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4 INDIVIDUAL-ENVIRONMENT INTERACTIONS: FOCUS ON THE ENVIRONMENT This chapter reviews research on a number of the environmental factors that influence the choices individuals make about their use of alcohol. (In its use of the term environment in this case, the committee refers to the drinking setting and the cultural and economic milieu surrounding alcohol use.) Environmental factors can affect many people at a time or only a few. This chapter considers those factors that affect broad populations (e.g., national legislation concerning minimum purchase age requirements, mass media influences), as well as factors that do not have as broad a reach (e.g., the influences of a local bar or restaurant). It will also discuss aspects of the workplace that influence alcohol consumption. Framing alcohol-related problems from an environmental perspective is part of the public health approach described in Chapter 1 that views behavior as a function of the interaction of individual and agent attributes with factors in the drinking environment. In the past, alcohol abuse and alcohol problems have often been blamed on the "weak wills or irresponsibility of the drinker. Demonstrating that conditions in the environment can affect and alter behavior allows for understanding another part of the behavioral equation relating to alcohol use. Selective modifications of these conditions represent promising approaches to research on the prevention of alcohol-related problems. ENVIRONMENTAL CONTROLS ON THE AVAILABILITY OF ALCOHOLIC BEVERAGES The focus of this section is on the mechanisms that influence the availability of alcoholic beverages. The factors considered here include physical availability (e.g., minimum age requirements, geographic density of alcohol outlets), as well as economic availability (the price of alcohol relative to income and other goods). Although availability and subsequent consumption of alcohol are affected by federal and state restrictions concerning the production and distribution of alcoholic beverages, most of these limits are no longer intended to prevent consumption. State statutes that established alcoholic beverage control (ABC) commissions after the repeal of Prohibition in this country were designed to prevent drunkenness and alcohol misuse. Today, however, state and local control of alcoholic beverages is intended rather to ensure that taxes are collected, that the marketplace is orderly, and that undesirable persons do not secure licenses for retail sales (Rice, 1984~. The study of alcohol availability and its relation to consumption has generally been approached in one of two ways. Researchers have looked at aggregate indices of alcohol availability (e.g., a combination of age restrictions, law enforcement, pricing structures, and other factors thought to be important) and their relationship to the full range of alcohol problems and consumption levels. Alternatively, researchers have studied such specific alcohol availability policies as an increase in the minimum purchase age as it relates to specific types of alcohol problems (e.g., auto crashes). -75

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Studies That Measure the Effect of Multiple Influences on Consumption Studies of aggregate influences and results frequently show positive associations between aggregate measures of alcohol availability and alcohol consumption. A combined cross-sectional and longitudinal analysis of the consumption of distilled spirits by Hoadley, Fuchs, and Holder (1984) showed that certain laws and restrictions do significantly hold down distilled spirits consumption. In another effort, Rush, Gliksman, and Brook (1986) conducted statistical analyses using linear structural relations applied to a set of county-level data from Ontario, Canada. They found a high positive association among the retail availability of alcohol, alcohol consumption, and alcohol-related morbidity and mortality. These investigators concluded from their analyses that government policies that restrict the availability of alcohol will reduce per capita consumption and indirectly lessen alcohol-related damage. Another set of studies, however (Popham, Schmidt, and DeLint, 1976; DeLuca, 1981), concluded that state ABC laws and regulations have little or no effect on reducing per capita consumption and alcohol-related problems. Watts and Rabow (1981) claim that interstate tourism, particularly for Nevada, Vermont, New Hampshire, and the District of Columbia, accounts for much of the association between availability and consumption. Their conclusion, however, was based on 1972 state consumption data and on results from a 1977 national survey--a period during which the minimum age for drinking was changed in 29 states. In a study published later, the same research team found positive links between availability and alcohol-related problems in California (Rabow and Watts, 1982~. In addition, Colon and colleagues (1981), while controlling for tourism and urban conditions, found a significant association between consumption and two types of composite measures of availability. Most of the studies noted above used state-level data. Yet it has been argued (Hooper, 1983) that the most appropriate unit of analysis for this type of research is the county because of differences by county in alcoholic beverage regulation. For example, Those and Holder (1987a) used an interrupted time-series analysis in a quasi-experimental design on alcohol-related crash data in North Carolina following the legalization of liquor by the drink (LBD). They found statistically significant increases in counties that permitted LBD and~no changes in matched comparison counties that did not legalize LED (Blose and Holder, 1987b). MacDonald and Whitehead (1983) conducted a literature review of U.S. and Canadian studies of the relationship between consumption and the frequency of outlets for alcoholic beverages. As a group, these studies, along with cross-cultural analyses from other countries (see DeLint, 1980; Makela et al., 1981; Single et al., 1981), have provided evidence that environmental restrictions can affect both consumption levels (which are linked to alcohol-related problems) and alcohol abuse. Room (1984, p.310), in reviewing studies from the United States and other countries, concluded, "The evidence is thus by now compelling that alcohol controls can affect the rates of alcohol-related problems, and that they often particularly affect the consumption patterns of high-risk drinkers." Other researchers have looked into the influence of such factors as statewide alcohol policy changes or the pricing structure of alcoholic beverages as they relate to the level of alcohol consumption. The committee has selected for review three such factors that have received serious study and attention: (1) alcohol prices and taxation, (2) minimum age of purchase, and (3) zoning and conditional-use permits. Certainly, there are other aspects of the drinking environment (e.g., hours of sale, number of outlets, rationing, strikes among -76

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brewery workers) that have been investigated and that may provide useful insights into the effects of environmental factors on alcohol-related problems. The committee chose to discuss research on the three topics below as illustrative of the work in this area and as offering particularly rich possibilities for further inquiry. Studies That Measure the Effects of Specific Factors upon Consumption Alcohol Prices and Taxation Research has confirmed that alcoholic beverage sales are sensitive to price and that a relationship ens Is between the price of alcoholic beverages, alcohol consumption, and alcohol-related problems. Alcohol pricing and taxation policy, therefore, is an important consideration in the development of an alcohol problem prevention strategy. Although researchers have not reached a consensus on the exact level of price sensitivity, they agree that alcoholic beverage consumption does respond to changes in price. Cook (1981), Cook and Tauchen (1982), Levy and Sheflin (1983), Ornstein and Hanssens (1983), and Hoadley, Fuchs, and Holder (1984) all confirm a relationship between price and total consumption in the United States. Room (1984) summarized studies in other countries with similar findings. The research of Cook (1981) and Cook and Tauchen (1982) has also shown a strong relationship between cirrhosis mortality (as a surrogate measure of heavy, chronic drinking) and the price of liquor. In addition. Cook (19811 found that increases in liquor taxes tended to reduce auto fatalities. Researchers differ in their estimates of the price sensitivity of alcoholic beverages. Furthermore, there are likely to be different sensitivity levels for alcoholic beverages by type of beverage and by age of the purchasers (Grossman, Coate, and Arluck, 1987; Saffer and Grossman, 1987a). Young people, for instance, may exhibit a unique alcohol consumption rate as a function of price because their relative inexperience as drinkers also means that they will have less rigid drinking habits (Levy and Sheflin, 1983; Coate and Grossman, 1986~. In addition, the marginal cost of alcohol relative to disposable income is greater for young people (Coate and Grossman, 1986~. Grossman, Coate, and Arluck (1987) determined the differential price sensitivity of consumption by young people 16-21 years old. They concluded that youthful consumption is sensitive to price changes in both beer and distilled spirits. They found that a 10-cent increase in the price of beer will result in a 14.8 percent decrease in the number of youthful heavy beer drinkers (defined as three to five drinks of beer per day) and that a 30-cent increase in distilled spirits would result in a 27.3 percent decline in the number of youthful heavy liquor drinkers (three to five drinks of liquor per day). Saffer and Grossman (1985) examined the association between beer prices and traffic fatalities among young people. Separate analyses were performed for young men and young women in three age groups (15-17, 18-20, and 21-24 years). Minimum purchase age, demographic variables, and driving exposure were controlled. Findings indicated that the states with higher beer prices had lower fatality rates for all of the age groups studied. Studies of the specific drinking environment have also been undertaken to determine what price-relevant factors in the immediate surroundings might contribute to alcohol-related problems. Babor and his colleagues (1980) found that happy-hour promotions increased consumption in laboratory and barroom settings, but Smart and Adlaf (1986), using aggregate-level data, were unable to detect changes in consumption with the elimination of happy hours in Ontario, Canada. In another study, Geller, Russ, and Altomari (1986) -77

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reported that the size of the serving was associated with overall consumption. Those who ordered cups (10 ounces), bottles (12 ounces), or pitchers (40 ounces) of beer drank an average of 10, 15.1, and 35.2 ounces per person, respectively. These differences do not reflect different rates of consumption, however: the pitcher drinkers stayed in the bar approximately three times longer than did the cup drinkers. Based on the results of price sensitivity research, Cook (1984b), Harris (1984), Levy and Sheflin (1983), Grossman, Coate, and Arluck (1987), Bruun and colleagues (1975), Saffer and Grossman (1987a), and Phelps (in press) have pointed out the polisher potential of increasing taxes to reduce or stabilize consumption and to reduce alcohol-related problems. Several observations may be made on this issue, based on current research: 1. Taxes are politically viable as a prevention policy if voters understand that increased prices can reduce alcohol misuse, particularly among the young (Levy and Sheflin, 1983; Mosher and Beauchamp, 1983~. 2. Price increases are not regressive because consumption has been shown to increase with income (Cook, 1981; Harris, 1984~. 3. Potential reductions in alcohol-related problems as a result of price increases are substantial, even if one allows for overestimates of the reductions in cirrhosis deaths (Cook, 1984a; Harris, 1984~. Minimum Age of Purchase For the majority of young people, drinking is initiated before they finish their first year of high school, at an average age of 13. By ages 14-15, about 85 percent have drunk alcohol at least once, and 65-70 percent of 14 to 15 year aids drink on at least a monthly basis (NIAAA, 1987~. The early age of onset of drinking and the frequency of alcohol use among young people lead to questions about the role alcohol plays in many social and medical problems that affect teenagers. Alcohol is involved in as many as 50 percent of teen suicides and plays a large role in car crashes, the number one killer of teenagers. There is also concern that the early use of alcohol can lead to later drinking problems and drug use. Historically, the minimum age of purchase has been used to reduce alcohol consumption by the young and to prevent alcohol-related problems, particularly accidents and injuries, involving young people. The effect of changes in the minimum purchase age on youthful drinking and traffic accidents has been extensively researched. Overall, evidence suggests that a higher minimum purchase age results in lower per capita consumption (Maisto and Rachal, 1980~. Longitudinal analyses of aggregate sales, of which young purchasers represent a small part, have shown that beer (and sometimes wine) sales are sensitive to changes in the minimum purchase age (Douglas and Freedman, 1977; Smart and Goodstadt, 1977; Wagenaar, 1983~. An exception to such findings occurred in Massachusetts, where the level of self-reported alcohol consumption by young people did not change following an increase in the minimum drinking age from 18 to 20 years (Hingson et al., 1983; Smith et al., 1984~. This exception might be explained by the under-or overreporting of drinking by the young respondents, a lack of compliance with the law, or a lack of enforcement. After the drinking age increase, -78

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teenage purchases of alcohol in liquor stores, bars, and restaurants in Massachusetts declined sharply, but the proportion of teens who had other people purchase alcohol for them almost doubled. In the case of alcohol-related traffic accidents, however, research findings support the conclusion that a higher minimum age of purchase can reduce the number of such accidents. The longest time-series analysis of a state increase in the minimum age was conducted by Wagenaar (1981, 1987) in Michigan. Michigan is a good state for such analyses because the greatest population concentrations are sufficiently far from state borders to reduce the "border effect" whereby underage youths cross to a state with lower minimum-age requirements to purchase alcohol. Wagenaar (19813 found an 18 percent reduction in alcohol-related crashes among young drivers in the first year following a change in the minimum age of purchase from 18 to 21. His follow-up analysis, which was carried out four years after the age change, showed a statistically significant 9 percent reduction over the total five-year period (Wagenaar, 1987~. These findings are consistent with those of Filkins and Flora (1981) in an independent analysis also conducted in Michigan. Other states show similar results. Maxwell (1981) found a statistically significant reduction in alcohol-related accidents in Illinois for 18-to 21-year-old drivers following an increase in the minimum purchase age to 21. These findings were confirmed by a nine-state analysis conducted by Williams and colleagues (1983), who also found decreases in the number of fatal crashes among young drivers following an increase in the minimum alcohol purchase age requirement. Massachusetts experienced the lowest reduction in fatal crashes following a one-year increase in the minimum purchase age from 18 to 20. No statistically significant changes in fatal crashes in Massachusetts were found by Hingson and coworkers (1983) for the entire 16-to 20-year-old age group and by the same research team (Smith et al., 1984) for the 16-to 17-year-old group. However, a statistically significant reduction in single-vehicle, nighttime fatalities was found in Massachusetts for 18 to 19 year olds over the three years following the increase in the minimum age requirement. These outcomes are consistent with the findings by Williams and colleagues (1983) that Massachusetts had the lowest reduction in fatalities of nine states that raised their minimum purchase age. Other states that appear to have a higher level of enforcement of the minimum purchase age laws and of compliance with the laws have recorded statistically significant reductions in alcohol-related crash involvement among the age groups most affected by the raised minimum ages. A recent study of 26 states by DuMouchel, Williams, and Zador (1987) found similar results. In an adjoining state, New York, which was used as a comparison state for the Massachusetts study by Hingson and coworkers (1983), a subsequent purchase age change from 18 to 19 yielded statistically significant changes in the auto accident rate. Lillis, Williams, and Williford (1987) reported nearly a 21 percent decrease in fatal and injury crashes and a 46 percent decrease in self-reported drinking and driving for New York young people following the age requirement change. A recent study conducted in Texas also showed that a one-year change in the minimum drinking age affected youthful crashes (Wagenaar and Maybee, 1986~. Taken as a group, such studies of individual states or clusters of states support the conclusion that a higher minimum purchase age requirement has the potential to reduce consumption by youth (particularly of beer, the beverage of choice of the young) and -79

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alcohol-related traffic accidents. The potential reduction, like the effects of most restrictions on alcohol availability, appears to be a function of compliance and enforcement. If compliance is poor as a result of the lack of diligence by retail establishments in checking identification or the lack of enforcement by ABC authorities and law enforcement officers, the decline in alcohol-related traffic accidents is reduced. Three national studies are worthy of note. An analysis by Cook and Tauchen (1982) found a 7 percent increase in the number of youths killed in automobile accidents that eras associated with a lowering of the drinking age from 21 to 18. A national comparison by the National Highway Traffic Safety Administration (1982) found that states with higher drinking-age requirements had lower rates of serious injuries. In a related study, Grossman, Coate, and Arluck (1987) conducted a national evaluation of the sensitivity of youthful consumption of specific alcoholic beverages to minimum-age changes. Based on their projections, they concluded that an increase in the minimum age for the purchase of beer from 20 to 21 would yield a 10 percent drop in the number of youths who drank beer, a 17 percent reduction in those drinking beer two to three times a week, and a 17 percent reduction in the number drinking as many as three to five glasses of beer on a typical drinking day (for a similar analysis, see Saffer and Grossman, 1987b). A report by the National Highway Traffic Safety Administration (Arnold, 1985) analyzed traffic crash data for drivers up to age 23 in 13 states that had raised their minimum purchase age between 1975 and 1982. The study compared annual figures for drivers in areas affected by minimum age changes who were involved in fatal crashes with those drivers who were involved in fatal crashes in areas not affected by the law change. Pooled data from all states revealed an average reduction of about 13 percent (with a range of 6-19 percent) in fatal accident involvement among the drivers affected by increased minimum-age requirements. Zoning and Conditional-Use Permits Recently, decision makers in some municipalities have considered employing local land-use zoning to directly limit the density of alcohol outlets. Another proposal has been to employ conditional-use permits to place specific restrictions on the hours of operation, decor, and perhaps serving practices of any business that plans to serve alcohol (see Wittman, 1986~. However, relatively little research has been conducted to date on the topics of zoning and conditional-use permits. Published research on alcohol zoning practices appears to be limited to a single survey of California cities reported by Wittman and Hilton (1987~. The survey's purpose was to describe current zoning practices. It found that approximately 41 percent of the cities did not regulate outlets, 29 percent required conditional-use permits for on-premises sales outlets, and 30 percent required conditional-use permits for both on-and off-premises sales; 26 percent of the cities had incorporated restrictions on alcohol outlets into the local zoning ordinance. It remains unclear what leads cities to adopt these restrictions, although larger urban areas are more likely than smaller areas to adopt zoning regulations of all types. Although a basic relationship between the overall indicators of alcohol availability and alcohol use and misuse has been demonstrated, research should be focused on the effects of specific changes in the forms and types of restriction on alcohol availability. -80

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The following are some promising opportunities for research on alcohol availability: The differential effects of retail price changes for alcohol should be examined in terms of their potential to affect heavy, high-risk drinking. Because age and gender are related to some high-risk consumption behavior, age- and gender-specific studies of price sensitivity for alcoholic beverages are needed to improve our understanding of the economic dimensions of alcohol use and misuse. Current economic models of variables do not differentiate among alcohol-dependent persons, heavy drinkers, and moderate consumers; also, the relative sensitivity of alcoholics and nonalcoholics to price changes is not well delineated. Elements of alcohol availability (e.g., happy hour price incentives) have economic and social dimensions that have not been studied. Further investigations in this area could provide direction for the formulation of policy concerning these sales strategies. The influence of location, density, and hours of sale of alcohol outlets, as well as the types of outlets that should be permitted and their proximity to major driving locations, is just now being investigated. This research may suggest additional prevention strategies that can be instituted at many different levels of government. Recently, localities have become more involved in the regulation of alcohol availability, a role previously dominated by the state alcoholic beverage control authority. As communities become more involved in preventing alcohol problems, new territory will be opened up for studies of the epidemiology of alcohol problems at the community level. An equally important topic for investigation in itself is the use of local community resources for the development of prevention initiatives. For instance, further research could answer questions about (a) the effectiveness of existing local controls on alcohol outlets for reducing alcohol-related problems; (b) the factors that stimulate action by communities to use their own local resources to prevent alcohol problems related to alcohol availability; and (c) the effect of using local proprietors to regulate alcohol availability. Studies such as these can help to develop knowledge about the potential effectiveness of local planning for alcohol availability and to support policy development. Major questions include the following: Should controls on the distribution of availability remain at the state level, where they have been since the repeal of Prohibition? Should the trend toward de facto allocation of responsibility for control on availability to local authorities continue? How is physical planning for alcohol availability related to other aspects of environmentally based prevention planning (e.g., prices, alcohol advertising, media portrayals of alcohol, age-related aspects of alcohol availability)? ENVIRONMENTAL INFLUENCES ON INDIVIDUAL DRINKING BEHAVIOR The environmental influences on an individual's drinking behavior are many and varied, reaching out to encompass a wide range of forces that may affect the development of alcohol problems. The committee discusses several of these influences in the following pages: the normative environment and the mass media, the legal environment, and the effects of drinking context and setting. -81

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The Normative Environment and the Mass Media The standards set by a community and communicated both explicitly and implicitly play a large role in shaping many different behaviors, including alcohol consumption. Appropriate alcohol-use behavior in one era may not be appropriate in another. Similarly, appropriate drinking behavior may change from setting to setting or from group to group. The normative environment can be rather complex, with one level of norms operating in a local area (e.g., a college campus or even a single dormitory) and a different, perhaps even competing set of norms accepted in the society at large. The media, especially television, play an increasingly substantive role in communicating information of all kinds to the public, and they are thought to play a significant part in shaping public perceptions and norms about alcohol use. Alcohol-related information is conveyed through at least three media modes: (1) public information campaigns that are designed to educate the public about alcohol (2) advertising by the alcohol industry and (3) fictional television and movie programming that depicts drinkers and drinking situations. The contribution that each is thought to play in shaping the environment in which we operate has been the object of a great deal of research. As one might expect, observations of the impact of commercial advertising and fictional media programming are necessarily different from planning and testing intentional media campaigns as a mode of preventive intervention. Public Information Campaigns In the 1970s, several efforts were made to educate the general public about the importance of moderate drinking. A three-year mass media demonstration project in California that promoted responsible drinking showed some increase in citizen awareness but no significant changes in attitudes or behavior (Wallack, 1983~. A review of 15 mass media campaigns conducted by Hewitt and Blane (1984) revealed that some campaigns were effective in changing some audience attributes, including knowledge, attitudes, or behavior. In later work, Wallack (1985, 1987) proposed that the mass media can be used as an intentional change agent to alter the social agenda, increase awareness and knowledge, stimulate public discussion, and provide a background of legitimacy for the problems that detract from the health of society. Conclusions from the California campaign and others are that public education may not be sufficient to change behavior, but it could be an important component of a larger prevention effort. There are, however, serious reservations about whether the potential of public education for changing behavior has been adequately tested, especially in the context of a comprehensive program that integrates environmental and regulatory changes with multichannel education. It is not likely that significant changes in attitudes, behavior, or both, will occur primarily through mass media campaigns (Farquhar, Maccoby, and Wood, 1985~. Rather, the evidence from cardiovascular disease prevention programs (Farquhar et al., 1977; Puska et al., 1981) suggests that change may be more likely to occur when a comprehensive campaign involves several change agents in addition to the mass media. At the same time, it is unlikely that a large-scale public health campaign directed at the general public can be successful without mass media involvement. Existing research indicates that the mass media may be most effective in inducing cognitive (as opposed to behavioral) changes and setting the public agenda about an issue. From reviews of health campaign research compiled in the late 1970s and the 1980s, the most reasonable goals of mass media campaigns in the health area appear to be to increase -82

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awareness, information levels, and the salience of specific issues. When the mass media focus on a topic, they create and reinforce public awareness about an issue and contribute to its salience. In addition, continuing emphasis on the issue is likely to increase the absolute level of its perceived importance. Unfortunately, when focus on an issue subsides, so does public attention. Health issues are brought to public attention in one of two ways: either through selection by the media or through a targeted health education campaign. These two approaches differ greatly because selection by the media is largely uncontrolled, whereas a health organization's efforts generally are purposeful, with specific, measurable goals. Health organizations often initiate efforts to make the public aware of, and informed about, health issues, and these efforts are designed to affect the media agenda. Agencies create films, public service announcements, news releases, photo and interview opportunities, television and radio programs, and so forth, sometimes to stimulate direct public response but more typically to trigger media response as well. Another goal of mass media campaigns is to provide information in the form of new knowledge, as well as knowledge to replace misinformation and correct myths. The goal is a better informed public, and research indicates that this is a reasonable expectation of a mass media campaign (although target groups are never as well informed as health agency administrators might wish). If public education campaigns are to be successful in reducing alcohol abuse, there is a need periodically to monitor the target populations, usually through surveys, to accomplish the following: assess areas of information and misinformation. (What do people know, and what do they think they know? What should they know that they do not know?; determine the public's awareness of alcohol abuse and alcohol problems; determine the salience of those problems to the public, both in terms of personal importance and in terms of perceived social importance; examine relevant beliefs and attitudes held by the public; and identify their alcohol-related behaviors. This assessment should precede any concerted health campaign because it provides background information for planning such efforts. It should also be the substance for the formative evaluation of media campaign efforts and strategies discussed below. To the extent that campaign themes and strategies are in a developmental phase, they should be pretested through formative research and modified in preparation and design as such evaluation suggests--not when it is too late to make changes. Another element that is critical in developing mass media health messages is to specifier the target audience. Specification allows research planners to assess more accurately the knowledge, awareness, salience, and orientation toward alcohol use and abuse that is characteristic of target subgroups. It also permits planners to use each group's message exposure habits to design more effective media campaigns. Formative research is a necessary tool to create campaign messages for media dissemination and should be carried out in two phases. In the first phase (preproduction), a target group is surveyed to determine members' cognitive knowledge and affective responses to alcohol, their motives for drinking, and their media usage patterns as a way to identify potential areas of "vulnerability" for change. The areas that are so identified are then examined by media, content, and persuasion experts to design messages. Formative research in message -83

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design involves informal testing from early tentative versions of a message to the one that Is ultimately used. Prototype messages emerging from this process can then be experimentally tested with sample target audience groups in the second (or postproduction) phase to determine whether the campaign's desired goals are being achieved. The results of these tests can serve as the basis for improving the messages. Summative or final evaluation research may follow in the waning days of the campaign or thereafter (Atkin and Freimuth, in press). Alternative modes of reaching target groups with media messages should also be devised and tested. For example, the radio is a particular favorite of teenagers and could be used for public service announcements directed toward them. In addition, drinking-and-driving messages would appear to be most appropriate if received by radio while driving. Field experiments in selected communities could assess the ability of radio to deliver such messages. Furthermore, there are specialized magazines for virtually all groups that can be appropriately used to deliver alcohol-related messages. Music, in any medium, is another strong influence for young people. The demonstrated attractiveness of some specialized cable channels, such as Music Television (M - , should be considered as a means to reach this group. Another major avenue for reaching adolescents is films. For teenagers, moviegoing is a major social experience, often followed by drinking opportunities and incidents. The movie theater is rich in possibilities for intervention: for example, it provides a forum for public service announcements (PSAs) before the movie begins, acts as a venue to mount antidrinking/driving posters, and offers the possibility of print messages on soda and popcorn containers. Another way of reaching adolescents (and others) with alcohol-use messages might be to approach videocassette producers and request the inclusion of PSA messages as trailers on rental or purchase tapes. A social inoculation approach (i.e., using media messages to ninoculaten individuals against persuasion efforts) has been shown to be effective, not only against persuasion (Lumsdaine and Janis, 1953; McGuire, 1973) but against the effects of counterpersuasive messages. This approach has recently been demonstrated to be effective against social temptation (Killer, 1985) in smoking prevention research. The identification of effective inoculations against some media messages could help to prevent young people from forming unhealthful and dangerous patterns of alcohol use (see the discussion under Commercial Alcohol Advertising" below). The following are opportunities for research on public information campaigns and education: The formative evaluation process is necessary to identify credible communicators for different groups. The "sources used to present alcohol-related messages to any particular target audience must be credible. It is as unlikely that there are universally credible sources for different audiences as it is that there is a universal antialcohol message. Questions that require answers include: When are women credible commentators on alcoholism prevention, as well as which women and for whom? Who is a hero to adolescents and, as a hero, an effective spokesperson? A wealth of literature exists on source credibility, little of which is linked to specific content areas. Especially for such contemporary issues as driving after drinking or after using drugs, it may be particularly difficult to predict credible sources accurately. In these cases, pretesting is essential. Preproduction research on media campaigns should identify which media are accessible and are used by particular target groups, how often they are used, and when. For example, -84

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if a substantial subset of problem drinkers or individuals consists of late-night television fans, that characteristic suggests a time and medium in which to reach them with media messages. The coverage of alcohol issues in local newspapers and television programs should be sampled. Commercial Alcohol Advertising The majority of the information on alcohol use is presented by the alcoholic beverage industry. About $1 billion is spent annually on alcohol advertising, an amount that greatly exceeds the public education budgets both of federal and state governments and of nonprofit agencies. The messages that are common in alcohol advertising promote drinking as a healthy, attractive, and success-oriented activity (Minkler, Wallack, and Madden, 1987~. However, research on the effects of that advertising is conflicting. Smart (1988, p.321) reports that "injo study (with one exception) has concluded that alcohol advertising has a substantial effect on alcohol consumption.... Current research suggests that advertising is, at best, a weak variable affecting alcohol consumption." Strickland (1983, p.221) concurs, concluding that televised advertising has "meager effects on the level of consumption" by adolescents in school. According to him, television advertising to promote alcohol use is "rarely translated into effects on alcohol problems. In a notable exception to these studies, Atkin and Bloch (1981) and Atkin, Hocking, and Bloch (1984) concluded that schoolchildren who have seen more television and magazine ads for alcohol generally drink more than those who have seen fewer ads; in addition, among those who do not yet drink, those who have seen more ads report that they are more likely to begin. In his most recent review, Atkin (1988b, p.ii) found the following: Despite ambiguities about causal direction, the findings indicate that televised beer ads mildly increase beer drinking, magazine liquor ads have a modest positive influence on consumption of spirits, and that the impact of traditional wine advertising is weak. In reference to the several dozen studies he critiqued in the article, Atkin (1988b, p.iii) concluded, Although each technique and most specific executions can be attacked, rendering conclusions suggestive and tentative, the preponderance of the evidence from the alcohol advertising literature indicates that ads stimulate higher consumption by both adults and adolescents. . There is sufficient basis for rejecting the inference of null effects and for rejecting claims that advertising exerts a powerful influence on drinking behavior. It appears that advertising is a contributing factor that increases consumption to a modest extent. Other researchers agree that advertising may be a contributing factor to increased alcohol use. Farrell (1985, p.27) notes that advertising is "only one element of a complex mix of marketing techniques. . .whose combined impact may well be substantially greater. She also points out that there are no studies that explore the cumulative, long-term effects of advertising on alcohol consumption and alcohol-related problems over the course of a generation, no studies of the impact of a sharp reduction in advertising where it has been pervasive, and no research on the impact of a sharp increase in advertising in cases in which it has been largely unknown (e.g., Third World countries). -85

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