figure 1 Alcohol problems are understood as the result of an ~nteractior among individuals, the agent alcohol and the environment. '~ Individual ~ / (Host) \ Physical & Social Drinking Contexts (Environment) Alcohol (Agent) researcher to test an etiologic theory which may not be amenable to other sorts of empirical verification (a situation that is particularly applicable to human populations). These techniques enable prevention researchers to make a major contribution to an understanding of the etiology of a disorder. If experimentally induced changes in a risk factor are followed by a reduction in the incidence rate of disorder, one can be reasonably confident that the risk factor is part of the causal chain. Alternatively, well-designed and well-implemented preventive trials that fail to document a preventive effect cast doubt on established hypotheses concerning etiology. In addition to serving as an experimental test of a causal hypothesis, a preventive trial allows an evaluation of (a) the feasibility of an intervention, (b) its potential interaction with individual and community variables, and (c) how its effect may vale across different settings and populations. -25

OCR for page 23
PREVENTION RESEARCH FROM A PUBLIC HEALTH PERSPECTIVE The public health approach to primary prevention traditionally has been oriented toward lowering the rate of occurrence (incidence) of a disease or disorder in a defined population. Prevention interventions generally can be seen as attempts either to alter an agent, a host (individual), or an environmental factor that contributes to an alcohol problem or, conversely, to exploit a factor that reduces risk. Broadening the scope of this traditional pattern somewhat, Gordon (1983) has proposed a novel conceptual scheme for preventive interventions, suggesting that they be considered universal, selected, or indicated in nature. Universal preventive interventions are directed at an entire population and not at subgroups that are presumed to be at heightened risk. Fluoridation of water, vitamin supplementation of bread and milk, and diphtheria-pertussis- titanus (DPT) immunization of infants are examples of preventive interventions that are deemed desirable for everyone. Selected interventions, on the other hand, are directed at a class of individuals who, by virtue of membership in a subgroup of the population, are presumed to be at greater risk for a problem outcome than those who are not part of the group. This presumption, which is typically the result of prior epidemiological findings, serves as a basis for designating certain individuals as appropriate candidates for preventive intervention. These individuals do not exhibit preclinical signs or report symptoms of disorder, but they do possess the factor that is presumed to heighten risk. The last interventions in Gordon's scheme, indicated interventions, are directed at specific individuals who are chosen because they exhibit indices of preclinical dysfunction. The primary prevention of alcohol and other substance use-related problems, in the sense that this is generally understood to mean prevention of the onset of such problems, may be best achieved by using a combination of universal and selective approaches. (Indicated interventions would be considered secondary prevention; these approaches are discussed in the treatment section of the report.) Universal strategies, whether implemented through the mass media, legislation, community-wide interventions, or other types of efforts, can ~- do- - - 7 __ _ _ _ ___ _ _ _ 7 _ _ on- - - - - - - - --7 - - ------ -- --- -~ - reach broad segments of the population. Selective procedures can target classes of individuals who have a high probability of developing a problem outcome with interventions of greater scope and intensity than would be necessary, practical, or affordable in a universal approach. The model also helps us to visualize points that may be only peripherally related to the etiology of a specific problem but that nevertheless can be effective opportunities for interventions. Whether bars and taverns cause someone to become intoxicated, for example, is not as important as whether they can be designed or modified to prevent intoxication. In another case, although some individuals may be at greater risk of drinking and driving than others, the specific drinking context (e.g., a bar) may increase or decrease the given probability of the occurrence of alcohol-related problems. Similarly, certain normative environments (e.g., religious) may provide a high degree of protection to individuals who might otherwise be at risk. The strength of the public health perspective is that it broadens our awareness and understanding of alcohol-related problems. It moves us beyond a focus on the drinker (host) alone and directs our attention to the interaction between the individual and the environment that results in a specific problem (Wallack, l983~. Recently, several strategies have been designed, and in some cases implemented, to reduce injuries and deaths from alcohol-impaired driving. For example, server interventions have been developed that encourage commercial servers of alcoholic beverages to intervene before a drinker can -26

OCR for page 23
become intoxicated or before the drinker drives while intoxicated. In some jurisdictions, these interventions are used to supplement identification and treatment of alcoholics. Other suggestions to reduce deaths due to driving under the influence of alcohol include making roads and vehicles safer. No single prevention strategy is likely to be sufficient, however, given the complexity of the problem and the heterogeneity of drinkers and drinking situations. The public health model also indicates the role played by the agent, alcoholic beverages. A lengthy discussion of the production, marketing, and wholesale or retail distribution of alcohol is beyond the scope of this report; however, it conveys a sense of the importance and complexity of the role of alcohol to say that, in the United States, a billion dollars a year is spent on advertising and marketing beer, wine, and spirits. Further research is needed to define and clarify the industry's role in the worldwide increase in per capita consumption (Ashley and Rankin, 1988~. Research is also needed to delineate the ways in which economic factors affect the development of public policy in this area. A SYSTEMS APPROACH Although the perspective of the public health model provides a synthesizing overview of prevention goals, it is also necessary to apply theoretical models at the level of both the individual (micro) and the larger environment (macro) to design and evaluate effective prevention programs. Different theoretical constructs may apply at different levels of social complexity: individuals at different stages of the life course, social networks, organizations, communities, and regions. Optimally effective interventions require better integration of preventive efforts at several levels, and research is needed to permit the development of specific and comprehensive models that can bridge the gap between individual and societal factors. Holder and Those (1987) offer one solution to the need for integration. They contend that alcohol problem prevention efforts should be designed as a system rather than conceived of as isolated components; consequently, they call for concurrent use of several strategies that can result in synergistic effects. In this regard, valuable lessons may be learned from the community heart disease prevention trials (Farquhar et al., 1977, 1988~; from studies of groups at high risk, using the methods of what has been called developmental epidemiology (Zucker and Gomberg, 1986; Kellam, in press); and from the school-based smoking and drug prevention programs (F-lay, 1984; Perry, 1986) over several generations of studies. Within the various levels of the social structure, distinct, unique elements may be isolated and employed to enhance or accelerate social change processes. For example, within the individual there are biological, cognitive, and behavioral factors that are thought to mediate individual behavior change. At the organizational level (e.g., school, work site), in addition to the individual and group levels, there are unique constructs that are relevant to the organization as a whole (e.g., social climate, work environment). It is possible to capitalize on these unique features both within and between levels of social structure so that additive and synergistic prevention effects can be obtained (Abrams et al., 1986~. In addition to the need to bridge the gap between micro and macrolevel approaches, it is important to consider a multidisciplinary approach. Insularity within disciplines does not promote theory building but results in a tendency to design interventions and select measures that are suboptimal. Priority should be placed on encouraging interaction among -27

OCR for page 23
- ~. ~- ~ theoretical models that will help to optimize the change process. the disciplines that specialize in microlevel conceptualizations (biological markers, individual psychological factors) and macrolevel disciplines (mass media, social marketing, organizational and community change, health education, diffusion theory, policy, economics). It is also important to combine findings from disciplines focusing on the ~no~vtoua' with those from such population-based disciplines as developmental and clinical epidemiology, anthropology, and sociology. In this manner, high-risk subgroups, subcultures, or critical developmental stages across the life span (e.g., puberty) can be identified. In addition, it is crucial to identify the relevant mediating mechanisms and behavioral end points for both theory development and evaluation of impact. A multidisciplinary approach will allow for appropriate selection of targets for prevention as well as the application of relevant . _ .. .. . .. ~. The chapters that follow review current research in the alcohol field and relevant lessons from other public health fields. They also raise some unanswered questions about the prevention of alcohol-related problems. REFERENCES Abrams, D. B., J. Elder, T. Lasater et al. A comprehensive framework for conceptualizing and planning organizational health promotion programs. In M. Cataldo and T. Coates, eds. Behavioral Medicine in Industry. New York: John Wiley and Sons, 1986. Ashley, M. J., and J. G. Rankin. A public health approach to the prevention of alcohol related problems. Ann. Rev. Public Health 9:233-271, 1988. Collins, J. J., Jr. Drinking and Crime: Perspectives on the Relationships Between Alcohol Consumption and Criminal Behavior. New York: Guilford Press, 1981. Farquhar, J. W., N. Maccoby, P. D. Wood et al. Community education for cardiovascular health. Lancet 1:1192, 1977. Farquhar, J., S. Fortmann, J. Flora et al. The Stanford Five-City Project: Results after 5 1/3 years of education. American Heart Association, Cardiovascular Disease Newsletter No. 43, abstract 27, Winter 19~. Flay, B. R. What do we know about the social influences approach to smoking prevention? Review and recommendations. Pp. 67-112 in C. S. Bell and R. Battles, eds. Prevention Research: Deterring Drug Abuse Among Adolescents and Children. NIDA Research Monograph No. 63. USDHHS Publ. No. (ADM)85-1334, Rockville, MD: National Institute on Drug Abuse, 1984. Gordon, R. S. An operational classification of disease prevention. Public Health Reports 98:107-109, 1983. Haddon, W., Jr., P. Valien, J. R. McCarroll, and C. J. ~ Umberger. Controlled investigation of the characteristics of adult pedestrians fatally injured by motor vehicles in Manhattan. J. Chron. Dis. 14:655-678, 1961. -28

OCR for page 23
Hingson, R., and J. Howland. Alcohol as a risk factor for injury or death resulting from accidental falls: A review of the literature. J. Stud. Alcohol 48:212-219, 1987. Holder, H. D., and J. O. Those. The reduction of community alcohol problems: Computer simulation in three counties. J. Stud. Alcohol 48~2~:124-135, 1987. Honkanen, R., L. Ertama, P. Kuosmanen, et al. The role of alcohol in accidental falls. J. Stud. Alcohol 44:231-245, 1983. Howland, J., and R. Hingson. Alcohol as a risk factor for injuries or death due to fires and burns: A review of the literature. Public Health Reports 102:475-483, 1987. Howland, J., and R. Hingson. Alcohol as a risk factor for drownings: A review of the literature (1950-1985~. Accid. Anal. Prev. 20:19-25, 1988. Institute of Medicine. Causes and Consequences of Alcohol Problems: An Agenda for Research. Washington, DC: National Academy Press, 1987. Kellam, S. G. Developmental epidemiological framework for family research on depression and aggression. In G. R. Patterson, ed. Depression and Aggression: Two Facets of Family Interactions. Englewood Cliffs, NJ: Lawrence Erlbaum Associates, in press. McCarroll, J. R., and W. Haddon. A controlled study of fatal automobile accidents in New York City. J. Chron. Dis. 15:811-826, 1962. Merrigan, D. The Link Between Alcohol and Child Abuse: A Review of the Literature. Social and Behavioral Sciences Section, School of Public Health, Boston University School of Medicine, 1988. Moore, M. H., and D. R. Gerstein, eds. Alcohol and Public Policy: Beyond the Shadow of Prohibition. Washington, DC: National Academy Press, 1981. National Institute on Alcohol Abuse and Alcoholism. Sixth Special Report to the U.S. Congress on Alcohol and Health. USDHHS Publ. No. (ADM)87-1519, Rockville, MD: NIAAA, 1987. Perry, C. L. Community-wide health promotion and drug abuse prevention. J. School Health 56~9~:359-363, 1986. Room, R. The case for a problem prevention approach to alcohol, drug and mental problems. Public Health Reports 96~1~:26-33, 1981. U.S. Department of Transportation. Progress Report on Recommendations Proposed by the Presidential Committee on Drunk Driving. Washington, D.C., 1986. Wallack, L. Alcohol advertising reassessed: The public health perspective. Pp. 243-248 in M. Grant, M. Plant, and ~ Williams, eds. Economics and Alcohol: Consumption and Controls. London: and New York: Gardner Press, 1983. Zucker, R., and E. Gomberg. Etiology of alcoholism reconsidered: The case for a biopsychosocial process. Am. Psychol. 41:783, 1986. -29

OCR for page 23