"Prevention of Substance "Prevention of Substance Abuse: What science tells Abuse: What science tells us” us” Harold D. Holder, Ph.D. Harold D. Holder, Ph.D. Senior Scientist Senior Scientist Prevention Research Center Prevention Research Center Pacific Institute for Research and Pacific Institute for Research and Evaluation Evaluation Berkeley, CA Berkeley, CA Tucson, Arizona Tucson, Arizona December 13, December 13, 2005 2005
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"Prevention of Substance Abuse: What science tells us” Harold D. Holder, Ph.D. Senior Scientist Prevention Research Center Pacific Institute for Research.
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"Prevention of Substance "Prevention of Substance Abuse: What science tells Abuse: What science tells
us”us”
Harold D. Holder, Ph.D.Harold D. Holder, Ph.D.Senior ScientistSenior Scientist
Prevention Research CenterPrevention Research CenterPacific Institute for Research and Pacific Institute for Research and
Evaluation Evaluation Berkeley, CABerkeley, CA
Tucson, ArizonaTucson, Arizona
"Prevention of Substance "Prevention of Substance Abuse: What science tells Abuse: What science tells
us”us”
Harold D. Holder, Ph.D.Harold D. Holder, Ph.D.Senior ScientistSenior Scientist
Prevention Research CenterPrevention Research CenterPacific Institute for Research and Pacific Institute for Research and
Evaluation Evaluation Berkeley, CABerkeley, CA
Tucson, ArizonaTucson, Arizona
December 13, 2005December 13, 2005
More local problems are More local problems are caused by heavy drinking caused by heavy drinking
than by alcoholics.than by alcoholics.
Prevention Paradox:
0
10
20
30
40
50
60
70
Alcoh
ol
Tobac
co
Mar
ijuan
a
Inhal
ants
Hallu
cinoge
ns
Tranq
uiliz
ers
Amph
etam
ines
Cocai
ne
Narco
tics
Students Who Reported Using Alcohol, Students Who Reported Using Alcohol, Tobacco, and Other Drugs in Past 30 DaysTobacco, and Other Drugs in Past 30 Days
Just what Just what isis prevention, anyway?prevention, anyway?
Goals of ATOD preventionGoals of ATOD prevention
Prevent health and safety problems related to Prevent health and safety problems related to substance use, e.g., traffic crashes, violence, substance use, e.g., traffic crashes, violence, lung cancer, overdose.lung cancer, overdose.
Prevent Prevent allall use of tobacco and illicit substances use of tobacco and illicit substances for everyone, for everyone, regardlessregardless of age. of age.
Prevent heavy and high risk use of substances.Prevent heavy and high risk use of substances.
Delay adolescent initiation of substances that are Delay adolescent initiation of substances that are licit for adults (e.g., tobacco and alcohol).licit for adults (e.g., tobacco and alcohol).
Approaches to the reduction of ATOD use and resulting problems
Individual behavioralchange leading to demand reduction
Community/state system or population change leading to both demand and supply reduction
TargetIndividual, directly or through others (e.g., family, peers)
Social, economic and physical environment
Orientation
But lots of hybrid , multi-component models
Substance Abuse Influences and FactorsSubstance Abuse Influences and Factors
(3) Economic - (3) Economic - Cost of alcohol, drugs, tobacco; Cost of alcohol, drugs, tobacco; geography of availability geography of availability
(3) Economic - (3) Economic - Cost of alcohol, drugs, tobacco; Cost of alcohol, drugs, tobacco; geography of availability geography of availability
(1)(1)Physical - Physical - Proximity of alcohol & Proximity of alcohol & tobacco outlets and drugtobacco outlets and drugsupplies, places of public usesupplies, places of public use
(1)(1)Physical - Physical - Proximity of alcohol & Proximity of alcohol & tobacco outlets and drugtobacco outlets and drugsupplies, places of public usesupplies, places of public use
(2) Social - (2) Social - Family, peers and larger Family, peers and larger social networks, norms, social networks, norms,
mass mediamass media
(2) Social - (2) Social - Family, peers and larger Family, peers and larger social networks, norms, social networks, norms,
mass mediamass media
For Example, Youth DrinkingFor Example, Youth DrinkingFor Example, Youth DrinkingFor Example, Youth Drinking
AlcoholAlcoholAvailabilityAvailability
DrinkingDrinkingBy PeersBy Peers
RetailRetailPricePrice
Alcohol purchases by other youthAlcohol purchases by other youth
EconomicEconomicSocialSocial
Cost &Cost &availabilityavailability to youthto youth
Availability of Availability of alcohol to & alcohol to & from peersfrom peers
PhysicalPhysical
Public Health Model of PreventionPublic Health Model of Prevention
IndividualIndividual
EnvironmentEnvironment AgentAgent
Public Health Model of Substance Public Health Model of Substance Abuse Problem PreventionAbuse Problem Prevention
IndividualIndividual(User)(User)
EnvironmentEnvironment(Context)(Context)
AgentAgent(Substance)(Substance)
Individual ApproachesIndividual Approaches
3.3.
4.4.
1.1.
2.2.
School-Based EducationSchool-Based Education
Mass Communication and Public Mass Communication and Public EducationEducation
Family Education/counselingFamily Education/counseling
Alcohol and Tobacco Warning labelsAlcohol and Tobacco Warning labels
DeterrenceDeterrence: : Possession or sale of drugs, Possession or sale of drugs, Drinking and driving Laws, Sale of tobacco or Drinking and driving Laws, Sale of tobacco or alcohol to minors.alcohol to minors.
5.5.
Brief Intervention in health care or workplace6.
Public Health Model of Substance Use Public Health Model of Substance Use PreventionPrevention
EnvironmentEnvironment(Context)(Context)
IndividualIndividual(User)(User)
AgentAgent(Substance)(Substance)
Environmental ApproachesEnvironmental Approaches
1.1.
2.2.
3.3.
Retail Access to substances, e.g., Retail Access to substances, e.g., price, outlet locations, minimum price, outlet locations, minimum purchase laws, parental restrictions on purchase laws, parental restrictions on youth.youth.
Restrictions or constraints on the Restrictions or constraints on the Drinker’s or Smokers Behavior, Drinker’s or Smokers Behavior, e.g., e.g., drinking & smoking locations, drink drivedrinking & smoking locations, drink drive
Reduce Risk or Problem SeverityReduce Risk or Problem Severity
Public Health Model of Substance Use Public Health Model of Substance Use PreventionPrevention
AgentAgent(Substance)(Substance)
IndividualIndividual(User)(User)
EnvironmentEnvironment(Context)(Context)
Agent ApproachesAgent Approaches
1.1.
2.2.
3.3.
Low or No Alcohol Beverages or lower Low or No Alcohol Beverages or lower tar tobacco productstar tobacco products
Alcohol container size or Alcohol container size or tobacco package restrictions tobacco package restrictions
Restrictions on Product Restrictions on Product AdvertisingAdvertising
Standards of EvidenceStandards of Evidence
1.1.
2.2.
3.3.
Achieves significant effects (actually Achieves significant effects (actually reduces ATOD problems) under scientific reduces ATOD problems) under scientific standards.standards.
Replicated across two or more studies Replicated across two or more studies under diverse community or national under diverse community or national conditions.conditions.
Has practical applicability and can affect Has practical applicability and can affect the total community, not only target the total community, not only target groups, i.e., groups, i.e., has public health importhas public health import..
Problem Prevention Strategies: Problem Prevention Strategies: Solid EvidenceSolid Evidence
¤¤
¤¤
¤¤
¤¤
¤¤
¤¤
Retail price of alcohol or tobaccoRetail price of alcohol or tobacco
Density & location of alcohol outletsDensity & location of alcohol outlets
Lower BAC limits for drivingLower BAC limits for driving
Minimum drinking/purchase ageMinimum drinking/purchase age—retail —retail compliance checks for alcohol and tobaccocompliance checks for alcohol and tobacco
¤¤ Form and style of retail sale, Form and style of retail sale, e.g., hours and days of retail e.g., hours and days of retail sale.sale.
As price increases, smoking and heavy As price increases, smoking and heavy drinking declines (Chaloupka, 1993)drinking declines (Chaloupka, 1993)
Heavy drinkers/smokers as well as youth are Heavy drinkers/smokers as well as youth are affected by price. (Coate and Grossman, affected by price. (Coate and Grossman, 1988)1988)
Youth who drink weekly up to daily are Youth who drink weekly up to daily are more affected by price (Grossman, et al., more affected by price (Grossman, et al., 1991; Coate and Grossman, 1988)1991; Coate and Grossman, 1988)
Underage DrinkingUnderage Drinking
Increase community awareness of underageIncrease community awareness of underagedrinkingdrinking
Reduce physical availability of alcohol to minorsReduce physical availability of alcohol to minors
Increase awareness of retail establishments andIncrease awareness of retail establishments andadults of the legal and social risks of providingadults of the legal and social risks of providingalcohol to minorsalcohol to minors
ActionActions:s:
Alcohol Use (30-day mean) Before and After Alcohol Use (30-day mean) Before and After Minimum Drinking Age (MDA) was Raised--United StatesMinimum Drinking Age (MDA) was Raised--United States
Alcohol Use (30-day mean) Before and After Alcohol Use (30-day mean) Before and After Minimum Drinking Age (MDA) was Raised--United StatesMinimum Drinking Age (MDA) was Raised--United States
Years Before and After MDA was Years Before and After MDA was RaisedRaised
2.2
2.4
2.6
2.8
3
3.2
-3 -2 -1 1 2 3Me
an
30
-Da
y A
lco
ho
l M
ea
n 3
0-D
ay
Alc
oh
ol
Us
eU
se
Source: O’Malley & Wagenaar (1991)
13% Decline13% Decline
Environment Environment Environment Environment Person ActivitiesPerson ActivitiesPerson ActivitiesPerson Activities
Drinking and DrivingDrinking and Driving
Increase law enforcement efficiencyIncrease law enforcement efficiency
Increase perceived risk of DWI detectionIncrease perceived risk of DWI detection
Increase community support of DWI Increase community support of DWI enforcementenforcement
GoalGoal::Reduce the number of community drinking and Reduce the number of community drinking and driving eventsdriving events
ActionsActions::
Access InterventionAccess Intervention
GoalGoal: : Decreased physical availability of SubstancesDecreased physical availability of Substances
ActionsActions::
Changes in planning and zoning lawsChanges in planning and zoning laws
License challengesLicense challenges
Reduction in outlet densities and sales to minorsReduction in outlet densities and sales to minors
Problem Prevention Strategies:Problem Prevention Strategies:Positive Evidence – Need ReplicationPositive Evidence – Need Replication
Responsible beverage service – Policy & server trainingResponsible beverage service – Policy & server training
Primary health care interventionsPrimary health care interventions
Liability for sales or serving alcoholLiability for sales or serving alcohol
Popular prevention strategy--mostly US studiesPopular prevention strategy--mostly US studies
Information only – no effectInformation only – no effect
Mixed results across studies and substances & Mixed results across studies and substances & onlyonly in controlled research studies in controlled research studies
Most effective with some combination of:Most effective with some combination of:1. Normative beliefs1. Normative beliefs2. Personal commitment2. Personal commitment3. Information3. Information4. Resistance skills4. Resistance skills
Responsible Beverage ServiceResponsible Beverage Service
Goal:Goal: Reduce alcohol intoxication or impairment for Reduce alcohol intoxication or impairment for patrons of bars and restaurantspatrons of bars and restaurants
Actions:Actions:
New alcohol serving policies (price promotions, New alcohol serving policies (price promotions, serving sizes, non-alcoholic beverages and food)serving sizes, non-alcoholic beverages and food)
Enforcement of no service to underage and Enforcement of no service to underage and obviously intoxicated patronsobviously intoxicated patrons
Server and manager trainingServer and manager training
Problem Prevention Strategies:Problem Prevention Strategies:Promising -- Too early to tellPromising -- Too early to tell
Similarities across Similarities across allall effective prevention effective prevention strategiesstrategies
Comprehensive and multi-componentComprehensive and multi-component Targets specific causal variables which have Targets specific causal variables which have
been shown to affect total local population as been shown to affect total local population as well as the environmentwell as the environment
Based on methodologically sound, Based on methodologically sound, independently replicated evaluations under independently replicated evaluations under “real world” conditions“real world” conditions
Community System StrategiesCommunity System Strategies
Impact both heavy & moderate drinkers/usersImpact both heavy & moderate drinkers/users
Yield longevity of effectsYield longevity of effects
Effectiveness at population levelEffectiveness at population level
Do not target subgroups--non discriminatingDo not target subgroups--non discriminatingHave lower costsHave lower costs
-No case-finding-No case-finding
--Individual services NOT requiredIndividual services NOT required
-NO continued costs to sustain effects-NO continued costs to sustain effects