Prevention of Underage Drinking : Macroenvironmental Interventions

by National Institute of Health

(Page 4 of 6)

Macroenvironmental Interventions

Environmental approaches may have both direct and indirect influences on drinking by youth. Enforcement of MLDA laws directly reduces alcohol availability, a critical element in comprehensive risk models. Penalties for alcohol use and misuse that apply directly to youth increase the social "cost" of drinking, which is expected to affect decisions about drinking. Changes in monetary price have been associated with decreases in use and related problems. Public awareness campaigns in support of environmental change serve to change community norms regarding the acceptability of underage drinking, which should further reduce opportunities to drink and increase social costs to young drinkers.

Environmental interventions are among the recommendations included in the recent NRC and IOM report, Reducing Underage Drinking: A Collective Responsibility, and by the Panel on Prevention and Treatment of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Task Force of the National Advisory Council on Alcohol Abuse and Alcoholism. Such programs seek to reduce commercial and social availability of alcohol and/or reduce driving while intoxicated. They may use a variety of strategies, including implementing server training, instituting compliance checks in outlets, deterring adults from purchasing for minors or providing alcohol to minors (public education and policies), restricting drinking in public places, enforcing penalties for use of false IDs, strengthening policies to detect and terminate underage drinking parties, establishing penalties for providing alcohol to a minor, enforcing DUI and zero-tolerance laws, and creating publicity regarding policies and sanctions.

Three community trials in the United States are noteworthy and are described below. Collectively, they show the utility of community environmental strategies to reduce underage drinking and related problems.

The Massachusetts Saving Lives Program. This 5-year comprehensive intervention implemented in six communities was designed to reduce alcohol-impaired driving and related traffic deaths. This program decreased fatal crashes, particularly alcohol-related fatal crashes involving drivers ages 15-25, and reduced the proportion of 16- to 19-year-olds who reported driving after drinking relative to the rest of Massachusetts. It also increased teen awareness of penalties for drunk driving and for speeding. Other significant outcomes related to traffic safety were not age-specific.

The Community Prevention Trial Program. This program was implemented in three intervention communities matched to three comparison sites. The formal goal of the project was to assist each experimental community to make effective, long-term changes to reduce alcohol-involved injuries and death but not necessarily to change individual drinking patterns. The intervention strategies included efforts to reduce alcohol availability to minors. Sales to apparent minors (people of legal drinking age who appear younger than age 21) were significantly reduced in the intervention communities compared with the control sites.

Communities Mobilizing for Change on Alcohol. This program was a randomized 15-community trial to reduce the accessibility of alcoholic beverages to youths under the legal drinking age. It emphasized environmental factors that affect the supply of alcohol to youth, using a community organizing approach to achieve policy change among local institutions. Among the significant findings were that merchants in participating communities were less likely to sell alcohol to minors and that 18- to 20-year-olds were less likely to try to purchase alcohol or provide alcohol to younger teens. There also was a decline in DUI arrests among 18- to 20-year-olds. There were no program effects, however, on self-reported drinking by 12th graders, the youngest age group surveyed. This may be a result of the short duration of the intervention - 2.5 years - or it may be that younger adolescents obtain alcohol from adults and are not directly affected by changes in commercial availability.

Community-level interventions clearly can reduce commercial sales of alcohol to minors, and this can affect overall drinking by older adolescents. It remains to be seen whether sustained interventions can reduce social availability of alcohol to younger adolescents. Additionally, the fact that community interventions can simultaneously reduce alcohol-related problems among adults and youth increases their cost-effectiveness and should make them attractive to policymakers.

Multicomponent Comprehensive Interventions

Comprehensive interventions provide coordinated programs at the school, family, and community levels and target multiple pathways for risk. Ideally, they also should integrate universal, selective, and indicated prevention programs and treatment for youth who are alcohol dependent. To date, one such program, Project Northland, has been evaluated.

Project Northland is a comprehensive universal prevention program that was tested in 22 school districts in northeastern Minnesota in a randomized trial. The intervention included 1. innovative social behavioral school curricula, 2. peer leadership, 3. parental involvement programs, and 4. communitywide task force activities to address larger community norms and alcohol availability. The intervention was delivered to a single cohort in grades 6 through 12. Intervention intensity and focus varied over the study period. The first phase had strong school and family components. By the end of grade 8, fewer students had initiated alcohol use, and the prevalence of alcohol use was significantly lower in the intervention communities compared with control communities. During the next phase of the study, grades 9 and 10, there was minimal intervention. In grades 11 and 12, intervention activities resumed, and the community component to reduce availability was featured more prominently.

Significant differences were observed between intervention and comparison communities during each project period for "tendency to use alcohol" (a composite measure that combined items about intentions to use alcohol and actual use) and "five or more in a row." The rates of increase in underage drinking prevalence were lower in the intervention communities during phase 1; higher during the interim period and again lower during phase 2 when intervention activities resumed.

Based on its success, Project Northland has been designated a model program by SAMHSA, and its materials have been adapted for a general audience and marketed by Hazelden. It now is being replicated in ethnically diverse urban neighborhoods.

Very Early Interventions

The Project Northland findings at the same time point to a dilemma that may be a significant hurdle when working to prevent underage drinking in the highest risk groups. The program began in sixth grade, when children were approximately 12 years of age, and although it was able to reduce rates of drinking among those who were nondrinkers at the initiation of the project, the intervention had no effect on those who had already begun drinking. The study was not able to parse out the reasons for these differential effects on initial nonusers vs. users, but youth who are already drinking at sixth grade are very much an early onset group, given that the median age of onset of first use is age 14. Given also what is known about the impulsivity, heavier drinking by parents, and conflicted family backgrounds of early onset users, it is likely that the social micronetworks within which the early onset drinkers moved would have insulated them to a greater degree from the program's effects. For this subgroup, earlier precursive risk intervention programs may be necessary.

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