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Suggested Citation:"INTRODUCTION." National Research Council. 1984. Toward the Prevention of Alcohol Problems: Government, Business, and Community Action. Washington, DC: The National Academies Press. doi: 10.17226/18637.
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Suggested Citation:"INTRODUCTION." National Research Council. 1984. Toward the Prevention of Alcohol Problems: Government, Business, and Community Action. Washington, DC: The National Academies Press. doi: 10.17226/18637.
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Suggested Citation:"INTRODUCTION." National Research Council. 1984. Toward the Prevention of Alcohol Problems: Government, Business, and Community Action. Washington, DC: The National Academies Press. doi: 10.17226/18637.
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Suggested Citation:"INTRODUCTION." National Research Council. 1984. Toward the Prevention of Alcohol Problems: Government, Business, and Community Action. Washington, DC: The National Academies Press. doi: 10.17226/18637.
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Suggested Citation:"INTRODUCTION." National Research Council. 1984. Toward the Prevention of Alcohol Problems: Government, Business, and Community Action. Washington, DC: The National Academies Press. doi: 10.17226/18637.
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Suggested Citation:"INTRODUCTION." National Research Council. 1984. Toward the Prevention of Alcohol Problems: Government, Business, and Community Action. Washington, DC: The National Academies Press. doi: 10.17226/18637.
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Suggested Citation:"INTRODUCTION." National Research Council. 1984. Toward the Prevention of Alcohol Problems: Government, Business, and Community Action. Washington, DC: The National Academies Press. doi: 10.17226/18637.
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Suggested Citation:"INTRODUCTION." National Research Council. 1984. Toward the Prevention of Alcohol Problems: Government, Business, and Community Action. Washington, DC: The National Academies Press. doi: 10.17226/18637.
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Suggested Citation:"INTRODUCTION." National Research Council. 1984. Toward the Prevention of Alcohol Problems: Government, Business, and Community Action. Washington, DC: The National Academies Press. doi: 10.17226/18637.
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Suggested Citation:"INTRODUCTION." National Research Council. 1984. Toward the Prevention of Alcohol Problems: Government, Business, and Community Action. Washington, DC: The National Academies Press. doi: 10.17226/18637.
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1 Introduction The National Research Council accepted a difficult assignment five years ago in agreeing to organize an objective and comprehensive study of historical, current, and proposed programs and policies—many of them controversial—aimed at preventing alcohol abuse and alcoholism. The panel was asked by the National Institute on Alcohol Abuse and Alcoholism to: • delineate the conceptual, normative, and political dimensions of the problem; • find and evaluate the best available evidence concerning the effec- tiveness of preventive measures; and • provide a clear set of conclusions to guide further research and debate on practical means to prevent or reduce alcohol-related prob- lems. The report we produced in 1981 was Alcohol and Public Policy: Beyond the Shadow of Prohibition. In it we presented a portrait of alcohol problems and possibilities for dealing with them that turned out to be slightly different from what most people had been thinking about before. We began with the idea that public policy in a democracy is a very subtle concept. People often imagine that it is located in the official documents of legislatures and the speeches of chief elected officials, or that it lies in the mechanics of programs. Our view was that public policy in a democracy is what people say, do, and believe. 1

2 PREVENTION OF ALCOHOL PROBLEMS CONCEPTUAL DIMENSIONS OF ALCOHOL PROBLEMS When we looked at public policy on alcohol over the last generation in the United States, we noticed a certain coherence. Alcohol problems have been seen largely as the problems of alcoholics, and the most important way to deal with them has been to identify efficiently the people who are alcoholic and to treat them as effectively as possible. That was a sensible policy. It put on the table a very important piece of the alcohol problem, probably the largest single piece, and managed it in an interesting and valuable way. Voluntary organizations have been committed to that cause, and the approach has created consider- able public awareness. A CHANGING CONCEPTION OF ALCOHOL POLICY At the same time, it seemed clear that many alcohol problems are caused by people who could in no useful sense be called alcoholics and who would rightfully be surprised to be counted in that group. While alcoholics have contributed the largest share of alcohol problems, noticeable pieces of the problem, conceived in its entirety, have been generated by ordinary people drinking recklessly, unwisely, or in con- junction with inappropriate activities. These people, standing at risk in ways they might not quite appreciate, stood out clearly in the aggregate statistics of fatalities, social disruption, and costs of health care. This piece of the alcohol problem was simply out of the reach of treatment instruments, and it seemed important not only for these individuals but also for society as a whole to find ways to deal with these problems effectively. It was this dimension that seemed to us out of focus in the existing strategy of treating alcoholism. We thought it important, then, to examine public policy instruments that might successfully handle this piece of the problem. These instru- ments had to have some rather special characteristics: they had to operate across a very large segment of the population, and they had to rest lightly. They could not be controlling, containing, powerful instru- ments; they had to be broad, consistent, yet light in structuring incen- tives for the general population. We suspected that policy instruments that would be effective in dealing with neglected alcohol problems and shaping drinking practices in the general population might also help reduce the rate at which people become alcoholic or advance to chronic or very dangerous levels of consumption. Such policy instruments might even help move current alcoholics out of their alcoholism by giving them added support in

INTRODUCTION 3 staying away from drinking. These possibilities, too, seemed somewhat peripheral to the current conception of alcoholism. We scanned the possibilities for controlling these problems without overly constraining people's freedom of choice or preventing them from taking advantage of the benefits offered by alcohol.Our conclusion was that more attention needed to be given to the underemphasized area of prevention—not individualized approaches such as early detection and intervention, designed to reach hidden alcoholics or prealcoholics, but nonpersonalized approaches that would operate broadly on drinking practices throughout the population or break typical links between drinking practices and adverse consequences. THREE ASPECTS OF PREVENTION We divided the general concept of prevention into three somewhat narrower ideas. The first was to affect the terms and conditions under which alcohol is available, through special taxes, minimum age require- ments, regulation of outlets and availability and times of sale—all the things that determine how easy and convenient it is for people to have access to alcohol. We imagined using the apparatus of distribution to affect not only how much people drink, but also conceivably when, where, and how they do their drinking. This seemed important, given our belief that many of the bad consequences of drinking were associ- ated as much with when, where, and how people drink as with simply how much. The second idea was to shape drinking practices directly by talking to people about what constitutes safe and appropriate drinking behav- ior. That could be done informally, through educational approaches (sponsored by the state or by others), as well as formally, through the special weight of laws instructing people on what constitutes safe and appropriate versus suspect or criminal practices. Such laws would invoke the prestige and coercive power of the state on behalf of these particular conceptions. The third idea was to make the environment a safer one in which to be drunk. This idea included redesign of consumer products, rearrange- ment of places so that people might drink more safely in them, arranging transportation to get drinkers back home as safely as possible. We found this category interesting in that it included efforts to break the link between drinking and certain sets of consequences. Given these three broad classes of prevention instruments, which we considered logically available, our next task was to find evidence on whether these approaches would work. For some, we found a modest

4 PREVENTION OF ALCOHOL PROBLEMS amount of positive or negative evidence, while for others we could only state the logical possibilities since there was no evidence to demonstrate whether they could succeed. We found the most evidence in the area of terms and conditions of supply. This persuaded us that raising taxes could have substantial effects on levels of alcohol use as well as on deaths from liver cirrhosis and traffic fatalities. There was also good evidence to show that adjust- ing the drinking age up or down has an effect on traffic fatalities. The other approaches, including teaching people to drink safely and well through education or the law and making the world somewhat safer for intoxication, were less well backed by empirical evidence, but stood as opportunities for society to consider and experiment with. In short, when we reviewed the evidence and the logic of the problem, some specifics within the three broad areas seemed possible or likely to be effective. That became our conclusion. It did not claim a great deal, but what it did claim was important, and it implied that the nation's strategy should shift enough to build up more kinds of prevention- oriented approaches to alcohol problems. FOCUSING ON PREVENTION EFFORTS Two major developments occurred between the last meeting of the panel that authored Alcohol and Public Policy, in May 1980, and the follow-up conference from which the present report derives, in May 1983. The first development began with the national election of 1980: in its aftermath a series of policy changes substantially affected relations between the federal and the state governments, markedly altering the role of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in activities at the state level. These changes, particularly the absorption of many state-administered federal programs into the block grant sys- tem, moved a great deal of detailed programmatic decision making out of the federal agency and into the statehouses. The second development was the remarkable growth of citizen and legislative concern with the problem of drunk driving, spurred by the formation of grass-roots organizations such as Mothers Against Drunk Drivers (MADD), Remove Intoxicated Drivers (RID), and Students Against Drunk Driving (SADD). Working on the county and state levels, these groups spearheaded movements to raise the drinking age, and also turned their efforts toward more assured use of criminal penalties and civil liability actions, adoption of alcohol-education curricula by school boards, increasing police attention, surveillance of courtroom actions, and other related issues.

INTRODUCTION 5 The concatenation of these events argued for focusing our follow-up effort at least in part on state and local prevention opportunities, a focus not difficult to reconcile with the report, since virtually all the options it discussed were subject to implementation at these levels. ORGANIZATION OF THE VOLUME Of course it would have been impossible for this or any other con- ference to be comprehensive in examining local and regional prevention efforts, nor would that have served the purpose of generating discussion based on the 1981 report. We chose instead to draw a matched sample: first, a handful of the most prominent and interesting policy instruments discussed in the report, selected to represent the three broad classes of instruments as well as different degrees of experience with implemen- tation; second, a selection of individuals from across the country and across the landscape of viewpoints and activities involving prevention and alcohol policy. A number of the conferees were asked to prepare remarks beforehand in the form of brief papers or essays. These pieces served to open discussion of each prevention instrument; thereafter, the conferees took each subject through its own paces in spirited and candid discourse. Each chapter in this volume includes one or more papers or essays, followed by discussions edited from the conference transcripts. Chapter 2 sounds the general theme around which the conference turned: the idea of community ownership of alcohol problems. This idea is simple yet elusive. It means collectively owning up to the prob- lem—acknowledging that it belongs to every individual who is part of the community and accepting responsibility for carrying out solutions— which may entail a measure of sacrifice, in one form or another, for everyone. In this context, William Mayer, then administrator of the federal Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), compares alcohol abuse to the great public health chal- lenges of the past, calling on Americans to mobilize and act in concert to further our traditional public health ideals. Illinois mental health commissioner Margaret Hastings reminds us that calls for community action are inherently competitive with other agendas; she notes the political obstacles that prevention interests must overcome, as well as the political assets they can wield. Frank Raflo, supervisor of Loudoun County, Virginia, then draws us directly into the thinking of key com- munity members, poignantly illustrating the common sensibility that recognizes alcohol problems as serious—but as belonging to someone else. Chapter 2 concludes with an exchange between research scholar

6 PREVENTION OF ALCOHOL PROBLEMS Mark Keller and conference chair Mark Moore on whether our insti- tutions and leaders bear a collective responsibility to take preventive action with the various instruments now at hand, or whether we should forgo such action and await future generations whose attitudes toward drinking may be revised by an educational process that we can only initiate. Chapters 3 through 6 examine in greater detail a sample of policy options in the areas of regulating the supply of alcohol and shaping drinking practices directly. Chapter 3, beginning with a summary by economist Philip Cook, focuses on the ways in which alcohol—its consumption, distribution, and abuse—affects and is affected by the taxing and spending powers of legislatures. This chapter handles two controversial themes: the strategic importance of alcohol taxes as both a potential preventive measure per se and a potential source of funds for general revenue and preventive programs; and the tactical dimen- sion, in which political coalitions form around diverse interests—eco- nomic, health, and criminal justice—touched by tax issues. Chapter 4 examines the responsibilities of businesses, both as sup- pliers who may be subject to liability for their product's abuse and who can take steps to prevent or curtail such abuse, and as employers concerned with the performance and welfare of their work force. Begin- ning with attorney-researcher James Mosher's paper on comprehensive server intervention, this chapter notes the role of legal and regulatory actions as well as voluntary initiatives by beverage servers and other firms and describes a number of joint public-private ventures in this field. Chapter 5 comes to grips with the mass media, particularly the role of television programming and advertising in creating images and con- veying information about alcohol use and its consequences. After reviewing the major scientific studies that bear on the relation of mass media to alcohol abuse, health educator Lawrence Wallack, in his lead paper, concludes that ethical values and logical principles must remain the major guides to coordinating action in this realm. The conferees take up this challenge, painting a broad spectrum of such guides. Chapter 6 concerns drinking and drunk driving among young people, two highly charged aspects of alcohol abuse that have become firmly linked in public debate and policy, although, as the discussion indicates, each problem extends beyond that direct linkage. The lead essay on parental action is by Keith Schuchard, research director of the Parental Resource Institute for Drug Education (PRIDE). Chapter 7 draws together most of the main themes of the conference, following a lead essay by Robert Reynolds, San Diego County Alcohol

INTRODUCTION 7 Program chief. It brings into focus the third major area of prevention instruments, those that modify the environment to reduce risk. This final chapter concentrates on the community level, where all preventive policies must take effect or at least draw on grass-roots support to be politically viable. It concludes, in counterpoint to where the panel began, with questions about the detailed shape and scope of the prob- lems and the effectiveness of alternative preventive programs in local communities. State and county policy makers strongly encourage NIAAA to extend its work in bringing this sort of information into their hands. RECURRENT THEMES The conferees do not seek or reach any grand consensus that could form a ringing conclusion to these proceedings. Their periodic return during the discussions to the most general issues shows that it is difficult enough just to grasp fully the broad prevention strategy recommended in Alcohol and Public Policy. Although presented as a fairly simple idea, this strategy runs askew from nearly everything we have been thinking about alcohol problems for many years; we are all to some degree prisoners of persistent habits of thought, the power of which we only dimly perceive. Prevention still seems automatically to suggest particular instruments—selective prohibition, efforts aimed at youth, or punitive laws. While none of these ideas is completely out of line, each represents only a single, limited set of possibilities that, if stretched too far, becomes ineffective, untenable, or destructive. The broader idea of prevention encompasses dozens of creative, well-balanced pos- sibilities linked by the simple prescription that they be general, non- personalized, and dedicated to reducing the aggregate risk of harmful consequences. IMPORTANT ISSUES IN ALCOHOL POLICY This conference also brings home the point that there is no simple structure for implementing the general idea of prevention. Legislators, executive branch officials, treatment providers, and business and vol- unteer group leaders keep using such words as "networking," "orga- nizing," and "politicking," because there is no central bureaucratic site to approach, no single structure within which to carry out many of these prevention policies. The capacity to act is dispersed broadly throughout society; therefore, to mobilize it, to start the body politic marching in a particular direction, one has to network, organize, and politick.

8 PREVENTION OF ALCOHOL PROBLEMS This is no less true of alcohol policy as it currently exists. No one simply announced that as of 1960 or 1975 our alcohol policy was to treat alcoholics. What organized this policy was a series of shared percep- tions about what the problem was and what people were trying to do. It is hard to grasp a revised strategy and even harder to develop a structure or consensus for it, but clearly there are three operating levels on which such things are ultimately worked out: politics, policies, and programs. POLITICS, POLICIES, AND PROGRAMS By politics, we mean the Aristotelian idea of trying to change people's minds about what a problem is and what can reasonably be done about it. To a certain extent, Alcohol and Public Policy is a part of politics: it has become a common discussion item, a touchstone that people can use to certify the legitimacy and complementarity of a broad band of possible preventive measures. Discussing, arguing, and thinking about which values are to be served and which subordinated in particular situations, and trying to agree on what the world is really like, are what democratic republican politics means. Our report seems to have earned a place in that tradition. The second operating level is policies. It is important to understand that many of the things discussed here involve little government money. They use another very productive resource of the state: authority backed by moral leadership. This formulation may sound old-fashioned, but the state in fact produces many effects simply by leading, by using its authority and its moral position, as well as by taxing and spending. Measures such as liability and the educational impact of laws work without spending vast amounts of government money. They work rather by reminding people of their responsibilities to the community. Finally, there is the level of programs. This is where bureaucracies spend money and volunteer groups design and carry out particular ideas. Many people think the core of the issue has not been reached until one starts to talk about programs. But something is accomplished even when we talk only about politics and policies. When we are politicking, not only are we building support for policies and programs, but very often we also go much of the way toward implementing them. When people are persuaded to attend to a certain piece of the alcohol problem and begin acting on it, the result is often strong volunteer efforts. This volume describes such efforts by the Caucus of Producers, Writers, and Directors; Mothers Against Drunk Drivers; the Georgia Power Company; and many others. Much of this work goes on without

INTRODUCTION 9 direct government sponsorship. Encouragement that comes from knowledge and the redefinition of problems, and the energy that we always associate with voluntary initiative can augment or exceed the programmatic, bureaucratic, funding-based capability of the govern- ment. PREVENTION POLICIES AND THE ALCOHOL BEVERAGE INDUSTRY One prominent issue in this field is the relationship between proposals for prevention policies and the position of the alcohol beverage industry. There is a strong temptation to see these interests as inevitably and diametrically opposed, to think that when prevention policies gain force, the alcohol beverage industry has to take losses. There may be hard truth to this view. All prevention policies, to be successful, may have to slice into the business of the beverage-making and beverage-serving industry, and it seems reasonable for those in the industry to be con- cerned. At the same time, it is important to take account of a possibility that may seem remote or utopian: that the alcohol beverage industry, those who produce, market, and sell the products, may have a propitious opportunity to make a contribution. The practices and proposals of the S & A Restaurant Corporation, for example, or the advertising restric- tions that members of Wine Institute have imposed on themselves, ought to please anyone interested in prevention approaches. It would be a mistake to look down on such efforts, to abandon them, or to think that they were ultimately irrelevant. The public commitment, knowl- edge, and position of the alcohol beverage industry could have real potential for helping to prevent harmful consequences of alcohol use while protecting as much appropriate use as society can manage. We cannot know for certain at this stage exactly how much potential to reduce problems might have to be sacrificed to avoid cutting too far into appropriate drinking. There may be a very harsh trade-off, and it may be very optimistic to think that one could solve many problems without cutting deeply into consumption. Whatever the particulars, it is clear that we face a very complicated social decision on how much loss to take in legitimate consumption for how much gain in reducing problems associated with alcohol use. CONCLUSION It expresses the final and overall sense of the conference to say that, as we move further into prevention, there should be as much sharing

10 PREVENTION OF ALCOHOL PROBLEMS of responsibility and cooperative enterprise as possible. It is crucial to take advantage of the wide body of experimentation now going on throughout the country and to learn as much as possible from the variety of approaches to prevention, ranging from taxation, to controls over availability, to educational enterprises through private or governmental groups, to making the world safer to drink in. It is highly appropriate for the National Institute on Alcohol Abuse and Alcoholism to support and serve as a conduit of high-quality information about the success— and failure, when that occurs—of these experiments in prevention policy.

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