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Substance Use Disorders in the U.S. Armed Forces (2013)

Chapter: Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems

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Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

TABLE I-1 Ratings of Policy-Relevant Strategies and Interventions

Strategy or Intervention Effectiveness Breadth of Research Support Cross-National Testing Cost to Implement or Sustain Comments
Pricing and Taxation         Generally evaluated in terms of how price changes affect population level alcohol consumption, alcohol-related problems and beverage preferences.
Alcohol taxes +++ +++ +++ Low Increased taxes reduce alcohol consumption and harm. Effectiveness depends on government oversight and control of the total alcohol supply.
Minimum price ? + + Low Logic based on price theory, but there is very little evidence of effectiveness. Competition regulations and trade policies may restrict implementation.
Bans on price discounts and promotions ? + + Low Only weak studies in general populations of the effect of restrictions on consumption or harm; effectiveness depends on availability of alternative forms of cheap alcohol.
Differential price by beverage + + ++ Low Higher prices for distilled spirits shifts consumption to lower alcohol content beverages resulting in less overall consumption. Evidence for the impact of tax breaks on low alcohol products is suggestive, but not comprehensive.
Special or additional taxation on alcopops and youth-oriented beverages + + ++ Low Evidence that higher prices reduce consumption of alcopops by young drinkers without complete substitution; no studies of impact on harms.
Regulating Physical A vailability         Generally evaluated in terms of how changes in availability affect population level alcohol consumption and alcohol-related problems.
Ban on sales +++ +++ ++ High Can reduce consumption and harm substantially, but often with adverse side-effects from black market, which is expensive to suppress. Ineffective without enforcement.
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Bans on drinking in public places ? + ++ Moderate Generally focused on young or marginalized high-risk drinkers; may displace harm without necessarily reducing it.
Minimum legal purchase age +++ +++ ++ Low Effective in reducing traffic fatalities and other harms with minimal enforcement but enforcement substantially increases effectiveness and cost.
Rationing ++ ++ ++ Moderate Effects greater on heavy drinkers.
Government monopoly of retail sales ++ +++ ++ Low Effective way to limit alcohol consumption and harm. Public health and public order goals increase beneficial effects.
Hours and days of sale restrictions ++ ++ +++ Low Effective where changes in trading hours meaningfully reduce alcohol availability or where problems such as late night violence are specifically related to hours of sale.
Restrictions on density of outlets ++ +++ ++ Low Evidence for both consumption and problems. Changes to outlet numbers affect availability most in areas with low prior availability, but bunching of outlets into high-density entertainment districts may cause problems with public order and violence.
Different availability by alcohol strength ++ ++ + Low Mostly tested for strengths of beer.
Modifying the Drinking Environment         Generally evaluated in terms of how staff training, enforcement, and legal liability affect alcohol-related violence and other harms.
Staff training and house policies relating to responsible beverage service (RBS) 0/+ +++ ++ Moderate Not all studies have found a significant effect of RBS training and house policies; needs to be backed by enforcement for sustained effects.
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Strategy or Intervention Effectiveness Breadth of Research Support Cross-National Testing Cost to Implement or Sustain Comments
Staff and management training to better manage aggression ++ + ++ Moderate Evidence currently limited to one randomized control study and supportive results from multi-component programs.
Enhanced enforcement of on-premises laws and legal requirements ++ ++ ++ Moderate Sustained effects depend on making enhanced enforcement part of ongoing police practices.
Server liability ++ ++ + Low Effect stronger where efforts made to publicise liability. Research limited to the United States and Canada.
Community action projects ++ ++ ++ Moderate to high Need commitment to long time frame; uncertain which components are responsible for effects.
Voluntary codes of bar practice Ο ++ ++ Moderate Ineffective when strictly voluntary but may contribute to effects as part of community action projects.
Late-night lockouts of licensed premises Ο + + Low to moderate Limited research and no studies have identified effective approaches.
Drink-Driving Countermeasures         Most research has focused on intervention effects on traffic accidents and recidivism after criminal sanctions.
Sobriety checkpoints ++ +++ +++ Moderate Effects of police campaigns typically short-term. Effectiveness as a deterrent is proportional to frequency of implementation and high visibility.
Random breath testing +++ ++ + Moderate Effectiveness depends on number of drivers directly affected and the extent of consistent and high-profile enforcement.
Lowered BAC Limits +++ +++ ++ Low The lower the BAC legal limit, the more effective the policy. Very low BAC levels (“zero tolerance”) are effective for youth, and can be effective for adult drivers but BAC limits lower than 0.02 are difficult to enforce.
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Administrative license suspension ++ ++ ++ Moderate When punishment is swift, effectiveness is increased. Effective in countries where it is applied consistently. Target population: high-risk drinkers.
Low BAC for young drivers (“zero tolerance”) +++ ++ + Low Clear evidence of effectiveness for those below the legal drinking or alcohol purchase age.
Graduated licensing for novice drivers ++ ++ ++ Low Can be used to incorporate lower BAC limits and licensing restrictions within one strategy. Some studies note that ̴zero tolerance” provisions are responsible for this effect.
Designated drivers and ride services Ο + + Moderate Effective in getting impaired drinkers not to drive but do not affect alcohol-related accidents, perhaps because these services account for a relatively small percent of drivers.
Severity of punishment 0/+ ++ ++ Moderate Mixed evidence concerning mandatory or tougher sanctions for drink-driving convictions. Effects decay over time unless accompanied by renewed enforcement or media publicity.
Restrictions on Marketing         Better quality studies evaluate impact in terms of youth drinking and attitudes. Impact also studied in terms of ability to limit youth exposure to marketing campaigns.
Legal restrictions on exposure +/++ +++ ++ Low Strong evidence of dose-response effect of exposure on young peoples' drinking, but mixed evidence from ecological on per capita consumption; advertising bans or restrictions may shift marketing activities into less regulated media (e.g., Internet).
Legal restrictions on content ? Ο Ο Low Evidence that advertising content affects consumption but no evidence of the impact of content restrictions as embodied in industry self-regulation codes.
Alcohol industry's voluntary self-regulation codes Ο ++ ++ Low Industry voluntary self-regulation codes of practice are ineffective in limiting exposure of young persons to alcohol marketing, nor do they prevent objectionable content from being aired.
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Strategy or Intervention Effectiveness Breadth of Research Support Cross-National Testing Cost to Implement or Sustain Comments
Education and Persuasion         Impact generally evaluated in terms of knowledge and attitudes; effect on onset of drinking and drinking problems is equivocal or minimal. Target population is young drinkers unless otherwise noted.
Classroom education 0 +++ ++ Moderate May increase knowledge and change attitudes but has no long-term effect on drinking.
College student education—universal 0 + + Moderate May increase knowledge and change attitudes but has no effect on drinking.
Brief interventions with high-risk students + + + High Brief motivational interventions can impact drinking behaviour.
Mass media campaigns, including drink-driving campaigns 0 +++ ++ Moderate No evidence of impact of messages to the drinker about limiting drinking; messages to strengthen policy support untested.
Warning labels and signs 0 + + Low Raise public awareness, but do not change drinking behaviour.
Social marketing 0 ++ + Moderate to high Raises public awareness but alcohol specific campaigns do not change behaviour.
Treatment and Early Intervention         Usually evaluated in terms of days or months of abstinence, reduced intensity and volume of drinking, and improvements in health and life functioning. Target population is harmful and dependent drinkers, unless otherwise noted.
Brief intervention with at-risk drinkers +++ +++ +++ Moderate Can be effective but most primary care practitioners lack training and time to conduct screening and brief interventions.
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Mutual help/self-help attendance ++ ++ ++ Low A feasible, cost-effective complement or alternative to formal treatment in many countries.
Mandatory treatment of drink-driving repeat offenders + ++ + Moderate Punitive and coercive approaches have time-limited effects, and sometimes distract attention from more effective interventions.
Medical and social detoxification 0 ++ ++ High Safe and effective for treating withdrawal syndrome but have little effect on long-term alcohol consumption unless combined with other therapies.
Talk therapies ++ +++ ++ Moderate A variety of theoretically-based therapies to treat persons with alcohol dependence in outpatient and residential settings. Population reach is low because most countries have limited treatment facilities.
Pharmaceutical therapies + ++ ++ Moderate Consistent evidence for a modest improvement over talk therapies and clinical management only for naltrexone.

The following rating scale was used to evaluate effectiveness

    0 Evidence indicates a lack of effectiveness
    + Evidence for limited effectiveness
    ++ Evidence for moderate effectiveness
    +++ Evidence of a high degree of effectiveness
    ? No controlled studies have been undertaken or there is insufficient evidence upon which to make a judgment

SOURCE: Reprinted from Babor, T. F., R. Caetano, S. Casswell, G. Edwards, N. Giesbrecht, K. Graham, J. Grube, L. Hill, H. Holder, R. Homel, M. Livingston, E. Osterberg, J. Rehm, R. Room, and I. Rossow. 2010. Alcohol: No ordinary commodity: Research and public policy. Oxford, UK: Oxford University Press.

Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

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Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
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Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Page 374
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Page 375
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Page 376
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Page 377
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Page 378
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Page 379
Suggested Citation:"Appendix I: Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Page 380
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Problems stemming from the misuse and abuse of alcohol and other drugs are by no means a new phenomenon, although the face of the issues has changed in recent years. National trends indicate substantial increases in the abuse of prescription medications. These increases are particularly prominent within the military, a population that also continues to experience long-standing issues with alcohol abuse. The problem of substance abuse within the military has come under new scrutiny in the context of the two concurrent wars in which the United States has been engaged during the past decade--in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom and Operation New Dawn). Increasing rates of alcohol and other drug misuse adversely affect military readiness, family readiness, and safety, thereby posing a significant public health problem for the Department of Defense (DoD).

To better understand this problem, DoD requested that the Institute of Medicine (IOM) assess the adequacy of current protocols in place across DoD and the different branches of the military pertaining to the prevention, screening, diagnosis, and treatment of substance use disorders (SUDs). Substance Use Disorders in the U.S. Armed Forces reviews the IOM's task of assessing access to SUD care for service members, members of the National Guard and Reserves, and military dependents, as well as the education and credentialing of SUD care providers, and offers specific recommendations to DoD on where and how improvements in these areas could be made.

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