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5 Alcohol and the Mass Media TELEVISION PROGRAMMING, ADVERTISING, AND THE PREVENTION OF ALCOHOL-RELATED PROBLEMS LAWRENCE WALLACK, University of California, Berkeley There is a tale, often told in public health circles, about a health worker walking alongside a river. Suddenly there is the sound of a person thrashing about in the water and a cry for help. The health worker leaps into the water and pulls out the drowning person. Just as the victim is being revived, there is another cry for help, and the same process is repeated. This happens several more times until it finally strikes the health worker that she or he is so busy pulling people out of the water that there is no time to explore upstream to determine how people are falling or being pushed into the river. Our society has taken a primarily downstream approach to meeting human needs. We wait for people to develop problems and then invest substantial resources in an effort to rescue them. Once pulled out of the river, these people are then sent back into the same social system that was a significant part of the problem to begin with. Prevention means shifting the emphasis of our efforts upstream to address the conditions that give rise to and sustain the problems that ultimately emerge downstream. We need to undertake long-term plan- ning that addresses the many contributory causes to a problem and involves a difficult process of rethinking our basic assumptions about health. Such a shift is not practically or politically easy. Significant 79
80 PREVENTION OF ALCOHOL PROBLEMS economic and ideological interests are strongly vested in the existing system. Such interests are sure to question any redefinition of the problem or reexamination of basic assumptions that underlie how we view these problems (Beauchamp, 1976; McKinlay, 1979; Wallack, 1982; Ratcliffe and Wallack, 1983). The purpose of this paper is to briefly examine the role that mass communication plays in the prevention of alcohol-related problems, focusing particularly on advertising and television programming. In doing so it attempts to move upstream and look at how mass media may be one of the environmental determinants of alcohol-related problems. The upstream country can be described by identifying three specific territories. First, there is the regulatory system that serves to limit or enhance the availability of alcoholic beverages. It entails formal rules and laws that attempt to reduce the supply of alcohol in society. Exam- ples are regulations determining who can buy alcohol, when and where it can be purchased, how much it costs, etc. A secondary emphasis of the system is to legislate a safer environment so that when drinking does take place the consequences may be less severe. Passive restraints in cars and safer consumer products are two examples of this approach. A second territory contains informal rules that structure the imme- diate environment in which drinking takes place. The expectation is that the microenvironment of drinking can be made safer through vol- untary approaches. The current emphasis on server intervention pro- grams is an example of this approach. The two primary differences between this territory and the first one is that these strategies are voluntary, and there is a much greater emphasis on the influence of the environment on behavior. The third territory is education regarding the effects of alcohol and the appropriate use of alcohol in society. This education has many sources, including peers, family, teachers, and mass media. Education about drinking and appropriate alcohol use is also conveyed by the messages reflected in the arrangement of the other two territories. For example, heavier concentrations of outlets that offer easy availability of alcoholic beverages reflect an attitude of the larger community regarding alcohol use. The way parties and other entertainment activities are structured can also provide strong messages about alcohol use. The most common understanding of alcohol education is through the schools or planned mass media campaigns. This paper, however, addresses the unplanned types of alcohol education that occur during television programming and advertising. The prevention of alcohol-related problems is an ambitious task. For such an undertaking to make progress toward a realistic goal, it must address the problem on each of the levels on which it existsâa major
ALCOHOL AND THE MASS MEDIA 81 objective being consistency of purpose and action across the entire system. It makes little sense to educate schoolchildren about respon- sible drinking or decision making, or to educate communities through mass media campaigns that people should, if they drink, drink in mod- eration, when the larger physical and social environment is laden with messages that directly contradict the content of the educational approach. This is not to say that specific skills to facilitate safer drinking practices cannot be taught in the classroom or through mass media campaigns. The potential success of these efforts or their possible failure will, however, be greatly affected by the supportiveness of the rest of the environment in which social behavior and alcohol use takes place. Television and Health Behavior The television set is a fixture in virtually every American household. Recent estimates indicate that 98 percent, or almost 78 million, of the homes in the United States have at least one television set. On the average, Americans watched approximately 30 hours of television per week in 1981 (World Almanac, 1981). For children, television can be a major mechanism of socialization. By the time a boy or girl graduates from high school, he or she will have spent more time in front of a television set (17,000 hours) than in a formal classroom (11,000 hours). From early childhood through the high school years, television viewing consumes more time than any other single activity except sleeping (Rubinstein, 1978). The media are now being recognized as a major source of observational learning and a definer of cultural norms (Ham- burg and Pierce, 1982). Nonetheless, educators in general and health educators in particular pay far too little attention to the media as a source of education. Television is a source for a range of information but appears to be an especially important source of health information for a substantial num- ber of adults. Gerbner and his colleagues (1981:904) suggest that tele- vision "may well be the single most common and persuasive source of health information." Unfortunately a great deal of this information is of questionable accuracy (Greenberg, 1981) and may contribute to the adoption of unhealthy behaviors in the viewing audience. A more con- servative notion is that heavy exposure to such programming may decrease the likelihood of individuals adopting preventive behaviors (Gerbner et al., 1981) rather than cause the adoption of negative behav- iors. A causal connection between television viewing and health behavior has yet to be explored. Over the past 15 years, however, the number of studies on the effect of televised violence on children has grown
82 PREVENTION OF ALCOHOL PROBLEMS considerably. Although there are still those who dispute the causal connection (e.g., Milavsky et al., 1982), the overwhelming sense of the scientific community supports the causal relationship. Given that the level of violence on television has not declined since the original surgeon general's program on television and violence (Signorielli et al., 1982), television may be seriously influencing the status of the society's health by continuing to portray high levels of violence. Although there have been well over 2,000 studies of the effects of televised violence on children, virtually no attention has been paid to the effects of televised portrayals of alcohol use on viewers. When Comstock (1976) reviewed the scientific literature for the Hathaway hearings (U.S. Senate, 1976) on media images of alcohol, he could not find one scholarly reference on alcohol and mass media. What did exist was a series in the Christian Science Monitor (Dillin, 1975a,b,c) on alcohol use on prime-time programming and a book chapter that only briefly addressed portrayals of alcohol on television in the early 1970s (Winick and Winick, 1976). Since the hearings, several research studies analyzing the content of prime-time television portrayals of alcohol have been conducted (Greenberg et al., 1979; Breed and DeFoe, 1981; Greenberg, 1981; Gerbner et al., 1982). The findings of these studies are presented below. Television Programming As Alcohol Education There is increasing concern about the role television plays in the construction of reality. At the recent White House Conference on Fam- ilies (1980:92), one participant noted: Television has become another member of the family. We eat meals near it, we learn from it, we spend more time with it than any single individual. Television is central in our children's lives, as a tutor; babysitter; teacher; entertainer; and sales-person all rolled into one. Delegates to this series of conferences rated the overglamorization of alcohol and drugs in television programming and advertising as a priority area for attention. The content analysis of alcohol portrayals on prime-time programming and the existing theoretical basis for the potential effects of such programming suggest that the concern of par- ents, consumer groups, and some scientists is justified. What kind of alcohol education is being offered by one of America's more prominent teachers? The Christian Science Monitor series by John Dillin looked at prime- time (8-11 pm) shows in the spring of 1975. Scenes involving alcohol
ALCOHOL AND THE MASS MEDIA 83 were found on 201 of the 249 shows studiedâ81 percent. (The definition of drinking must be considered very loose, i.e., it had only to be men- tioned to be counted.) The most popular beverage, alcoholic or other- wise, was found to be distilled spirits. This is somewhat ironic because, as Dillin points out, the advertising of this product is prohibited through industry self-regulation (Dillin, 1975a). In a later article, Dillin (1975b) reported on a brief study that the National Institute on Alcohol Abuse and Alcoholism (NIAAA) con- ducted as a background piece to meetings with network officials. The 2-day study looked at soap operas as well as prime-time programming and found levels of alcohol involvement as high as those reported in the Christian Science Monitor article. Although no details on the study were provided, Dillin reported the identification of four aspects of alcohol use on television: the frequent use of alcohol, the humorous portrayal of drunkenness, the use of alcohol as a problem solver, and the portrayal of alcohol use as glamorous, sophisticated, and mature. The latter three types of alcohol portrayal subsequently became key elements in NIAAA's public information campaigns, which tried to change attitudes about alcohol. This is again somewhat ironic, in that the emphasis on alcohol use, which is contrary to the National Asso- ciation of Broadcasters (NAB) code, continued even while the media provided some public service time presumably to counter conditions to which the code violations contributed. A final Christian Science Monitor article (Dillin, 1975c) reviewed prime-time programs in the fall of 1975. Despite NIAAA's efforts to work with writers and the networks, the study of 71 programs indicated little difference between the new season and the previous one. Keyed by the brief federal study that had been done in the interim, the Christian Science Monitor found gratuitous use of liquor, inappropriately humor- ous portrayals of drunkenness, the association of drinking with sophis- tication, and the use of alcohol as a tension reliever. Alcohol consump- tion, particularly the use of distilled spirits, was found to be far out of proportion to the use of other, more common beverages that people actually consume. A brief study of drinking on soap operas was conducted before the Christian Science Monitor study but was not reported until late 1977. Garlington (1977) used four women observers to assess the rate of drinking on soap operas. A total of 79 half-hour segments were viewed over a 5-day period and were coded on the basis of actual drinking or reference to drinking and the setting in which drinking took place. Drinking was classified in three categories: verbal reference, drinking scene, and/or background drinking. The reason for drinking was also
84 PREVENTION OF ALCOHOL PROBLEMS recorded but was not reported because of low observer reliability. The study found that there were 236 events involving alcoholic beverages, or three events per show. There were 205 soft drink events coded, for an average of slightly more than 2.5 per show. The use of distilled spirits was greater than wine or beer consumption, and the most common setting for consumption was the home. Recently a reanalysis of Garlington's data (Calfiso et al., 1982:1241) found that drinking most often occurred in the home and was most commonly done as a relief from stress. The findings, according to the research team, suggest that alcohol use is generally not troublesome and is an integral part of normative behavior. Breed and DeFoe (1981) reviewed prime-time television shows during the 1976-1977 season. The review included the top 15 situation comedies and the top 15 dramatic series taken from the Nielson ratings after 5 weeks of the new television season. The study covered 14 weeks and 150 hours of air time. Scenes that indicated significant alcohol use were noted and studied in detail. To be considered significant the scene had to meet one of seven criteria: portrayal of heavy drinking; a purpose in drinking that went beyond sociable sipping; a consequence that prob- ably would not have occurred if a nonalcoholic beverage had been ingested; some response to drinking activity by another person; an evaluation of drinking as good or bad; a contribution of drinking behav- ior to the plot or characterization; or humor that reflected on any of the criteria listed above. They reported that almost 60 percent of the drinking scenes observed involved heavy drinking (five or more drinks) or chronic drinking. Compared with the U.S. population this would be considered atypical drinking, since only about 25 percent drink as many as five drinks in a given situation (Clark and Midanik, 1981). Similar to results of past studies, distilled spirits were the beverage of choice, and the most frequent reason for consumption was in response to a crisis or as a social prop. Although drinking was common and heavier drinking was the mode, the researchers reported little disapproval of alcohol abuse, and when disapproval was seen it tended to be mild. In addition, more often than not no serious consequences of alcohol abuse were shown (Breed and DeFoe, 1981). The study also compared televised portrayals of consumption of alcoholic beverages, soft drinks, coffee, and water with estimated actual consumption. They found that television consumption of alcoholic bev- erages was higher than for other beverages, despite the opposite rela- tionship existing in the real world. For example, the consumption of alcoholic beverages was first on television but last in actual per capita consumption data among the four categories of beverages considered.
ALCOHOL AND THE MASS MEDIA 85 Nicholas Johnson, former commissioner of the Federal Communica- tions Commission, had done a similar comparison in testimony at the Hathaway hearings (U.S. Senate, 1976); he compared beverage use not only to actual consumption but also to the level of advertising of the product. He found a direct relationship between frequency of advertis- ing and how often a product is consumed and also found the televised use of alcoholic beverages to be greatly out of proportion to their actual use. The researchers also coded the context of drinking and foundâto some extent in contrast to the findings of Garlington (1977)âthat although 58 percent of the drinking in situation comedies took place in the home, only 29 percent of the drinking in dramatic series was done in a domestic setting. One interesting point was that 25 percent of the drinking took place before or during work. Overall, four purposes of drinking were identified. First, drinking was seen as a response to personal crises. Second, drinking was seen as secondary to other activities and used as a social lubricant or as some- thing to do while standing around. (This is much the way that cigarettes were used in the mass media in the 1940s and 1950s.) The third and fourth purposes, ceremonial drinking and drinking for manipulation, were found with limited frequency. A group of Michigan State researchers examined a composite week of network programming for the 1976-1977 and 1977-1978 seasons. The sample included one episode of each prime-time and Saturday morning fictional series. The researchers observed approximately 80 shows rep- resenting 60 hours for each season (Greenberg et al., 1979:4). Substance use was broadly defined as "that set of behaviors that included each incident of the consumption of, attempt to consume, inducement to consume, and making laudatory remarks about the consumption of alcohol." In the 1976-1977 season alcohol use was observed 2.19 times per hour; the next season it had increased to 2.66 times per hour. This use was highest between 9 and 11 pm (4.92 times per hour in the 1977-1978 season) and on situation comedies and crime shows (over 4.5 times per hour in the 1977-1978 season). The most recent study on television and drinking also comes from Michigan State University (Greenberg, 1981). The top 10 prime-time fictional series of 1980 and the top-rated soap operas were observed. Four episodes of each of the prime-time series were reviewed along with eight episodes from the soap operas. Greenberg (1981:12) reported that "television characters may not smoke or use drugs, but they drink with prodigious frequency." The rate of alcohol consumption far exceeded that reported in earlier seasons, averaging 8.13 incidents of alcohol
86 PREVENTION OF ALCOHOL PROBLEMS consumption per hour on the 10 top-rated prime-time series. Soap opera drinking was substantially lower, at 2.25 events per hour, or slightly fewer than Garlington (1977) had found. Similar to the Breed and DeFoe (1981) study, alcohol use was shown in an almost entirely positive context, with no indication of potential risk. The research of Gerbner and his colleagues (1982:298) on the Cultural Indicators Project at the Annenberg School of Communication has recently been summarized in the area of health. The data on alcohol, stretching back several years, indicated that over one-third of major television series characters drink, but only about 1 percent have a drinking problem. In general, drinking was found to be widespread and condoned. It would appear that drinking on television has not changed much since the Christian Science Monitor series. It should be remembered, however, that we don't know what level of drinking would be shown were it not for the information provided by the studies that have been conducted. But what difference does it make that drinking is shown so frequently on television? It really makes little sense to compare con- sumption of water, soda, or alcoholic beverages on television with their actual consumption in real life. Television deals with smaller than 24- hour segments of people's lives. For example, if we compared the rate of drinking of characters on television with that of a real person coming home from work, the rate of drinking on television might more closely mirror real life. The frequency of drinking per se may tell us little. The larger implications of drinking on television, however, can be seen in two ways. First, is the drinking process shown accurately? That is, are the risks as well as the benefits of alcohol conveyed in a clear fashion? Second, what is the potential theoretical importance of frequent, non- problematic portrayals of drinking on television? Scholarly articles on television and drinking rely substantially on Bandura's (1977) social learning theory for discussing this topic. Bandura suggests that expo- sure to content stimuli that are consistent in theme and are seen with considerable frequency can affect the viewer. Greenberg and his col- leagues (1979:10-11) note: To the extent that social behaviors on television, such as acts of drinking, are performed by liked characters, in a positive context, without negative conse- quences, or with positive rewards, social learning is more likely to occur. Such learning can take several forms. It can affect the viewer's aspirations and expectations about the observed behaviors; it can impinge on the viewer's beliefs with regard to the acceptability or appropriateness of the behavior, it can teach the behavior, and it can induce either imitation or a desire for
ALCOHOL AND THE MASS MEDIA 87 imitation. To the extent that the behavior is a common one, with the implements easily accessible, then the likelihood of such learning is further enhanced. Another related theoretical issue is time frame. For example, a few drinking incidents per show may not seem like a great deal of exposure. When this exposure is stretched over a year, considering current levels of television viewing and alcohol-related incidents, a person under the legal drinking age will be exposed to more than 3,000 acts of drinking over the course of a year (Greenberg et al., 1979). This level of exposure, which does not include commercial messages about alcohol, is a con- tinuing reinforcement of inaccurate health information. It is a major contributor to the shared symbolic environment in which we interact (Gerbneretal., 1982). In summary, television has not been a very good educator about drinking in society. The rate of drinking on television is greater than that in real life and the rate of problems associated with drinking tends to be much lower. Despite the NAB's position that alcohol use should be deemphasized on television, this has clearly not been the case. Television in general has probably served to legitimize increased use of alcohol by conveying the image that it is acceptable or even required to drink in an expanding array of situations (Breed and DeFoe, 1981). If indeed alcohol is a major public health problem and, as the panel estimates, is responsible for 50,000-75,000 deaths annuallyâyou could not find this out from watching television. Advertising As Alcohol Education While television programming may be inadvertently educating view- ers about alcohol use, advertising uses sophisticated and highly spe- cialized techniques to educate consumers about the uses and rewards of alcohol. As might be expected, advertising seeks to place the product in the best possible light and is little, if at all, concerned with its possible adverse consequences. Thus the "education" the consumer receives from advertising is severely limited. As Neubauer and Pratt (1981:217) note, the outcome of the advertising exchange is always in the interest of the producer and only rarely in the interests of the consumer: Examination of the advertiser's message reveals that the objective of selling outweighs, to the point of defrauding, the objective of providing information. Consumers are left to make empty choices. They cannot know enough to make substantive distinctions between apparent options. We have the illusion of information and the reality of people making psuedo-choices. Those pseudo- choices often lead consumers to act against their own interests.
88 PREVENTION OF ALCOHOL PROBLEMS Well over $1 billion will be spent on alcoholic beverage advertising in 1984. We will hear it on radio and see it on billboards, television, magazines, buses, subways, calendars, sports schedules, and most any other place where space is available. In 1979 beer producers alone purchased $369 million worth of print and broadcasting space (Bottom Line, 1981). In 1980, alcoholic beverage advertisers spent $903 million on "measured" mediaâmagazines, radio, television, newspapers, and outdoor placements (Monday Morning Report, 1981). This includes over $316 million in advertising space purchased for distilled spirits (Liquor Handbook, 1981) and $134 million worth of placements of wine advertising (Wine Marketing Handbook, 1981). Numerous other types of advertising, such as sponsorship of various athletic and cultural events and on-site, point-of-sale promotions, are not included in the advertising figures. These estimates also do not include the production costs for these creative and technically sophisticated advertisements. The attention of the American public is clearly the focus of intense competition among alcoholic beverage producers. Advertising permeates every facet of our daily lives, and many of the messages run counter to good public health practices. Such messages often misleadingly link the attainment of valued ends to product use. It is somewhat ironic that advertising, often justified on the basis of pro- viding useful information to the consumer in order to facilitate informed choice, is so often subtly false and misleading. Goldsen (1980), com- menting on television commercials, notes that prices and terms are rarely specified, product descriptions are vague and ambiguous, and the names of the real corporate owners are seldom heard. Alcohol advertisers rely heavily on persuasive messages that have little or noth- ing to do with the product. In a content analysis of alcohol advertise- ments in national magazines, Breed and DeFoe (1979) found wealth, prestige, and success to be an "indirect promise" made in 28 percent of such ads. Social approval or acceptance as a consequence of product use was coded in 23 percent of the ads reviewed. In general the research- ers found "little logical relationship between the product and the adver- tised message." Content relevant to public health concerns, such as cautions regarding the negative effects of excessive drinking, were "seldom mentioned." Mosher and Wallack (1979b), commenting on proposed reforms in the advertising of alcoholic beverages (federal regulations have not been revised since their promulgation in the early 1930s), concluded that alcoholic beverage advertising is misleading in two ways: (1) Alcoholic beverages are promoted by appeals to desires and needs that are irrel- evant to the product. (2) The absence of accurate health information in
ALCOHOL AND THE MASS MEDIA 89 the marketing of a product with serious public health consequences hampers the consumer in making an informed choice. A recent major study of the effects of alcoholic beverage advertising has produced findings that are cause for concern for those involved in promoting public health. A team of Michigan State University research- ers found that advertising was a significant informal source of sociali- zation about alcohol for adolescents and that there was "little doubt that alcohol advertising exerts an influence on the frequency and quan- tity of adult alcohol consumption" (Atkin and Block, 1980:18). As might be expected, these findings have generated some controversy; in fact the study, funded by four federal agencies, was released only after extensive delay. These findings contradict a larger body of previous research that has failed to indicate a relationship between advertising and increased alcohol consumption (most of this literature has been summarized in Pittman and Lambert, 1978). Two recent studies on the content of alcoholic beverage advertising in national magazines (Strickland et al., 1982) and television (Finn and Strickland, 1982) indicate little concern over the content of the ads. Examination of 640 unique magazine ads found that the controversial themes identified by critics of alcoholic beverage advertising were infre- quent. The most frequent themes were product-related and addressed information, quality, and traditions or heritage. Although the 131 unique television ads studied were more likely to use hazardous or exotic activities to promote products, these ads were also found to be generally free of controversial themes (Finn and Strickland, 1982). There are several reasons for the conclusions of the Breed and DeFoe study to differ so greatly from those of Finn and Strickland, and Strick- land et al. The differences are due to methodological as well as ideo- logical issues. For example, the construction of the coding categories is essential to the content analysis method. The instructions to coders as to what is allowed in each category essentially determines the out- come of the study. The Strickland et al. (1982) and Finn and Strickland (1982) studies provided the following instructions to coders for the "sexual connotations" category: "Do not code this theme 'present' for such things as: -Good-looking or sexy models that are less than 'pro- vocative' or -Models that are simply 'showing skin,' but are less than provocative" (Finn and Strickland, 1982:987). For the "wealth and affluence" category, coders were instructed: "Do not code this theme 'present' for such things as: -Average wealth portrayed on television (most ads show people who are well-off; this category is only for wealthy appeals)" (p. 983). Yet in an important way the debate about the content and effects of
90 PREVENTION OF ALCOHOL PROBLEMS alcoholic beverage advertising is interesting but somewhat irrelevant. The analysis of content and effects cannot be separated from the larger marketing mix of price, physical availability, and general institutional and social support for drinking. In addition, such analysis cannot be separated from researchers' disciplinary training and the values inher- ent in their backgrounds. In summary, the debate over what alcoholic beverage ads are "really" saying and what effects such ads might have may never be resolved. The advertising issue is primarily one of public policy; science, in its traditional form, can contribute in only a limited way. As I have noted elsewhere (Wallack, 1981), the fundamental issue that we need to address is whether the wide-scale promotion of alcoholic beverages is consistent with the goals of a society concerned with minimizing the social, eco- nomic, and personal hardship associated with current levels of alcohol- related problems. Facts themselves play a smaller role in determining policy than how we determine which facts to choose and the values we hold to interpret these facts. Empirical studies analyzing the content of alcoholic beverage ads are based in part on personal value orientations. The numerous decisions that researchers must make as they frame their questions, construct their categories for the data, and elect what to analyze and what to ignore all involve subjective judgments. At a time when many consumer groups are entering the debate over the wisdom of massive alcoholic beverage advertising, the research that is expedient will be used to hammer a particular viewpoint. This is an important part of the process of establishing reasonable public policy. It may well be that the traditional tools of science simply cannot provide the clarity in this area necessary to resolve major issues: the ensuing debate on advertising must also be a debate on the role of science in determining social policy. Even without conclusive studies to show that advertising is a poor educator on alcohol, there can be little doubt that health education is not the primary point of such ads. In an interview with Business Week, Edgar Bronfman, chairman and chief executive of Seagram Co. Ltd., showed a different side than most industry leaders on the issue of advertising. Rather than touting informational value and arguing against the thesis that such advertising appeals to the consumer to drink exces- sively, Bronfman (Business Week, 1981:139) told the interviewer: You can get just as drunk drinking cheap stuff as expensive stuff. So what you're really selling is glamour and an impression. Another recent Business Week article focused on wine marketing trends. The entry of the Coca-Cola company into the wine market,
ALCOHOL AND THE MASS MEDIA 91 much like the entry of the Philip Morris Company into the beer market, has led to a marketing explosion. Coca-Cola's goal, according to Busi- ness Week (1982:110), is to establish wine as a beverage that can be consumed at any time in any place: [T]he industry's key to doubling wine sales is to get its product message across to potential customers. Wine advertising spending has already leaped from $55 million in 1970 to about $136 million last year (1981) and is likely to double again in 1985. The expected effect of more aggressive wine marketing in general is illustrated in the comment of John Senkevich (quoted in Council on Alcohol Policy Quarterly Newsletter, 1983:7), president of Geyser Peak Winery: By picking up on the merchandising, selling and distribution of the soft drink industry, the wine industry can change the image of wine to a regularly con- sumed beverage as opposed to today's image of a special occasion drink. In reference to televised beer commercials, Richard Cohen (1983), writing in a syndicated Associated Press column, made the following comments: Call them 30 second lies or a shuck or anything you want, but what you don't see in the commercials is what happens to the customers they are aimed at. It's understandable. For many of them, "Miller Time" leads to the hardest time of all. Strategies for Change The prevention of alcohol-related problems requires far-reaching strategies that address the conditions contributing to the development and maintenance of these problems. The mass media, particularly through television programming and advertising, are important contributors to the social environment in which drinking takes place. The message of the media is not consistent with the serious public health implications of alcohol use. Indeed, advertising and repeated portrayals of drinking on television may well contribute to alcohol-related problems. Although the causal relationships needed to satisfy most scientists and industry representatives will never be absolutely proven, this should not deter others from promoting specific actions to remedy the communication of misinformation on alcohol through advertising and television pro- gramming. Television Programming George Gerbner has said: "If you can write
92 PREVENTION OF ALCOHOL PROBLEMS a nation's stories, you needn't worry about who makes its laws. Today television tells most of the stories to most of the people most of the time." Television is waking up to its role as an educator on alcohol. Recently the Caucus for Producers, Writers, and Directors sent out a "white paper" to its members. Ostensibly this action, reported 22 February 1983 in the newspapers, was actually a reaction to the crash, caused by a drunk driver, that seriously injured actresses Mary Martin and Janet Gaynor and killed Martin's manager. The one-page paper, titled "We've Done Some Thinking," asked whether . . . any of us as members of the creative community in Hollywood unwittingly glorified the casual use of alcohol in one of our projects? Have we written it as macho? Directed it as cute? Produced it as an accepted way of life? In short, are we subliminally putting a label of "perfectly okay" on alcohol related behavior and selling it to the American people? . . . The answer we fear is yes. The paper went on to list seven remedial suggestions based on the work of Breed and DeFoe. Warren Breed and James DeFoe (1982) developed a process called "cooperative consultation" to work with media personnel. This tech- nique has been used successfully with the comic book and television industries. Cooperative consultation is based on the assumption that industries will be willing to correct a problem when it is tactfully and convincingly brought to their attention. Cooperative consultation is a four-part process. First comes research. Breed and DeFoe conducted detailed content analysis of drinking on television over a period of several years, researched television produc- tion methods so they could frame their findings and suggestions in an acceptable way, and became well informed on issues related to alcohol problems and alcoholism. From research the process moves to general education of the industry (in this case all those involved in the many stages of television production). This included a series of presentations to the Standards and Practices Office of two of the three networks, extensive personal contacts with writers, and the development of a newsletter on alcohol topics that was widely distributed to industry people. The next stage is specific education. This stage was reached when someone requested further information, which often took the form of a request for help on specific problems on scripts addressing alcohol-related issues. To meet these requests DeFoe, a member of the Writers Guild, offered a series of alternatives that could move the script along but not at the cost of providing inaccurate information about alcohol. The final part of the process is feedback from the industry (Breed and DeFoe, 1982).
ALCOHOL AND THE MASS MEDIA 93 In a sense, the apparent success of Breed and DeFoe is in part due to the way that they have carefully developed their project as a resource for the industry. In this case both the industry and the viewer benefit. The process of research, general and specific education, and feedback fits well with a constructive, active approach to prevention. This pro- cess has been effective in attaining change in media portrayals of alcohol use, and several excellent examples of the outcome of this process are available (Breed and DeFoe, 1982). The caucus's white paper also indicates the success of this approach. It is certainly premature to suggest that the cooperative consultation process has changed the way that alcohol is portrayed substantively enough to create larger change in the social environment of drinking. Nonetheless, the work of Breed and DeFoe and the response by the caucus are extremely positive indications that television will be a more knowledgeable and accurate source of information on alcohol than it has been in the past. The content analysis work of Breed and DeFoe should be continued. An ongoing, annual analysis of alcohol portrayals on prime-time tele- vision is important for three reasons: first, as more consumer groups become involved in the debate over television, it will be important to have a solid data base to avoid distortions and exaggerations of how television is handling alcohol. At this time, this type of content analysis seems to generate little if any controversy, as does the same method applied to advertising. Second, the decision makers in the television industry are clearly interested in having this kind of data to guide their efforts. They are interested in not providing misleading information about alcohol use and appear quite willing to use the type of feedback that can be derived from these carefully collected data. Third, continued research in this area will allow us to monitor how well the media is responding to alcohol problems. At the same time, this research can keep us informed in general about this important issue. Advertising Although television may be inadvertently misinforming viewers about alcohol, advertisers are presenting "rigged demonstra- tions" (Goldsen, 1980) to make sure their "educational" point is not lost. If the task of education about health is to make health-generating choices less difficult and health-damaging choices more difficult (Milio, 1976), then advertising is a formidable barrier that must be overcome. The Bureau of Alcohol, Tobacco, and Firearms (BATF) is the federal regulatory agent for alcoholic beverage advertising. It has been almost five years since BATF announced the pending revision of existing regulations and called for public comment. The bureau received more
94 PREVENTION OF ALCOHOL PROBLEMS than 9,000 comments, over 99 percent of which favored significant curbs on alcoholic beverage advertising. Though there has been no final action to date, BATF's initial reaction was to ignore virtually all these com- ments and relax rather than tighten controls on advertising. Such adver- tising, for several reasons, is clearly misleading, yet the public's rep- resentative (BATF) has been and continues to be the handmaiden of the industry it should be regulating (Mosher and Wallack, 1979b, 1981; Wallack, in press), and it is unlikely that any change in this relationship will be forthcoming. Continued research is needed on the content and effects of alcoholic beverage advertising. However, we cannot look for simple, concrete answers. Future work should emphasize the cumulative nature of adver- tising. Study of individual brand advertisements will tell us a little, but study of the broad nature of advertising and how it introduces, supports, and reinforces norms over time will greatly increase our understanding. As Dhalla (1978:87) notes: "Each piece of advertising influences sales today, and at the same time adds another brick to the structure of good will that increases business tomorrow." Advertising needs to be under- stood both historically and in relation to current broad systems of norms and values. Only by doing so can we understand the contradiction pointed out by an editorial in Advertising Age (quoted in Bottom Line, 1978): "A strange world it is, in which people spending millions on advertising must do their best to prove that advertising doesn't do very much!" Future research must also acknowledge that advertising is purpose- ful. It tries to promote one end at the expense of some other. Advertising alone may not cause alcohol problems, but it certainly contributes to the development and maintenance of these problems in the community. The successes of advertising are therefore won at the expense of indi- viduals and groups of people who suffer directly or indirectly from alcohol-related problems. Researchers must recognize the ethical impli- cations involved in choosing which aspect of the effects of advertising to study. This subject does not permit value-neutral approaches; the very nature of the issue to be studied invokes conflicting values. Those who conduct research need to clarify the basic ethical assumptions on which their particular research strategy is based and to recognize the need for a balance of ethical perspectives. There have been several excellent suggestions for strategies to deal with alcoholic beverage advertising. Consumer groups such as the Cen- ter for Science in the Public Interest (Jacobson et al., 1983) are injecting new enthusiasm into the advertising issue and building coalitions to press their perspective. The following suggested policies can serve as a starting point for further discussion.
ALCOHOL AND THE MASS MEDIA 95 ⢠Withdraw the tax deduction for alcoholic beverage advertising. It has been estimated that 35 cents of every dollar of the more than $1 billion annually spent to place ads is deducted from corporate taxes (Mosher, 1983a). This amounts to over $350 million in lost tax revenue that is going to subsidize the misinformation campaigns of the alcoholic beverage industry. ⢠Levy a 10 percent tax on alcoholic beverage advertising to fund advertisements that show the other side of the alcoholic beverage story. Conclusion The prevention of alcohol-related problems should be a broad effort encompassing a range of strategies. The usual focus of prevention efforts since Prohibition has been the individual drinker, with little or no attention given to the producers, marketers, or distributors of alco- holic beverages. This has resulted in a narrow range of prevention strategies that usually rely on small-scale (school or community) efforts to alter attitudes and thereby change behavior, or a few large-scale mass media programs. Both types of programs, no matter how well planned or implemented, are unlikely to succeed because they exist in a gener- ally hostile environment rich with messages supporting and encouraging the use and misuse of alcohol. The major contributor to this anti- education environment is clearly alcoholic beverage advertising. The massive amount of misleading information being disseminated through alcoholic beverage advertising acts as a barrier to the success of com- munity-based programs and larger public information efforts. Televi- sion programming is also a great, though inadvertent, contributor to this vast reservoir of misinformation. Recent events, however, do sug- gest that major figures in the television industry are quite responsive to the seriousness of the public health problems generated by alcohol. A great deal more effort is needed in this area. An effective prevention policy does not simply look at one small segment of the problem but seeks to comprehend the issues as they exist in a broader context. In my view, current policy seriously over- emphasizes the responsibility of the individual drinker and underem- phasizes the industry that produces alcohol and the government that regulates availability of the product. The role of the television industry has not been fully explored. A comprehensive policy should include attention to all these segments and ensure that a consistent, ethical responsibility to the consumer is carried out. Even if we do accept the emphasis of current prevention strategies to persuade the individual to drink moderately, then it follows that the government must, at a minimum, ensure accurate consumer informa-
96 PREVENTION OF ALCOHOL PROBLEMS tion. Currently this function is executed in two ways: First, the National Institute on Alcohol Abuse and Alcoholism (NIAAA), Division of Pre- vention and Research Dissemination, has funded a national public infor- mation campaign and provides current information at no charge through the National Clearinghouse for Alcohol Information. Second, the Bureau of Alcohol, Tobacco, and Firearms has the authority and the respon- sibility to regulate alcoholic beverage advertising. Even though these two agencies presumably serve the interest of the same public, their orientations are almost totally opposed. In a recent year NIAAA allocated roughly $11.4 million to provide accurate alcohol information to the public (S. Maloney, personal com- munication, 1981). If we make an extremely liberal assumption and further estimate that each state spends approximately $1 million on prevention-related activities for the same purpose, the total still amounts to only half the 1978 advertising budget of the Anheuser Busch or the Miller Brewing companies, a pittance compared with the more than 1 billion tax-deductible dollars spent on alcoholic beverage advertising this year. This differential in spending is particularly disturbing because much alcohol advertising functions as an antieducation force. As Katzper and his colleagues (1978) have pointed out, the alcoholic beverage industry is quite willing to educate the public about the good life asso- ciated with alcohol but not about the potential negative consequences. If we are serious about preventing alcohol-related problems, we need to start addressing some of the critical ethical issues that are evident in television programming and alcoholic beverage advertising. Yet work in this area alone will not make much of a dent in this significant public health problem. Only extensive action, planned and coordinated across the many levels on which the problem exists, will provide any hope for change. DRINKING IN PRIME TIME: SHOW BUSINESS RESPONSIBILITY LARRY STEWART, Caucus of Producers, Writers, and Directors I am chairman of the Alcohol and Drug Abuse Committee of the Caucus of Producers, Writers, and Directors. The caucus is not a guild, a union, or a lobbying group; it is 160 individuals, many of whom are entrepreneurs involved in creating what the American public views on television every night. We formed this caucus to assume a more direct responsibility to the American viewing public in television programming and related fields: We wish to exercise our creative freedom in making
ALCOHOL AND THE MASS MEDIA 97 television shows but we also know that what we do in our work has an impact on 70 million people every night. In the autumn of 1982 three tragedies rocked Hollywood. First, Mary Martin and Janet Gaynor were critically injured in San Francisco when their taxi was hit by a drunk driver. Second, Natalie Wood, after a few glasses of wine, slipped off the side of a boat and drowned trying to do something she had done many times. And third, Bill Holden died alone in his room because he was too drunk to know he was bleeding to death. These tragedies helped wake us up and made us pay more attention. Soon after Thanksgiving, CBS aired a local television series of five news pieces called "The Hollywood Alcoholic." The commentator, Carl Fleming, introduced George Peppard, Jan Clayton, Gary Crosby, Sheckie Green, and othersâall familiar personalities who are admitted recovering alcoholics. As they talked about their own problems dealing with alcohol in their milieu and in films, a theme recurred: they were required from time to time, but more and more often, to perform with a drink in their hands. They began to think: "We are doing it too much. Every time we walk into a room, the ice is already there. We even walk into an elevator and someone says, 'Do you want a drink?' " They concluded that they had bought their own message and ended up alco- holics. I watched that show, as did other people on our committee. We then got together to consider whether we, the creative artists who manufac- ture television, are putting a subliminal stamp on alcohol-related behav- ior as being perfectly all right. We discussed this in committee and decided, "We have found the enemy, and he is us." We went to the caucus as a whole and laid out to them the notion that maybe we portray alcohol use too much, that too much boozing happens on television. We know that we produce role models in this society, in the electric culture that we all live with. We looked around the room, at 160 people, and said: "Maybe we are all involved in this conspiracy." The caucus charged our committee to find a way to reverse this trend. We relied heavily on the Breed and DeFoe studies, which were rec- ommended by a director of "The Jeffersons" television show. The black community had come to "The Jeffersons" and said, "George Jefferson is giving us a bad role model for our kids." Breed and DeFoe worked on improving George Jefferson's image by limiting alcohol use on the show. Breed and DeFoe had also worked successfully with "M.A.S.H.," "All in the Family," "The Ropers," and "One Day at a Time." After carefully studying their research, we adopted their approach to the portrayal of alcohol use and abuse. In carrying out our charge, we decided not to act like a pressure
98 PREVENTION OF ALCOHOL PROBLEMS group; our business faces every pressure group that was ever born and we did not want to become colleagues pressuring each other. Our tactics were not to police, not to intimidate, but to create something that would make some sense to our colleagues. From this process came a white paper with the following suggestions. 1. Try not to glamorize the drinking or serving of alcohol as a sophis- ticated or an adult pursuit. 2. Avoid showing the use of alcohol gratuitously in those cases in which another beverage might be easily and fittingly substituted. 3. Try not to show drinking alcohol as an activity that is so "normal" that everyone must indulge. Allow characters a chance to refuse an alcoholic drink by including nonalcoholic alternatives. 4. Try not to show excessive drinking without consequences or with only pleasant consequences. 5. Demonstrate that there are no miraculous recoveries from alco- holism; normally it is a most difficult task. 6. Don't associate drinking alcohol with macho pursuits in such a way that heavy drinking is a requirement for proving one's self as a man. 7. Portray the reaction of others to heavy alcohol drinking, especially when it may be a criticism. This white paper was sent to 4,000 writers, 2,300 directors, 700 pro- ducers, and all network heads. It also appeared in Emmy magazine, which has a subscription of 10,000 industry members. What it said is that we are all guilty of not paying enough attention to something. We used only one statistic: 26,000 alcohol-related traffic deaths each year. We asked our colleagues to join us in thinking about this problem and to see if there was a way to do a little less of what we have done so wellâand yet so badly. And they seem to have joined us, the colleagues who are now saying, "My God, we never thought we were doing that. We didn't realize that Tom Selleck was drinking too much on 'Mag- num.' " All of these role models, the Lou Grants, etc., always have a glass in their hands, and we sell this to the American public every night. Our committee has attempted to bring an idea to the attention of the creative community and we feel confident that the community will respond on its own in a positive way. We think we are sensible and that our colleagues are going to react sensibly. We are not a policing or censorship body; we are not going to single out shows that violate our guidelines. We are not telling "Love Boat" that they should not have a bar; we are not telling "Cheers" or "Archie Bunker" to close down their sets because they take place in bars. But if drinking is not germane to the story, why show it? If it is germane, portray it, but do so with
ALCOHOL AND THE MASS MEDIA 99 the awareness that the people we create become role models. That is what we are asking for: the awareness of our colleagues, a dedicated group that understands our impact in prime-time television and wants to be responsible about it. ADVERTISING ALCOHOL: A RESPECTABLE, BILLION- DOLLAR-A-YEAR BUSINESS STANLEY COHEN, Advertising Age It is said that advertising is supposed to give information to the consumer. I think that is a hazardous formulation because the word "information" has a very special meaning to the people who use it. Advertising people give consumers the information that advertising people want them to have. The function of advertising is to serve the purpose of the advertiser. The advertiser pays for it, the advertiser takes the risk, the advertiser takes the penalty if it does not work. Advertising is not a public service when it is used to sell products. Any proposal that starts with the assumption that the advertiser owes some- thing to the public in the advertising is built on sand. For some people alcoholic beverage advertising is a moral and sci- entific issue. For some advertising people, however, it is a livingâa profitable one. It is a challenge to their professional skills, a perfectly natural activity for experienced, upwardly mobile marketing and mer- chandising specialists who pursue the accoutrements of material suc- cess in a culture that tends to regard material success as a mark of excellence. Any strategy to contain the perceived evils in the advertising and marketing of alcoholic beverages must take into account a number of fundamental political realities. I offer these questions and observations as a basis for discussion: 1. How receptive are the industry and the public to the proposition that the advertising of alcoholic beverages should be subject to special restraints? Historically, both the industry and the public believed that alcoholic beverage advertising was in fact a special case. When Prohi- bition ended, the marketing of beer, wine, and hard liquor resumed under the strongest regulatory schemes ever applied to mass-marketed products. The industry as well as the public was determined to prevent the return of the promotional abuses that had helped bring on Prohibi- tion in the first place. During the 1940s and 1950s every alcoholic beverage ad was subject to prepublication clearance by federal regula-
100 PREVENTION OF ALCOHOL PROBLEMS tors. Federal rules and industry codes were devised to keep out anything resembling glamour. Liquor could not be associated with women, national heroes, patrotism, health, etc. Promotion was banned. Nothing but labels and institutional brand identification ads were permitted. Wine and liquor could not be advertised on the air. But attitudes changed, and case by case, the rules changed as well. Someone got permission to use a picture of Mount Vernon in an ad; someone else showed a group enjoying drinks on the porch. The gov- ernment decided it was pointless to preclear ads for an industry that was thoroughly familiar with the ground rules and had a fine record for staying well within the permissible areas. What seemed intolerable to a generation determined to prevent the return of the practices that had led to Prohibition had little meaning for a new generation more con- cerned about bureaucracy, restraints on free speech, and the inherent right to advertise products that are legally sold. There is still little or no hard liquor advertising on the air. But Anheu- ser Busch and Heublein are among the top 25 television advertisers, and four brewersâAnheuser Busch, Schlitz, Coors, and Van Munch- ingâare among the top 25 advertisers on radio. Moreover, there is no law barring hard liquor advertising from the air. A few outliers have already tested acceptance on offbeat radio stations. The code of the National Association of Broadcasters, which barred this type of adver- tising, recently folded up following an ill-advised antitrust attack from the U.S. Department of Justice. Given the permissive environment that has developed on so many other matters, I assume it is only a matter of time before liquor will be on television, too. 2. What is the momentum behind liquor advertising? Obviously moneyâbut hardly Mafia money. The original distillers after Prohibi- tion may have been ex-bootleggers and the beer industry may have been a mom and pop venture with hundreds of local and regional brands, but beer today is big money. Three giants, including Philip Morris, dominate that industry. (And now Coca-Cola has revolutionized the marketing of wine. As Kraft Foods discovered when it proposed to go into wine marketing, Wall Street analysts have a greater influence over who succeeds than the federal government does.) When you talk about restricting beer advertising, you talk about curtailing the money avail- able for sponsoring professional football broadcasts on television, tak- ing bread and butter from the mouths of 7-foot-tall basketball stars and superstar extra-point kickers. In recent years the marketing of wine and beer in particular has gone through a significant transformation, which has made these beverages indistinguishable from other mass-marketed products. The entry of Philip Morris into the beer industry brought the fast-moving tactics of
ALCOHOL AND THE MASS MEDIA 101 package goods marketing to beer: new brands and varieties, slickly researched and produced television campaigns, and well-organized marketing and sales promotion at the retail level. Under Philip Morris, Miller shook the industry by introducing Miller Lite. The number of major brewers is declining, but the variety of brands and packages proliferates. Every new brand and variety becomes a theme for more advertisingâsomething to fill the time between innings in the ball games and during the time-outs at other sports events. Then of course there are the special promotions: the tennis tournaments, the race cars with Schlitz emblems, etc. Essentially the same process took place in the wine industry. Coca- Cola acquired the Taylor brand in New York State and used it for a new series of wines produced in California. Actually, it farmed out production to Franzia Brothers and focused all its capital on marketing. By 1980, Coca-Cola was spending $30 million to advertise its Taylor brands, more than half as much as the entire industry had spent for advertising before its arrival. Two years after Coca-Cola became a figure in the wine industry, total wine industry ad spending nearly doubled. Industry experts estimate that on an investment of $150 million, Coca- Cola created a business worth $400 million. 3. How good is your case? Alcoholism is no doubt a sickness. Alco- hol involves very serious health and safety issues. Is that enough in today's political and legal environment to win the kind of support needed to bring the power of the state into play? You have to assume that the other side is going to mobilize its own experts to fuzzy up the issues. It is a fact, for example, that some doctors do suggest that some of their older patients imbibe a bit as a tension reliever at the end of the workday. Skilled public relations people can get a lot of mileage out of that because it conforms to the daily experience of millions of people. It also fits neatly into a lobbying campaign based on the idea that how much alcohol to drink is something people ought to be free to decide for themselves. Then, of course, there is the inevitable high-level scientific confron- tation. There are experts expressing the view that evidence establishing a relationship between advertising and drinking is inconclusive. Before shrugging this off, I suggest you check with Peggy Charron of Action for Children's Television. It seemed obvious to her that a civilized society would be concerned about television ads that sell highly sugared breakfast cereals to young children. But by the time the public relations folks had done their thing, The Washington Post was denouncing the Federal Trade Commission (FTC) as a "National Nanny," pointing out that parents should decide what ads their children watch on television. In the end Congress rose up in righteous indignation, ordering the FTC
102 PREVENTION OF ALCOHOL PROBLEMS to cease and desist from interfering with the constitutional right of children to know about breakfast cereals. 4. And finally, what about the legalities? True, there is something of a no-man's-land for liquor created by the states' rights provisions of the Twenty-first Amendment. But essentially the courts today take a dim view of any government effort to interfere with the dissemination of truthful information in advertising. When the government tried to stop Coca-Cola from running Taylor wine ads involving comparative taste tests on television, Coca-Cola won in court. Later, when the government tried to bar a claim that Chablis "light" wine has 25 percent fewer calories, the government lost again: It might be "unfair" to use some promotional themes in liquor ads or to fail to disclose hazards, but would the courts say it is "deceptive"? And in particular, would they say it is "deceptive" given the much more stringent definitions of "unfair" and "deceptive" that the Federal Trade Commission is rec- ommending to Congress as part of the watered-down FTC act now moving through the legislative machinery? Alcoholic beverages have achieved respectability and are marketed by the same people and through the same channels as soap, Chevys, and cigarettes. Inhibitions that existed after repeal of Prohibition have eroded, and the advertising and marketing strategies followed no longer distinguish alcoholic beverages from other products. At the same time the scientific and legal issues have been effectively fudged by competent public relations and lobbying experts. The public's awareness of regulatory overkill in other product categories has helped neutralize the shock effect when health and safety issues arise, and our governmentâall three branchesâis now controlled by officeholders who tend to worry more about property rights than consumer welfare. That is the down side. There is another side: powerful religious and scientific support for restraint, and a residual recognition in the industry that the public has misgivings and that the industry would not neces- sarily prevail if its promotional activity were effectively challenged. Many times in the past, efforts to test television advertisements for liquor were stopped merely because some powerful senator let it be known that this would not be acceptable. Congress does in fact have power to prohibit liquor advertising on the air if it opts to insert such restrictions in the licenses issued to broadcasters. Drunk driving is something the public understands. Even the people now in power recognize that this counts more with the public than the property rights of alcoholic beverage advertisers. In my presentation I have deliberately gone beyond the mere adver-
ALCOHOL AND THE MASS MEDIA 103 Using of alcoholic beveragesâalthough that in itself is a formidable activity, amounting to about $1 billion a year. A successful campaign to curb abuses in alcoholic beverage advertising begins with an honest evaluation of the nature of the economic and political clout behind this advertising. It requires a cohesive and realistic strategy. The odds are not attractive, but they are not impossible. COMMENTS ON ALCOHOL AND THE MASS MEDIA SHEILA BLUME, National Council on Alcoholism The portrayal and interpretation of events and circumstances in our lives by the media extends beyond fictional characterizations in pro- gramming and advertising. Consider the deaths of four brilliant and talented men who died due to alcoholism, and the way their deaths were interpreted. W.C. Fields died on Christmas Day, 1946, in a nursing home in Pas- adena, California, with advanced cirrhosis of the liver. He bled to death from his gastrointestinal tract. His obituary in The New York Times said nothing about the cause of his death even though he made his living portraying an alcoholic, namely himself. Eight years later, in 1954, Dylan Thomas died after drinking 18 straight shots of whiskey in a hotel room in New York. The New York Times said only: "Dylan Thomas, noted Welsh poet, died yesterday in St. Vincent's Hospital of a cerebral ailment. He had been here on a lecture tour. His age was 39. Mr. Thomas collapsed last Wednesday night in his room at the Chelsea Hotel." Contrast those earlier obituaries with that of Tennessee Williams, who died in 1983 at the age of 71; he choked to death on a bottle cap, which is a terrible way to die. The obituaries openly discussed the role of alcohol and drug abuse in his life, how it interfered with his creativity and caused great problems for him. Finally, the Phillips Exeter Academy Alumni Bulletin recently reported the death of a member of the class of 1951: "He died of cirrhosis last December in New York City. Probably the outstanding member of our class, he earned a distinguished record at Yale, followed by an accel- erated rise within the New York financial community, and a promising marriage. During his last years, his family life, his business career, and his life succumbed to alcoholism. His illness was refractory to attempts by many concerned friends, associates, and medical personnel to arrest the morose side of a unique and wonderful individual. He leaves two children, Andrew, 14, and Abigail, 10." I think we should appreciate the sensitivity and honesty of that recent
104 PREVENTION OF ALCOHOL PROBLEMS obituary even as we mourn the tragedy of the deaths of these talented, useful, brilliant, valuable people. We should hold this honesty in our minds as a standard when we look at communications about alcohol. EDWARD BRECHER, West Cornwall, Connecticut The mass media have clearly played a central role in molding popular views on alcoholism. Almost everyone knows, for example, thanks mainly to the mass media, that alcoholism is a disease and should be treated as a disease and that alcoholics cannot take just one drink. Since the media are so effective in establishing broad and simple generaliza- tions in the popular mind, those of us concerned with alcohol education should be alert to other simple truths about alcohol that are ripe for dissemination today. One is the very simple notion that alcohol is a drug, a mind-affecting, addicting drug. Far too many people continue to think of alcohol in one way and of marijuana, cocaine, LSD, and heroin in quite different ways. Sound public policies concerning alcohol as well as the other mind- affecting drugs are much more likely to emerge once the similarities are appreciated. The mass media are admirably suited to distribute this simple messageâthat alcohol is a drugâconvincingly. However, there is a complication: Relatively few people understand what is meant when a drug is classified as addicting. Let us tell them: First, addicting drugs such as alcohol and heroin produce a phenom- enon called tolerance. If someone drinks more than a threshold dose of alcohol week after week, it will take larger doses to produce a given level of excitement or sedation or disinhibition or inebriation next week than it took last week. Second, addicting drugs such as alcohol and heroin produce a phe- nomenon called dependence. This means that a person who drinks a sufficient quantity of alcohol repeatedly will suffer withdrawal symp- toms when the drinking is discontinued. If the doses are large enough and are taken over a long enough period of time, withdrawal symptoms may take the devastating form of delirium tremens (DTs). But the familiar alcohol hangover is in fact a milder withdrawal syndrome. The third and fourth characteristics of an addicting drug are the most important and least publicized. Following withdrawal symptoms come a craving for the drug and a phenomenon known as drug-seeking behav- ior. Rats engage in drug-seeking behavior following withdrawal of either alcohol or heroinâand so do human alcoholics and heroin addicts. These four phenomenaâtolerance and dependence while drinking,
ALCOHOL AND THE MASS MEDIA 105 craving and drug-seeking behavior following withdrawalâare what is meant when a drug is labeled as addicting. In developing future pro- grams of alcohol education for the mass media accordingly, I urge that these ideas be high on the list of priorities. MARK KELLER, Rutgers University I am pleased that Mr. Brecher pointed out that hangover is a weasel word for withdrawal. He mentioned another weasel word, and that is dependence. Twenty years ago, the World Health Organization's expert panel tried to eliminate the word addiction from the expert lexicon in favor of the euphemism dependence for no other reason than that some members felt that addiction was a very severe word. MARK MOORE, Harvard University The debate over these terms seems to involve where the responsibility lies for bad drinking practices. If we say "addiction," it sounds like the drug or commodity is liable; if we say "dependence," it sounds like the responsibility is shared between the commodity and the user. The panel's report took the view that the effects came partly from the commodity and partly from the particular waysâat what rates, over what periods of time, and under what circumstancesâpeople used it. That seemed to us a more accurate characterization, in many respects, than simply to say it is the drug. EDWARD BRECHER, West Cornwall, Connecticut It is the drug. Your report calls attention to a marvelous public health/ anti-heart-disease campaign in California, which successfully reduced the consumption of eggs in one community by 66.6 percent. I defy anyone to develop an educational campaign that will reduce the con- sumption of alcohol by 66.6 percent. BARRY SWEEDLER, National Transportation Safety Board I think some of the most effective means of controlling smoking were the required smoking-and-health ads that were on television when cig- arettes were advertised on television. When the smoking ads were dropped, the antismoking ads were dropped. Would it be appropriate to require antidrinking ads, to counteract some of the beer commercials? The beer industry spends $400 million annually on advertising. What if
106 PREVENTION OF ALCOHOL PROBLEMS that same industry were required to set aside money for ads giving basic information on drinking and health? HENRY KING, United States Brewers Association There has been much conjecture regarding the purported impact of alcohol beverage advertising as it relates to the misuse of the product. However, in no way can this legitimate concern be construed as empir- ical research on the issue. Several years ago, the United States Brewers Association commissioned a major investigation of the role of alcohol beverage advertising in the use and misuse of the product (Finn and Strickland, 1982; Strickland, 1982a, 1982b; Strickland et al., 1982). Principally the findings emanating from this work demonstrated that beer advertising does not contribute to the abuse of the product. These scientific studies illustrate that there is no causal connection between the advertising of beer and the misuse of alcohol beverages. LAWRENCE WALLACK, University of California, Berkeley I discussed the Strickland et al. studies in my paper and the reasons why they diverge from the results of other studies. But I think there is a more fundamental issue here: Who controls the messages that are transmitted about alcohol? Who has access to the media? Where does the other side of the alcohol story get told? I am not talking about begging and scrimping to air an occasional public service announce- ment, or a campaign that appears once a year and is gone the other 364 days or 51 weeks of the year. What about the fact that alcoholic beverage advertising on prime-time television is a major source of misinformation about alcohol in society, which makes very difficult the task of all other alcohol educatorsâto communicate a consistent, accurate message about the use of alcohol? PATRICIA SCHNEIDER, Wine Institute California vintners are especially concerned about social messages conveyed in advertising, as exemplified in our advertising code. This session has focused almost exclusively on alcohol-related problems, advertising as "antihealth" education, and subliminal appeals to con- sumers that have little to do with the product. The California wine industry takes great exception to the failure to distinguish between beer, wine, and spirits, and the homogenizing effect of talking about wine as ethanol, a drug. When you talk about people's perceptions versus real-
ALCOHOL AND THE MASS MEDIA 107 ity, a perspective on the cultural background and agricultural nature of wine is important. I would like to express the philosophy of the California winegrowers and our educational materials. Wine Institute is a trade association of California vintners, representing approximately 95 percent of the Cali- fornia wine industry. We do not represent either wineries outside the state or makers of imported wines. We include several large firms, but the vast majority are small family operations. We are pleased that our 460 members all voluntarily subscribe to our Code of Advertising Stan- dards. Those standards have been strengthened significantly over the past five years, and no violation of either the spirit or the letter of the code has occurred. We have a very specific educational approach in presenting California wine. Four aspects are emphasized consistently: promote the product responsibly; educate consumers about wine's proper use; emphasize the heritage of wine as a moderate mealtime beverage; participate in credible, innovative projects to reduce alcohol misuse. Why have we taken these steps'? Although the vast majority of our consumers use wine in moderation, we recognize that wine contains alcohol and can be misused; therefore, we have a responsibility as an industry, as concerned corporate citizens, to be part of the solution to the problem. Highlights from the code: We hold overindulgence and intoxication to be absolutely unacceptable. We advocate integrated social contexts, in which wine is accompanied by food as a table beverage and drinking is not the focus of the activity. We prohibit the use of amateur or professional athletes, celebrities, and past or present heroes attractive to young people. We prohibit any suggestion of drinking and driving. And we discourage any association of wine with rites of passage. The code goes into greater detail about these specific provisions. This code was not developed by an advertising firm or an outside or in-house public relations firm. It was developed over a year and a half, with groups of people sitting down in a room much like this, representing the alcoholism field, the media, public health, government representa- tives, and of course our own members, to get meaningful input about social issues raised and how we could best respond. Those organizations included the National Council on Alcoholism, the Alcohol and Drug Problems Association, the Health Education Foundation, the Associ- ation of Labor-Management Administrators and Consultants on Alco- holism, and the NIAAA, which was very helpful in those early stages, as were our sister industries, the brewers and the distillers. My remarks pertain only to the wine industry's advertising practices, but we feel that through this code, advertising plays an important role as a way to
108 PREVENTION OF ALCOHOL PROBLEMS educate and teach consumers about the proper use of wine. That is a very important role in meeting both business and public health needs. CHARLES CRAWFORD, Gallo Winery Wine Institute has officially requested the U.S. Treasury Department to make this code of advertising standards mandatory, not only for wine, but also for beer and liquor. I do not know how far we will get, but we have asked for it to become an official part of the regulations. MARK MOORE, Harvard University As I read through this code of advertising standards and heard this presentation, I imagined the set of advertisements I see on television, and it seemed perfectly consistent. Would advertising that fit these guidelines be described by Breed and DeFoe and others who do content analysis as glamorizing alcohol? PATRICIA SCHNEIDER, Wine Institute From the research we have seen, no wine ads from our member wineries have fallen into the "glamorizing" category. MARK MOORE, Harvard University Every child wants to become a mature, successful adult. So in some sense the very image of responsible drinking might turn out to be inherently glamorous. I wonder whether the problem may be in the receiver, the child looking at the ads and trying to make a distinction between "me now" versus "what I aspire to be." The problem may be in wanting to aspire to that status too early. JOHN DOYLE, National Council on Alcoholism In Lincoln, Nebraska, junior high students are shown how seductive advertising can lead to false inferences such as "If your life-style involves drinking, then all these different things are going to happen." It may be illogical to reach these conclusions, but the advertising has become very sophisticated, so that you can jump to wrong conclusions, such as that you are going to be a macho person and succeed in all kinds of ways if you live the good life with this beautiful sparkling beverage. Kids quickly catch on; they go home and tell their parents, "We are
ALCOHOL AND THE MASS MEDIA 109 being taken advantage of, we are being ripped off.'' I have no statistics because the program has not proceeded very far, but the preliminary results on student acceptance are amazing. LAWRENCE WALLACK, University of California, Berkeley There is certainly an interaction between factors inherent in the individual and different levels of reinforcement in the marketing systems and the larger social structure. When you look at just one adâas some people have tried to ask, "Does this rock song about marijuana make people smoke marijuana?"âthe answer is: Of course not. You have to take a much broader perspective. STANLEY COHEN, Advertising Age In the course of some 40 years in Washington I think I have heard every cause in the country argue that the solution to their problem is a big information campaign. When you deal with big institutional prob- lems, you cannot conceive of the resources required for an effective information campaign. One notice, one poster, one public service announcement does not mean a thing. These solutions are not mutually exclusive, but a public information campaign is a slim reedâit has to be part of something else. It has to be part of a large, well-organized effort. GEORGE HACKER, Center for Science in the Public Interest Some people have used the metaphor of swimming against the tide and building a dam to stop the flow. The tide that I see is: Alcohol is easily available to young kids, many of them below the drinking age, at prices that make alcohol less expensive than soft drinks. We have promotions on college campuses and in the media encouraging drinking and portraying it as a sexy, great, adult, social thing to do (Jacobson et al., 1983). That tide affects all of us in one way or another. We need athletes and celebrities to get on the air as positive role models to say, "I drink occasionally, maybe one or two, but you will not find me out there drinking all night with the boys." But with a billion dollars of alcohol advertising out there, we obviously have to do a lot of positive portrayal to be effective.
6 Alcohol, Youth, Drunk Driving WHAT PARENTS CAN DO KEITH SCHUCHARD, Parental Resource Institute for Drug Education Recognizing the Problem: An Intoxicating Media Environment I am an English professor and I would much rather be teaching Milton and Spenser to adolescents than drug and alcohol information. But my own teenagers told me that all parents need "reality education" about popular culture and the everyday world in which kids are growing up. Otherwise, parents will be unable to communicate with their children, for we are out-communicated by a tremendous commercial industryâ not just the advertising on television, but also T-shirts, comic books, and perfumesâa blitz of advertising without precedent. We are dealing with the widespread availability and commercial glamorization of plea- sure-giving chemicals. We are just now emerging from a decade in our history in which pleasure was deemed an extreme good, and adults taught that philosophy of hedonism to children and teenagers. This philosophy was accepted and encouraged by a large portion of the popular media and by advertising. Thus, we are dealing with an issue that we are hesitant to confront: chemicals that people like, that feel good, that are fun: alcohol, cocaine, marijuana, and whatever. "Head shops" were a godsend to efforts in prevention, for they were a visible dragon: adults selling "space guns" to 8-year-olds to smoke 110
ALCOHOL, YOUTH, DRUNK DRIVING 111 marijuana in, doll-sized cocaine kits. Even naive parents could say, "Now, wait a minute, that seems a little bit out of line." Many lawyers and civil libertarian organizations went to bat for the head shops because they believed in a constitutional right to sell toy cocaine kits to kids. Fortunately, parents won most of those legal battles. We are now facing something much more difficult, because the acceptability of selling intoxication has become so widespread. A gen- eration of people are in positions of influence in the media, merchan- dising, and advertising worlds, a generation that came through the 1960s and linked up drug use with ideas of civil rights, liberation, and progress. In the old days, being liberal did not necessarily mean that you wanted your kids to smoke pot. But today the 34-year-old professional in the media industry who still uses drugsâand still links that use with con- notations of fun, progress, intellectual enlightenment, etc.âis a big problem for network executives and filmmakers. Unfortunately, many merchandisers have worked aggressively, in a very predatory way, to lower the age of consumption of alcohol, drugs, and many other kinds of products. The industry talks about responsible marketing, but I see alcoholic milk shakes in stores and I hear advertising on teen-oriented radio stations for beer, wine, and other kinds of drinks. Most parents and many health professionals do not know what life is like for an ordinary American kid. They should see what children see in the local shopping centerâin the record stores, where songs glam- orize alcohol and cocaine; in the T-shirt shops, where there is a tre- mendous increase in displays of drunkenness-oriented T-shirts. Here are some examples from the nicest gift shops and boutiques, in kiddie sizes for 6-year-old children: "Party till you puke." "Avoid hangovers, stay drunk." "Thank you for pot smokingâthe American Cannabis Society." Here are some T-shirt messages for older children: "A day without dope is like a day without sunshine." "I don't have a drinking problemâI drink, I get drunk, I fall down. No problem." Pro-drug advertising appears in the newspapers. Consider these movie ads in the Atlanta Constitution, a family newspaper: Richard Pryor, with his foot on fire from free-basing cocaine, is "America's funniest man." "Arthur"â990 at the kiddie special showâis drunk all the time and always very amusing and attractive. The movie "Personal Best" shows how to be a teenage Olympic aspirant: use Quaaludes and mar- ijuana, smoke opium, drink tons of beer, and become a great athlete. Here are Cheech and Chong in "Still Smoking": the ad says, "You can smell the fun in the air. It has everybody rolling in the seats" (i.e., rolling marijuana joints). Drugs are even advertised on television. Cheech and Chong, the "lovable, furry comedians," are advertised during the
112 PREVENTION OF ALCOHOL PROBLEMS morning cartoon hours smoking big joints. Rasta Man, on "Fridays," shows how to roll a giant marijuana cigarette while the audience chants along. "Saturday Night Live" has reruns at six o'clock in the evening with skits like "What this country needs is to put the cocaine back in Coca-Cola." Drug-oriented comic books show kids how to shoplift and do drugs in the kitchen. The ad that appears first (probably the most expensive slot) in the April 1982 issue of Seventeen magazine is for Visine; it targets the teenage drinker and pot smoker: a boy who looks about 15 holds a drink up in his hand and points slyly to his eyes. The ad says: "When should you take the Visine test? After partying." Any sixth grader can tell you that means to get the red out of your eyes after you smoke pot, so your parents will not catch you. The magazine is read mainly by girls ages 10-14. Hashish frisbees and marijuana dashboard pipes are found in many of America's nicest gift stores and ordinary shopping centers. The worst example is Yves St. Laurent's "Opium" perfume, manufactured by Squibb Pharmaceutical Company and marketed with drug-related advertising: a glossy ad exhorts the reader to enter the "Opium" world of fantasy and desiresâa clear allusion to smoking opium. Thus, cor- porate exploitation of the drug culture is pushing the idea of drug intoxication. The Florida Pediatric Society has voted to boycott all Squibb pharmaceutical products if it does not change the advertising for "Opium" perfume. This action follows three years of protest from medical groups and parents which the company simply shrugged off. If you are raising children today you must feel a sense of urgency. Children are experiencing something that no other generation in world history has gone through. They live in a society that has forgotten to protect children from predatory merchandising and commercial manip- ulation. The cleverest and most effective advertising and marketing strategies are being designed to take advantage of normal adolescent insecurity. I think this merchandising of drugs to kids is a new problem. All of you have been working for years with alcoholism; many of you have been working for years with drugs. But only since about 1976 has the lid been taken off what merchants are doing to sell to kids. Alan Blum, who founded "Doctors Ought to Care"âa maverick group of street guerillas made up of medical students and interns who counteradvertise on cigarette billboardsâcalls his presentations "How the Corporate Pushers Keep on Truckin' After the Kids." He shows how the soft drink industry, the wine industry, the tobacco industry, and other cor- porations are getting kids onto "starter drugs"âcigarettes, beer, and pop winesâwhich we know have links with illicit drug-abuse behavior.
ALCOHOL, YOUTH, DRUNK DRIVING 113 You cannot isolate one product from the other. This is how the kids beginâthese are what my husband calls the "training bras of drug abuse." Practical Parental Action Many teachers and parents working in the alcohol- and drug-abuse field are optimistic about the changes we have seen in the past few years since parents started organizing, educating themselves, and trying to work more effectively with other groups. The parents' effort has not always been easy. Quite often there have been battles with agencies and professionals. But a more and more constructive coalition is devel- oping. We all have to recognize that adolescence is a very special time. We cannot treat teenagers as little children, using naive prevention strate- gies. We cannot treat them as adults because they are in a vulnerable period of internal stress, confusion, and irrationality. They are partic- ularly vulnerable because of their tendency to be more loyal to their friends than to their own welfare. Kids are much more afraid of losing friends than of using drugs; this is something parents have had a very hard time learning. But what do kids care more about than Opium perfume, Visine ads in Seventeen magazine, Schlitz beer, etc.? First, they care about their bodies. They want to be attractive to their peers; hence all that preening in front of the mirror, the endless showers, all the irritations parents go through with 13- or 14-year-olds. Young adolescents are utterly insecure about whether they are normal and attractive. Second, they care about access to automobiles, which carry an aura of freedom and fun. Third, they care about working out a rewarding relationship with their parents. Finally, they want to know how to deal with peer pressure. In teaching parents how to teach their children about alcohol and drugs we have found it best to tell them about the biology of pleasure, what it means, and how it can be short circuited. This covers the role that the brain's reward system plays in motivation, the desire for achievement, self-discipline, etc. This may sound difficult, but we find that children and adolescents are fascinated to learn that things that feel goodâfood, sex, physical exertion, etc.âmay have a function in terms of survival and the ability to protect oneself and one's family. The biological aspects can be a positive part of prevention, because in an age of physical fitness mania, people are very interested in their bod- iesâparticularly 12- to 14-year-olds whose bodies seem to be giving them a lot of trouble. Parents' groups and voluntary educational groups in the communities
114 PREVENTION OF ALCOHOL PROBLEMS really need more information on the physiological effects of alcohol and drugs on children who are still growing. We need new information on developmental problems of puberty, on the reproductive system, mus- cle structure, and bone structure. This has been our most effective educational strategy. Yet five years ago, when we tried to get infor- mation on how the depletion of testosterone caused by marijuana may affect a 14-year-old boy at a time when his voice is changing and his muscles are developing, we could not get it anywhere. We had to go to amateurs and then to researchers and doctors in other fields to help us put this profile together. Despite what we were seeing right before our eyesâthin-waisted, undeveloped young boysâwe could still not get anyone in the research field to say it was real. Clinical reports are only now beginning to appear in the pediatric literature. We need alcohol information that applies to adolescent and pubertal development. This is something kids are interested in, that their parents can talk to them about. What goes on when your voice changes or your breasts begin to develop? What changes go on in your body that chem- icals may disrupt? It is an unemotional way to talk about problems that have been very difficult and embarrassing to discuss. We need helpâ we cannot get enough of this information. All over the country, mothers have been trying to read medical journals, trying to find out why the information they need is not available when millions of kids are using alcohol and drugs. We get very little help from the medical and research community in this area; there is a tremendous information gap. The parent movement started out on the drug issue, which scared parents more than the alcohol issue because they did not understand it. We began by trying to get parents to face their responsibility for their children's health, to ask their children: What are the risks you are taking for the future of your own children? Is it worth taking a chance that someday this drug use may show up in an unhealthy offspring or some kind of genetic problem? The health approach also has immediate appeal: parents, teachers, coaches, or pediatricians can talk to youngsters about what a healthy body is. Parents are responsible for their children's health and make the rules about vaccination, measles, and everything else medical; they should make it about drugs and alcohol. We try to teach parents why these drugs are more physiologically harmful to someone who is not physically mature. This approach avoids having to get into psychoanalysis, into emotional judgments such as saying to teenagers that they are not mature yet. Most kids believe they are mature at 12âthey will admit that sixth graders are not mature, but they believe that seventh graders are. A very important element in our strategy is for parents to link up in
ALCOHOL, YOUTH, DRUNK DRIVING 115 networks or with peer groups. These parent support groups, which can be very loose and informal or quite organized, are able to say: "Regard- less of the media, regardless of what is on television, regardless of what is for sale at the nearby store, we will maintain around our children a mutual code that stipulates what is permissible behavior." Such a code does not have to cover everything, but it should cover illegal activity, the use of drugs and alcohol, getting into dangerous situations with automobiles, etc. It should be based on common sense. The most disparate types of parentsâatheists and Baptists, liberals and conser- vativesâcan agree on essential areas of risk, and then build a mini- society around their children that has a different standard of behavior, a different standard of what is tolerated, than the trashy commercial culture. Parents can stick together and support each other. The process is simple, it is a matter of reinventing the wheel, but it works because the main thing by which kids judge their own behavior is what their friends are allowed to do. In situations of divorce, of working parents, etc., the parental network is a godsend; it gives a person 15 other parents to work with to raise a batch of kids. The parents can help each other and swap places at times. If mothers cannot be home in the afternoonsâsingle, working mothers particularly have a hard time with thisâthey can call on neighbors, other people in the network to say, "Can my kids come check in at your house?" The process does workâit is very practical. We have found that parents need to understand the health and devel- opmental risks that children face when they experiment with drugs and alcohol. It is not something to waffle about. Parents are trying to help them mature and become independent and leave homeâthat is the whole point. The kids need to know that, too. The specter we hold out to the teenagers is this: "What if you become a burn-out or an alcoholic, still living with your mother, getting an allowance, when you are 28?" We present the ultimate nightmare to the parents: "What if they come home when they are 28 because they are immature and can't make it? What if you end up with a burnt out, permanent adolescent on your hands?" There are consequences to the misuse of pleasurable chemicals that are not just a matter of hitting someone with a car, but of a young person's ability to develop capacities for controlling impulses in a way that is constructive and can lead to a productive life. Teenage Parties and Parental Responsibility I want finally to address the question of adult legal liability in relation to underage drinking. The 16-year-old male driver is statistically the
116 PREVENTION OF ALCOHOL PROBLEMS biggest killer on the highway; the glands reach their height of activity at the same time the kid gets a gearshift in his handâit is not a very rational period. The laws on underage drinking are too often not enforced by parents, police, merchants, or even medical personnel such as emer- gency room crews and ambulance drivers. In my own community in Atlanta, where for many years prevention efforts went nowhere because anything entailing the slightest restriction of individual choice was immediately backed away fromâeven when kids were stoned at school or drunk on the highwaysâwhat finally got through to parents was their legal liability. What we say in PTA meetings and such is the following. First, there are good, sound, medical reasons for the laws on underage drinkingâ the physiology of puberty makes the kids vulnerable; it is not the same to be 16 and drinking as to be 21 and drinking. Second, parents are responsible for the behavior of minors in their homes and under their supervision, whether their own children's or someone else's. If the daughter is having a slumber party and the parents are upstairs watching television, the kids get drunk from bottles out of the liquor cabinet and one of them drives away and kills someone, it is the host parents' responsibility. If they did not know it was going on, that is neglect in the supervision of minors. Even for the libertarian parents in our com- munity, this made sense. Even the kids thought it made sense; at the PTA forums they asked us incredible lawyer's questions: "Well, what if the parents were asleep and we all got drunk, is it still their fault?" The answer is "Yes"; parents are responsible for the safety and welfare of the kids in their home or on their property. The point made the teenagers recognize their own responsibility not to get parents in trou- ble. This is a tremendous public message. The typical high school party now is a completely unsupervised scene of very heavy drinking. It begins in about the seventh grade. By ninth grade, kids feel they cannot give a birthday party without having drinks, because no one will come. Parents are buffaloed, and police often do nothing because that is what the community demands. I mention two recent, shocking episodes involving the kids from suburban Atlanta, from nice schools, good homes, etc. First, a party was held when someone's parents were out of town. The word went out at the high school and the kids all flocked thereâa nice big house, a doctor's family. A boy who was never in trouble with alcohol before got drunk. His girlfriend got mad at him, he lost control, and knocked her down the stairs. She became paralyzed. The kids, all about 14-16 years old, panicked and called the emergency room. The ambulance came, the attendants revived the girl, decided she was not
ALCOHOL, YOUTH, DRUNK DRIVING 117 permanently damaged, and drove awayâfrom a household of teenage drunks. The crew never made a record. The house, with some 200 drunk kids partying in it, was trashed. The incident was completely covered up until some of the kids grew concerned because the girl was still having back trouble and her parents did not know what had hap- pened. Two weeks later there was an incident involving two more teenage parties. The parents were not home at one and were upstairs at the other; there was heavy drinking at both parties. The police were called by the neighbors to the first party four times. They told the 16-year-old teenage host, "Cool it, the neighbors are mad at you," and went on. The kids from that party went to another party; there was a fight between football team members of different schools; a boy who was not drinking tried to break up the fight, was stabbed six times and died. The host parents were upstairs and had no idea there had been a fight until the boy bled to death in their living room. This is nice, suburban, good- family America. In these instances the parents were either upstairs or absent, yet they were legally liable. That may seem cruel if they were unaware of the law and their responsibility, but they should not have been unaware. The police and paramedics did not expect community support, so they took no strong preventive action, even in cases of violence and injury. These are the realities of what we are dealing with. The widespread adolescent drug and alcohol problem is urgent and unprecedentedâwe should remember that. The sophisticated marketing of intoxicants to children has never happened before, especially not at the accelerating rates of the last few years. But the parental instinct to protect a child's physical well-being is the strongest instinct in nature and in society. If we can tap that instinct and reinforce it with community support and legal sanctions, we can build an effective prevention movement. WHAT SCHOOLS CAN DO: A PHILADELPHIA STORY SISTER MADELEINE BOYD, Shalom, Inc. I first entered the field of drug and alcohol abuse as a school disci- plinarian, responsible for the behavior problems of 3,000 girls in a school in Philadelphia's Little Italy. Though my background was in guidance, administration, and psychology, I had always had children with behav- ior problems, mainly because I was always bigger than they were. My first drug case confused me because I thought that my 6-foot-tall, Ger- man-Irish demeanor would make her stop and think twiceâit usually
118 PREVENTION OF ALCOHOL PROBLEMS did. But the drug-prone adolescent was a bird of a different feather. She would look at me with cocker spaniel eyes and I would believe anything she saidâuntil I was burnt once, twice, but never a third time. I realized I needed an education in how to communicate with these children, how to understand their game. They had to be liars because drugs were illegal. I took off for a summer, and for a religious, taking a summer off is like asking for four years of sabbatical. I visited every nearby drug and alcohol program to see which ones I could trust with the lives of my girls. When I returned I had a pretty good evaluation of which programs I would send girls to, but I also wondered, what am I and the other teachers in the schools going to do about this? Treatment was a great resource. Much of my work would be preparation for treatment, support during treatment, and support after treatmentâbut treatment comes after the child is already scarred. What about preven- tion? We needed to give students some weapons and skills to handle their own problems and make their own decisions. Most important, we needed to give them the truth. In the early 1970s there were volumes of absolutely wrong information about drugs. Gradually, the students became so sophisticated in their use of drugs that they turned to alcohol because it was easier and safer and involved less pressure from the adult world. I thought we had an obligation or responsibility to gain knowledge, skills, strategies, and techniques to face this problem hon- estly and communicate with the children. As an educator I saw a need to reach children before they were scarred. I hear a lot of rhetoric about prevention but I do not see many green bucks coming into this field. While I respect the idea and the contri- butions of volunteerism in prevention, I believe we also need profes- sionals who are well instructed in psychology, social work, guidance techniques, life-planning skills, etc. There the government is deficient. It comes through at times, but only after treatment has received the lion's share. What is left over, treated as a luxury, is prevention. The principal reason my program got drug and alcohol money from the state was the fear that high school children were becoming involved in criminal behavior. Legislatures respond more readily to criminal offenses and to anything connected with criminal justice; the govern- ment is pressured more strongly to stop crime than to help human growth. So I told the government of Pennsylvania that I resented the fact that they pay 175 dollars a day for a child who is incarcerated, and 0.3 cents to prevent him or her from becoming incarcerated. It was a long, hard job, but with support from teachers, parents, and students, I was able to flesh out my skeleton of an idea and gradually
ALCOHOL, YOUTH, DRUNK DRIVING 119 develop the program, Shalom. We began our program in the schools by hiring people who had professional life-training skills. They were social workers, psychologists, and guidance counselors, who had a way of communicating with teenagers. Our program now operates in 15 high schools, 22 grammar schools, and 3 counties, and we have 5 men out on the streets from 2-10 pm doing work in the community. To communicate with children we first had to gain rapport with them. We had to know what they were reading, what they were listening to, what they were seeing on television and in the movies, and what their language communicated. This was and is a prerequisite to understanding why, where, with whom, and in what places they drink and what attracts them to drinking and drugs. The kids know alcohol is socially accepted. They feel not only peer pressure but also social pressure. What scene on television does not have a decanter and wine glasses? At present, alcoholism in youth is a terrific problemâeven for 10-year-olds. We start our program in the high schools, where there is a captive audience. The program is not in the health class curriculum. It is offered during study periods and before and after school. It is a highly structured discussion group from which they can learn new skills and at the same time gain new knowledge, techniques, and strategies to implement this knowledge. The facts are presented in various ways: through psycho- drama, magazines, music, videotapes, and movies. It is not labeled "drug education." It is labeled "personal awareness" or "leadership training''âeveryone wants to be a leader. We give kids the truth about all the ramifications of drinking and taking drugs. Then we can say: "If you are still willing to take the risk and you gamble and lose, then you can cry on your own shoulder." This spring we have been showing the movie "The Last Prom," so that the kids would see all the possible problems created by drinking before the prom: "You can get messed up with the law, with your insurance, with dad's car, with the girl's familyâso if you take the risk, you make an informed choice." If we give information to teenagers in a rational way and give them the skills to discuss it openly, we will not only whip drugs and alcohol, but all sorts of problematic behavior. We are now dealing with rape, incest, homosexuality, and child abuse, networking to bring in other agencies to help deal with these problems. We have to communicate the dignity of the child to the childâmake it known that he or she is valuable, lovable, and that his or her health is a primary consideration and most essential. There is no need for drugs and alcohol, for kids can learn to get high on life.
120 PREVENTION OF ALCOHOL PROBLEMS RESEARCH APPROACHES TO PRIMARY PREVENTION ALFRED MCALISTER, University of Texas Health Sciences Center Primary prevention of alcohol abuse is among the great modern public health challenges. Society is eager for ideas about how to communicate with children and young people to reduce or deter the irresponsible use of alcohol. There are two basic educational approaches to the preven- tion of youthful alcohol abuse. One can be labeled "direct" or "spe- cific," in that it represents direct efforts specifically concerned with alcohol. A contrasting approach can be termed "indirect" or "general," as it refers to efforts intended to have a general, indirect impact on a number of different behavioral threats to health. I will illustrate each approach with studies by research teams. Direct, Specific Prevention Approaches The most direct approaches to prevention are proscriptions enforced by harsh punitive systems, or the promise of hellish consequences. American political philosophy, however, is based on the notion of voluntary self-restraint; we do not impose harsh restrictions and pun- ishments to control alcohol abuse as do Moslem societies, for example. Moral approbations also seem to have lost much of their force in our secular society. Pursuing the ideal of enlightenment, educators have in recent years appealed to young people's capacity for rational decision, providing straight, factual information about alcohol and its effects. These efforts have yielded disappointing results (Gordon and McAlister, 1982). While leading to increased knowledge and understanding, factual alcohol education has not appeared to have much impact on behavior. The most recent preventive efforts have been concerned less with enlightment than with motivation. Peer pressure is a widely recognized motive for adolescents' risk-taking behavior (Sherif and Sherif, 1974), and efforts to create positive peer influences and interfere with negative peer influences have shown promising results in the prevention of ado- lescent cigarette smoking (Evans et al., 1979). In research undertaken first at Stanford and then at Harvard University, I have evaluated the effects of peer programs for alcohol and other substance abuse preven- tion. In the Stanford study, peer leaders about age 16 led 12-year-old students in sessions designed to reduce the perceived social desirability of cigarette smoking, frequent marijuana use, and drunkenness. In the follow-up, self-reports of drunkenness were significantly less frequent among students in the program than among those in a control school
ALCOHOL, YOUTH, DRUNK DRIVING 121 (McAlister et al., 1980). In a more recent study, students in inner-city schools in Boston were randomly assigned either to a peer program that opposed specific substance use or to serve as a comparison population. Of 16 classroom hours of special substance abuse prevention activity spread across 2 years of junior high or middle school, 7 hours were concerned with alcohol. Of 6 sessions involving peer-nominated "opin- ion leaders," 3 contained material concerned with alcohol. A variety of educational approaches was included. For example, a videotape was produced in which an on-screen character attempted to persuade the viewer to engage in a drinking contest. Counterarguments were scrolled across the bottom of the screen so that by reading the lines the viewer experienced the illusion of interpersonal communication. The most popular students in each classroom were chosen to read the responses, followed by a group reading. The script was designed to promote the perception that heavy drinking was socially undesirable. Although the frequencies of self-reported drinking at monthly or shorter intervals were comparable at baseline, there were sharp differ- ences between comparison and experimental groups in reported alcohol abuse at follow-up, which suggests that a preventive effect was achieved. Differences between cohorts are presented in Table 6-1. These results are not definitive: only about half the students eligible for longitudinal study are represented; the treatment and control schools had different attrition rates; and there were serious inconsistencies in program deliv- ery, severely limiting confidence in inferring a preventive effect. Never- theless, at least some part of the differences can be attributed to the preventive program. More rigorous experimental research is needed to determine just how effective a short-term preventive strategy has been developed. Indirect, General Preventive Approaches Long-term patterns of alcohol abuse may be determined more by the larger social environment than by immediate peer pressure. A variety of evidence links alcohol abuse with factors such as disruptions in family or community relationships. If such factors cause a broad range of detrimental behaviors, then these factors should be addressed by pre- ventive efforts, even though they are resistant to modification. In research on general, indirect approaches to primary prevention, the most important studies may be ones that seek to improve social skills, family relations, and school attendance and achievement. Few investigators have been bold enough to intervene in these difficult areas. The stimulating reports of Bry (1982) and Bry and George (1980) suggest
122 PREVENTION OF ALCOHOL PROBLEMS TABLE 6-1 Percentage of Frequent Alcohol Users at Baseline and Follow-up in Treatment and Control Cohorts Start of 6th Grade End of 7th Grade Treatment (n = 140) Control (n=105) Monthly or More Frequent Drinking Monthly or More Frequent Drinking Monthly or More Frequent Drunkenness 11.4 12.4 7.1- 3.6* "x2=15.8, p< »x2= 9.2, p< .001. .001. 25.7 14.3 that intensive efforts to improve school attendance and achievement may be successful, but the small number of subjects and the short time- span of these and related studies weaken confidence in their implica- tions. Other studies have attempted to improve family relationships (Pratt, 1976) or individual characteristics such as self-esteem (Botvin et al., 1980), but no clear-cut findings have yet been obtained from well- controlled studies. The progress of research in this area is limited by difficulties in conceptualization; family and community life appear to be influenced by differences among individuals, but the personal attri- butes most central to the quality of human experience have not been isolated. It may be impossible to improve family and school relationships on any significant scale under conditions of high unemployment or other social stress and deterioration. Despite the magnitude of such pressing structural problems, they are not necessarily beyond the scope of social- psychological analysis or intervention on a small-scale basis. Small- scale changes may produce only short-term results, but they can provide evidence for the potential and possibility of change. In a recent study, an effort was made to investigate the short-term psychological impact of altering an important structural variable: eighth- grade students in an inner-city, minority setting of high youth unem- ployment, where the number of government-sponsored summer jobs had been sharply cut, were randomly assigned to be eligible for enhanced summer employment opportunities related to long-term career goals. At the beginning and end of the school year the assigned students completed an interview that measured future orientation, self-esteem, and coping styles. Experimental subjects participated in a series of weekly classroom sessions and field trips designed to increase social support and self-
ALCOHOL, YOUTH, DRUNK DRIVING 123 esteem and to improve coping skills. The summer jobs were a salient part of the intervention: there was evidence of short-term increased attendance when special job eligibility forms were issued. Self-esteem was enhanced by direct social approval and by identification of each individual's positive qualities. Coping skills were taught by actual prob- lem solving in small groups in which students were urged to express their most pressing problems, to discuss solutions, and to apply those solutions experimentally. All sessions were led by a group of Harvard undergraduates with cultural backgrounds similar to the study partici- pants. Group differences in self-reports about relevant variables are pre- sented in Table 6-2. At follow-up with about two-thirds of the partici- pants, the experimental subjects tended to display more positive future orientation and greater self-efficacy. These experimental methods and short-term findings may not be generalizable or stable, but the data point toward future, more substantial studies. Implications There are many conferences on smoking, heart disease, cancer, and similar disease-specific or substance-specific issues. In these meetings, 95-98 percent of the discussion involves the policies or actions that might be addressed to specific problems, without looking at broader, underlying matters. If one points out that unemployment causes families to break up, and when families break up, wider disruptions happen, such as not using hypertensive medication, not quitting smoking, not controlling alcohol use, and so on, everyone will agree and then drop the subject. Similarly, one can point out that the overall quality of education in the schools is fundamental. How can a school mount an effective alcohol abuse program unless it has adequate funding, unless the teachers are paid well enough that the social climate in the school is not "I hate this place," but "This is a good place to be"? If one says the fundamental problem is the quality of schools and the amount of money that we as a society invest in our children and their socialization, everyone may agreeâbut nothing comes of it. I do not think we can reach our long-term goals without building coalitions that cut across all these specific concerns, bringing along those whose lives are touched by alcohol, by smoking, and so forth. I want to illustrate this with one specific example. In Texas the governor has promised teachers a pay raise and he is committed to improving the overall quality of education. In order to fund that pay raise, he wants
124 PREVENTION OF ALCOHOL PROBLEMS TABLE 6-2 Follow-up Group Differences in Future Orientation and Self-Efficacy Experimental Control n (percent) Future Orientation Do you look forward to your future? Yes 27(90)° 18(58) Undecided 3(10) 9(29) No 0(0) 4(13) Self-Efficacy Could you do something about a recent problem?* Yes 15(65)' 12(52) Undecided 6(26) 2(9) No 2(9) 9(39) "p < .05 by Kolmogorov-Smirnov test. 'Among those reporting a recent problem. cp < . 10 by Kolmogorov-Smirnov test. to increase alcohol and cigarette taxes. No one has yet drawn the connection that if the overall quality of schooling improves, maybe that will help prevent adolescent alcohol abuse, smoking, and other such problems. The people in the state who are concerned with alcohol sit on the sidelines asking, "What does the teachers' pay raise have to do with alcohol problems?" I think that it is important to make this kind of connection explicit. It would be terribly misleading to say, "Let us look just at the quality of education," and forget regulatory laws and prevention curricula and other alcohol-specific measures, but I think we should invest something more than 2-5 percent of our effort in these more general problems, and I do not think we will build successful coalitions for prevention until we do that. PREVENTING DRUNK DRIVING EDWARD KUNEC, Mothers Against Drunk Drivers I am not in this field as a professional but because some 21 months ago my wife and I lost a 20-year-old son, killed by a 19-year-old drunk driver. I became affiliated with Mothers Against Drunk Drivers (MADD), an association of mothers, fathers, sons, daughters, friends, and rela- tives. The organization has blossomed in 3 years as a result of a national
ALCOHOL, YOUTH, DRUNK DRIVING 125 tragedy that affects every one of us. Currently, MADD has 153 chapters in 38 states; to establish a MADD chapter requires at least 20 people who are committed to writing letters, meeting with local political lead- ers, speaking before organizations, and trying to elicit public sympathy and action. My chapter is made up of 100 dues-paying members and 100 others who contribute in one way or another to our efforts. Our organization receives no outside fundingâit is all volunteer helpâand as a result, our resources and our help are limited. Within the limits of the resources that we have, we do try to look at things from a system perspective and to cover as many of the elements as we can. We have discussed the overall problem with local officials. Alcohol is not just a problem of the youngâit covers all age groups. But our sheriff indicates that approximately 80 percent of those in jail in my county are under the age of 30, and most of the problems they have are alcohol- and drug-related. This 80 percent figure is mind-boggling. We have tried to make the local community aware of the drunk- driving problem through news media exposure, through television, through schools, and in speaking with our friends and neighbors before organizations like the Kiwanis, the Lions, the PTA, etc. We have thus far successfully persuaded five county governments in Virginia to form task forces comprised of civic leaders, public officials, and interested citizens, to study their local problem and their resources to cope with it and to make recommendations for public and private action. We successfully encouraged the governor of Virginia, Charles Robb, to form a task force at the state level. We have encouraged legislative change, which is one of the most difficult things we have encountered and on which we need a great deal of assistance. We have encouraged better enforcement of our laws, which is also very difficult in Virginia because the judges are appointed by the legislature and somehow feel beholden to that body instead of to the people in the community. That is one of our most difficult problems on the local levelâto encourage judges to pass sentences to the full extent of the law. For example, we were recently appalled to learn that an individual who drunkenly killed a young woman with his automobile in 1978, when he was a juvenile (for which reason, nothing happened to him), has subsequently been arrested on five infractions related to drunk driving. His attorney has, in our view, subverted the intent of the law, using the legal system such that the individual has served not one day in jail. The legal system simply has not provided the necessary and just sanctions. Because of a newspaper article on this case, the commonwealth's attor- ney in this jurisdiction has instituted a grand jury hearing; possibly some reasonable justice will now be imposed.
126 PREVENTION OF ALCOHOL PROBLEMS We feel that our local court systems, although fair, could do their job in a more just way. One of the biggest problems is continuance of trials, that is, delay from the originally scheduled day the trial was to take place, for weeks, months, or years, while the defendant shops for a more sympathetic judge or a lesser plea. Depending on the jurisdiction, between one-third and one-half of all trials are continued. If such an appalling degree of absenteeism existed in our school system, we would call it a tragedy. It is a national tragedy that the whim of the defense can gain a continuance, and that our prosecuting attor- neys and court system allow this. I am outraged at our current system after seeing how it operates. I know in my heart that something needs to be done. The problem in the past has been a lack of community support at the local level. This is the key: the more people become knowledgeable about this problem, the better off our communities will be. COMMENTS ON ALCOHOL, YOUTH, AND DRUNK DRIVING FRANK RAFLO, County of Loudoun, Virginia In light of the many suggestions for using the law to control the problems we have been discussing, I would particularly like to know what the evidence is on whether restrictive measures on individuals, or the fear of punishment for the abuse of alcohol and possible crimes resulting from it, have any impact on the use of alcohol. We are a nation that says, "Put them in jail." We also say, "We do not want to pay any more money for jails, rehabilitation, or courts." Under these circum- stances, do punitive measures or the fear of punishment have any impact on lessening the abuse of alcohol? CLAY HALL, National Highway Traffic Safety Administration We do not know if fear of punishment has any impact on reduction of consumption. We are seeing some results in terms of drunk driving. Where we are increasing the fear of arrest and the general deterrence aspect using fines, licensing action, etc., these actions are having some impact in reducing alcohol-related fatal and injury crashes. The biggest problem nationally is that we still do not have a sufficient fear of punishmentâwe can create it for a short time, but people soon perceive that the courts are not really fining people or taking licenses away; it is
ALCOHOL, YOUTH, DRUNK DRIVING 127 a paper tiger. Some communities are turning this around; in Maryland, for example, there has been good public information, good enforcement, and significant reductions in nighttime fatal crashes. We are at least changing the attitude in some communities such that drunks are not getting behind the wheel of a car. I do not know whether they are drinking any less, but they are not driving when they do. MARK MOORE, Harvard University Are we in the grip of a struggle over restrictive policies? Is there not some middle ground or different front that can be opened to somehow make that tension, which nearly everyone seems to feel, between indi- vidual license on one hand and paternalistic restrictiveness on the other, a little less sharp? What public spirit is out there that makes it easy or attractive to pass repressive measuresâwhich, after all, will turn out to cost a great deal of money in the form of jail capacity and required treatment? MARILYN GOLDWATER, Maryland House of Delegates In today's climate in state legislatures, at least in the Maryland leg- islature, it is politically easier to pass legislation that deals with punitive aspects of problems than to pass legislation that deals with education or, particularly when you have tight budgets, provides funds for the type of programs that educate people and change public attitudes. That is where the public pressure comes from; the other kind of pressure is there and is increasing, but it is not nearly as strong. In the same way, sometimes it is easier to pass legislation in the capital budget, which builds a building you can point to, than to find money in the operating budget to provide the programs and services necessary to make that building do what it is intended to do. Of course, punitive or restrictive measures are not all that easy to legislate. For example, no Maryland law prohibits drinking while you drive. I proposed legislation for several years, before finally giving up, that would prohibit open bottles of alcohol in the car. There were all kinds of interesting reactions. "If I am in the middle of mowing my lawn and run out of beer and drive to the local store to get some more and take a sip when I get into my car on the way home, can I get arrested?" Or let us say you wanted to make a law to permit carrying an open bottle of alcohol from the house to the beach or to a picnic, as long as the bottle was in a concealed part of the car, like the trunk;
128 PREVENTION OF ALCOHOL PROBLEMS unfortunately, some cars do not have a trunk or other place to put something so that the driver and passengers cannot get at it. People come to the legislature and say, "This is a problem in my community; let us get it solved." They look at it as very simple, but to draft a piece of workable legislation and get consensus on it is very difficult. Sometimes we can get consensus only on a piece of empty legislation. ROBERT REYNOLDS, County of San Diego There is a lack of comparability in the clarity of the alternatives we have been discussing. It is easy for legislators to understand punishment and treatment; it is difficult to understand prevention. If you spend money on prevention, how do you measure the results? We are not able at this point to give clear enough recommendations to legislative bodies on what is an efficient use of resources. I think it is both the climate of the times as well as the status of our research and knowledge that is preventing us from moving forward. We are simply not able to speak clearly on the directions in which we should move forward, particularly in the face of some rather grim research on some historic prevention efforts. MARK MOORE, Harvard University When we take official, government-sponsored, authorized action with budgets and laws attached to it, there is a special need for simplicity, and maybe it comes out a little punitive because that fits with what people think the government is capable of doing. That would be one way to think about it. And yet we have heard eloquent accounts of unofficial, nongovernmental enterprises, which seem to have a lot of force behind them as well as a great deal of sensitivity to detail, so that the force is exercised in a careful and discreet way by volunteer groups. I have a general kind of view that all of these things turn out to be more complementary than we are inclined to think, that public and private work together, that punitive and treatment approaches work together, that taxation and education work together, that all the things that we imagine as being starkly opposite, as representing alternative routes, gain power when we put them together. KEITH SCHUCHARD, Parental Resource Institute for Drug Education Laws work best when they represent the concerns of citizens. I think most drunk-driving laws, for example, which we call punitive (I do not
ALCOHOL, YOUTH, DRUNK DRIVING 129 think that has to have negative connotations; it means that we publicly define something as wrong and therefore apply a legal penalty), work when there has been enough education in the community to arouse the concern of the people who will be affected and who are willing to vote those laws in. Mothers Against Drunk Drivers got laws passed that many legislators hated because so many of them drink and drive. It was a very difficult lobbying effort. Prevention education for youth is a nebulous area. It comes into play somewhere between the naivete and idealism of preteensâwho believe their parents and like their teachersâand norms of responsible use for adults. In between there are mixed-up, muddy messages going to the adolescent, who is supposed to become adult and responsible in han- dling intoxicating chemicals that basically make him or her irresponsi- ble. This is a very difficult area for the government to get involved in. Parents are legally responsible for their minor children's behavior and they are really the only ones who can make much difference. I do not think there has to be a dichotomy between legislative and voluntary approaches, but I think that forces that work on a large scale must fit in with the actual concerns of people most directly connected to the problem. SHEILA BLUME, National Council on Alcoholism Most people do not realize that the best data we have on public policy for alcohol problems relate specifically to the effect that changing the minimum legal purchase age has Oil road accidents. The studies indicate that the minimum purchase age does not stop teenagers from drinking but does powerfully influence where they drink. Data charts I have seen recently from a longitudinal study at Rutgers showed that below age 18 (the legal drinking age when this study cohort reached 18), the bar- drinking column was empty; above that age, the bar-drinking column had big numbers in it. The purchase age seems to determine when young people go to on-premise drinking sites in large numbers, and that influences road accidents. It also presumably affects the degree of control that parents can exercise over adolescents' drinking practices. ROBERT STRAUS, University of Kentucky The strongest argument that came out of the 1950s for lowering the drinking age in the first place was based on available data suggesting that in areas in which drinking was restricted fewer people drank; those who did, however, drank more, and the prevalence of drinking problems was much greater. College data were used as well as comparisons of
130 PREVENTION OF ALCOHOL PROBLEMS consumption patterns and problems in local-option states. By the time implementation of the lower drinking age occurred in the early 1970s, based of course mainly on the shift in the voting age, we were in a completely different era with respect to intoxicant use in the United States. I have been a bit concerned with the extent to which we may apply rather simplistic explanations to the apparent rise in problems due to the change in drinking age, without taking into account about six other things that were happening in society at the same time, such as the generalized increase in consumption of alcohol, the increase in use of a whole variety of substances by younger people, the enormous increase in the number of vehicles licensed to and driven by younger people, and several others. PHILIP COOK, Duke University A general social science research principle that is relevant here is that you have to actually try something to know whether it works the way you expect it to. And even then you will never know whether it works unless you intervene in a way that lends itself to assessment and make sure that someone is actually positioned to do the necessary research. That quasi-experimental situation occurred after the drinking age was lowered in many states in the early 1970s. BARRY SWEEDLER, National Transportation Safety Board The National Transportation Safety Board has made recommenda- tions based on that research. While our recommendations are not man- datory and we have no enforcement authority, they have a high level of credibility and are usually given careful consideration, focusing national attention on what we consider to be important transportation safety issues. We were particularly concerned about the problem of youth in traffic accidents, since about 20 percent of all fatal accidents involve drivers under the age of 21, while less than 10 percent of licensed drivers are in this age group. We felt this overrepresentation needed our attention. We considered the evidence very strong that raising the drinking age to 21 would help the problem of youth/alcohol/driving. I stress that this is not a total solution, but one that we felt had been proven indisputably effective by statistical analyses. About 5,000 lives are lost each year in alcohol-related accidents in which the drivers are under 21. On the basis of the studies that have
ALCOHOL, YOUTH, DRUNK DRIVING 131 been done, we felt that about 1,250 lives, most of them young ones, could be saved each year if each state raised its drinking age to 21. With that information and a synopsis of all the research that we were familiar with, we addressed public recommendations to the governors and leg- islative leaders of 35 states (and the District of Columbia) that had a drinking age of less than 21 for some or all alcoholic beverages. These recommendations were made in July 1982, and support for them has come from across the board: the highway safety community, parents' groups, police groups, medical and insurance groups, the Bartenders Union, the President, the Secretary of Transportation, the Secretary of Health and Human Services. Congress has urged states to do this. The Gallup poll has shown that 77 percent of the population supports leg- islation to raise the drinking age to 21. Surprisingly, 58 percent of the youngsters in the affected age group, 18- to 20-year-olds, support this legislation. In almost every affected state, relevant legislation has been introduced; 4 states have raised the drinking age to 21, 3 other states to 19, and 1 to 20. Whenever a proposal to raise the drinking age has been voted on by a legislative body in this country, it has not lost. But in many states it has been bottled up in committee, primarily because of strong lobbying efforts by people who sell alcohol primarily to youth, such as certain tavern owners. Citizens in a number of states have become disgusted with their own legislative process and have gone to the ballot initiative, where that is available. Michigan passed the proposition with a 58 percent majority. In Ohio, proponents are collecting signatures. In Arizona, the campaign was headed by a conservative Republican and a liberal Democrat, and the governor signed the first petition. If the legislative bottlenecks on this issue were brought before the public through the media, the public that supports the change would put enough pressure on their legislators to force a vote. MARK. MOORE, Harvard University I would like to ask Deputy Chief Kenny of the New York City Police what their experience has been with respect to the enforcement of some of these drunk-driving laws. JOHN KENNY, New York City Police Department In 1982 we made over 4,200 arrests for driving while intoxicated. About 52 percent were involved in accidents. The figures are not all up- to-date, but 83 percent of the chemical tests taken were at the 0.10
132 PREVENTION OF ALCOHOL PROBLEMS blood alcohol content level or higher (19 percent of the people refused to take the test). We were able to look at only 1,832 out of the 4,000- odd arrests, but we found an 83 percent conviction rate with an average fine of $234.00. We also found a lot of misdemeanor arrestsâthe vio- lator pleaded to the lesser charge of driving-while-ability-impaired. A total of 4,281 arrests may not seem like many for New York City, but this was a 51 percent increase over 1981. The priority for driving-while- intoxicated has not been very high; we have problems with robberies and crimes against the person that have a much higher priority. But we are now putting more people into this; we want to do a better job. In 1981 a law was passed in Albany, New York, providing that 50 percent of the fines collected as a result of driving-while-intoxicated arrests could be returned to the county in which the arrest was made for education, rehabilitation, and enforcement. So in May 1982 we started a very small, token program: We had 18 officers working Friday and Saturday nights between 6:00 pm and 4:00 am. We made 800 arrests with this program from May 1982 until May 1983. Of the 800 arrests, 93 percent were made by observation onlyâpeople not involved in accidents. It is a good program; we will get the money back; the only problem is that everyone is looking to get a piece of the money, and it conies back only after we have arrested the drunk driver. It is too late then. We should try to reach these people with education and rehabil- itation before the police get to them; we wind up with them in family fights, child-battering incidents, accidents, and murders, as well as driving while intoxicated. MARK MOORE, Harvard University It seems to me that these two instruments are not separate. There is educational value associated with having the law and the arrests. In fact, the power of the educational effort is strengthened when you can say that the legislature decided that this is a bad level of drinking, that the risk of arrest for it is going up, and regardless of whether you think it is wise for you as an individual to drink and drive, this is what the law and other people think. The law and education seem to have poten- tiating effectsâone helping the other. And the law itself has enormous educational power.
ALCOHOL, YOUTH, DRUNK DRIVING 133 CHARLES CRAWFORD, Gallo Winery I think that we should focus on encouraging social responsibility among young people and not on trying to force prevention on anyone. Let me illustrate this. During Prohibition, the town I lived in was 80 percent Italian, and everyone drank wine. My family made the legal limit of wine, 200 gallons, each year. If we went to someone else's house, the jug of wine came out and everyone had a glass, including the children. There was no drunkenness on these occasions. I do not remember seeing anyone intoxicated all the time I grew up. But when I went to high school in 1932, we took a mandatory field trip to the closest jail, to see the drunk tank. That was the first time I had seen anybody drunk, and I will never forget it. How can we encourage responsible behavior today? The Bible is probably the most-read book in the United States, but nextâat least in Californiaâis the official driver's license handbook. The California Driver's Handbook has two full pages about punitive sanctions on drunk driving but nothing on how much alcohol it takes to achieve a blood alcohol content (BAC) of 0.10 percent. The reader should learn that two glasses of wine over a mealtime period of 1-2 hours will not cause 0.10 percent BAC, while four beers consumed quickly to quench thirst on a hot day can put BAC over 0.10 percent. I know 18- and 19-year- olds who actually think they can drink a six-pack and drive better! If every driver's handbook had a few pages, not on punitive laws but on what causes drunk driving and what constitutes social responsibility, I think it would mean a lot. The next most widely read documents are the newspaper and the comics. The Bureau of Alcohol, Tobacco, and Firearms put out a comic book on alcohol a couple of years ago that I thought quite effective. Something could be done in every Sunday comic, to catch kids who are 12-16 years old, who I do not say should not drink, but should drink temperately and understand that food and beverages go together. Much can be done. I am on the Stanislaus County Advisory Board on Alcohol Problems. Drunk driving is down by 40 percent in Stanislaus County, but we see it slipping back up again, because people lose interest: the police lose interest, the judges have no more room to throw people in jail, and they start to forget about it. I try to stir them up again. I believe that social responsibility is the answer. In Stanislaus County right now we are using role playing to talk about drinking. One kid pretends he has a new car and a six-pack of beer; he picks up two friends, and they invent a dialogueâwhat do you say, what do you do if somebody says have a drink of beer? This approach works. If you
134 PREVENTION OF ALCOHOL PROBLEMS give them a lecture, 50 percent do not even listen; when you get them doing it voluntarily, they become socially responsible. JAY LEWIS, National Council on Alcoholism Mr. Crawford, you would put messages about the social responsibil- ities involved in alcohol use on widely read materials like the driver's handbook. I wonder if you would put information related to the addic- tive quality of alcohol on the labels of wine bottles? I assume that purchasers of wine would be reading the labels. CHARLES CRAWFORD, Gallo Winery I wish that were true. Yet I watch my daughter smoke cigarettes, and you know what it says on the package of cigarettes. Warning labels on the bottles will not do any good at all. They might be read once and then forgotten. But applicants are going to be asked questions about their driver's license handbook, and if they miss a few of those ques- tions, they will not get the license. Every day, thousands of people take that driver's license test. DAN BEAUCHAMP, University of North Carolina In North Carolina you only have to read the driver's handbook once every five years. I do not think that will be very helpful to us. GAIL HEALY, White House Office of Drug Policy We need to offer positive alternativesânatural highsâto young peo- ple, to combat the media and advertising campaigns to "take this sub- stance and be superwoman or superman." I recently spent a weekend watching a meet of the U.S. white-water canoe team. The way of life they are dedicated to does not totally exclude alcohol, but their schedule does not give them time to become addicted. Young people are involved in ballet, in art, in music, in many things outside of "dedicated partying" of the sort that Keith Schuchard described. MARK MOORE, Harvard University I would take issue with the suggestion that the out-of-control teenage party leading to violence or injury is "typical." The problem is that it is not typical; it is an extreme event that happens in circumstances that
ALCOHOL, YOUTH, DRUNK DRIVING 135 are typical but that hardly ever produce the results that were described. For every 1,000 drunken teenage parties, or some number like that, there will be one that produces a broken limb. Certainly, the drunken party in some sense produces that injury, but it produces it probabilist- ically. Over a large enough group of people it is going to happen, but for each party it is a very unlikely event. How should we manage that? Not by banning teenage parties, but by managing them. As a parent, incidentally, 1 would be grateful for a law that gave me responsibility and set the community's standard, so that I would be in the position of enforcing the law and the standard with respect to my own house and children. I would take that responsibility seriously and I would know when I was well inside or outside that standard. The dilemma for us is that there are a lot of activities that sometimes, probabilistically, pro- duce bad consequences, but mostly do not, and yet these probabilities call on us to exercise substantial managerial effort. KEITH SCHUCHARD, Parental Resource Institute for Drug Education Unfortunately, these cases are not as isolated as we might like to think. County and neighborhood newspapers carry local stories like this constantly. The problem is usually underreported, because the law does not get involved or these cases are not reported in the paper as drinking incidents. DAVID KRAFT, University of Massachusetts, Amherst The liability issue has been one of the things that got my prevention program moving into the university dormitories, because the dormitory managers were worried about their liability if something happened. This galvanized the students; they were worried that they were not going to be able to use alcohol at their parties at all, and we got a major change in party planning. I think liability can be used to good advantage, and circumstances in which people realize they might be responsible are important. SISTER MADELEINE BOYD, Shalom, Inc. Many parents ask us what to do about parties for their teenagers, who do not want to give a party unless there is beer. My answer is that the parents can be sued. For one's own child, one's own family, it is okay. But many people in Pennsylvania have been prosecuted when a child from another family was served beer with an adult present. This
136 PREVENTION OF ALCOHOL PROBLEMS is a real-life deterrent in the home. If you serve somebody outside the family, you are legally liable. MICHAEL Fox, Ohio General Assembly The liability issue is very important to the question of making students take breathalyzer tests when suspected of being intoxicated or under the influence of alcohol. In my district in Ohio, when a principal thought that a high school student was involved with alcohol, he would send the student to the emergency room and ask that a blood test be done. Doctors did not want to deal with this because they had to have parental consent to give the test. As a result, the only results that the principal heard about were those that showed that the child did not have any alcohol or drugs in his or her body. If the test results did not come back the way the parents wanted them to, they faced the choice, "If I communicate the results of this test, my child will be expelled from school; if I do not tell them, my child may not learn a lesson." What is the doctor's liability? In the situation that Keith Schuchard mentioned involving the ambulance driver, did that person have the authority to shut that party down? Did he have any liability for not acting? The general point is that liability is a powerful tool, that it affects many situations in which alcohol is involved, and that a coordinated approach, drawing on the interests of a variety of groups, may be a solid base that can attract the workable coalitions necessary to get legislative action.
7 Community Cooperation to Reduce Alcohol Problems ALTERING THE DRINKING ENVIRONMENT AT THE COUNTY LEVEL ROBERT REYNOLDS, County of San Diego Examples of community cooperation to reduce alcohol problems abound in our society. Unfortunately, most of these examples involve what Mark Worden has labeled popular prevention: efforts directed at involving functioning individuals in life enchancement activities (Wor- den, 1979:425). In the alcohol field there is a plethora of in-school programs that incorporate information giving, values clarification, and peer counseling, which usually enjoy broad-based community cooper- ation. In our prevention efforts in San Diego County we encourage speaker invitations to Soroptimist and Rotary luncheons, court favor- able attention from the news media, and sponsor neighborhood coffee klatches and community forums. Most of these efforts are premised on the notion that if individuals had better information or felt better about themselves, then they would not develop alcohol problems. Despite the lack of any substantive evidence that these activities produce the desired result, we persist in these efforts because they are, indeed, popular. Given the magnitude of our community alcohol problems, it is evident that individually focused prevention efforts, even if proven effective, are unacceptably inefficient. As a society we simply cannot afford to thoroughly educate every citizen about alcohol problems and the use of alcoholic beverages. Fortunately, we have an alternativeâa choice 137
138 PREVENTION OF ALCOHOL PROBLEMS perhaps best exemplified by our responses to other community prob- lems. For example, when we have a dangerous traffic intersection we very seldom mount a campaign to educate the public about the dangers of the intersection. Instead, we install a traffic light or in serious instances we construct an overpass. In short, we alter the physical environment in lieu of attempting to modify individual behavior through increased awareness of the problem. This alternative response is both efficient and effective, but until recently similar response systems have seldom been employed in responding to community alcohol problems. The National Research Council's report Alcohol and Public Policy: Beyond the Shadow of Prohibition provides focus to prevention policies that "... operate in a nonpersonal way to alter the set of contingencies affecting individuals as they drink or engage in activities that . . . are considered risky" (Moore and Gerstein, 1981:53). Regrettably, the alco- holism constituency has limited experience in generating community cooperation in support of policies designed to change the circumstances of the drinking event. Until recently, post-Prohibition prevention efforts had been largely directed at changing the drinker per se. In spite of this limited experience, we may expect tremendous expansion of commu- nity support during this decade of prevention efforts designed to reduce alcohol problems through direct alteration of the drinking environment. Basis for Optimism There are four main reasons for optimism. First, in the past decade there has been a dramatic increase in our society's acceptance and definition of alcohol problems. Alcohol problems are now a topic of community discussion at the local, state, and national level, and this discussion is no longer narrowly focused on the alcoholic. As a society we are beginning to recognize that drunk driver problems, stadium crowd control problems, home accidents and violence, and many other alcohol-related problems cannot be blamed exclusively on the alcoholic. As an example, a study recently completed in San Diego demonstrated that of those convicted for a first-time drunk driver offense, fewer than 20 percent exhibited serious drinking problems, compared with 80 per- cent of those with second convictions (Ryan and Segars, 1983). Thus, as our society redefines alcohol problems and the causes of these prob- lems, our definition of prevention policies must also change. Second, the groups and individuals historically involved in providing alcoholism services have begun to acknowledge resource limitations and the need for new allies. As the definition of alcohol problems
COMMUNITY COOPERATION 139 expands, and as institutions across our nation confront the limitations of public- as well as private-sector resources, the historical alcoholism constituencies are forced to face the reality that there will always be insufficient resources to provide direct personal recovery services to all those in need. While prevention efforts have always received lip service, this acceptance of resource limitations has belatedly begun to generate a genuine interest in prevention policies focused on societal rather than individual changes. Third, recent prevention policy research has presented new options for community cooperation in reducing alcohol problems. As recently as three years ago the literature was essentially devoid of discussion of the impacts of minimum age restrictions, media portrayal of alcohol consumption, beverage labeling, excise tax levels, bartender liability and training, and other similar policy issues. The emergence of this literature will provide guidance and encouragement to community efforts to reduce alcohol problems. Finally, success tends to have a catalytic effect. Community groups are beginning to again become involved in efforts to reduce community alcohol problems. While the negative consequences of Prohibition have long been interpreted as demonstration that alcohol problems cannot be managed or resolved through controls on alcohol availability, local community experience is beginning to challenge this interpretation. As communities have confronted specific alcohol problems, they have rediscovered that these problems can be resolved and that controls on alcohol availability are an important factor in problem resolution. Whether directed at alcohol problems occurring at a public beach or park, a sports stadium, or a neighborhood corner, the availability of alcohol itself is increasingly acknowledged as a legitimate concern. While com- munity prevention efforts have typically been focused on small-scale neighborhood problems, success in resolving these issues of limited scope has encouraged a community willingness to respond to alcohol problems of a broader scope. Initiation of Prevention Efforts Most frequently, we discuss and analyze prevention efforts that have been initiated through the efforts of individuals in the field of alcoholism. Special projects and campaigns understandably draw our attention and our praise or criticism. These efforts typically identify a problem, define its magnitude, initiate an awareness campaign, and hope that awareness will generate concern and then action. This hope is seldom realized, and the critics announce that another prevention effort has failed.
140 PREVENTION OF ALCOHOL PROBLEMS This failure is not difficult to understand. Prevention efforts that seek to make the special concerns of those in the field of alcoholism the concern of the general community must be extremely well designed and conducted to be successful. In short, it is very difficult to convince others that "my" problem should become "their" problem, and it is even more difficult to convince the community that this problem is of such priority as to merit individual time, money, or changed behavior. While it is certainly understandable that the alcoholism constituency has concentrated on its self-initiated efforts, this parochialism has diverted attention and resources from other, more spontaneous, and probably more successful community prevention efforts. The alcohol problem most likely to motivate an individual or group to action is the problem that emerges from a personal crisis, e.g., a child killed by a drunk driver or a business suffering declining floor traffic due to street drinking. These events, and the resulting opportunities for mobilizing concern into action, are not predictable. Who can predict the death of a Carrie Lightner and the resultant development of Mothers Against Drunk Drivers? Who knows when central business district employers will join together in opposition to public inebriation, or when parents will object to student drinking at school social events? Ultimately, action initiated within the community is the action most likely to seize the community agenda and provide the opportunity for successful community cooper- ation to reduce alcohol problems. Too often, however, these opportunities are lost. People are other- wise engaged, and bureaucracies are often insensitive to community initiatives. Consequently, initial community action is too frequently allowed to dissipate. All too seldom are those interested in prevention policies able to capture the public's attention; we in the alcohol field must learn to respond with sensitivity, support, and creativity to the opportunities provided by others. Role of Prevention Staff Community denial of alcohol problems is still pervasive in American society. For alcohol program staff who have worked to achieve recog- nition of these problems, the emerging community acknowledgment of alcohol problems can pose an ironic dilemma. While community denial of alcohol problems and the consequent lack of recognition of past accomplishment and effort have frustrated alcohol program staff, the emerging community acceptance of alcohol problems is in fact primarily predicated on responses to individual losses or problems identified as external to the alcohol constituency. While recognition of
COMMUNITY COOPERATION 141 past efforts may well be deserved, such recognition does not advance community initiative to resolve alcohol problems. Community members often become involved in community alcohol problems for intensely personal reasons. The personal motivation is usually quite immediate and may relate to a tragic event or loss. With such individuals the recounting of prior staff efforts to resolve the problem is likely to be discounted or rejected and is often resented because of prior perceived failures. In fact, unless staff can relate on a personal level to the problem identified, whether it be loss of business, property, family, health, or comfort, staff involvement in problem res- olution is likely to require both explanation and justification. Whether it is the common experience of concerned parents, aroused neighbors, or victims of drunk drivers, it is this common anger or frustration that provides the initial fuel for community cooperation to reduce alcohol problems. Staff experience, no matter how expert, must remain secondary and supportive. The challenge is to weave staff knowledge into the analysis of the problem without detracting from the sense that the group is capable of and responsible for resolving it. Arenas for Action Certain areas of recurring concern can be expected to provide fruitful arenas for prevention efforts, whether initiated by the alcoholism con- stituency or by the general community. While many classes of concerns are possible, Friedner Wittman (1982) has developed a helpful structure: 1. Problems of neighborhood tranquillity, including rowdy outlets, late-night drinking and parties, and drinking in public places. 2. Concerns about alcohol outlets, including sales to minors and the relationship of alcohol outlets to crime and vice. 3. Concerns about drinking and driving, including accidents, enforce- ment levels, and freeway-oriented outlets. 4. Young people's and minors' uses of alcohol, including problems of growth and maturation and social interactions. 5. Public inebriates and alcohol problem areas, including public and private-sector costs and inconveniences. Clearly there are other areas of community concern about alcohol problems; however, problems in these five areas exist and surface from time to time in almost every American community. Those with an interest in resolving alcohol problems should prepare generalized strat- egies of response for each of these problem types, remain sensitive to emerging community concerns, and be able to tailor involvement and
142 PREVENTION OF ALCOHOL PROBLEMS activities to each specific event generating community interest. Thus, prevention planning becomes less a matter of predesigned campaigns, slogans, and media events, and more a matter of contingency planning and support for community-initiated concerns and events that, while unscheduled, are predictable in their general theme. A number of planned responses could be developed for each problem type. For instance, for concerns about alcohol outlets, community responses could include efforts to improve bartender training, to reduce hours of sale or occupancy limits, to increase police presence, and to improve physical settings such as noise barriers or parking lot lighting. When a specific community concern is identified, these options should be tailored for application to the presenting problem. Advance planning will help ensure that a full range of options is examined in the devel- opment of an integrated response, thus avoiding incomplete problem analysis, single-dimensional responses, and ultimately unsatisfactory problem resolution. Principles for Success There are at least six principles that when followed promote suc- cessful community cooperation to reduce alcohol problems. First, groups must listen to each other. To succeed, community coalitions established to reduce alcohol problems must draw support from a broad field of interests. The view of the problem and position of each coalition mem- ber will vary, but these divergent positions must be understood and accepted by the group as a whole if the coalition is to succeed. As an example, the problem of street drinking and public inebriety might involve the following interests, problem definitions, and solu- tions: Interest Group Perceived Primary Problem Perceived Primary Solution Merchants Sheriff City police Courts Loss of business Jail overcrowding Merchant complaints Crowded dockets Eliminate street drinkers Expand jail Additional police officers Reduce arrests/ Add judges Expansion of resources Church missions Alcohol program Indigents needing food and housing Alcoholics needing Additional treatment treatment programs Street drinkers Police harassment Jobs and housing Shoppers/Employees Panhandling/Safety fears Eliminate street drinkers
COMMUNITY COOPERATION 143 Each group has a legitimate interest in the problem and a particular view of the problem and solution. However, it is only through open communication that these groups will be able to avoid conflict. Often the perceived solution for one group (additional police officers) contrib- utes to the perceived problems (crowded court dockets, jail overcrowd- ing) of another group equally committed to resolution of the initial problem (public inebriety). Second, underlying assumptions must be challenged. Few areas are as fraught with myths as are alcohol problems. Typical examples include the common belief that most drunk drivers are alcoholics and that central-city street people are primarily public inebriates. In the example of public inebriety described above, each interest group has made cer- tain assumptions about the nature of the problem and the solutions. After each group has an opportunity to be heard and understood, the assumptions of each must be challenged before they are accepted as a basis for action. This challenge often involves the next principle. Third, problems must be precisely defined, described, and disaggre- gated. Social survey research is especially helpful in this effort. In San Diego it was discovered that individuals arrested by the police for public inebriety were not as transient (only 19 percent with under a year's residency, 56 percent with over 5 years' residency), as old (42 percent under 30, only 9 percent over 60), or as frequently a problem (88 percent picked up once per month, only 6 percent more often than twice per month) as commonly assumed (Wynne, 1982a, 1982b). These data were essential in defining central-city problems and designing achievable and successful responses to them. Fourth, responsibility for each problem segment must be both iden- tified and defined. Often responsibility isjointly held, but mutual respon- sibility must be acknowledged and accepted by the responsible parties before cooperative effort can begin. At times it is difficult for groups to acknowledge mutual responsibility. In fact, many prevention efforts are initiated by one group accusing another of failing in its responsibil- ities. Merchants often blame street drinking problems on lack of police action, while failing to recognize that the police do not distribute and sell alcoholic beverages. Placing blame is counterproductive and must be replaced with acceptance of mutual responsibility if a successful coalition is to be sustained. Fifth, all involved parties must move forward in an integrated and incremental response to the problem. Independent and sudden or dra- matic actions should be avoided to decrease the likelihood of unintended negative consequences for other coalition members. Clearly, unilateral and unexpected increased police actions in a central-city area can over-
144 PREVENTION OF ALCOHOL PROBLEMS whelm community jail, court, health, and social service systems. Changes in agency procedures or policies should be carefully coordinated to avoid negative impacts on others. In addition, such sudden and uncoor- dinated changes pose unnecessary risks. Communities and community alcohol problems are dynamic. Few alcohol problems can be resolved by a single action. Most actions create a reaction and probably a new problem. Even with the best planning, these new problems are difficult to predict. Incremental implementation of new policies and procedures provides for a margin of error and an opportunity for assessment. This permits midcourse corrections to minimize the development of serious new problems. The five principles presented above are dynamic and nonlinear. They are most effective when applied simultaneously and continuously, which is the sixth principle. While listening must never stop, discussion and consensus must not become goals in and of themselves. Assumptions must be challenged, problems defined, responsible parties identified, and action plans implemented. Community prevention efforts are begin- ning. However, there is no middle or end to these efforts. Although alcohol problems may change or their magnitude increase or decrease, they are very seldom eliminated. Even as one prevention plan is imple- mented, new problems emerge in a complex drinking society, with new underlying assumptions, providing additional challenges and opportu- nities. Prospects In this era community cooperation to reduce alcohol problems is still a relatively rare phenomenon. Our society is only beginning to cease blaming the individual alcoholic for the full range of alcohol problems in society. As we begin to overcome our collective denial of societal alcohol problems, there are signs that we are beginning to accept our collective responsibility for them. As helpful as prevention grants and staff experts may be, our hope rests primarily with the reemergence of citizen-initiated prevention efforts. Beginning on a small scale, community groups are discovering that alcohol problems can be moderated. Community cooperation to reduce alcohol problems is synergistic. This emerging cooperation promises to become the catalyst for affecting the societal changes nec- essary to reduce alcohol problems. This new social movement may well lead to major redefinitions of the role of alcohol in our society in the years ahead.
COMMUNITY COOPERATION 145 REGULATION AND EDUCATION IN A UNIVERSITY COMMUNITY DAVID P. KRAFT, University of Massachusetts, Amherst The Demonstration Alcohol Education Project at the University of Massachusetts, Amherst The University of Massachusetts at Amherst is the main undergrad- uate and graduate campus of the state university. The enrollment is approximately 22,000 students, over half of whom live in university housing. During the decade between 1973 and 1983, the campus focused special attention on alcohol-related problems. With the assistance of a federally funded grant from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) for approximately $600,000 between 1975 and 1980, the campus attempted to study ways of influencing commu- nity wide practices to reduce alcohol problems. The program developed certain methods that combined educational and regulatory approaches in a consistent fashion and became a "model" used by other university campuses. Extensive evaluation of program efforts produced a mixture of results that may be useful to prevention efforts in many locations (Duston et al., 1981; Kraft, in press). Campus efforts since 1980 have capitalized on these findings. The Demonstration Alcohol Education Project (DAEP) at the Uni- versity of Massachusetts relied heavily on community development principles with various campus constituencies. The program combined awareness-raising mass media approaches, small group educational efforts and community-supported special efforts, and behavioral regulations to effect changes. Program planning and evaluation tasks were guided by the PRECEDE health education model developed by Green and associates (1980). PRECEDE requires that specific adverse health con- sequences be defined and then analyzed to determine factors in the individual as well as the environment that inhibit or facilitate antecedent health-related behaviors. The model helped identify specific factors that needed to be addressed not only in individual students, but also in affiliative groups of students, key leaders of the institution and campus groups, drinking settings, and treatment resources. The PRECEDE model is consistent with the Fishbein and Ajzen (1975) theory of behav- ior change, which suggests that a person's intention to change his or her behavior can be influenced not only by knowledge, attitude, and belief changes in the individual but also by changes in community norms.
146 PREVENTION OF ALCOHOL PROBLEMS The Problems The perceived problems on campus shifted over time. For example, in 1973-1974, campus leaders were concerned about the number of "alcoholics" that seemed to be increasing and was especially reflected in alcohol-related dorm damage and arrests. Subsequent research actually showed that alcohol consumption had remained unchanged between 1971 and 1974, according to random surveys, and no more than 20 alcoholics (0.1 percent of the student population) could be identified through a review of comprehensive health records. However, the abuse of illicit drugs had certainly decreased between 1971 and 1974, and many periodic drinkers other than alcoholics were found to have expe- rienced alcohol problems. Beginning in 1975, campus leaders focused most of their attention on alcohol-related problems, including health problems, dorm damage related to parties, and campus police arrests in the following four categories: driving under the influence (DUI); protective custody (PC); malicious destruction and vandalism (MD&V); and disturbing the peace (DP). DAEP attempted to influence these behaviors. By 1979, after the legal drinking age had been raised from 18 to 20, concerns focused more heavily on minor accidental injuries, emotional problems, underage drinking on and off campus, and increased arrests for DWI and PC. (While dorm damage actually increased, DAEP studies had shown that much of it was not directly attributable to alcohol use.) By 1982, attention had shifted more directly to students with arrests for DWI and with disciplinary problems related to alcohol use. The historical shifts reported above reflected careful work that reg- ularly attempted to define the kinds and extent of alcohol problems that prevailed on campus. Very quickly, key community members began to realize that the highest proportion of alcohol problems occurred among both regular and occasional heavy consumers of alcohol, only some of whom would be defined as "alcoholic" by any standard criteria. The focus of community alcohol program efforts rapidly shifted to prevent- ing certain problems by a variety of strategies, only some of which focused on heavy drinkers, including alcoholics. Over the 5 years of DAEP, specific alcohol problems were recorded by both self-report surveys and community agencies. Each year a sig- nificant proportion of students reported driving under the influence (an average of 29 percent), academic problems (23 percent), minor physical injuries (17 percent), abusive behavior (16 percent), and job-related difficulties (14 percent) related to drinking. Property damage (7 percent) and alcohol dependence (1 percent) were also reported by a smaller proportion of students (Kraft, in press). Many of the adverse drinking-related behaviors seemed to be asso-
COMMUNITY COOPERATION 147 ciated with social events, including campus parties and drinking at pubs and bars. Survey data revealed that heavier-drinking students fre- quently attended both parties and pubs or bars (Kraft, 1981) and were more likely to experience adverse consequences than lighter or mod- erate drinkers. During the survey, which followed the raising of the legal drinking age from 18 to 20, the proportion of students reporting driving under the influence increased from 32 percent in October 1978 to 42 percent in October 1979 (Kraft, in press). Campus and Town Involvement The campus community was involved in DAEP activities and was monitored in an ongoing fashion. The relationship between campus perceptions and programmatic response was dynamic and evolutionary. For example, in 1973 the perceived problems of "alcoholics" led to an Alcohol Task Force in 1974-1975 that involved staff of the health ser- vices, police, dormitories, and the office of the dean of students. The result was a more general focus on drinking problems and the pursuit of federal funding for a campus alcohol abuse prevention project. In 1975, the receipt of federal funding led to an extensive effort to prevent alcohol problems by the use of peer education methods, mass media and public education efforts, intensive educational workshops for stu- dents, and active involvement of community groups and agencies. By 1977, problems related to campus parties (e.g., dorm damage, personal injuries, and questions of staff liability for party injuries) led to the establishment of an Alcohol Beverage Policy Task Force, com- posed of an equal number of the staff and students most concerned. The result was the implementation in September 1978 of a comprehen- sive party-planning policy that defined the responsibilities and training required for party planners, bartenders, security personnel, and staff supervisors for medium- and large-size parties. The policy showed initial positive effects until April 1979, when the legal drinking age was raised from 18 to 20, making it illegal for most on-campus students to drink. Another task force was convened that revised party-planning regulations to retain most of the important fea- tures of the previous policy. More significantly, reduced revenues at the on-campus pub led to cooperative efforts between the pub managers and DAEP staff to produce an attractive social center for students of all ages. We struggled with ways to improve the supply picture, such as changing practices so that the pubs would make as much profit on a pitcher of Coke for underage students as they used to make on a pitcher of beer. In 1981, a fatal accident in Amherst involving four youths who had
148 PREVENTION OF ALCOHOL PROBLEMS been drinking mobilized constructive "town-gown" cooperation to begin the Safety Action Program. It included both education about drinking and driving in the secondary schools and on college campuses, and stricter, highly visible enforcement of drunk driving laws with subse- quent convictions. Finally, in 1982, questions by off-campus bar owners regarding liability for accidents caused by drunken patrons leaving and attempting to drive led to an expansion of the campus bartender training to off-campus establishments. In the same year on-campus disciplinary cases, mainly involving alcohol-related abusive behavior and property damage, led to a special group education effort called the Student Opportunity Program. Students were helped to control their behavior before they experienced more severe disciplinary actions, including suspension. Most of the changes made over the decade between 1973 and 1983 had been identified in the preliminary needs assessments made in 1973 and 1974. However, the needs often could not be adequately addressed until relevant individuals or groups in the community became suffi- ciently concerned to help effect necessary changes. Also, many of the resultant changes might not have occurred if alcohol program personnel had not been alert and available to guide naturally occurring interests and events in a constructive direction (e.g., the 1977 conflict between students and staff over dormitory parties and the 1981 highway fatali- ties, which initially threatened to place the town and the university against each other). Five general steps were developed based on the prevention experi- ence at the university: 1. Determine the problems related to alcohol that concern commu- nity members most. Common themes and independently validated per- ceptions are important to pursue. List specific problems, not general categories of "drinkers," as much as possible. 2. Enlist aid in developing and continuing the programs, not only from those personally interested in the topic under discussion but also those agencies and/or key leaders who can influence or implement changes that might be needed. Involvement of key individuals and groups usually requires the recognition and use of each person's self- interests in the issues at hand. 3. Using the list of problems developed above, examine the evidence regarding the actual as well as the perceived extent of each problem and the factors that may contribute. Avoid either jumping to premature and oversimplified solutions until sufficient data have been examined or refusing to act once sufficient clarity has developed, even though the data are not conclusive or exhaustive.
COMMUNITY COOPERATION 149 4. Engage as many of the interested and necessary groups as pos- sible in a cooperative endeavor to design the solutions, especially if they will have to implement or enforce certain changes or will be the target of certain actions. In cases in which self-interest may impede progress, graduated steps may help overcome initial resistance. For example, if a voluntary educational approach is not effective to correct a certain problem within a specified period of time, then a more direct approach may need to be employed. 5. Evaluate the results in an ongoing manner and refine strategies accordingly. Use a combination of systematic observations, special surveys of "gatekeepers," and random surveys of individuals. The evaluation method should not be fancier than the accuracy of the data to be analyzed. Any change in a community system will also create or uncover new problems that require further study and evaluation. The Results of Community-Based Efforts Between 1975 and 1980, DAEP efforts focused on specific problems, especially party-related behaviors, driving under the influence, dis- rupted personal relationships, and interrupted personal career goals. Extensive approaches raised the awareness of up to 70 percent of students on campus about important alcohol messages through the use of posters, newspaper advertisements and articles, radio advertise- ments and interviews, and special displays in the student center (Kelly, 1978). Intensive, face-to-face educational efforts were used to reach about 10 percent of students each year. Most involved single-session, small group discussions led by peer educators (i.e., trained students) and were held in dormitories or apartments. Close to 0.5 percent of students participated in multiple-session group discussions or academic courses on prevention each year. Community development efforts con- centrated on key groups, agencies, and leaders according to the per- ceived needs and interests of both program staff and targeted personnel or groups. One result was that about 5 percent of staff and faculty of the university were involved in staff training each year, especially staff in the residence halls. Another result was involvement in an ongoing sequence of special groups to study and modify various regulatory practices both at the university level (e.g., party-planning guidelines) and at the individual agency level (e.g., bartender training at the on- campus pub). Efforts were evaluated in a number of ways. The most "scientific" evaluation instrument was a self-report questionnaire sent to a random sample of between 1,200 and 1,450 students each year with a response
150 PREVENTION OF ALCOHOL PROBLEMS rate of between 60 and 70 percent. Special surveys were also conducted with intermediate-level observers, including dormitory heads, medical staff, mental health staff, and campus police. Indirect "archival" data were examined for any trends, including routine reports reflecting dor- mitory damage, alcohol-related arrests, alcohol-related medical and mental health visits, and party permits. Finally, special controlled stud- ies of specific educational attempts were conducted to determine the relative value or effects of such efforts to change attitudes and behaviors (Kraft, in press). At the individual level most students learned certain facts and agreed with desired attitudes about alcohol. Program efforts also attracted the attention of a slightly higher proportion of the "at risk" population than other students, namely heavier drinkers, younger students, and stu- dents living on campus. However, no significant decrease in drinking behaviors or adverse consequences were noted among a random sample of students during DAEP. The only significant decreases in problem drinking behaviors were noted in students who participated in multiple- session educational programs designed to train them to teach other students. At the intermediate-observer level, a number of changes occurred. In the dormitories, a significant increase was observed over the five years in the number of parties that included nonalcoholic food and beverages, and in the active confrontation of problem drinkers by other students in an attempt to change their behaviors, including referrals to treatment resources. Among helping agencies, more staff reported recognizing alcohol problems much earlier and attempting to make appropriate interventions. Archival data proved useless in measuring the actual occurrence of alcohol problems. Most episodes measured are either low-frequency events (e.g., DUI arrests compared with the actual proportion of stu- dents reporting driving under the influence) or are so inaccurate due to a variety of other factors that no confidence could be placed in them (Kraft, in press). Special studies did show important results. One-session group dis- cussions did not result in behavioral changes whereas multiple-session discussion groups did show such changes. Media efforts can produce changes in knowledge about simple facts, such as the equivalent alcohol content of beer, wine, and liquor, without leading to behavior changes. Other studies also confirmed that significant changes did occur at aggre- gate levels, such as observations about party planning behavior, without being reflected in self-reported individual patterns of drinking. Finally, special spot surveys conducted on a regular basis with med-
COMMUNITY COOPERATION 151 ical and mental health staff confirmed much higher levels of people seen with alcohol problems than indicated on routine archival reports. Since the conclusion of DAEP, alcohol education efforts have con- tinued with a reduced level of specific alcohol-program personnel. Var- ious facets have been integrated within the ongoing efforts of other involved groups, such as party planning and early problem detection activities of residence hall staff, and bartender training and supervision by campus pub managers. Conclusions Community involvement in the prevention of alcohol problems in a college population is extremely important. Efforts to enlist and utilize community resources at the University of Massachusetts at Amherst over the past decade have demonstrated these main points: 1. Time Required: Broad changes usually require a long time to develop (years and even decades), frequently in response to a series of unexpected needs and circumstances. The shape of program efforts shifts according to the self-interests and needs of individuals and groups involved. 2. Specific Needs: Cooperation usually develops in response to some combination of perceived and actual needs of community members to combat alcohol problems. Perceived needs are often based on myths or incomplete data. As much as possible, specific alcohol problems should be defined and assessed to determine the actual extent of a given problem, with solutions developed accordingly. 3. Broad Strategies: Solutions to alcohol-related problems should focus not only on directly modifying the drinking behaviors of individ- uals, but also on training friends and family as well as gatekeepers (bartenders, police, medical personnel, etc.), altering environmental factors (drinking environment, public transportation to and from bars, etc.), and establishing norms and regulations that are both reasonable and enforceable. 4. Combined Approaches: Methods of changing drinking behaviors should combine mass media approaches to focus attention and mobilize support with in-depth education of significant groups and individuals regarding the prevention of specific alcohol problems and enforcement of reasonable regulations. The combination of efforts can often change aggregate behaviors in significant ways without necessarily altering self- reported alcohol consumption levels of individuals. (Young people drink the same amounts of alcohol, on average, but in safer ways.)
152 PREVENTION OF ALCOHOL PROBLEMS 5. Empowering Groups: Cooperative efforts should continually seek to use diverse groups in the community to design and implement various strategies. The cooperative endeavors can give the various groups a common understanding and also a collective response to such problems as driving under the influence or underage drinking in schools. 6. Treatment Sources: Prevention efforts must be built on adequate treatment resources for people with drinking problems. The resources must not be limited to those needed for severe alcoholics but should include general counseling and health services for the broad spectrum of people with alcohol problems. 7. Evaluation: Efforts to evaluate programs must be built into each endeavor. The evaluation methods used need not be highly advanced or complicated, but should be systematic and honest in order to detect changes or effects, if any. Without such evaluation, resources may be inappropriately used, only to fade away when their ineffectiveness is finally discovered. Systematic evaluation can also help ensure ongoing community funding and support even if efforts are only moderately successful. Community-based approaches seem to work best when they include a combination of education and regulation (or enforcement). Education alone, while ideally the most effective solution, is impractical. The amount of time and expense involved in attempting to modify unhealthy drinking beliefs and practicesânot merely informing people of unde- sirable consequencesâwould take resources and cooperation well beyond most communities' financial base and certainly beyond their authority. Yet a small but significant group of educated citizens can influence constructive changes in community norms and practices that can lead to desired changes. Regulation alone also can be fraught with difficulties of polarizing community residents with eventual rebellion in one form or another (often lax enforcement of an unpopular or unfair statute or law). Too often, regulations are developed and implemented with little input from various community constituencies and poor information disseminated to all residents concerning the need for regulations. The educational process can often make certain regulatory approaches more palatable and enforceable. Community strategies should not focus solely on changing alcohol consumption but also on changing people' s reactions to a given behavior (e.g., a bar owner not allowing a drunken patron to drive home) or insulating problem behaviors from undesirable consequences (e.g., pro- viding free bus service between popular drinking establishments and major living areas or encouraging drunken guests to sleep overnight).
COMMUNITY COOPERATION 153 In fact, efforts to involve the "alcohol distribution centers" (i.e., bars, restaurants, off-premise stores) with public information, trained per- sonnel, and modified practices are frequently ignored in community- based programs. Due to fears of liability, many establishments are now eager for useful training and assistance in some communities. Although difficult to achieve and maintain, community-level strate- gies can influence drinking behaviors more effectively than approaches based solely on individual education approaches. In fact, a combination of education and regulation proved to be the most effective way to produce community-level changes at the University of Massachusetts. COMMENTS ON COMMUNITY COOPERATION AND KNOWLEDGE DISSEMINATION FRIEDNER WITTMAN, Medical Research Institute of San Francisco James Mosher, Lawrence Wallack, and I have developed a Com- munity Substance Abuse Assistance Program in the San Francisco Bay area for the kind of community organizing that Mr. Reynolds talked about. Our emphasis has been to draw together representatives of each of the major sectors in the community. We held a series of workshops last year in San Francisco, attended by about 20 people representing the Public Defenders' Office, the City Planning Department, the down- town development area of San Francisco, the alcoholism treatment services community, the mayor's office, the Board of Supervisors, the local office of the Alcoholic Beverage Control Department, Wine Insti- tute, etc. By pulling together these major actors, we developed a com- munity of concern to begin sharing values and approaches to dealing with alcohol problems. We can report that organizing such a community group takes quite a lot of energy and a very heavy commitment of time. Just calling the first meeting was a major difficulty. But once we pulled together people from these constituencies, the ball began to roll and synergistic things began to happen. A critical incident was an oil company petition to the city to permit mixing alcoholic beverage and gasoline sales in drive-through mini-mart operations. That served as a galvanizing or rallying point around which the different people in the group could contribute their skills, resulting in the withdrawal of the petition to change the city ordinance. This success occurred while we were in the midst of calling together, plan- ning, and organizing these meetings. It is a small example of how calling people together and identifying areas of shared concern can work. We recommend working with the highest level of people in charge of
154 PREVENTION OF ALCOHOL PROBLEMS agencies, institutions, and organizations as well as at the grass-roots level of neighborhoods. Moving back and forth between these two levels, we think, is most effective. CATHERINE ANDERSON, Metropolitan Pittsburgh Public Broadcasting I would like to note how a major outreach campaign began in public broadcasting to fight teenage drug and alcohol abuse. In May 1981, WQED-TV in Pittsburgh launched a major campaign in western Penn- sylvania. We developed 12 hours of programming and created a task force composed of elected officials, the police, the universities, the churches, and so forth. Each of the people on the task force took responsibility for local high school communities and formed local task forces. Those task forces, we were told, would dry up over the summer. But by the fall, we had 112ânow 114. So we decided to make this a national outreach project called "Chemical People." We received grants from the Metropolitan Life Foundation and from the Mellon Foundation to do this. The White House is involved; Nancy Reagan hosted 2 hours of prime-time programming on public television. We have gotten 26 national organizations, including the National Council on Alcohol- ism, the National Council of Churches, PTAs, Junior Leagues, Kiwanis, Lions, and similar kinds of groups involved and committed to work on this project. Our goal is to create task forces in every high school community in this country. Public television stations have agreed to carry these national programs; most of them also agreed to produce a local program to talk about their particular problem and to spearhead the task force outreach in their community. ROBERT Ross, State of New York I recently attended a meeting of the Planning Group of Southeast Bronx. That community was so devastated in 1967-1968 that they are almost rebuilding the entire area; the planning group has an enormous amount of control over what gets back into the community. It is an interesting and rather eclectic group, consisting of religious and local business leaders, people who live or work in the community, etc. They represent not only people interested in social issues but also people interested from an economic point of view. As an example of the kind of policy issues that they focus on, the group has taken a very strong stand on housing and has prevented the building of any new high-rise residential buildings. I made an informal presentation on alcohol issues related to youth,
COMMUNITY COOPERATION 155 and one of the questions after the meeting was whether we could provide any guidance that could prevent the density of liquor outlets, both bars and package stores that had been there before, from returning to that community. The business leaders there were saying, "We only want certain kinds of businesses coming back." They are looking for guid- ance; state alcohol agencies, in providing information and direction for local guidance, can be very helpful. This community group does not want to see the problems replicated, and they want to feel that they can have some control over it. One of the things that our state agency focuses on is acquiring a better understanding of natural support groups that are tangential to the alcoholism provider network but would have a lot of impactâin some cases more than the alcoholism service pro- vidersâin determining local policy. HENRY KING, United States Brewers Association The range of local options varies with different state constitutions. For instance, in North Carolina a community can vote wet or dry. If they vote dry, they have no outlets. If they vote wet, they are allowed to have so many per population. Each state has different alcoholic beverage laws. We are talking about 230 million people living in a country in which there are established patterns of sales and distribution. So I do not think availability per se is the issue as much as the manner in which alcohol is made available. If the goal is to reduce consumption by reducing the number of outlets, there is just no way you can do that successfully with what is in place now. As a practical matter, it is not a reasonable option for those who want to reduce consumption. ROBERT REYNOLDS, County of San Diego But specific disaggregated alcohol problems are susceptible to change at the local level. There are many strategies that are the prerogatives of local government, such as zoning, that can be used in heavily impacted areas. Why should a community not choose to refuse more outlets if, for example, its alcohol-related crime rate is already 20 percent above the norm? Communities can mobilize around those kinds of issues and have an impact on the number of outlets permitted. In our central-city redevelopment in San Diego, the community testified against a certain type of drinkingâstreet drinking. A poor black community organized around the ready accessibility of package sales, because they did their drinking at home; you could not go anywhere in that community without seeing ready access to alcoholic beverages. In a skid row area, too, I
156 PREVENTION OF ALCOHOL PROBLEMS think the community has a right and an obligation to reduce outlets and consumption. Let me cite a different example of land use that is subject to local control: stadium sales. Is there any real reason to continue the sale of beer and wine in a stadium after the seventh inning, when people are about to drive out? Or in recreation sites: in many of our parks, distilled beverages are not permitted but beer and wine are, and we are steadily increasing our police force there. These are areas of availability that do not specifically have to do with licensing regulations, but with local values and mores. PHILIP COOK, Duke University Do you think, to take the example of reducing the number of outlets in a community, that if someone has to walk an extra block, or three or four extra blocks for a drink, that would make a difference for the neighborhood? ROBERT REYNOLDS, County of San Diego I think spontaneous buying is a very important factor, but we have a paucity of evidence demonstrating this relationship. We have very little social research, prevention research. Sociocultural and environmental research proposals go to grant review panels of psychological and bio- logical researchers, which give them very low priority. Typically, we are still looking for the pill, the biological factor. We still cling to the old notion that alcoholics cause all these problems. We are only begin- ning to understand that alcoholics contribute only part of the alcohol problems of our society. The number of cross-cultural and demographic studies in the area of alcohol abuse in our society is pitifully small. When you try to focus a specific intervention, when you look at a specific type of problem, you often do not have the data to apply to that specific instance. DWI is a good example. Who are the DWI drivers? They are impaired, and we too often confuse drunkenness with impair- ment. In my county, they tend to be young, white male adults whoâif you look at the Cahalan studies of drinking in the general population (Cahalan et al., 1969)âare getting drunk on weekends in the manner characteristic of that age stratum. Relatively fewâin our studies less than 20 percentâhave addictive drinking problems. Without these kind of data you do not really know how to intervene. I am persuaded by the basic formula of increased availability leading to increased con- sumption leading to increased problems. But when we try to intervene
COMMUNITY COOPERATION 157 with a specific problem, this kind of collective data falls apart. The proposition needs to be studied in a variety of settings and levels, making use of detailed demographic and survey research data. MICHAEL GOODSTADT, Alcoholism and Drug Addiction Research Foundation But would the data that do exist suggest that we should become more liberal? This is similar to the debate on television violence. For a long time people said that it is not proven that violence portrayed on tele- vision causes violence in society. But the data at that time, in the 1960s and the early 1970s, at least would have led you to be conservative, not to increase the amount of violence. In the case of alcohol, quite a number of studies, in addition to common sense, would suggest that we should stop making alcohol ever more available in the many ways it becomes more availableâincreased per capita number of outlets, let- ting the price drop as the cost of living increases, lowering the drinking age, making it permissible to drink in places other than licensed prem- ises or at home (camping sites and so forth)âall these "liberalization" measures. The data are not sterling, you would not stake your entire reputation on any single study, but collectively you would say, "Hold on." If we are going to make a changeâand there are pressures for change from all of us, in all parts of Western societyâthen at least we should attempt to assess it, always to ask ahead of time what are the likely implications of this proposed change for health and other aspects of things based on common sense and the data. We should look, as far as we can, at the impact, and try to act sensibly in light of what we can anticipate. MICHAEL Fox, Ohio General Assembly Another area in which we need more information is cataloging costs and evaluating programs. As we fight for dollars and compete for scarce resources across the board in the budgeting process at the state and local levels, the pressure to determine which social programs are cost- effective will increase. As a legislator and as a policy maker, one of the most frustrating things I deal with is the number of great plansâ"Let's do this in the courts, let's do this in the schools." (I have my own drug education package that I am trying to get into the schools, but most of the superintendents I talk to tell me that we could spend $100 million and not have an impact on the problem.) A resource that pulls together the social costs in the criminal justice system, the health care system,
158 PREVENTION OF ALCOHOL PROBLEMS the drunk driving fatalities, the teenage population problemsâthat cat- alogs these costs and offers a menu from which we can choose programs that have proven to be successful in a cost-effective wayâwould be extremely useful to policy makers, in the legislatures and state bureau- cracies, and in county governments. MARILYN GOLDWATER, Maryland House of Delegates Does some mechanism exist to pull together this kind of data and disseminate this information? It seems to me that there are many dif- ferent things going on, and it is important not only to evaluate them but also to disseminate the information around the country so that others can try them. The federal government works very well in disseminating information to counterparts in the state bureaucracy, for example, but not as well in getting information to state legislators, who also make policy. FRANK PADAVAN, New York State Senate The federal government could be very helpful if it would make such a resource available. For example, we have heard about liability for serving underage minors who later get involved in an auto accident. A number of states have it; a number of legislators in other states would like to have it. How effective is it and what are its positive benefits? It would be helpful to get that information to the state legislatures. When we were considering raising the drinking age in New York (which we did in 1982), we were not able to draw on an easily usable body of knowledge. I had to assign a researcher, and it took a lot of time and effort. We did pull it all together; we did present the case; we did publish a report, as did the state executive department. That was a lot of effort to expend. I hope that in the aftermath of this conference someone could make available to us information about things that have worked effectively that we are interested in accomplishing on our indi- vidual turfs, such as civil liability. It is a question of getting all the relevant data and analysis together, evaluating it, making it conciseâ we do not really have the resources to do that, as much as we would like to. DONALD MCCONNELL, State of Connecticut A body of knowledge about model programs has been created. The old Law Enforcement Assistance Administration (LEAA) of the U.S.
COMMUNITY COOPERATION 159 Department of Justice had model programs in criminal justice that could be replicated. That knowledge still exists somewhere, even though LEAA has been reorganized. The National Institute on Alcohol Abuse and Alcoholism has a national clearinghouse full of information relevant to programs and the evaluation of programs. The National Institute on Drug Abuse has a clearinghouse on programs that they have developed over the years. Some libraries have also put this material together; Rutgers has a fine library on the alcohol field, nationally and interna- tionally. A lot of material has been collected and evaluated. But we are generally weak on outcome indicators and longitudinal studies. During the years it takes to really evaluate a program, the scene changes, and the emphasis in society changes. Governments become interested in something else: holes in the highways rather than holes in the society. FRANK RAFLO, County of Loudoun, Virginia As for cataloging costs, one cost that is certainly rising faster than anything else is the cost of health, including and maybe especially mental health. I think that cost is being exacerbated considerably because of alcohol. For example, the social services board on which I serve has jurisdiction over one youngster who had an alcohol problem. He has been in a mental retardation rehabilitation center for 4 years, at a tuition of $28,000 a year. That is over $100,000 for one youngsterâso far. FRANK PADAVAN, New York State Senate Mr. Raflo's point is buttressed by dollars-and-cents figures in New York. The cost of health care relevant to alcohol, directly or indirectly, has gone beyond the reach of any average individual, with large sec- ondary and tertiary effects on the family, on the community, and on the employer. We are attempting in New York to mandate insurance carriers to provide alcoholism treatment in all group insurance plans to spread that burden. MARK MOORE, Harvard University With regard to the medical cost of chronic, intensive alcohol users: Researchers at Harvard Medical School studied high-cost medical care consumers. They turned out to be heavy smokers and drinkers, people who got sick early in life but not sick enough to die. They absorbed an enormous amount of the budget, far more than their proportion.
160 PREVENTION OF ALCOHOL PROBLEMS GAIL BURTON ALLEN, St. Luke's-Roosevelt Hospital Center I direct an alcoholism treatment program in New York. People in the field estimate that 25-50 percent of the cases in general hospital services would, if diagnosed, carry a secondary diagnosis of alcoholism or alco- hol abuse. This is a very significant fraction of medical costs. Cirrhosis is immediate, visible, and clearly measurable, but you must add general gastrointestinal diseases and all of the mental health problems. There is also the relation to child abuse, the delinquency of children of alco- holics, and the fact that these children are a high-risk population for general drug abuse and alcoholism. The costs are far-reaching and a little frightening. LORAN ARCHER, National Institute on Alcohol Abuse and Alcoholism A number of studies on the costs of alcoholism in terms of mental and physical health care have shown them to be quite substantial. As with the study of any disease, there are limitations to the knowledge we have. We are limited quite often to studies of admissions and there- fore limited to how accurate the admission diagnosis is. We have been trying to refine and gather better information. People who manage those records need to be able to highlight the issue of cause and effect. It is like the question, "How many deaths are caused by smoking?" Very seldom does smoking per se show up as a cause of death or illness, so the numbers have to be inferred on the basis of epidemiological and clinical research. We have the same problem with alcohol. We also need to build into the equation answers to the difficult question: What are the benefits of low-level alcohol use? We have started research from an epidemiological standpoint to look fairly at benefits and costs and balance the result. We have begun to show a substantial finding, as limited as the records are, in emergency room admissions, specific hospitals, and among high utilizers of health care. As gross as the figures are, we know that the cost is substantial. Alcohol has a tremendous impact on the health care system. The NIAAA and the National Institute on Drug Abuse are working jointly with the states to develop a dissemination network for epide- miological data. We have a great deal of data. At the present time we can provide, down to the county level, a great deal of information on specific indicators such as traffic fatalities, cirrhosis, and other vital statistics. Our major problem is how to get the information dissemi- nated, how to make that information available to state and local policy makers in a useful and easily accessible manner.
COMMUNITY COOPERATION 161 MARILYN GOLDWATER, Maryland House of Delegates I think it is clear that a body of knowledge exists, and a more effective mechanism to gather all that knowledge and disseminate it to policy makers and other individuals who need it should be developed. The climate is now right, and we ought to take advantage of it. While I think we need still more research, we cannot wait for that research. I think that is why it is important to catalog now what is out there and dissi- minate it to policy makers.
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Participants CONFERENCE ON ALCOHOL AND PUBLIC POLICY May 20-21, 1983 GAIL BURTON ALLEN, Department of Psychiatry, St. Luke's- Roosevelt Hospital Center, New York CATHERINE ANDERSON, National Program Underwriting, Metropolitan Pittsburgh Public Broadcasting, Inc. DAN E. BEAUCHAMP, School of Public Health, University of North Carolina MARILYN BEGGS, Vice President, Region V, National Parent-Teacher Association, Lincoln, Nebraska BEVERLY BLAKEY, Commission on Behavioral and Social Sciences and Education, National Research Council SHEILA BLUME, National Council on Alcoholism, New York BERNELL N. BOSWELL, School on Alcohol and Other Drug Dependencies, University of Utah SISTER MADELEINE BOYD, SND, Shalom Inc., Philadelphia EDWARD BRECHER, West Cornwall, Connecticut PETER BROCK, Johnson Institute, Minneapolis WILLIAM BUTYNSKI, National Association of State Alcohol and Drug Abuse Directors, Washington, D.C. THEA CHALOW, WGBH-TV Public Broadcasting, Boston STANLEY COHEN, Washington Bureau, Advertising Age PHILIP COOK, Institute of Policy Sciences and Public Affairs, Duke University CHARLES CRAWFORD, Ernest and Julio Gallo Winery, Modesto, California 171
172 PARTICIPANTS JOHN DOYLE, National Council on Alcoholism, New York RIPLEY FORBES, Subcommittee on Health and the Environment, Committee on Energy and Commerce, U.S. House of Representatives BARBARA FORDE, Research Department, National School Boards Association, Washington, D.C. MICHAEL Fox, Ohio General Assembly, Columbus PAUL GAVAGHAN, Distilled Spirits Council of the United States, Inc., Washington, D.C. MINDY GAYNES, National Conference of State Legislatures, Denver DEAN GERSTEIN, Commission on Behavioral and Social Sciences and Education, National Research Council STEPHEN GODWIN, Transportation Research Board, National Research Council MARILYN GOLDWATER, Maryland House of Delegates, Annapolis MICHAEL GOODSTADT, Alcoholism and Drug Addiction Research Foundation, Toronto GEORGE HACKER, Center for Science in the Public Interest, Washington, D.C. CLAY HALL, Office of Alcohol Countermeasures, National Highway Traffic Safety Administration JEFFREY E. HARRIS, Department of Economics, Massachusetts Institute of Technology, and Massachusetts General Hospital MARGARET HASTINGS, Illinois Commission on Mental Health and Developmental Disabilities, Chicago GAIL HEALY, White House Office of Drug Policy MARY HEVENER, Tax Policy Office, U.S. Department of the Treasury ALAN KAPLAN, Washington, D.C. MARK KELLER, The Center of Alcohol Studies, Rutgers University FRANK KENEL, Office of Traffic Safety, American Automobile Association, Falls Church, Virginia JOHN KENNY, New York City Police Department HENRY KING, United States Brewers Association, Washington, D.C. DAVID P. KRAFT, University Health Services, University of Massachusetts, Amherst EDWARD J. KUNEC, Mothers Against Drunk Drivers, Northern Virginia MILDRED LEHMAN, Alcohol, Drug Abuse, and Mental Health Administration, U.S. Department of Health and Human Services JAY LEWIS, Public Policy Office, National Council on Alcoholism, Washington, D.C. CHRIS LUBINSKI, Subcommittee on Alcoholism and Drug Abuse, Committee on Labor and Human Resources, U.S. Senate
PARTICIPANTS 173 KLAUS MAKELA, Social Research Institute of Alcohol Studies, The State Alcohol Monopoly, Helsinki BEN MASON, Adolph Coors Company, Golden, Colorado WILLIAM MAYER, Alcohol, Drug Abuse, and Mental Health Administration, U.S. Department of Health and Human Services ALFRED MCALISTER, Center for Health Promotion, University of Texas Health Sciences Center, Houston DONALD MCCONNELL, Commission on Alcohol and Drug Abuse, State of Connecticut MICHAEL McGiNNis, Health Promotion and Disease Prevention, U.S. Department of Health and Human Services ROBERT MCKEAGNEY, Department of Human Services, State of Maine MARK H. MOORE, John F. Kennedy School of Government, Harvard University JAMES F. MOSHER, Prevention Research Group, Medical Research Institute of San Francisco WALTER MURPHY, National Council on Alcoholism, New York FRANK PADAVAN, New York State Senate JANE SMITH PATTERSON, Department of Administration, State of North Carolina LORNE PHILLIPS, Alcohol and Drug Abuse Services, State Department of Social and Rehabilitation Services, Topeka FRANK RAFLO, Board of Supervisors, County of Loudoun, Virginia ROBERT REYNOLDS, Department of Health Services-Alcohol Program, County of San Diego ROBERT A. Ross, Division of Alcoholism and Alcohol Abuse, State of New York PATRICIA SCHNEIDER, Wine Institute, San Francisco KEITH SCHUCHARD, Parental Resource Institute for Drug Education, Atlanta SHARMAN STEVENS, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services LARRY STEWART, Laurland Productions and Caucus of Producers, Writers, and Directors, Los Angeles ROBERT STRAUS, Department of Behavioral Sciences, College of Medicine, University of Kentucky BARRY SWEEDLER, Bureau of Safety Programs, National Transportation Safety Board DIANA TABLER, Office of the Administrator, Alcohol, Drug Abuse, and Mental Health Administration RICK THEIS, Office of Public Affairs, Wine Spectrum, Atlanta ROGER THOMSON, S & A Restaurant Corporation, Dallas
174 PARTICIPANTS THOMAS TURNER, Johns Hopkins Alcohol Research Center, Baltimore JOHN F. VASSALLO, JR., Division of Alcoholic Beverage Control, State of New Jersey, Trenton LAWRENCE WALLACK, School of Public Health, University of California, Berkeley FRIEDNER WITTMAN, Prevention Research Group, Medical Research Institute of San Francisco NANCY WOLICKI, Subcommittee on Alcoholism and Drug Abuse, Committee on Labor and Human Resources, U.S. Senate JEFFREY WYNNE, Department of Health Services-Alcohol Program, County of San Diego NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOLISM LORAN ARCHER, Deputy Director FRAN COTTER, Office of Policy Analysis SUSAN FARRELL, Office of Policy Analysis JUDI FUNKHOUSER, Prevention Branch BRENDA HEWITT, Special Assistant to the Director STEVEN LONG, Financial Management and Budget Office BARBARA LUBRAN, Planning Branch JOHN NOBLE, Division of Biometry and Epidemiology ALBERT PAWLOWSKI, National Centers Branch GIAN C. SALMOIRAGHI, Office of Scientific Affairs LEE TOWLE, International and Intergovernmental Affairs JEANNE TRUMBLE, The Secretary's Initiative on Teenage Alcohol Abuse JOAN WHITE, Office of Policy Analysis
