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know that AIs generally are more likely to develop a variety of physical health conditions related to alcohol use (Hisnanick, 1992; Indian Health Service, 1999; Sugarman and Smith, 1992) and to die from alcohol-related causes (Campos-Outcalt, Prybylski, Watkins, Rothfus, and Dellapenna, 1997; Gilliland, Becker, Samet, and Key, 1995; Indian Health Service, 1999; May, 1996; May and Van Winkle, 1994; Singh and Hoyert, 2000). Research to date also suggests that rates of alcohol use and related problems vary substantially across AI/AN tribes (Indian Health Service, 1999; May, 1996; Novins, Beals, Roberts, and Manson, 1999).

Prevention of underage drinking in AI/ANs requires an appreciation of the historical, cultural, and sociodemographic contexts of alcohol use and related problems as well as an understanding of its epidemiology and theoretical relationships to key cultural contexts. Several promising prevention efforts have either been transferred successfully to AI/AN communities or emerged from these communities themselves. Although these efforts demonstrate community-level impacts, research suggests that efforts through the mid-1990s had failed to reduce high-risk substance use among AI/ANs overall (Beauvais, 1996).

The goal of this paper is to review our current knowledge regarding the prevention of underage drinking in AI/AN communities. We will include descriptions of the key contexts and epidemiology of underage drinking among AI/ANs, prevention efforts to date, and the role of cultural constructs in understanding and preventing underage drinking and related problems.

KEY CONTEXTS

Sociodemographics

AI/ANs are a diverse and heterogeneous population. There are more than 500 federally recognized tribes with a population of 4.1 million as of 2000 (U.S. Census Bureau, 2001). These tribes differ substantially in terms of language, customs, family structures, religions, and social relationships (U.S. Department of Health and Human Services, 2001). Most AIs live in western states, including California, Arizona, New Mexico, South Dakota, Alaska, and Montana, with 42 percent residing in rural areas, compared to 23 percent of whites (Rural Policy Research Institute, 1999). They are also relatively young, with a birth rate 1.6 times that of the U.S. all-races rate (U.S. Department of Health and Human Services, 1998). The Indian Health Service (IHS) reported that 65.3 perecnt of the AI/AN population living in reservation states have completed high school and 8.9 percent have completed 4 years of college—much lower than the 75.2 percent and 20.3 percent, respectively, for the U.S. as a whole (U.S. Department of Health and



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