Alcohol Availability
Drinking Contexts
Community and Policy
Economics
Program Portfolio

Drinking and Driving
Violence
Program Portfolio
Worksite
Program Portfolio

Youth
Program Portfolio
Advertising/Media
Program Portfolio

Minorities
Program Portfolio
AIDS
Program Portfolio
Basic Behavioral Research
Program Portfolio

A: Subcommittee for Review of Prevention Portfolio
B: Experts in Prevention
C: NIAAA Program Staff
D: NIAAA Staff, Representatives from other NIH Institutes, and Guests
E: Research Priorities from Scientists Who Prepared Reviews
F: Recommendations by Participants

Sixty-five percent of the U.S. population consumed alcoholic beverages in 1990, with 29 percent consuming alcohol weekly and 3.9 percent consuming > five drinks at least once per week (Midanik and Clark, 1994). There are a number of social, health, safety, and economic problems in the U.S. that are associated with the consumption of alcohol (see NIAAA report: Alcohol and Health 9, 1997). In most instances, alcohol is rarely the single and only cause of this problem. Of course, there are exceptions, e.g., alcoholic liver cirrhosis. In general, alcohol is a contributing factor that increases the risk beyond a base level. For example, traffic crashes are caused by a number of factors including speed, road and vehicle conditions, weather, and driver skills and experience. If the driver is drinking and impaired, the risk of a crash is increased. Another example involves the risk of birth defects. If the mother has been drinking heavily during the prenatal period, the risk of an alcohol-related birth defect (Fetal Alcohol Syndrome) is greatly increased.

It is useful to consider alcohol problems as acute and chronic. Acute problems are those which arise from drinking events usually involving heavy drinking such that the person is impaired. Acute alcohol problems may include traffic crashes (injuries and death for the driver and others); non-traffic injuries and fatalities (falls, fires, or drowning, as well as violent events resulting from domestic conflict or public assaults in which either the perpetrator or the victim has been drinking); and unprotected sex.

In 1993, 7 percent of all automobile crashes and 44 percent of fatal crashes involved alcohol use, resulting in nearly 17,500 deaths and 289,000 injuries, with a disproportionate representation of 16-24 year olds (NHTSA, 1994). Alcohol use has been implicated in 15-63 percent of fall fatalities, 13-37 percent of nonfatal injuries from falls, and in 33-61 percent of burn fatalities (Hingson and Howland, 1993). Available data suggest that alcohol use may be a major risk factor for drowning and other fatal and nonfatal injuries that occur on or near the water (Hingson and Howland, 1993).

It has been estimated that 50 percent of both victims and perpetrators of violence use alcohol, and this finding is consistent across countries, demographic subgroups, and types of violence (homicides, suicides, assaults) (Martin, 1992). Alcohol consumption represents a significant risk factor for husband-to-wife violence (Collins and Messerschmidt, 1993), and approximately 30 percent of child abuse cases may involve alcohol (Murdoch et al., 1990).

Associations have been reported between alcohol use and high-risk sexual behavior, such as failure to use condoms or engage in safe sex practices in heterosexual adults (Ericksen and Trocki, 1992) and homosexual men (Paul et al., 1991). Individuals who satisfy diagnostic criteria for alcohol abuse/dependence, consume > two drinks per day, or consume > 9 drinks on one occasion at least once per year are at a much higher risk of exposure to HIV and of developing AIDS (Stinson et al., 1992). It has also been reported that adolescents are more likely to engage in unprotected sex when they consume alcohol (Strunin and Hingson, 1992).

Examples of chronic problems resulting from long-term and often heavy drinking include alcohol dependency, alcohol abuse, alcohol poisoning, Fetal Alcohol Syndrome, and health/medical consequences.

Prevalence rate of alcohol abuse or dependence has been estimated at 7.4 percent (Grant et al., 1994). Alcohol-related morbidity is a significant factor in non-Federal, short-stay hospital discharge surveys. In 1993, an alcohol-related diagnosis was listed first in the medical records for approximately 429,000 (1.5 percent) of the discharge episodes from short-stay hospitals for persons aged 15 years and older (Caces et al., 1995).

Chronic, excessive alcohol consumption is a significant risk factor for liver cirrhosis, which accounted for 25,407 deaths in the U. S. in 1992 (DeBakey et al., 1995).

The incidence of Fetal Alcohol Syndrome (FAS) has been estimated to range from 0.97 to 1.90/1000 live births (Alcohol and Health 9, 1997). Moreover, most experts agree that the incidence of partial presentations of FAS, including neurobehavioral anomalies, is much higher.

Alcohol abuse also can contribute to a variety of social, legal, and occupational difficulties, including problems with friends, family, and spouses; fighting; problems at work; difficulties with police; financial problems; loss of control over drinking; binge drinking; and alcohol-related health problems or accidents. Two or more social consequences were reported by 12.8 percent of current drinkers in 1990 (Midanik and Clark, 1995).

There is evidence that the younger the age of drinking initiation, the greater the risk that the drinker at some time in life will develop an alcohol disorder (alcohol abuse or dependence). Young persons who began drinking before age 15 were four times as likely to develop alcohol dependence and twice as likely to develop alcohol abuse as those who began drinking at age 21. The risk for lifetime alcohol abuse decreased by 8 percent with each increasing year of age of drinking onset (Grant and Dawson, 1998). This finding is based upon cross-sectional data and needs to be confirmed with longitudinal analyses.

The estimated cost of alcohol abuse in 1992 in the U.S. was $148 billion, and it is estimated that alcohol is involved in about 100,000 deaths annually. Even though some 14 million Americans (about 7 percent of the adult population) satisfy the diagnostic criteria for alcohol abuse and/or dependence, most Americans consume alcoholic beverages without adverse effects. Moreover, many individuals who experience alcohol-related problems do not satisfy the criteria for alcohol abuse/dependence. Consequently, the prevention of alcohol-related problems needs to include these individuals, with specific interventions for specific populations.

Within each type of alcohol-involved problem, it is possible to consider levels and rates of such problems across age groups (children, youth/adolescents, young adults, adults, and elderly), gender, and racial/ethnic groups.

The prevention of excessive alcohol consumption has to take into account what has been called the "prevention paradox". This paradox was first observed in the prevention of coronary heart disease (Rose, 1981), wherein a preventive effort to reduce the cholesterol levels of only high-risk individuals had less of an overall effect in reducing the incidence of heart disease than reducing the cholesterol levels of an entire population. This same perspective was extended to alcohol consumption by Krietman (1986), who found a similar phenomenon with reference to many alcohol problems. Alcohol-dependent drinkers are much more at risk individually for a wide variety of problems. Yet, since they are a relatively small percentage of total drinkers, they do not account for the majority of alcohol-involved problems, particularly acute problems. This had been confirmed earlier by Moore and Gerstein (1981), who found that most event-based alcohol problems, such as injuries, are accounted for by moderate and heavy, non-dependent drinkers. This means that even so-called "moderate" drinkers, on the average, can incur acute problems during a heavy drinking event or while drunk.

Heavy drinking has been defined as 5 or more drinks per occasion for men and 4 or more drinkers per occasion for women, following the research of Cahalan et al. (1969), Johnston et al. (1996), and Midanik et al. (1996). This level of consumption on a single drinking occasion has often been called "binge" drinking. Wechsler et al. (1994) found that college students who over the previous year binge drank one to two times (infrequent binge drinkers) or more than two times (frequent binge drinkers), had five times and 10 times greater risk of drinking and driving when compared to those drinking college students who did not binge. These college binge drinkers were at substantially greater risk of a variety of alcohol problems during the academic year than non-binge drinking students. Duncan (1997) used the Brief Risk Factor Surveillance System from 47 states to examine the relationship between binge drinking, chronic regular drinking, and DWIs and found that DWI rates were significantly associated with binge drinking but not with chronic heavy drinking. For example, it is estimated that dependent drinkers only account for 7-15% of alcohol-involved traffic crashes.

The challenge for the prevention of alcohol problems is not to shift the target of prevention away from dependent drinkers to moderate drinkers. Rather, the challenge is to find those strategies that can reduce specific problem events, even those which result from long-term drinking. There is consistent evidence that heavy drinking, whether in a specific event or overtime, greatly increases the risk of social, health, and economic problems. Drinking while driving can increase the risk of a traffic crash for any type of drinker, and regular heavy consumption can substantially increase the risk of health problems, especially liver disease. In addition, there is evidence from studies of alcohol price and changes in alcohol availability, caused by strikes or changes in control measures, that heavy and dependent drinkers are affected by population-level prevention strategies (Mäkelä, 1992).

Thus, the challenge for the prevention of alcohol problems is formidable, because the domain for prevention is much wider than simply identifying and targeting dependent or likely dependent drinkers. This has been described as a shift from "high-risk drinkers to high-risk drinking". A much wider public health perspective is essential. The change is not trivial and has notable implications for the future investments in prevention research.

Given the significant morbidity, mortality, and social consequences associated with excessive alcohol consumption, a review of the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) extramural grant portfolio seemed appropriate. Hence, NIAAA's Subcommittee for the Review of the Extramural Research Portfolio for Prevention met on 21-22 October 1998. The charge to the Subcommittee was to examine the appropriateness of the breadth, coverage, and balance of the prevention portfolio, identifying research areas that are well covered and others which are either under-investigated or which otherwise warrant significantly increased attention. The Subcommittee was asked also to provide specific advice and guidance on the scope and direction of the Institute's extramural research activities in the prevention area.

The Subcommittee for the Review of the Extramural Research Portfolio for Prevention consisted of a NIAAA Advisory Council chair and an advisory group of seven individuals. Four of these individuals have demonstrated expertise in alcohol-related areas, and three individuals have demonstrated expertise in non-alcohol-related areas (see Appendix A).

The review process was initiated by having experts (see Appendix B) in prevention prepare written assessments of the state of knowledge, gaps in knowledge, and research opportunities. NIAAA program staff (see Appendix C) presented the current extramural portfolio, categorized into the areas of policy, problem areas, youth and media, special populations and basic research and methodology, and training and career development. All information was shared with experts, selected NIAAA staff, and the chair and advisory group before the meeting.

A summary of FY 98 prevention awards is detailed below.

¹ includes SBIR awards and reimbursable funds

NIAAA Prevention Studies

On 21-22 October 1998, experts and NIAAA program staff made abbreviated presentations of their material followed by discussion among all of the participants, including representatives from other NIH Institutes and guests (see Appendix D).

Prevention can occur within a variety of sites, settings, and situations, including the family, workplace, schools, colleges and universities, medical care system, roadways/ transportation, waterways, communities, states, nation, and internationally. Prevention of alcohol-associated problems is a national priority in itself, and any set of research priorities should reflect both a consideration of scientific opportunities and findings as well as the needs of prevention policy and program decision makers at the national, state, and local levels. There is a considerable demand now for scientific-based prevention strategies by all states and communities, and there is an increasing requirement for "evidence-based" prevention by governments at all levels. The NIAAA prevention research portfolio should be at the forefront of providing research findings of value to practitioners.

After completing this process, the chair and advisory group, with input from the experts, delineated the following list of research priorities, in order of importance. The challenge to NIAAA is how to select from among the large number of potential target problems, groups, and settings for those that are sufficiently important to dedicate scare research resources or that have a sufficient research base from which to test potential prevention strategies to reduce such problems over the next 10 years. Following are the research priorities that the Subcommittee recommends.

The Subcommittee concludes that NIAAA should give emphasis in prevention research to the design and testing of prevention interventions. This emphasis is based upon two conclusions. First, there is sufficient basic and developmental research in some areas of prevention to support the actual testing of interventions in actual field settings, such as communities, colleges, and organizations. Second, even when the complete understanding of the causal mechanisms and risk factors involved in a specific set of alcohol problems is lacking, intervention testing can actually increase the scientific understanding of causal relationships. In short, the Subcommittee concludes that alcohol prevention research can best confirm its understanding of a problem by actually testing interventions based upon the best existing basic research. Prevention interventions can both test for reductions in alcohol problems as well as increase the understanding of causal mechanisms.

There are a number of possible approaches to alcohol-problem prevention, including studies of individuals, family, and group risks; specific types of prevention interventions or approaches; location or site of the prevention intervention, e.g., family, school, or workplace; and the risk factors surrounding a specific alcohol problem. This complexity has stimulated a wide range of prevention studies within the NIAAA portfolio that cover the spectrum of alcohol problems. With the exception of a few large-scale community intervention studies and state-level alcohol policy studies, the prevention portfolio can be characterized as a considerable number of highly focused but separate research studies. This has provided a rich and diverse research portfolio. Missing, however, is an emphasis on comprehensive, research-based interventions that have as their goal the actual reduction of specific alcohol problems. There is no question that the investment of research funds in a number of smaller risk studies provides greater coverage of possible topics and that large, comprehensive prevention interventions reduce the funds for such a large number of diverse studies. However, the pressing societal need for prevention strategies that actually reduce problems and the public call for more science-based prevention in communities and states, support new priorities that emphasize studies of large scale and comprehensive prevention interventions that actually reduce problems.

Studies of alcohol problems have shown that they are the result of interaction of many factors acting together and rarely result from a single cause. In like fashion, single prevention interventions appear to have limited effectiveness in isolation, but multiple strategies have the potential to be mutually reinforcing, that is, enhancing to each other. Priority should be given to studies of the effects of integration of prevention strategies, e.g., changes in hours of alcohol sale, reductions in the densities of alcohol outlets, or efforts to teach parents and school children about drinking linked with purposeful reductions in the sales of alcohol to youth.

Thus, the following priorities emphasize testing prevention interventions with recognition of the need for basic research in key areas as well as the importance of targeted specific studies.

Fund community-level (cities and towns, neighborhoods, and colleges) prevention interventions (both program and policy studies) which show potential effectiveness to: (a) reduce alcohol-involved injuries and death, and (b) delay initiation of youth drinking and reduce frequency for youth drinking, binge drinking, and alcohol-related problems for youth.

The most promising evidence of effectiveness for prevention interventions (both program and policy interventions at the local and state levels) has shown reductions in acute alcohol problems, including alcohol-involved traffic crashes, injuries, as well as assaults and deaths (across all ages). Such studies should be expanded and replicated in a variety of locations and conditions to test their generalizability as well to seek the most effective prevention interventions and mix.

In addition, there is evidence of the effects of school and community programs and minimum age policies (at the state level and enforcement at the local level) on reducing the age of drinking initiation by youth and their drinking levels. Unfortunately, the specific delay of initiation based only upon school and parent programs appears to decay over time. The clear potential, based upon existing research, is that comprehensive community prevention interventions to reduce acute alcohol-associated problems can also delay youth drinking initiation. Studies of community alcohol policy in conjunction with school/parent programs are needed to determine the most effective means to sustain this effect and to investigate the potential reductions in youth drinking levels and binge drinking as associated alcohol-related harm for youth, including violence, injuries, and unprotected sex.

Building upon the community-based prevention research to date, emphasis should be given to determining the most cost-effective combination of policy, education, and media strategies at the local level that can reduce acute alcohol problems. Priority should be given to proposed studies that build upon the developmental and efficacy research findings concerning effective interventions over the past five years. By investing in such a priority, NIAAA can support the development, testing, implementation, and evaluation of important prevention initiatives that can address both long-term public health and safety issues as well as the potential to reduce alcohol dependency.

Thus, based upon the evidence to date, this is the most promising area of alcohol prevention research and should be given priority over the next 10 years by NIAAA. Some supporting priorities as described below:

1. Establish better surveillance systems, based on development of actual and surrogate

   outcomes, measures, and indicators of alcohol involvement in non-fatal injuries and in fatalities as well as better linked survey items concerning drinking and self-reported alcohol problems.

   The development of a monitoring system to accurately measure alcohol involvement in non-traffic injuries and death is essential to any long-term assessment of the effectiveness of community/state-level interventions to reduce alcohol impairment leading to increased risk of trauma and reductions in age of drinking initiation. A useful model for the development of such a monitoring system for alcohol-involved traffic crashes is the Fatality Analysis Reporting System (FARS) of the National Highway Traffic Safety Administration. It is recommended that NIAAA take the lead in developing a Federal agency collaboration in the development of such a monitoring system that can be used to augment the data available via FARS. There is a clear need for such a database to go beyond traffic crashes. More specifically, it is recommended that a working relationship with such agencies as the U.S. Department of Justice and the Center for Disease Control be established by NIAAA with the express purpose of creating a system like FARS to monitor alcohol-involved assaults, rapes, theft, suicides, other intentional injuries, alcohol and drug overdose, and homicides. In addition, this database should develop a means to collect data on non-traffic but alcohol-related injuries and deaths, including falls, burns, and drowning.

   In addition, there are a number of state and national surveys sponsored by the federal government which include questions concerning personal drinking, high-risk drinking, and personal problems potentially related to drinking. Examples include the national household survey, the individual state needs assessment surveys, the Center for Disease Control Behavioral Risk Factor Surveillance surveys, etc. Frequently these surveys are designed and undertaken in very separate and uncoordinated ways that often limits the generalizability of results concerning alcohol across surveys at the state and national levels. The field of alcohol epidemiological research has developed the measurement of drinking and alcohol-related problems in surveys to a very high level. This has enabled prevention studies supported by NIAAA to make use of a robust range of survey items. However, such robust and field tested survey questions are often not utilized by other institutes and agencies. As a result, it is recommended that NIAAA stimulate a need among National Institute of Health as well as other centers, institutes, and departments of government to better coordinate survey efforts and to make more extensive use of tested survey questions from the alcohol research field. This will be invaluable to the advancement of prevention research.

2. NIAAA should assume the lead in developing a series of interagency cooperative initiatives and associated funding that support research concerning the prevention of alcohol-related problems that are within the responsibility of more than one Federal agency.

   Prevention of alcohol-associated problems is within the domain of a large number of Federal Agencies and Departments, and the careful and scientific study of alternative strategies for preventing such problems requires considerable funds. There is an opportunity and need for NIAAA, as the major Federal health research agency concerned with alcohol abuse and alcoholism, to assume the lead in interagency research initiatives to develop and test strategies for preventing alcohol-associated problems. These cooperative initiatives/programs can also provide the types of funding required for careful and comprehensive prevention research.

3. Confirm, through longitudinal research, that any delay in the initiation of drinking by youth contributes to reductions in future alcohol problems, including alcohol dependency, binge drinking, and alcohol-associated traffic crashes, injuries, fatalities, and violence.

   There is promising evidence that age of initiation of drinking is related to alcohol dependency. This evidence is largely based upon cross-section studies. There is research evidence based upon longitudinal studies that the legal drinking age results in a lower age of drinking initiation, lower incidence of alcohol-involved traffic crashes, and delayed drinking into young adulthood. Priority should be given to longitudinal research to determine if actual delay in youthful drinking initiation results in reduced incidence of alcohol dependency, associated health problems, and alcohol-involved acute problems such as traffic crashes, injuries, unplanned pregnancy, HIV infections, fatalities, and violence. Such tests can be a part of comprehensive community prevention interventions.

4. Determine the best means to restrict social and retail access of alcohol by youth at the local level and determine the most effective combination of local/state policy, youth sales and serving enforcement, school-based education, family/community training and involvement, and local news coverage (media advocacy) that can achieve the lowest access.

There is evidence of the relationship between frequency and volume of drinking by youth and the convenience and availability of alcohol to drink either in social or family situations as well as retail sales. Therefore, lower social and retail access to alcohol by youth has a real potential to reduce initiation of drinking, frequency and high-volume drinking, as well as reduce alcohol problems.

Monitor the implementation of state policies concerning alcohol, the administration and legal support of this implementation, and determine the effectiveness of state policies on reducing alcohol-involved problems such as traffic crashes, injuries, fatalities, and violence at the state and local level.

Every year there are a number of state policies that are directed at reducing alcohol problems. These policies provide the opportunity to undertake single and multi-policy multi-year studies and stimulate important methodological advances that capitalize on natural variation in intervention and implementation overtime. There is need to establish and maintain a research database that can identify/track state and local changes in alcohol-related policies and programs and enforcement efforts in order to evaluate effects. Pre-planned set of designs would facilitate rigorous evaluation. Such research should be used to define underlying effects in order to learn what (a) policies and (b) their administration actually results in decreased excessive consumption and related consequences.

Determine the generalizability as well as the need for custom-designed (targeted) prevention strategies for gender groups, racial/ethnic minorities, social class, elderly, and age groups.

There is clear evidence of differences in rates and frequencies of drinking as well as associated alcohol problems according to gender, age, racial/ethnic, education, and occupational factors. There are many reasons why custom-designed prevention programs may be required. However, there are insufficient research resources to design, field test, implement, and evaluate a full range of prevention programs and policies that can address the numerous combinations of individual characteristics and special groups. Therefore, this priority recommends emphasis on research to determine the generalizability of more universal prevention strategies across gender, age, and racial/ethnic groups. For example, how effective are programs/policies to reduce alcohol-involved traffic crashes, in general, with women, especially young women or how effective are community programs to increase the age of drinking initiation across all youth on drinking initiation by young African Americans, Native Americans, or Hispanics/Latinos? Attention should be given to the college-age group and testing the effectiveness in reducing drinking, especially high-risk drinking with college youth, that may have been developed for a larger age group as well as developing and testing college-age specific strategies. Also, the prevention of the Fetal Alcohol Syndrome is a good example of a gender-specific intervention directed at pregnant women who drink.

The second aspect of this recommendation, based upon the first, is the design and testing of prevention strategies which are targeted to unique age, gender, racial/ethnic, educational, and occupational groups in order to be effective or achieve more effects than strategies designed for general populations. This emphasis, based upon the results of tests of generalizability, is to design and test targeted prevention strategies when it has been shown that general population programs/policies are not effective with the special group under consideration. Such prevention designs should emphasize cultural relevance to the target group(s).

Develop and test interventions for reducing alcohol consumption in workplace that are generalizable across occupations, age groups, gender, ethnicity, and that are acceptable to management and union and is appropriate for workplaces of varying sizes and types.

There has been an historical emphasis on employee assistance programs as a means to assist existing problem drinking (often dependent) employees and family members with such problems and to assist the employee to continue to maintain productive employment. This priority is to give emphasis to workplace prevention strategies to actually reduce the level of drinking on the job, especially in high-risk occupations such as transportation, law enforcement, and heavy construction. Such prevention strategies should test educational programs only, workplace policies only, and a combination of educational approaches and workplace policies.

 Priority 5

Determine the causal relationship between alcohol and violence and explicate the risk curve between violent and non-violent incidents and levels of alcohol consumption.

There is considerable evidence that drinking is associated with violence. For example, approximately half of all murder victims had been drinking prior to their death and drinking is frequently reported in conjunction with domestic violence. Research is needed which goes beyond this simple epidemiological finding to study the factors that yield this result. We simply do not understand the causal or contributory effects of drinking by the perpetrator or the victim and/or the setting that may involve drinking on resulting violent events. Emphasis should be given to studies that seek to determine the causal or contributory relationships among drinking; settings; and violence both at the home (domestic violence) and outside of the home in public settings, as well as prevention interventions that seek to reduce violent events in such settings. Studies of prevention interventions can actually contribute to our understanding of the causal mechanisms involved in the relationship of violence and drinking.

Understand effects of changes in alcohol price alone and in interactions with alcohol control policies on a variety of alcohol problems, including traffic and non-traffic injuries and fatalities, violence/crime, and health consequences.

There is considerable evidence of the responsiveness (sensitivity in economic terms) of drinking to the price of alcohol. The higher the price of alcohol the lower the purchase and consumption of alcohol, and vice versa. There is further evidence that aggregate price levels, e.g., at a state or national level, are related to the levels of alcohol-associated problems, such as traffic crashes, homicide, cirrhosis of the liver, and other health problems. However, there is a need for studies of actual changes in price and their effects on drinking levels of youth and the general population, as well as on alcohol-associated problems.

In addition, econometric studies of alcohol price have most often been conducted without a consideration for the potential interactive effects of changes in alcohol prices with other public policies. Therefore, a priority should be given to studies that examine the interaction or synergistic effect of public policies that both change alcohol prices as well as seek to reduce alcohol problems though the enactment and implementation of non-price policies.

It should be noted that an important research opportunity exists in the study of the interactions among price, outlet density, local policies that affect alcohol availability, and other factors, such as family history of alcohol dependency and abuse, personality variables, peer influences, and demographics with alcohol problems and alcohol dependency.

Test the effects of media and product marketing/advertising on consumption and alcohol-related problems. This is an important priority which addresses efforts to determine the effects of media and alcohol product marketing on consumption especially youth drinking.

1. Determine the effect of the entertainment media and promotional campaigns on expectancies, especially for youth, related to alcohol consumption.
2. Determine the relationships between new forms of alcohol packaging, products, and marketing and alcohol-related problems.
3. Design and test the purposeful use of media to reduce heavy and high-risk consumption. This supporting priority is separate from the above other priorities which address effects of specific marketing and entertainment on drinking. This supporting priority address the potential effects of both "counter advertising" as well as planned and purposeful efforts to utilize the new media in support of public health prevention programs, especially at the local level, to reduce alcohol-involved problems.

Development of well-defined prevention strategies to reduce HIV risk by disentangling alcohol/ drug use and sexual behavior in clinical and general populations.

The relationships among heavy drinking, high-risk sexual behavior, and HIV infection are not well understood, and there is often an implicit assumption that illicit drugs are the major substances for increasing the risk of HIV. However, studies of drinking and risky sex suggest that the ability of alcohol to impair judgment and cognitive processes increase the risk of unprotected sex. Therefore, the design and testing of prevention strategies to reduce the contribution of drinking to risk of HIV exposure are needed. Such prevention strategies would both provide a means to better determine the contributory relationship of drinking to HIV infection as well as test means to reduce such exposure.

The following general observations and recommendations are also advanced by the Subcommittee for consideration by NIAAA:

Observation: The current prevention research portfolio is extensive but is not organized along any particular progression or logic. Current prevention intervention projects are not evaluated in terms of the level of research evidence that exists to support the potential value for this intervention. Further, demonstrated effective prevention interventions are not seen within a progression which tests the robustness of these findings in situations with less and less researcher control, in other words, the real world outside of the laboratory.

Recommendation: Adopt a phases of prevention research model or paradigm that identifies natural and progressive steps in the development of prevention research, beginning with foundational or pre-intervention research and progressing through diffusion testing. The Subcommittee recommends consideration of the following phases of research model by NIAAA as defined in Holder et al. (1999) and summarized below:

Phases of Research in Developing and Testing Alcohol-Problem Prevention Interventions

Phase I - Foundational Research: Basic studies to define and determine the prevalence of specific alcohol-associated problems; establish working causal models of factors and processes that yield the specific problems or increase the risk of a problem; and provide the foundations for the development of effective prevention interventions.

Phase II - Developmental (preliminary effectiveness) Studies: Preliminary studies to develop and test the likely effectiveness, safety, and early cost estimates of new interventions or an existing intervention.

Phase III - Efficacy Studies: Rigorous studies (of maximized internal validity) of intervention effects, safety, and costs under optimal conditions with maximal implementation (or availability or enforcement) and acceptance (or adoption at the community, organizational, or group level; or participation, compliance, or adherence at the individual level).

Phase IV - Effectiveness Studies: Studies of real-world effectiveness of preventive interventions with purposeful or natural variation in implementation and acceptance.

Phase V - Dissemination/Diffusion Research/Evaluation: Studies of the effects of different levels, or types of implementation, or acceptance on effectiveness, safety or costs.

Since research opportunities for the prevention of alcohol problems can be stimulated by investigators as well as naturally occurring situations and settings, this model accounts for both investigator-initiated research and program-initiated research or so called "natural experiments". Natural experimental studies sponsored by NIAAA have yielded

considerable scientific knowledge about prevention strategies that can actually reduce alcohol-involved problems. Since the timing for such opportunities is outside of the control of the scientist, a phases research program must allow for the potential to respond in a timely fashion to the opportunities to study these natural experiments. Examples of prior prevention research studies that NIAAA has supported include: minimum drinking age laws, changing the BAC limit for drunk driving, zero tolerance laws aimed at reducing youth drinking and drinking initiation, and an alcohol price change caused by a tax increase in California.

Observation: The field of alcohol-problem prevention research has had some important and remarkable findings over the past 10 years. Much is now known about potentially effective prevention strategies. Often the importance of NIAAA sponsored prevention research is not recognized or known. Also there is a diverse audience for the prevention research sponsored by NIAAA including the U.S. Congress, the National Prevention Network, National Association of State Alcohol and Drug Abuse Directors, alcohol and drug authorities in each state, etc. This is a much wider audience than the National Institute of Health. Better working communication with these diverse audiences both provides a means to inform them about the prevention research program of NIAAA but also provides a means to learn about the needs for scientific-based results in support of prevention interventions.

Recommendation: Prepare a dissemination plan for sharing the scientific findings from alcohol- problem prevention research in a way that is useful to prevention practitioners. This plan should provide for the dissemination of accomplishments of NIAAA prevention research to prevention constituencies throughout the U.S. For example, NIAAA sponsored much of the major research concerning the effects of changes in the minimum drinking age and this research was used to support national legislation which had important public health and safety implications. Subsequent research, much of it sponsored by NIAAA, further demonstrated the actual effects in terms of saved lives and reduce traffic crashes for young people.

NIAAA should develop a report immediately on "State of the Science in Alcohol-Associated Problem Prevention" that summarizes the specific general conclusions, findings, and principles resulting from prevention research sponsored by NIAAA. Such a publication would have importance to the U.S. Congress in demonstrating the value of NIAAA sponsored prevention research as well as to prevention specialists and community activists at the state and local levels.

Concurrently, it is essential that NIAAA seek a means for communications with a diverse audience of organizations to which scientific-based prevention is increasingly important. Such communication should be expected to be two-way, i.e., a means to communicate with various constituencies and to learn from them and about their needs. Further, NIAAA should include members of the hospitality industry which produces, distributes, and sells alcohol in regular communications in order to better disseminate the results of prevention research as well as learn about the perspectives of this industry.

Observation: There is concern about the visibility of prevention research within NIAAA and a question of whether the co-location with treatment and health services research within the Division of Clinical and Prevention Research is the most effective.

Recommendation: Create a prominent and highly visible organizational location for prevention research that demonstrates the strong commitment of NIAAA to prevention and provides a means to "show case" the activities and leadership of prevention research as well as stimulates even greater leadership within the field of alcohol-problem prevention.

The scientists who prepared reviews of current alcohol-prevention research efforts (Appendix E) proposed a number of suggestions for research priorities. Moreover, candidate recommendations were discussed by participants at the meeting and are listed in Appendix F.

Back to Top

(Jan Howard, Ph.D.)

The Prevention Research Branch (PRB) at NIAAA was formed in the Fall of 1987. I was appointed its Chief in November of that year. The professional staff already assigned to the PRB consisted of four persons. Two of them had Ph.D.'s (in psychology), and both of the others had substantial graduate work. The portfolio of grants assigned to the PRB consisted of a small potpourri of studies in the general area of social science. There was confusion in the minds of senior staff at NIAAA regarding the meaning of prevention research, because in the recent past there had been a Division of Prevention and Research Dissemination at the Institute which had been involved in prevention program activities. Those activities along with the Division Director (Robert Denniston) had been transferred to the newly created Office of Substance Abuse Prevention (OSAP) at ADAMHA.

In essence, the task at hand was clear: Define the meaning of prevention research, frame and implement a research agenda, attract established researchers to the field, improve the scientific quality of grant applications, and prove that prevention research in the alcohol area deserved to be recognized as a legitimate field of inquiry in its own right. Ideally, all that would be accomplished without denigrating the concept of "prevention activity" or "prevention programs", because at a higher theoretical level prevention researchers understand that the proof of the value of their research lies in its impact on the focal problem that society is trying to prevent. In the National Cancer Institute from whence I had come, the bottom line was the reduction of cancer mortality and morbidity. And the same was true for the National Heart, Lung, and Blood Institute where I had previously helped conduct multicenter clinical trials.

While the PRB was embarking on its research mission, the newly created Office of Substance Abuse Prevention was heavily engaged in its more applied mission of stimulating prevention programs throughout the United States. With help from OSAP, the National Association of State Alcohol and Drug Abuse Directors, which also includes all the state prevention coordinators, launched the first in a series of annual conferences to apprise prevention activists of the latest research findings regarding effective (and ineffective) preventive intervention strategies. Over the ensuing 10 years, there has been increasing pressure on the PRB's of NIAAA and NIDA to participate in the process of science-based technology transfer so that prevention activists supported by federal and state agencies can make informed choices. To the extent possible, we have tried to be partners in this endeavor, which can be a humbling experience when salient research is yet to be undertaken or when relevant research findings are in conflict.

With the exception of myself, none of the original PRB professional staff are still among us, although they played critical roles in implementing the PRB agenda. Early on, we were helped in our mission by several senior sociologists who jointed the PRB on yearly assignments. These scientists, included the late Larry Ross, internationally known for his research on drinking and driving, who helped mentor staff and write literature reviews; Frank Camilleri, who had strong methodological credentials and essentially wrote the RFA on Community-Based Prevention Research; and Phyllis Langton, an expert on alcohol policy research, who chaired a working group and edited an NIAAA/CSAP monograph on the Challenge of Participatory Research: Preventing Alcohol-Related Problems in Ethnic Communities.

The present staff, all but one of whom have been with the PRB more than six years, are all well published health scientist administrators with Ph.D.'s in a variety of social/ behavioral science disciplines and with special interests in selected segments of the grant portfolio. They and I are responsible for providing technical assistance to applicants and re-applicants; for writing and circulating RFA's and program announcements; for publishing monographs, guides, chapters and papers; for reviewing and editing massive amounts of material to be published by NIH, NIAAA, and other government agencies; for interfacing and collaborating with dozens of public and private organizations responsible for research and/or prevention activity; for presenting papers at national conferences; and for identifying prospective researchers and stimulating research in a variety of understudied areas.

Initially, our RFA's and program announcements were so detailed in their literature reviews and descriptions of projected research themes that it was an easy step to convert them into articles for publication. This was our way of saying: "Prevention research is a legitimate area of scientific inquiry, and here is our proof." We no longer feel the need for that degree of documentation in our program announcements. But we still believe it important to review and evaluate the state of the science. Over the past eight years, PRB staff have served as senior editors or co-editors of 14 books, monographs, guides, and special issues of journals on a wide range of prevention-research topics including, methodological issues, community trials, effects of alcohol advertising and media-based prevention strategies, alcohol-related violence, rural alcohol problems, economic issues, alcohol problems in racial/ethnic communities, women and alcohol, alcohol abuse among youth, the bio-psycho-social matrix of risk, family-based prevention research, and guides for sentencing DWI offenders and disposing of alcohol use/abuse offenses by youth. The two guides were developed in collaboration with the National Highway Traffic Safety Administration.

Over the ten years since its inception, the PRB has issued a substantial number of program announcements and requests for applications. These announcements were designed to publicize our research agenda, to stimulate applications in key subfields of prevention research (e.g., underage drinking, worksite alcohol problems, high-risk sexual behavior, alcohol abuse among the elderly, alcohol-related violence, economic issues in prevention research, racial/ethnic minorities) and to identify cross-cutting intervention and methodological issues. In the case of the RFA's, designated funds were set aside to support high-priority studies (e.g., research on community-based interventions, effects of alcohol warning labels, alcohol-related problems among racial/ethnic minorities, prevention of alcohol-related HIV/AIDS, economic issues, and underdeveloped areas of prevention research). Co-funding from OSAP (later CSAP) made it possible to issue two of these RFA's and recently a third that focused on the effects of alcohol advertising. Two new RFA's have just been issued for funding in FY 1999 concerned with preventing alcohol abuse among college students and preventing fetal alcohol syndrome. The Department of Education and CSAP collaborated in the development of the college-focused RFA and will help co-fund grants that evaluate preventive interventions.

As our research agenda was being developed, the PRB sponsored a large number of Working Group meetings that included extramural researchers and PRB staff. In many instances revised drafts of the solicited papers for these Working Groups resulted in the monographs described above. In one unique case, four working groups were held over an eight-year period in an attempt to articulate a research agenda for preventive intervention studies in work settings. The United States Coast Guard funded one of these meetings. In spite of these efforts, all current worksite studies supported by the PRB can be considered pre-intervention studies. Attention has shifted away from Employee Assistance Programs that were the core of PRB-funded worksite research when the Branch was initially formed; but with rare exceptions, proposals for other types of intervention research have either not been forthcoming or have not been funded.

Until June 1996, grant applications that were coded AP (Alcohol Prevention) were reviewed by standing and ad hoc Initial Review Groups that were organized and managed by NIAAA. The usual review committee for AP applications was known as ALCP 2, which focused primarily on prevention and epidemiological studies. For the first several years, the PRB closely monitored the fate of AP applications, subdivided by type of grant (R01, R03, R29) and the grant's Type 1/ Type 2 and new or amended status. These data clearly indicated that AP grants had a relatively steep hill to climb in the review process, particularly if they proposed to test preventive interventions.

Our response and that of the prevention research constituency involved multiple actions. Gradually, guided by PRB suggestions, the Office of Scientific Affairs added more experienced prevention researchers to the review committee. Second, two members of ALCP 2 raised the issue for discussion at the beginning of a review meeting and expressed concern that prevention research was being stigmatized as not being scientifically based, when in other fields of health research it was considered a very important area of scientific study and discourse. There was also concern that prevention intervention grants were being evaluated in terms of inapplicable methodological criteria, inconsistent with the state of the science. Third, program staff brought to the attention of the review committee that R03 and R29 applications, which were mechanisms used relatively frequently by prevention researchers for pilot studies, appeared to be evaluated by the same criteria as R01's, contrary to the rules of the review process. Committee members immediately implemented a new procedure to call attention to R03's and R29's so that they would be treated more appropriately. Simultaneously, the review outcomes for these types of grants changed appreciably, permitting more of them to be funded. Fourth, the PRB intensified its efforts to obtain set-aside funds for RFA's wherein prevention researchers would be competing solely against prevention researchers.

Fifth, and perhaps most important, the PRB initiated an extramural technical assistance program consisting of annual workshops and one-on-one mentoring for applicants who had failed to obtain a fundable score. The workshops were also used as a mechanism for recruiting new investigators to the field of alcohol-problem prevention research. This approach has since been adopted by other Branches within NIAAA to improve the scientific quality of grant submissions and to stimulate interest in various subfields of alcohol research. Attempts to assess the value of the PRB program suggested that both types of technical assistance were useful, depending on the experience and credentials of the persons being mentored. A definitive answer to the benefit question proved difficult because the participants were not randomly assigned to intervention and control categories.

Since June 1996, most grants that are coded AP have been reviewed by IRG's within the Division of Research Grants, now called the Center for Scientific Review (CSR). A particular IRG concerned with prevention studies has been reviewing AP applications from NIAAA as well as prevention applications from other institutes such as NCI and NHLBI. So far, the AP grants appear to have received their appropriate share of fundable scores. However, further organizational changes are underway within CSR that have important implications for the future review of AP prevention grants.

Finally, it is important to mention the expedited review system for natural experiments that has been implemented through the collaborative efforts of the PRB, the NIAAA Office of Scientific Affairs, and the Center for Scientific Review. In several situations, it has been necessary to expedite the review of applications that propose to study naturally occurring preventive interventions to enable the investigators to collect uncontaminated baseline data. With the permission of NIAAA and DRG (or CSR), the applicant was allowed to submit his or her application as soon as possible, off cycle; and the application was either reviewed in an upcoming regularly scheduled IRG meeting or through a specially convened telephone review. In three cases that resulted in funding, the telescoped review process even permitted the principal investigators to amend their original applications. In several other situations, the investigator applied for and received an administrative supplement to an existing grant to enable the collection of baseline data preceding the implementation of a new naturally occurring preventive intervention. Then, he or she submitted a regular grant application to study the impact of the new intervention.

This Fall, the PRB negotiated a contract with CDM Group, Inc. in Bethesda, Maryland to design and pilot test a Distance Learning and Mentoring Program for potential grant applicants. The program is intended to establish a system of mentoring and learning for investigators new to the field of alcohol prevention research, particularly investigators from underrepresented racial and ethnic minority groups. Funds to support the project come primarily from the NIH Office of Research on Minority Health, with co-funding from NIAAA. PRB staff concluded that the training workshops and one-on-one technical assistance visits that the Branch has been utilizing for many years could not meet the needs of new investigators who are associated with colleges and universities that are geographically distant from the main stream of alcohol research. These new researchers much have access to mentors who can interact with them on a more sustained basis. The proposed innovative system will utilize a variety of electronic communication technologies (such as the internet, electronic libraries, and e-mail) to pair new researchers with experienced mentors despite long geographic distances. It should also permit mentoring and guidance over a long enough period for the prospective applicants to frame and fine tune viable research proposals.

According to the generally accepted definition of prevention research used by the Office of Disease Prevention at NIH, and established by the U.S. Public Health Service in 1984, prevention research includes "only that research designed to yield results directly applicable to interventions to prevent occurrences of disease or disability, or the progression of detectable or asymptomatic disease." In addition to intervention research per se, prevention research includes so-called pre-intervention studies, the ingredients of which appear to vary somewhat from institute to institute. In the 1984 definition, pre-intervention research includes the identification of risk factors for disease and disability; development of methods for identification of disease controllable in the asymptomatic state; and refinement of methodological and statistical procedures for quantitatively assessing risk and measuring the effects of preventive interventions. A more all-inclusive category of prevention studies (prevention-related research) has also been identified. It includes "research which has a high probability of yielding results which will likely be applicable to disease prevention," namely, studies aimed at elucidating the chain of causation of acute and chronic diseases. Such basic research is perceived as generating the fundamental knowledge that contributes to the development of future preventive interventions.

This broad conception of prevention research has guided the orientation of the Prevention Research Branch over the course of its existence, permitting it to claim as relevant a fairly wide range of studies concerned with risk and protective factors, mediating processes, and methodological approaches. Thus, many of the studies supported by the PRB have focused on identifying and dissecting a variety of alcohol-related problems (such as violence, driving under the influence, absenteeism, underage drinking, and high-risk sexual behavior) as a prelude to the design, development, and testing of appropriate preventive interventions.

Within the category of preventive intervention research, the PRB distinguishes between tests (or evaluations) of interventions that occur naturally in society (natural experiments) and tests of interventions designed and developed by the investigators themselves, which we refer to as studies of investigator-initiated interventions.

Generally speaking, studies of naturally occurring prevention strategies have focused on policy interventions, such as changes in laws and regulations relevant to the reduction of alcohol abuse and related problems. And, clearly, these types of studies have made very important contributions to policy science in alcohol-problem prevention research. Using quasi-experimental techniques such as time series analysis, investigators have proved the effectiveness of laws that raised the legal minimum drinking age, which lowered legally acceptable BAC limits to "zero tolerance" for youthful drivers, that permitted administrative license revocation for drivers who violate drinking/driving laws, and that limited the availability of beverage alcohol through constraints on its sale and distribution.

Much of the research on natural experiments in the alcohol area has been funded by NHTSA; but NIAAA has broadened the sphere of such research to include studies of the effectiveness of alcohol warning labels, the effects of raising the price of beverage alcohol on consumption levels and related problems, the impact of a variety of laws and regulations on alcohol-related violence (such as suicide), the effects of bans on alcohol advertising, and the effectiveness of naturally occurring community-based prevention programs in terms of reducing deaths from alcohol-related crashes. In several RFA's and program announcements, the PRB has encouraged investigators to nest studies of investigator-initiated interventions within the context of larger natural experiments - for example, having a subset of primary-care physicians call attention to the risk of birth defects from drinking during pregnancy within the context of the warning label that mentions such risks. An ongoing study of the overall effects of the zero tolerance law in California includes a substudy of the effectiveness of relevant "investigator-initiated" preventive interventions that have been implemented in selected communities (e.g., media advocacy). The technology of natural experiments has also been used to evaluate the possible deleterious effects on drinking behavior of naturally occurring events such as the revocation by the spirits industry of their self-imposed ban against television advertising.

In at least two situations involving proposed natural experiments, the principal investigator received a fundable priority score even though the naturally occurring intervention to be studied rested on a foundation of uncertainty. This was true for the so-called "nickel a drink" referendum in California, which would have raised the tax on beverage alcohol and for the announcement by the spirits industry that they intended to advertise their products on television and radio. In the case of the pending referendum, which later failed to win voter approval, the principal investigator proved to the IRG that the baseline survey of store prices would be a worthy research project in its own right. When the referendum failed, a tax increase by the state legislature combined with a federal tax increase on beverage alcohol made it possible to continue the study past the baseline year. In the case of spirits advertising, the timetable was obviously in the hands of the industry; but shortly after baseline data were collected, the advertising began in earnest. Clearly, investigators who respond in a timely manner to naturally occurring policy changes, and agencies that fund such studies, must be willing to prepare for and adjust to somewhat unique forms of research uncertainty.

Over time, an increasing number of researchers supported by the PRB have launched studies of preventive interventions that they themselves have designed, developed, and implemented - frequently in collaboration with representatives of the system, community, or organization in which those strategies are being tested. Moreover, it is anticipated that the number of such investigators will increase appreciably in the near future, because all the recent RFA's issued by the PRB (concerned with FAS, college binge drinking, and alcohol-related sexual risk-taking) focus exclusively on intervention rather than pre-intervention research. Within that rubric, investigators may still elect to conduct natural experiments, but the option of testing investigator-initiated (i.e., "research-driven") interventions generally provide more choices. Currently, a broad range of investigator-initiated strategies is being tested. They can be categorized in terms of the alcohol problem being addressed (e.g., underage drinking, alcohol-related trauma), the settings in which research is being conducted (e.g., health-care systems, communities, worksites, schools), the populations or groups being targeted, and characteristics of the interventions themselves. It is traditional in alcohol-relevant prevention research to distinguish between interventions that focus on the environment and those that focus on individuals. This is true for naturally occurring prevention strategies as well as investigator-initiated interventions. But, as noted, natural experiments have usually focused on changes in laws and policies, which are generally interpreted to be changes in the environment. Investigator-initiated interventions are as likely to focus on targeting and changing individuals as they are on changing the environment.

Environmental interventions: The concept of "environment' in this context is not necessarily used in a consistent fashion, but there is a general understanding by people in the field that it stresses the importance of social/structural factors and forces that tend to be beyond the influence of individuals as individuals. Thus, several community-based studies stress the importance of implementing specific policies that control the availability of alcohol (e.g., conditional use permits, responsible beverage service) and/or enhance the enforcement of sanctions against sales of alcohol to minors and drinking and driving. As noted, media advocacy is another environmentally oriented strategy that is being implemented and tested at the community level. In addition, media strategies being studied include specially-designed TV and radio prevention messages for youth; a guide for parents to use in confronting the problem of drinking and driving; and a series of visits and discussions with parents that involve prepared materials about the problem of underage drinking. Depending on how media strategies are designed and implemented, they may be considered to be focusing on the environment, the individual, or both. Where parents or families are the targets of the intervention, as is occurring more frequently in alcohol prevention research, the concept of environment may be extended to include families as micro-systems, which have their own potential for norm setting, norm enforcement, and social control, as well as socialization.

In the grant portfolios of PRB staff members, the environmentally oriented interventions being tested also include anticipatory guidance protocols implemented by primary-care physicians, condom distribution procedures and safe-sex advertisements in gay bars, prevention-focused norm-setting strategies implemented by fraternities and sororities, and attempts to determine appropriate outcome measures for policy interventions in college settings.

Interventions focused on individuals: It is becoming more and more difficult to distinguish between environmental interventions and those that focus on individuals, because there is increasing appreciation of the need to combine these approaches. For example, in the current Northland studies, one of the two interactive grants involves classroom interventions that would historically be considered to have an "individual" focus, while the other grant is concerned with community task forces and policy change. Similarly, the interactive studies of media messages in Vermont involve the development of messages for TV and radio, on the one hand, and a community action component to bolster the effects of the messages. In addition to these composite studies, the PRB supports several projects that are entirely school- or curriculum-based. But here again, it is unclear whether they should be labeled as having an "individual focus," given that the schools have endorsed and are implementing the prevention curricula.

It is perhaps more appropriate to pin the "individual-focus" label on the group of studies that in one form or another involve one-on-one motivational counseling. This is true for Marlatt's successful preventive interventions with college students and for some of the HIV/AIDS intervention studies. Moreover, Goldman's "expectancy challenge" interventions with college students are concerned with changing the expectancies or beliefs of individuals rather than the large environment that may generate those beliefs.

Since its inception, the PRB has emphasize the need for research that develops and/or tests interventions that have the potential of preventing or reducing alcohol abuse and related problems. Yet, over the ten-year period of the PRB's existence, the majority of its grants have been characterized as "pre-intervention" rather than "intervention" studies. Currently, the proportion of pre-intervention studies is 55%, which is probably lower than at any previous time in the history of the Branch. To ensure that the proportion of intervention studies will continue to increase, the PRB has recently been restricting its RFA's to requests for intervention research.

The titles of the pre-intervention studies currently supported by the PRB suggest the variety and range of these research efforts. They consist of studies that explore risk and protective factors, family processes as mediating variables, environmental cognitions of drinking and of alcohol-related violence, development of alcohol cognition's and expectancies, predictors of alcohol use and abuse in rural or urban settings and among different racial and ethnic groups, methodological tools for prevention research, relationships between alcohol abuse and labor market outcomes, mediators and moderators of alcoholism inheritance, methods for detecting underage drinking, follow-up behaviors of DWI offenders, worksite influences on problem drinking, gang behavior and alcohol use, psychosocial correlates of adolescent driving behavior, and relationships between alcohol use/abuse and risky sexual behavior or various forms of violence. Sometimes the studies are longitudinal and involve competitive renewals; in other instances, time is not a key variable of interest, except as a manifestation of process.

It has gradually become apparent to us that investigators who conduct pre-intervention studies do not necessarily take the next step of moving into the intervention phase, even after they have identified critical parameters of the focal alcohol problem. Understanding the science of cause does not necessarily prepare one for understanding the ingredients of behavioral change. In some cases, however, principal investigators have successfully moved from pre-intervention to full-blown intervention research. Illustrative is Mark Goldman's transition from basic studies of expectancy theory to more applied expectancy challenge studies, or Ron Stall's transition from studies of relationships between alcohol use or abuse and risky sexual behavior to tests of safer-sex interventions for alcohol abusers in treatment. In other cases, investigators with a history of pre-intervention research have joined a team of investigators engaged in intervention studies.

Intervention research: Two new RFA's have just been released requesting applications for intervention studies that respectively address the problem of fetal alcohol syndrome and the problem of alcohol abuse on college campuses. The PRB anticipates that the responses to these RFA's will be of sufficient quantity and quality to use the existing set-aside funds. However, we would like to encourage further research in these two areas and have requested that future NIAAA funds also be committed to expanding these subfields of study.

Other area of intervention research that are considered high priority include:

Pre-intervention research: Clearly, preventive intervention research must rest on a firm foundation of more basic pre-intervention studies. But important questions concern the ingredients of that foundation. What tends to be missing from the pre-intervention portfolio of the PRB is basic research on processes of behavioral and social change as opposed to studies of causal processes or risk and protective factors. It is also clear that in certain areas of prevention research, none of the studies supported by the PRB are testing investigator-initiated interventions or even naturally occurring prevention strategies. In these situations, it is important to consider what further pre-intervention research may be necessary to move the process forward. Alternatively, it may be necessary to attract more intervention researchers to the field of alcohol-focused prevention research.

Back to Top

State of Knowledgez (Paul J. Gruenewald, Ph.D.)

There is a rapidly growing research literature on theoretical models and empirical relationships between the physical and social availability of alcohol, alcohol use and alcohol-related problems. Theoretical contributions include the development of (1) demographic-ecological models relating the geographic distribution of alcohol outlets to population growth and alcohol use, (2) geographic-ecological models relating the distribution of outlets to the distribution of alcohol-related traffic crashes, and (3) social-ecological models relating the geographic distribution of population characteristics and outlets to availability and alcohol-related violence. Empirical contributions include (1) conclusive demonstration of the effects of large-scale changes in availability on alcohol use and problems, (2) successful assessment of the effects of outlet densities on alcohol sales independent of reciprocal causation, (3) extraordinary growth in social area analyses relating patterns of violence to patterns of availability, (4) the development and application of advanced geostatistical methods for the analysis of community-level data, and (5) the preliminary development of multi-level approaches to the analysis of the relationships between environmental measures of availability and individual alcohol problems. Although important future research agendas can be identified in every area of study, greatest emphasis should be placed upon the assessment of neighborhood alcohol availability in relation to community-based alcohol-related problems.

Back to Top

State of knowledge (A. James McKnight, Ph.D.)

Historically, efforts to prevent injury from alcohol impairment have been largely directed to modification of long-term drinking behavior through education and information, counseling and, in the case of alcohol dependence, therapy. Over the past two decades, prevention efforts have been increasingly focused upon the context in which drinking occurs, attempting to prevent episodes of impairment from drinking and harm to the impaired. The nature of prevention varies greatly as a function of drinking context. From the viewpoint of prevention, drinking contexts are more readily classified in terms of the resources available to provide prevention than in the physical setting. Dividing prevention resources into the following three categories will accommodate the most important differences among settings.

Servers - who provide alcohol in licensed on-premise establishments.
Hosts - who provide alcohol in social gatherings.
Peers - who accompany drinkers where alcohol is served.

Servers of alcohol in licensed establishments are most clearly distinguished from other resources by the extent to which their prevention activity is prescribed by law and regulation. The sale of alcohol by licensed on-premise establishments has been the primary focal point of efforts to prevent harm from the over-consumption of alcohol. These prevention efforts include direct-intervention bartenders and waitpersons, as well as policy-level prevention by managers and owners. The strongest incentive to prevention of alcohol service to the already impaired appears to be rigorous enforcement of laws in all but one state prohibiting such service. Even a modicum of enforcement yields substantial increases in compliance, offering potential cost-benefit relationships exceeding those of almost any available alcohol countermeasure.

Most of the drinking that occurs in the company of others occurs at gatherings hosted by some individual or organization. While not subject to the same degree of outside control as licensed establishments, hosts at least provide a focal point for organized prevention efforts. There is a relative lack of research or programs addressing involvement of social hosts in preventing harm from overdrinking among guests. Obstacles include general lack of public support for legal measures holding hosts liable for harm, lack of any good route of access for formal programs, and difficulty that hosts have in monitoring the drinking of guests. Access to hosts is also limited, with public information being the only way of reaching the large numbers of social hosts. The objectives of such efforts address any and all who are present when drinking occurs, and do not differentiate hosts from peers.

Often referred to as "peer intervention", the participation of the drinker's associates in preventive efforts has gained widespread public attention. It is of particular value in drinking that occurs outside of licensed establishments and hosted gatherings and which lack any one person with a legal or social obligation to intervene. While the concept of peer intervention applies to all that drink, it has been most frequently advanced and studied within the under-age population. Attempts to induce people to intervene directly in the drinking and driving of intoxicated associates have been most successful with youth, both because they seem more receptive to the idea of intervention and because they can be reached through high school and college with the kind of group-interactive training believed necessary to build skill and confidence in carrying out intervention. Among adults, the proposition that friends don't let friends drive drunk seems best advanced through non-confrontational approaches.

Back to Top

State of Knowledge (Alexander C. Wagenaar, Ph.D. and Traci L. Toomey, Ph.D.)

There are 319 research evaluation studies for 35 alcohol control policies. By far the most studied alcohol policy is the minimum legal drinking age, with 102 studies. The second most studied policy is alcohol excise tax, with 50 studies. Two other policies, warning labels on products and density of alcohol outlets had more than 20 studies each and 26 studies were identified that assessed amount and effects of general exposure to alcohol advertising. Other than these five alcohol policies, all other alcohol policies have received little, if any, scientific research attention.

Alcohol control policies can be categorized by how they affect drinking behavior: (1) how, when, and where alcohol is sold, (2) where and when alcohol is consumed, (3) price of alcohol, (4) broader social environment surrounding alcohol use, (5) how existing policies are enforced, and (6) how underage youth obtain alcohol. Most of the extant research literature on alcohol policy is in 1, 3, 4, and 6. The dearth of studies of policy implementation and enforcement is notable.

The 35 policies may also be differentiated by whether they can be implemented at national, state, local, or institutional levels.

Alcohol consumption is the most common outcome measure (129 studies). The second most commonly analyzed outcome measure is traffic crashes and related drink-driving measures (93 studies). Only four policy studies used measures of unintentional injuries other than traffic crashes, and only nine studies examined intentional injury outcomes. Thirty-one policy studies examined other alcohol-related problems, including health, crime, school, family, and other problem indicators. Thus, one factor that impedes the growth of research literature on alcohol policies is limited data on multiple outcomes.

The overwhelming majority of studies are focused on state-level policies, with national policies receiving the second most research attention. Local and institutional policies have received little research attention. There were at least 463 alcohol control bills introduced during the 1997 state legislative sessions and 148 were enacted. Most legislative activity occurred for alcohol policies that affect how, when, and where alcohol is sold, with 229 bills introduced and 86 passed. Another large amount of legislative activity occurred for policies affecting the price of alcohol and the social environment.

For only a few alcohol policy topics are the research evidence extensive - excise taxes/price, warning labels, and legal drinking age. Even for these topics, many research questions remain unanswered, most notably what are their effects on alcohol-related problems beyond drinking behavior and traffic crashes? There is a moderate amount of evidence in the literature for privatization of distribution systems, hours of sale, days of sale, density of outlets, server training, and advertising. For all other alcohol policy issues, there is little or no research in the peer-reviewed scientific literature.

Most programmatic interventions to reduce alcohol problems and its consequences in recent years have focused on reducing the demand for alcohol by youth, traditionally through school-based programs. Programs from the 1960s to mid-1980s used information-based and affective-change strategies and were found to be ineffective (Moskowitz, 1989). More recently, programs based on the social influence model have emerged, teaching specific drug use resistance skills or more general life skills. Some of these programs have shown beneficial effects, although the effects typically decay quite rapidly after program implementation ends (Botvin et al., 1995).

As the limitations of school-based interventions, such as DARE (Clayton et al., 1996), have become apparent, interest in community-based interventions has increased. Results from three large-scale community-based alcohol intervention projects were recently published. Project Northland was a 28-community, randomized trial with social-influences-model school curricula implemented in sixth through eight grade, supplemented with peer leadership, parent education, and community task forces (Perry et al., 1996). Results showed significantly lower prevalence of alcohol use after three years of intervention, with the effects most notable among those who were nonusers of alcohol at baseline. The effects decayed, however, as these adolescents moved into high school (Komro, 1998).

A five-year, quasi-experimental prevention trial implemented in three communities was designed to specifically reduce alcohol-related injuries. Results indicate significant reductions in alcohol sales to minors and alcohol-involved traffic crashes, and no demonstrated effects on sales to intoxicated patrons or other broader measures of alcohol availability (Holder, 1997).

The Communities Mobilizing for Change on Alcohol (CMCA) project was a randomized, 15-community trial of a community organizing intervention designed to reduce the accessibility of alcoholic beverages to youth under the legal drinking age (Wagenaar et al., 1994). Results show that the CMCA interventions significantly and favorably affected both the behavior of 18-20 year olds and the practices of on-sale alcohol establishments may have favorably affected the practices of off-sale alcohol establishments, but had little effect on younger adolescents (Wagenaar et al., in press).

Back to Top

State of Knowledge (Frank J. Chaloupka, Ph.D.)

Numerous econometric studies of the demand for alcoholic beverages have concluded that increases in the prices of beer, wine, and distilled spirits will reduce alcohol consumption. However, estimates of the magnitude of the effects of price on various measures of alcohol use and abuse vary significantly across studies. Moreover, there appears to be important differences in the effects of price on alcohol use by various population subgroups, including those defined by age, gender, race/ethnicity, and drinking behavior, with particularly mixed evidence on the impact of price on the heaviest drinkers.

Econometric research on the impact of price on outcomes related to alcohol use and abuse produces generally consistent evidence that increases in the prices of alcoholic beverages lead to reductions in drinking and driving and related accidents, other accidents, delinquency, violence and other crime, liver cirrhosis and other health consequences of alcohol use, and other negative consequences of alcohol consumption, while also improving educational attainment.

Back to Top

(Susan E. Martin, Ph.D. and Jan Howard, Ph.D.)

This grouping is not a single program within PRB but 2 ongoing programs focused, respectively, on community and policy studies and on economics. The issue of alcohol availability permeates each of the community/policy studies, and it is also a focus in research concerned with DUI and violence, which has been summarized in a separate paper.

The community and policy portfolio includes four grants: The Community Prevention Trial to Reduce Alcohol-Involved Trauma (CT) which is a single study that currently involves two grants; Complying with Minimum Drinking Age (CMDA), a new study that continues the work initiated in the Communities Mobilizing for Change on Alcohol (CMCA) study; and a newly-funded Evaluation of Efforts to Reduce Border Binge Drinking. CT and CMCA were funded in response to a 1990 RFA; the former was awarded a competing continuation, while the latter has been completed. CMDA, like CMCA, focuses on the problem of youth access to alcohol. It examines the combined effects of compliance interventions and deterrence interventions to reduce the sale of alcohol to underage persons. The interventions, aimed at on- and off-premise alcohol outlets, include a compliance intervention designed to reduce underage alcohol sales, followed by a deterrence-based intervention. Nine intervention communities will be compared with 14 comparison sites using a two-group time series design.

The Community Prevention Trial to Reduce Alcohol-Involved Trauma involves three intervention communities that were paired with three matched control sites in California and South Carolina in a quasi-experimental prevention trial of a comprehensive community intervention to reduce alcohol-involved trauma. In the three intervention communities (two in California and one in South Carolina), a multi-faceted package of environmental interventions has been implemented, and the prevalence of alcohol-related trauma is the primary dependent variable. The five intervention components are: (1) a community knowledge, values, and mobilization component which involves working with existing community coalitions to develop an integrated public awareness and education program; (2) a responsible beverage service component; (3) an underage drinking component that includes normative curriculum programs in schools and community programs for parents; (4) a drinking and driving component aimed at increasing the actual and perceived risk of apprehension for DUI; and (5) an access to alcohol component that includes use of local zoning powers to reduce outlet density. Preliminary findings suggest that the project has significantly reduced alcohol-involved traffic crashes and alcohol sales to minors and that an environmentally-directed approach to prevention, using policies as the form of intervention, can reduce alcohol problems at the local level and produce substantial cost savings.

The border binge drinking study is examining the implementation and impact of the Safe Border Project, a coordinated community effort to enhance enforcement of drinking laws at the (San Diego-Tijuana) border and to establish a media advocacy program designed to alter expectancies regarding the risks of being arrested for public drunkenness and DUI.

Drs. Howard and Heurtin-Roberts are currently managing the small "Economics" portfolio described below. Four of the principal investigators are economists, and one (the PI of the gin epidemic study) is an historian. In addition, at least two grants being managed by Dr. Martin have economists as principal investigators. Thus, Dr. Michael Grossman is studying the impact of alcohol regulations on violence, and Dr. Frank Sloan is examining the impact of various deterrents on drunk driving.

Two of the studies in the Howard/Heurtin-Roberts portfolio are closely related companion projects and are funded together as an IRPG (Interactive Research Project Grant). The overall IRPG addresses alcohol demand and labor market outcomes by means of econometric analyses of existing national survey data (NLAES). The first of these studies examines the price responsiveness of beverage specific demand for alcohol and whether heavy and/or frequent drinkers are less sensitive to price. In addition to NLAES data on drinking behavior, the study utilizes data on the prices for beer, wine, and spirits reported by the American Chamber of Commerce Researchers Association. In his final report to NIAAA, Dr. Manning (the PI) concludes that: "The point estimates of the various overall price coefficients are of a magnitude that suggests that price could be an effective tool for reducing alcohol consumption." However, the results also suggest that "price may not be well targeted at the problem end of drinking behavior."

The second study in the IRPG investigates relationships between alcohol use and labor market outcomes such as labor supply, employment, earnings, and wages, again using the NLAES data for analysis. The two studies together employ an innovative synthesis of methodologies and results to assess the social costs of alcohol misuse as a means of better targeting prevention efforts.

Another econometric analysis of existing data sets seeks to understand 1) the effects of alcohol abuse and dependence on labor market success and marital status and stability; and 2) how parents' alcoholism, labor market success, and marital status affect their children. The study is composed of several sub-studies that are being incorporated to analyze complex interlinkages between parents' and grandparents' alcoholism and children's behavioral and other problems.

A panel analysis of young workers entering the job market, using data from the National Longitudinal Survey of Youth (NLSY), examines young adults' drinking patterns in relation to labor market outcomes. It investigates the effect of heavy alcohol consumption on job choices, job advancement, and investments in education following departure from high school.

The portfolio also contains an interesting historical case analysis of the London Gin Epidemic (1720-1751) being conducted by means of archival research. The study seeks to investigate the factors (social, cultural, political and economic) that influenced both the formulations of alcohol control policy and its actual impact on the consumption of distilled spirits and beer. Qualitative methods are being used to identify cultural constraints influencing policy formulation and the impact of policy on consumption. Quantitative methods being used employ an econometric time series analysis charting the relative impact of policy and market forces on consumption.

While the community-based studies portfolio is small, it strongly suggests that environmentally directed approaches are effective in addressing alcohol-related behavioral risks. Further research priorities include the following:

With respect to the economics portfolio, important areas of pre-intervention and intervention research need to be expanded or launched anew.

Back to Top

DRINKING AND DRIVING, VIOLENCE, AND WORKSITE PROBLEMS
DRINKING AND DRIVING: NEEDED RESEARCH

State of Knowledge (Robert B. Voas, Ph.D.)

Since DOT was founded in 1967, four programs have had a significant impact on alcohol research and policy, gradually resulting in the integration of drinking and driving into the mainstream of public health programs: (1) development of practical breath-testing devices, which resulted in the blood alcohol concentration (BAC) measure being written into the nation's drunk-driving laws; (2) development of reliable traffic record systems with standardized definitions of crash types at both state and federal levels; (3) demonstration of the impact of drinking age on alcohol-related fatalities among underage drinkers; and (4) development of the citizen activist movement. Unfortunately, all to often drinking and driving research is driven by current policy and program developments rather than by theory.

Although the national concern with drinking and driving has led to the implementation of tougher, more consistent drunk-driving legislation, such legislation is not always based on research. Research supporting lower BAC limits is convincing, with some alcohol impairment beginning at .02 BAC (Moskowitz et al., 1985), and roadside survey and crash data showing that there is a significant increase in the risk of involvement in an alcohol-related fatal crash at a BAC of > .05 (Zador, 1991). Currently, 39 states have laws that suspend the licenses of offenders who have a breath sample over the legal limit. There are studies that have demonstrated that this law has a general deterrent effect (Klein, 1989) and reduces recidivism among DUI offenders (Voas et al., 1998a). In contrast, states have passed open-container laws principally based on their face validity.

Most drivers in fatal crashes do not have a prior DWI, but those convicted of a previous DWI have an increased risk of being involved in fatal crashes (Simpson et al., 1996). Reducing DWI recidivism has been shown to accompany license suspension (Ross, 1992), vehicle impoundment (Voas et al., 1998b), vehicle license plate impoundment (Rodgers, 1994), alcohol-safety interlocks (Voas et al, in press), treatment for alcohol-related problems (Wells-Parker et al., 1995), and vehicle license plate tagging (Voas et al., 1997). There is little evidence that jail sentences have a special deterrent effect on offenders who are actually incarcerated (Simpson et al., 1996).

While state legislation has driven much of the progress in the reduction of drinking and driving to date, it is clear that action at the community level is critical to the effective implementation of impaired driving laws. To have an impact, new legislation must be enforced and publicized and combined public information/community action programs have been found to be particularly effective. Evidence that public information alone can impact drinking and driving is generally lacking (Atkin, 1989). There is considerable evidence, however, that publicizing new laws and enforcement programs can increase their effectiveness (Blomberg, 1992). For some years, the National Safety Council supported a program focused on the slogan "if you drink, don't drive". There is little evidence that this national effort, which did not have an action component, had any significant impact on alcohol-related crashes. In contrast, a "self-regulation training" program, wherein bartenders and counter clerks used small handheld calculator to identify a customer's BAC level based on weight and number of drinks consumed, showed promise (Worden et al., 1989). The designated-driver concept is widely recognized, and most drivers claim to have used one on some occasion. However, formal designated-driver programs implemented by bars and restaurants appear to be underutilized, and there is no evidence that such programs reduce alcohol-related crashes. A number of communities have organizations that provide rides to individuals who have been drinking and who are believed to be unable to drive safely. Unfortunately, there are no controlled evaluations of these programs. Similarly, there have been no controlled studies of the popular campaign "friends do not let friends drive drunk."

Special DWI patrols (Voas and Hause, 1987) and sobriety checkpoints (Stuster and Blowers, 1995) are the two basic methods for enforcing DWI laws in the United States. While there is considerable evidence that passive sensors, which detect expired alcohol when held in front of the face of a suspected driver, increase the rate of detection of impaired drivers at checkpoints by 50%, they are not frequently employed by police departments (Lund and Jones, 1987).

Back to Top

State of Knowledge (Kenneth E. Leonard, Ph.D.

Epidemiological research has clearly and consistently documented as association between excessive alcohol consumption by perpetrators and/or victims in homicides, assaults, domestic violence, dating violence, sexual aggression, and rape. Alcohol involvement in violent episodes is observed in alcoholics and heavy drinkers, violent men, trauma and emergency room samples, criminal justice samples, and samples from the general population.

There is minimal information regarding the prevention of alcohol-related violence. While there are numerous programs designed to reduce violence, most have not been subjected to methodologically sound outcome evaluations, much less controlled empirical investigation (Becker et al., 1994). Much of the available research, though theoretically driven, tends to derive from narrow rather than comprehensive theoretical analysis. Much of the prevention research has involved small-scale studies that have assessed hypothetical mediating variables (e.g., social skills, parent-child relationships) but have not assessed violent behavior. These studies have typically involved short, rather than more extended follow-ups. Another reason for the paucity of prevention research on alcohol-related aggression stems from the view that alcohol does not cause violence, because neither alcohol intoxication nor alcoholism invariably results in violence.

Models of alcohol-related aggression (Graham et al., 1998; Leonard, 1993) have differentiated between distal and proximal causal aspects of the violent event. The distal aspects are usually viewed as relatively stable within individuals and/or the social environment that serve to facilitate or inhibit drinking, aggression, or alcohol-related aggression. In contrast, proximal (contextual) factors are temporally unstable and are presumed to operate at the time of a potential drinking or aggression situation.

Interventions in Social Environmental Distal Factors. One of the major approaches to reducing drinking has been through policy initiatives that limit drinking such as increasing the age of legal drinking, limiting hours and/or days of sales, restrictions on the potential venues for alcohol sales, laws against serving intoxicated patrons, and increasing the cost of alcohol. These measures are of interest because of the evidence that at least some of these may have an overall impact on alcohol consumption. There is also some evidence that overall levels of consumption are associated with violent behavior (Norstrom, 1996) and more specific associations linking the density of alcohol outlets to the level of violence (Schribner et al., 1995). To the extent that alcohol-related policies reduce the frequency of intoxication, they may have a palliative effect on alcohol-related violence. There are some distal interventions specific to alcohol-related violence that have not been evaluated. For example, judicial orders for alcohol treatment in instances of alcohol-related violence might be a potential point of intervention, given evidence from at least one study that prior alcohol/drug problems increase the likelihood of re-abuse among wife abusers who are served restraining orders (Klein, 1996).

Intervention in Individual Difference Distal Factors. Although it is obvious that interventions that result in abstinence will eliminate alcohol-related violence, even highly successful interventions do not entirely do not eliminate drinking nor do they eliminate heavy drinking. Moreover, violence does not occur every time an individual drinks. Thus, it is possible that drinking reductions short of abstinence may have no discernable impact on alcohol-related aggression. Interventions with individuals who are at high risk for drinking or violence have not proven successful (Valentine et al., 1998). In the few interventions with individuals who have already demonstrated problems with drinking or violence, drinking reductions may reduce excessive alcohol use and violent behavior (O'Farrell and Murphy, 1995). There have been few criminal justice programs that have specifically targeted alcohol use or abuse. However, individual behavioral treatment of individuals with a history of alcohol abuse associated with > 2 criminal offenses has been reported to decrease the posttreatment likelihood of being convicted of violent crimes (Funderburk et al., 1993), and there are two successful, small-scale, alcohol-education programs (Baldwin et al., 1991). In addition to interventions designed to reduce drinking dispositions in order to reduce alcohol-related violence, it is possible to address general dispositions that facilitate violence, such as changing alcohol expectancies related to marital violence (Leonard and Senchak, 1993) and to rape (McMurran and Bellfield, 1993). Unfortunately, there is little evidence that these expectancies predict future violence or alcohol-related violence (Quigley and Leonard, in press).

Reducing Intoxication through Intervention in the Proximal Social/Context. While interventions in disposition factors have the broadest potential for violence prevention, focused attention on the social-physical context is also a potentially valuable strategy. Although violence can occur in a variety of contexts, alcohol-related violence tends to be more contextually restricted. For example, 70% of alcohol-related violent victimization reported to the police occur in a residence, while 10% occur in a bar or restaurant. Unfortunately, public contexts of alcohol consumption and violence (in and around bars, sporting events) are much more accessible for prevention efforts than are private contexts. The prevention of intoxication in public drinking settings has been one of the major sets of interventions directed primarily at the public drinking contexts, with most efforts focused on training servers to refrain from serving intoxicated patrons (Saltz, 1988). However, Stockwell (1992) has argued that even extensive interventions may have limited impact because servers lack consistent incentives.

There have been a variety of community action projects that have attempted to effect change at the distal social/environmental level and at the proximal level, as well as strengthening the link between the distal and proximal levels (Lang and Rumbold, 1997). The immediate social environment has been shown to play a major role in alcohol-related violence by providing aggression-invoking conditions (which can include elements of physical and social environments). Although most of the available research relevant to the context-specific changes has been concerned with taverns and bars, other contexts such as concerts or sporting events would seem amenable to such an approach.

Back to Top

(Susan E. Martin, Ph.D.)

Alcohol consumption is directly related to violence, car crash injuries and fatalities, and other types of unintentional injuries (e.g., boating accidents and falls). About half of all homicides and between a quarter and half of all assaults involve alcohol use on the part of the perpetrator, victim, or both. Similarly, about 40% of fatal crashes involve alcohol (down from more than 50% a decade ago). Thus, research on the etiology, magnitude, and nature of the association between alcohol and injury provides an important basis for designing effective preventive interventions. Nevertheless, knowledge about the etiology and prevention of drunk driving is far more advanced than our understanding of either the other sources of unintentional injury or alcohol-related violence. In part this distinction is due to two decades of research supported by the Department of Transportation, and to a lesser extent NIAAA, that has sought to: a) identify and characterize the drinking driver (focusing on the individual); and b) deter him or her through implementation and evaluation of a variety of increasingly-tough sanctions and/or other environmental approaches including separating driving from drinking, administrative and other license restrictions, and availability controls.

The Prevention Research Branch portfolio of ongoing studies related to Intentional and Unintentional Injury and the Drinking Context as of September 26, 1998 included 16 Research Grants (R01s), one new investigator award (K01), and one post-doctoral fellowship (F33). Nine of these studies are focusing on one or more aspects of alcohol-related violence, eight are examining drinking and driving or other unintentional injuries, and one cuts across these issues in assessing the impact of changes in seven different alcohol-related policies (e.g., MLDA; .08 BAC laws; server training laws) over a 20 year period on rates of both violence and injury mortality.

It should be noted that this portfolio overlaps both the youth and the community-based/policy research portfolios since involvement in risk taking behavior (including violence and driving after drinking) are characteristic behaviors and problems of young people. While most of the 18 studies might be characterized as pre-intervention research, the intervention studies include both efforts aimed at changing individuals (e.g., through a handbook designed to help parents talk to their 15-year old children about drinking and driving) and those designed to evaluate the implementation of laws and public policies to influence a range of behaviors, such as underage drinking and alcohol-impaired driving. The effects of laws, regulations, and other policies are generally evaluated through the methodologies of "natural experiments." Behavioral and social science disciplines represented by the principal investigators also range widely including sociology, anthropology, psychology, economics, and public policy, with their respective data collection and analytic approaches. There is particular overlap between this portfolio and the portfolio defined as "Community, Policy, Economics, and Availability," since Holder's Community Trial study seeks to assess interventions designed to reduce both intentional and unintentional injuries through enforcement of DUI laws and community policy mobilization to change relevant policies.

While the evidence of an alcohol-violence association is strong and consistent, understanding is limited regarding (1) the individual characteristics and environmental conditions, situations, and circumstances under which alcohol and violence are causally connected; (2) the mechanisms and processes by which alcohol use and violent behavior are connected; (3) the behavioral consequences of violence including subsequent alcohol abuse and violence; and (4) how best to intervene to most effectively reduce alcohol-related violence. These are the focal areas for research identified in Program Announcement PA-93-095 "Research on Relationships between Alcohol and Violence," and at least one ongoing study addresses each of these areas.

There are four studies focused on relevant conditions, situations and populations: two focus on bar violence; one focuses on gangs and alcohol abuse, and the fourth addresses outlet density and Mexican-American youth violence. There are three studies of the processes in which alcohol relates consumption and violence. One focuses on the contribution of alcohol consumption to men's misperceptions of women's sexual intentions in sexual assault perpetration through a laboratory experiment and interpretation of vignettes. Another addresses the contribution of alcohol to sexual assault using a self-administered survey in which respondents will describe circumstances associated with either an alcohol-involved and a no-alcohol involved sexual assault; or a sexual assault and similar social occasion that did not involve sexual assault. It will examine similarities and differences in each of these pairs of experiences, impact of various situations on misperceptions of sexual cues and sexual assault, and differences in perceptions of sexual assault related to gender and ethnicity. The third study explores the effects of alcohol abuse on mothers' punitiveness and protectiveness. The lone study of the consequences of violence looks at the long term effects of child abuse on subsequent alcohol and other drug abuse. There are two intervention studies, both of which use secondary data analyses to examine the consequences of various policies that restrict alcohol availability (e.g., state taxes on spirits) on the violent actions committed by various groups. The growth of the portfolio has received a boost from outside sources of funding: two of the studies have received co-funding from the Office of Research on Women's Health; a third was initially funded by NIMH but following that agency's reorganization transferred to NIAAA for the final two years of support.

Because alcohol affects cognitive and motor skills required to drive a car and to operate other machinery, various interventions have been implemented to reduce drinking and driving and its consequences including alcohol-related crashes and other injuries; in addition, pre-intervention studies have sought to identify those high risk individuals most likely to drink and drive and to be injured. Ongoing research supported by PRB includes five studies focused on understanding the psychosocial, environmental, and personal correlates or risk factors associated with drinking and driving in particular populations (2 focused on general youth populations; one focused on women convicted of DWI; and one involving an in-depth longitudinal examination of a nonclinical sample investigating the dynamics of daily alcohol consumption patterns over a 2-year period, and the biopsychosocial correlates of those dynamics and specific risk factors for alcohol abuse and dependence. In addition, the first three of those studies are looking at the effects of race/ethnicity. Two other studies involve interventions at the individual level: one is assessing the utilization and effectiveness of a handbook for parents on talking to their youth about drinking and driving; the other involves assessment of the effects after 6 and 12 months of a brief counseling session for adults hospitalized for burns, falls, near-drowning, and pedestrian injuries compared with a control group. The remaining four studies focus on assessing the effects of policies designed to reduce driving after drinking. They include an evaluation of the effects of California's zero tolerance law for persons under 21; a comparison of the effects and effectiveness of legislation encouraging alcohol server education as a DUI prevention method through either state-mandated server education or state laws providing license protection or liability reduction for participating establishments; a study that investigates how various forms of liability and related deterrents affect the behavior of commercial servers in ways likely to reduce drinking and driving; and a new study that will conduct an outcome evaluation of a statewide randomized trial of alcohol interlock systems in Maryland as a means of preventing first time (Driving While Intoxicated) DWI recidivism. The latter study involves all first time DWI offenders in Maryland. They will complete a state-mandated diagnostic evaluation and those that are alcohol dependent/abusive DWI offenders (N approximately 6500) will be randomly assigned to the Standard Treatment (T) or the Ignition Interlock and Standard Treatment (IIT) condition that will be mandated by the state for 12 months. They will be assessed at 12 and 24 months following ST or ITT with respect to both conventional measures (i.e., alcohol-related crashes and rearrests for DWI), as well as data on interlock tampering and assessments of psychological functioning.

In addition to the research grants, NIAAA has cooperated with the National Highway Traffic Safety Administration (NHTSA) in supporting a research contract (managed by NHTSA) to study Crash Risk at various BAC levels which is replicating (and improving on) the 35-year old Grand Rapids Crash Risk study.

Research on alcohol-related violence needs to continue to address each of the four areas previously identified: etiology, mechanisms, consequences, and interventions. Much of the research to date has taken advantage of the natural experiments that have occurred as a consequence of changes in policies related to the minimum legal drinking age and other limits on alcohol availability. Additional studies of this sort should be supported and a mechanism for rapid review of such "targets of opportunity" research proposals would greatly facilitate collection of baseline data before legal/policy changes are implemented. Both pre-intervention and intervention studies need to focus on high risk populations ---both likely perpetrators and their victims--- and on high risk environments such as "hot spot" locations since it often is easier to prevent violence by altering environmental factors than individuals. New methodologies and approaches such as geostatistical and mapping techniques should support theoretical developments and help identify effective intervention strategies. Such initiatives might overlap with college age interventions by focusing on the Greek system and on the vulnerability of young women to date rape associated with alcohol abuse.

Research on alcohol and unintentional injuries also needs to focus on: high risk individuals, particularly young, recidivist, and elderly drivers (since this group is a growing segment of the population); non-crash injuries (falls, injuries from recreational activities such as skiing); and systematic evaluations of the effects of various combinations of sanctions and interventions to which offenders may be sentenced. Very little is known about the effectiveness of "standard" sanctions with underage drivers or even about the differences in procedures, sanctions and outcomes in handling underage DUI offenders in juvenile or traffic court. In addition, the use and expansion of geostatistical methodologies to identify high risk places in which to target interventions for DUI offenders would be useful. There are also many opportunities for studies of natural experiments and assessments of diverse "good ideas" that are being implemented without evaluation (e.g., licensing ceremonies held by judges throughout Virginia or variations in the presentational features of victim impact panels).

Back to Top

State of Knowledge (Genevieve M. Ames, Ph.D.)

Over the past decade, there has been an increase in research on the relationship of work to employee drinking patterns and costs of employee drinking to the workplace. The growing interest in occupational alcohol problems has been driven by wider societal concerns over the costs of alcohol and drug use, employer and employee concerns about safety and productivity in the workplace, employer recognition that in addition to adequate treatment for troubled employees there is an urgent need for adequate prevention of alcohol-related problems.

Prevalence, Problems, and Costs of Occupational Drinking

Prevalence of Drinking Patterns by Occupational Category. Rates of alcohol consumption differ widely by occupational categories, specific job types, and gender. Overall, percentages of current drinkers among men and women are higher in white-collar populations, with the highest percentages found in managerial and administration, professional, technical, and sales groups. However, blue-collar workers tend to have higher average daily consumption levels than white-collar workers, with highest rates found in jobs under the groupings of food service, health, cleaning and personal service, construction, machine operators, and laborers. Heavy daily consumption was found among certain white-collar workers to include writers, artists, and entertainers among men, and computer scientists and mathematicians among women (Parker and Harford, 1992). The highest rates of alcohol abuse and dependency were more prevalent in blue-collar jobs, and men had higher rates of alcohol abuse than women in all but six job categories (Stinson et al., 1992).

Employee Drinking and Workplace Problems. Drinking at work has been shown to be associated with sleeping on the job, arguing with supervisor, being criticized by supervisor, and being in a serious fight or argument with a coworker (Ames et al., 1997). Four categories of negative consequences have been related to reduced productivity.

Health and Social Consequences. Causal links have been described between injuries and traumatic accidents and work-related drinking in specific employee populations (Lewis, 1990). Moreover, 16% of emergency room patients who had been injured at work had positive blood alcohol concentrations (Wechsler et al., 1969).

Mortality Consequences. Research has documented deaths from alcohol-related accidents at work (Lewis, 1990).

Economic Consequences. All alcohol problems have economic consequences, but those that are most obvious include absenteeism (Trice and Roman, 1978), lowered work performance, and higher average costs for employer insurance and health care expenditures (Holder and Cunningham, 1992).

Legal Responses to Alcohol Use and Misuse. Employers can be liable for employee involvement in accidents that occur on the job after drinking and off the job following on-premise or work-sponsored drinking events (Geidt, 1986).

The majority of work on environmental risk factors has been on theoretical approaches that propose that undesirable drinking behavior is associated with quality and organization of work (stress, alienation, and job satisfaction), social control (policy and other forms of social regulation), alcohol availability (physical and social availability), and individual factors consisting of psychosocial factors of alcohol expectancies (beliefs about negative and positive aspects of drinking for the individual) and personal background (ethnicity, gender, age, family drinking history, and individual consumption rates).

Interventions are usually designed to change the workforce (i.e., individual) and/or change the work environment. Brief intervention programs have been developed that target the workforce, but the effects have been modest (Cook et al., 1996). A more successful worksite intervention improved coping skills, resulting in a modification of work and family-related risk and protective factors for stress, and reduced negative outcomes, including alcohol abuse (Kline and Snow, 1994). The 3M Company has developed a comprehensive alcohol and other drug prevention program designed to alter workplace drinking and promote employee participation and thereafter ownership of the program (Stoltzfus and Benson, 1994). Although worksite educational sessions have some limitations, when coupled with Employee Assistance Programs and health promotion programs, they have potential for changing undesirable uses of alcohol, reducing alcohol consumption, and reducing negative consequences of drinking. An intervention modality that targets alcoholic abusing employees is the peer-intervention program. This intervention is based on the belief that the social environment of work peers around the problem drinking or alcoholic employee will have influence through gradual and persistent feedback, affective exchanges, advice-giving, and accountability mechanisms (Sonnenstuhl, 1996).

Back to Top

(Susan E. Martin, Ph.D.)

The worksite is not only the primary source of income for most adults, but also a source identity and sociability. The centrality of the occupational and organizational aspects of work in adult lives makes the worksite a key institution both for understanding and intervening in alcohol-related problems. Since issuance of a Program Announcement in February 1990, "Research on Worksite-related Alcohol Problems: Causative Processes, Primary And Secondary Prevention, "NIAAA has sustained a small but continuing program of research on worksite-related alcohol problems. The program's focus over the past eight years has been on exploring causative processes: namely, the ways workplace factors may contribute to alcohol problems among workers and understanding the key etiological factors contribute to work-related alcohol problems in order to provide a more solid theoretical and empirical base on which subsequently to develop prevention strategies and interventions. To date all but one of the studies supported by the PRB have involved "pre-intervention" research; in the past five years the studies have focused on the social or group context of drinking; previously there were several studies examining Employee Assistance Administration policies and practices.

All of the completed and ongoing worksite studies focus on the impact of one or more of five theoretically-based social and environmental influences in workplace alcohol-related problems: workplace cultures (i.e., understandings and norms that participants within a work setting share); social control (i.e., degree of managerial observation of and/or constraint on employee opportunities to drink); alienation (i.e., estrangement from work, social isolation, or a sense of powerlessness); occupational stress (arising from boredom, or work overload or difficult work conditions); and alcohol availability (both social and physical). Across these common themes, however, there continues to be diversity among the studies with respect to methodologies and the occupations and organizations from which data have been obtained. There also has been a growing sophistication in the analytic models and thinking about the dynamic interaction of social situation, individual personality, and sociodemographic characteristics.

The current portfolio consists of 4 R01 grants (including one that has recently been completed but not yet submitted a final report), a new R29 (first award), and one T32 focused on pre-doctoral training; total expenditures in FY1998 were about $1 million. The researchers are focusing on environmental and personal factors that affect drinking different populations. One study is focusing on the effects of work stress and organizational policies among urban transit workers. A recently completed grant focused on workplace cultures, social control, alienation and stress as risk factors for drinking behavior among unionized blue-collar workers. Initially only focusing on male-dominated occupations, the sample was expanded to include unionized garment and domestic workers and include gender-related issues. Following in-depth interviews and on-site observation, a survey was designed and administered to approximately 1,500 workers and for analysis using structural equation modeling. The findings are not yet available. Another study is exploring whether corporate restructuring (downsizing) affects employees' alcohol-related behaviors by heightening levels of stress and dissatisfaction among employees, and undermining their feelings of worth and confidence. Additionally, it examine whether restructuring and drinking practices among workers adversely affects work performance and whether participation in self-directed work teams serves as a counterbalance to the potentially destructive effects of downsizing and job re-engineering. A fourth study involves a longitudinal examination of the interactive influences of intrapsychic, socioeconomic, and larger societal factors operating to put African-American workers at risk for the development of problematic alcohol behaviors (e.g., heavy drinking), and problem drinking outcomes (e.g., role impairment). It also seeks to identify unique protective factors and coping resources that may mitigate against problem drinking behaviors in the African-American population. A new R29 (first award) involves intensive participant observation and interviews among Navaho young adults regarding normative understanding of alcohol, patterns of drinking, and employment. The training grant to the University of Georgia is supporting doctoral students in sociology students focusing on work organizations and human resources management issues.

There is ample room for growth in this portfolio. The clearest gap is the lack of intervention research in the worksite area. Historically, NIAAA was involved with the creation and development of Employee Assistance Programs (EAPs) which in the past two decades have been widely adopted by large-scale organizations. Nevertheless, there has been virtually no NIAAA-supported research examining the programs and outcomes of EAPs or other more innovative-types of workplace prevention programs. To encourage interventions and their assessment in a variety of work settings, it would be desirable to have an RFA on behavior changes based on the one recently jointly sponsored by the Office of Behavioral and Social Science Research but with a greater emphasis on a) interventions based in the worksite and b) addressing alcohol-related problems and other health risk behaviors simultaneously (e.g., diet and drinking). The focus might be on exploring the effects of altering organizational policies (from changing management and union practices regarding alcohol availability on site and at social activities); providing health promotion and/or stress reduction programs that include self-assessment of alcohol problems; or other interventions to alter the occupational and/or organizational culture related to drinking.

Other gaps that research might address include:

Back to Top

 PREVENTION OF ADOLESCENT DRINKING AND DRINKING PROBLEMS

State of Knowledge (Joel W. Grube, Ph.D.)

School-based educational prevention interventions, even those using the most recent normative education and resistance-skill training program innovations, are only modestly effective. Such programs produce small effects that are typically short-lived. Moreover, although some evaluations have considered heavy drinking and self-reported problems as outcomes, very few have demonstrated substantively important effects on outcomes such as intoxication, drinking and driving, injury, or alcohol-related crashes. In most cases, such outcomes are not reported.

The results of community and comprehensive programs are mixed, but appear promising. In part, the problem in interpreting the results from current community projects is the inability to ascertain exactly what interventions are responsible for the observed changes in problem outcomes. It is also unclear at this point whether communities can sustain environmental efforts to reduce alcohol problems once research funding has ended. Few, if any, community interventions have focused on minority communities where alcohol problems may show distinctive patterns and where the solutions to these problems may be different than for other communities. Although some community programs have included substantial minority populations (Holder et al., 1997), the interventions were not specifically designed around the particular needs and strengths of these communities.

There is some evidence that certain subgroups may be more affected by school-based interventions than others. For example, those who have had previous unsupervised drinking experience may be more responsive to resistance-skills training (Dielman, 1995), and those who are more rebellious are more responsive to normative education (Kreft, 1997). Apparently no community-based studies have investigated differential effectiveness.

There is very little information about how prevention programs influence young people. With few exceptions (e.g., Botvin et al., 1995), analyses of how program effects are mediated are absent. For example, it is unclear whether resistance-skills training affect drinking because it actually increases resistance skills or because of some unknown processes that are initiated by the intervention. Similarly, it is unclear to what extent changing access to alcohol in the community affects underage drinking and whether such changes are mediated through changes in perceptions of availability, changes in perceptions of community norms, or other processes.

Back to Top

(Gayle M. Boyd, Ph.D.)

Despite over 30 years of prevention efforts, alcohol remains the drug of choice among youth. In 1997 approximately one half of high school seniors reported drinking in the previous 30 days, one third reported high-risk or "binge" drinking (five or more on a single occasion) in the past two weeks, and one fourth reported having been drunk. Although long-term trends show a decline in youthful drinking that parallels that among adults, prevalence has remained steady, since 1991. Episodic heavy drinking or "binge" drinking is more prevalent among young adults (including those under 21) than any other age group; and among young adults, college students have the highest prevalence of binge drinking. Alcohol-related problems have become a major health concern on college campuses.

Studies of the etiology of alcohol problems indicate multiple pathways; and risk is seen to be a dynamic quality that may increase or decrease over time with the interplay of a variety of influences emanating from individual characteristics, family, peers, schools, physical environment (drinking settings), social and community norms, and the alcohol policy environment. Environmental factors are believed to increase in importance with age, and alcohol availability and the social and economic "costs" associated with drinking play a major, immediate role in adolescent drinking behavior. At each age, the strongest predictor of experiencing alcohol-related problems is previous drinking history, and the age of initiating drinking correlates negatively with the probability of experiencing alcohol problems in adolescence and adulthood. These findings support the importance of both delaying drinking onset and retarding age-related increases in frequency and quantity of drinking.

The research portfolio on prevention of drinking by youth includes study populations with ages ranging from infancy, through childhood and adolescence, into young adulthood. Both pre-intervention and intervention studies are included. Pre-intervention studies do not test interventions, but provide important foundational information with immediate relevance to intervention development, implementation and evaluation. Table I indicates the distribution of studies across categories defined by population age and research type.

There are two major research foci for this age range: intergenerational transmission of risk and identification of early markers for risk. Two pre-intervention studies evaluate potential cognitive, emotional, and behavioral differences between offspring of alcoholics and nonalcoholics. One examines attachment and cognitive development longitudinally in infants from ages 12 to 36 months. The other investigates the effects of marital conflict on child development and tests differences in children's emotional responses to simulated inter-adult conflict according to family history for alcoholism and marital conflict. A third study of childhood indicators of risk, which NIAAA co-funds with NIDA, is examining the relationships between observed social behaviors in elementary school and the use of alcohol and other substances in adolescence and young adulthood. There are no studies testing preventive interventions for young children.

Pre-intervention studies seek to identify predictors and test causal models for early onset drinking, changes in alcohol use over time, and appearance of alcohol problems. Of the ten studies of this nature currently supported, five are conducting secondary analyses on data sets that were collected under the auspices of other projects. Two of these have strong methodological components directed toward developing new techniques for analyzing longitudinal data and improved measures of alcohol use by youth. Most data sets bracket transition points for adolescents that are associated with sharp increases in risk: entrance from elementary school into middle or junior high school (3 studies); middle school into high school (1); and high school into college or the work force (1). Four data sets span the full age range from late elementary school through high school.

In accordance with NIH guidelines, almost all of these studies include minority populations. In many the sample size is large enough to support in-depth analyses within ethnic and racial sub-samples, and some racial or ethnic populations are a primary focus of the study. Table 2 indicates the age and ethnic/racial composition of study populations.

The models of risk being tested are multivariate and longitudinal, and vary in complexity and primary focus. Key factors being examined include:

NIAAA is supporting nine research projects (funded through eleven separate grants) and is co-funding a Program Project (P50) with NIMH that test interventions to prevent and reduce drinking by adolescents. Two other intervention research studies are currently on no-cost extensions and are not included in Table 1. Seven of the active grants support interventions directed toward preteens and young adolescents. Only one study, which is composed of two interactive research grants (IRPG), is directed toward drinking by high school students. An additional program for parents of high-school students focuses specifically on drinking and driving and is also included in the portfolio on prevention of alcohol-related unintentional injuries. A third project assesses alcohol use outcomes in a follow-up study of young African American males who participated in a mentoring and job-placement program while in junior high or high school.

PRB is not encouraging research on the development of single component interventions that rely entirely on alcohol prevention school curricula. As demonstrated by the long-term evaluation of the Alcohol Misuse Prevention Study (AMPS), well designed school curricula can serve to prevent and delay alcohol misuse by students. However, there is a long history of research in this area, and effect sizes are not likely to be increased significantly by further refinements in course content. Research has been encouraged to address alternate modes of intervention delivery, environmental change, and multi-component approaches.

The interventions being tested currently include:

Two studies evaluate the efficacy of alcohol-related preventive interventions delivered to adolescents by health care providers in primary care settings. Only one of these is housed within PRB and is included in Table 1. It tests the use of tailored alcohol abuse prevention strategies for disadvantaged youth in urban primary health care and school settings. The prevention strategies are based on a Stages of Change theoretical model. A second study, housed within the Health Services Program but managed by PRB staff, is testing a preventive intervention for adolescents and their families that is delivered by pediatricians and nurse practitioners.

Additionally, two community and policy interventions, described elsewhere in this review, specifically focus on underage drinking.

There are two pre-intervention research projects studying college-age young adults, and one prospective study of newly wed couples included in Table 1. Additionally, one pre-intervention study of adolescents includes some young adults (age 25), and one of the college intervention studies has a substantial pre-intervention component. Features of these studies include:

Prevention of alcohol problems among college students is an NIAAA special emphasis area, and an RFA in this area is being published. There are currently nine research projects, five of which are in their first year of funding. The intervention approaches being tested include:

There are no studies of preventive interventions for young adults who are not attending college.

1. Children. Some early childhood behaviors, especially conduct disorder and aggression, are reliable predictors of a variety of problem behaviors in adolescence, including alcohol use and misuse. However, alcohol-related interventions have not been developed for these high-risk children. Given the length of follow-up necessary to obtain alcohol outcomes and the variety of other problems these children may experience, research in this area might be best advanced through cross-institutes collaboration.

2. High-Risk Adolescents. Universal preventive interventions for this age group are often less effective with youth who have already initiated drinking. Early onset drinking is associated with increased risk for future alcohol problems. Additionally, very early onset is non-normative, which suggests drinking in this highest-risk group may not be mediated by the same factors that influence those who initiate drinking later. Directed and indicated preventive interventions may be needed for these high-risk youth. Alternatively, universal intervention approaches might be augmented to achieve preventive effects in a broader population.

3. Family-Based Intervention. As described in an NIAAA-supported supplement to Journal of Studies on Alcohol (in press), there is converging evidence from cross-sectional and longitudinal studies of risk, behavioral genetics, and preventive intervention studies that parent practices have a major influence on children's drinking and that these practices are often amenable to change. Relatively little research has been directed toward the development and testing of universal preventive interventions for parents. Although some comprehensive interventions have included parental involvement components, these have not been evaluated separately. Changing or reinforcing parent attitudes, knowledge and behavior related to underage drinking would directly affect norms for adolescent drinking within individual families and could contribute to changing community norms.

4. Older Adolescents. The majority of universal preventive interventions have been developed for young adolescents. Program effects generally disappear when youth enter high school, and the few evaluated interventions for older adolescents have not been found to be effective regarding alcohol use. Alcohol use is normative in this age group, and interventions are needed that will change the general social climate that tolerates and encourages underage drinking. Environmental strategies to reduce alcohol availability to youth and alter public acceptance of teen drinking may be especially important for older teens.

5. College. NIAAA is strongly encouraging research in this area through its designation as a special emphasis area, an RFA, "Prevention of Alcohol Problems Among College Students," and the ongoing work of the NIAAA Advisory Council subcommittee on this topic. Although there are nine active intervention studies, they focus primarily on individual behavior and do not address the college environment.

6. Young Adults. There are no intervention studies directed toward young adults who are not attending college, and much less is known about their drinking patterns. They are more difficult to reach for data collection and intervention delivery than are school-based populations. Possible locations and systems for accessing this population include the military, low-paying work sites, health care systems, employment offices, social services, and the judicial system. Community-based policy interventions that reduce alcohol availability are also relevant for this population.

Table 1

Back to Top

State of Knowledge (Michael D. Slater, Ph.D.)

Media appear to play a role in socializing young people across a variety of behavioral domains (Walsh-Childers and Brown, 1993) and to be especially influential when direct personal experience is lacking (Adoni et al., 1984). Media effects and psychological research are consistent in finding that experience will generally prevail over media, while media is particularly influential when personal experience is limited (Ball-Rokeach and DeFleur, 1976; Wu and Shaffer, 1987). Thus, alcohol advertising and other media content may influence alcohol expectancies with preadolescents who have little direct experience with alcohol (Austin and Nach-Ferguson, 1995), while for youth in early to mid adolescence, alcohol advertising may primarily reinforce perceptions of social norms and reinforce optimistic appraisals regarding alcohol risks.

Identifying the nature and extent of alcohol advertising effects on behavior, especially youth behavior, is highly desirable given the on-going public policy controversy regarding such advertising. Correlational research has provided consistent evidence that exposure and awareness of advertising is related to alcohol attitudes and consumption among underage youth (Grube and Wallack, 1994). Examples of harmful advertising practices among youth include sports content in beer ads (but not sports programming context) was found to increase receptivity to TV beer ads among adolescent males (Slater et al., 1996) and awareness of beer advertised was predictive of positive beliefs about alcohol use and intent (Grube and Wallack, 1994). Most researchers assume that alcohol advertising effects on behavior are indirect, mediated via advertising influences on expectancies and normative perceptions. Such a premise seems more consistent with existing research than a direct stimulus-response model of alcohol advertising effects, for which no credible current evidence exists. Advertising is intended to influence specific perceptions in target audience members, such as identifying a particular beer with special occasions and social acceptance or with masculine independence (Cohen, 1995).
Econometric studies of the relationship between alcohol advertising expenditures and consumption have been conducted in an attempt to identify causal evidence for a relationship between advertising and behavior (Saffer, 1995). Results to date have been contradictory and appear highly dependent on assumptions used, and there is no theoretical reason to assume a simple dose-response relationship between amount of advertising and amount of consumption (Cohen, 1995).

Event promotion, merchandise, and produce placements in film are forms of commercial promotion outside the traditional definitions of advertising (Cohen, 1995). There may be an overemphasis on the effects of advertising relative to non-advertising media content, including TV dramas and comedy, films, and MTV. Theory and communication practice suggests that portrayals of alcohol use and alcohol users in these story-telling contexts are potentially more influential than portrayals in advertising. The impact of such programming is of greatest concern with children and younger adolescents; even children's cartoons portray alcohol use with surprising frequency (Klein et al., 1998). Non-advertising media portrayals of alcohol may be especially influential with at-risk youth. Youth at risk for substance abuse typically have become dissociated from family and school and are primarily linked to similarly dissociated youth (Oetting et al., 1991). Such youth may be more likely to turn to alternative media both as part of their rebellious identification and as a means of obtaining socialization information outside of family, school, and other conventional channels.

Although the prevention of misuse of alcohol can employ mediated communication in a variety of ways, surprisingly little is know about how best to develop effective message strategies (Petty and Cacioppo, 1986). It is important to distinguish efforts directed at those already engaged in risky behavior from efforts intended to discourage experimenters and from efforts designed to reinforce individuals who are not using alcohol Porter Novelli, 1998. There is some suggestion that, in general, positive appeals (Monahan, 1995), high sensation appeals (Donohew et al., 1991), and appeals with anecdotal information (Slater and Rouner, 1996) may be most effective with youth at higher risk, and messages that focus on threat/risk and related information content may be most effective with those at lower risk (Witte, 1995; Slater and Rouner, 1996).

Research indicates that most public health risks are poorly understood by the general public and perceived risks are more typically a function of amount of media coverage than actual statistical evidence (Combs and Slovic, 1979). Moreover, there is evidence that perceptions of risk and potential to motivate concern and possible change in behavior (Bachman et al., 1991), will vary depending on how statistical risks are presented (Slater et al., 1998). There is evidence that unfamiliar information in warnings is not received as positively as familiar information, though unfamiliar information appears to contribute more to knowledge gain (Slater et al., 1998).

Alcohol prevention programs often contain components concerning the critical, skeptical viewing of alcohol advertising. Such training can influence alcohol expectancies and attractiveness of alcohol-branded merchandise even after a three-month delayed post-test among third-grade children (Austin and Johnson, 1997). Improving media coverage of alcohol-related risks is likely to increase community prevention activities, support legislative initiatives, and increase public understanding of risks. Prevention-oriented theory and research has primarily been concerned with media effects on individual attitudes and behavior, rather than effects on community action and civic or political leadership (Wallack and DeJong, 1995). Recent research on community readiness to undertake substance abuse prevention activities (Oetting et al., 1995) suggests that community and civic leadership recognition of the problem must precede community action; media may contribute to such recognition and community agenda building. Research on youth suggests that perceptions of peer and community norms can play an important role in substance use decisions among youth (Oetting et al., 1991) and that perceptions of peer norms concerning alcohol use are exaggerated (Hansen and Graham,1991).

(Susan Martin, Ph.D.)

Although there is widespread belief that alcohol advertising contributes to the initiation and continuation of alcohol consumption, research documenting the nature and extent of this association is limited. Four studies in the PRB research portfolio focus on assessing the impact of advertising in various media (but primarily television) on the initiation and establishment of drinking among youth and on identifying mediating and moderating factors affecting this relationship.

One of these studies takes advantage of a unique historical event -- the introduction of spirit ads on television in the United States -- by measuring the effects that TV spirits ads have on viewers. The fact that liquor ads will first appear only in select markets provides an opportunity to maintain much more experimental control than is normally possible in field studies of alcohol ad effects. The research will compare individuals exposed to liquor ads with those from comparison communities without any liquor ads. It will also measure the degree of spirit and beer advertising in each community and explore the possibility that ads do not affect overall consumption, but merely cause people to shift from one brand or product to another, such as from beer to liquor. In addition, the long and short-term effects of broadcast advertisements on alcohol beliefs and consumption will be explored.

Three newly-initiated studies were funded in response to an RFA, "Effects of Alcohol Advertising on Underage Drinking," which sought studies that explore causal relationships among advertising, alcohol use by youth, expectancies, and other potential mediators and moderators. Each of these new studies involves a longitudinal design in order to determine whether alcohol advertising affects initiation and continued consumption of alcohol by youth. Each is examining both the short- and longer-term relationships among exposure to alcohol advertising, alcohol expectancies, other mediating variables (e.g., personality and family norms), and actual consumption of alcohol by youth. They will address both the role of mediating and moderating variable in associations between alcohol advertising exposure and alcohol consumption, and the relative magnitude of the advertising effect on actual drinking behavior. These studies are complementary. Collectively they include cohorts of youth between the ages of 9 and 16; they include populations with different ethnic compositions; and although they utilize different data collection schedules, the investigators have agreed to collaborate on the development of some common measures and to share data.

Back to Top

(Gayle M. Boyd, Ph.D.)

Currently, in the U.S. the fastest growing segment of the population is persons age 65 and over. Between 1980 and 1990 this population increased by 21.6%, compared to an increase of only 8.5% in the population under 65 (U.S. Census, 1992). By the year 2030 there will be approximately 65 million persons over the age of 65, comprising about 22% of the total population (U.S. Census, 1989). Given the size of the projected population and some evidence that this generation may drink more that their predecessors, alcohol-related problems among persons over the age of 65 will be an increasingly important public health issue.

The older population is at risk for a variety of alcohol-related problems. Some effects of alcohol mimic changes that normally occur with aging, and its use may produce additive deleterious effects. In addition to adverse effects on the liver, heart, gastrointestinal tract, and immune system and increased risk for some cancers, alcohol use has been associated with disturbances of sleep, cognitive and motor impairment, accidents, violence, depression, personal neglect, inability to carry out responsibilities, and disruption of personal relationships. (DHHS, 1990 & 1994) Adverse consequences of particular concern due to the numbers of persons at risk include interactions with medications, depression, and accidents. Due to age-related increased sensitivity and decreased tolerance, problems may occur at very low levels of drinking in susceptible individuals.

However, moderate use is not necessarily contraindicated for healthy elderly persons, and some studies have found evidence of positive effects. Therefore, as with the younger population, prevention objectives are not limited to reducing alcohol abuse and dependence, but should encompass a full array of problems that may be associated with various patterns of consumption. Unfortunately, relatively little is known about the true prevalence of these problems in the older adult population.

Despite the publication of a Program Announcement in 1990, "Research on the Prevention of Alcohol Abuse in the Older Population," there have been only three research grants and two SBIR awards in this area. None of these are currently active, although a phase 1 SBIR grant and a phase 2 SBIR contract are on no-cost extensions. These projects are developing a screening instrument and educational materials. A third study on no-cost extension was submitted to NIAAA in response to a 1995 RFA, "Moderate Alcohol Consumption: Benefits and Risks." It is making use of an existing database to relate alcohol consumption and medications use to morbidity and mortality. There are no randomized controlled intervention studies for the prevention of alcohol problems among the elderly. Prevention is virtually absent from the NIAAA monograph on Alcohol and Aging (in press) because there has been so little research in this area. Nor does there appear to be adequate foundational or basic research to support full-scale intervention trials at this time. Additional preintervention research is clearly needed, but it is essential that it address research questions directly related to the development of future interventions. Research and intervention approaches must take into account the heterogeneity of the older population with respect to health, level of functioning, type of residence, life style, and other demographic variables. Not all segments of the population are at risk for alcohol problems, and risk profiles are needed for specific sub-populations that explore the full range of alcohol problems that may be experienced.

Research needs include:

Back to Top

State of Knowledge (Fred Beauvais, Ph.D.)

The best epidemiology data are available on adolescents as well as more complete descriptions of prevention interventions. Treatment and recovery are more completely covered for adults. It is well established that alcohol use is quite common among American Indian youth. Indian youth are similar to their non-Indian counterparts, except that when they do use alcohol, they drink more and experience more serious consequences (Oetting and Beauvais, 1989). Unlike for adults, there does not appear to be significant differences in use rates from one location to the next. Although peer influence is of significance in predicting drug use among Indian youth, it is considerably less influential than for other youth, and family influence on drug use is more influential (Swaim et al., 1993). School has a smaller influence on decisions to use drugs for Indian youth than for other youth. Religious involvement appears to be a protective factor for non-Indian youth but has little effect for Indian youth (Austin et al., 1993).

May and Morgan (1995) and May (1995) have provided comprehensive reviews of drug and alcohol prevention programs among Indian populations. Although there is a clear consensus that prevention programs must be designed to be culturally appropriate (May, 1995), there is little research data that are supportive of this linkage (Bates et al., 1997). Skill enhancement programs (Gilchrist et al., 1987) and the teaching of social competence skills (Schinke et al, 1988) have reduced subsequent alcohol-related difficulties in young Indians. Given the importance of the family, it is surprising that there is only scant literature addressing prevention interventions that feature the family. A few school-based programs have demonstrated specific, short-term gains (Davis et al., 1989), but most lack any evidence that can be generalized or that the gains are sustained overtime. Particularly overlooked is the need for continued booster sessions. An area that has received virtually no attention in substance abuse prevention in Indian communities is that of policy (May, 1992). The majority of research has been focused on problem behaviors with very little addressing healthy or resiliency behaviors.

The terms "Asian-American" and "Pacific Islander" refer to groups (as many as 60) so diverse as to make generalizations questionable (Zane and Sasao, 1992). In cross-population studies, Asians (variously defined) typically show among the lowest rates of alcohol use of any ethnic population; this holds for both adult and adolescent age groups (Kim et al., 1992). Among the Asian populations, Japanese Americans are among those with the highest rates of use with Chinese Americans showing the lowest rates (Parrish, 1995). Typically found in most studies is a very large gender disparity with Asian women exhibiting very low rates of use (Parish, 1995). It has been demonstrated that alcohol use will gradually change among Asian immigrants over succeeding generations to match that of the majority culture (Kim et al., 1992). While this is a common observation, little is known about the value and attitudinal shifts that occur among individuals that lead to increased alcohol use although there is a modest correlation between increased drinking and improved socioeconomic status (Parrish, 1995). It is generally agreed that most Asian individuals have a genetically determined propensity for flushing when using alcohol. In the past, the existence of this noxious response has been used to explain the lower rates of alcohol use among Asians. More recently, the strength of this deterrent has been questions with the assertion that social norms are sufficiently strong to counteract the physical effects (Parrish, 1995).

While there is a modest literature discussing alcohol abuse prevention issues among Asian populations, very little has been reported on the effectiveness of specifically designed and implemented prevention programs. Results have been conflicting and inconclusive (Austin et al., 1989).

State of Knowledge (Raul Caetano, M.D., Ph.D.)

There have been no published outcome-based comprehensive evaluations of either environmental or "risk factor-based" interventions with a special focus on Hispanics or Blacks. There are, however, a number of programs being implemented across the country, many of which reach both Hispanics and Blacks in the school-based population and in the community.

It is generally accepted that cultural identity and distinctiveness of minority communities must be recognized and understood so that both prevention strategies and evaluations are culturally appropriate and include such characteristics as gender roles, stress due to racism or poverty, stress due to immigration and acculturation, family involvement, and birthplace (Cervantes and Pena, 1998).

Since the 1980's, heavy alcohol use among White and Hispanic adolescents has continued to rise, while rates for Black youth have slowly decreased (Johnston et al., 1996). Student dropouts are at a greater risk for high rates of substance use and delinquency, particularly Mexican-Americans (Chavez et al., 1994). There is evidence that the same amount of alcohol may trigger more problems among minority youth than among White youth (Welte and Barnes, 1987). There are data that suggest that the recent drop in the perception of the risk attached to alcohol is one of the factors explaining an increase in the prevalence of alcohol use among older adolescents (Grube and Agostinelli, 1998). Newcomb (1995) notes that although ethnic groups share common predictors of substance use, their exposure and responses to such risk factors vary. Dusenbury et al. (1994) found that being male, having friends who drink, and having parents with neutral or favorable attitudes toward alcohol use were shared predictors across ethnic groups. It has been observed that the strength of the relationship between different risk factors and substance use varies across ethnic groups. There is some evidence that as risk factors accumulate, the risk of alcohol and other substance use increases (Bry et al., 1982); the number of protective factors showed a similar cumulative protective effect (Newcomb, 1995).

Recent survey findings with adults confirm that Hispanics and Blacks continue to be at a higher risk for heavy drinking and alcohol problem development than Whites; these findings are especially apparent in men (Caetano and Kaskutas, 1996).

Only a small number of programs are offered to ethnic minority populations, e.g., only 19 of 415 school-based programs had a focus on minorities (Tobler, 1986). In meta-analyses of school-based programs of 5th to12th graders, Tobler and Stratton (1997) found that interactive programs were more effective than non-interactive programs in schools with 50% or more students in ethnic minority groups. This result was also found for those schools where the majority of students were White. Unfortunately, interactive programs only had a success rate of 7%. It is not yet clear whether generalizability of current prevention programs across ethnic groups is superior to program specificity (Dent et al., 1996).

Back to Top

(Suzanne Heurtin-Roberts, Ph.D.)

Consideration of a portfolio on Special Populations raises questions of definition. What is meant by special? Are some populations not special? Do we mean special in terms of culture, ethnicity, minority status, or race? Certainly all peoples possess culture, and culture influences to varying extent the use of alcohol and development of problems related to it. So, are all ethnic groups to be included in this specific portfolio of the Prevention Research Branch? Should ethnic groups only be included, or should we also consider other subgroups of the general population such as women and persons with disabilities? To address these questions we must consider the history and intent of this portfolio.

The impetus for a Special Populations grant portfolio within NIAAA preceded the formation of the PRB, because racial and ethnic influences on alcohol use and abuse had been a long standing interest of several professional staff, including Elsie Taylor, who was one of the original PRB staff members. Several rather historic NIAAA monographs and numerous presentations at NIAAA working groups addressed this issue. To move the focus more toward prevention research, the PRB in collaboration with CSAP, issued an RFA to stimulate intervention and pre-intervention research on racial/ethnic minority groups. Two applications received fundable scores, and both proposed studies of risk and protective factors rather than studies of the effects of interventions. The RFA was then converted into a standing program announcement that had the stated purpose of expanding the limited information available about the prevention of alcohol-related problems among ethnic minorities. That emphasis clearly identified ethnic minorities as a special population, however, the PA goes on to say that research within its domain should address factors that facilitate or impede the development, implementation, and evaluation of prevention strategies among diverse sociocultural populations. This indicates a broader perspective.

Over time, a substantial number of other grant applications were submitted in response to the PA on ethnic minorities, expanding the range of subpopulations proposed for examination to include Asians and Alaska Natives, as well as the more usual groups of interest, namely African Americans, Hispanic Americans, and Native Americans. At least five of the studies that received fundable scores can be defined as intervention research because they tested or evaluated the effectiveness of investigator-initiated or naturally occurring prevention strategies. Other studies that were funded can be classified as pre-intervention research because they explored causes of the focal alcohol-related problems, their incidence and prevalence, and mediating factors rather than the process of behavioral change.

In addition to studies that were directly responsive to the RFA and PA on ethnic minorities, racial/ethnic subpopulations were, of course, included in a variety of other studies supported by the PRB, especially after NIH mandated that the target populations being examined be representative of a cross section of America, or at least of the area in which the research project was located. Thus, for example, Holder's community trial of interventions to prevent alcohol-related trauma deliberately included two intervention communities that respectively had large Hispanic and African American populations. And in Minnesota, Perry's study of school/parent based interventions for the prevention of underage drinking included several school districts composed largely of Native American students. This permitted the investigators to test whether the general findings also applied to the Native Americans, which they apparently did.

Because grants within the PRB are assigned to specific program directors in terms of certain priorities (e.g., drinking and driving takes precedence over special populations as a classification variable), the special populations portfolio directed by Dr. Heurtin-Roberts does not contain the full complement of studies that focus on racial/ethnic populations and variables. In fact, the Special Populations sub-portfolio managed by Dr. Heurtin-Roberts currently contains only ten research projects. This number, however, is deceptive because, as indicated, research on racial/ethnic minorities and also on women is spread throughout the entire PRB portfolio -- in studies of worksites, violence, youth, and HIV, among others. Thus, if overlap between this portfolio and others are taken into account, it can be seen that the number of grants that examine special populations increases appreciably.

Rather than being overly concerned with boundaries for inclusion of specific groups, it seems more useful to employ a flexible, working definition of the concept of special populations. From this perspective, "special populations" are those which require specially focused attention by virtue of social and historical circumstance, process or elements of culture, or having been significantly neglected in past studies or programs. Operationally, in accord with this interpretation, "special populations" refer to racial/ethnic minorities, women, and persons with mental or physical disabilities. In the future, relevant populations may change as the special emphasis areas of NIH, NIAAA, or the PRB change.

Pre-Intervention and Intervention Studies

Concerning the theme of prevention, the major distinction in the special populations' cross-PRB portfolio is between pre-intervention studies and those that test actual interventions to prevent alcohol-related problems. Another important distinction is whether the prevention focus is the individual or the environment. In the racial/ethnic area, pre-intervention studies predominate, as they do for PRB grants as a whole. To an extent, this may indicate the state of our knowledge base on which to build prevention interventions for specific populations. It may also indicate a need to encourage our researchers to be a bit bolder in proposing interventions for study.

Intervention Research:

Among the intervention grants, one newly funded study focuses on two "special populations," women as well as Native Americans. It proposes to test a comprehensive multi-site community-based preventive intervention for Fetal Alcohol Syndrome in four high-risk Native American communities, compared with two control communities. Components of the intervention include community reinforcement, motivational enhancement, individual empowerment and skills building as well as social structural change and policy advocacy. Thus, this intervention focuses on both the individual and the environment.

A second study that can be considered to have an intervention focus involves an historical and social analysis of African American grassroots community movements in various sites across the country. The study seeks to understand how these African American communities have organized to address their alcohol problems. Although these movements also include activists who are not African American, the focus of the intervention efforts has been to address alcohol problems in inner city African American populations. The principal investigator also plans to study a unique social movement within a rural Southern community.

A third study (located in the youth portfolio) tests the effects of a community-based program that offers culturally relevant guidance and mentoring, combined with employment training and placement, for African-American male adolescents. Preliminary findings indicate changes in the desired direction for 6 of the 8 behavioral outcomes, but only for youth who had participated in the more intense intervention -- guidance plus job training and placement. These changes were marginally significant (p< .10) for carrying a gun and selling illegal drugs. Heavy drinking exhibited a large but non-significant effect in the desired direction.

A fourth study (also located in the youth portfolio) is testing a learner-centered, experiential and empowerment-oriented prevention model that involves predominantly Hispanic youth from low income, high-risk communities, as well as their families, peers, and representatives from the larger community. After several visits to the University-affiliated hospital and the county detention center, where they interview patients, families of patients, and jail residents who have alcohol and drug problems, the participating students are trained to be peer educators in their schools and communities.

In addition to these studies, the PRB portfolio as a whole contains several other research projects that test interventions targeted toward minority populations. First-year findings from a study by Chudley Werch suggest that a brief primary-care-based preventive intervention can result in significant reductions in alcohol initiation and consumption, particularly among "more at-risk inner-city youth." In this study, 85% of the participating students were African American. However, two other investigators have found it extremely difficult to recruit the special ethnic populations they planned to target with their interventions. And one of them has tentatively concluded that urban Native American youth are not necessarily responsive to "culturally sensitive" interventions that incorporate elements of Native American culture. Finally, as noted in the discussion of the youth-focused portfolio, NIAAA is funding a supplement to an NIMH grant so that the principal investigator can re-test a family-focused program that previously proved successful among rural white youth to determine whether it proves to be equally effective among rural African American youth.

As is evident from this review of minority-focused intervention research, at least one intervention study is being funded among each of the major minority groups except Asians. However, even when completed studies are taken into account, there continues to be a dearth of findings concerning what interventions "work" in preventing and reducing alcohol problems in specific racial/ethnic communities. State and local directors of alcohol prevention programs are forced to rely for guidance on the results of program-driven evaluations funded by service components of the Federal Government (such CDC and CSAP), because research-driven studies of the effectiveness of interventions among minority populations are few and far between. The alternative is to assume that what works for populations that are largely Caucasian will also work among non-Caucasians, but that is an assumption that requires appropriate testing in its own right.

 Pre-Intervention Studies:

The PRB pre-intervention studies of racial/ethnic minority populations can be subdivided into those that focus on one specific group and those that make comparisons across groups.

Although the Special Populations portfolio of Dr. Heurtin-Roberts currently contains no pre-intervention studies specifically focused on African-Americans, Dr. Martin's portfolio includes a survey of problem drinking among African American workers. And as indicated below, alcohol-related behaviors of African Americans are being addressed in comparative studies across ethnic groups.

Several PRB pre-intervention studies (all in Dr. Heurtin-Roberts' portfolio) focus exclusively on Native Americans. One project (which is co-funded by the NIH Office of Dietary Supplements) is investigating the diets of the Wichita Indians for dietary protein, a source of tryptophan. This study is examining whether low levels of dietary tryptophan may be associated with low brain serotonin, possibly increasing the risk of both depression and problem drinking. Another pre-intervention study, which has just been completed, examines possible links between alcohol dependence and the diagnosis of antisocial personality disorder among the Navajo. Although the relationship is far from a simple or clear one, the findings do suggest the possible utility of designing interventions which focus on the specific group of Navajos diagnosed with antisocial personality disorder and on youth at risk for this diagnosis. As a prelude to the comprehensive, multi-site FAS intervention trial mentioned earlier, the principal investigator has been conducting a large prevalence study of FAS and adult drinking patterns among four Plains Indian tribes. This study, which is still to be completed, is providing the baseline data for the intervention trial. Also included in Dr, Heurtin-Roberts' portfolio is an ethnographic study of drinking patterns among Navajo workers, which was discussed by Dr. Martin in relation to worksite research on alcohol use and abuse.

We presently have no funded pre-intervention or intervention research on Alaska Natives although such studies are sorely needed. Hence, we are currently providing technical assistance to a research team that is developing a pre-intervention project concerned with this population. In the recent past we funded a study that measured the impact of "wet" and "dry" villages on violence among Native Alaskans.

The only funded research on Asians or Pacific Islanders in the PRB grant portfolio is a pre-intervention study investigating alcohol use and abuse among Filipinos in California and Hawaii. The study seeks to describe drinking patterns and estimate the prevalence of alcohol use disorders among Filipino Americans as well as to identify factors associated with these patterns of alcohol consumption and associated disorders.

At present we have no funded research specifically focusing on Hispanic Americans, although we are providing technical assistance to several investigators who are developing or re-submitting grant applications.

It is also worth noting here that the same research team that is investigating FAS in Native Americans is also engaged in a comparative epidemiological study of FAS prevalence and in case finding in the town of Wellington, South Africa. This study is focusing on the Colored population in Wellington in order to gather baseline data to assist the government of South Africa in its prevention efforts.

The Special Populations portfolio of Dr. Heurtin-Roberts includes a current study that is analyzing alcohol-relevant mortality data in relation to social and ethnic factors. This involves the secondary analysis of already existing data, and ethnicity is used as an independent, categorical variable.

Comparison of ethnic differences is also the focus of a number of youth studies managed by Dr. Boyd. Three of these are studies of adolescent development and norms, beliefs, and behaviors relative to alcohol use. The first, a longitudinal study, tests a developmental model of individuation and alcohol use and abuse. The model, which considers individuation in the context of a variety of psychosocial factors, is being tested among three adolescent ethnic groups: African Americans, Mexican Americans, and non-Hispanic whites. Another longitudinal study investigates the development in early adolescence of alcohol cognition (expectancies about alcohol and about the reactions of others to drinking). The process of this development relative to race/ethnicity, family, peer group, and individual characteristics is being compared in three groups of adolescents: Anglos, Hispanics, and African Americans. The third study, located in rural Georgia, is testing another developmental model that describes the conditions that foster the transmission of parent's norms for adolescent alcohol use. The study makes comparisons across the primarily white and African American sample of rural families.

Two other pre-intervention adolescent studies are conducting secondary data analyses that assess alcohol use across different ethnic groups. One study analyzes data from a large-scale NCI-funded trial of a cognitive/behavioral intervention to prevent smoking. The study examines longitudinal predictors of alcohol use among Hispanic American, African American, and White youth. The other secondary analysis is examining trends in the patterns of alcohol and related substance misuse among ethnic minority school students in grades 5-12 in New York State. A variety of ethnic groups are represented in this large sample including American Indians, West Indians, African Americans, and Hispanics.

In contrast to these secondary analyses of large data sets is a project in Dr. Martin's portfolio that explores relationships between alcohol consumption and violence among ethnically defined youth gangs. Using both qualitative and quantitative research methods, this study compares gangs in each of three ethnic groups in the San Francisco Bay Area (African American, Latino, and Asian American) in terms of alcohol consumption, aggression, and violence.

Finally, it is important to highlight a pre-intervention study in Dr. Bryant's HIV/AIDS portfolio where the sample is composed of multiple ethnic groups who live in Miami, Florida. The research examines the relationship between coerced sexual experience, patterns of alcohol and other substance misuse, and HIV-related risky sexual behavior among adolescents and young adults in alcohol and substance abuse treatment. The subjects primarily come from racial/ethnic minority groups, with Hispanics being the single largest group represented.

In addition to RFA's and Program Announcements, another way to promote research on ethnic minorities is by attracting new researchers to the field and by further developing the skills of established researchers who are interested in issues concerning alcohol and ethnicity. One way in which skill enhancement is being achieved is through career development awards. We have one career development award in which the PI is preparing for a research career that involves evaluating relationships among alcohol abuse, education level, and family history of problem drinking across ethnic groups, with a special focus on African Americans. Another career development award is now supporting a PI whose work to date has examined biological and psychosocial risk and protective factors in Asian Americans and American Indians. The career development award will give the PI training in psychosocial factors in developmental models of alcohol use and alcohol problems, as well as advanced statistical techniques to further prepare her to study psychosocial factors across ethnic groups.

Grant supplements can also be awarded to enable researchers who are members of recognized racial/ethnic minority groups to "piggy-back" studies on pre-existing "parent" grants. The Office of Research on Minority Health and NIAAA have cooperated to award a number of minority research supplements over the last several years. It is not required that the supplemental studies conducted by these minority investigators also focus on minority groups and issues. The intent is to provide mentoring and training opportunities to help them become independent investigators regardless of their chosen area of interest within alcohol prevention research. However, these areas of interest frequently include minority-oriented themes.

One such supplement has been awarded to a Filipino researcher to work on the previously mentioned research project studying alcohol-related behavior among Filipinos in San Francisco and Hawaii. Through use of these funds, the minority investigator has designed an important component of the study examining whether psychological well being, alcohol use, and alcohol abuse vary as a function of racial/ethnic phenotypes and self-identification. Another minority supplement was awarded to an African American pediatrician as a supplement to an ongoing study of an office-based family-focused intervention for pediatric practices to reduce alcohol use and abuse among adolescent patients. In the supplemental study, the investigator will assess the applicability of this intervention to clinics that treat urban ethnic-minority and poor youth in Boston, Massachusetts. A third supplement was awarded to an African American behavioral scientist to design a "booster" intervention to increase the effectiveness of an ongoing media/school-based intervention aimed at reducing alcohol and sexual risk-taking among adolescents. And a fourth supplement was awarded to an African American undergraduate student to assist in the evaluation of an intervention to reduce alcohol abuse and related problems among college students.

As indicated in Dr. Howard's Overview, the NIH Office of Research on Minority Health (ORMH) and NIAAA have also contributed funds to enhance technical assistance to minority investigators who are developing or resubmitting grant applications. During the past year, five minority investigators (three Hispanic Americans, one African American, and one Native Alaskan) received extramural one-on-one mentoring through this collaborative system. In the spring of 1996 a special workshop, funded by ORMH, was held for 22 minority investigators who had expressed interest in entering the field of alcohol-relevant prevention research. Several of these participants are currently being supported through minority supplements to "parent" NIAAA grants. Recently, the technical assistance program has been expanded to include sponsoring the attendance of early-career minority investigators at national professional meetings on prevention research. Thus, three of these new investigators attended the Annual Meeting of the Society for Prevention Research in Park City, Utah, June 3-7, 1998, where they also enrolled in special half-day seminars on methodological issues in prevention research. A fourth investigator attended the Annual Research Findings Conference of the National Prevention Network (a component of the National Association of State Alcohol and Drug Abuse Directors), which was held in San Antonio, Texas. Three of the four attendees at these national conferences are faculty members at universities that are quite distant from centers of excellence in alcohol studies.

The Prevention Research Branch has just added a contract to Dr. Heurtin-Roberts' Special Populations portfolio to fund the design and management of a Distance Learning and Mentoring Program for new prevention researchers, particularly those from under- represented minority groups. This innovative program will utilize a variety of electronic mechanisms such as internet websites, electronic mail, and computer databases and libraries to put relatively inexperienced researchers in ongoing communication with established alcohol researchers. The program will facilitate the ongoing mentoring of new researchers as they develop or amend grant applications, despite long geographic distances between mentors and mentorees.

The need for more research on all of the groups discussed previously is readily apparent. We have some very noticeable gaps and areas requiring further work. African Americans compose the largest ethnic minority group in the U.S., and alcohol problems among this group have been widely demonstrated. Yet we have little research specifically focused on the context of their alcohol problems and very little in the way of intervention research in the adult population.

American Indians, although represented in this portfolio, are under researched in proportion to the enormity of the alcohol problems they face. Native Alaskans in particular warrant a special effort. Alcohol consumption is exceedingly high for this group, as are estimates of FAS rates.

Among Hispanics, it is important to move beyond the census type category of Hispanic or Spanish speaking and fund research that differentiates among members of the category in terms of true ethnic groups. There is tremendous diversity among Spanish speaking peoples, and meaningful prevention research and the interventions being tested must reflect this diversity. Although epidemiological surveys have been conducted that are sensitive to these distinctions, there is a dearth of intervention research that targets Hispanics as a whole, let alone subgroups of them. This is even more true for Asians and subpopulations within that category.

There are still other ethnic groups, perhaps newer to the U.S. than some, who may well have alcohol problems that merit research attention, including subgroups within the White/Caucasian (or European) category. Their drinking patterns may be affected by selective immigration, acculturation, and socioeconomic status, as well as by culturally induced behaviors characteristic of their countries of origin. Some subgroups within ethnic categories are not only recent immigrants but also refugees, here in the U.S. because of displacement due to sociopolitical and economic problems. This fact may need to be explored in relation to the development and maintenance of alcohol problems.

Depending on which populations are studied, insights regarding protective factors might be gained from pre-intervention research in addition to information about risk factors.

The Special Populations portfolio of Dr. Heurtin-Roberts at present contains little research on women specifically, save for the large intervention trial on Fetal Alcohol Syndrome among Native Americans. The recently issued RFA on interventions to prevent FAS is expected to expand our research base on at least one segment of this group, pregnant women and women of childbearing age. Certainly other PRB portfolios contain studies that address women's issues such as sexual risk taking, violence, and sexual abuse in relation to alcohol. But the PRB has not issued any RFA's or PA's that invite research that directly addresses women's alcohol use, the context of its use, and special issues that preventive interventions for women might need to take into account.

In relation to gender, more comparative findings according to gender would be useful. A PRB working group on women's issues concluded that researchers infrequently report data according to respondent gender. Also important would be studies addressing alcohol misuse, gender identity, and sexual orientation among women. Although gay men have been the subject of PRB-supported intervention and pre-intervention research, lesbians have been understudied. Some data suggest that lesbians report higher rates of alcohol-related problems than do heterosexual women.

Similarly, we have no prevention research addressing persons with disabilities, mental or physical. There are at least two relevant groups within this population. One group includes those whose disabilities are secondary to or related to their alcohol misuse (e.g., disabilities related to alcohol-related crashes and injuries). A second group includes persons with disabilities or physical or mental challenges (e.g., persons with mental disorders, chronic diseases, congenital defects) who develop alcohol-related problems as a result of stress and stigmatization associated with their primary disorder. Populations such as these definitely require further inquiry in order to design and implement adequate preventive interventions.

In many respects the PRB research portfolio on racial/ethnic minority groups has been population-, rather than issue-, focused. To some extent this needs to change, as does our thinking about these special populations. Thus far much of the research tends to conceptualize these ethnic, and also gender groups, as static categories to be compared in terms of outcomes. While this is one legitimate approach to take, it cannot be our only approach. Our research must take conceptualizations of these populations to higher levels of sophistication. That is, we need to turn our attention to the processes by which ethnicity or gender, for example, are related to particular alcohol related behaviors and prevention outcomes. If we are going to compare groups, we cannot simply use group type as an independent variable. Rather, as was well stated by Dr. Fred Beauvais, in his presentation at a recent meeting of the National Advisory Council on Alcohol Abuse and Alcoholism, we need to compare groups on meaningful dimensions.

If we find that outcomes differ for different groups, we need to be able to understand why. What is it about a particular group that makes a difference? Is it culture content or cultural process? Is it socioeconomic conditions, social psychological processes, or personality variables? Is it an interaction among any or all of these? In sum, we need to ask: What are the contexts, conditions, qualities, and processes that make a difference in alcohol-related problems and in the success of interventions for the various groups whose problems we address?

To ask and answer such questions, an increased use of qualitative methods is in order. Certainly this is so in the case of pre-intervention studies where context, norms, and attitudes regarding alcohol require description and analysis. But in intervention studies, too, qualitative research can aid in gaining insight and understanding of the reasons for success or failure in prevention efforts.

In summary, we have a substantial number of accomplishments, but there is much more work to be done. We need to increase research on all special populations. For some groups, this is urgent. We need to train and support a new generation of alcohol researchers in the subfield of prevention, particularly those who are members of the special populations being investigated. We need to conceptualize problems and solutions in terms of the complexity and fluidity in which they exist, using the highest level of theoretical and methodological sophistication the social, behavioral, and public health sciences have to offer.

To increase the amount of funded research on special populations in this portfolio, active outreach and solicitation of applications is imperative. An energized approach to liaison work with various professional organizations, many of whom have their own minority sections is in order, as is contact with universities and research bodies known to have significant minorities.

There is no single solution to increasing and improving prevention research among the special populations identified in this review. It will take a creative investment of staff effort and financial resources, as well as collaborations with organizations that represent populations that are relatively inaccessible.

Back to Top

State of Knowledge (Ron Stall, Ph.D., M.P.H.)

Over the past 15 years, a series of empirical papers have been published about whether individuals who combine alcohol or drugs with sexual activity are more likely to engage in high-risk sexual behavior (see Leigh and Stall, 1993 for a review of this literature). If this is the case, then interventions to prevent the combination of substance use and sexual behavior might effectively prevent the continuing spread of HIV infections. However, the findings from this literature have been inconsistent, with some studies finding a statistical relationship between drug or alcohol use during sexual activity and the likelihood of participating in high-risk sexual activity (Davidson et al., 1992), while others have not found evidence of this relationship for alcohol alone (Weatherburn et al., 1993).

The inconsistency in findings in the series of behavioral studies has given rise to a considerable controversy over whether there is anything to the hypothesized link between alcohol or dug use and high-risk sex, and whether some other variables underlie any observed relationship between substance use and high-risk sex. At the extreme, some people have argued that if it cannot be established that substance use causes unsafe sex, then interventions should not address this hypothesized connection. It is important to note, however, that there are actually two research literatures focusing on the relationship between AIDS and alcohol. The first literature examines relationships among measures of self-reported sexual behavior and substance use; the second examines the relationship between measures of self-report substance use and HIV seroconversion itself.

The findings from a series of AIDS natural history studies on self-reported substance use and incident HIV seroconversion conducted on three continents unanimously converge to show that gay men with higher levels of non-injection substance use at baseline are more likely to become infected with HIV over time (e.g., Chesney et al., 1998). HIV seroconversion is a valid and medically meaningful outcome variable - characteristics not necessarily true of outcome variables constructed from self-report data measuring "high-risk" sexual behavior. Although it is instructive to try to understand why the literature that uses self-reported high-risk sex yields contradictory findings, the studies that demonstrate a link between higher levels of non-intravenous substance use and subsequent HIV infections are the studies that may be most relevant to considering whether the relationship between substance use and high-risk sexual behavior is an appropriate part of AIDS risk reduction efforts. Nonetheless, it should be acknowledged that even seroconversion studies remain correlational in nature, and that other underlying variables could be responsible for this observed relationship.

It is difficult to argue during periods of epidemiological crisis that theoretical questions of causation or correlation regarding the associations between concurrent alcohol/drug use and high-risk sexual behavior need to be resolved before behavioral interventions can be attempted. In a recent study, Stall and colleagues (in press) determined that (1) substantial HIV risk reductions can occur after initiation of substance abuse treatment among gay men; (2) risk reductions begin soon after treatment starts; (3) lapses to unsafe sex are common during treatment; (4) continued unprotected anal sex is most likely among those men who are riskier at intake, who continue to be more sexually active, and who are more likely to continue substance use and sexual behavior; and (5) AIDS prevention activities conducted at substance abuse treatment agencies cannot alone reach all high-risk substance-abusing gay men. Whether these general lessons, and most notably the finding that substance abuse treatment is associated with substantial reductions in high-risk sexual behavior, is replicated by other research projects now in the field remains an important question.

An agenda to study the relationships between alcohol use and AIDS must also consider the effect that alcohol use may have on adherence to triple combination HIV therapies. The past two years have seen remarkable advances in our understandings of HIV pathogenesis and in the treatment of HIV infection itself. However, the many challenges surrounding widespread adherence to complicated HIV drug therapies threaten to transform these clinic-based advances in the treatment of HIV disease into short-term gains that will eventually be lost. For this reason, research to design and evaluate proven interventions to support adherence of triple combination therapies may be as important as the development of these therapies themselves. Study of the ways that alcohol-abusing HIV seropositive individuals use these complicated HIV treatments is an urgent public health priority. Future research on the relationships between HIV treatment adherence patterns among HIV seropositive individuals will become an increasingly important AIDS research and service agenda over time.

Back to Top

Alcohol use may be a key determinant in adherence to therapeutic regimens among HIV-infected individuals. Research is needed on interventions to improve treatment adherence and to ameliorate negative physical, behavioral, affective, cognitive, and social consequences of HIV infection in alcohol-using and -abusing populations.

Research efforts are needed to-

• Improve medication adherence in alcohol-using and -abusing HIV+ patients.
• Prevent alcohol relapse and related HIV risk behaviors among HIV+individuals
• Enhance linkage of primary medical care with alcohol prevention and treatment services for HIV-infected alcohol abusers.
• Develop and test interventions to improve quality of life for alcohol using and abusing HIV-infected persons (e.g., ameliorating the interaction of alcohol use and medical sequelae of AIDS progression).

OVERVIEW: The Intersecting Epidemics of Alcohol Abuse and AIDS

Reducing the spread of AIDS in populations that are alcohol -using or -abusing or under treatment because of alcohol can be accomplished through behavioral change. Developing effective interventions in these populations requires an understanding of the dual epidemics of HIV and alcohol abuse. The activities that transmit AIDS-unprotected sexual intercourse with an HIV-infected individual, use of HIV-contaminated injection drug equipment, birth of an infected child-may interact directly and indirectly with alcohol use and abuse. How alcohol use affects specific HIV risk behaviors at an individual level is not precisely understood; investigation is ongoing. Studies of cross-sectional samples, however, have consistently shown that heavy alcohol use predicts increased rates of HIV risk behaviors and infection. Longitudinal multisite AIDS studies have reported that baseline heavy alcohol consumption is associated with seroconversion. Risk reduction interventions among alcoholics have significantly reduced HIV risk behaviors, and interventions among young adults show promise. Treatment of seropositive (HIV+) alcoholics presents additional challenges in the delivery of appropriate services.

HIV and sexually transmitted diseases (STDs) are among the most common infectious diseases. There are an estimated 40,000 to 60,000 new cases of HIV infection per year in the United States. These cases of new infection are primarily among young women (47%) and young adults age 13-29 (39%). Although deaths from AIDS are beginning to decline, it is estimated that more than 40,000 deaths occurred in 1996. AIDS is the leading cause of death among men and women between the ages of 25 and 44, many of whom became infected as young adults.

Assessments of both male and female alcoholic inpatients from multiethnic backgrounds have indicated HIV infection rates from about 3% to 12% among heterosexuals without substantial comorbid injection drug-use histories. In urban samples, both sex trade and STDs were common among women in treatment for alcohol abuse. Multiple sex partners and nonuse of condoms were common among men. Multiple sex partners and nonuse of condoms were reported by approximately 30% of individuals in treatment samples, which included blacks, Hispanics, and whites; males and females; and individuals in gay treatment settings. Antisocial alcoholics had the highest rates of STDs, sex trade involvement, numbers of sex partners, and other drug use.

There is an overlap between individuals at risk for alcohol abuse and individuals at risk for HIV infection. Dual risk groups include, for example, gay men, runaway and homeless youth, drug users, high-risk mothers, and victims of sexual coercion. These groups are often at risk because of vulnerable lifestyles (e.g., gay men, runaway or homeless youth, partners of substance abusers) and share similar ages for onset of heavy drinking and HIV/STD infection. In a national probability study, men and women who reported a history of problem drinking were three times more likely to have a STD than those without such a history. Certain personality characteristics associated with both drinking and sexual risk-taking have been identified (e.g., impulsive decision making, stimulus seeking, and poor socialization), particularly among young adults.

Drinking and HIV risk behaviors may often occur together in the same physical location (e.g., high-risk bars) or during a particular activity (e.g., exchange of drugs and alcohol for sex). Individuals and the social network to which they belong often share multiple HIV risks. The general riskiness of the social network may be indexed by alcohol use among its members. The distribution of liquor outlets or enforcement of laws aimed at controlling availability of alcohol may also impact the spread of STDs at the community level.

Examination of the social and cultural contexts for alcohol use and HIV risk offers another level of understanding of these dual risks. For example, research on gay culture and the development of gay identity poses important behavioral research questions about the relationship between alcohol use and HIV transmission. Gay bars, which provide opportunities for gay men to socialize, also represent a high-risk context for excessive alcohol use. Alcohol use is the most frequent precipitant of relapse to unsafe sex among gay and bisexual men, and locations that combine sexual opportunities and alcohol availability pose the greatest risk for populations vulnerable to HIV. Thus, some gay bars continue to represent an important intervention point for altering social norms and diffusing information. Similarly, understanding how acculturation patterns and social norms impact on drinking among new immigrants, migrant workers, or individuals in new settings such as colleges may improve our understanding of how patterns of alcohol and HIV risk converge.

Developing Comprehensive Models for Alcohol Use and HIV Risk Behaviors

While the need for preventing the transmission of HIV in dual risk groups is a pressing public health concern, the development and testing of interventions in these groups should be informed by sound scientific research. A number of theoretical perspectives have been proposed to explain the relationship between alcohol consumption and sexual risk-taking. Direct causal explanations have focused on the disinhibiting properties of alcohol use. These psychophysiological explanations have been modified to include cognitive factors such as alcohol-related sexual expectancies, alterations in risk judgments, and memory processes. Other explanations have also been advanced that identify specific personality characteristics -- such as stimulus seeking or impulsive decision-making styles, or more general risk-prone dispositions -- as determinants of alcohol-related sexual risk taking. Beliefs about the potential positive or negative consequences of an activity have been shown to predict risk-taking behavior. In addition, experimental research is clarifying the role of alcohol use in specific sexual risk-taking situations. This research examines how alcohol intoxication influences participation in dangerous activities.

Testing the mediating role of key constructs in preventive interventions requires multicomponent interventions with well-measured outcomes. Advances in the understanding of alcohol-related outcomes are dependent on improved measurement of co-occurring alcohol and HIV risk behaviors, and the application of alcohol-focused theories. The ideal methodological approach is to obtain global, situational, and event-specific measures of drinking behavior and unsafe sexual behavior in conjunction with partner characteristics, use of other substances, and frequency of these encounters. These improvements in data collection methodologies are producing important insights into the relationship between alcohol use and unsafe sexual behavior. However, models for both analyzing the data and explaining the influence of alcohol in these complex results are in need of further development.

Recent trends in changes in HIV infection point to increasing rates of infection in younger aged populations and among women. In addition, the development of effective antiretrovirals for the treatment of HIV extends the lives of individuals who are infected. However, adherence to medication regimens has become increasingly important in preventing the emergence of drug-resistant strains of HIV. Alcohol and HIV research addresses these changing trends among adolescents, women, and individuals undergoing treatment for HIV.

Primary Prevention of Alcohol-Related AIDS Risk Behaviors among Adolescents

The combination of drinking and early sexual intercourse places adolescents at risk for sexually transmitted diseases and HIV infection. Given the long incubation period for AIDS, many individuals diagnosed with AIDS today probably became infected as teenagers. In 1997, more than 100,000 cases of AIDS were diagnosed in the age group 20 to 29-individuals who likely became infected as teenagers.

The misuse of alcohol in this age group may lead to risky behaviors such as unprotected sex. The 1995 Youth Risk Behavior survey by the Centers for Disease Control and Prevention (CDC) found that 53% of males and 50% of females in grades 9 to 12 reported using alcohol in the last month. Similarly, 36% of males and 29% of females reported heavy episodic drinking in the last month. CDC reports that 25% of ninth graders in the U.S. have engaged in recent heavy episodic drinking. A similar percentage is currently sexually active. Approximately one third to one half consumed alcohol at last sexual intercourse.

Alcohol is readily accessible and clearly the primary substance of abuse in this age group. Fatal driving accidents and other serious injuries are among the many easily identified consequences of alcohol misuse. Early initiation of alcohol use may serve as a marker for increased risk of later alcohol-related problems-including unprotected sex. Use of alcohol in new situations by inexperienced young adults may lead to unsafe sex. Even if individuals intend to enact safer behaviors, peer social norms or the specific context of the relationship may make this difficult. Adolescents who report a lack of norms for safe sex among their peers are less likely to use condoms. In addition, the male partner's alcohol use significantly increases risky sex irrespective of the level of alcohol use by the female partner.

Delaying the initiation of sexual activity and dissuading young adults from using alcohol and drugs are important HIV prevention strategies. Interventions among adolescents seek to reduce the use of alcohol and other substances both before and during sexual encounters. These interventions often focus on high-risk youth that are likely to use alcohol in the context of sexual behavior. These include runaway or homeless youth, incarcerated youth, or adolescents who have characteristics associated with risk-taking (e.g., high sensation seekers, impulsive decision-makers, and individuals with pessimistic outlook). These interventions are carried out in a variety of school-based, family, and public health settings, such as STD clinics. Multicomponent interventions may seek to change individual knowledge about alcohol-related HIV risks, perceived susceptibility to these risks, and normative beliefs about health consequences. Interventions may also target peer and family social networks or may include other sources of social influence such as physicians.

Unfortunately, an increasing number of adolescents are being identified who not only misuse alcohol on particular occasions, such as parties, but also are chronic drinkers in need of alcoholism treatment. The lifestyles of these individuals, many of whom are from broken families, put them at especially high risk for HIV infection. These individuals-who may be runaway or homeless, victims of early sexual abuse, or participants in sex for money or drugs-are often difficult to engage in interventions. Addressing the substance abuse and health care needs of this population calls for the development of innovative interventions.

The urgency for interventions focused on women is highlighted by the rapidly increasing rates of HIV infection among urban minority women. AIDS is the leading cause of death among women of color ages 25 to 44. This group constitutes 75% of all AIDS-infected women, and almost half of the infections are contracted through heterosexual contact. Almost 90% of children with AIDS contracted the virus perinatally as a result of being born to an infected mother. African-American women account for 40% of AIDS cases among heterosexuals and 60% of pediatric AIDS. Deaths attributed to AIDS are increasing among African American women while declining for other risk groups.

Many socioeconomic factors such as availability of treatment for HIV or substance abuse as well as changing social norms and enforcement of laws influence local variations in HIV prevalence rates. Rapid increases in HIV infection can occur among women in specific neighborhoods, particularly among alcohol and drug users. State agencies have concluded that reductions in alcohol and drug abuse are critical in controlling rapid changes in HIV-infection. They have recommended a significant increase in substance abuse interventions as part of comprehensive prevention strategies.

Researchers need to incorporate what they have learned about problem drinking and alcoholism into interventions among HIV at-risk populations. Male-oriented intervention models may not be appropriate for alcohol-abusing women. A variety of factors need to be considered. These include: understanding women's perceptions of their susceptibility to AIDS; the actual severity of exposure to HIV in women's lives; barriers to enacting safer behaviors with partners; and the perceived benefits of changing high-risk behaviors.

Interventions need to address the interactive role of alcohol use and abuse and sexual risk taking. Harm reduction strategies may be of particular importance for low-income women who may have limited personal control over decisions that affect their lives. These strategies focus on reducing the negative consequences of alcohol abuse by encouraging consistent condom use, reduction of number of sex partners, treatment for STDs and developing realistic drinking goals. Women in alcohol treatment settings are at particularly high risk for both HIV infection and transmission. Efforts should be made to monitor alcohol dependent women both in and out of alcohol and substance abuse treatment settings. Effective interventions need to consider lifestyle issues, such as childcare, family and partner roles, and other potential barriers to receiving health care.

Recent advances in antiviral therapies for HIV infection have raised the hope that AIDS can be treated as a chronic disease. To be successful, however, these HIV treatments require access and strict adherence to drug regimens. Long-term HIV treatment with these new drug therapies is particularly difficult for alcohol-abusing populations. Research is needed to identify issues that compromise access to HIV treatment and adherence to treatment among alcohol-using and -abusing seropositive populations. Special populations of interest include HIV-infected gay men, pregnant women, and underserved minorities. In addition, the impact of treatment settings and services needs to be identified, particularly for alcoholics in institutional (e.g., prisons) and self-help (e.g., Alcoholics Anonymous) treatment settings.

Research is needed to identify how successful alcohol intervention strategies and HIV risk reduction strategies can be modified to become more effective in HIV-infected alcohol-abusing populations. Theoretically grounded, yet practical, multicomponent interventions need to be developed that include accurate assessment of patterns of alcohol use, facilitation of medication with antiretrovirals, changing expectancies for effects of alcohol use on medication efficacy, and tailoring of pill-taking to individual patients' daily living circumstances. In addition, recent pharmacological advances in the treatment of alcohol abuse (e.g., the advent of Naltrexone) suggest that enhanced pharmacotherapies should be tested along with behavioral therapies for alcohol abuse.

Preliminary research indicates that alcohol use is a key determinant of adherence to new regimens of antiretrovirals. Research in this area is focused on answering several key questions:

• Is increased severity of alcohol problems associated with poor medication adherence?
• Do interventions that focus on reducing alcohol problems improve medication adherence?
• Do improvements in adherence persist as long as alcohol problems are controlled?
• Does relapse to alcohol abuse determine poor long-term outcomes?

Although these questions have not yet been answered, it is clear that routine HIV testing with counseling should be strongly considered for alcohol treatment populations and that interventions should call for enhanced linkage of alcohol treatment services to primary medical care-to include HIV testing, initiation of therapy, treatment of tuberculosis and STDs, and prevention/cessation of other substance use.

Table 1 reflects the distribution of grants and other funding mechanisms for FY97 and FY98. R01 grants represent the majority of dollars spent and have risen from 13 funding commitments in FY97 to 18 in FY98 as a result of the RFA. In addition, average total grant cost has risen from $300,281 to $382,891, primarily as a result of funding interventions within HIV positive populations with increased medical assessment costs. A wide variety of other mechanisms are in use including Small Business Innovative Research grants and contracts, intra-agency agreements, and K and F awards. Overall, approximately $5 million in funds were allocated to behavioral research in FY97, with an increase to $7.5 million in FY98.

Table 2 reflects the distribution of funds for AIDS behavioral grants (excluding epidemiology) for 1997 and 1998. The comparison of these two years shows the impact of receiving fundable applications under RFA 97-003 and 98-001. Both RFAs focused on developing and testing behavioral interventions. Important trends in the portfolio have been highlighted. Although the number of grants, contracts, and agreements (18) has remained the same in the two years, the pattern of funds has been redistributed across OAR categories. The number of primary prevention grants reflecting both uninfected and infected alcohol using or abusing populations has increased from 9 to 11, but the number of basic behavioral grants has dropped from 6 to 4, and two secondary prevention grants have been added. Changes in types of grants account for an increase of approximately $1.7 million from FY97 to FY98 ($4.0 to $5.7 million).

Funding for this area increased by approximately $2 million in FY1997 and again in 1998. From 1997 to 1998 the number of commitments increased from 10 to 14. These commitments included 2 within general or targeted alcohol using or abusing populations and 2 within alcohol dependent or treatment populations.

The number of commitments has been reduced from 6 to 4 within the alcohol prevention research area. A commitment of approximately $500k in behavioral funds was used to fund the core component of an interactive grant focusing on neurocognitive deficits among HIV infected alcoholics. Longitudinal developmental studies of risk and protective factors are identified within this area. Additional support for these studies is needed.

As previously described, increases in secondary prevention among HIV infected alcoholics can be seen in the addition of 3 grants. These grants focus on HIV+ individuals receiving treatment for HIV and represent a broad spectrum of alcohol use from minimal usage to those in "recovery." Development of research in this area focuses on improving adherence to medication.

Commitments within the methods development area may often be reflected under area 5B also. Alcohol and AIDS research has had a particular commitment to methodological research that establishes the contribution to HIV infection of general alcohol use and alcohol use within specific situations or contexts. Improved methodological rigor has demonstrated the contribution of alcohol to increased risk taking and risk of infection.

Collaboration between agencies is encouraged in sharing expertise and supporting research on diverse at-risk populations. A primary collaboration has been with NIAID in the development of alcohol abuse intervention within the context of HIVNET (the vaccine preparedness trials).

The current portfolio is responsive to the development of preventive interventions in diverse alcohol-using populations. Continued development of preventive research on high-risk women and adolescents is called for. Alcohol misuse is also proving to be a key determinant of poor compliance with AIDS medication regimens. Further investigation in this area is needed. Finally, technology in rapid screening for HIV and in determining changes in viral resistance among infected individuals is advancing. How application of these changes impacts alcohol-using and-abusing populations calls for further study.

Alcohol abusers often delay entering medical settings where they could be identified as needing appropriate interventions and are often difficult to retain in controlled clinical trials. Such difficulties in attracting and retaining alcohol-abusing individuals may have particular significance for the testing and evaluation of HIV vaccines and therapeutics. New interventions need to be developed to attract and retain individuals at extremely high risk for alcohol abuse and HIV infection. New research designs and analytic strategies need to be developed to evaluate these interventions adequately in settings where high rates of attrition may occur. Intervention strategies might, for example, include more informal and culturally relevant drop-in clinics. Different analytic procedures-such as case-control or case-based designs- may be necessary to test the effects of these interventions on such variables as HIV exposure, alcohol abuse, and retention in vaccine or therapeutics trials.

Increasing attention is being paid to the role of healthcare systems and professionals in preventing alcohol-related problems before they occur, in facilitating early detection of alcohol-related high-risk behaviors, and in providing appropriate treatment. Experimental and quasi-experimental designs may be used within healthcare settings to test the efficacy of preventive strategies. These strategies may include risk assessment, brief and more extensive advice, case monitoring, and improved linkage to services for alcoholics in treatment or for HIV-infected individuals with alcohol problems.

Ongoing research is needed to assess the efficacy of media strategies-alone or combined with other strategies-to prevent alcohol-related risky sexual behavior. Researchers are encouraged to develop and test promising media messages, new communications technologies, and special media for cultural subgroups to determine the most effective media/communications approaches for varied target audiences. Of particular interest are communication strategies that reach audiences at highest risk for alcohol abuse and HIV infection, which include impoverished youth and women, selected ethnic minorities, gay and bisexual men, and male and female partners of HIV-infected individuals.

Research suggests that family involvement, broadly defined, can enhance the effectiveness of school-based and clinic-based alcohol prevention programs among youth at risk for alcohol problems. Research on homeless and runaway youth indicates a high rate of co-occurring alcohol abuse and unsafe sexual behavior-often resulting in the spread of sexually transmitted diseases and HIV. Research needs to be expanded in this area to develop effective interventions among group or family members to reduce the risk for HIV infection.

As behavioral researchers focus on problems of substance abuse and AIDS, they are increasingly involved in the communities that are most affected. Urban ethnic and racial minority neighborhoods are particularly affected and often hard to access. Community characteristics such as density and location of liquor outlets or community organization of health services may significantly affect the spread of STDs including HIV. To overcome barriers to access, behavioral scientists have formed productive collaborative alliances with organizations within these community environments, including nongovernment organizations.

Substantial changes in alcohol use and HIV-related risk behaviors can be achieved through substance abuse treatment. Changes in alcohol use have been associated with reduced use of other drugs, decreased HIV risk behaviors, and increased attendance at AA meetings. However, variation exists in the ability of men and women to reduce sexual risk-taking during substance abuse treatment. In general, greater risk at intake, more sexual activity, and a tendency to combine alcohol use/other substance use and sexual behavior were associated with continued sexual risk taking during the year after entry into treatment. Current interventions being studied include integrated behavioral approaches that promote alcohol abstinence or controlled drinking and improve consistency in safer sex behaviors among both HIV- and HIV+ men and women. These studies aim to reduce the sexual transmission of HIV and to improve the quality of life for infected individuals. Further research is needed that focuses on individuals in need of alcohol treatment who are at-risk of HIV infection.

 Greatest increase was in number of R01 applications awarded with an increase from 13 to 18 with increased funding from $3.9 million to 6.9 million.

Funding for prevention intervention grants increased by approximately $1.7 million from 1997 to 1998 ($4.0 to $5.6) as a result of RFA-98-001 "Developing Alcohol-Related Preventive Interventions."

 Appendix A: FY1998 Area Descriptions for NIH AIDS Behavioral Research.

5.B Support basic social and behavioral research to strengthen
understanding of the determinants and processes influencing HIV-related
risk and protective behaviors and the consequences and
impact of HIV disease, including treatment for and management of
HIV infection. This includes research that examines the societal,
community, organizational, social network, dyadic, and individual
barriers to the utilization of effective preventive and treatment
interventions.

5.C Support research for the development, evaluation, and diffusion of
strategies to improve treatment adherence and to prevent or
minimize the negative physical, psychological, cognitive, and social
consequences of HIV, including stigmatization of persons with or at
risk for HIV infection. Support research strategies for promoting
effective health care utilization among all persons with HIV
infection.

5.D Support research to advance innovative quantitative and qualitative
methodologies to enhance HIV-related behavioral and social science
research.

Back to Top

State of Knowledge (R. Lorraine Collins, Ph.D.)

Basic behavioral research in alcohol prevention uses models of cognitive variables/factors (expectancy, drinking restraint, appraisal-disruption) and behavioral economics.

Alcohol expectancy theory suggests that individuals hold generally positive beliefs about the effects of alcohol and that these beliefs influence drinking and many of the socially mediated behaviors that occur in the context of alcohol use. Research over the past 20 years has brought the field to the general consensus that (1) beliefs about the effects of alcohol are held by most people (Miller et al, 1990); (2) expectancies influence drinking behavior (Smith et al., 1995); (3) expectancies vary for self versus others (Rohsenow, 1983), dose of alcohol (Collins et al., 1990), and drinking history (Connors et al., 1987). Research suggests a developmental course in which children form alcohol expectancies prior to experience with alcohol. These initial beliefs seem to be based on exposure to the broader culture, family of origin, and media messages (Miller et al., 1990). As the individual moves to adolescence and begins experimenting with or regularly using alcohol, these beliefs are refined and crystallized (Smith et al., 1995). Current theory suggests that beliefs about the effects of alcohol are stored in long-term memory as expectancy nodes that are organized along the dimensions of arousal-sedation and positive-negative (Rather and Goldman, 1994). The expectancy network is thought to function via automatic processes, with little or no consciousness required on the part of the individual. Moreover, heavy drinkers possess memory networks that contain more alcohol-related information, and light drinkers possess memory networks that are more diffuse.

In that expectancies may influence alcohol consumption and the effects of alcohol in turn lead to the refinement of expectancies (Smith et al., 1995), it seems likely that an effective strategy for preventing the development of alcohol problems would involve changing positive expectancies either prior to the start of drinking or as drinking behavior develops. It has been demonstrated that challenging expectancies leads to a reduction in alcohol consumption, with a greater impact on the alcohol intake of heavier drinkers (Darkes and Goldman, 1993). Increasing beliefs about the negative effects of alcohol (negative expectancies) also may reduce intake among heavier drinkers, thereby serving as an effective secondary prevention strategy (Jones and McMahon, 1998).

The drinking restraint model suggests that certain social drinkers become preoccupied with controlling their alcohol intake. They try to regulate their alcohol intake by developing rules of setting limits on consumption. When regulation fails, they engage in excessive consumption, which over time puts them at risk for alcohol problems. A number of studies have indicated that among some social drinkers, the failure to regulate alcohol intake typically results in episodes of excessive drinking (Collins, 1993). The drinking restraint model suggests that for prevention efforts to be successful, they should focus on helping restrained drinkers to maintain a balance between the two competing inclinations of being tempted to drink and regulating/ controlling alcohol intake. To date, no such programs have been undertaken. Moreover, research on drinking restraint is relatively new and no research has been conducted on secondary prevention programs.

The appraisal-disruption model (Sayette, 1993) suggests that alcohol impairs the individual's cognitive ability to evaluate new information by limiting the spread of activation of related (associated) information stored in long-term memory. Thus, when an individual is intoxicated, exposure to a particular stressor will evoke only a limited set of associations. When fewer associations are evoked, (i.e., when the appraisal process is impaired or the stressor is difficult to appraise), alcohol will lessen stress. When the full set of associations to the stressor is evoked (i.e., when the individual accurately appraises the negative impact of the stressor), alcohol is less likely to reduce stress. The conditions under which alcohol provides stress relief include (1) when drinking occurs prior to experiencing the stressor, thereby dampening the full experience of the stressor; (2) when the stressful information is less salient due to distractions present in the situation; and (3) when the stressor is difficult to appraise due to its novelty and/or complexity.

Secondary prevention efforts with high-risk groups (e.g., FH+) could include providing more specific information about alcohol's effects. Such information would enhance the individual's understanding of cognitive processes and reasons for drinking in order to foster more appropriate expectations for alcohol. The model also suggests that the issue of timing of drinking in response to stress is very important. Drinking following the appraisal of a stressor is less anxiolytic and therefore less reinforcing. Secondary prevention efforts designed to capitalize on this possibility also could lessen the reinforcement from alcohol. To the extent that the timing of alcohol consumption provides less stress reduction, it also may reduce drinking. This is a relatively new model and research related to its key constructs is currently being conducted.

The behavioral choice model suggests that use of a substance becomes a preferred behavior when there are few constraints on access to the substance and other reinforcers are either not available or have constraints placed on gaining access to them. The focus of this model is on the development and maintenance of alcohol use once alcohol has been established as a reinforcer (Vuchinich, 1995). This research suggests that (1) preference for substance use varies inversely with direct constraints on access to substances, regardless of the nature of the constraints (e.g., cost, availability); and (2) preference for substance use varies inversely with the availability of alternative reinforcers. Each condition has relevance to the prevention of excessive consumption. The first condition suggests that placing some constraints on the availability of alcohol will lead to decreases in drinking. Strategies for placing constraints on alcohol are likely to be most effective if enacted in the form of policies, and we already have evidence that such policies are effective in reducing drinking (Holder, 1998). The second condition suggests that providing attractive alternatives to alcohol will lead to decreases in drinking. There are results from laboratory and clinical studies that are consistent with this model (Vuchinich, 1995).

Back to Top

(Kendall J. Bryant, Ph.D.)

Several additional areas of basic behavioral research are included in the prevention portfolio. The areas represented are Behavior Genetics (9 grants for $4.5m) and Basic Psychological Research (9 grants for $1.4m). The Behavior Genetics research area has been previously reviewed in the context of NIAAA's commitment to basic genetics research. The review presented here focuses on prevention aspects of the portfolio.

Vulnerability to alcoholism and alcohol problems reflects a complex interaction of genetic, behavioral, and environmental factors. One of the most consistent observations in the alcohol research field is that alcoholism often runs in families. Alcoholics are approximately six times more likely than non-alcoholics to come from a family containing other alcoholics. Twin and family studies of alcoholism have sought to understand the sources of familial resemblance for alcoholism, and in particular, how parents transmit the vulnerability to alcoholism to their offspring. Research has been carried out with several population-based twin registries of information on male and female monozygotic and dizygotic twins and their families. Assessments have focused on the diagnosis of alcohol abuse, dependence, and the severity of alcohol-related problems including tolerance and withdrawal from alcohol. The current research portfolio in behavior genetics includes a wide range of twin samples from various national and international twin registries. Approximately 15,000 twins are under study in six registries, including twin samples in Finland and Australia.

In general, familial resemblance for alcoholism due to genetic factors is approximately 50%. The vulnerability to alcoholism is transmitted equally to offspring by both parents and the genetic factors that affect liability for alcoholism are the same for both parental and twin generations. However, exposure to initial alcohol use is not accounted for by genetic determinants. Interventions directed at controlling environmental factors related to exposure to alcohol use may be of particular importance in families at increased risk for alcoholism.

For example, in a sample of 700 twin pairs and their parents, initial findings indicate that alcoholism is associated with personality characteristics of low behavioral constraint (i.e.; impulsivity) and high negative emotionality (i.e.; anxiety, depression) in both men and women. Furthermore, low behavioral constraint is specifically associated with drug abuse and dependence, whereas high negative emotionality appears to be specifically associated with alcoholism. These personality characteristics are both heritable and a result of early family environment.

 A wide range of topics is under investigation in the current portfolio. These include:

Genetic influences among women: A generation of behavioral genetic research has established the importance of a genetic influence of alcoholism in males. Less is known about the extent to which genetic factors influence women's drinking behaviors and the existence of differential mediators and moderators of genetic risk. Work is being carried out to replicate and extend past research.

Improved research methodology: New methodology is being developed and tested to understand models for the natural history of alcohol abuse. These methodologies focus on the development of longitudinal models, identification of periods of differential risk for genetic and environmental influences, and the understanding and modeling of trajectories to alcohol abuse and dependence from childhood to adulthood. New methodologies employ simulation studies using high-risk samples, causal modeling using a variety of improved estimation procedures, and understanding of reciprocal causation (gene-environment correlation and interaction).

Personality/Comorbidity: Of central importance to understanding the development of alcohol abuse and dependence and related behavioral problems is the interaction of early precursors of the predisposition toward alcohol problems and the environment. Researchers are articulating conceptual models that identify broad personality components as precursors to alcohol problems that involve genotype-environment interactions. These interactions are hypothesized to be the mechanism underlying transition from adolescent personality to adult psychopathology. Dimensions that have been studied include Emotional Reactivity, Socialization, Self-control and others co-occurring disorders such as ADD, Hyperactivity, etc.

Identification of environmental influences and their interaction with genetic susceptibility is critical to knowing how to develop and implement preventive interventions. For example, while onset of alcohol drinking is largely under environmental control, latency to problem drinking behavior, once drinking behavior has begun, is primarily genetic. Clearly, greater prevention efforts should be directed at delaying initiation of drinking in adolescents. Other issues include the appropriateness of genetic counseling for individuals with family histories of alcoholism and the delivery of appropriate advice based on developing scientific evidence.

Research is needed to evaluate the possible benefits of preventive counseling for high-risk families that takes into account the aggregate familial risk factors including genetics. Such interventions should: be developmentally appropriate; address the initiation and progression of drinking; deal with mediating behavioral processes and family dynamics; and avoid misattribution, labeling, and stigmatization. Interventions with these families may prove to be effective in reducing later problems including, alcohol and substance use, school, and family problems.

In addition, many methodological issues need to be addressed because of the longitudinal design of most investigations. Research design must take into account developmental, temporal, and differential effects of genes and environment, as well as homogeneity of sample characteristics. For example, research is needed to: (1) improve measurement of mediators and moderators of Gene x Environment interactions, (2) improve longitudinal statistical models (e.g., the integration of Latent Growth Models with latent class and related genetic models), and (3) understand the role of the environment (e.g., better measurement of sibling and peer influence on alcohol availability).

The role of basic behavioral research is critical in developing a solid foundation of knowledge on which to base preventive interventions. Research on basic psychological processes such as cognition and affect regulation and other individual differences provides the basis for developing efficacious interventions targeted to individuals. A diverse set of grants focuses on psychological processes that may underlie the use and abuse of alcohol. For example, alcohol misuse has been associated with a variety of co-occurring disorders in the same individual. Most notably, researchers have suggested that alcohol may be used to self-medicate for other underlying disorders of anxiety and depression. Experimental and laboratory findings have indicated that acute intoxication from alcohol may reduce anxiety while chronic use may increase anxiety. These competing processes may be seen as the basis for linking together anxiety disorders and alcohol abuse. Findings from both longitudinal and family studies suggest that either disorder can increase the risk of developing the other, and clinical studies indicate that anxiety disorders can serve to maintain ongoing substance use disorders and promote relapse in alcoholics.

Basic psychological studies include experimental and nonexperimental studies of:

1. attribution and risk appraisal,
2. basic memory encoding for alcohol information that may influence alteration in patterns of perception and attention,
3. influence of social modeling in alcohol use situations, such as bars,
4. impact of other comorbid conditions such as anxiety and depression in sustained alcohol use and abuse,
5. influence of alcohol consumption on task performance.

Future research in this area needs to address the utility of competing conceptual and theoretical frameworks for guiding alcohol prevention research. Research should emphasize theoretical and conceptual issues over those of primarily clinical interest. More specifically studies should address the validity of competing views within basic behavioral research and test these "theoretical" perspectives in the context of interventions. To this end, studies should employ both experimental and prospective methodologies, with careful attention to methodological differences (and advances) in addressing new areas of research.

Back to Top

 Adoni H, Cohen AA, Mane S: Social reality and television news: Perceptual dimensions of social conflicts in selected life areas. J Broadcasting 1984;28: 33-49.

Alcohol and Health 9, Special Report to the U.S. Congress from the Secretary of Health and Human Services, 1997.

Ames GW, Grube JW, Moore RS: The relationship of drinking and hangovers to workplace problems: An empirical study. J Stud Alcohol 1997;58: 37-47.

Atkin CK: Advertising and marketing: Mass communication effects of drinking and driving. Surgeon General's workshop on drunk driving: Background papers, Washington, DC, December 14-16, pp. 15-34, 1988.

Austin EW, Johnson KK: Immediate and delayed effects of media literacy training on third graders' alcohol beliefs. Health Com 1997;9: 323-349.

Austin EW, Nach-Ferguson B: Sources and influences of young school-age children's general and brand-specific knowledge about alcohol. Health Com 1995;7:1-20.

Austin G, Gilbert M: Substance abuse among Latino youth. Prevention Research Update 3. Los Alamitos, CA, Western Center for Drug-Free School and Communities, 1989.

Austin G, Oetting E, Beauvais F: Recent research on substance abuse among American Indian Youth. Prevention Reset Update (No. 11). Los Alamitos, CA, Southwest Regional Educational Laboratory, 1993.

Bachman JG, Johnston LD, O'Malley PM: How changes in drug use are linked to perceived risk and disapproval: Evidence from national studies that youth and young adults respond to information about the consequences of drug use. In: Donohew L, Sypher HE, Bukoski WJ (eds.), Persuasive Communication and Drug Abuse Prevention. Hillsdale, NJ, Erlbaum, pp: 133-156, 1991.

Baldwin S, Heather N, Lawson M, et al: Comparison of effectiveness: Behavioural and talk-based alcohol education courses for court-referred young offenders. Behav Psychotherapy 1991; 19: 157-172.

Ball-Rokeach S, DeFleur M: A dependency model of mass media effects. Commun Res 1976;31.

Bates SC, Beauvais F, Trimble JE: American Indian adolescent alcohol involvement and ethnic identification. Sub Use Misuse 1997;32: 2013-2032.

Becker JV, Barham J, Eron LD, Chen SA: The present status and future directions for psychological research on youth violence. In Eron LD, Gentry JH, Schlegel P (eds), Reason to Hope: A Psychological Perspective on Violence and Youth. Washington, DC, American Psychological Association, pp: 435-445, 1994.

Blomberg R: Lower BAC limits for youth: Evaluation of the Maryland .02 law. DOT HS 806 807, Washington, DC, U.S. Department of Transportation, 1992.

Botvin GJ, Baker E, Dusenburg L, et al: Long term follow up results of a randomized drug abuse prevention trial in a white middle class population. JAMA 1995;273: 1106-1112.

Bry BH, McKeon P, Pandina R: Extent of drug use as a function of number of risk factors. J Abnormal Psychology 1982;91: 273-279.

Caces FM. Stinson FS. Duouir MC: Trends in Alcohol-Related Morbidity among Short-Stay Community Hospital Discharges, United States, 1979-93. Surveillance Report No. 36. Rockville, MD, NIAAA, Alcohol Epidemiologic Data System, 1995.

Caetano R, Kaskutas LA: Changes in drinking problems among Whites, Blacks and Hispanics: 1984-1992. Substance Use Misuse 1996;31: 1547-1571.

Cahalan D, Cisin IH, Crossley HM: American Drinking Practices: A National Study of Drinking Behavior and Attitudes. New Bruswick, NJ, Rutgers Center of Alcohol Studies, 1969.

Carey K, Carey M, Weinhardt L, et al: Improving methods to assess the co-occurrence of sexual behavior and alcohol use. 12th World AIDS Conference, Geneva, Abstract #14122, 1998.

Cervantes RC, Pena C: Evaluating Hispanic/Latino programs: Ensuring cultural competence. Alcoholism Treat Quart 1998;16: 109-131.

Chavez EL, Oetting ER, Swaim RC: Dropout and delinquency: Mexican-American and Caucasian Non-Hispanic youth. J Clin Child Psychology 1994;23: 47-55.

Chesney M, Barrett D, Stall R: Histories of substance, sex and risk behavior: Precursors to seroconversion in homosexual men. Amer J Pub Health 1998;88: 113-116.

Clayton R, Cattarello A, Johnston B: The effectiveness of drug abuse resistance education (Project DARE), 5 year follow up results. Prev Med 1996;25: 307-318.

Cohen JB: Reconceptualizing alcohol advertising effects: A consumer psychology perspective. In: Martin SE (ed.), The Effects of the Mass Media on the Use and Abuse of Alcohol. Bethesda, MD, NIAAA, U.S. Dept. of Health and Human Services, 1995.

Collins JJ, Messerschmidt PM: Epidemiology of alcohol-related violence. Alcohol Health Res World 1993;17:93-100.

Collins RL: Drinking restraint and risk for alcohol abuse. Exp Clin Psychopharmacol 1993;1: 44-54.

Collins RL, Lapp WM, Emmons KM, Isaac LM: Endorsement and strength of alcohol expectancies. J Stud Alcohol 1990;51: 336-342.

Combs B, Slovic P: Newspaper coverage of causes of death. Journalism Quart 1979;56: 837-843.

Connors GJ, O'Farrell TJ, Cutter HSG, Thompson DL: Dose-related effects of alcohol among alcoholics, problem drinkers, and nonproblem drinkers. J Stud Alcohol 1987;48: 461-466.

Cook RF, Back MS, Trudeau J: Substance abuse prevention in the workplace: Recent findings and an expanded conceptual model. J Primary Prev 1996;16: 319-339.

Darkes J, Goldman MS: Expectancy challenge and drinking reduction: Experimental evidence for a mediational process. J Consult Clin Psychol 1993;61: 344-353.

Davidson S, Amanda M, Penkower L et al: Substance use and sexual behavior among homosexual men at risk for HIV infection: Psychosocial moderators. Psychol Health 1992; 7: 259-272.

Davis S, Hunt K, Kitzes J: Improving the health of Indian teenagers - A demonstration program in rural New Mexico. Pub Health Rep 1989;104: 271-278.

DeBakey SF, Stinson FS, Grant BF, Dufour MC: Liver Cirrhosis Mortality in the United States, 1970-1992. Surveillance Report No. 37. Rockville, MD, NIAAA, Alcohol Epidemiologic Data System, 1995.

Dent CW, Sussman S, Ellickson P, et al: Is current drug abuse prevention programming generalizable across ethnic groups: Amer Behav Scientist 1996;39: 911-918.

Donohew L, Lorch EP, Palmgreen P: Sensation-seeking and the targeting of televised anti-drug PSAs. In: Donohew L, Sypher HE, Bukoski WJ (eds.), Persuasive Communication and Drug Abuse Prevention. Hillsdale, NJ, Erlbaum, pp: 209-226, 1991.

Duncan DF: Chronic drinking, binge drinking, and drunk driving. Psychol Reports 1997;80: 681-682.

Dusenbury L, Epstein JA, Botvin GJ, Diaz T: Social influence predictors of alcohol use among New York Latino youth. Addict Behav 1994;19: 363-372.

Ericksen KP, Trocki KF: Behavioral risk factors for sexually transmitted diseases in American households. Soc Sci Med 1992;34: 843-853.

Funderburk FR, MacKenzie A, DeHaven GP, et al: Evaluation of the multiple offender alcoholism project. Eval Prog Plan 1993;6: 181-191.

Geidt T: Drug and alcohol abuse in the work place: Balancing employer and employee rights. Employee Relat Law J 1986;11: 181-205.

Gilchrist L, Schinke S, Trimble J, Cvetkovich G: Skills enhancement to prevent substance abuse among American Indian adolescents. Int J Addict 1987;22: 869-879.

Graham K, Leonard KE, Room R, et al: Current directions in research on understanding and preventing intoxicated aggression. Addiction 1998;93: 659-676.

Grant BF, Dawson DA: Age of onset of drug use and its association with DSM-IV drug abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. J Subst Abuse 1998;10: 163-173.

Grant BF, Harford TC, Dawson DA, et al: Prevalence of DSM-IV alcohol abuse and dependence: United States, 1992. Alcohol Health Res World 1994;18: 243-248.

Grube JW, Agostinelli G: Risk perceptions and adolescent drinking, smoking, and drug use. Berkeley, CA, Prevention Research Center, 1998.

Grube JW, Wallack L: Television beer advertising and drinking knowledge, beliefs, and intentions among school children. Am J Pub Health 1994;84: 254-259.

Hansen WB, Graham JW: Preventing alcohol, marijuana, and cigarette use among adolescents: Peer pressure resistance training versus establishing conservative norms. Prev Med 1991;20: 414-430.

Hingson R, Howland J: Alcohol and non-traffic unintended injuries. Addiction 1993;88: 877-883.

Holder H, editor: A community prevention trial to reduce alcohol-involved trauma. Addiction 1997;92.

Holder HD: Alcohol and the Community: A Systems Approach to Prevention. Cambridge, UK, Cambridge Univ Press, 1998.

Holder HD, Cunningham DW: Alcoholism treatment for employees and family members: Its effect on health care costs. Alcohol Health Res World 1992;16: 149-153.

Holder H, Flay B, Howard J, et al: Phases of alcohol problem prevention research. In press.

Johnston LD, O'Malley PM, Bachman JG: National Survey Results on Drug Use from Monitoring the Future Study, 1975-1995, Volume 1, Secondary School Students. Washington DC, Government Printing Office, 1996.

Jones BT, McMahon J: Alcohol motivations as outcome expectancies. In Miller WR, Heather N (eds.), Treating Addictive Behaviors, Second Ed., Plenum Press, New York, pp: 75-91, 1998.

Kim S, McLeod J, Shantzis C: Cultural competence for evaluators working with Asian-American communities: Some practical considerations. In: Orlandi M, Weston R, Epstein L (eds.), Cultural Competence for Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners Working with Ethnic/Racial Communities. Rockville, MD, Office for Substance Abuse Prevention, Dept. of Health and Human Services, 1992.

Klein AR: Re-abuse in a population of court-restrained male batterers: Why restraining orders don't work. In Buzawa ES, Buzawa CC (eds), Do arrests and restraining orders work? Thousand Oaks, Ca, Sage, pp: 192-213, 1996.

Klein H, Shiffman KS, Welka DA: Alcohol-related content of animated cartoons. In preparation.

Klein T: Changes in alcohol-involved fatal crashes associated with tougher state alcohol legislation. Final Report for Contract No. DTNH-122-88-C-07045. Washington, DC, U.S. National Highway Traffic Safety Administration.

Kline ML, Snow DL: Effects of a work-site coping skills intervention on the stress, social support, and health outcomes of working mothers. J Primary Prev 1994;15: 105-121.

Komro KA: Project Northland. Presented at the Society of Prevention Research annual meeting, Park City, UT, 1998.

Kreitman N: Alcohol consumption and the prevention paradox. Brit J Addict 1986;78: 353-363.

Lang E, Rumbold G: The effectiveness of community based interventions to reduce violence in and around licensed premises: A comparison of three Australian models. Contemp Drug Prob 1997;24: 805-826.

Leigh B, Stall R: Substance use and risky sexual behavior for exposure to HIV: Issues in methodology, interpretation and prevention. Amer Psychologist 1993;48: 1035-1045.

 Leonard KE: Drinking patterns and intoxication in marital violence: Review, critique, and future directions for research. In Martin SE (ed), Alcohol and Interpersonal Violence: Fostering Interdisciplinary Research. Rockville, MD, NIAAA Research Monograph No. 24, NIH Pub. 93-3496, 1993.

Leonard KE, Senchak M: Alcohol and premarital aggression among newlywed couples. J Stud Alcohol Suppl 1993;11: 96-108.

Lewis RJ: Day-night patterns in workplace accidental deaths: Role of alcohol abuse as a contributing factor. In: Chronobiology: Its Role in Clinical Medicine, General Biology, and Agriculture, Part B. Progress in Clinical and Biological Research, Vol. 341B. New York, Liss, pp: 327-335, 1990.

Lund AF, Jones IS: Detection of impaired drivers with a passive alcohol sensor. In: Noordzij PC, Roszbach R (eds), Alcohol, Drugs and Traffic Safety. New York, Excerpta Medica , pp: 379-382, 1987.

Makela K: Impact of changes in availability of alcohol on heavy and dependent drinkers. In: Drug Dependence: From the Molecular to the Social Level. New York, Elsevier, 1992.

Martin SE: The epidemiology of alcohol-related interpersonal violence. Alcohol Health Res World 1992;16: 230-237.

May P: Alcohol policy considerations for Indian reservations and bordertown communities. Amer Indian Alaskan Native Mental Health Res 1992;4: 5-59.

May P: The prevention of alcohol and other drug abuse among American Indians: A review and analysis of the literature. In: Langton P (ed.), The Challenge of Participatory Research: Preventing Alcohol Related Problems in Ethnic Communities. Rockville, MD, Center for Substance Abuse Prevention, Dept. of Health and Human Services, pp: 185-243, 1995.

May P, Moran J: Prevention of alcohol misuse: A review of health promotion efforts among American Indians. Amer J Health Promotion 1995;9: 288-298.

McKnight AJ, Voas RB: The effect of license suspension upon DWI recidivism. Alcohol Drugs Driving 1991;7: 43-54.

McMurran M, Bellfield H: Sex-related alcohol expectancies in rapists. Crim Behav Mental Health 1993;3: 76-84.

Midanik LT, Clark WB: Demographic distribution of US drinking patterns in 1990: Description and trends from 1984. Am J Pub Health 1994;84: 1218-1222.

Midanik LT, Clark WB: Drinking-related problems in the United States: Description and trends, 1984-1990. J Stud Alcohol 1995;56: 395-402.

Midanik LT, Tam TW, Greenfield TK, Caetano R: Risk functions for alcohol-related problems in a 1988 U.S. national sample. Addiction 1996;91: 1427-1437.

Miller PM, Smith GT, Goldman MS: Emergence of alcohol expectancies in childhood: A possible critical period. J Stud Alcohol 1990;51: 343-349.

Monahan JL: Thinking positively: Using positive affect when designing health messages. In: Maibach EW, Parrott RL (eds.), Designing Health Messages: Approaches from Communication Theory and Public Health Practice. Newbury Park, CA, Sage, pp: 81-98, 1995.

Moore M, Gerstein: Alcohol and Public Policy: Beyond the Shadow of Prohibition. Washington, DC, National Academy Press, 1981.

Moskowitz H, Burns MM, Williams AF: Skills performance at low blood alcohol levels. J Stud Alcohol 1985;46: 482-485.

Moskowitz JM: The primary prevention of alcohol problems: A critical review of the research literature. J Stud Alcohol 1989;50: 54-88.

Murdoch D, Pihl RO, Ross D: Alcohol and crimes of violence: Present issues. Int J Addict 1990;25: 1065-1081.

National Highway Traffic Safety Administration: Traffic Safety Facts 1993: A Compilation of Motor Vehicle Crash Data from the Fatal Accident Reporting System and the General Estimates System. Washington, DC, U.S. Department of Transportation, National Center for Statistics and Analysis, 1994.

Newcomb MD: Drug use etiology among ethnic minority adolescents. In: Botvin G, Schinke S, Orlandi M (eds.), Drug Abuse Prevention with Multiethnic Youth. Thousand Oaks, CA, Sage Publications, pp: 105-127, 1995.

Norstrom T: Effects on criminal violence of different beverage types and private and public drinking. Presented at the International Conference on Intoxication and Aggressive Behavior: Understanding and Preventing Alcohol-Related Violence. Toronto, Canada, 1996.

Oetting ER, Beauvais F: Epidemiology and correlates of alcohol use among Indian adolescents living on reservations. In: Spiegler DL, Tate DA, Aitken SS, Christian CM (eds.), Alcohol Use among U.S. Ethnic Minorities. Washington, DC, NIAAA, U.S. Government Printing Office, pp: 239-267, 1989.

Oetting ER, Donnermeyer JF, Plested BA, et al: Assessing community readiness for prevention. Int J Addict 1995;30: 659-683.

Oetting ER, Spooner S, Beauvais F, Banning J: Prevention, peer clusters, and the paths to drug abuse. In: Donohew L, Sypher HE, Bukoski WJ (eds.), Persuasive Communication and Drug Abuse Prevention. Hillsdale, NJ, Erlbaum, pp: 239-262, 1991.

O'Farrell, Murphy: Marital violence before and after alcoholism treatment. J Consult Clin Psychol 1995;63: 256-262.

Parker DA, Harford TC: The epidemiology of alcohol consumption and dependence across occupations in the United States. Alcohol Health Res World 1992;16:97-105.

Parrish K: Alcohol abuse prevention research in Asian American and Pacific Islander communities. In: Langton (ed.), The Challenge of Participatory Research: Preventing Alcohol Related Problems in Ethnic Communities. Rockville, MD, Center for Substance Abuse Prevention, Dept. of Health and Human Services, pp: 389-409, 1995.

Paul JP, Stall R, Bloomfield KA: Gay and alcoholic: Epidemiologic and clinical issues. Alcohol Health Res World 1991;15: 151-160.

Petty RE, Cacioppo JT: Communication and Persuasion: Central and Peripheral Routes to Attitude Change. New York, Springer-Verlag, 1986.

Porter Novelli: A Communication Strategy Statement: The National Media Anti-Drug Campaign. Washington, DC, Porter Novelli, Inc.

Quigley BM, Leonard KE: Husband alcohol expectancies, drinking, and marital conflict styles as predictors of severe marital violence among newlywed couples. Psychol Addict Behav, in press.

Rather BC, Goldman MS: Drinking-related differences in the memory organization of alcohol expectancies. Exp Clin Psychopharm 1994;2: 167-183.

Rodgers A: Effect of Minnesota's license plate impoundment law on recidivism of multiple DWI violators. Alcohol Drugs Driving 1994; 10.

Rohsenow DJ: Drinking habits and expectancies about alcohol's effects for self versus others. J Consult Clin Psychol 1983;51: 752-756.

Rose G: Strategy of prevention: Lessons from cardiovascular disease. Brit Med J 1981;282: 1847-1851.

Ross HL: Are DWI sanctions effective? Alcohol Drugs Driving 1992;8: 61-69.

Saffer H: Alcohol advertising and alcohol consumption: Econometric studies. In: Martin SE (ed.), The Effects of the Mass Media on the Use and Abuse of Alcohol. Bethesda, MD, NIAAA, U.S. Dept. Of Health and Human Services, 1995.

Saltz RF: Research in environmental and community strategies for the prevention of alcohol problems. Contemp Drug Prob 1988;15: 67-81.

Sayette MA: An appraisal-disruption model of alcohol's effects on stress responses in social drinkers. Psychol Bull 1993;114: 459-476.

Schinke S, Orlandi M, Botvin G, Gilchrist L: Preventing substance abuse among American-Indian adolescents: A bicultural competence skills approach. J Counsel Psych 1988;35: 87-90.

Scribner RA, MacKinnon DP, Dwyer JH: The risk of assaultive violence and alcohol availability in Los Angeles County. Amer J Pub Health 1995;85: 335-340.

Simpson HM, Mayhew DR, Beirness DJ: Dealing with Hard Core Drinking

Driver. Ottawa, Canada, Traffic Injury Research Foundation, 1996.

Slater MD, Rouner D: Value affirmative and value protective processing of alcohol education messages that include statistics or anecdotes. Com Res 1996;23:210-235.

Slater MD, Karan D, Rouner D, et al: Developing and assessing alcohol warning content: Responses to quantitative information and behavioral recommendations in warnings with TV beer ads. Pub Policy Market 1998.

Slater MD, Rouner D, Murphy K, et al: Male adolescent's reactions to TV beer advertisements: The effects of sports content and programming context. J Stud Alcohol 1996;57: 425-433.

Smith GT, Goldman MS, Greenbaum PE, Christiansen BA: Expectancy for social facilitation from drinking: The divergent paths of high-expectancy and low-expectancy adolescents. J Abnorm Psychol 1995;104: 32-40.

Sonnenstuhl WJ: Working Sober: The Transformation of an Occupational Drinking Culture. Ithaca, New York, ILR Press/Cornell University Press, 1996.

Stall R, Paul J, Barrett D, Crosby M: An outcome evaluation to measure changes in sexual risk-taking among gay men undergoing substance abuse treatment. J Stud Alcohol, in press.

Stinson FS, DeBakey SF, Grant BF, Dawson DA: Association of alcohol problems with risk for AIDS in the 1988 National Health Interview Survey. Alcohol Health Res World 1992; 16: 245-252.

Stinson FS, Debakey SF, Steffens RA: Prevalence of DSM-IIIR alcohol abuse and/or dependence among selected occupations, United States 1988. Alcohol Health Res World 1992;16: 165-172.

Stockwell T: On pseudo-patrons and pseudo-training for bar staff. Brit J Addict 1992;87: 677-680.

Stoltzfus JA, Benson PL. The 3M Alcohol and Other Drug Prevention Program: Description and evaluation. J Primary Prev 1994;15: 147-159.

Strunin L, Hingson R: Alcohol, drugs, and adolescent sexual behavior. Int J Addict 1992;27: 129-146.

Stuster JW, Blowers MA: Experimental Evaluation of Sobriety Checkpoint Programs. Washington, DC, National highway Safety Administration, 1995.

Swaim RC, Oetting ER, Jumper T, et al: American Indian adolescent drug use and socialization characteristics: A cross-cultural comparison. J Cross-Cultural Psych 1993;24: 53-70.

Tobler NS: Meta-analysis of 143 adolescent drug prevention programs: Quantitative outcome results of program participants compared to a control or comparison group. J Drug Issues 1986;16: 537-567.

Tobler NS, Stratton HH: Effectiveness of school-based drug prevention programs: A meta-analysis of the research. J Primary Prevention 1997;18: 71-128.

Trice HM, Roman PM: Spirits and Demons at Work: Alcohol and Other Drugs on the Job. Second Edition. Ithaca, New York, Cornell University Press, 1978.

Valentine J, Griffith J, Ruthazer R, et al: Strengthening causal inference in adolescent drug prevention studies: Methods and findings from a controlled study of the urban youth connection program. Drugs Society 1998;12:127-145.

Voas RB, Hause JM: Deterring the drinking driver: The Stockton experience. Accident Anal Prev 1987;19: 81-90.

Voas RB, Marques PR, Tippetts AS, Beirness DJ: The Alberta Interlock Program: Evaluation of a province-wide program on DUI recidivism. Addiction, in press.

Voas RB, Tippetts AS, Lange JE: Evaluation of a method for reducing unlicensed driving: The Washington and Oregon license plate sticker laws. Accident Anal Prev 1997;29: 627-634.

Voas RB, Tippetts AS, Taylor EP: Impact of Ohio administrative license suspension. Paper presented at the 42nd Annual Proceedings of the Association for the Advancement of Automotive Medicine, October 5-7, Charlottesville, VA, 1998a.

Voas RB, Tippetts AS, Taylor E: Temporary vehicle impoundment in Ohio: A replication and confirmation. Accident Anal Prev 1998b;30: 651-655.

Vuchinich RE: Alcohol abuse as molar choice: An update of a 1982 proposal. Psychol Addict Beh 1995;9: 223-235.

Wagenaar AC, Wolfson M: Enforcement of the legal minimum drinking age in the United States. J Pub Hlth Policy 1994;15: 37-53.

Wagenaar AC, Murray DM, Gehan JP, et al: Communities Mobilizing for Change on Alcohol: Outcomes from a randomized community trial. J Stud Alcohol, in press.

Wallack L, DeJong W: Mass media and public health: Moving the focus from the individual to the environment. In: Martin SE (ed.), The Effects of the Mass Media on the Use and Abuse of Alcohol. Bethesda, MD, NIAAA, U.S. Dept. of Health and Human Services, 1995.

Walsh-Childers K, Brown J: Adolescents' acceptance of sex-role stereotypes and television viewing. In: Greenberg BS, Brown JD, Buerkel-Rothfuss NL (eds.), Media, Sex, and the Adolescent. Cresskill NJ, Hampton Press, pp: 117-133, 1993.

Weatherburn P, Davies P, Hickson F, et al: No connection between alcohol use and unsafe sex among gay and bisexual men. AIDS 1993;7: 115-119.

Wechsler H, Davenport A, Dowdall G, et al: Health and behavioral consequences of binge drinking in college: A national survey of students at 140 campuses. JAMA 1994;272: 1672-1677.

Wechsler H, Kasey EH, Thum D, Demone HW: Alcohol level and home accidents. Pub Health Rep 1969;84: 1043-1050.

Welte JW, Barnes GM: Alcohol use among adolescent minority groups. J Stud Alcohol 1987:48: 329-336.

Witte K: Generating effective risk messages: How scary should risk communication be: In: Burleson BR (ed.), Communication Yearbook/18. Thousand Oaks, CA, Sage Publ., pp: 229-254, 1995.

Worden JK, Flynn BS, Merrill DG, et al.: Preventing alcohol-impaired driving through community self-regulation training. Amer J Pub Hlth 1989;79: 287-290.

Wu C, Shaffer DR: Susceptibility to persuasive appeals as a function of source credibility and prior experience with the attitude object. J Personality Soc Psychol 1987;52: 677-688.

Zador PL: Alcohol-related relative risk of fatal driver injuries in relation to driver age and sex. J Stud Alcohol 1991;52: 302-310.

Zane N, Sasao T: Research on drug abuse among Asian Pacific Americans. Drugs Soc 1992;6: 181-219.

Back to Top

Harold D. Holder, Ph.D.
Pacific Institute for Research
and Evaluation
2150 Shattuck Avenue, Suite 900
Berkeley, California 94704

Mark S. Goldman, Ph.D.
Department of Psychology
University of South Florida
4202 East Fowler Avenue, BEH 339
Tampa, Florida 33620-8200

William B. Hansen, Ph.D.
Tanglewood Research, Inc.
4420 Hunter's Run Drive
Clemmons, NC 27012

Ralph W. Hingson, Sc.D.
Chairman, MPH Behavioral Sciences
Boston University
715 Albany Street, M840
Boston, MA 02215

G. Alan Marlatt, Ph.D.
Addictive Behaviors Research Center
Department of Psychology (Box 351525)
University of Washington
Seattle, WA 98195

Brian R. Flay, Sc.D.
Health Research and Policy Center
SPH (M/C 275)
University of Illinois at Chicago
850 W. Jackson, Suite 400
Chicago, IL 60607-3025

Jean Forster, Ph.D.
Department of Epidemiology
University of Minnesota
1300 S. 2nd Street
Minneapolis, MN 55455

Mary Ann Pentz, Ph.D.
Institute for Health Promotion and Disease
Prevention Research
Department of Preventive Medicine
1540 Alcazar Street, CHP 207
University of Southern California
School of Medicine
Los Angeles, CA 90033

Back to Top

Genevieve M. Ames, Ph.D.
Prevention Research Center
2150 Shattuck Avenue, Suite 900
Berkeley, CA 94704-1306

Frederick Beauvais, Ph.D.
Tri-Ethnic Center for Prevention Research
Department of Psychology
Colorado State University
Fort Collins, CO 80523

Raul Caetano, M.D., Ph.D.
University of Texas Southwest Medical Center
5323 Harry Hines Blvd.
Room V8-112
Dallas, Texas 75235-9128

Frank Chaloupka, Ph.D.
Department of Economics (M/C 144)
2118 UH
University of Illinois at Chicago
Chicago, IL 60607

R. Lorraine Collins, Ph.D.
Research Institute on Addictions
1021 Main Street
Buffalo, NY 14203-1016

Joel W. Grube, Ph.D.
Prevention Research Center
2150 Shattuck Avenue, Suite 900
Berkeley, CA 94704-1306

Paul J. Gruenewald, Ph.D.
Prevention Research Center
2150 Shattuck Avenue, Suite 900
Berkeley, CA 94704-1306

Kenneth E. Leonard, Ph.D.
Research Institute on Addictions
1021 Main Street
Buffalo, NY 14203-1016

A. James McKnight, Ph.D.
National Public Services Research Institute
8201 Corporate Drive, Suite 230
Landover, MD 20785

Michael D. Slater, Ph.D.
Department of Technical JournalismBR Rm. C-225, Clark Building
Colorado State University
Fort Collins, CO 80523

Ronald Stall, Ph.D.
Center for AIDS Prevention Studies
University of California, San Francisco
74 New Montgomery, Suite 600
San Francisco, CA 94105

Robert B. Voas, Ph.D.
Pacific Institute for Research and Evaluation
7315 Wisconsin Avenue, #1300W
Bethesda, MD 20814

Alexander C. Wagenaar, Ph.D.
Department of Epidemiology
1300 S. 2nd Street
University of Minnesota
Minneapolis, MN 55455

Back to Top

Jan Howard, Ph.D., Chief
Prevention Research Branch, NIAAA
6000 Executive Blvd., Suite 505
Bethesda, MD 20892-7003

Gayle Boyd, Ph.D.
Prevention Research Branch, NIAAA
6000 Executive Blvd., Suite 505
Bethesda, MD 20892-7003

Kendall Bryant, Ph.D.
Prevention Research Branch, NIAAA
6000 Executive Blvd., Suite 505
Bethesda, MD 20892-7003

Suzanne Heurtin-Roberts, Ph.D.
Prevention Research Branch, NIAAA
6000 Executive Blvd., Suite 505
Bethesda, MD 20892-7003

Susan Martin, Ph.D.
Prevention Research Branch, NIAAA
6000 Executive Blvd., Suite 505
Bethesda, MD 20892-7003

Back to Top

Henri Begleiter, Ph.D., M.D.
Department of Psychiatry
Box 1203
State University of New York
Health Science Center at Brooklyn
450 Clarkson Avenue
Brooklyn, NY 11203

Daryl Bertolucci
Epidemiology Branch, NIAAA
6000 Executive Blvd., Suite 514
Bethesda, MD 20892-7003

William Bukoski, Jr., Ph.D.
Division of Epidemiology and
Prevention Research, NIDA
Parklawn Building, Room 9A-54
5600 Fishers Lane
Rockville, MD 20857

Susan Cahill
Planning and Financial Management Branch, NIAAA
6000 Executive Blvd., Suite 412
Bethesda, MD 20892-7003

Faye Calhoun, D.P.A.
Office of Collaborative Research, NIAAA
6000 Executive Blvd., Suite 400
Bethesda, MD 20892-7003

Mary Dufour, M.D., M.P.H.
Deputy Director, NIAAA
6000 Executive Blvd., Suite 400
Bethesda, MD 20892-7003

Michael J. Eckardt, Ph.D.
Office of Scientific Affairs, NIAAA
6000 Executive Blvd., Suite 409
Bethesda, MD 20892-7003

Anita Eichler, Ph.D.
OA/OPPC/SAMHSA
Parklawn Building, Room 12C-26
5600 Fishers Lane
Rockville, MD 20857

Susan Farrell, Ph.D.
Office of the Director, NIAAA
6000 Executive Blvd., Suite 405
Bethesda, MD 20892-7003

Laurie Foudin, Ph.D.
Division of Basic Research, NIAAA
6000 Executive Blvd., Suite 402
Bethesda, MD 20892-7003

Richard K. Fuller, M.D.
Division of Clinical and Prevention Research
NIAAA
6000 Executive Blvd., Suite 505
Bethesda, MD 20892-7003

Enoch Gordis, M.D.
Director, NIAAA
6000 Executive Blvd., Suite 400
Bethesda, MD 20892-7003

Nancy Hondros
Planning and Financial Management Branch, NIAAA
6000 Executive Blvd., Suite 412
Bethesda, MD 20892-7003

William M. Lands, Ph.D.
Office of the Director, NIAAA
6000 Executive Blvd., Suite 400
Bethesda, MD 20892-7003

Steve Long
Office of Policy Analysis, NIAAA
6000 Executive Blvd., Suite 405
Bethesda, MD 20892-7003

Ann Maney, Ph.D.
Office of Prevention, NIMH
Parklawn Building, Room 9C-25
5600 Fishers Lane
Rockville, MD 20857

Matthew McGue, Ph.D.
Department of Psychology
University of Minnesota
Elliot Hall, Room N-218
75 East River Road
Minneapolis, MN 55455

Suzanne Medgyesi-Mitschang, Ph.D.
Office of the Director, NIAAA
6000 Executive Blvd., Suite 405
Bethesda, MD 20892-7003

Eve K. Moscicki, Sc.D., M.P.H.
Division of Services and Intervention Research
NIMH
Parklawn Building, Room 10C-19
5600 Fishers Lane
Rockville, MD 20857

Antonio Noronha, Ph.D.
Office of Scientific Affairs, NIAAA
6000 Executive Blvd., Suite 409
Bethesda, MD 20892-7003

Carrie L. Randall, Ph.D.
Department of Psychiatry and
Behavioral Science
Medical University of South Carolina
171 Ashley Avenue
Charleston, SC 29425

Robert Reynolds, Ph.D.
National Center for the Advancement
of Prevention
11140 Rockville Pike
Rockville, MD 20852

Elizabeth B. Robertson, Ph.D.
Prevention Research Branch, NIDA
Parklawn Building, Room 9A-53
5600 Fishers Lane
Rockville, MD 20857

Kenneth Warren, Ph.D.
Office of Scientific Affairs, NIAAA
6000 Executive Blvd., Suite 409
Bethesda, MD 20892-7003

Ellen Witt, Ph.D.
Division of Basic Research, NIAAA
6000 Executive Blvd., Suite 402
Bethesda, MD 20892-7003

Ms. Migs Woodside
35436 Indian Camp Trail
Scottsdale, AZ 85262

Sam Zakhari, Ph.D.
Division of Basic Research, NIAAA
6000 Executive Blvd., Suite 402
Bethesda, MD 20892-7003

Back to Top

Based upon the papers developed for this portfolio review and the observations from the authors of these papers, the following recommendations for future research were noted and considered by the Subcommittee.

1. Price of Alcohol

1. Determine relationships between alcohol price and alcohol control policies, and implications for changes in price elasticity over time.

2. Document impact of changes in alcohol price and alcohol control policies on tobacco and other substance use.

3. Determine influence of alcohol price on non-traffic outcomes, including violence, crime, educational attainment, and health consequences.

2. Adolescents/Young Adults

1. Test effects of restrictions and enforcement of alcohol access (retail and social) on drinking, intoxication/impairment, and problems.

2. Test effects of expectancy interventions on drinking, high-volume consumption, and alcohol-related problems.

3. Determine approaches to (1) institutionalize effective prevention strategies and (2) extend effectiveness.

3. DUI

1. Determine approaches to motivate police to enforce DUI laws as part of community policing activities.

2. Test for optimal integration/mix of DUI sanctions to reduce recidivism.

4. Violence

1. Develop and test prevention strategies to reduce alcohol-associated (1) domestic violence and (2) public assaults.

2. Study contribution of alcohol to violence and explore potential of alcohol-specific strategies for current violence prevention interventions.

5. Workplace

1. Study interaction of gender and work, including stress.

2. Develop and test workplace prevention strategies to reduce (1) on-job drinking, (2) absenteeism, (3) accidents, and (4) lowered performance.

6. Alcohol and AIDS

1. Detuned HIV assay to document contribution of drinking to exposure.

2. Develop and test environmental strategies to reduce alcohol's contribution to high-risk sexual activity.

7. Alcohol Access - 1

1. Test effects of local and state policies to restrict access on (1) high-volume drinking, (2) traffic crashes, (3) non-traffic injuries/deaths, and (4) violence.

2. Test effects of enforcement levels on (1) high-volume drinking, (2) traffic crashes, (3) non-traffic injuries/deaths, and (4) violence for adults, youth, and minorities.

3. Develop and test strategies that can effect social host responsibility and determine outcome.

8. Alcohol Access - 2

1. Test effects of Alcohol Beverage Control enforcement.

2. Develop surveillance system for local outlets and determine economic and social costs for levels of outlet densities.

3. Test effects of changes in alcohol outlet density on (1) high-volume drinking, (2) traffic crashes, (3) non-traffic injuries, and (4) violence-related death.

9. Communications

1. Develop and test strategies to increase media attention to alcohol problems and policy (media advocacy).

2. Test effects of alternative prevention messages on (1) youth drinking, (2) high-volume drinking, (3) traffic and non-traffic injuries and fatalities, and (4) violence.

10. Racial/Ethnic Populations

1. Determine generalizability of general population prevention strategies/policies across racial/ethnic groups and need for culturally specific attributes/designs.

2. Test effects of bicultural competence training.

3. Develop and test effects of theory-based interventions across ethnic/racial groups.

The following basic research areas were identified as foundational research that will be important to the further development of prevention research initiatives.

• Aging and alcohol
• Gender-specific problems with alcohol
• Older women and preventing alcohol abuse at retirement
• Women and drinking in different cultural settings
• Alcohol-problem interventions with immigrants
• Protective factors and drinking (e.g., African American youth; Hispanic women)
• Childhood trauma as a risk factor for subsequent alcohol problems
• Study of factors that constitute and can increase community support for enforcement
• Identify and test the effects of positive alternatives to drinking (e.g., exercise)

Back to Top

Following extended discussion at the meeting on October 21-22, 1998, participants made suggestions of possible research priorities. These were considered and used by the Subcommittee in the development of research priorities. Possible research priorities included:

1. Multi-policy/multi-year studies, with methodological advances, which capitalize on natural variation cases (one intervention/implementation at a time), should be used to define underlying effects in order to learn what (a) policies and (b) organizations decrease excessive consumption and related consequences.

2. Determine best practices (interventions) for delaying initiation of drinking, intoxication, and abuse. It is expected that interventions will vary with age and the specific behavior to be delayed. Best ways to restrict access of individuals < 21 years of age to alcohol should also be determined.

3. Development of well-defined best practices to reduce HIV risk by disentangling alcohol/ drug use and sexual behavior in clinical and general populations. Need to develop interventions that enable HIV⁺ alcoholics to adhere to treatment regimens. Treatment agencies need to develop procedures for responding rapidly to new, alcohol-related viral epidemics, e.g., hepatitis C.

4. Establish better surveillance systems, based on development of actual and surrogate outcomes, measures, and indicators of alcohol involvement.

5. Explicate risk curve between violent and non-violent incidents and alcohol consumption.

6. Develop interventions for reducing alcohol consumption in workplace that are generalizable across occupations, age groups, gender, ethnicity, and that are acceptable to management.

7. Need to develop capacity to identify/track state and local changes in alcohol-related policies and programs in order to evaluate effects. Pre-planned set of designs would facilitate rigorous evaluation.

8. Understand effects of changes in alcohol price alone and in interaction with alcohol control policies on a variety of problems including, traffic and non-traffic injuries and fatalities, violence/crime, and health consequences.

9. Develop interventions for reducing alcohol problems in the elderly, women, and various ethnic groups.

10. Establish tested strategies for determining impact of media on alcohol-related problems. Need a better understanding of entertainment media and promotional campaigns on expectancies, especially of youth, related to alcohol consumption.

11. Establish linkages to other fields in order to promote the view that alcohol consumption affects everyone, thereby integrating the alcohol constituency.

12. Determine the relationship between new forms of alcohol packaging, products, and marketing and alcohol-related problems.

Back to Top

Updated: June 1999