"Prevention of Substance Abuse: What science tells us”
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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 and Evaluation Berkeley, CA Tucson, Arizona. December 13, 2005. Prevention Paradox:.

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December 13, 2005

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December 13 2005

"Prevention of Substance Abuse: What science tells us”Harold D. Holder, Ph.D.Senior ScientistPrevention Research CenterPacific Institute for Research and Evaluation Berkeley, CATucson, Arizona

December 13, 2005


More local problems are caused by heavy drinking than by alcoholics

Prevention Paradox:

More local problems are caused by heavy drinking than by alcoholics.


December 13 2005

Students Who Reported Using Alcohol, Tobacco, and Other Drugs in Past 30 Days

63%

46%

25%

11.4%

10.8%

6.1%

4.5%

3.5%

4.5%


December 13 2005

Experimentation and Established Smoking by Age

Source: 1996 CTS


December 13 2005

Past Month Illicit Drug Use—any drug


Just what is prevention anyway

Just what is prevention, anyway?


Goals of atod prevention

Goals of ATOD prevention

  • Prevent health and safety problems related to substance use, e.g., traffic crashes, violence, lung cancer, overdose.

  • Prevent all use of tobacco and illicit substances for everyone, regardless of age.

  • Prevent heavy and high risk use of substances.

  • Delay adolescent initiation of substances that are licit for adults (e.g., tobacco and alcohol).


December 13 2005

Approaches to the reduction of ATOD use and resulting problems

IndividualchangeEnvironmental

approacheschange approaches

Orientation

Individualbehavioralchange leading to demand reduction

Community/state system or population change leading

to both demand and supply reduction

Goal

Individual, directly or through others (e.g., family, peers)

Target

Social, economic and physical environment

But lots of hybrid , multi-component models


Substance abuse influences and factors

Substance Abuse Influences and Factors

  • Physical - Proximity of alcohol & tobacco outlets and drug

  • supplies, places of public use

(2) Social - Family, peers and larger social networks, norms, mass media

(3) Economic - Cost of alcohol, drugs, tobacco; geography of availability


December 13 2005

Alcohol

Availability

Drinking

By Peers

Retail

Price

For Example, Youth Drinking

Physical

Cost &

availability

to youth

Availability of alcohol to & from peers

Social

Economic

Alcohol purchases by other youth


Public health model of prevention

Public Health Model of Prevention

Individual

Environment

Agent


Public health model of substance abuse problem prevention

Environment(Context)

Agent(Substance)

Public Health Model of Substance Abuse Problem Prevention

Individual

(User)


Individual approaches

Individual Approaches

1.

School-Based Education

2.

Mass Communication and Public Education

3.

Family Education/counseling

4.

Alcohol and Tobacco Warning labels

5.

Deterrence: Possession or sale of drugs, Drinking and driving Laws, Sale of tobacco or alcohol to minors.

6.

Brief Intervention in health care or workplace


Public health model of substance use prevention

Individual(User)

Agent(Substance)

Public Health Model of Substance Use Prevention

Environment(Context)


Environmental approaches

Environmental Approaches

1.

Retail Access to substances, e.g., price, outlet locations, minimum purchase laws, parental restrictions on youth.

2.

Restrictions or constraints on the Drinker’s or Smokers Behavior, e.g., drinking & smoking locations, drink drive

3.

Reduce Risk or Problem Severity


Public health model of substance use prevention1

Individual(User)

Environment(Context)

Public Health Model of Substance Use Prevention

Agent(Substance)


Agent approaches

Agent Approaches

1.

Low or No Alcohol Beverages or lower tar tobacco products

2.

Alcohol container size or tobacco package restrictions

3.

Restrictions on Product Advertising


December 13 2005

Scientific Evidence about Prevention

What works?


Standards of evidence

Standards of Evidence

1.

Achieves significant effects (actually reduces ATOD problems) under scientific standards.

2.

Replicated across two or more studies under diverse community or national conditions.

3.

Has practical applicability and can affect the total community, not only target groups, i.e., has public health import.


Problem prevention strategies solid evidence

Problem Prevention Strategies: Solid Evidence

¤

Retail price of alcohol or tobacco

¤

Minimum drinking/purchase age—retail compliance checks for alcohol and tobacco

¤

Graduated licenses & “zero tolerance for Youth

¤

Drinking/driving deterrence (RBT)

¤

Lower BAC limits for driving

¤

Density & location of alcohol outlets

¤

Form and style of retail sale, e.g., hours and days of retail sale.


December 13 2005

Retail Price

Drinking & smoking

As price increases, smoking and heavy drinking declines (Chaloupka, 1993)

Heavy drinkers/smokers as well as youth are affected by price. (Coate and Grossman, 1988)

Youth who drink weekly up to daily are more affected by price (Grossman, et al., 1991; Coate and Grossman, 1988)


Underage drinking

Underage Drinking

Goal:Decrease underage drinking

Actions:

Increase community awareness of underage

drinking

Reduce physical availability of alcohol to minors

Increase awareness of retail establishments and

adults of the legal and social risks of providing

alcohol to minors


December 13 2005

Environment

Person Activities

Mean 30-Day Alcohol Use

Years Before and After MDA was Raised

Source: O’Malley & Wagenaar (1991)

Alcohol Use (30-day mean) Before and After

Minimum Drinking Age (MDA) was Raised--United States

13% Decline


Drinking and driving

Drinking and Driving

Goal:Reduce the number of community drinking and driving events

Actions:

Increase law enforcement efficiency

Increase perceived risk of DWI detection

Increase community support of DWI enforcement


Access intervention

Access Intervention

Goal:

Decreased physical availability of Substances

Actions:

Reduction in outlet densities and sales to minors

Changes in planning and zoning laws

License challenges


Problem prevention strategies positive evidence need replication

Problem Prevention Strategies:Positive Evidence – Need Replication

Responsible beverage service – Policy & server training

Community Prevention Trials utilizing local policy

Primary health care interventions

Liability for sales or serving alcohol

Alcohol & tobacco warning labels

Administrative driver license suspension

School education alone & w/ community

interventions


School education

School Education

  • Effective programs:

    • Values and norms clarification

    • Decision-making

    • Life skills

    • Use interactive teaching methods

  • Ineffective programs:

    • Target self-esteem

    • Increase knowledge

    • Use scare tactics

    • Use didactic methods


Individual school based education

Individual: School-based Education

Popular prevention strategy--mostly US studies

Information only – no effect

Mixed results across studies and substances & only in controlled research studies

Most effective with some combination of:

1. Normative beliefs

2. Personal commitment3. Information4. Resistance skills


Responsible beverage service

Actions:

Server and manager training

New alcohol serving policies (price promotions, serving sizes, non-alcoholic beverages and food)

Enforcement of no service to underage and

obviously intoxicated patrons

Responsible Beverage Service

Goal:

Reduce alcohol intoxication or impairment for patrons of bars and restaurants


Problem prevention strategies promising too early to tell

Problem Prevention Strategies:Promising -- Too early to tell

Workplace interventions—workplace policy

Genetics and alcohol drug dependency risk

Alcohol sales to intoxicated persons

Auto ignition controls

Curfew laws

Parent training and mobilization

Restrictions on drinking & smoking location

Low or no alcoholic beverages; low tar tobacco

Alcohol container and tobacco product sizes


Alcohol problem prevention strategies mixed findings uncertain implications

Alcohol Problem Prevention Strategies:Mixed Findings -- Uncertain Implications

Mass communication and public education alone

School-based education alone

Restrictions on Advertising


Examples of media programs

Examples of media programs

  • ONDCP Anti-drug media campaign

  • Partnership for a Drug-Free America


Individual mass communication and public education

Individual: Mass Communication and Public Education

Increases awareness

Produces little behavioral change

Reinforces environmental strategies


Latest scientific advance comprehensive mix of evidence based prevention strategies at local level

Latest Scientific Advance:Comprehensive Mix of evidence-based prevention strategies at local level

Community Action Trials which use complimentary interventions


December 13 2005

Legal Action about Drinking

Social Control and Communication

Alcohol-involved Mortality & Morbidity

CONSUMPTION

Social, Health, and Economic Consequences

Formal Regulationand Control of Alcohol Sales

Retail Sales by Average Type

Social and Health Services

Alcohol Production, Marketing and Distribution

Community Economic Sector

Community System of Alcohol Use & Abuse


National community trial to prevent alcohol involved trauma

-

Modesto

Modesto

.

.

Salinas

Salinas

.

.

Orange

Orange

.

Florence

Florence

.

Oceanside

Oceanside

Sumter

Sumter

Experimental

Experimental

Comparison

Comparison

National Community Trial to Prevent Alcohol-involved Trauma


December 13 2005

Alcohol-involved Trauma at the Community Level: Conceptual Model`````````

MOBILIZATION

DRINKING AND DRIVING

Local News about AlcoholProblems & Enforcement

Perceived

Risk of Arrest

Local Law

Enforcement

RESPONSIBLE BEVERAGE

SERVICE

Social Access

to Alcohol

Driving after

Drinking

Alcohol

Serving and

Sales Practices

UNDERAGE DRINKING

Local Regulation

of Alcohol

(Density, Hours

of Sale)

Alcohol-involved

Injury

Retail Alcohol Availability

(On and Off-premise)

Alcohol Intoxication

or Impairment

ALCOHOL ACCESS

Non-Traffic Risk Activities


Underage alcohol purchase survey experimental and comparison communities

PRETEST

POSTTEST

53

47

45

35

19

16

Comparison

ExperimentalNo Training

ExperimentalTraining

Comparison

ExperimentalNo Training

ExperimentalTraining

Underage Alcohol Purchase Survey-Experimental and Comparison Communities-

60

50

40

Percent Selling

30

20

10

0

Holder, et al., J. American Medical Association, 2000


Community trials final results

Community Trials Final Results

Holder, et al. 2000. J. Amer. Medical Assoc.

Total Consumption (+2%)

Heavy Drinking (-6%)

Driving after “Too much to drink” (- 49%)

BAC Positive Drivers (- 44%)

Nighttime Injury Crashes (-10%)

Assaults

-- Hospital Cases (-2%)

-- Emergency Room Cases (- 43%)


Similarities across all effective prevention strategies

Similarities across all effective prevention strategies

  • Comprehensive and multi-component

  • Targets specific causal variables which have been shown to affect total local population as well as the environment

  • Based on methodologically sound, independently replicated evaluations under “real world” conditions


Community system strategies

Community System Strategies

Effectiveness at population level

Impact both heavy & moderate drinkers/users

Yield longevity of effects

Do not target subgroups--non discriminating

Have lower costs

-No case-finding

-Individual services NOT required

-NO continued costs to sustain effects


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