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s COMMUNITY APPROACHES AND PERSPECTIVES FROM OTHER HEALTH FIELDS Major advances in the prevention of health-related problems have been made recently in several public health fields through the development and application of theory, the careful documentation of implementation processes, and the application of formative and summative evaluation methods. As a result of several well-planned, community-wide prevention programs based on sound experimental research designs, significant changes have been effected in the health behaviors of Americans, and declines in the risk of morbidity and premature mortality have been achieved. These systematic efforts to reduce cigarette consumption, control high blood pressure, lower accident rates, and modify unhealthy eating habits have resulted in sustained, community-wide health risk reductions that can be linked to a lowered incidence of disease and early death. The use of controlled experimentation to test prevention theory in programs such as these provides research findings that can guide the design of alcohol prevention approaches and permit the evolution of sound program designs and methods. This chapter reviews current perspectives on alcohol-related prevention and identifies applicable findings from prevention efforts in other public health fields. Published reports of research on alcohol using comprehensive approaches at the community level are limited in number. Wallack (1984-1985) reports on one case study, and Geisbrecht, Douglas, and McKenzie (1981) are evaluating a three-community demonstration project in Canada. There have also been several other studies, but they have not involved the total "community" and have not been evaluated. Consequently, they are not reported here. The Midwestern Prevention Project (MPP), also referred to as Project STAR, is an example of the community-wide approach to alcohol problem prevention. It is an as yet incomplete federally funded demonstration project under way in the states of Kansas, Missouri, and Indiana. The STAR project is a multilevel program addressing individual, social, and environmental factors that are thought to influence adolescent drinking. The project staff developed a school-based curriculum and supplements classroom studies with media messages, vendor education, police patrols, and alternative activities. The project has reported significant reduction in the use of three drugs (tobacco, marijuana, and alcohol) in a two-year follow-up of 15 communities near Kansas City, Missouri (Pentz et al., 1989~. A full report is not expected until around 1991, following a two-year trial in communities in Indiana, which serve as controls for the Kansas City phase of the project. Probably the most ambitious and comprehensive existing program with an alcohol-use prevention component, MPP will contribute many insights relevant to the prevention of alcohol-related problems even though it is restricted to adolescents. Comprehensive approaches need not be limited to cities or counties. Kraft (1984) and Mills and associates (1983) described comprehensive programs for college campuses that employed media, discussion groups, and experimental workshops. Community organizational planning was used to modify campus regulations. The programs appeared to be successful in modifying knowledge and attitudes regarding alcohol but not behavior. Although not as yet fully evaluated, a similar project targeted at high school youth, has demonstrated changes in knowledge, attitudes, and behaviors of teachers and peer leaders -109

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(Mecca, 1984). Other examples of community-based prevention are the actions taken by local, grass-roots movements to reduce such specific alcohol-related problems as drunk driving on prom night. A descriptive case study of parent groups sponsored by the National Institute on Drug Abuse (NIDA), found wide differences in activity, organization, and perceived efficacy (Moskowitz, 1985; Klitzner et al., 1987~. Preliminary results of a study by NIAAA of Students Against Drunk Driving (SADD) programs have not detected measurable effects at two high schools (M. Klitzner, Pacific Institute for Research and Evaluation, personal communication). Another study (Ungerleider et al., 1986) used questionnaires sent to members of Mothers Against Drunk Driving (MADD) chapters to gather data for a descriptive study; no data are yet available. LIMITATIONS OF ALCOHOL PREVENTION RESEARCH Prevention research in the alcohol field--in general and at the community level--has been limited by problems in program design and evaluation. Project designs have relied heavily on the acceptance of prevention strategies based on the face validity of the intervention. For example, innovative means of education and policy changes such as warning signs at the point of purchase and bans on the sale of beer or wine at gas stations have been widely adopted without sufficient evidence of their effectiveness. Other design weaknesses include focusing on a single strategy for change rather than using multiple and mutually reinforcing strategies. Another problem has been a tendency among policymakers to ignore complementary policy change strategies and legislative measures, such as local zoning ordinances. Surprisingly, these problems persist despite the well-accepted principle that successful health promotion and disease prevention programs maximize program effects through the integration of several components (Green and McAlister, 1984; Farquhar et al., 1985~. Room (1984) also contends that alcohol problem prevention efforts should be designed as a system rather than conceived of as isolated components. Because limited controls on alcohol consumption do not appear likely to have a significant effect, Room calls for the concurrent use of several strategies that can result in synergistic effects. The measurement of outcomes has also posed difficulties in research on the prevention of alcohol-related problems. Tax receipts from the sale of alcoholic beverages have been used successfully as a quantitative measure for some studies that have furnished considerable empirical data on interventions designed to control consumption. Yet most studies have only used such measures as the number of participants in a program or have relied entirely on changes in knowledge or self-reports of behavior change. Only a few have measured such outcome variables as blood alcohol levels of individual participants or changes in community rates of injuries or arrests for driving under the influence. The sections that follow first present a case study of two cardiovascular disease (CVD) prevention programs in California. An in-depth look at these programs illuminates some of the major lessons learned from more than 15 years of effort to achieve measurable risk reduction for cardiovascular disease. Next, selected examples from other primary prevention efforts are reviewed, both to report on successes and to identify principles for possible application to alcohol abuse prevention. -110

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COMMUNITY-BASED CARDIOVASCULAR DISEASE PREVENTION STUDIES The Stanford Three-Community Study (TCS) conducted during the 1970s provided evidence that community-wide health education involving the mass media and supplemental face-to-face instruction can be quite effective in changing knowledge, attitudes, and behavior and, consequently, in reducing CVD risk factors (Farquhar et al., 1977~. The results of the TCS demonstrated the potential for community-wide risk reduction using a three-year program of education. The TCS was carried out in one town largely through the mass media (including electronic media, newspapers, and printed self-help booklets) and in another town through the mass media supplemented by a face-to-face program of intensive instruction. A third town served as a reference community. In contrast to prior projects in health education, the TCS project staff relied heavily on formative evaluation to develop educational strategies. The results strongly suggest that health status at the community level can be improved significantly through a well-designed educational program using both mediated and interpersonal channels. Results of the TCS educational components were assessed over time, by using a multiple logistic function of CVD risk that incorporated age, sex, plasma cholesterol, systolic blood pressure, relative weight, and smoking. Several techniques were used to collect these data, including periodic field surveys of knowledge, behavior, and physiological testing in representative samples of the general population. During a two-year period of community education, a statistically significant reduction was achieved in the composite risk score for cardiovascular disease as a result of significant declines in blood pressure, smoking, and cholesterol levels. , ~ This risk score decreased approximately 25 percent for the media-only community and 30 percent for the community in which media were supplemented by face-to-face instruction (Farquhar et al., 1977~. This outcome suggests that considerable success was achieved when mass media programs were supplemented with intensive instruction but that adequate exposure to mass media alone was often successful without the supplemental education (Maccoby et al., 1977~. The Stanford Five-City Project (FCP), an ongoing, 13-year study that began in 1978, is an outgrowth of the TCS. It involves 350,000 people and employs multiple methods of education and community organization. The primary goal of the FCP is to reduce the risk of cardiovascular disease; however, subsidiary coals of the program also have important pUbllC health 1mpllcatlons. these goals Include cost-enectlveness analysis, development of educational and community organization methods, transfer of control to community organizations, and measurement of morbidity and mortality end points through a new, low-cost community surveillance method (Farquhar et al., 1985~. The FCP represents an ambitious new endeavor in experimental epidemiology of potential relevance to field applications of noncommunicable disease control methods. It also offers a significant opportunity for testing generalizable and cost-effective community organization and health education methods. Interim results from the FCP show that the risk factor reduction that has been achieved through this program is quite promising. Smoking rates have declined significantly in both treatment and reference communities, with a 2.5 percent per year greater drop in the proportion of smokers occurring in the treatment communities than in those locales in which no intervention occurred. The interventions also produced significant improvements in such health status indicators as blood pressure, blood cholesterol, and physical activity. -111

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The multiple logistic of CVD risk for total mortality and for coronary heart disease events was reduced significantly in treatment communities by amounts ranging from 7 to 29 percent measured during four time periods from 2 to 5-1/3 years after education began (Farquhar et al., 1988~. Promising results have also been achieved in meeting other program goals. For example, preliminary results support the feasibility of transferring responsibility for program maintenance to local organizations. In addition to the overall community effect, the FCP provided evidence for individual or combined effects on various groups (in school and work site settings) of environmental or regulatory changes when coupled with mediated or face-to-face educational programs. Other data have shown that, although all three components were effective and have a place in a comprehensive prevention program, low-cost self-help booklets for smoking cessation are more cost-effective than either classes or contests (Altman et al., 1987~. Lessons from the Three-Community~Study and the Five-City Project The successful reduction of risk factors for cardiovascular disease through a primary prevention approach has been very encouraging. The results are promising because they suggest that it is possible to change the health habits of entire communities and to mobilize existing community resources to achieve those changes. The next step, however, is to learn how to replicate these results. Although there have been successes in other fields of primary prevention, the results of the CVD efforts have been much better documented. Therefore, the two CVD prevention programs in California may serve as models (Farquhar et al., 1977; Maccoby et al., 1977; Farquhar, 1978; Farquhar, Maccoby, and Wood, 1985~. Several Lessons or "keys to success" that were used repeatedly by these projects to ensure that the program was well-planned, well-implemented, and well-evaluated are described below. Theory should be used as a basis for program planning, implementation, and evaluation. To provide a foundation for planning, implementing, and evaluating a large-scale community intervention to reduce the risk of heart disease, the Stanford group drew from several disciplines to develop a theoretical framework for individual behavior change. Relying on theory-based planning was essential for interpreting the results of evaluations and hypothesis testing. Without a theory or a model for change, outcome evaluation results would have been difficult to explain; without a previously determined hypothesis, it would have been nearly impossible to determine which strategies were effective and which were ineffective. Theories and models that have been used in community CVD prevention include the communication-behavior change model, the social marketing framework, and the community organization model (Farquhar, Maccoby, and Wood, 1985~. The communication-behav~or change model draws on Bandura's social learning theory, McGuire's communication-persuasion model, and Rogers' diffusion theory (Farquhar et al., 1985) to identify a series of sequential steps for behavior change: (1) creating awareness of the need for behavior change; (2) producing a change in attitude toward the behavior; (3) increasing the motivation to change; (4) learning skills for change; and (5) learning maintenance and relapse prevention skills. The Stanford group used social marketing theory to develop health messages for communities. Kotler and Zaltman (1971) define social marketing as "the design, -112

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implementation and control of programs seeking to increase the acceptability of a social idea or cause in a target group or groups. Based on its consumer orientation, social marketing dictates that the product--in this case, either a health information product such as a public service announcement (PSA) or a behavior--be developed and promoted to meet the needs of the consumer. The community organization model is founded on the notion that the process of organization within the community is required to create a mechanism for collaborative action that leads to the adoption of programs, a step needed to ensure both cost-effectiveness and program maintenance. A comprehensive, integrated program is needed. Primary prevention approaches used in effective programs have sought to address the entire population rather than high-risk individuals only. Because complex health problems involve individual and institutional behavior, social norms, and family modeling influences, a comprehensive, integrated program is required for program success. The "comprehensive" feature embraces the notion of Room's ~system," an approach that he advocated for the prevention of alcohol-related problems (Room, 1984~. The "integrated feature implies that the components of the system, which may be inadequate when initiated singly, are more effective when they are integrated and when they are delivered in the right sequence. Comprehensive health promotion programs are those that actively involve all of the following elements: Multiple channels of communication (e.g., media, face-to-face contacts). Regulatory change and environmental change are additional "channels of influence. Multiple target audiences (e.g., youth, families, health professionals, adults). For example, high-risk individuals or families, "hard-to-reach" individuals, highly motivated Early adopters," and less knowledgeable adults are common subgroups. Groups or organizations such as schools or work sites may also be the target. Multiple outcome objectives (e.g. knowledge gain, behavior change, policy change, physical environmental change, media promotion). These different outcome objectives reflect the use of different intervention strategies--for example, the use of advocacy activities to change organizational or community policy. Multiple levels of evaluation, including formative, process, and summative evaluation, applied to individuals, groups, organizations, and communities. An integrated program ensures that each program component reinforces and strengthens other program components. For example, a smoking cessation program may rely primarily on self-help booklets and classes, but it will also reinforce its message through a campaign at local work sites, publicize itself in the local media, and collaborate with other local agencies on such events as a ~quit-smokin~" contest or legislation to restrict smoking in _ , _ . _, ~ . . . public areas. An integrated program must also be transferable to institutions within the community so that it can be maintained over time. Formative and process evaluation is needed for success. Three general categories of formative evaluation were employed in the Stanford risk reduction programs: (1) needs analysis, (2) pretesting of educational programs, and (3) analysis of the implementation process following the introduction of the educational programs into the field. These three categories of formative research are based on social marketing theory by Kotler and are analogous to methods used in product marketing (Kotler and Zaltman, 1971~. In the California programs, an audience needs analysis was used to discover the interests, educational needs, media use, and other characteristics of the different subsections of the -113

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community. This type of formative research helped determine the proper name, location, and time for educational activities, as well as the cost and comprehensibility of any educational materials developed.: Prototypes of educational programs were developed and tested to determine the appropriate content and method of delivery of the message. The pretest data were then used to revise the message or program prior to implementation to ensure effectiveness. Process evaluations, or analyses of educational programs following their introduction into the community, were also employed to revise programs and examine content issues. Process evaluation identified some of the factors that influenced attendance, dictated how much was learned, and determined whether an event or program actually affected behavior. Extensive evaluation of outcomes is essential. Cardiovascular disease prevention programs in the United States and other countries have invested considerable resources in evaluating the effects of their projects. For example, the FCP involved two intervention and three control communities. Periodic independent and cohort surveys were conducted in these communities throughout the life span of the project, and epidemiological data on CVD morbidity and mortality were also collected. In addition to collecting outcome measures during the entire five years of the multicomponent intervention, specific risk reduction strategies (e.g., smoking cessation, dietary counseling) were evaluated to determine their effects on individual knowledge, attitudes, and behavior. For example, the effects of one quit-smoking contest with 500 participants were evaluated through several outcome measures: a mail survey of contest finishers; a telephone survey of selected nonrespondents; a carbon monoxide (CO) assessment of contestants who quit; and a one-year follow-up CO test of those same contestants (King et al., 1987~. Data from this study allowed program planners to see both the successes and the shortcomings of the contest. The findings showed that the quit rate for -contestants was twice as high as the rate in the general adult population in the control communities, and the cost of the oro~ram--includinn its evaluation--was lower than that of traditional classes or groups. Program planners concluded that the contest could be strengthened by adding a relapse prevention element (in this case, extending the length of the program) and by the use of incentives to maintain abstinence. Because the TCS and FCP attempted to change both individual and organizational behavior, many levels of analysis were used to measure these changes. Change occurring at the individual level was perhaps the most studied outcome in these two projects and had the strongest basis in theory. Individual change strategies included the use of booklets, self-help kits, correspondence courses, contests, and classes. Limiting analysis to the individual, however, makes an artificial distinction between the individual and the environment. Therefore, change in organizations, including social service agencies, restaurants, grocery stores, hospitals, and work sites, was examined in a second level of the intervention analysis. Community change--for example, changes in laws, regulations, and taxation--was considered in a third analytical tier. Each of these levels of change was conceptualized differently and required different intervention strategies and somewhat different evaluation methods. Throughout the TCS and FCP, component testing was the critical first step in designing strategies that had positive, short-term effects. Once these program components were tested, those that were found to be successful were incorporated into a larger multicomponent program. For example, school-based, peer resistance programs to prevent the adoption of cigarette smoking in seventh-grade students was one of the first components tested (McAlister, Perry, -114

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and Maccoby, 1979). Analogous studies have recently been extended to older adolescents in a broad nutrition, exercise, and weight control project (Killer et al., 1988). School-based and work site studies are prime examples of "components that, once developed, may be used together with an expectation of svneraistic effects. , ~ Results from Other Comprehensive CVD Prevention Programs A growing number of community-based studies in CVD prevention have been reported or are under way. The status of some 10 projects initiated between 1972 and 1982 was reviewed by Farquhar, Maccoby, and Wood (1985~. The best known of such projects outside of the United States is the Finnish North Karelia Project, which began in 1972 (Puska et al., 1981). The successes in cholesterol reduction, blood pressure control, and smoking cessation after two and three years of education in the Stanford TCS were comparable to those achieved after the first five years of education in the North Karelia Project. The Finnish study was extended for a total of 10 years to allow scrutiny of its impact on CVD morbidity and mortality. The favorable effects of the interventions mounted by the project were reported in comparison not only with the adjoining county but also with respect to trends in the remaining parts of Finland (Tuomilehto et al., 1986). The results of four other community-based studies that used methods similar to those of the TCS and the North Karelia Project have been published. Only one of them, which took place in three small, rural South African towns, reported significant changes in cholesterol levels and blood pressure control as well as in smoking cessation (Rossouw et al., 1981). Another study, which was undertaken in four Swiss towns (Gutzwiller, Nater, and Martin, 1985), and a three-town study in Australia (Eager et al., 1983) reported significant decreases of 6 and 9 percent, respectively, in smoking rates. In the fourth project, which was carried out at work sites in two Pennsylvania counties, favorable body weight and dietary habit effects were reported (Felix et al., 1985; Stunkard, Felix, and Cohen, 1985). At this point, the analogous results achieved in replications of the two Stanford programs, along with the comparable results of the North Karelia Project, support the notion that this extensive type of community approach may be reasonably generalizable, at least to cardiovascular disease and quite possibly to the prevention of alcohol-related problems as well. An important caveat is that trials of extensions of these methods to alcohol-related problems should first be carried out in a research format. Two additional ambitious and well-evaluated studies are now in progress in the United States: the Minnesota Heart Health Study, involving six communities with a total population of 356,000 (Blackburn et al., 1984), and the Pawtucket Heart Health Study, involving two cities in Rhode Island with a total population of 173,000 (Lasater et al., 1984~. Results from these two studies will add additional information about the feasibility of carrying out such research and will help identify effective methods that can be used in community recruiting and implementation and in institutionalization of the projects to maintain effects. One exciting finding to date in the Minnesota study is that food labeling, nutrition education, and environmental changes at the "point of purchase" in grocery stores and restaurants have been shown to be effective (Mullis et al., 1987; Glanz and Mullis, 1988; Mullis and Pirie, 1988~. This finding is another example of "component development," which may occur prior to the use of a component in a more comprehensive community campaign. The result of this research is that now the three studies (the Stanford FCP and the Pawtucket and Minnesota studies) all use point-of-purchase components in their overall programs. -115

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RESULTS FROM PRIMARY PREVENTION PROGRAMS IN OTHER HEALTH FIELDS Although cardiovascular disease prevention has a relatively long and well-documented history, success stories from many other public health fields provide evidence that prevention in matters involving life styles is possible. Lessons from these programs shed new light on how specific health risk behaviors can be prevented and offer guidance on program planning and evaluation. Although there are as yet no examples of comprehensive community-wide programs in fields other than cardiovascular disease, there are many successful illustrations of potential components of broad programs: studies in work sites, examples of the use of regulatory change, the use of the national mass media, or education and environmental change at the point of purchase of tobacco. From the extensive published literature on prevention, several successful programs that have particular relevance to alcohol problem prevention are highlighted below. Promoting Seat Belt Use Because injuries are a leading cause of morbidity and mortality in the United States, many public health programs address this problem. Promoting seat belt use as a means of preventing injuries from car crashes is one example of the successful use of statewide legislation and work site-based incentives and education in prevention. Strategies to promote seat belt use can be mandated by legislation or encouraged through public education campaigns. Both of these approaches have been used and evaluated, and a comparison or tne results of two studies offers insight into these very different means of achieving a preventive health behavior change. Fortunately, a reduction in automobile fatalities has also been noted as a consequence of increased seat belt use, although enforcement procedures that allow random inspection have also been found to be a necessary step to ensure continued compliance with new seat belt laws (Campbell, 1988; Williams and Lund, 1988~. Nevertheless, questions remain on the relative roles of regulations, education, and incentives and on the role of work site programs in achieving change in seat belt use. Michigan's mandatory seat belt law serves as an example of using legislation for prevention purposes. To study its effects, random samples of drivers were observed in various locations in the state before passage of the law, immediately after implementation, and five months later. Results revealed a dramatic increase in use immediately after the change in the law and a slight decrease five months later. Observed an increase of 117 percent over the prelaw use rates. Still, Wagenaar and Wiviott (1986) Two lessons relevant to the prevention of alcohol-related problems can be extracted from the results of the Michigan study. First, legislation can promote behavior change, at least with respect to seat belt use. Because the results raised some questions about whether the public would maintain the behavior, it appears that legislation combined with periodic campaigns to remind the public to use seat belts may be a more effective strategy than legislation alone. The second lesson applicable to the prevention of alcohol-related problems and to all programs that intend to measure behavior change is the value of an extended data collection effort. Assessing change after five months gave researchers a more accurate picture of how adoption rates fluctuated over time than would have been possible with a more limited period. -116

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In a review of 28 voluntary seat belt use campaigns at work sites, Geller and his colleagues (1987) found that all programs effectively increased use, although at varying rates. Programs were compared on the basis of motivational messages and the use of incentives to encourage seat belt use. Although some programs offered such incentives as meal coupons, cash awards, and prizes, those that emphasized an awareness of, and commitment to, seat belt use but offered no incentives were by far the most effective. The net gain in use from intervention to follow-up several months later varied from 15 to 62 percent in incentive-based programs; it was 152 percent in awareness/commitment programs (Geller et al., 1987~. ~a--- ~ Geller's conclusions counter previous assumptions about the use of incentives in health behavior change programs. For example, such incentives as free trips and cash prizes have been used successfully in community-wide smoking cessation programs and are an integral part of health promotion strategies based on social marketing (King et al., 1987~. Other studies show that incentives increase effectiveness when they are added to campaigns that include components to enhance awareness, knowledge, and behavior change skills (Brownell et al., 1984; Sallis et al., 1986~. Because the studies reviewed by Geller were not symmetrical with respect to their educational components, the independent effect of providing incentives is difficult to ascertain. Cancer Prevention Through Mass Media Advertising From the long history of education and screening programs to prevent cancer, only the dietary education campaign to promote a low-fat, high-fiber diet will be discussed. The National Cancer Institute (NCI) Cancer Prevention Awareness Program, now in its fourth year, is a nationwide program that seeks to change individuals' knowledge, attitudes, and behavior to prevent cancer. NCI hopes to achieve these goals through the launching of a mass media campaign on cancer prevention, the production and distribution of print materials for the general public, and the education of health professionals about cancer prevention. After the start of these efforts, a campaign intended especially for black Americans was initiated in an effort to reduce the relatively high incidence of cancer in the black population (NCI, 1986~. An evaluation of one component of the NCI program revealed dramatic behavior changes in diet. NCI collaborated with Kellogg Company to publicize a message promoting a low-fat, high-fiber diet in the national media and to promote Kellogg's new bran cereal. A two-year cereal advertising campaign that publicized NCI's diet message and telephone number in television ads and on the back of cereal boxes produced more than 20,000 telephone calls and 30,000 written inquiries to NCI. Furthermore, a study of cereal sales in the greater Washington, D.C., area revealed that sales of all high-fiber cereals, not merely Kellogg's brand, increased (Freimuth, Hammond, and Stein, 1988~. This publicity campaign demonstrates the powerful role that private industry can play in health promotion: NCI was able to reach an audience of millions as a result of the cooperation and extensive financial backing of Kellogg's cereal company. This lesson has important ramifications for the alcohol problem prevention field, because there are many potential allies in the food and nonalcoholic beverage industries that could promote their products as healthful alternatives to alcoholic beverages. However, cooperation between health promotion agencies and the private sector must be carefully considered because the alcoholic beverage industry is not likely to assist in any attempt to reduce sales. Some -117

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large companies have integrated the production, distribution, and sales of food, nonalcoholic beverages, and alcoholic beverages. As a result, alcohol abuse prevention efforts will not serve the corporate objectives of such organizations. A second lesson that can be derived from the NCI program is that consumers were able to generalize the health message promoted by Kellogg's to the purchase of all types of high-fiber cereals. For the alcohol field, this finding may mean that the promotion of one particular nonalcoholic beverage may translate into an increase in consumption of many types of nonalcoholic beverages. Further research on consumer behavior is necessary before any conclusions can be drawn. Smoking Prevention and Cessation Smoking prevention and cessation programs are components of prevention programs in several fields of public health because smoking is a risk factor both for cardiovascular disease and for certain types of cancers. The terms prevention and cessation refer to different techniques and different target audiences. Smoking prevention programs are designed to prevent the onset of smoking among adolescents; smoking cessation programs are designed to help smokers quit. From the large body of research on both of these topics, only a few examples have been selected for review here. Although evidence is still needed to establish long-term effectiveness, smoking prevention programs in schools have been successful in delaying the onset of smoking among early teens. Among such programs, the most effective method appears to be what Killen has called the social pressure resistance training approach (Flay, 1985; Killen, 1985; Best et al., 1988~. The resistance training approach alerts young people to the various pressures that may encourage them to smoke and teaches specific skills to use in resisting those pressures. Generally, these programs are evaluated through follow-up surveys conducted several months after the intervention and through the use of carbon monoxide tests to detect recent smoking. Results show that the rate of smoking is significantly lower in treatment populations than in control groups (McAlister, Perry, and Macoby, 1979; Botvin, 1982; Telch et al., 1982; Luepker et al., 1983; Flay, 1985; Killen, 1985; Hansen et al., 1988; Telch, Miller, and Killen, in press). Best and colleagues (1988) draw the following conclusions and make recommendations for future research based on the adolescent smoking/peer resistance training experience: (1) social influence peer resistance curricula are effective, but more needs to be learned about individual participant, provider, and setting factors that mediate effectiveness; (2) research must continue with renewed vigor and a focus on lessons learned from the previous decade's work (in the area of program development, for example, it is suggested that research focus on those individuals who seem able to "resists the current smoking prevention curricula); and (3) research must focus not only on program development issues but also on how to achieve widespread diffusion. There are five factors to address in diffusion research: (1) how best to plan diffusion, (2) program packaging, (3) provider training, (4) implementation monitoring and corrective feedback, and (5) determination of costs, efficacy, and cost-effectiveness. Finally, it is unclear how generalizable the findings from adolescent smoking prevention are to the area of alcohol abuse and especially to the domain of alcohol-related problem behaviors. Some of the targets for behavior change with respect to alcohol (e.g., violence, -118

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drunk driving, vandalism) are very different from the targets for adolescent smoking. Research must focus on the commonalities and differences in conceptual models and the clustering (or lack thereof) of problem behaviors and substances of abuse. Another research question is whether drug abuse programs should focus on single or multiple drugs and which type of program is the more cost-effective. It is of interest that self-reported decreases in both marijuana and alcohol were reported in two separate studies on adolescent smoking prevention by the Stanford group, even though intervention was directed solely toward tobacco (McAlister Perry, and Macoby, 1979; Telch et al., 1982; Telch, Miller, and Killen, in press). Furthermore, a school project in Los Angeles, Project SMART, which used analogous peer resistance training on substance abuse, has also shown reductions in tobacco, marijuana, and alcohol use (Hansen et al., 1988~. . . . . A recent study by Altman and coworkers (Altman et al., 1989) has shown that a very low-cost mobilization of political action, volunteer community worker efforts, and the mass media succeeded in reducing retail outlets' illegal sales of cigarettes to minors. As in the seat belt example, the Altman results suggest that community-wide environmental change strategies could interact with education to increase overall effectiveness. An even larger volume of research has been conducted on smoking cessation, mostly in adults, and essentially all since the 1964 Surgeon General's Report on Smoking and Health. There is a surprising consensus on the use of group or classroom methods as successful approaches to smoking cessation (Glasgow, 1986), but less has been done in large-scale community efforts beyond those included as components of the Stanford studies and other CVD community prevention programs. In Flay's (1987) review of 40 smoking cessation programs designed for adults, he finds that mass media-only or media with print material campaigns were somewhat successful in changing knowledge and attitudes about smoking but that mass media combined with support groups produced significant changes in behavior and actually affected the quit rate of participants (Filly, 1987~. This conclusion lends credence to the argument that combined prevention strategies reinforce each other and suggests that a combination strategy should be adapted to other fields of health promotion, including alcohol problem prevention. Research on smoking cessation programs also demonstrates that program costs can be reduced by using methods other than the six class sessions that are usually offered (Altman et al., 1987~. A cost-effectiveness study of a community-wide smoking cessation program in the Stanford Five-City Project found that, although instructor-led classes produced the highest quit rate, this prevention strategy was three times as expensive as an intervention using a manual (a six-step approach to quitting) and about twice as expensive as a strategy using minimal personal contact (a smoking cessation contest). Preventing Adolescent Pregnancy Through School-Based Clinics Among the adolescent population in the United States, the problem of unplanned pregnancy has nearly reached epidemic proportions. Because teenage pregnancies result in long-term medical, economic, and social consequences for the teenage parents and their children, prevention programs have sought to bring about lower rates of unplanned pregnancies in this age group. Few of these prevention programs have been evaluated to determine whether teenagers who participate in prevention programs have a lower incidence of unplanned pregnancy. The most systematic of the available evaluations showed little -119

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change in knowledge and no change at all in attitudes or behaviors resulting from one such program (Scales and Kirby, 1981~. Some success has been reported in reducing teenage pregnancy through the use of school-based clinics (Zabin et al., 1986~. Zabin and colleagues argue, however, that it may be impossible to assess the full impact of school-based clinics on teenage pregnancy owing to the difficulty of following students over a period of several years after graduation, dropping out, or moving. They overcame this problem with a methodology that has potential application to alcohol problem prevention: another variable--the amount of time between first intercourse and first contraceptive use (i.e., the first clinic visit)--was used as a valid and feasible substitute for the real variable of interest, the incidence of pregnancy (Zabin et al., 1986~. This prox r variable was derived from the findings of an earlier study, which revealed that half of all initial teenage pregnancies occurred within the first six months of intercourse (Zabin, Kantner, and Zelnik, 1979~. Dr. Zabin and her colleagues are currently measuring this and other variables as part of their evaluation of two school-based clinics in Baltimore. In lieu of data on the incidence of pregnancy among teenagers, these researchers track the prosy variable; then, if the time between first intercourse and the first clinic visit decreases, they can conclude that the risk of an unplanned pregnancy has been effectively reduced. Developing valid measures based on epidemiological data is especially useful for programs that address early indicators of problem behaviors that have delayed consequences, as in the case of pregnancy. A similar method could be developed to measure the delayed consequences of drinking behavior. This development would promote epidemiological research into the antecedents of alcohol-related problems and would allow for the development of more innovative and revealing evaluations. SUMMARY OF LESSONS LEARNED FROM OTHER FIELDS From this examination of comprehensive, integrated, community-based programs in preventing cardiovascular disease and of certain more limited studies (potential components of comprehensive programs), eight lessons may be derived: 1. As previously stated, theories of change are an important part of any successful intervention. Theory should guide not only the development of the intervention and its evaluation but also the interpretation of the intervention's effects. Studies vary in their use of theory. In general, programs oriented toward changing the behavior of individuals by direct education are more theory driven than environmental change efforts or efforts to change organizations. This difference may reflect what has been only a recent initiation of scientific investigations on environmental change programs as solutions to health problems. 2. Establishing multiple outcome objectives and matching those outcome objectives to the level of intervention is important to increase our understanding of change. For example, few work site programs measure organizational change along with individual change. Yet most investigators agree that organizational characteristics determine much of the success of such interventions. In addition, comprehensive programs should create a hierarchical, ordered set of outcome objectives. For individuals, these objectives should include awareness, knowledge, and behavior change. For organizations, programs should seek evidence of commitment, adoption, policy change, regulatory change, environmental change, implementation, and maintenance of policies and programs. -120

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3. Extensive formative, process, and outcome evaluations are needed for the development of the program, for monitoring the implementation process, and for determining program effects over time. 4. Programs should attend to the special needs of the target population. Teen clinics illustrate the successful effects of making information and health resources accessible to young adolescents, of providing support for change at the place at which change is needed (i.e., norm changes within the school and community), and of actively providing resources to a particular target audience during a phase in personal development when only certain of outreach may succeed. 5. There is a potentially beneficial synergistic effect that may be achieved by combining approaches across different levels of intervention. In the case of seat belt use, combining legislation with education serves to inform the public of the benefits of use and the hazards of nonuse and to keep the issue on the public agenda. 6. Primary prevention strategies are particularly important for adolescents. Prevention strategies that include delaying the onset of a particular behavior, minimizing the use of harmful substances, or preventing entirely the initiation of a behavior are important components to any population-wide strategy for prevention. Attention to high-risk subsets of adolescents is particularly important in selecting prevention strategies. 7. The generalization of principles from previous efforts should be a carefully planned endeavor involving formative evaluation, pilot testing, behavioral analysis, and the critical review of research. Table 5-1 presents a matrix of studies conducted in various health fields that cover such components as work sites, schools, and regulatory change. Decisions on studies that may be analogous to alcohol-related problem prevention and on needed replications should stem from surveys of existing data to reveal any important gaps. Table 5-1 lists by author and year studies that are described in this chapter. A further breakdown of each study into the relative importance of different intervention strategies can also be done to identify additional research necessary. Moreover, a judgment as to the strength, validity, and cost-effectiveness of intervention strategies is needed to create a prospective master plan for research in the prevention of alcohol-related problems. Table 5-1 is therefore presented only as an example of an early step in displaying what has been accomplished to date. 8. Objective data should be collected to assess the specific impact of interventions on targeted behaviors. Issues of validity must be considered. IMPLICATIONS FOR ALCOHOL PROBLEM PREVENTION Each of the lessons derived from these varied prevention programs has challenging implications for the prevention of alcohol-related problems. The first, and perhaps most important, is that community-level prevention is possible. Beyond that, applying each lesson to alcohol problem prevention raises additional challenging questions: What theories have been used in alcohol problem prevention planning, and how thoroughly have they been tested? Is it possible to integrate a variety of seemingly unrelated prevention strategies into a single effective program to prevent alcohol-related problems? How can such social marketing techniques as audience needs analysis be used in prevention efforts? What role do these lessons play in designing alcohol-related policy changes? The techniques from a program designed to prevent one public health problem will never fit exactly the needs and goals of another prevention effort. Nonetheless, it would be -121

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imprudent to disregard the years of experience in CVD prevention and the lessons to be learned from the failures and successes of other community-level primary prevention programs. This discussion of the possible applications of these lessons to the prevention of alcohol-related problems Will begin with the use of theory as a basis for program planning. Behavior change theory has important implications for the prevention of alcohol-related problems at the level of the individual. For example, it can be used as a model to test the teaching of resistance skills to youth and the promotion of moderate, low-risk drinking among adults. If, as suggested by the theory, either abstinence or awareness of the problem is the first step in the change process, there is much more work to be done in educating the public about the scope and severity of alcohol problems before contemplating anv move to the next step of changing attitudes and behavior. --rig ~ A_ ~ Social marketing theory also offers practical guidance to alcohol problem prevention. Applying its principles requires an investigation into the orientation of ~consumers" of prevention efforts rather than merely focusing on the prevention strategy. To use this theory for preventing alcohol problems, one must begin by asking: How do such preventive behaviors as moderate drinking or such prevention "products" as special zoning ordinances for alcohol outlets meet the needs of the consumer? How does the repeal of prohibition laws affect the public's perception of prevention programs, and how can this Dercention be used to design effective education programs? - r----r Studies of the effects of legislation to promote positive health behaviors are especially relevant to the prevention of alcohol problems because many of these prevention strategies (e.g., legislating server responsibility, zoning ordinances) are based on policy change. Results from studies of mandatory seat belt use suggest that legislation can have some effect on health behaviors, but more study is needed before conclusions can be drawn about the effects of the policy changes that have been proposed for alcohol problem prevention. Nonetheless, the expectation is that the marginal impact of a single intervention will be compounded when used in concert with other interventions. Finally, prevention programs directed toward adolescents offer some interesting directions to programs that seek to reduce alcohol problems among youth. The use of resistance skills training in program design and employing epidemiological data to identify periods of intensified risk for adolescents (see Chapter 3) are two possible routes. In considering the evidence for success that has been obtained in areas other than alcohol-related problems, certain generalizations emerge about community-level approaches to prevention. It appears that life-style issues of cigarette smoking, diet, and physical activity can be influenced in both young and old through complementary change strategies directed at individuals, groups, organizations, and communities. The health habits that have been altered are all influenced by social norms, peers, and environmental and regulatory factors. Alcohol use shares many of the same predictors and precursors as the health habits that have been successfully changed by prevention programs in other health fields. Given the growing evidence of success in these other areas, it seems clear that the prevention of some alcohol-related problems can be achieved through the use of analogous methods. -123

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