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6 METHODOLOGICAL ISSUES IN ALCOHOL PREVENTION RESEARCH: CONCLUSIONS AND RECOMMENDATIONS No single set of research designs or analytical strategies has characterized research on the prevention of alcohol problems. A variety of approaches can be used depending on the goals of the research, the setting or opportunity afforded, the amount and type of variation one wishes to control or explain, and the generalizability of the findings. One of the difficulties in prevention research--particularly the kind of research that is most relevant to public policy deliberations--is the need to conduct such research outside the laboratory setting. ~Real-world" research, however, is difficult to undertake, often expensive to conduct, and difficult to analyze. It is less precise than laboratory work because researchers do not have the opportunity to manipulate variables as they would in laboratory experimentation. It also raises questions of ascertainment and of the validity of self-reports and other measures that are commonly used to assess the efficacy of a preventive intervention. On the other hand, because of the controlled or "hothouse" conditions used in laboratory settings, the extent to which prevention research undertaken in the laboratory can be generalized to the real world is not known. In recent years, alcohol prevention research has made use of a variety of qualitative and quantitative methods. For example, ethnographic methods and the observation of behavior in natural settings have been employed. Ethnographers gather data through semistructured interviews and through traditional participant-observer techniques. Examples of ethnographic/observational studies in prevention include studies of blue-collar workers and family drinking (Ames and Janes, 1987), of public drinking and drinking contexts (Rosenbluth, Nathan, and Lawson, 1978; Storm and Cutler, 1981; Harford et al., 1983; Single and Storm, 1985; Geller, Russ, and Altomari, 1986), and of the work site (Ames, 1987~. In many respects, the social and health problems that are associated with alcohol need to be viewed in a historical context. Historical analysis, by using both U.S. and international data sources, offers promising opportunities for prevention research. For example, it has been reported that between 1830 and 1850 there was a dramatic decline in per capita consumption in the United States (Rorabaugh, 1976) and that the temperance movement and government policies contributed to this decline and to a concomitant decrease in alcohol problems (Popham, 1978; Moore and Gerstein, 1981; Pendergast, 1987~. Historical analysis could provide a method to discover potential "lessons" that might be useful in the modern alcohol problem prevention arena. Community, school, and work site prevention trials have begun to reflect the use of combinations of several relevant theories (learning, organization, communication, behavior change, health education, and social marketing) in their design. Interest in such designs has been stimulated by the success in health promotion programs to reduce heart disease that are discussed in Chapter 5 (Farquhar et al., 1984; Puska et al., 1985~. These approaches have been used in studies of community interventions for alcohol problems at schools (see the review by Moskowitz, 1989), local availability of alcohol (Wittman and Hilton, 1987), and the influence of the mass media (Hewitt and Blane, 1984~. Because of the difficulty of random assignment in field studies, quasi-experimental designs have been used (Cook and Campbell, 1979~. These designs are often employed in the policy analysis -128

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of Naturals experiments, such as changes in alcohol availability. One useful statistical tool Is the interrupted time-series analysis (Box and Tiao, 1975; Box and Jenkins, 1976), which has more power than conventional least-squares regression to deal with problems of autoregression, seasonali~, and trending (Skim lo Wanennar 19~ Rln.ce ~nr1 Mn1~1f~.r 1987; Holder and Those, 1987a). O ~=, , ~-, _ _, ~^ ~,, Quasi~xperimental designs are also used to address problems related to nonequivalent control conditions or groups (Cook and Campbell, 1979~. These designs frequently employ multivariate analysis techniques to increase statistical power. Examples include evaluations of server intervention (Saltz, 1987), happy-hour bans (Smart and Adlaf, 1986), college prevention programs (Mills et al., 1983), cross-cultural drinking behavior (Moskowitz, 1989), alcohol taxes (Cook and Tauchen, 1982), and changes in driving-under-the-influence sanctions and enforcement in Maine (Hingson et al., 1987~. The multifaceted and dynamic nature of the social, cultural, and economic systems in which prevention occurs requires techniques that can deal with such complexity. One approach that has been used is computer modeling. This tool is used in astronomy, physics, and business and economic research and has particular utility for prevention research because it provides the ability to predict potential outcomes prior to expensive field implementation (Katzper, Ryback, and Hertzman, 1976; Holder and Those, 1987b). For example, complex statistical modeling has been used to examine the sensitivity of drinking and alcohol problems to changes in price levels. Examples include studies by Grossman, Coate, and Arluck (1987) and by Levy and Sheflin (1983~. RESEARCH DESIGN FOR FUTURE ALCOHOL PREVENTION RESEARCH PROGRAMS There are several primary issues relevant to the design of prevention research in the alcohol field. Three of these issues are discussed below: (1) the importance of using theory as a basis for design, (2) the need for both laboratory and field research, and (3) the practical as well as the statistical significance of research findings. The Importance of Theory A truly comprehensive theory for prevention research must encompass complex and dynamically changing biobehavioral mechanisms, individual and group behaviors, organizational influences, and cultural patterns. It is particularly important to incorporate the dimension of time into theoretical models in order to take account of life-span or developmental milestones. Theory is required to establish priorities, to develop and test hypotheses about mediating mechanisms, and to develop or select appropriate interventions, program evaluation, and intermediate and longer term outcome measures. When used for these purposes, theory can help prevention researchers identify the active ingredients in prevention programs and anticipate and account for intervention effects. Theory-driven programmatic research could then be undertaken by using combinations of methodologies including laboratory-based randomized trials, analogue studies, ethnographic and other naturalistic data collection methods, and complex model building. Such research can be undertaken within and between different levels of the social structure ranging from the individual to the community. -129

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In other public health efforts that have utilized community, school, or work site as the base in prevention trials, combinations of several relevant theories (learning, organizational, communication, behavior change, health education, media, social marketing) have been used to guide intervention and evaluation (Flay, 1984; Farquhar et al., 1985; Abrams et al., 1986~. This diversity in approach is illustrated by the Stanford, Minnesota, and Pawtucket heart disease prevention trials discussed in the preceding chapter (Maccoby et al., 1977; Blackburn et al., 1984; Lasater et al., 1984; Farquhar et al., 1985~. Crucial to developing effective and adequate strategies of prevention intervention is the use of formative research, program evaluation, process tracking, and assessment of program impact and potential problems. A varietr of research approaches can be used in which the design of programs results from an interactive process, combining theoretical and scientific input with practical input from the community and individual consumers. These approaches include ethnographic methods derived from anthropology, unobtrusive or naturalistic observation, the use of focus groups, random-digit rapid telephone surveys, and the use of small-scale randomized designs in the field or laboratory. ~ -' - -' O ouch eva~uauon methods are crucial for developing effective interventions, for making early or midcourse corrections in a program, and for evaluating whether, in fact, the manipulation of independent variables did occur at a sufficiently strong level (dosage) and with the intended impact on the target variables, mediating mechanisms, or processes. In community prevention programs, interactive and synergistic effects sometimes occur or are intentionally encouraged, making it necessary to consider the question of contamination and to measure impact in areas other than the direct intervention targets. For example, do single-focus, school-based smoking prevention programs actually reduce (or increase) alcohol and other drug use? Are multifocus programs more or less effective? Unlike traditional research in which one variable is manipulated whereas all other factors are controlled, the use of multiple criteria (including factors such as cost-effectiveness) may be more appropriate in program evaluation or prevention research (e.g., Warner and Luce, 1982; Altman et al., 1987~. In some cases, the spillover effects that result from such multifocused, synergistic processes as changing social norms and social network interactions in a school, work site, or other system are regarded as beneficial. They are viewed as an intentional part of the intervention and evaluation process rather than ~contamination." However, it is crucial to decide what is acceptable synergism and what is contamination, especially with respect to the unit of analysis, the questions being asked, and the comparison groups and settings being used. Need for Both Laboratory and Field Prevention Research The term laboratory research is used here to mean research conducted under conditions that permit the direct manipulation of the variables under investigation. Studies conducted within a controlled environment to allow the manipulation of variables have the advantage of providing better opportunities to assign subjects randomly to treatment and no-treatment conditions. Laboratory studies permit the examination of particular variables and the determination of whether specific experimental factors may play a role in a prevention program or policy. For example, the potential role of retail price in alcohol use can be demonstrated in a laboratory experiment that simulates an actual retail drinking situation in which the subjects' drinking is measured as the price of alcohol is manipulated. Such analogue studies can demonstrate (or fail to demonstrate) that retail price (or the economic accessibility of alcohol) affects drinking behavior. Such studies cannot tell, however, -130

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whether price is actually a significant variable in the natural setting, given the number of other factors at work. Prevention research also requires studies that are conducted in the field or in naturalistic environments in which physical manipulation of the situation may be difficult or impossible. Such studies can be more generalizable, but they lack the convenience or appropriateness of random assignment for controlling variance in extraneous factors; however, multivariate statistical tools are available as the means for control. Both laboratory and field studies are needed in prevention research because they have complementary strengths. In particular, the validity of conclusions is strengthened when consistency is demonstrated between the two approaches. In recent years, empirically minded social scientists have become increasingly concerned with the problem of inferring individual-level behavior from aggregate data (Lanbein and Lichtman, 1978~. (The term ecological fallacy has been used to describe an incorrect inference about individual behavior based on proud data.) By far the most obvious intervening variable in need of disaggregation is the consumption history of the drinker. Many authors who have written about the policy implications of economic variables have lamented the fact that current models have been unable to differentiate among alcohol-dependent persons, heavy drinkers, and moderate consumers. Although there has never been a systematic program of experimental research designed to investigate the interaction between environmental variables and alcohol consumption, a number of studies have been conducted to investigate the important policy questions raised by economic and epidemiological studies. For example, several studies have investigated the relative impact of economic variables on the behavior of alcohol abusers (Mello, 1968; Cohen et al., 1971; Bigelow and Liebson, 1972; Engle and Williams, 1972; Marlatt, Demming, and Reid, 1973~. The findings in these studies suggest that the strengths of both experimental and quasi-experimental research designs can be combined in complementary studies that move from laboratory analogues to more complicated natural settings. One question of interest in prevention research concerns whether persons with alcohol problems differ from persons without alcohol problems in their responsiveness to economic incentives for drinking or abstinence. Babor and colleagues (1978) demonstrated that heavy drinkers were as responsive as casual drinkers to the afternoon price manipulation known as the happy hour. Indeed, one of the most encouraging findings of the happy-hour studies was the extent to which the discount drink policy was associated with similar alterations in drinking behavior in both laboratory and natural settings (Babor et al., 1980~. Laboratory analogue research was also combined with naturalistic observation in the studies of Langenbucher and Nathan (1983~. Three experiments were used to test the ability of social dnnkers, bartenders, and police officers to estimate sobriety. This study has important implications for public policy regarding alcohol sale or use and the legal penalties for purveyors who knowingly or unknowingly serve alcohol to intoxicated persons. Naturalistic studies have the advantage of being heuristic, realistic, and relevant to important social problems when they include three important dimensions: natural behavior (e.g., drinking), natural settings (e.g., a tavern or bar), and natural treatment (e.g., price variations). -131

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The Practical Significance of Prevention Research In addition to the concern that no false conclusions be drawn from data, the prevention researcher must also consider the practical significance of any finding. A statistical change may be too small to justifier the operational costs of a prevention strategy. Alternatively, the level of statistical significance may be set so high by the researcher, or the variable selected for measurement may occur so infrequently, that a finding of practical significance is overlooked. In selecting a research design, the variables to be studied, and the statistical approach, researchers should be aware that prevention research must accommodate both substantive and statistical significance. DIRECTION AND DESIGN OF FUTURE ALCOHOL PREVENTION RESEARCH PROGRAMS: CONCLUSIONS AND RECOMMENDATIONS The conclusions discussed below constitute the committee's recommendations for future directions in research designed to reduce alcohol-related problems. Attempts should be made to integrate findings from biomedical research (e.g., biobehavioral vulnerability) with theories on individual, social, educational, and economic variables that influence alcohol use and abuse. Integrated models can then be used to guide the development of prevention interventions and the matching of at-risk subgroups with appropriate intervention strategies. It is important to ensure that theory drives the research, which can be achieved by borrowing theory-based analogues from studies in other health fields. Although such theories as social learning approaches have helped in understanding behavior change in individuals, there is little assurance that an adequate theoretical framework is available for the fields of community organization, regulatory and polipy-based interventions, environmental change strategies, and interventions that depend on changing the organizations themselves. Life-span considerations and developmental factors over time should be incorporated into comprehensive theories. If it can be anticipated that a specific interaction between individual characteristics (e.g., social skills deficits) and environmental/cultural demands (e.g., peer pressure to conform during early puberty) is likely to produce a large at-risk group, then such predictions can be used to plan both individual and community prevention programs. In this manner, findings from biological, psychological, and cultural areas can be used to plan prevention strategies for use during an earlier developmental phase so as to ~inoculate" a vulnerable population prior to exposure. Research should also be undertaken to shed light on the determinants of social norms regarding alcohol use. Such research should include creative methods to determine the effects of corporate policies, advertising, and the popular mass media on the nation's attitudes regarding the use of alcohol. Multidisciplinary collaboration in theory development should be encouraged from such diverse fields as the biomedical sciences, econometrics, education, psychology, sociology, clinical epidemiology, anthropology, and other relevant disciplines. The development of theories that examine the interaction.s amen ~ varinhles rl~.riv~1 from adherent levels or analysis or olllerent olsclpllnes should be particularly encouraged, especially if the theories can be used to guide the selection of intervention components and evaluation approaches. The use of new methodologies for formal theory development and model building should also be encouraged. Such methods as structural modeling and path-analytic procedures, computer simulation, and other multivariate approaches to causal . . ana yses appear promising. -132

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Program planning and implementation should be integrated with evaluation. The use of formative research, one of the main components of social marketing, should be increased to ensure success in pilot studies of untested components of programs. Researchers are often unable to obtain sufficient funding to implement programs they may want to evaluate, and program personnel often do not have the funds to support a full evaluation of their programs. The result is that major prevention programs are ~evaluated" after the fact and only in a descriptive or cursory manner. A mechanism needs to be found to facilitate a coherent demonstration evaluation plan whereby program and research designs are fully integrated. Until then, program evaluations, particularly at the community level, will remain piecemeal, inconsistent, and generally inadequate. (One of the great barriers to community prevention research is the enormous cost of collecting the data necessary for measuring whether an intervention has had an effect. NIAAA may want to consider ways to encourage local and county agencies to develop information management systems that can sense as existing data bases for measuring changes within the community. As local agencies begin to see the value of such data bases, they would undoubtedly expand their range to incorporate community and environmental variables that at first may seem remote to their needs. Ideally, such a system might include regular spot surveys of the alcohol-related concerns, knowledge, consumption, and problems of the community.) Community trials of prevention strategies should be instituted. One essential prevention research finding derived from heart disease and cancer prevention studies is the value of long-term community trials, such as those reported in Chapter 5. Such approaches have rarely been undertaken in efforts to prevent or reduce alcohol problems or to conduct alcohol problem prevention research. Tested research components should be combined into comprehensive, integrated, and reasonably long-term community-based projects to test the hypothesis that synergistic effects occur and that significant reductions in alcohol-related problems may be demonstrated. Effective community trials are long-term investments in the health and well-being of community members. They represent an opportunity to carefully monitor changes or the absence of change in targeted behaviors and situations. Prevention efforts to reduce alcohol problems have matured to a stage at which cost-effective longitudinal research projects could be undertaken. Such community prevention research trials will require (a) a long-term funding commitment for project development, implementation, and evaluation; (b) an effective partnership between prevention program specialists and prevention researchers; and (c) application of the latest research findings to identify behaviors and situations that can be effectively targeted for change. Prevention research should be used in policy development. The interests of researchers, prevention policymakers, and program planners are similar but not identical. Polipymakers and planners are interested not merely in understanding the general effects of a particular strategy or documenting its past impact but also in anticipating its future impact in a specific situation. Conventional research and evaluation studies do not by themselves Drovide the tvDes of "Drosnective" information that nolicvmakers require. ~ ~ or-- -- r---r~ ~~ ~~~~~ a---- ~~-~- ~~~- Although traditional research methods are often the most effective approach for examining a small number of variables in isolation from other factors, the policymaker must deal with the considerable Messiness" of detail contained in the real world. Tools are needed to assist policymakers and planners in making the best use of available resources, which would enable them to bring empirical and theoretical knowledge to bear on (a) understanding the complex network of factors that surround a set of alcohol problems and (b) estimating the likely impact of interventions in specific situations. Prevention research must develop the methods and techniques needed to assist prevention planners in estimating potential effects based on the best available research. One potentially valuable area of research is computer simulation, which permits perturbation (nwhat ifs) experiments to be undertaken to examine changes in a complex system. In such research, the computer is programmed to act like -133

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the system under study and changes are made to represent the analogous changes expected with a planned prevention policy or program. This type of computer-based experiment is intended to provide policymakers and researchers with data about likely or possible long-term results or outcomes of a set of potential prevention actions. Cost factors must be considered in prevention research. Much of prevention research is still in a formative stage and thus basic in nature. However, some areas of prevention research have developed beyond this stage to a point at which public policy and programs to prevent or reduce alcohol problems have already been based on such research. In these cases, both program costs and effects should be part of the evaluation; that is, what does it cost to undertake this program or policy given its effect in comparison with other strategies? As has been learned in other public health prevention efforts, cost/effect considerations aid in the selection of the best mix of programs and policies for reducing problems. All prevention approaches do not have similar costs or similar effects. To date, most prevention research has addressed contributory and risk factors and the potential effects of specific prevention strategies. Such research has not addressed the cost to implement or create programs based on research findings. Prevention research should include cost as a part of the outcome measures when such research has moved beyond the formative and developmental stages to a point at which programs can be based on this research. Together, these recommendations present an ambitious program for the coming years. Considerable financial resources and a commitment from researchers in the field will be required to realize the progress called for in this report. Yet the benefits to be gained from reductions in the human and economic tolls of alcohol-related problems will most certainly justify the needed investments of money and intellectual energy. REFERENCES Abrams, D. B., J. Elder, T. Lasater et al. A comprehensive framework for conceptualizing and planning organizational health promotion programs. In M. Cataldo and T. Coates, eds. Behavioral Medicine in Industry. New York: John Wiley and Sons, 1986. Altman, D., T. Flora, S. Fortmann et al. The cost effectiveness of three smoking cessation programs. Am. J. Public Health 77~2~:162-165, 1987. Ames, G. Environmental factors can create a drinking culture at worksite. Business and Health 5:44-45, 1987. Ames, G., and C. R. Janes. Heavy and problem drinking in an American blue collar population: Implications for prevention. Soc. Sci. Med. 25:949-960, 1987. Babor, T., J. Mendelson, I. Greenberg et al. Experimental analysis of the happy hour: Effects of purchase price on alcohol consumption. Psychopharmacology 58:35-41, 1978. Babor, T., J. Mendelson, I. Greenberg et al. Drinking patterns in experimental and barroom settings. J. Stud. Alcohol 41~7~:635-651, 1980. Bigelow, G., and I. Liebson. Cost factors controlling alcohol drinking. Psychol. Rec. 22:305-314, 1972. -134

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Blackburn, H., R. Luepker, F. Kline et al. The Minnesota Heart Health Program: A research and demonstration project in cardiovascular disease prevention. Pp. 1171-1178 in J. D. Matarazzo, N. E. Miller, S. M. Weiss et al., eds. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: John Wiley and Sons, 1984. Those, J. O., and H. Holder. Liquor-by-the-drink and alcohol-related traffic crashes: A natural experiment using time-series analysis. J. Stud. Alcohol 48:52-60, 1987. Box, G. E., and G. M. Jenkins. Time Series Analysis: Forecasting and Control. San Francisco: Holden-Day, 1976. Box, G. E., and G. C. Tiao. Intervention analysis with applications to economic and environmental problems. J. Am. Statist. Assoc. 70:70-79, 1975. Cohen, M., I. ~ Liebson, L. ~ Faillace et al. Alcoholism: Controlled drinking and incentives for abstinence. Psychol. Reports 28:575-580, 1971. Cook, P. J., and G. Tauchen. The effect of liquor taxes on heavy drinking. Bell J. Economics 13~2~:379-390, 1982. Cook, T. D., and D. T. Campbell. Quasi-Experimentation: Design and Analysis Issues for Field Settings. Boston: Houghton-Mifflin, 1979. Engle, K B., and T. K Williams. Effects of an ounce of vodka on alcoholics' desire for alcohol. Q. J. Stud. Alcohol 33:1099-1105, 1972. Farquhar, J., S. Fortmann, N. Maccoby et al. lathe Stanford Five City Project: An overview. Pp. 1154-1165 in J. D. Matarazzo, N. E. Miller, S. M. Weiss et al., eds. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: John Wiley and Sons, 1984. Farquhar, J., S. Fortmann, I. Flora et al. The Stanford Five City Project: Designs and methods. Am. J. Epidemiol. 122:323-343, 1985. Flay, B. R. What do we know about the social influences approach to smoking prevention? Review and recommendations. Pp. 67-112 in C. S. Bell and R. Battles, eds. Prevention Research: Deterring Drug Abuse Among Children and Adolescents. NIDA Research Monograph No. 63. USDHHS Publ. No. (A13M)85-1334. Rockville, MD: National Institute on Drug Abluse, 1984. Geller, E. S., N. W. Russ, and M. G. Altomari. Naturalistic observations of beer drinking among college students. J. Appl. Behav. Anal. 19:391-396, 1986. Grossman, M., D. Coate, and G. M. Arluck. Price sensitivity of alcoholic beverages in the United States: Youth alcohol consumption. Pp. 169-198 in H. D. Holder, ed. Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. Greenwich, CI: JAI Press, 1987. Harford, T., S. Feinhandler, J. O'Leary et al. Drinking in bars: An observational study of companion status and drinking behavior. Inter. J. Addict. 18:937-950, 1983. -135

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Hewitt, L. W., and H. T. Blane. Prevention through mass media communication. Pp. 281-323 in P. M. Miller and T. D. Nirenberg, eds. Prevention of Alcohol Abuse. New York: Plenum Press, 1984. Hingson, R., T. Heeren, D. Kovenock et al. Effects of Maine's 1981 and Massachusetts' 1982 D.U.I. legislation. Am. J. Public Health 77:593-597, 1987. Holder, H., and J. Those. Impact of changes in distilled spirits availability on apparent consumption: A time series analysis of liquor-by-the-glass. Br. J. Addict. 82:623-631, 1987a. Holder, H., and J. Those. The reduction of community alcohol problems: Computer simulation experiments in three counties. J. Stud. Alcohol 48~2~:124-135, 1987b. Katzper, M., R. Ryback, and M. Hertzman. Preliminary Aspects of Modeling and Simulation for Understanding Alcohol Utilization and the Effects of Regulatory Policies. Report submitted to the National Institute on Alcoholism, September 1976. Kellam, S., C. Brown, B. Rubin et al. Paths leading to teenage psychiatric symptoms and substance use: Developmental epidemiological studies in Woodlawn. Pp. 17-51 in S. Guze, F. Earls, and J. Barrett, eds. Childhood Psychopathology and Development. New York: Raven Press, 1983. Lanbein, L. J., and ~ J. Lichtman. Ecological Inference. London: Sage Publications, 1978. Langenbucher, J. W., and P. E. Nathan. Psychology, public policy and the evidence for alcohol intoxication. Am. Psychologist 383~10~:1070-1077, 1983. Lasater, T., D. Abrams, L. Artz et al. Lay volunteers of a community- based cardiovascular risk factor change program: The Pawtucket Experiment. Pp. 1171-1178 in J. D. Matarazzo, N. E. Miller, S. M. Weiss et al., eds. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: John Wiley and Sons, 1984. Levy, D., and N. Sheflin. New evidence on controlling alcohol through price. J. Stud. Alcohol 44:929-937, 1983. Maccoby, N., J. Farquhar, P. Wood et al. Reducing the risk of cardiovascular disease: Effects of a community-based campaign on knowledge and behavior. J. Community Health 23:100-114, 1977. Marlatt, G. A., B. Demming, and J. B. Reid. Loss of control drinking in alcoholics: An experimental analog. J. Abnormal Psychol. 81:223-241, 1973. Mello, N. K Some aspects of the behavioral pharmacology of alcohol. Pp. 787-809 in D. H. Efrow, ed. Psychopharmacology: A Review of Progress, 1957-1967. Public Health Se~vice Publ. No. 1836. Washington, DC: Government Printing Office, 1968. -136

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Mills, K, D. McCarty, J. Ward et al. A residence hall tavern as a collegiate alcohol abuse prevention activity. Addict. Behav. 8:105-108, 1983. Moore, M. H., and D. R. Gerstein. Alcohol and Public Polipy: Beyond the Shadow of Prohibition. Washington, DC: National Academy Press, 1981. Moskowitz, J. M. The primary prevention of alcohol problems: A critical review of the research literature. J. Stud. Alcohol, 50~1~:54-88, 1989. Pendergast, M. L. A history of alcohol problem prevention efforts in the United States. Pp. 25-52 in H. Holder, ed. Advances in Substance Abuse, vol. 1, Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. Greenwich, CI: JAl Press, 1987. Popham, R. The social history of the tavern. Pp. 225-302 in Y. Israel et al., eds. Research Advances in Alcohol and Ding Problems, vol. 4. New York: Plenum Press, 1978. Pu~ska, P., ~ Nissinen, J. Tuomilehto et al. The community-based strategy to prevent coronary heart disease: Conclusions from the ten years of the North Karelia Project. Ann. Rev. Public Health 6:147-193, 1985. Rorabaugh, W. Estimated U.S. alcoholic beverage consumption, 1790 - 1860. J. Stud. Alcohol 37:357-364, 1976. Rosenbluth, J., P. E. Nathan, and D. M. Lawson. Environmental influences on drinking by college students in a college pub: Behavioral observation in the natural setting environment. Addict. Behav. 3:117-121, 1978. Saltz, R. The role of bars and restaurants in preventing alcohol- impaired driving: An evaluation of server intervention. Evaluation and the Health Professions 10:5-27, 1987. Single, E.,-and T. Storm, eds. Public drinking and public policy. Proceedings of a Symposium on Observation Studies held at Banff, Alberta, Canada, April 26-28, 1984. Toronto: Addiction Research Foundation, 1985. Skog, O. Trends in alcohol consumption and violent deaths. Br. J. Addict. 81:365-379, 1986. Smart, R. G., and E. M. Adlaf. Banning happy hours: The impact on drinking and impaired-driving charges in Ontario, Canada. J. Stud. Alcohol, 46~3~:256-258, 1986. Storm, T., and R. Cutler. Observations of drinking in natural settings: Vancouver beer parlors and cocktail lounges. J. Stud. Alcohol 42:972-997, 1981. Wagenaar, ~ Preventing highway crashes by raising the legal minimum age for drinking: The Michigan experience six years later. J. Safety Res. 17:101-109, 1986. -137

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Warner, K E., and B. R. Luce. Cost Benefit and Cost Effectiveness Analysis in Health Care: Principles, Practice and Potential. Ann Arbor, MI: Health Administration Press, 1982. Wittman, F., and M. Hilton. Local regulation of alcohol availability: Uses of planning and zoning ordinances to regulate alcohol outlets in California cities. In H. Holder, ed. Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. Greenwich, CI': JAI Press, 1987. -138

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II RESEARCH OPPORTUNITIES IN THE TREATMENT OF ALCOHOL-RELATED PROBLEMS -139

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INTRODUCTION Within the framework of universal, selected, and indicated interventions noted in Chapter 1 of this report, treatment can be said to be an indicated intervention; its focus is on persons with already evident problems rather than on the preventions of problems in unaffected individuals. Given the heterogeneity of persons with alcohol problems-- and the wide range of such problems--reflected in the concept espoused by the committee of a continuum of severity, it should be no surprise to find that a variety of treatment methods and modalities have arisen in response. These numerous approaches testify to the vigorous interest of treatment providers and researchers and offer numerous opportunities for continued development and research on treatment efficacy and effectiveness. In response to its charge, the committee conducted an extensive review of recent treatment research with a view toward identifying promising avenues of inquiry for future studies. Chapters 7 though 14 summarize its findings, necessarily presenting illustrative as opposed to comprehensive considerations of the various topics. Chapter 7 describes the social and historical context of alcohol treatment research, noting the past extent of federal support as well as emerging trends in service delivery and demographics that may affect future funding and research interests. Chapter 8 deals with issues of assessment, methodology, and research design. It describes some of the notable achievements in treatment evaluation in recent years (e.g., conceptual advances, new measurement techniques) and discusses a number of the major unresolved research issues. Many of the available treatment approaches have not been systematically or rigorously evaluated. Nevertheless, Chapter 9 surveys outcome evaluation research since 1980 on several treatment modalities (e.g., pharmacotherapies, psychotherapy and counseling, mutual help groups) and also considers recent process evaluation research. Chapters 10 and 11 discuss research on two recent trends that appear to offer promise for impairing treatment outcome--namely, early identification of persons with alcohol problems and patient-treatment matching. Both of these areas hold promise for improving treatment outcome. Chapter 12 highlights selected findings from treatment studies of other psychoactive substance-use disorders that may be applicable to research on the treatment of alcohol problems; Chapter 13 discusses treatment of health consequences of heavy alcohol use or dependence; and Chapter 14 considers recent research on some of the public policy implications of alcohol treatment, particularly those related to costs and efficiency. In all of these chapters, the committee reviews research directions that have already been pursued and highlights potentially fruitful opportunities for further progress in identifying effective treatment approaches for alcohol problems. -140