Prevention of Underage Drinking

by National Institute of Health

(Page 3 of 6)

Intervention Approaches

Environmental-level interventions seek to reduce opportunities for underage drinking, increase penalties for violating minimum legal drinking age and other alcohol use laws, and reduce community tolerance for alcohol use and misuse by youth. Individual-level interventions seek to change knowledge, expectancies, attitudes, intentions, motivation, and skills so that youth are better able to resist the pro-drinking influences and opportunities that surround them. This section discusses four types of individual- and environmental-level programs: school-based programs, family-based programs, macroenvironmental programs, and multicomponent programs.

School-Based Prevention Programs

School-based curricula to prevent use of alcohol and other drugs by youth have a long history. However, the use of research-based findings to guide the content and evaluation of such curricula is a fairly recent development. The first school-based programs were primarily informational and often used scare tactics - it was assumed that if youth understood the dangers inherent in alcohol misuse, they would choose to abstain. These programs were ineffective. Better programs are now available, but researchers have found that sometimes they are not used or implemented as designed.

Efforts to clarify theoretical and methodological issues relevant to improving school-based prevention curricula have made steady progress. However, methodological issues remain a critical barrier to interpreting the large number of published studies, as many were conducted with less than optimal degrees of scientific rigor. Additionally, variations in design and methodology make comparisons across studies difficult. For example, there is wide variability in alcohol use outcome measures, and it is common for some measures within a single study to show significant intervention effects whereas others do not.

Researchers are increasingly interested in collecting information on alcohol-related problems and high-risk drinking practices in addition to more straightforward measures of quantity and frequency of drinking. Outcomes based solely on knowledge and attitudes are no longer acceptable. Variation in measures makes comparisons across studies difficult. Also, the frequent use of study-specific composite scales often makes practical interpretations of findings difficult. This latter problem, coupled with the failure to report effect sizes, makes it difficult to judge the likely benefit from implementing programs on a large scale. Analysis based on intention-to-treat is the most relevant from a public health standpoint, but application of this analytic standard often eliminates statistical significance. Differences in program intensity, followup periods, age/grade of students, program goals, population characteristics, and attrition also impede meta-analysis and cross-study comparisons.

Unfortunately, effect sizes generally are small. Even state-of-the-art programs are not sufficient to prevent adolescent use and misuse of alcohol in the absence of social and environmental change. Much of the literature suggests universal prevention curricula are less effective with higher risk students - those who have initiated drinking prior to grades five or six; additional research is needed in this area because of inconsistencies in the literature.

School curricula operate at the individual level by trying to provide students with the knowledge, skills, and motivation needed to resist pressures to drink. However, schools also may be considered from an environmental perspective. Policies and practices within the school, such as consistent enforcement of sanctions for violating alcohol rules, are another arena for intervention. Students' bonding or attachment to their schools is found to predict less alcohol and other drug involvement, so overall school climate and cohesiveness also seem to be important. However, there are few studies linking specific school policies with alcohol use and even fewer studies of policy changes.

Family-Based Prevention Programs

The ability of parents to influence whether their children drink is well documented and is consistent across racial/ethnic groups. Setting clear rules about children not drinking, consistently enforcing those rules, and monitoring child behavior reduce the likelihood of underage drinking. Family conflict and lack of cohesion are associated with increased risk. Family interventions encourage parents to be aware of the risks from underage drinking, to communicate with children, to clarify expectations regarding alcohol use, to set rules and consequences for violations, to monitor children's activities, and to reduce the availability of alcohol in the home. Additionally, content on family management practices and communication skills often are included. Parent-directed programs have been included with school-based interventions, some of which have evidence of success; but these components have not been evaluated separately. Stand-alone family interventions have been successful in reducing alcohol use and other risk behaviors.

The Iowa Strengthening Families Program, delivered when students were in grade six, has shown long-lasting preventive effects on alcohol use, even when evaluated on the basis of intent-to-treat. This finding is striking on two counts: First, it suggests that the intervention succeeded in changing the normative environment of schools in which the program was offered, because even students whose families did not participate benefited. Second, the increase in effect size over time and the duration of effects into high school compares favorably with school-based interventions. A recent Cochrane review identified the ISFP as one of two potentially effective interventions for the primary prevention of alcohol misuse by youth.

Family interventions operate at both the individual and environmental level. Interventions seek to change behavior of both parents and children by increasing knowledge and skills. However, by changing parent practices, they affect a primary social environment for the child. This microenvironment-level change effectively reduces availability and increases "costs" associated with drinking, which probably accounts for the lasting intervention effects that have been observed.

Families in distress or youth who are exhibiting behavior problems may need more intensive interventions. Tiered or stepped-intervention strategies have been described to restrict more costly services to the subset of families in most need.

About the Author

NIH is the nation's medical research agency - making important medical discoveries that improve health and save lives. The National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services, is the primary Federal agency for conducting and supporting medical research.