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Prevention and Treatment of Alcohol Problems: Research Opportunities (1990)

Chapter: 4 Individual-Environment Interactions: Focus on the Environment

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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"4 Individual-Environment Interactions: Focus on the Environment." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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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

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

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

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

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

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

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

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

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

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

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

Other sections of this report emphasize the importance of a comprehensive or community-wide approach to combating alcohol problems. In that same vein, the most effective use of mass media may be as part of a multimedia effort. The single insertion of a single advertisement is unlikely to produce change in the level of alcohol-related problems or to increase awareness, salience, or knowledge. The proponents of alcohol consumption use all of the mass media; so, too, must the proponents of alcohol problem prevention. For example, in advertising, there is a need to identity the type and style of advertising content (e.g., life-style appeals versus consumer information, brand imaging) that has the most impact on alcohol consumers. Identification could be followed by theoretically grounded experimental research to determine how inoculating messages might diminish the acceptance and impact of advertising content. Contrary themes could be examined as a potential message strategy. If one theme of commercial alcohol ads is the social benefits of drinking, it is important to determine how alternative messages (e.g., public service advertisements that identify the social deficits of drinking) might be used to counteract the commercial ads. (For a recent review of the research on using alcohol-related advertising as an intentional change agent, see Atkin, 1988a; see also Alcalay, 1983; Hewitt and Blane, 1984; and Wallack, 1985.) The following are opportunities for research on the effects of commercial advertising on alcohol use: · Given the association between teenage drinking and driving, targeted examinations are needed to assess the impact of alcohol advertising on those young people currently approaching legal drinking ages, in terms of exposure to advertising and its impact on brand recognition, preference, interest in drinking, and expectations as to the social merits (and demerits, if any) of drinking. Other targeted groups might include light drinkers, women, and ethnic minorities. · As suggested earlier in the text, studies should explore the cumulative, long-term effects of advertising on alcohol consumption, the impact of a reduction in pervasive advertising, and the impact of increased advertising in situations in which it has not previously been used. There is also a need to test the impact of advertising within a specific program context. For example, a study of the short-term effects of beer advertising during a popular sports event covered by the media may provide useful insights. Fictional Media Content The focus in this discussion is on the depiction of drinking and drinkers in fictional television programming. Often, the rationale for these studies comes from social learning theory (see Chapter 3), which predicts that learning and behavior change may occur by obseIving new kinds of behavior (e.g., watching an individual refuse an alcoholic drink and subsequently being rewarded for doing so, seeing attractive persons become ill with drink). In this instance the media can be seen as an object of study rather than as an intentional change agent. Content analysis clearly demonstrates the prevalence of alcohol on commercial television programs. In 1976-1977, there were 2.2 incidents of alcohol use per hour during prime time and Saturday morning programs (Greenberg et al., 1978~; there were 2.7 incidents per hour the following season (Greenberg et al., 1979) and 8.13 incidents per hour in the -86

10 top-rated prime time shows after the next season (Greenberg, 1981~. Similar levels have been identified in afternoon soap operas. No studies have been conducted, however, that directly link the quantity of these portrayals to consumption or attitudes. It has been suggested by Atkin (1988b) that a group that is particularly vulnerable to such program content would be young adolescents because (1) they watch as much or more television than any other age group; (2) they have limited direct experience with alcohol; and (3) whereas other influential agents such as parents are likely to be uniformly discouraging of alcohol experimentation, the primary message in the TV programs and advertising content they will read, see, or hear is one of positive social consequences. ~ ~ . ~ ~ ~ ~ Preteens may oe another vulnerable group. In a study by Rychtarik and coworkers (1983), preteens who were exposed to a situation comedy that included multiple drinking scenes were more likely to offer whiskey drinks to potential adult guests than were preteens who did not see the program. Because media messages may act as formative influences and change agents, content analysis should be used to monitor the portrayal of alcohol use in television programs and films that are most heavily viewed by target groups of interest (e.£., in soap operas, if the target . , _ _ , ~ _ . . , , _ . . . . . . . . . group is adolescent females and nonworking women; in situation comedies featuring minority characters, if the target group is minority). Follow-up research should explore the impact of these alcohol portrayals on their audience, within specified target groups. In addition, what the national media present to the public about alcohol as news should be regularly monitored and supplemented by a sampling of local coverage in newspapers and on television in communities throughout the country. News media personnel responsible for science writing at the wire services, major newspapers, and television networks should be identified and surveyed about their knowledge of attitudes about alcohol. The Legal Environment Alcohol-Impaired Driving Between 1980 and 1985, the United States experienced an unprecedented emergence of public concern about the problems posed by drunk drivers. More than 400 chapters of local citizens groups such as Mothers Against Drunk Driving (MADD) and Students Against Drunk Driving (SADD) were formed. News media coverage of drunk driving, as measured in numbers of stories, increased 50-foId from 1980 to 1984. A national commission was formed to examine the problem, and more than 500 laws were passed aimed at reducing drunk driving. All of the states now have legal drinking ages of 21. More than 40 states have now adopted laws making it illegal Per se" to drive with a blood alcohol level above 0.10-- the equivalent of four to five drinks for a 150-pound person in an hour on an empty stomach. In addition, half of the states adopted "administrative per set laws that permit states to hold the licenses of arrested drivers until their court trials. Many other states have recently adopted stiffer penalties for drunk driving, including increased automatic fines, license suspensions, and jail sentences. These activities have had a profound influence on drinking-and-driving behavior in this country. Serious limitations remain, however, which hamper efforts to evaluate the changes that have occurred. -87

First, most states do not obtain blood alcohol information on all drivers who are involved in fatal crashes. Accordingly, when a new drunk-driving law is enacted, researchers cannot determine whether there is a change in the number of crashes involving intoxicated drivers as a proportion of all crashes. Because the key dependent variable (blood alcohol level) cannot be precisely observed, researchers have used surrogate measures to study the impact of drunk-driving legislation. However, some researchers have cautioned that such surrogate measures are so imprecise that their use can, on occasion, lead to incorrect conclusions, particularly in short-term studies of small jurisdictions (e.g., Heeran et al., 1985~. A second constraint that prevents researchers from measuring the effectiveness of drunk-driving laws results from the kind of individuals who drive after heavy drinking. They are less likely to wear seat belts, are more likely to drive after using psychoactive drugs, and are more likely to have been arrested for speeding, running red lights, and other moving violations (Hingson and Howland, 1987~. Consequently, it may be possible to reduce drunk driving and still not reduce the number of fatal crashes because persons who reduce the amount they drink before driving may still be at high risk for vehicular · . Injury. Finally, changes in drinking-and-driving laws usually do not occur in isolation. When several related laws are enacted within a short period of time, it is difficult to attribute any effects that might occur to a specific intervention. Numerous confounding variables can influence alcohol-related vehicular crash rates. Such variables as unemployment rates, use of seat belts, and rates of speeding are seldom, if ever, controlled analytically in research evaluating drunk-driving interventions. Previous research also shows that the impact of drunk-driving laws can vary widely among jurisdictions. Thus, findings from one region cannot be generalized to another. Nonetheless, from 1980 to 1985, when media attention, community organization, and legislative activity peaked nationwide, fatal crashes declined 13 percent from 45,284 to 39,168. Single-vehicle, nighttime fatal crashes--the kind most likely to involve alcohol- declined even more, down 20 percent from 18,277 to 14,603. Among teenage drivers, declines were even steeper: single-vehicle, nighttime fatal crashes declined 34 percent, with 2,497 fewer in 1985 than in 1980 (Hingson, Howland, and Levenson, 1988; Hingson et al., 1988~. These dramatic reductions occurred for many reasons. First, the laws themselves produced positive beneficial effects. As noted earlier, studies of drinking age increases revealed that, although effects were variable from state to state, states that raised their drinking ages typically achieved 10 to 15 percent declines in night-time fatal crashes in targeted age groups relative to states that did not (Hingson et al., 1983; Williams et al., 1983; DuMouchel, Williams, and Zador, 1987; U.S. General Accounting Office, 1987~. An analysis of national traffic data from the period 1978-1985 by the Insurance Institute for Highway Safety (Zador et al., 1988) indicated that states that passed administrative per se laws reduced nighttime fatal crashes on the average of 9 percent relative to states that did not pass such legislation. In addition, states that passed criminal per se laws or imposed increased penalties for drunk driving achieved 6 percent declines in nighttime fatal crashes relative to states that did not pass such laws. Most states have criminal per se laws, but only a few have administrative per se laws; the institute estimated that if all states passed such laws, 2,600 fatal crashes could be avoided annually (Zador et al., 1988~. Police enforcement of drunk-driving laws and court conviction rates have also increased in numerous states, developments that may produce further reductions because -88

quasi-experimental community studies have shown that increased drunk-driving enforcement by police is associated with crash declines (Lacey et al., 1986; Voas, Rhodenizer, and Lyon, 1986; Voas and Hause, 1987~. An additional finding of interest regarding this topic is that the extensive use of random breath testing in two states of Australia has been shown to substantially reduce alcohol-involved crashes and fatalities (Homer, 1988a,b). Perhaps equally as important as these formal, legal counter-measures during the early 1980s was the emergence of informal social pressure that discouraged drunk driving. Media attention and political lobbying often preceded new laws. Annual surveys conducted in Massachusetts from 1981 to 1985 revealed that the proportion of drivers who said they would not care at all if their best friends found out that they had been arrested for drunk driving declined from 25 to 12 percent (Hingson et al., 1987~. During the same time, the proportion of drivers who reported driving after five or more drinks during the past month also declined, from 18 to 6 percent. Massachusetts' experience in fatal crash declines was comparable to the national trends. Reported drunk-driving and nighttime fatal crash trends began to decline in Massachusetts and in many other states even before major legal changes occurred. Thus, the informal social pressures that stimulated passage of drunk-driving laws may also have produced drunk-driving reductions. Despite the progress that has been achieved in the United States, however, experience in Great Britain and several other countries indicates that fatal crash declines after the passage of drunk-driving laws may be only temporary if public discussion of the problem diminishes and people become aware that the chances of being caught by the police are really quite low (Ross, 1982~. This situation could well occur in the United States. The number of new citizens groups concerned with drunk driving peaked in 1983 (McCarthy, Wolson, and Baker, 1988~. News and magazine stories about drunk driving declined sharply after 1984 (Hingson, Howland, and Levenson, 1988~. After several years of decline, single-vehicle, nighttime fatal crashes rose 7 percent in 1986; other fatal crashes rose only 3 percent. Parallel estimates of the U.S. DeDartment of Transportation showed an overall , . ~ Increase In alconol-related fatalities of 6 percent and an increase in such fatalities among teenage drivers of 14 percent in 1986 relative to 1985 (U.S. Department of Transportation, 1988~. Compared with 1986, data from 1987 indicate slightly fewer single-vehicle, nighttime fatal crashes among all ages and among teenage drivers; nevertheless, the overall total is still 5 percent higher than in 1985, and the teenage total is still 9 percent higher than in 1985. Police enforcement of drunk-driving laws may not be sufficient to sustain long-term general deterrence effects of the laws. In a recent study comparing the effects of Maine's 1981 operating-under-the-influence (OUI) law with the 1982 Massachusetts drunk-driving law, only one-quarter of the drivers queried in the surveys in both states believed it likely that drunk drivers would be stopped by police, even though a majority thought arrested drunk drivers would be convicted and receive automatic penalties (both laws had instituted tougher penalties). Their perceptions appear to have had some validity: in Massachusetts in the postlaw period, despite increased police arrests for drunk driving, only one arrest, compared with 2.5 crashes, occurred per 1,000 drunk-driving trips reported by survey respondents (Hingson et al., 1987~. Maine's arrest rate was only slightly higher and declined during the third postlaw year. The study also showed that nighttime fatal crashes in Maine, which had declined 33 percent in the first postlaw year, returned to prelaw levels by the third postlaw year. During the same period, state police speeding arrests also declined by one-third, and the proportion of drivers traveling over 65 miles per hour on five roads posted at 55 miles per hour -89

increased markedly (Hingson et al., 1987~. Thirty-eight states raised speed limits on rural interstate highways in 1987. Speeding in general and the return to higher speeds on the highways are an emerging concern; because of poor sensory motor coordination and reaction time, drunk drivers may be particularly vulnerable to crashes at high speeds. The following are opportunities for research on alcohol-impaired driving: · The combined effect on actual behavior of social and legal pressures against drinking and driving and the influence of media attention on drinking-and-driving issues should be investigated further. Together, these influences are thought to exert considerable environmental controls on behavior. · Theoretically, more disposable income is available for alcohol and gasoline purchases in times of strong economic conditions. It would be useful to conduct a study that controls for economic conditions to isolate their effects on automobile crashes. · Further research is needed to identify the causes of the marked declines in fatal crashes in the early 1980s. We also need to assess whether recent increases in the number of fatal crashes will be temporary or whether other legal interventions, education, or enforcement efforts may be able to sustain long-term declines in the number of fatal crashes. · The effects of speed limit increases on drunk-driving deaths, new legislation to reduce the blood alcohol levels that are considered to constitute legal intoxication, and the states' adoption of administrative per se laws are all areas for fruitful research. Other topics of interest include the interactive effect of vehicle speed with alcohol use in traffic crashes and the physical characteristics of drinking environments or settings that enhance safer drinking decisions or, alternatively, promote high-risk drinking. Dram Shop or Server Liability Server liability refers to the legal responsibility of someone who serves alcohol (usually for profit in a retail establishment). Server liability includes civil responsibility for damage and injury caused by a patron who is served while obviously intoxicated and later causes damage or injury to him- or herself or to others (e.g., in an auto accident). The term also encompasses criminal liability for service to an underage person. Before and after Prohibition, server liability laws (also called dram shop laws) were often enacted as an element of public prevention policy; most recently, such statutes have been used as the basis for individual litigation to obtain damages. During the past several years, Mosher (1984a,b) and others have called for the use of server liability as part of a comprehensive approach to prevention called server intervention. According to Mosher, server intervention has three components: (1) legal, (2) training, and (3) environment. The legal component is discussed below; server training and the serving environment are discussed later under "Server Intervention. The legal component of the server intervention approach includes state and local ABC statutes and regulations, criminal statutes, and dram shop liability. The dram shop liability element in particular has been explored by Mosher, who developed the Model Alcoholic Beverage Retail Licensee Liability Act of 1985 (Mosher, 1985~. In its full form, this approach is designed to be incorporated into existing state-ABC statutes and emphasizes the preventive potential of the legal approach. The statute would provide both deterrents and incentives. Dram shop liability could be considered the "stick," that is, the threat of financial (and possibly criminal) liability of the server or retail establishment that makes -90

alcohol available either illegally or irresponsibly. The ~carrot," or reward, would be the availability of the statute as a defense by a licensed beverage outlet that engages in responsible serving practices and can prove that it did so on a specific occasion. The preventive approach embodied in the statute would also reduce liability insurance premiums. A parallel issue that warrants additional research is social host liability. As noted earlier in this chapter, many teenagers under the legal age of purchase obtain alcohol by having persons over the legal age purchase it for them (Hingson et al., 1983~. Whether such persons should be held liable for the actions of those teenagers while under the influence of the liquor purchased for them is being debated. The effects of such liability on behavior should be explored. Context and Setting as Environmental Influences Drinking contexts and settings are studied by researchers in the alcohol field to determine how drinking behavior varies across different situations and to investigate whether certain strategies can be applied to different situations to reduce alcohol-related problems. One such strategy is server intervention training, which is discussed below. The context or setting in which drinking occurs may also influence alcohol consumption. Context includes such elements as the time of day, the occasion, and drinking companions. A setting is generally characterized by place (e.g., workplace, home, school) or by elements in the physical environment (e.g., lighting, size of tables). Server Intervention The most recent research to examine drinking settings arises from an interest in server intervention as a prevention strategy. The goal of server intervention is to reduce a customer's likelihood of intoxication or of driving while intoxicated through a combination of revised management and serving practices, server training, and changes in the physical environment. One of the first evaluations of server intervention (to determine its impact on customer consumption) was reported by Saltz (1987), who studied a Navy enlisted persons' club that had implemented a comprehensive server intervention program. The program itself involved extensive consultation with the club manager, which produced several changes in club policies and practices and an 18-hour training course for all staff. The policy changes included promoting nonalcoholic beverages and food, overtly delaying service of an alcoholic beverage if it would put the patron at or above the legal limit for intoxication, and the discontinuance of beer sales in pitchers. Where before, food service had been separated from the bar area, a food service station was now installed in the barroom, and money incentives were provided to senders and cooks to promote food sales. In addition, servers had been free to roam anywhere in the building to serve customers; under the new program, servers were assigned to specific sections of optimal size to monitor customers' consumption. The food and beverage menus were expanded, and drink prices were marginally raised to cover the program's costs. For two months before and after the program was in place, randomly selected customers were interviewed on Thursday, Friday, and Saturday evenings at both the study site and a -91

comparable Navy club at which no program was implemented. Data from the interviews were used to estimate customer consumption and blood alcohol concentration (BAC). Results showed that the program led to a 50 percent drop in the likelihood of intoxication. Although the Saltz study included changes in both bar practices and server training, other evaluations have been conducted on server training alone. Russ and Geller (1987) employed research assistants who posed as patrons who attempted to drink beyond the limits of intoxication at two bars at which approximately half of the staff had been trained. By recording the frequency and type of interventions used by the servers, they were able to show that the trained servers intervened in some way significantly more often than did untrained servers. Furthermore, when the pseudopatron's BAC was measured after leaving the bar, those who had been served by trained servers had lower BAC:s than those who had been served by the untrained personnel. Another evaluation of server training is currently being prepared for the National Highway Traffic Safety Administration (NHTSA) by James A. McKnight. This study also employs pseudopatrons who in this case affect intoxication to see if servers who have been trained are less likely to serge them alcoholic beverages. The results from this study are not yet available. Server intervention and server training studies suggest that environments can influence consumption and that these environments can be altered to lower the risk of alcohol-related problem outcomes. At the current stage of development of this strategy, however, the serving policies or training topics are most effective in bringing about these changes cannot yet be identified. Drinking Establishments The bar and restaurant are public settings in which alcohol typically makes up a large portion of the total revenue earned by the establishment. There are several good observational studies of bars and restaurants that examine the influence of the drinking group and its impact on consumption. Several researchers have found that the size of drinking groups is correlated with the duration of drinking and thus with the total amount of alcohol consumed. although not C7 ' ~ .. . . , . , ~ . , _ ~ _ . _ . ~ _ ~ ~ ~ ~ . necessarily with the rate of consumption (Somer, 1965; Foy and Simon, 1978; Rosenbluth, Nathan, and Lawson, 1978; Graves et al., 1981; Storm and Cutler, 1981; Harford et al., 1983; Geller, Russ, and Altomari, 1986~. An additional influence on the drinking done by members of the group has to do with social modeling: it appears that faster drinking companions have more influence over the group than do slower drinkers (Caudill and Marlatt, 1975; DeRicco and Garlington, 1977; DeRicco, 1978; Reid, 1978; Skog, 1979; DeRicco and Niemann, 1980~. Other studies have suggested that bars with entertainment (e.g., live music, dancing, television, games) prolong the duration of a customer's stay and presumably increase overall consumption fBach and Schaeffer 1979 Ratcliffe et al 19801 however. no one has directly -a of ~ r------o ---- ----------- -- -- ----------- - ----J ~ A-- -----A 7 7 ,, 7 observed whether individuals who actually engage in those activities are likely to drink more. Naturalistic studies of drinking contexts are a helpful tool for framing research questions and generating research hypotheses. Unfortunately, they cannot tell us about causal influences on consumption and intoxication or about adverse consequences. By their -92

nature, most observational studies have been unable to assess the interaction between characteristics of the individual and facets of the drinking environment. Indeed, to date, most experimental research in drinking behavior has focused on interpersonal influences rather than contextual ones (for a discussion of the need to integrate these influences, see Harford, 1979~. The following are opportunities for research on the drinking context: · The contribution of the context of drinking to the development or inhibition of alcohol-related problems is a major factor that is not yet fully documented or understood. For example, we know that a majority of driving-while-intoxicated (DWI) offenders do most of their drinking in on-premises alcohol outlets (see the review by O'Donnell, 1985), but we do not know if this is a personal preference only of high-risk drinkers or whether the drinking site contributes to the development of the problem outcome. · Measures of drinking contexts also need to be developed, especially because they are likely to involve structured observations of public drinking, a form of data collection that has not developed as rapidly as survey sampling and instrumentation. Measures of drinking environments need to be developed, refined, and assessed for reliability. Research into environmental influences is also likely to require integrating several forms and modes of data collection (survey, observation, archival) to maximize the reliability of measurement. The Workplace as a Drinking Setting Problem drinking exacts high costs for any work organization. Trice and Roman (1978) point out three direct costs: (1) the worker's on-thejob behavior (e.g., lower production, reductions in quality); (2) the impact of the drinker on other employees; and (3) the costs associated with treating problem drinking once it has been identified. A fourth cost that is not mentioned by Trice and Roman is the generally direct association between problem drinking and absenteeism. Although a dollar value can be attached to these costs, the subtle and indirect costs of problem drinking--in terms of loss of morale, erosion of supervisory authority, and errors in decision making--can only be estimated roughly. When only directly identifiable costs are considered, it has been estimated that a problem drinker costs the employer at least twice as much as an employee who is not a problem drinker in terms of the need for treatment, the increased utilization of medical facilities and benefits, the expenses associated with disciplinary measures, and below-average job performance (Winslow et al., 1966; Trice and Roman, 1978~. Because of the demonstrable extent of the physical, social, psychological, and economic costs of problem drinking to the individual and to the employer, a great deal of research has focused on the workplace setting as it relates to alcohol use by employees. In general, the literature on occupational drinking does not make a clear distinction between on-thejob, job-related, and nonjob-related drinking. The assumption seems to be that because drinking behavior is an element of a person's entire social life and because work is a significant component of a person's existence, workplace factors are as important as nonworkplace factors in understanding patterns of drinking. Essentially, the problem with this research is one of failing to distinguish among the varying role domains through which people move in their day-to-day lives and thus failing to specify the linkages and overlaps between them. Drinking at work, drinking after work, drinking at home, and drinking at a bar on weekends with neighbors are all important phenomena to consider. In each social arena, the role, contexts, and meanings of drinking are likely to be unique. -93

As noted in Chapter 3, one way of conceptualizing a person's environment is as a series of domains. Hannerz (1982) also employs this concept to emphasize that urban life is a composite of roles that individuals play in different social arenas or role domains. Several significant domains may be identified: work, leisure, family, neighborhood, kin, and community. For some individuals, particularly those in well-established, ethnically based communities, the people who occupy roles in these distinct domains are relatively few; that is, coworkers are neighbors, may be kin, are certainly friends, and are those with whom one spends leisure time. Such networks--often termed "close-knit" (Bott, 1957--are significant insofar as they are able to exert social control on network members (Mitchell, 1969~. In these communities there will clearly be a spillover effect of work-related drinking into the family, neighborhood, and leisure domains. Conversely, in very loose-knit networks, which are often the result of social and geographic mobility, the people an individual knows in the work domain are rarely met in roles outside that domain. Coworkers may be friendly at work, but there is often no significant social interaction outside that setting. The same may be said of the community and leisure domains. In loose-knit networks the social control exerted on the network member is weak overall (although possibly significant within some contexts) and is not consistent across the role domains. In these cases, workers may drink together on the job, at the union hall, or at an after-work softball game, but the style of drinking the individual does in such settings may not carry over into other domains. In the case of loose-knit networks, it may be important to specify clearly the differences, similarities, and overlaps between the work and nonwork worlds in terms of drinking behavior (Janes and Ames, 1986~. Until now, research has focused primarily on two aspects of occupational drinking: (1) occupational characteristics of clinical populations and the use of mortality statistics to identify "high-risk" jobs; and (2) examination of the relationship between subjective perceptions of work structure, satisfaction, or stress and drinking behavior or problems. The results of these studies generally indicate that alcohol problems are unevenly distributed across occupations and industries and that the determinants of this distribution stem either from the self-selection of deviant drinkers into certain occupations or from workplace conditions that foster problematic drinking in susceptible individuals (Cosper, 1979, Fillmore and Caetano, 1982; Parker and Brody, 1982~. There is a clear and unresolved discrepancy in the available literature between investigations that locate the source of drinking problems in the environment and those that specify individual, psychosocial attributes. The specific occupational risk factors that have been identified (Archer, 1977; Trice and Roman, 1978; Cosper, 1979; Fennel, Rodin, and Kantor, 1981; Parker and Brody, 1982) include · lack of visibility (e.g., nonexplicit production goals, flexible work schedules, lack of . . ~ supervisions; · stress factors stemming from the absence of a structured work environment, including work addition, occupational obsolescence, novel job roles; · stress factors stemming from overstructured work (low job complexity, time pressure, little control over work); · the absence of social controls; and · the high social availability of alcohol in work or work-related contexts, including occupational subcultures in which heavy drinking is normative. Although the majority of findings point to the possible importance of certain kinds of work roles or occupational characteristics in the development of alcohol-related problems -94

in the workplace, no single job-based risk factor emerges consistently across studies. The difficulty with much of this work is that it relies primarily on survey methods that combine individuals from many different industries into occupational categories that are defined a priori. Thus, it fails to consider the unique social and cultural contexts that characterize different workplace environments. Given the tremendous variety of work settings within a single industry, it seems superficial to focus on individual workers without considering the impact of environmental and sociocultural factors. Although seldom addressed explicitly, conceptual models used in the occupational field frequently do not consider the relationship between environmental and individual factors in explaining alcohol-related behavior. Nowhere is this more evident than in the apparent dichotomy between the "subcultures and "social control" models. The subculture model, developed most extensively by Cosper (1979), argues for the normative underpinnings of alcohol use in specific occupational groups or settings. Heavy drinking by group members is thus ~normal" and may even be functional in enhancing social solidarity in work groups, developing a coherent identifier for group members, expressing masculinity, and other such effects. Conversely, Roman and Trice (1970) have developed a Social controls model that posits deviant drinking as an outcome of ineffective or absent social controls (loose supervision and low work visibility) in the workplace. Related to this supposition of deviance is that those individuals who are deviant may in fact select themselves (or may be placed) in environments in which they can express such deviance. Although on their face these are contradictory explanations, both models address different explanatory levels of reality. For example, occupational drinking, although deviant from a management perspective, may in fact be adaptive under certain conditions: it may relieve the stress, tension, or boredom that characterize many jobs. The point to be emphasized here is that the values suggested by attributions of Normative or "deviants labels to describe worker drinking unnecessarily distract attention from the real issue: individual heavy drinking may be considered a cultural artifact (the individual is following normative guidelines), a group response to work conditions, or a consequence of individual proclivities to join drinking groups. The real research concern should be with whether, how, why, and to what purpose occupational drinking groups evolve, and the determinants of an individual's affiliation with such groups. The tendency to treat subcultural and deviant drinking models as opposing explanations points up the unwillingness of scholars to consider the intersection of individual and environmental factors. Understanding this intersection is vital for considering the relationship between quality or kind of work and alcohol-related behavior. Some work obviously is stressful; much work is boring; and few jobs offer a great deal of flexibility. Why do some people react to such conditions by drinking, and how does drinking as a social behavior develop out of individual responses to stress? Do poor working conditions have alternative effects? This question has often been posed in stress research in which the assumption is made that stress leads to a general susceptibility to one or more of a range of possible adverse health outcomes: heart disease, anxiety, depression, suicide, drinking, drug abuse, ulcers, and so forth (Cassel, 1976~. The following are opportunities for research on the workplace as a drinking setting: · Conceptual models should be developed in which drinking may be considered as an outcome of a complex set of interrelationships among the work environment, the social 95

organization of work, the evolution of informal work groups, other social spheres of the worker's life, and specific characteristics of the worker. Such a conceptual model demands a research strategy that can attend to different levels of analysis with some rigor. _ . _ · Research should be undertaken to luently those observable aspects of work te.g., the structural organization of work, job stress, job complexity) that may explain differential rates of drinking practices and problems in the workplace. · Studies should be conducted to determine the effects of formal and informal workplace alcohol policies, levels of supervision, and relative visibility of workers and job performance on alcohol consumption and alcohol-related problems. · Research is needed to determine the level of alcohol availability in the workplace and the characteristics of workplace social networks or subcultures in relation to alcohol use. FACTORS THAT AFFECT THE RISK OR SEVERITY OF THE NEGATIVE CONSEQUENCES OF DRINKING There is another area of prevention in the alcohol field that is not specifically targeted at reducing alcohol consumption per se but that aims to reduce the risk or severity of subsequent alcohol-related problems. These measures tend to be problem specific and · . . . . . . . . . . · . ~ . . . · · . . · · . include such strategies as reducing deaths and injuries from alcohol-impaired driving by promoting the use of safety belts; reducing drownings through mandatory life preserver laws or the redesign of boats to make capsizing or falling overboard less likely; or reducing loss from fires (often alcohol related) through the manufacture of cigarettes that extinguish themselves quickly when unattended. Measures to reduce the violence that may attend heavy drinking are also a part of this area of prevention and have been the subject of recent research. For example, a study in Vancouver, British Columbia, looked at the physical characteristics of bars and taverns to discover which characteristics most influence the level of aggression associated with drinking (Graham, 1985~. Other useful work in the area of alcohol-related violence has been carried out by Coleman and Strauss (1983) and Collins and Schlenger (1988~. Also of interest in this area is the book edited by J. J. Collins (1981) entitled Drinking and Crime: Perspectives on the Relationships Between Alcohol Consumption and Criminal Behavior. One~prevention measure of this type that specifically targets youthful drinking is the adoption of a nighttime curfew, which can be a component of a comprehensive prevention policy. curlews are meant to reduce crash risks by preventing the young from driving during late-night and early-morning hours, the greatest crash-risk periods. Curfews also tend to limit nighttime access of the young to alcohol and the opportunity to drive while drinking at night. As of May 1984, 12 states had curfew laws. These laws vary with respect to the ages of the drivers covered, the curfew hours, and the exceptions permitted (Williams, Lund, and Preusser, 1984~. In a study of 4 of the 12 curfew states, Preusser and colleagues (1984) found that crashes of 16 year olds were reduced 25 to 69 percent during restricted hours. In interviews with young people in New York and Louisiana, which are both curfew states, Williams, Lund, and Preusser (1984) found that most high school students generally know about the curfew law in their state and conform to the restrictions to a considerable extent. The research team also found that, although the students believe the police do not enforce the curfew law, many parents believe they do. In considering opportunities for research in the area of reducing the risk or severity of the negative consequences of drinking, one must recognize the considerable gap in -96

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A thorough examination of nearly everything known about the prevention and treatment of alcohol problems, this volume is directed particularly at people interested in conducting research and at agencies supporting research into the phenomenon of drinking. The book essentially is two volumes in one. The first covers progress and potential in the prevention of alcohol problems, ranging from the predispositions of the individual to the temptations posed by the environment. The second contains a history and appraisal of treatment methods and their costs, including the health consequences of alcohol abuse. A concluding section describes the funding and research policy emphases believed to be necessary for various aspects of research into prevention and treatment.

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