Toward the Prevention of Alcohol Problems: Government, Business, and Community Action (1984)

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2 Prevention and the Community PUBLIC HEALTH IDEALS AND NATIONAL OBJECTIVES WILLIAM MAYER, Alcohol, Drug Abuse, and Mental Health Administration The easy problems in public health have mainly been solved. Alcohol-related problems are far more complicated and their solu- tions more fraught with trouble than when our predecessors tried to clean up the water supply, wipe out cholera and dysentery, and immu- nize people against smallpox. I do not mean to suggest that conquering smallpox and purifying the water supply were really easy. Riots were connected with the idea of inoculating innocent babies with scrapings from diseased cows. But we see in alcohol-related problems a spectrum of considerations broader than any involved in the great achievements of public health in the past. Attempts to solve problems of alcoholism have not been sufficient to address the broader public health issues involved in alcohol consump- tion. As Moore and Gerstein (1981:44) point out: "While chronic drink- ers with high consumption both cause and suffer far more than their numerical share of adverse consequences of drinking, their share of alcohol problems is still only a fraction—typically less than half—of the total. Alcohol problems occur throughout the drinking population; they occur at lower rates but among much greater numbers as one moves from the heaviest drinkers to more moderate drinkers." Since many health and social problems related to the use of alcohol clearly 11

12 PREVENTION OF ALCOHOL PROBLEMS lie far beyond the range of treatment and prevention services that we can offer to the individual, some approaches to prevention are inextri- cably tied up with matters of pressing and important public policy. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) is mandated to support a broad base of informative studies that can be used in the search for effective measures to prevent alcohol-related problems. That is why we asked the National Academy of Sciences to convene this remarkably diverse collection of people—including state, national, and local policy makers and lawmakers, researchers, profes- sional people, treatment providers, civic leaders, and economic lead- ers—to try to examine together from each special point of view (and no field has more special points of view than that of alcohol abuse and alcoholism) the implications and possible applications of the National Research Council report. This conference is a nucleus for the kind of a broad general debate that will help to determine public policy for pre- venting alcohol-related problems. Some issues raised by the report are highly controversial, not just in this country but around the world. Among the most controversial pre- vention policies identified in the report are ones that influence the pricing, taxing, and availability of alcohol. Less controversial, perhaps, are policies for shaping drinking practices through education (though it is unclear how effectively we can do that), public information and training programs, and laws regarding drinking and driving and public drunkenness. Finally, there are policies to promote environmental safety for drinkers and others in the workplace, in the home, in public recre- ational areas, on the streets, and on the highways. The three kinds of approaches specified in the report conform in an interesting way to the traditional categories of solutions to major public health problems. The first approach, having to do with the supply of alcoholic beverages, conforms in a sense to the public health focus on the causative agent and its vectors. Second, shaping the drinking prac- tices of individuals and groups resembles closely the public health preoccupation with the host who accepts the agent. Third, attention to manipulating the environment is a fundamental underpinning to many great achievements of public health in the past. The report offered recommendations for research and policy discus- sion in each of these areas. We hope to stimulate lively and spirited discussion, both pro and con, of the report's recommendations and to encourage further high-quality research in this complex field. This is a particularly opportune time for such discussions to take place. It is clear to those who have worked for any length of time in this field that the extent and quality of attention now being directed

PREVENTION AND THE COMMUNITY 13 toward alcohol-related problems is without precedent in our lifetimes. States, local areas, and the private sector at all levels are giving attention in new ways to alcohol-related problems that have had such debilitating effects on our society, effects that have for so long been denied. Alcohol abuse and alcoholism are now being recognized here and throughout the world as major public health problems, and prevention has a high priority in this administration. Examples include the Presidential Com- mission on Drunk Driving, the Department of Health and Human Ser- vices' Secretarial Initiative on teenage alcohol abuse, and the enormous relative increases in the 1983 and 1984 federal research budget for alcohol abuse and alcoholism, which far outstripped increases for research in other health areas. This is a time for everyone to contribute to the solution of problems far too long ignored. Progress has been impeded by the special biases, however sincere, held by various elements who have been at war with one another for the last 10 years over the best way to approach alcohol problems. Almost none of us is innocent of participation in such battles. What is abundantly clear in the National Research Council report is the need for many disciplines, many social agents, and agencies with quite different agendas to become involved, to draw together, to com- municate freely and openly with one another, and thus to avoid the dangers of simplistic and retributive measures, and of simply defending special biases. In short, we should join our efforts together as Americans tradition- ally have when faced with great national problems, to reverse a dan- gerous, fatal, devastating social and health problem that we can only hope to solve collectively, as a people. POLITICAL REALITIES AT THE STATEHOUSE MARGARET HASTINGS, Illinois Commission on Mental Health and Developmental Disabilities Prevention is a public health ideal that everyone favors—in the abstract. But when it comes to voting on real programs and real dollars, preven- tion policy has certain politically difficult characteristics. First, prevention is futuristic. It requires a commitment to future outcomes, not short-term results. This is antithetical to an American political need attached to short electoral cycles: the need to show immediate gains. Elected officials have a hard time voting for prevention programs unless there is a well-educated constituency willing to keep

14 PREVENTION OF ALCOHOL PROBLEMS those programs alive by reelecting leaders who support future-oriented policies. Second, state and national legislation in this country is usually fos- tered by advocacy groups concerned with specific categorical problems, such as blindness or heart disease. Prevention cuts across categories. It is a comprehensive concept, not a casualty area. This absence of a specific constituency can act as an obstacle politically. Although pre- vention efforts may be seen as humane and cost-effective, they have trouble moving to the forefront of national, state, and local health and human services policy. The lack of a constituency often makes preven- tion programs most vulnerable to funding cuts. Third, because good prevention programming cuts across many cate- gories, coordination becomes essential between agencies, within com- munities, and among professionals, volunteers, and citizen leaders. This requires an unusual willingness to set priorities, share responsibilities, and believe in causes beyond a single individual, agency, or organiza- tional turf. Fourth, prevention policy has an impact on personal value systems. Prevention programs may demand greater personal responsibility and challenge life-style choices and excessive personal freedom. In my seven years of experience in developing state policy, the potential collision of values has been the major hurdle, and it grows more com- plicated as our belief systems become more pluralistic. Enormous pres- sures on legislators from individual industries, religions, and special interest groups make consensus difficult. These pressure groups often have far more influence on policy than their actual number of supporters would suggest. When a collision in values occurs, it must be resolved through a new consensus on a purpose more general than the individual interests of the groups involved. Recent efforts to restrict drunk driving and smoking in public places, for example, show that we are collectively beginning to endorse limited regulation of life-style—but primarily in areas in which self-destructive behavior also affects others. We have known for years, for example, that young drunk drivers were killing themselves. But not until the relatives of victims of drunk drivers organized did we begin to change laws and policies. These new, articulate constituencies have changed attitudes and reshaped public opinion, a necessary precursor to policy changes. A second area in which life-style choices affect others is health care costs. The state of Illinois, for example, supports hundreds of nursing home residents who have drunk so much for so long that they are nonfunctional and brain-damaged, with serious sensory and cognitive

PREVENTION AND THE COMMUNITY 15 deficits. No one was too concerned about this expense before this era of finite resources. Now we have to allocate scarce public dollars among many needy populations. The second-largest expense in many state governments is Medicaid, and much of that cost is alcohol-related. About 40-60 percent of all hospitalizations are alcohol-related. Alcohol is involved in high percentages of reported child abuse incidents, sui- cides, assaults, and homicides. These events, plus accidents, represent a major national expense in illness care and lost productivity. Recent studies show that life-style factors account for as much as half of illness costs, which now total more than 10 percent of the nation's gross national product. These findings provide new political impetus for pre- vention policies. We have found in Illinois that state prevention planning can be thought of in terms of three areas: services (particularly for high-risk groups), regulation, and education. The state has set out to develop a prevention plan for alcoholism that brings all the relevant groups together. We selected priorities within each area, considered where we could inter- vene to have an impact on the priorities, and defined the appropriations and the responsibility for policies so that each priority could have a sufficiently broad-based constituency. We have had a difficult time agreeing which prevention programs should have priority, due to diffi- culties in measuring relative cost-effectiveness. Again and again an isolated agency would get an idea and develop it, but the system would not sustain it long enough for claims of long-term results to be substan- tiated. People involved in the budgetary process would say, "We want to give money to treatment instead, because that is the only thing that we know works." There has to be firm priority setting, and there has to be ownership of issues by key legislators so that monies and ideas will remain intact when various special interest groups attack them. One of our most successful prevention efforts in Illinois used block grant money to establish two prevention resource centers, which were repositories of information, materials, and people who were highly skilled in how to set up local prevention programs. The centers were available free of charge to community groups to help them develop their own prevention programs. Budgets for prevention programs are pro- tected most effectively when there is community ownership of the idea—not just the schools or a parent group, but a consortium of com- munity institutions. Then the chances that the prevention program will last are great. If programs are limited to the schools, the possibility of their having lasting impact in the community is small. Effective preven- tion policy depends on developing efforts in a variety of areas simul- taneously, with effective follow-up and evaluation efforts built into

16 PREVENTION OF ALCOHOL PROBLEMS programs and with a broad base of community involvement and support that can keep elected officials committed to prevention. COMMUNITY MOVERS AND SHAKERS FRANK RAFLO, County of Loudoun, Virginia In order to talk about community support, community involvement, community ownership, and the like, we need to know what a community is. Is it people, a place, organizations, a series of stores located on the same block, an area that has its own radio station or newspaper? Obviously, all of those elements might fit the definition of a community. Who, then, are the community movers and shakers we must look to in trying to prevent problems associated with alcohol? I want to introduce you to a few of them. Each one represents an important sector of what we identify as a community. I hope that after you have met them you will have a better conception of what goes into community action. One common thread will become clear. They all recognize alcohol as a "community problem" and express a willingness, indeed a strong motivation, to do something about it. At the same time, in identifying alcohol as a community problem, they certainly do not acknowledge it as belonging to them personally. Here are my characters; their monologue may be a bit disjointed, but that is the character of everyday thought. My name is Billy. I understand you want my advice about alcohol and drinking, and I am glad to give it to you. I know it's a problem. I see some of the dudes almost every night bouncing around from joint to joint, old ones as well as young ones. The other morning, for instance, I stopped at the Seven-Eleven for a pack of smokes, and some of the local big shots were lined up outside the state liquor store waiting to be first in line for the 10 o'clock opening. And a little thing I found out when I worked for a while as a bellhop is that they're always brushing their teeth. There was one guy who would take a snort and right away head for the men's room to brush. His toothpaste and mouthwash bill was probably as high as his booze bill. But I guess you really want to know what guys like me and our girls do. Simple: we cruise. Once in a while my girl and I split a beer or two at school—out on the back lot. But mostly it's weekend cruising: get in the car, load up with some six-packs and cruise. How old am I? Not

PREVENTION AND THE COMMUNITY 17 old enough to buy the stuff, but there are plenty of guys out there who will make the buy; after all, what's wrong with a few beers? It's better than getting hooked on the other stuff. Of course, there was the case of Harold. Two weeks ago he had a couple too many and rammed into a telephone pole. We all went to the funeral. It was too bad; he was a nice guy. He knew how to snag a pass and was going to be a regular on the team next year. He should have known better. I guess we should have warned him that you have to be careful, you can't overdo it. But as I was saying. We all work together here in this community: buy for each other, drive for each other, cruise around with each other, and get upset when someone has too much and flips over. You might say we have a sense of community that recognizes that too much alcohol is not good. But like our folks tell us, "Thank God it's only beer and not dope." It is lunch time at the best restaurant in town. J.P., chief loan officer at the bank and currently serving as public affairs chairman of the local chamber of commerce, has just been seated with his friend, Henry Bryant, assistant principal at the local high school. Henry, old boy, I do appreciate your coming. I know how busy you are at school, trying to get those SAT scores up and keep a winning football team at the same time—and doing a fine job. From what I hear, you're in line for promotion to the top. The superintendent is a good friend of mine; I've talked to him about you. Oh waiter, bring me a bourbon and water. What will you have, Henry? You want to pass? I guess that does look better; you don't want to smell up the principal's office, do you? I guess you're wondering why I asked you to come here today. It's like this: I got stuck with the public affairs committee this year, and the president and directors of the bank expect me to get some good com- munity projects going—you know the kind, a community project that will reflect well on the bank. It makes the directors feel good to read in the local paper that one of their top executives is hanging in there with a full load of community service. As I got to thinking about it, especially after reading about that triple fatality last week, where the driver of each of the cars was found to be loaded, I decided that the community issue that should get top priority is alcohol. So I asked myself, "How can we get this community involved in a combined effort to combat and reduce alcoholism?" The answer was obvious: Start with the youngsters. Education is our greatest asset, so

18 PREVENTION OF ALCOHOL PROBLEMS let's use it. I know you agree, Henry, and that's where you come in. I've sent off to some of these national organizations, and now I have all of this printed material plus a couple of videotapes about drinking and the problems of alcohol, and the various ways a community can line up behind its schools and churches to bring this problem under control. And that's where you come in, Henry. I want you to set up a school assembly program for me—/'// do it at your convenience, just give me a week's notice. I'll notify Charley down at the newspaper to make sure he covers it. It will make a great picture, and I want you in it along with a couple of top athletes and maybe two or three of your best-looking cheerleaders—wearing their uniforms, of course. Waiter, how about a short refill—just a sweetener to finish out my lunch. So you check out the details, Henry, and if you have any trouble, just let me know. We're going to start with the school kids and plaster this town with educational information about the need for the community to get behind a program to tackle the problem of alcohol. I really don't understand it myself; I guess some people just don't know when they've had enough. They really ought to be ashamed of themselves. You have to leave now? Thanks for listening. I hope you enjoyed lunch, and we'll be in touch. My name is Sally. I'm married to Bill, I have two small kids and a pretty good life. He works and I stay home and mind the kids and do the chores. The kids are asleep, taking their nap, and I'm finishing up a bit of dusting. It's 3:15 in the afternoon—oops, there goes the phone. Oh hello, Bill. You'll be late tonight? Yes, I'll go ahead without you and feed the children. Try to get back before they go to bed, dear. Sure, it's okay, no problem; your job comes first. Oh damn, another evening with no one to talk to and nothing to do but watch that blasted television. I wish it were five o'clock; I sure could use my daily gin and tonic. I know you're not supposed to drink before five; they say it's a bad habit. But then, the kids are asleep, and there isn't going to be much peace and quiet around here when they get up, especially if Bill isn't here. I think I'll mix a short one. I won't make a habit of it. Just today, because he's not coming home for dinner. Now that's more like it. There's nothing more relaxing than a gin and tonic, along with the peace and quiet of the afternoon. Maybe I'll have just a teenie refill later. I have other friends in the community, and you may have a chance to meet them another time. But those you have met here are represen- tative of my town. They are all concerned; you heard them say so

PREVENTION AND THE COMMUNITY 19 themselves. They want to help. If you called them up to ask them to serve on a committee to study the problem of alcohol, I am sure each one would agree to serve. But be sure you don't get them too close to the real problem. After all, they really feel that, conceptually, drinking too much alcohol is shameful. They are not the whole community. As in every community, we have a mix, and there are others who balance the wheel: those who work with the scouts, run the little league, provide other active recreation, sponsor book clubs, counsel at churches, teach in homes, and set examples of success without alcohol. We even have some in our com- munity who teach kids how to say no when offered a drink. I may have picked out the wrong ones for you to meet, but they were the ones I could round up on short notice, and they are the ones you have to reach if you want to get the community involved in preventing alcohol abuse. COMMENTS ON PREVENTION APPROACHES MARK MOORE, Harvard University Frank Raflo has put his finger on a central, bedeviling issue: who is a problem drinker, and who is not? We are used to thinking that anyone who drinks and is having associated problems such as unemployment or social or medical problems is an alcoholic, a "protoalcoholic," or a "near-alcoholic." Partly for that reason, anyone in the general popu- lation who gets drunk and is arrested or falls down stairs feels nervous about defining himself or herself as a "problem drinker," because that means that he or she is an alcoholic or is destined to become one, with all the associated special misery and special treatment. Therefore, our panel, in writing Alcohol and Public Policy, tried to keep separate the concepts of "heavy drinking" and "problems asso- ciated with drinking." One result was to highlight occasional, ill-timed drunkenness. The problem of people getting drunk somewhat too often, perhaps in the wrong place or at the wrong time, exists alongside the problem of people getting drunk repetitively over a long enough period of time that they begin failing systematically across a broad range of their activities. Just as when we look over time at the welfare population, the criminal- offending population, or panel surveys of drug abusers, we find that a small fraction of people stay in the worst condition, at the most deviant and extreme end, for a long time, and a great many people move back and forth at the nearer end. Some get into trouble while drinking at an early stage and their troubles keep getting worse; they seem to fit the

20 PREVENTION OF ALCOHOL PROBLEMS traditional idea of alcoholism. Many others enter and leave periods of harmful drinking practices on their own more or less frequently. People are distributed all along the set of possibilities. The main problem, against which preventive policy instruments could be uniquely effec- tive, is not so much the people who move rapidly to the far end of the distribution (for them we know that the best possible response is treat- ment of various types), but the people who move into and out of periods of harmful drinking practices intermittently, for a week or two, even a day or two, perhaps once every few months or years. The interesting surprise the panel found is that the problem of ill- timed drunkenness, badly fit into the environment, generates a sub- stantial portion of the medical problems, the violence and crime prob- lems, the employment problems, and even the marital problems that involve alcohol. In other words, a large portion of the alcohol problem is created by people who would never think of themselves as problem drinkers. As I watched Frank Raflo's characters materialize before us, each one drinking within, or at least not way outside, a normative pattern, I realized that these people were at risk. Partly the risk is that they might go on to higher levels of consumption, but presumably we are all at that risk all the time, and we all understand that if you move to very high levels of consumption, you can get into deep trouble. But they were also at risk in the moments that were described: The banker could have left the luncheon and made a mistake in his job; the housewife could have been inattentive to her child; Billy, cruising on the weekend, could get into an accident. Now, for any one of those individuals that risk is small, but from the community perspective, small probabilities distrib- uted across big populations add up to big problems. The normative drinking patterns that Frank Raflo so graphically illustrated for us con- tain within them the possibilities for creating a big problem. To attack this effectively, we have to emphasize policy instruments that cover large numbers of people—but uniformly and gently. Almost any device we could imagine that requires tailoring to individuals would be overwhelmingly expensive to apply to 50 million people. MARK KELLER, Rutgers University I want to raise a broad question about the effectiveness of generalized policy options, such as taxes on alcohol and restrictions on advertising for alcoholic beverages. I am skeptical that increased taxation or substantially raising the price of alcohol can really affect the volume of alcohol consumption. A

PREVENTION AND THE COMMUNITY 21 few years ago when I was in Russia, the price of vodka was about equivalent to $10 per liter here. The Russians cope with the high price in two ways. First, the very prosperous classes buy vodka at that price and drink much more of it than is good for them. Those who cannot afford the price, the working people, buy vodka on the black market, which supplies nearly as much as the government stores do, at a much better price. If the price of vodka were lower in Russia, would the Russians drink even more than they do now? That is really hard to imagine; I do not know if they could. So how important is the question of price? My second example is advertising. Does advertising affect the volume of drinking? In Russia there has not been one advertisement for liquor in over 60 years. You do not have to advertise alcohol to people. Why is the industry here spending millions of dollars on advertising? Because there is competition over who is going to sell how much of what. But I do not know whether advertising really increases the volume of con- sumption. MARK MOORE, Harvard University Dr. Keller, I would quickly agree that we cannot specify how the major factors determine the level of alcohol consumption, nor are we clear about the relationship between any given level of consumption and a set of bad consequences associated with drinking. Many factors enter the set of equations that relate social conditions, individual drink- ing, and social consequences. You have discarded some of them; you argue that price is unimportant, as is the special influence of mass media, as contrasted with the power of family or ethnic traditions. So how can we possibly affect consumption or the links between consumption and harmful consequences? I hold no singular brief for shrinking consump- tion; what I want to do is shrink the problem. If that can be done in some way without affecting the volume of consumption, that is fine; if it cannot, then we have to decide how much we need to or are willing to reduce consumption to get the benefit of shrinking the problem. How can we intervene to reduce the total amount of alcohol problems now, with or without reducing consumption? Do you spot an opportunity, with your many years of experience in this area? MARK KELLER, Rutgers University I think education is very important. It is different from advertising, which has a different purpose. I believe that a real reduction of alcohol

22 PREVENTION OF ALCOHOL PROBLEMS problems has to come from a change in the attitude that people have toward drinking, toward what you drink, how much you drink, when you drink, and so forth. People have a complicated involvement with alcohol, all of which needs to be changed if we are going to reduce the problems. I believe that it can work through a variety of educational methods, and that it will be a long, generational process. I think we can significantly reduce alcohol problems in this country in about 200-300 years. I would not be discouraged in trying for that, because it is the only thing that will work, in my opinion. MARK MOORE, Harvard University I think you would find a high degree of agreement that the fundamental issue is to change cultural attitudes about what constitutes appropriate, normative drinking practices in society. In general we would like to shape that set of norms so as to end up with fewer drinking problems— not zero drinking, not unlimited drinking, but some level of drinking with a much lower profile of harmful consequences than we now expe- rience. When we try to think concretely about how to affect people's atti- tudes, we think of using many things that are available to us, not only education programs, but also taxes and hours of sale that make buying less convenient. People's dietary habits changed some years ago, partly when they discovered that too much red meat was bad for them, and partly when the price of red meat doubled. Those two things went hand in hand. All our knowledge about how people's attitudes change sug- gests that they often go hand in hand. Again, in the late 1960s, when cigarette advertising was still on television, antismoking commercials appeared as the result of a lawsuit brought by John Banzhaf. At the same time, many states increased their cigarette taxes. Overall, average smoking rates fell in that period. Often there is some real condition that changes in the world, and then behavior changes; attitudes tend to follow along and become consolidated behind the new set of condi- tions. Much of what we are talking about here involves exactly the process you described. It is just that we see no particular reason to restrict efforts to an instrument called education, which typically means special classes in elementary schools.

PREVENTION AND THE COMMUNITY 23 MARK KELLER, Rutgers University I think we can be much broader than that about education. Let me say something about the effect of prices. I do not believe that Americans are strongly affected by prices. I do not believe Americans cut down on red meat because the price went up. At the same time that the price of the meat went up, the price of fish went up even more, yet they are buying more fish. MARK MOORE, Harvard University The price offish went up as demand shifted. But let me give you one more example. Another major social innovation was the reduction in traffic fatalities that occurred after the 55 mph speed limit became law. Again, the lower speed limit was passed at the same time that the price of oil was rapidly increasing. We think we cannot effect small changes in behavior via price shifts, mass media, and the like. And yet the smoking example, the dietary example, and the driving example all provide concrete evidence that our society does, in relatively short periods, have the capacity to alter people's conduct, at least a little in some areas that may not mean that much to them. Now you could say, "The difficulty here is that alcohol means an awful lot to them." I don't know. Maybe you are right, maybe you are wrong—maybe we should find out.