4
Psychosocial Factors and Prevention

PSYCHOSOCIAL FACTORS

How does use of tobacco, alcohol, opioids, and stimulants begin? Virtually all Americans, some of whom may have a genetic vulnerability to drug abuse, are faced with the decision of whether to smoke, drink alcohol, or take illicit drugs. Why do some individuals say yes and others refuse? Why do some people and not others begin using these drugs in excess and why is it so difficult for some individuals to stop? In addition to studies about genetic vulnerabilities, these and similar questions are the focus of behavioral, epidemiological, and social science research aimed at understanding and preventing drug addiction. The research includes human and animal laboratory studies, and examines such phenomena as environmental factors and personal characteristics that predict addictive behaviors, as well as individual differences in the behavioral mechanisms of drug abuse. This chapter presents a brief overview of key issues in research relevant to the psychosocial and behavioral underpinnings of addiction before presenting examples of the variety of prevention strategies currently used to reduce the prevalence of drug abuse and addiction.

Psychosocial factors include personality and presence of psychiatric disorder, as well as family, peer, and other environmental factors that either increase the risk of an individual developing an addictive disorder (risk factors) or decrease such risks (protective factors). Cognitive and behavioral research is the key to understanding how basic principles of learning and conditioning can be used to modify drug-taking behavior; this research has been reviewed in a variety of reports and monographs (Hawkins et al., 1992; IOM, 1994a,b; IOM, 1996a). Briefly, research indicates that beliefs and attitudes, many of which are learned by watching or listening to role models at home, in the community, or in



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4 Psychosocial Factors and Prevention PSYCHOSOCIAL FACTORS How does use of tobacco, alcohol, opioids, and stimulants begin? Virtually all Americans, some of whom may have a genetic vulnerability to drug abuse, are faced with the decision of whether to smoke, drink alcohol, or take illicit drugs. Why do some individuals say yes and others refuse? Why do some people and not others begin using these drugs in excess and why is it so difficult for some individuals to stop? In addition to studies about genetic vulnerabilities, these and similar questions are the focus of behavioral, epidemiological, and social science research aimed at understanding and preventing drug addiction. The research includes human and animal laboratory studies, and examines such phenomena as environmental factors and personal characteristics that predict addictive behaviors, as well as individual differences in the behavioral mechanisms of drug abuse. This chapter presents a brief overview of key issues in research relevant to the psychosocial and behavioral underpinnings of addiction before presenting examples of the variety of prevention strategies currently used to reduce the prevalence of drug abuse and addiction. Psychosocial factors include personality and presence of psychiatric disorder, as well as family, peer, and other environmental factors that either increase the risk of an individual developing an addictive disorder (risk factors) or decrease such risks (protective factors). Cognitive and behavioral research is the key to understanding how basic principles of learning and conditioning can be used to modify drug-taking behavior; this research has been reviewed in a variety of reports and monographs (Hawkins et al., 1992; IOM, 1994a,b; IOM, 1996a). Briefly, research indicates that beliefs and attitudes, many of which are learned by watching or listening to role models at home, in the community, or in

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the media, have a strong influence on drug use and abuse. For example, adolescents typically use drugs when with very close friends, and so the peer influence on drug use and abuse may occur in a cycle: a child chooses friends with similar interests and attitudes, and when one experiments with drugs, the others join in, and soon they are imitating each other's use or abuse. In addition, children are more likely to use drugs if drugs are used by other members of their families. In fact, a family history of drug abuse is the single most important indicator of risk for the children. Although some of this risk may be genetic, it is not clear either to what degree or how genetic vulnerability interacts with environmental factors in such families. The community environment is also crucial; children who live in communities with drugs readily available, drug-using peers, and where drug use is generally accepted are more likely to abuse drugs. Glantz and Pickens (1992) reviewed the literature on vulnerability to drug abuse and found complex relationships among family and community factors. For example, among Mexican Americans, the risks of drug abuse were higher for children from lower socioeconomic group families living in regions with high dropout rates from high school. In contrast, females from families who have a strong identification with Hispanic culture seem to be protected and to engage in drug abuse in lower numbers (Swaim et al., 1993). Changing the environmental conditions or cues associated with drug use or withdrawal can assist an individual's efforts to abstain from drugs. For example, if drinking a cup of coffee after a meal is associated with smoking, it is important to break that association in the same way that the association between working and smoking is broken when the workplace forbids smoking in one's office. Further, it is well known among treatment providers that patients in recovery from addiction have a higher chance of relapse if they are in environments in which their previous drug use took place, or if they are associating with friends who continue to use drugs. There has been considerable research on the personalities of alcoholics and individuals addicted to other drugs, but additional multidisciplinary research is needed to identify how specific risk and protective factors interact with biological vulnerability (Hawkins et al., 1992; IOM, 1994a,b; IOM, 1996a). Several studies indicate that children who are less conventional, more tolerant of deviant behavior, less religious, less oriented toward hard work, more rebellious, with lower expectations of academic achievement, and fewer negative beliefs about the harmfulness of drinking and more positive views of the social benefits of drinking are more likely to abuse alcohol as they become older. Similarly, adolescents who are unconventional and have low achievement in school or exhibit problem behaviors are more likely to start to use illicit drugs. Family factors, such as divorce or chronic stress, poor parenting, or a poor child-parent relationship, in addition to parent or sibling use of or attitude toward drugs, also may contribute to drug use. There is a very high co-occurrence of alcohol and illicit drug dependence with psychiatric disorders, and some experts believe that the drug use amounts

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to ''self-medication" after the psychiatric disorder is manifested (DHHS, 1993). The two most common psychiatric disorders observed in persons with addictive disorders are antisocial personality and depression (Block et al., 1988). In addition, conduct disorder, attention deficit disorder, and anxiety disorders are also associated with an increased risk of drug addition or alcoholism (Kessler et al., 1996). Research suggests that the psychiatric disorder is likely to appear before the drug problem. However, psychiatric problems also can occur after drug use or abuse; thus the precise nature of the co-occurrence of drug problems with other psychiatric illnesses is an important area of research (DHHS, 1993; Kessler et al., 1996). PREVENTION In a report focused on prevention of mental disorders, another IOM committee conceptualized new definitions for various levels of prevention interventions and recognized that prevention exists on a continuum with treatment and maintenance (IOM, 1994a). Instead of the classical categories of primary, secondary, and tertiary prevention, the committee defined universal, selective, and indicated levels of prevention. Universal includes interventions aimed toward an entire population. Selective interventions are those aimed toward individuals who are members of a subgroup or population that is known to be at higher risk for a given disorder, such as aiming interventions at teenagers to prevent drug abuse or drinking. Indicated interventions are for those individuals who exhibit a known risk factor, condition, or abnormality that identifies them as being at high risk for developing a disorder. Indicated interventions, then, could include providing education about alcoholism to young men whose fathers are alcoholics. All three types of interventions are employed to prevent drug abuse and the effectiveness of various approaches is the subject of ongoing research. The rest of this chapter describes some examples of these interventions. Warning Labels on Alcoholic Beverages Warning labels on alcoholic beverages, which were required in 1988 by Public Law 100-690, state, "According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects" and "Consumption of alcoholic beverages impairs your ability to drive a car or operate machinery and may cause health problems." A study of approximately 3,500 pregnant women showed that, after the warning label was introduced, pregnant women who drank very little decreased their alcohol consumption by an average of one ounce of beer per week, whereas pregnant women who drank the equivalent of more than one mixed

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drink per day did not decrease their alcohol consumption (Hankin, 1994). This study suggests that universal prevention efforts may have some modest success in decreasing the consumption of alcohol, but that more targeted efforts are probably necessary for individuals who are regular users or who are addicted. An IOM panel on fetal alcohol syndrome found that there are little data on the effectiveness of universal prevention efforts such as warning labels. The panel recommended, however, that these efforts should be continued to raise awareness of the dangers of alcohol, particularly fetal alcohol syndrome and alcohol-related birth defects and neurological defects (IOM, 1996b). Warning Labels on Tobacco Products In 1965, Congress passed the first law requiring warning labels on cigarettes (Public Law 89-92). The labels read, "CAUTION: Cigarette Smoking May Be Hazardous to Your Health." This language was strengthened in 1969 to read, "WARNING: The Surgeon General Has Determined that Cigarette Smoking Is Dangerous to Your Health" (Public Law 91-222). In an effort to further strengthen this warning, Congress passed the Comprehensive Smoking Education Act in 1984, which required four different warning labels. One specified the diseases caused by smoking, one urged quitting to improve health; one warned of birth defects and other dangers of smoking while pregnant; and one warned that cigarette smoke contains carbon monoxide (Public Law 98–474). Labeling changes occurred during a period of increased public information about the dangers of smoking and increasing restrictions on smoking in public places, making it difficult to determine the exact impact of these labeling changes. However, research conducted in Australia before the introduction of cigarette warning labels indicated the importance of varying warning labels so that they would attract attention and ensuring that they are easily understood and easy to see and read (CBRC, 1992). Advertising Bans Legal bans or voluntary bans on advertising of alcohol and tobacco also represent a prevention effort; they curb exposure to messages that encourage alcohol and nicotine use. Cigarette advertising has been banned from radio and television since 1969, and advertisements for little cigars were similarly banned in 1973 (Public Laws 91-222 and 93-109). As of 1996, 48 states had some type of restriction, from minimal to comprehensive, on smoking in public places (CHS, 1996). In 1996, the liquor industry ended a self-imposed ban on television advertising. This action spurred debate about whether there should be comprehensive

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regulation of alcohol advertising along the lines of that imposed on the tobacco industry. Cigarette Promotions Despite the ban on radio and television advertising, the tobacco industry spends approximately $4.5 billion each year on billboard and other advertising aimed at promoting consumption, approximately quadrupling their expenditures since 1980 (IOM, 1994b). Cigarette advertising uses images to portray smokers as independent, healthy, adventure-seeking, and attractive (IOM, 1994b). However, the vast majority of marketing dollars are spent on promotional activities, such as sponsoring sports events and public entertainment and distributing T-shirts, hats, and other items that provide free advertising by prominently displaying the companies" logos. A study of 166 televised sports events indicates that the TV audience is exposed to tobacco advertising through stadium sings and brief verbal or visual product sponsorships (Madden and Grube, 1994). There is increasing concern that advertisements and promotional activities are aimed at encouraging children to smoke, and there is research evidence to support that perception. For example, Camel Cigarettes' advertisements featuring a cartoon character, Joe Camel greatly increased Camel's market share among children, and studies suggest that participation in promotional activities (e.g., owning a promotional item) is strongly associated with a higher risk of tobacco use among adolescents (IOM, 1994b; Altman et al., 1996). Research on the effects of legal restrictions on promotional activities has been conducted in many countries. A study of 33 countries concluded that total advertising bans resulted in decreases in consumption that occurred four times faster than decreases following partial bans, whereas consumption increased in countries with no advertising restrictions (IOM, 1994b). In August 1996, the FDA issued final regulations aimed at decreasing advertising to young people. The new rule will ban brand-name sponsorship of sporting or other events, cars, or teams, and ban brand names on hats, T-shirts, gym bags, and other products. The rule also limits advertising in publications with at least 2 million youthful readers or where at least 15 percent of the readership is youths, permits black-and-white text only, bans billboards within 1,000 feet of schools and playgrounds, and restricts most other outdoor advertising to black-and-white text only. Alcohol Promotions Approximately $1 billion is spent every year to advertise alcoholic beverages, generally portraying drinking as a healthy, attractive, and success-oriented

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activity (IOM, 1989). A study of 166 televised sports events indicated that commercials advertising alcoholic beverages were aired more than any other product (Madden and Grube, 1994). During the 1996 Olympic Games, Budweiser beer TV commercials featured bullfrog characters, which Mothers Against Drunk Driving (MADD) criticized as aimed at a very young audience (Batog, 1996). An August 1996 marketing survey indicated that most children between 6 and 11 years of age recognized the bullfrogs. The impact of these and other advertisements on consumption is not clear, but there is evidence that advertisements tend to stimulate consumption of the products in general, not just the specific product advertised (IOM, 1989). Advertisements and commercials are not the only way that the media influence drug use. "Social learning theory" predicts that viewers will "model" attractive TV or film characters who smoke or drink, resulting in viewers having more positive attitudes toward these drugs and increasing their consumption (IOM, 1989). Recent analyses of prime-time television programs found that two-thirds of the programs made references to alcohol and half portrayed consumption of alcohol, averaging more than eight drinking acts per hour (Wallach et al., 1990). In that study, alcohol was consumed by affluent professionals and portrayed in a positive way; alcohol problems were clearly depicted in only 10 percent of the episodes. Television programs could therefore encourage drinking among viewers; this seems especially likely among adolescents, because they watch a lot of television and movies and tend to imitate the clothes, expressions, and behaviors they see in the media. The portrayal of smoking on TV, and in music videos and films could have a similar effect. Although there is no conclusive research in this area, social scientists presume that the consumption behaviors portrayed in such media programming have an impact similar to advertising, which has been extensively studied. Restrictions on Smoking in Specific Locations Smoking was first banned on U.S. domestic airline flights of two hours or less in 1987. This was later extended to flights of six hours or less in 1989, and in 1995 a treaty between Canada, the United States, and Australia banned smoking on all nonstop flights between the countries (Public Laws 100-202 and 101-164 and ICAO, 1995). Many international airlines also voluntarily ban smoking on some or all flights. Smoking was first banned from clinic areas that administered some federal programs in 1993 (Public Law 103-11); this was extended to schools, day care centers, and libraries receiving federal funds in 1994 (Public Law 103-227), and many federal agencies now ban smoking in their buildings. The private sector also restricts or bans smoking in many other buildings, including hospitals, office buildings, and restaurants. Smoking bans in the workplace have been associated with significant decreases in smoking during work hours (Stave and Jackson,

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1991; Daughton et al., 1992) and significant decreases in nonsmokers' exposure to environmental tobacco smoke (Borland et al., 1991; Hammond et al., 1995). There is mixed evidence as to whether bans result in higher quit rates; two studies have found positive effects of such bans (Longo et al., 1996; Stave and Jackson, 1991), but others have found no effect (Daughton et al., 1992). Prices and Use The federal government taxes tobacco products and alcoholic beverages, and all the states have additional taxes on these products (IOM, 1989; DHHS, 1991). Raising the costs of legal drugs such as alcohol and cigarettes has been shown to decrease use. For example, the consumption of alcoholic beverages is reduced when prices are increased (IOM, 1989). This is especially likely for youth (one study found that a 10-cent increase in the price of beer resulted in a 15 percent decrease in the numbers of youths who drink 3 to 5 beers each day, while a 30-cent increase in the price of distilled spirits resulted in a 27 percent decline in the numbers of youths who were heavy drinkers of liquor [Grossman et al., 1987]). As a result, taxes have the potential for decreasing consumption. Although taxes have tended to increase over the years, they have not risen nearly as much as other increases in cost; for example, in 1990 federal taxes accounted for 11 percent of the cost of cigarettes to consumers, compared to 37 percent in 1950. In contrast to efforts to decrease consumption, "happy hour" promotions at bars and restaurants, which offer discounts on drinks or free food with drinks, resulted in increased consumption in barroom and restaurant settings (Babor et al., 1980). In 1988, California voters passed Proposition 99, which increased the tax on a package of cigarettes from 10 cents to 35 cents (Tobacco Education Oversight Committee, 1993). Twenty percent of the funds from the tax were allocated to anti-tobacco education in schools and communities. Studies have shown a clear effect on consumption of the resulting increased per pack price of cigarettes. For example, the month the increase went into effect, there was a 25 percent decline in cigarette consumption (Hu et al., 1994) and it is estimated that sales were reduced by 819 million packs between 1990 and 1992 (Hu et al., 1995). Between 1988 and 1992, the proportion of Californians ages 20 and older who smoked dropped from 27 percent to 20 percent and cigarette consumption (defined as the number of packs sold per civilian adult) decreased by 14 percent (Tobacco Education Oversight Committee, 1993). Unfortunately, there were no differences in smoking behavior for adolescents ages 12 to 17. In contrast, prior to 1988 nationwide smoking during those years increased followed by smaller decreases from 1988 to 1992 for adults, and statistically significant decreases for adolescents.

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In Canada, similar decreases in the prevalence of smoking followed a substantial increase in cigarette taxes, one even greater than that in California. The prevalence of smoking among adults dropped from 36 percent to 26 percent between 1981 and 1991 when the taxes were significantly raised, and the proportion of adolescents ages 15 to 19 who smoked daily plummeted from 40 percent to 16 percent (Sweanor et al., 1993). Although there is no way to determine the extent to which decreases in adult smoking in California or Canada can be attributed to the higher costs of cigarettes or the public education program, the results suggest that when taxes are raised, and the resulting revenues used for public education campaigns, there can be considerable benefit to public health (Sweanor et al., 1992; Thompson, 1994). A study in Great Britain showed that both women and men in lower socioeconomic groups were more sensitive to the price of cigarettes than to health publicity campaigns, and that women were more sensitive to price in general than were men (Townsend et al., 1994). Access/Server Intervention Access to alcohol and cigarettes can be limited in a variety of ways. Decisions about the locations of liquor stores, the granting of liquor licenses to restaurants, the training of bartenders and waiters to limit alcohol consumption, and the locations of cigarette vending machines and cigarettes in stores can all serve to limit access. There is statistical evidence of an association between the number of outlets that sell alcoholic beverages and the levels of alcohol consumption and alcohol-related deaths (DHHS, 1993). However, more research is needed to determine if the increased availability of alcohol is responsible. Server intervention seeks to reduce a customer's likelihood of intoxication or driving while intoxicated by influencing the incentives and behaviors of those serving beverages. For example, servers can be trained to promote nonalcoholic beverages and food or to delay serving an alcoholic beverage if it would be likely to intoxicate the patron. There is some research evidence that these interventions are effective (IOM, 1989). In addition, a bar or restaurant can charge more for alcoholic drinks than soft drinks, serve smaller drinks, and stop selling pitchers of beer. The newly completed FDA regulations will, among other measures, ban cigarette vending machines and self-service displays except in nightclubs and other facilities that are totally inaccessible to persons under 18. Such a ban has been characterized as a law enforcement approach to reduce access to tobacco by children and youth and studies suggest that a law enforcement approach by itself may not be effective (DiFranza et al., 1996; Feighery et al., 1991). In addition, some have argued that the focus on youth access and law enforcement may have unintended consequences in part by emphasizing that smoking is for adults—therefore, something for adolescents to aspire to (Glantz, 1996). Most

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agree, however, that approaches to reduce access are necessary to a comprehensive strategy to reduce nicotine addiction in young people (IOM, 1994b). Thus, the impact of these new regulations will be a fruitful area of future research to determine which of their components are the most effective. The Role of Primary Care Physicians Primary care physicians represent another set of actors in the strategy for nearly universal prevention efforts. It is known that brief interventions by physicians can be quite effective in stimulating people to quit smoking or reduce their alcohol consumption (Ockene et al., 1991, 1994; Bien et al., 1993; Kahan et al., 1995; Fiore et al., 1990; Sachs, 1990). Most children and adults are seen by a primary care physician at least occasionally, and physicians have been encouraged by the federal government to ask patients about their smoking, drinking, and use of illicit drugs. These questions give physicians the opportunity to share information about the health risks of these behaviors. Integrating diagnosis, treatment, and prevention of addictive disorders into primary care settings is challenging, however, and often this integrative strategy is not provided by increasingly overburdened primary care physicians. In 1994, a major conference was held to explore this issue and participants found that this resistance was a result of a lack of appropriate training, negative attitudes of physicians about addictive disorders, and lack of time (Josiah Macy, Jr. Foundation, 1994). The participants, citing the cost of undiagnosed and untreated addictive disorders as almost $240 billion a year, made a series of recommendations to increase training and competencies of primary care physicians through changes in certifying medical board and accreditation councils, among other mechanisms. Achieving such a change in practice patterns will require not only training, but also further demonstrations of the effectiveness of these approaches. Although evidence exists that physician intervention increases the chances of abstinence from alcohol or tobacco, more research is needed on the ways in which physician interventions can be an effective prevention strategy. School-Based Prevention Programs Schools are the site of most programs designed to prevent drug abuse and addiction, and these programs have been systematically evaluated for almost two decades (IOM, 1996a). In recent years, large numbers of these studies have been evaluated together in meta-analyses aimed at determining patterns of effectiveness of various types of programs. For example, Tobler conducted a meta-analysis of 143 school-based drug programs (including nicotine) for students in grades 6 through 12, which he categorized into five types: informational

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programs about drug effects; programs that focused on enhancing self-esteem or general competence rather than knowledge about drugs; knowledge plus self-esteem; programs that focused on peer interaction; and programs that took place outside the school. The meta-analysis indicated that peer programs were the most likely to decrease later drug use, and that knowledge plus self-esteem programs and the programs outside the school also had some impact (Tobler, 1986, 1989). Tobler later re-analyzed the data, eliminating the weakest programs, and found that neither knowledge-only, self-esteem-only, nor knowledge plus self-esteem programs prevented drug use, whereas peer programs still were most effective and programs outside the school were moderately effective. Upon closer examination, Tobler concluded that the use of mental health professionals or counselors accounted for the peer programs' effectiveness. Bangert-Drowns conducted a meta-analysis on 33 programs, limiting his analysis to programs in schools with "traditional students," and eliminating any tobacco-only programs (NRC, 1993). Most of the programs were knowledge-only or knowledge plus self-esteem programs, usually led by teachers. The programs significantly increased knowledge and changed attitudes, but they did not affect behavior. He also found that the lecture format was the weakest and peer leaders were more effective than adults. The most widely disseminated school-based drug abuse prevention program in the nation is D.A.R.E. (Drug Abuse Resistance Education), but evaluations of these programs consistently show they have no long-term effects (Ennett et al., 1994a,b). Effective Programs Two school-based prevention programs have demonstrated long-term success: Life Skills Training and the Midwestern Project (IOM, 1996a). Life Skills Training is designed for seventh graders, with "booster sessions" in eighth and ninth grades. The program has been rigorously evaluated in 150 junior high schools in New York and New Jersey that serve primarily white middle-class students. Four-year follow-up results show that rates of smoking and marijuana use were one-half to three-quarters lower among students who participated, with more modest decreases in use of alcohol (Falco, 1992). Six-year follow-up showed significant decreases in use and heavy use of cigarettes and alcohol, but not in use of illegal drugs (IOM, 1996a). The Midwestern Project is a 10-session, school-based social skills and peer-resistance skills curriculum, supplemented by parental involvement, media campaigns, and training of community leaders (IOM, 1996a). An evaluation after six years found that the program significantly decreased the use of cigarettes, alcohol, marijuana, and cocaine for high-risk and low-risk students (Pentz et al., 1989a,b).

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Family-Based Interventions Although poor parenting causes many of the problems associated with children's drug abuse, there are few studies and as yet no evidence that family-based interventions alone are successful in preventing drug abuse (IOM, 1996a). However, one study found lower rates of alcohol initiation when parent training was used in conjunction with modified teaching practices (IOM, 1996a). Media-Based Prevention Interventions The positive portrayal of smoking and alcohol use on TV programs and in movies has been seen as a major influence on attitudes toward the use of these drugs. Efforts to use television overtly to counteract those messages have been made repeatedly over the years. Public service announcements and other media-based interventions are relatively inexpensive efforts to attempt to influence the knowledge and attitudes of a large number of children and youth. However, there are no rigorous studies of their impact on the audience's later drug use or abuse. Media interventions aimed at preventing adolescent smoking have been found to affect knowledge and, in some cases, attitudes, but have not shown a sustained impact on behavior (IOM, 1996a; Murray et al., 1994). However, TV anti-smoking messages have been found to be effective in combination with school-based programs at preventing or limiting adolescent smoking behavior (Flynn et al., 1992). Laws to Prevent Teen Alcohol Use and Smoking Epidemiological and public health research has been conducted in states and communities that have enacted new laws or policies to prevent or limit adolescent drinking and smoking by raising the age at which an individual can buy alcohol and tobacco products. The research examines how the environment, including the cost and availability of drugs, influences the likelihood of addiction and related problems. In 1983, Hingson et al. published a seminal study that evaluated the impact of raising the legal drinking age in Massachusetts from 18 to 20. They compared drinking, drinking and driving, and nonfatal accidents in Massachusetts and New York, which kept its drinking age at 18. Results indicated that the law was unevenly enforced, but that nighttime single-vehicle fatal car crashes declined more for 18- and 19-year-olds in Massachusetts than they did in New York (Waller, 1995). Other studies in different states clearly indicated that raising the legal drinking age decreased teenage drinking and driving and involvement in

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drinking-related car crashes (Waller, 1995). Despite these positive effects, it is not clear that laws restricting sales of alcohol to minors have actually reduced access. One large survey study, for example, has shown that, in 1995, 75 percent of eighth graders and 90 percent of tenth graders reported that it was easy to obtain alcohol (Johnston et al., 1996). Research on the effect of laws restricting tobacco sales to minors has been reviewed by another IOM committee (IOM, 1994a). By 1990, 45 states and the District of Columbia had legislation that prevented minors' access to tobacco products, but these laws were rarely enforced (DHHS, 1991). For example, in one Massachusetts community, an 11-year-old girl purchased cigarettes in 75 of her 100 attempts to do so (DiFranza et al., 1987). Several studies of young teenagers had similar results (DHHS, 1991). As discussed above, the new FDA regulations include legal sanctions for sale of tobacco to minors, along with other mechanisms to reduce youth access to tobacco, such as banning vending machine sales under certain circumstances (Kessler et al., 1996; Kessler et al., 1997). Because these approaches are similar to those taken for alcohol, some have argued that their effectiveness may be less than anticipated and, thus, the opportunity now exists for renewed evaluation of their efficacy. CONCLUSION Some of the key research challenges to be addressed in the area of psychosocial factors of addiction and prevention are listed in Table 4.1. Although we are now aware of many environmental risk factors for the development of drug abuse and addiction, a greater understanding of the relative strength of specific risk factors and what factors may protect individuals from addiction, is needed (Appendix H). Interdisciplinary research is also necessary to understand the relationships and interactions among specific risk and protective factors. Increased knowledge in these areas will not only help protect the health of individuals, but could also be used to design more effective preventive interventions to improve public health. Further research on existing preventive interventions is also needed. Although a rich and varied set of interventions is available, their effectiveness is sometimes unknown, particularly in special populations such as rural youth, minority groups, and others. Meeting these challenges and integrating research findings from these and other disciplines should be an area of high national priority to strengthen a science-based approach to the reduction of drug abuse and addiction.

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TABLE 4.1 Some Future Challenges in Psychosocial and Prevention Research • Examination of both the risk and protective environmental factors that are important in determining an individual's vulnerability to drug abuse or addiction • Examination of environmental and behavioral factors that are important in the development of addiction following initial or social use of drugs and alcohol • Examination of the relationship of drug abuse with other psychiatric disorders • Examination of relationship among alcohol abuse and the abuse of cocaine, nicotine, opioids, and other drugs • Investigation of strategies to identify at-risk youth and involve them in effective prevention programs • Development of effective prevention strategies for pregnant women who may drink alcohol or abuse drugs • Continued evaluation of prevention strategies aimed at reducing HIV transmission from needle sharing and other behaviors associated with drug abuse • Development and evaluation of methods to prevent smoking initiation and nicotine dependence in children and youth • Examination of the personality/temperament, as well as physiological and biochemical, attributes of resilient children from families with a history of drug abuse or alcoholism • Investigation of factors that affect the success of advertising bans and increased taxes in the prevention of alcoholism and nicotine addiction • Evaluation of effects of regulation of nicotine on prevalence of nicotine addiction and smoking cessation rates among populations differing in age, gender, ethnicity, economic status, or other variables • Evaluation of methods designed for use by primary care providers to assess risks of alcoholism and drug abuse in their patients • Examination of school-based prevention activities and the variables that may limit or augment their effectiveness • Review of the adequacy of existing national data sets to determine prevalence of drug abuse and alcoholism, particularly among youth REFERENCES Altman DG, Levine DW, Coeytaux R, Slade J, Jaffe R. 1996. Tobacco promotion and susceptibility to tobacco use among adolescents aged 12 through 17 years in a nationally representative sample. American Journal of Public Health 86:1590–1593. Babor TF, Mendelson JH, Uhly B, Souza E. 1980. Drinking patterns in experimental and barroom settings. Journal of Studies on Alcohol 41(7):635–651. Batog J. 1996. MADD demands Bud drop frog ads. Washington Post. September 13. Bien TH, Miller WR, Tonigan JS. 1993. Brief interventions for alcohol problems. A review. Addiction 88:315–336. Block J, Block J, Keyes S. 1988. Longitudinally foretelling drug usage in adolescence: Early childhood personality and environmental precursors. Child Development 59:336–355.

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