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; Why Prevention ? AN EXAMINA TION OF CURRENT A TTITUDES and policies toward drinking reveals an intriguing gap in America's approach to alcohol-related problems. The past several clecades have seen a great expansion of concern over the problem of alcoholism. As this concern has grown, many people have come to believe that most of the problems caused by alcohol occur within the relatively small group of people (1 to 4 percent of the adult population) who couIct be ciassifiect as alcoholics. It follows that the best way to deal with alcohol-related problems is to identify people who are or who are likely to become al- coholics and to treat them and those whom they put at greatest risknamely their children and spouses as effectively as pos- sible. Volunteer organizations and medical programs have aris- en to provide this treatment, and much of the public has come to understand and support such efforts. This focus on alcoholism has undoubtedly improved the lives of some of America's most troubled drinkers and their families. It has directec} attention toward a large part, perhaps the single largest part, of this country's alcohol problems, and it has dealt with those problems in interesting and productive ways. But alcoholics are not the only people who ever cause or get into trouble because of drinking. Certainly they are the drinkers most likely to experience physical or emotional distress because 20

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WHY PREVENTION? / 21 of alcohol. But the much greater number of more moderate drinkers can also suffer from the problems caused by drink- ingthe accidents, the illnesses, the marital discord. These are the people for whom certain kinds of prevention programs can be uniquely effective. Heavy drinkers are not the only ones with problems. Anyone who drinks may at some time be prone to alcohol-related accidents, family conflict, and illnesses. Thus, treat- ment programs for people classified as alcoholics ameliorate only a portion of America's alcohol problems. There are several ways to investigate the critical question of how alcohol-related problems are distributed across different kinds of drinkers. One is to examine how often people drink excessively. There are safer and less safe ways of drinking a given amount of alcohol. A person who drinks a little every night at home is less likely to get in a fight or an accident than a person who goes on binges in public twice a month. Both people may drink the same amount of alcohol overall, but the binge drinker is at greater risk during his or her infrequent nights on the town (although the stay-at-home drinker is of course not immune to alcohol problems).

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22 / ALCOHOL IN AMERICA A survey by Michael Polich and Bruce Orvis of personnel in the U.S. Air Force sheds some light on this important statistic.) The population they studied cannot be taken to represent the entire United States, but it is typical of the young, employed male population. Polich ancT Orvis divided the 3,078 people they surveyed into different categories of drinkers according to their overall average daily consumption of alcohol. They also noted how many times a year these different drinkers con- sumed more than eight drinks in a single day. Since little drink- ing took place during the day, these "intensive drinking days" effectively meant that the drinker was intoxicated for at least a few hours during the evening. What Polich and Orvis found is revealing. The 4 percent of this population who were very heavy drinkers (those who con- sumed a daily average of 10 or more drinks) accounted for just over a quarter of the total number of drunk days experienced. The 23 percent who were heavy drinkers (each averaging more than two but fewer than ten drinks ciaily) generated about five eighths of the drunk days. The 57 percent of Air Force men who consumed an average of less than two drinks each day (the remaining 16 percent were abstainers) still generated one eighth of the drunk days. Individually, the last set of drinkers is clearly the least likely to suffer from alcohol-related problems, but there are so many of them that their potential contribution to the total problem adds up. A more direct way to probe the distribution of aTcohol-related problems is to ask survey respondents about past problems. In their survey, Polich and Orvis also gathered data about the number of serious incidents associated with alcohol for different kinds of drinkers. Again, they found that the very heavy drink- ers accounted for only about one quarter of the total number of people with two or more serious incidents. A national house- hold survey reported by Walter Clark and Lorraine Midanik confirmed these findings.2 They found that the 11 percent of il. M. Polich and B. R. Orvis. Alcohol Problems: Patterns and Prevalence in the U.S. Air Force. Santa Monica, Calif.: Rand Corporation, 1979. 2W. B. Clark and L. Midanik. Results of the 1979 National Survey (mi- meograph). Berkeley, Calif: Social Research Group, University of California, 1980.

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WHY PREVENTION? / 23 LIG~l ERS DeRA8TSE DRIN K68S all adults categorized as heavy drinkers (defined as people con- suming an average of more than two drinks per day) suffered less than half of the total number of health and social problems associated with alcohol (see Figure 2-~. These studies clearly indicate that alcohol-related problems occur throughout the drinking population. Even if America's 15 million heaviest drinkers were to stop drinking tomorrow, a substantial fraction of the country's alcohol problems would ALCOHOL-RELATED PROBLEMS WITH GLEAM BELL~GE;~i~E~ spotty= JOs Talon CONTRIBUTION OF DRINKERS TO REPORTED PROBLEMS FIGURE 2.1 National surveys reveal that the majority of certain alcohol-related problems affect moderate drinkersthose having up to two drinks per day. Heavier drinkers are more likely to suffer some sort of alcohol problem than are moderate drinkers, but there are so many more moderate drinkers that their contribution to the total problem adds up. Source: Clark and Midanik (1980).

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24 / ALCOHOL IN AMERICA remain. These problems are borne by relatively unexceptional drinkers. They are people who do not always drink excessively; they may just drink inappropriately, recklessly, or unluckily. As Mark Moore of Harvard University puts it, "The problem of ill-timed drunkenness, badly fit into the environment, gen- erates a substantial portion of the medical problems, the viol- ence and crime problems, the employment problems, and even the marital problems that involve alcohol. In other words, a large portion of the alcohol problem is created by people who would never think of themselves as problem drinkers." This situation has important implications for public policy. The Elements of Prevention If America is to reduce the number of alcohol-related prob- lems that occur among people who are not alcoholics, it must consider diversifying its current approaches to drinking prob- lems. Techniques drawn from the alcoholism perspective alone clearly cannot reach this widely distributed part of the problem. For one thing, it wouic! be impossibly expensive to provide individually tailored treatment for the many millions of drinkers in America. It would also be inappropriate. Unlike the heaviest drinkers, more moderate drinkers are not individually at great risk of suffering from some sort of problem. They would resent being treated as if they were. A better and more practical way to reach the entire population of drinkers is through policies that can be thought of as pre- ventive. Prevention has a different starting point from that of treatment, though its ultimate goals are similar. In a treatment program, people who are alcoholics or who are closely related to alcoholics are identified and offered help. Their care involves personalized, face-to-face relationships with other individuals, often over a prolonged period. The prevention measures discussed in this book generally operate in a different way. They are nonpersonaTized ap- proaches that act throughout the drinking population. They do not focus on specific people. Rather, they can come into play for anyone who drinks. They seek to change the incentives, opportunities, risks, anct expectations that surround drinkers

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WHY PREVENTION? / 25 in society. Their objective is to alter drinking practices in the general population or to break the link between those practices and adverse consequences. Because of the complexity of that link, prevention measures can be fashioned from a wide variety of materials. The most extreme measures are those that draw on the force of the law to discourage a particular kind of drinking behavior. Drunk driving, which is the subject of Chapter 3, is the foremost ex- ample of such a behavior. Minimum drinking ages, public drun- kenness, and restrictions on sales to intoxicated customers are other areas in which the law plays a role. In all of these cases, however, legal action is only one of a broad range of preventive actions that can help reduce the problem. The combined influ- ence of many preventive initiatives can have a much greater effect than can legal constraints alone. The prevention initiatives considered in this book fall into three broad categories. The first category includes those actions that affect the price and availability of alcohol. Taxes on alcohol, minimum age requirements, restrictions on the numbers and hours of outlets, and the actions of servers all influence the ease of access to alcoholic beverages. By altering these condi- tions, it may be possible to affect not only how much people drink but also where, when, and how they drink, factors that can be just as important as overall consumption. Chapters 4 and 5 consider this category of prevention. Chap- ter 4 examines the effect that the price of alcohol has on drinking and on drinking problems, especially among the heaviest drink- ers. Chapter 5 discusses what commercial servers can do to see that the people they serve do not end up in trouble. The second category of preventive measures includes actions that seek to alter drinking practices more directly through var- ious forms of education and persuasion. These actions might take the form of radio, television, or newspaper messages that discuss unsafe or inappropriate drinking practices. They might also consist of formal educational programs in the schools. T e- gal sanctions fall into this category, since the law is a particularly strong form of persuasion. The government can also try to set an example of drinking practices through its own actions anct statements. ,

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26 / ALCOHOL IN ~ERICA Chapters 6 and 7 explore some of these possibilities. Chapter 6 considers the important issue of drinking by young people, asking how education and other influences can mold their ex- periences with alcohol. Chapter 7 examines the role of the mass media in shaping drinking practices, through educational cam- paigns, advertising, and commercial programming. The third category includes those actions that make the world a safer place in which to drink. These actions can involve both the physical and the social world. Changes in the physical worIct might mean safer homes, workplaces, consumer products, ma- chines, and highways. Changes in the social environment might entail offering to drive an intoxicated person home from a party or a bar. Such possibilities are the subject of Chapter S. Not all of these strategies are guaranteed to work. As ob- served in Chapter 4, higher prices for alcohol have been found to reduce overall levels of consumption, traffic fatalities, and cirrhosis of the liver. Teaching people to drink safely and mak- ing the environment safer for drinking have less empirical back- ing. Nevertheless, each of these measures holds enough promise to be carefully considered. it would also be a mistake to view a single prevention initia- tive outside of the full context of prevention. Each initiative ciraws strength from the others. Of course, each will fail or succeed only as it is implemented properly and thoroughly. But broad, comprehensive programs incorporating many dif- ferent approaches are more likely to be successful than actions taken in isolation. This perspective on alcohol-related problems requires that people resist the temptation to think in terms of opposed pairs: prohibition versus unlimited access, treatment versus preven- lion, education versus law enforcement. Says Moore, "l have a general kind of view that all of these things turn out to be more complementary than we are inclinecl to think, that public and private work together, that punitive and treatment ap- proaches work together, that taxation and education work to- gether, that all of the things that we imagine as being starkly opposite, as representing alternative routes, gain power when we put them together."

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WHY PREVENTION? / 27 Considerations in Designing Prevention Policies In deciding whether and how to implement preventive mea- sures, policymakers and other concerned individuals must move intelligently. To be effective, instruments of prevention should reach a broad segment of the population. But any particular approach, if stretched too far, can become ineffective or even destructive. When prevention begins to infringe excessively on innocuous or beneficial aspects of drinking, it has the potential to do more harm than good. Some people object to prevention on broader grounds, seeing any governmental attempt to influence drinking as an unwar- ranted restriction on personal freedom. In this view, govern- ments should constrain a person's actions only when those actions could harm someone who is unable to protect himself. Risks that people take of their own accord, such as excessive drinking, should not be the concern of government. Safeguarding individual freedoms, however, is not the only charge of government. Governments have also been seen as forces to enhance the general welfare, promote the spread of knowledge, and encourage civil behavior. The view that the government should promote good health has been gaining strength, as demonstrated by the antismoking and physical fitness campaigns. Of course, it is a moralistic position for the government to contend that people should act in such a way as to stay healthy. But it is a stance that the government has been encouraged to take. Preventive measures may also augment personal freedoms by avoiding some of the moralistic judgments involved in other approaches to alcohol problems. Specifically, by acting broadly throughout the population, they avoid labeling people as al- coholics. They do not have to answer what Moore calls "a central, bedeviling issue": Who is a problem drinker and who is not? "We are used to thinking that anyone who drinks and is having associated problems such as unemployment or social or medical problems is an alcoholic, a 'protoaTcoholic,' or a 'near-alcoholic,' " says Moore. "Partly for that reason, anyone in the general population who gets drunk and is arrested or

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28 / ALCOHOL IN AMERICA falls down stairs feels nervous about defining himself or herself as a 'problem drinker,' because that means he or she is an alcoholic or is destined to become one, with all the associated special misery and special treatment." Another possible objection to prevention is thatit will com- pete with other approaches to alcohol-related problems. For instance, people may feel that prevention will take money away from treatment programs that have taken years to establish, or that it will implicitly condone certain drinking practices. How- ever, there are good reasons to believe that treatment ancT pre- vention would be complementary rather than competitive. Prevention programs do not cost a great deal of money. They involve taxation, regulation, and messages that can be usect over and over. Even a major mass media campaign can reach large numbers of people at low per capita costs. Prevention programs may also reduce the number of people in need of treatment. According to several major studies, efforts that succeed in influencing general drinking practices also in- fluence the number of very heavy drinkers. If this is the case, altering drinking habits among the general population could reduce the number of people who drink excessively. In adcti- tion, prevention programs can shield these drinkers from the adverse consequences of drinking in ways that treatment pro- grams cannot, and they can reach the majority of problem drinkers who never do seek treatment. Barriers to Prevention Besicles the general objections to prevention mentioned above, there are certain more pragmatic problems that often arise when considering prevention policies. As Margaret Hastings of the Illinois Commission on Mental Health and Developmental Dis- abilities says, "Prevention is a public health ideal that everyone favors- in the abstract. But when it comes to voting on real programs and real dollars, prevention policy has certain polit- ically difficult characteristics." For one thing, prevention is oriented toward the future. Its success is measured not in terms of immediate accomplish- ments but long-term goals. "It requires a commitment to future

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WHY PREVENTION? / 29 outcomes, not short-term results," says Hastings. "This is an- tithetical to an American political need attached to short elec- toral cycles: the need to show immediate gains. Elected officials have a hard time voting for prevention programs unless there is a well-educated constituency willing to keep those programs alive bv reelecting leaders who sunnort future-oriented noli- cies." J ~ 1 1 ~ r - Prevention can suffer from the lack of a well-definecT con- stituency. Other health care lobbies concerned with such con- ditions as blindness, heart disease, and cancer have specific constituencies that foster state and national legislation. But "prevention cuts across categories," says Hastings. "It is a com- prehensive concept, not a casualty area. This absence of a spe- cific casualty constituency can act as an obstacle politically. Although prevention efforts may be seen as humane and cost- effective, they have trouble moving to the forefront of national, state, and local health and human services policy." Finally, prevention policies almost invariably involve a con- flict of values. People's attitudes toward alcohol are an obvious example. Many people see drinking as fundamentally immoral or, at least, morally weak. Others view drinking as a sign of liberal values or as a traditional means of sociability. The clash between these two outlooks can stymie political decision mak- ing, leaving prevention initiatives paralyzed. "In my seven years of experience in developing state policy," says Hastings, "the potential collision of values has been the major hurdle, and it grows more complicated as our belief systems become more pluralistic. Enormous pressures on legislators from individual industries, religions, ant! special interest groups make consen- sus difficult. These pressure groups often have far more influ- ence on policy than their actual numbers of supporters would suggest." Despite these practical obstacles to prevention, preventive measures have made consiclerable political headway in recent years, in large part because of the tremendous outpouring of support and action now focused on them. As William Mayer, former head of the Alcohol, Drug Abuse, and Mental Health Administration, says, "The extent and quality of attention now being directed toward alcohol-related problems is without prec-

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30 / ALCOHOL IN~ERICA edent in our lifetimes. States, local areas, and the private sector at all levels are giving attention in new ways to alcohol-related problems that have had such debilitating effects on our society, effects that have for so long been denied. Alcohol abuse and alcoholism are now being recognized here and throughout the world as major public health problems, and prevention has a high priority.... Examples inclucle the Presidential Commis- sion on Drunk Driving, the Department of Health and Human Services' Secretarial Initiative on teenage alcohol abuse, and the enormous relative increases in the 1983 and 1984 federal re- search budget for alcohol abuse anc! alcoholism, which far out- stripped increases for research in other health areas." At the same time, many nongovernmental grass roots or- ganizations have sprung up to combat the problem of drunk driving, including Mothers Against Drunk Driving (MADD), Remove Intoxicated Drivers (RlD), and Students Against Drunk Driving (SADD). These groups have supported such preventive actions as increasing the drinking age, changing criminal pen- alties, and installing new classroom curricula. Many other organizations in the United States also have the potential to make a significant contribution to the overall goal of reducing the number of alcohol problems. Just as prevention has diverse targets, so it can originate from diverse sources. Elected officials, treatment providers, business leaclers, bu- reaucrats, volunteer groups, educators, churches, and many other individuals can act to implement the general idea of pre- vention, just as they have acted in the past to deal with aTco- holism. Moreover, widespread public sentiment in the United States in favor of moderate drinking ensures a supportive cli- mate for such efforts. To give one example of unused potential, many government agencies not explicitly concerned with alcohol policy couIcl play an important role in prevention. According to lames Mosher and Tosenh Mott! of the University of California at Berkeley, , 1 "Significant portions of federal authority to regulate the avail- ability of alcohol and to respond to alcohol-related problems rest with federal agencies not usually associated with alcohol policy [such as the National Park Service, the Department of Defense, and the Internal Revenue Service]. This has resulted in little or no coordination in the development of the federal

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WHY PREVENTION? / 31 response to alcohol, particularly in the area of prevention. In some cases, contradictory policies are being made and enforced; in others, promising new prevention strategies (and potential new allies) are not being pursued." The Need for Cooperation For prevention to continue to make progress, the diverse range of groups and individuals with a stake in prevention need to cooperate and coordinate their efforts. Because prevention is a comprehensive concept, many different initiatives will be going on simultaneously. Information about the effectiveness of these initiatives, and about the practical difficulties of im- plementing them, must be shared if the initiatives are to survive and prosper. "This requires an unusual willingness to set prior- ities, share responsibilities, and believe in causes beyond a sin- gle individual, agency, or organizational turf," says Hastings. Organizations and individuals may even cooperate to the extent of forming coalitions that can back prevention initiatives in local, state, and federal governments. Michael Fox of the Ohio General Assembly, who has had extensive experience building such coalitions, believes that they are a uniquely ef- fective way to foster prevention policies: Policy objectives and public polls have to be translated into coalitions, which can be built on diverse bases. Revenue is one common concern. Another is the rising cost of health care. A third is criminal legislation; chiefs of police, local sheriffs, fraternal orders of police, judges, and so forth are very inter- ested in penal legislation. There is tremendous coalition-building potential over the concern about young people's involvement with alcohol. The op- portunity to greatly expand government partnerships with the private sector, with respect to alcohol and substance abuse, has never been better. The visibility given this issue by groups like MADD and by campaigns to make the public aware of the social costs and consequences of the abuse of this product has created an opportunity to move and move quickly. If you can design a coordinated strategy to incorporate all these factors, you will have built the base, the numbers, the power to confront opposing forces in the legislature. Now is the time to gather banners that have not traditionally been used together as effectively as they could be. I do not know how long the opportunity for building coalitions will last, but I suggest that this opening be used to the fullest extent to create prevention-oriented public policy.