Alcohol Proseminar
description
Transcript of Alcohol Proseminar
Alcohol ProseminarAlcohol Proseminar
Fall, 2002Fall, 2002
Address to the legislature by a Address to the legislature by a Mississippi state senator in 1958.Mississippi state senator in 1958.
You have asked me how I feel about whisky. All right, here is just how I stand on this question:
If, when you say whisky, you mean the devil's brew, the poison scourge, the bloody monster that defiles innocence, yea, literally takes the bread from the mouths of little children;
if you mean the evil drink that topples the Christian man and woman from the pinnacles of righteous, gracious living into the bottomless pit of degradation and despair, shame and helplessness, then certainly I am against it with all my power.
But, if you when you say whisky, you mean the oil But, if you when you say whisky, you mean the oil of conversation, the philosophic wine, the stuff that is of conversation, the philosophic wine, the stuff that is consumed when good fellows get together, that puts consumed when good fellows get together, that puts a song in their hearts and laughter on their lips and a song in their hearts and laughter on their lips and the warm glow of contentment in their eyes; the warm glow of contentment in their eyes;
if you mean Christmas cheer, if you mean Christmas cheer, if you mean the stimulating drink that puts the if you mean the stimulating drink that puts the
spring in the old gentleman's step on a frosty spring in the old gentleman's step on a frosty morning, morning,
if you mean the drink that enables a man to if you mean the drink that enables a man to magnify his joy, and his happiness, and to forget, if magnify his joy, and his happiness, and to forget, if only for a little while, life's great tragedies and only for a little while, life's great tragedies and heartbreaks and sorrows, heartbreaks and sorrows,
if you mean that drink, the sale of which if you mean that drink, the sale of which pours into our treasuries untold millions of pours into our treasuries untold millions of dollars, which are used to provide tender care dollars, which are used to provide tender care for our little crippled children, our blind, our deaf, for our little crippled children, our blind, our deaf, our dumb, our pitiful aged and infirm, to build our dumb, our pitiful aged and infirm, to build highways, hospitals, and schools, then certainly I highways, hospitals, and schools, then certainly I am in favor of it.am in favor of it.
This is my stand, I will not retreat from it; I will This is my stand, I will not retreat from it; I will not compromise. not compromise.
Prohibition: Legislative SummaryProhibition: Legislative Summary
PeriodPeriod• Up to 1906Up to 1906• 1907–19131907–1913
• 1914–19181914–1918 • 19171917• January 1918January 1918• January 1919January 1919
StatusStatus• 3 Prohibition States3 Prohibition States• 23 Prohibition States23 Prohibition States (17 by referenda)(17 by referenda)• 48 Prohibition States48 Prohibition States (25 new referenda; 16 < war)(25 new referenda; 16 < war)• 18th Amendment introduced18th Amendment introduced• Ratified by CongressRatified by Congress• U.S. Prohibition EffectiveU.S. Prohibition Effective
Source: Moore & Gerstein, 1981
Repeal: Alcohol ControlRepeal: Alcohol Control 1932: Roosevelt campaigns for repeal of 18th Amendment1932: Roosevelt campaigns for repeal of 18th Amendment December 1933: 21st Amendment (Repeal) ratified by 35 December 1933: 21st Amendment (Repeal) ratified by 35
states states Alcohol Control becomes “a pivotal idea” in post-Repeal eraAlcohol Control becomes “a pivotal idea” in post-Repeal era
FederalFederal• regulate production of spirits, wine & beer (curb illegal regulate production of spirits, wine & beer (curb illegal
production)production)
• manage product purity and labeling; impose excise taxesmanage product purity and labeling; impose excise taxes
• Authority with Department of Justice (ATF since 1972)Authority with Department of Justice (ATF since 1972)
StateState• Devolved Powers including dry option, retail monopolies, Devolved Powers including dry option, retail monopolies,
taxationtaxation
• Alcoholic Beverage Control (ABC Laws)Alcoholic Beverage Control (ABC Laws)Sources: Levine 1980; Moore & Gerstein, 1981
Alcohol Warning LabelAlcohol Warning Label (PL100-690, 1988)(PL100-690, 1988)Federal law required health warning on container labelsFederal law required health warning on container labels
• Government warning from credible source: Surgeon GeneralGovernment warning from credible source: Surgeon General• Pregnant women should not drink : risk of birth defectsPregnant women should not drink : risk of birth defects• Impairs ability to drive a car or operate machinery and may cause Impairs ability to drive a car or operate machinery and may cause
health problemshealth problems
Major ResultsMajor Results• By 1994, 60% drinkers reported exposure to label–curve flatteningBy 1994, 60% drinkers reported exposure to label–curve flattening• Messages reach many but not all target groups, heavier drinkers; Messages reach many but not all target groups, heavier drinkers;
e.g., > 50% males 18-20 (drunk driving); > 65% drinkers 18-29 e.g., > 50% males 18-20 (drunk driving); > 65% drinkers 18-29 (pregnancy); may miss less educated and ethnic groups(pregnancy); may miss less educated and ethnic groups
• Modest associations with precautionary behavior, conversationsModest associations with precautionary behavior, conversations
Sources: Greenfield & Kaskutas, 1998; Greenfield et al, 1999; Hankin et al, 1993
U.S. Support for Stronger Alcohol U.S. Support for Stronger Alcohol PoliciesPolicies
20
30
40
50
60
70
80
90
100
1989 1990 1991 1993 1994
Warning Labels
More Prevention
Server Training
Counter Ads
Increase Taxes
Store Hours
Drinking Age
Room et al, 1995; Giesbrecht & Greenfield, 1999
%
Domains of Alcohol InvolvementDomains of Alcohol Involvement
Abstention vs. DrinkingAbstention vs. Drinking Frequency of ConsumptionFrequency of Consumption Quantity of ConsumptionQuantity of Consumption Quantity-Frequency (Volume)Quantity-Frequency (Volume) Volume VariabilityVolume Variability Frequency of heavy consumption or Frequency of heavy consumption or
drunkennessdrunkenness ““Risky” drinkingRisky” drinking
Domains of Alcohol InvolvementDomains of Alcohol Involvement(continued)(continued)
Alcohol-related problems (consequences, Alcohol-related problems (consequences, disabilities)disabilities)
Alcohol dependence syndromeAlcohol dependence syndrome Alcohol use disordersAlcohol use disorders
Alcohol abuseAlcohol abuse Alcohol dependenceAlcohol dependence
Total per capita ethanol Total per capita ethanol consumption, United States, 1997consumption, United States, 1997
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
Gal
lons
of e
than
ol
U.S. Per Capita Beer, Spirits and Wine Salesand Total Alcohol Sales (Savitzky-Golay Smooth)
Source: Williams et al. (1996) and Adams Wine Handbook 1997 (for 1996)
1960 1970 1980 1990 2000Year
0
0.4
0.8
1.2
1.6
2
2.4
2.8
Gal
lons
Eth
anol
Wine
Spirits
Beer
Total
Relative Price of Alcoholic Beverages, Relative Price of Alcoholic Beverages, 1970-19971970-1997
1.00
2.00
3.00
4.00
5.00
AlcoholicBeverages
Consumer PriceIndex
Non-AlcoholicBeverages
Sources: Mosher, 1997; Mosher & Cowan, 1985; Bureau of Labor Statistics, 1996
Relative Price, 1970 $
Abstention by Age, Sex and Abstention by Age, Sex and RaceRace
0
10
20
30
40
50
60
70
80
90
100
18-29 30-44 45-64 65+
Age
Pe
rce
nt
Nonblack FemalesBlack FemalesNonblack MalesBlack Males
From NLAES, 1992
Concentration of U.S. Concentration of U.S. Alcohol ConsumptionAlcohol Consumption
0
10
20
30
40
50
60
70
80
90
100
2.5 5 10 20 30 40 50 60 70 80 90 100
Highest Volume Percentile of Drinkers Lowest Volume
Perc
ent of T
ota
l
60+
50-59
40-49
30-39
18-29
Greenfield TK & Rogers JD.J Stud Alcohol 60:78 (1999)
Hazardous U.S. Alcohol ConsumptionHazardous U.S. Alcohol Consumption
0
20
40
60
80
100
2.5 5 10 20 30 40 50 60 70 80 90 100
Highest Volume Percentile of Drinkers Lowest Volume
Per
cent
of T
otal
Wine
Spirits
Beer
Rogers & Greenfield, 1999
Total Per Capita Consumption of Total Per Capita Consumption of Ethanol by State, United States, 1997Ethanol by State, United States, 1997
1.99 or below
2.00 to 2.24
2.25 to 2.49
2.50 or over
U.S. total = 2.18
DC
Total Per Capita Consumption of Ethanol Total Per Capita Consumption of Ethanol among Current Drinkers by State, United among Current Drinkers by State, United
States, 1997States, 1997
3.99 or below
4.00 to 4.49
4.50 to 4.99
5.00 or over
DC
Quantity-FrequencyQuantity-Frequency
Frequency: Drinking days/year.Frequency: Drinking days/year. How often did you have a drink containing How often did you have a drink containing
alcohol, that is beer, wine or liquor?alcohol, that is beer, wine or liquor? Quantity: Drinks per Drinking DayQuantity: Drinks per Drinking Day
About how many drinks would you have on About how many drinks would you have on average on a typical day when you drank?average on a typical day when you drank?
Volume: (Drinking days/year X Drinks per Volume: (Drinking days/year X Drinks per drinking day)/days in a year = Drinks per drinking day)/days in a year = Drinks per dayday
Graduated QFGraduated QFThink of all kinds of alcoholic beverages combined, that is, any Think of all kinds of alcoholic beverages combined, that is, any combination of cans of beer, glasses of wine, or drinks combination of cans of beer, glasses of wine, or drinks containing liquor of any kind.containing liquor of any kind.
During the past 12 months,During the past 12 months, Start with largest amount drunk;Start with largest amount drunk;what is the largest numberwhat is the largest number ask frequency of consumingask frequency of consumingof drinks on a single day?of drinks on a single day? successively lower amounts per successively lower amounts per day.day.
•• Was it 24 or more drinks on Was it 24 or more drinks on • Daily or nearly every day • Daily or nearly every day
a single day? a single day? • 3 or 4 times a week • 3 or 4 times a week
• 12 to 23 drinks on a single day? • 12 to 23 drinks on a single day? • Once or twice a week • Once or twice a week
• 8-11? • 8-11? • 2 or 3 times a month • 2 or 3 times a month
• 5-7? • 5-7? • Once a month • Once a month
• 3-4? • 3-4? • 11-3 times in the past year • 11-3 times in the past year
• 1-2? • 1-2? • Twice in the past year • Twice in the past year
• No drinks • No drinks • Once in the past year • Once in the past year
• Never • Never
Drinking Pattern Questionnaire--DPQDrinking Pattern Questionnaire--DPQ11. . On Fridays during a typical month, how often did you drink - On Fridays during a typical month, how often did you drink -
every Friday, three Fridays, two Fridays, one Friday, or every Friday, three Fridays, two Fridays, one Friday, or hardly ever on Fridays? hardly ever on Fridays?
2. 2. How many drinks would you usually have on a Friday?How many drinks would you usually have on a Friday?
3. 3. Repeat for Saturday, Sunday, and weekdays.Repeat for Saturday, Sunday, and weekdays.
4. 4. Were there days when you had more than your usual in the Were there days when you had more than your usual in the past 12 months?past 12 months?
5. 5. If yes, what did you typically drink and how often.?If yes, what did you typically drink and how often.?
6. 6. Proportion of time you drank with a meal, while snacking, or Proportion of time you drank with a meal, while snacking, or without eating anything.without eating anything.
7. 7. Did you ever drink enough to get drunk or very high, that is, Did you ever drink enough to get drunk or very high, that is, your speech was slurred or you were unsteady on your your speech was slurred or you were unsteady on your feet?feet?
8. 8. If yes, how often did you drink enough to get drunk or very If yes, how often did you drink enough to get drunk or very high?high?
Heavy DrinkingHeavy Drinking** by Age, Sex, by Age, Sex, and Raceand Race
0
2
4
6
8
10
12
14
16
18
20
18-29 30-44 45-64 65+
Age
Per
cent
Nonblack FemalesBlack FemalesNonblack MalesBlack Males
From NLAES, 1992, *> 1 oz. ethanol per day
Drinking Volume Partitioned by 6 ContextsDrinking Volume Partitioned by 6 Contexts
14%
24%
14%4%
25%
19%
Restaurants
Bars
Parties
Public Places
Home, withFriends Home,"Quietly"
TOTAL
21%
7%
17%
16%
3%
37%
HAZARDOUS
1984 & 1995 National Alcohol Surveys; Clark, 1988; Greenfield et al, 2000
Hispanics, Abstention and Heavy Drinking by Gender Hispanics, Abstention and Heavy Drinking by Gender
and Country of Origin, United States, 1984.and Country of Origin, United States, 1984.
Abstention Heavy Drinking*
0
5
10
15
20
25
30
35
40
45
50
Pe
rce
nt
Cubans Mexican-Americans
PuertoRicans
MalesFemales
*Drinks at least once a week and has five or more at a sitting at least once a year.
Asian-Americans: Abstention and Heavy Drinking by Asian-Americans: Abstention and Heavy Drinking by
Gender and Country of Origin, Los Angeles, 1980s.Gender and Country of Origin, Los Angeles, 1980s.
0
10
20
30
40
50
60
70
80
Per
cent
Koreans Filipinos Chinese Japanese Koreans Filipinos Chinese Japanese
MalesFemales
Abstention Heavy Drinking*
*Drinks at least once a week and has five or more at a sitting at least once a year.
0
5
10
15
20
25
30
35
40
Perc
ent
Japan Hawaii California Japan Hawaii California
MalesFemales
Drinking Patterns of Japanese in Japan, Japanese-Drinking Patterns of Japanese in Japan, Japanese-Americans in Hawaii, and Japanese-Americans in Americans in Hawaii, and Japanese-Americans in
Santa Clara, California, 1988Santa Clara, California, 1988..
Abstention Heavy Drinking
DSM-IV Alcohol AbuseDSM-IV Alcohol Abuse
A person's maladaptive alcohol use causes clinically A person's maladaptive alcohol use causes clinically important distress or impairment, as shown in a important distress or impairment, as shown in a single 12-month period by one or more of the single 12-month period by one or more of the following: following: failure to carry out major obligations at work, home, or failure to carry out major obligations at work, home, or
school because of repeated alcohol use, school because of repeated alcohol use, repeated use of alcohol even when it is physically repeated use of alcohol even when it is physically
dangerous to do so,dangerous to do so, repeated experience of legal problems, or repeated experience of legal problems, or continued use of alcohol despite knowing that it has continued use of alcohol despite knowing that it has
caused or worsened social or interpersonal problems. caused or worsened social or interpersonal problems.
DSM-IV Alcohol DependenceDSM-IV Alcohol DependenceA person's maladaptive pattern of alcohol use leads to clinically A person's maladaptive pattern of alcohol use leads to clinically
important distress or impairment, as shown in a single 12-important distress or impairment, as shown in a single 12-month period by three or more of the following:month period by three or more of the following: tolerance; tolerance; withdrawal; withdrawal; amount or duration of use often greater than intended; amount or duration of use often greater than intended; repeatedly trying without success to control or reduce repeatedly trying without success to control or reduce
alcohol use; alcohol use; spending much time using alcohol, recovering from its spending much time using alcohol, recovering from its
effects, or trying to obtain it; effects, or trying to obtain it; reducing or abandoning important work, social, or leisure reducing or abandoning important work, social, or leisure
activities because of alcohol use; oractivities because of alcohol use; or continuing to use alcohol, despite knowing that it has continuing to use alcohol, despite knowing that it has
probably caused ongoing physical or psychological probably caused ongoing physical or psychological problems.problems.
NLAES Data on Alcohol Abuse and NLAES Data on Alcohol Abuse and Dependence by Age, Race, & SexDependence by Age, Race, & Sex
0
5
10
15
20
25
18-29 30-44 45-64 65+
Age
Pe
rce
nt
Nonblack FemalesBlack FMalesNonblack MalesBlack Males
1992 National Longitudinal Alcohol Epidemiology 1992 National Longitudinal Alcohol Epidemiology Survey (NLAES)Survey (NLAES)
Only 10% of the U.S. adult population currently abusing or Only 10% of the U.S. adult population currently abusing or dependent on alcohol had received any treatment in the 12 dependent on alcohol had received any treatment in the 12 months prior to interview.months prior to interview.
Only 28% of individuals with a past diagnosis of alcohol Only 28% of individuals with a past diagnosis of alcohol dependence reported ever having any kind of alcohol treatment.dependence reported ever having any kind of alcohol treatment.
75% of the people who recovered from a previous alcohol 75% of the people who recovered from a previous alcohol disorder did so without having received any treatment, often disorder did so without having received any treatment, often termed “natural recovery.”termed “natural recovery.”
Costs of Alcohol Abuse to the Nation - 1990Costs of Alcohol Abuse to the Nation - 1990
Core Medical Expenditures:Core Medical Expenditures:$10.5 Billion$10.5 Billion
Specialty organizations (33%)Specialty organizations (33%) Short-stay hospitals (44%)Short-stay hospitals (44%) Nursing homes (10%)Nursing homes (10%) Support & Other (13%)Support & Other (13%)
Indirect:Indirect: $70.3 Billion$70.3 Billion Morbidity (52%)Morbidity (52%) Mortality (48%)Mortality (48%)
Other Alcohol-related Costs:Other Alcohol-related Costs:$15.8 Billion$15.8 Billion
Crime (36%)Crime (36%) Victims of crime (3%)Victims of crime (3%) Incarceration (30%)Incarceration (30%) Motor vehicle crashes (24%)Motor vehicle crashes (24%) Fire destruction (4%)Fire destruction (4%) Social welfare administration (1%)Social welfare administration (1%)
Fetal Alcohol Syndrome:Fetal Alcohol Syndrome:$2.1 Billion$2.1 Billion
Total: $98.6 BillionTotal: $98.6 Billion
Rice, 1993; NIAAA, Alcohol & Health, 1997
Percent distribution of principal (first-listed) Percent distribution of principal (first-listed) diagnoses among discharges with any (all-listed) diagnoses among discharges with any (all-listed)
mention of an alcohol-related diagnosis, 1997mention of an alcohol-related diagnosis, 1997
6.8%
15.3%
3.7%
2.5%
3.0%
68.7%
Alcoholic psychoses
Alcohol dependencesyndromeCirrhosis, withmention of alcoholCirrhosis, withoutmention of alcoholNondependent abuseof alcoholNonalcohol-relatedfirst-listed diagnosis
Trends in percent of discharges with principal (first-Trends in percent of discharges with principal (first-
listed) or any (all-listed) mention of an alcohol-related listed) or any (all-listed) mention of an alcohol-related
diagnosis among all discharges, 1979-97diagnosis among all discharges, 1979-97
0
1
2
3
4
5
6
1979 1981 1983 1985 1987 1989 1991 1993 1995 1997
Pe
rce
nt
First-listed diagnosis
All-listed diagnosis
First-listed diagnosis (excluding pregnancy)
All-listed diagnosis (excluding pregnancy)
The influence of alcohol on morbidity and mortality: The influence of alcohol on morbidity and mortality: Alcohol-Attributable Fractions (AAF)Alcohol-Attributable Fractions (AAF)
AAF AAF AgeAge
Causes of death directly attributableCauses of death directly attributable
to alcohol to alcohol 1.01.0 >>1515
Diseases indirectly attributable to alcoholDiseases indirectly attributable to alcoholCancer of the esophagusCancer of the esophagus 0.750.75 >> 35 35Acute pancreatitisAcute pancreatitis 0.420.42 >> 35 35
Injuries and adverse effects indirectly attributable to alcoholInjuries and adverse effects indirectly attributable to alcoholMotor vehicle traffic and Motor vehicle traffic and
non-traffic deathsnon-traffic deaths 0.42 0.42 > 0> 0Suicide and self-inflicted injury Suicide and self-inflicted injury 0.28 0.28 >> 15 15Homicide and injury purposefully Homicide and injury purposefully
inflicted by othersinflicted by others 0.46 0.46 >> 15 15
Source: Stinson, F.S., and DeBakey, S.F., Alcohol-related mortality in the United States, 1979-1988, Brit. J. Addict. 87:777-783, 1992.
Death Rates and Premature Mortality by Death Rates and Premature Mortality by Years of Potential Life Lost (YPLL), Years of Potential Life Lost (YPLL),
1980.1980.
Percent ofPercent of Percent of Percent of
YPLL Deaths YPLL Deaths
Accidents, adverse effects 26.8 Accidents, adverse effects 26.8 5.2 5.2Suicides, homicides 14.0 2.5Suicides, homicides 14.0 2.5Chronic liver disease, cirrhosis 3.0Chronic liver disease, cirrhosis 3.0 1.7 1.7Malignant neoplasms (CA) 18.0Malignant neoplasms (CA) 18.0 21.9 21.9Diseases of heart (CHD)Diseases of heart (CHD) 16.4 37.5 16.4 37.5Cerebrovascular disease (CVD) 2.8Cerebrovascular disease (CVD) 2.8 8.3 8.3
Age-adjusted death rates of liver Age-adjusted death rates of liver cirrhosis by sex (death registration cirrhosis by sex (death registration
States, 1910-32, and United States, States, 1910-32, and United States, 1933-96)1933-96)
0
5
10
15
20
25
1910 1920 1930 1940 1950 1960 1970 1980 1990
Ra
te p
er
10
0,0
00
po
pu
latio
n
Both sexes
Males
Females
Reductions in Problems During Reductions in Problems During ProhibitionProhibition
Measure Dates Change
Cirrhosis mortality 1911–1929 29.5 to 10.7 per100,000
Admissions foralcoholic psychosis
1919–1928 10.1 to 4.7
Arrests for drunk &disorderly
1916–1922 50% decline
Source: Moore & Gerstein, 1981
Total and alcohol-related traffic fatality Total and alcohol-related traffic fatality rates per 100 million vehicle miles rates per 100 million vehicle miles
traveled (VMT), United States, 1977-97traveled (VMT), United States, 1977-97
0
1
2
3
4
1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997
Ra
te p
er
10
0 m
illio
n V
MT
All fatalities
Alcohol-relatedfatalities
What We’ll Be Doing This What We’ll Be Doing This SemesterSemester
Learning about various aspects of alcohol use, Learning about various aspects of alcohol use, consequences, and dependenceconsequences, and dependence EpidemiologyEpidemiology AssessmentAssessment NeurobiologyNeurobiology GeneticsGenetics ComorbidityComorbidity Personality and MotivationPersonality and Motivation TreatmentTreatment PreventionPrevention
What We’ll Be Doing This What We’ll Be Doing This Semester (cont’d)Semester (cont’d)
Getting training in various aspects of Getting training in various aspects of alcohol researchalcohol research
Learning about other forms of substance Learning about other forms of substance use, abuse, and dependenceuse, abuse, and dependence
Have a chance to hear from a variety of Have a chance to hear from a variety of scientists and clinicians with various scientists and clinicians with various perspectives on alcohol researchperspectives on alcohol research
Alcohol Policies: Levels, Types, IssuesAlcohol Policies: Levels, Types, Issues
Jurisdictional LevelJurisdictional Level Federal, state, county, municipal (or local community)Federal, state, county, municipal (or local community)
TypeType Taxation/pricing, access, advertising, transportation, Taxation/pricing, access, advertising, transportation,
etc. etc. Legally based policies, enforcement, and justice system Legally based policies, enforcement, and justice system Institutional policies (e.g., schools, workplace, military)Institutional policies (e.g., schools, workplace, military) Health services and public health measuresHealth services and public health measures Science priorities and research policiesScience priorities and research policies
IssuesIssues Studies of policy making, policy analysisStudies of policy making, policy analysis Evidentiary basis of policies and the role of scienceEvidentiary basis of policies and the role of science
Prevention PoliciesPrevention Policies
““They are all policies that operate in a They are all policies that operate in a non- personalized way to alter the set non- personalized way to alter the set of contingencies affecting individuals of contingencies affecting individuals as they drink or engage in activities as they drink or engage in activities that (when combined with intoxication) that (when combined with intoxication) are considered risky.”are considered risky.”
Moore & Gerstein (1981), p 53Beyond the Shadow of Prohibition
Controversy in Optimal Policy ApproachesControversy in Optimal Policy Approaches
Single Distribution Theory (Ledermann Theory)Single Distribution Theory (Ledermann Theory)
Posits that a substantial decrease in a population’s mean Posits that a substantial decrease in a population’s mean (or per capita) consumption will be accompanied by a (or per capita) consumption will be accompanied by a decrease in the prevalence of heavy drinkersdecrease in the prevalence of heavy drinkers
Harm Reduction: Abates hazardous drinking patternsHarm Reduction: Abates hazardous drinking patterns
AAttention is less on trying to modify everyone’s drinking, ttention is less on trying to modify everyone’s drinking, be it light or heavy, and more on policy measures be it light or heavy, and more on policy measures targeting heavy quantity per occasion drinking patternstargeting heavy quantity per occasion drinking patterns
Sources: Skog, 1985; Edwards et al, 1994; Rehm et al, 1996; Stockwell et al, 1997
Concentration of U.S. Alcohol Concentration of U.S. Alcohol
ConsumptionConsumption
0
20
40
60
80
100
2.5 5 10 20 30 40 50 60 70 80 90 100
Highest Volume Percentile of Drinkers Lowest Volume
% T
otal
V
olum
e (g
/day
)Cumulative Percent Volume (g/day)
Greenfield & Rogers, 1999
Economic costs of alcohol abuse by type, Economic costs of alcohol abuse by type, 19901990
10%
37%34%
18% Direct Costs
Morbidity Costs
Mortality Costs
Other Costs
U.S. Data
Rice, 1993; NIAAA, Alcohol & Health, 1997
(e.g., crime, crashes)
(e.g., medical)
Jurisdictional Levels: Example PoliciesJurisdictional Levels: Example PoliciesFederal Federal
• Excise taxesExcise taxes• Transportation (e.g., Minimum Drinking Age, aviation)Transportation (e.g., Minimum Drinking Age, aviation)• Commercial regulation, labeling, advertisingCommercial regulation, labeling, advertising• Federal agencies: Federal agencies: NIAAA, SAMHSA, CDC, USDA, FTC, ATF, etc.NIAAA, SAMHSA, CDC, USDA, FTC, ATF, etc.
StateState• State alcohol taxesState alcohol taxes• Access: alcohol distribution systems, State ABCs, retail Access: alcohol distribution systems, State ABCs, retail
monopolies, local options, regulating outlets, labeling, etc. monopolies, local options, regulating outlets, labeling, etc. • Server licensing, training, dram shop or server liabilityServer licensing, training, dram shop or server liability• Drinking driver laws: mandatory license actions, Drinking driver laws: mandatory license actions,
treatment,etc.treatment,etc.
Price and Taxation PoliciesPrice and Taxation Policies Studies at both federal and state levels show:Studies at both federal and state levels show:
• generally significant price effect on consumptiongenerally significant price effect on consumption• heavier drinkers are as or more affected than light onesheavier drinkers are as or more affected than light ones
• some studies have found affects on population-level problem some studies have found affects on population-level problem indicators: cirrhosis mortality, vehicular crashesindicators: cirrhosis mortality, vehicular crashes
• not particularly regressive tax measure compared to other not particularly regressive tax measure compared to other commodity taxes—there is a lower burden on the poorcommodity taxes—there is a lower burden on the poor
• supported by public health experts, anathema to industrysupported by public health experts, anathema to industry
Sources: Coate & Grossman, 1988; Babor et al, 1978; Cook & Tauchen, 1982; Edwards et al, 1994
Drinking Driving Legislative PoliciesDrinking Driving Legislative Policies
Minimum Drinking Age (MDA)Minimum Drinking Age (MDA) Federal law required 21 year old MDA for states to Federal law required 21 year old MDA for states to
receive national highway funds; created incentivereceive national highway funds; created incentive By mid 1980’s all states adopted uniform MDA of 21By mid 1980’s all states adopted uniform MDA of 21 Changes before and after federal law provide natural Changes before and after federal law provide natural
experiments: most studies found reductions in indicatorsexperiments: most studies found reductions in indicators
1987 GAO Review1987 GAO Review Reviewed 32 studies; 14 deemed methodologically sound Reviewed 32 studies; 14 deemed methodologically sound Found reductions of from 5 to 28% in drivers under 21 Found reductions of from 5 to 28% in drivers under 21 Conclusion: Sound scientific evidence for effectiveness Conclusion: Sound scientific evidence for effectiveness
of MDA policyof MDA policy
Sources: Moore & Gerstein, 1981; Edwards et al, 1994
U.S. Adults Seeing Warning Label, 1993U.S. Adults Seeing Warning Label, 1993
Weighted percentages of subgroup. Source: Greenfield, 1994; Greenfield, 1997
Less than 3039.4%
30 or more15.4%
Age
Never20.0%
1-4 times53.5%
Male >>74.7%
TimesPurchased
(last 30 days)
2 or less65.2%
3 or more82.7%
Female54.1%
Gender
5 or more68.7%
OpenedContainers
(last 30 days)
Saw Label38.6%
Alcohol Access RegulationAlcohol Access Regulation Access primarily regulated at state and local levelsAccess primarily regulated at state and local levels
• Responsibility of State Alcoholic Beverage Control agencyResponsibility of State Alcoholic Beverage Control agency
Monopoly StatesMonopoly States• By 2 years after Repeal, 15 states enacted retail monopoliesBy 2 years after Repeal, 15 states enacted retail monopolies• 1980’s saw increasing deregulatory pressure with privatization 1980’s saw increasing deregulatory pressure with privatization
of wine sales in Idaho, Maine, Virginia, and Washington (3 of 4 of wine sales in Idaho, Maine, Virginia, and Washington (3 of 4 showed increased wine consumption); also Iowa, W. Virginiashowed increased wine consumption); also Iowa, W. Virginia
• Iowa and West Virginia case studied separately: significant Iowa and West Virginia case studied separately: significant increase in wine consumption and net increase in ETOH increase in wine consumption and net increase in ETOH
Sources: Wagenaar & Holder, 1991; Edwards et al, 1994; Holder & Wagenaar, 1990.
Case Study: Stiffening Regulatory PowersCase Study: Stiffening Regulatory Powers
1994: California law gave ABC the right to rescind licenses1994: California law gave ABC the right to rescind licenses• Outlet license revocation process began following 3 cited infractions of Outlet license revocation process began following 3 cited infractions of
sales to a minor within a 3 year period (Three Strikes Bill)sales to a minor within a 3 year period (Three Strikes Bill)• California Supreme Court rules police can use minors as decoysCalifornia Supreme Court rules police can use minors as decoys• In 1997-98 law enforcement conducted 291 minor decoy operations, In 1997-98 law enforcement conducted 291 minor decoy operations,
finding a 20.6% violation rate, down from 29.4% in 1993-94finding a 20.6% violation rate, down from 29.4% in 1993-94• ABC developed Grant Assistance to local Law Enforcement (GALE) ABC developed Grant Assistance to local Law Enforcement (GALE)
1998: SB1696 introduced—weakens decoy & enforcement 1998: SB1696 introduced—weakens decoy & enforcement • Provided fourth strike; notification on decoys, GALE funds redirectedProvided fourth strike; notification on decoys, GALE funds redirected• Supported by retail groups, grocers, and beverage industry Supported by retail groups, grocers, and beverage industry • Sponsor forced to compromise after intensive media advocacy Sponsor forced to compromise after intensive media advocacy
Sources: Ryan & Mosher, 2000; Grube, 1997
Server Intervention, RBS ProgramsServer Intervention, RBS Programs
Steps servers take to reduce chance of intoxicationSteps servers take to reduce chance of intoxication• One third to one half alcohol-impaired drivers drank last at One third to one half alcohol-impaired drivers drank last at
public places—bars or restaurantspublic places—bars or restaurants• 1980’s: Server intervention training demonstrated efficacy1980’s: Server intervention training demonstrated efficacy• Newer studies focus on factors enhancing effectiveness: Newer studies focus on factors enhancing effectiveness:
management incentives, enforcement of laws banning management incentives, enforcement of laws banning service to intoxicated patrons; community involvementservice to intoxicated patrons; community involvement
State mandated training program for servers—OregonState mandated training program for servers—Oregon• Time-series analyses estimate 23% reduction in crashesTime-series analyses estimate 23% reduction in crashes• State-wide mandated programs may assure “critical State-wide mandated programs may assure “critical
mass” of trained servers, with greater adoption of RBS mass” of trained servers, with greater adoption of RBS practicespractices
Sources: Saltz, 1997; Holder & Wagenaar, 1994
Workplace PoliciesWorkplace PoliciesWorkplace management styleWorkplace management style
• Study contrasted U.S. traditional and Japanese Study contrasted U.S. traditional and Japanese management styles in 2 firms, same industry, same unionmanagement styles in 2 firms, same industry, same union
• Plant alcohol policies (and how genuine their enforcement) Plant alcohol policies (and how genuine their enforcement) predicted drinking norms and alcohol availability on jobpredicted drinking norms and alcohol availability on job
• Social control and enabling mechanisms mediated effectSocial control and enabling mechanisms mediated effect
New studies investigate drinking off the job & New studies investigate drinking off the job & hangovershangovers
• Hangovers found to relate to job problems and sleep on jobHangovers found to relate to job problems and sleep on job• Variation in experiences “thwarts the formulation of simple Variation in experiences “thwarts the formulation of simple
worktime-hangover policies”worktime-hangover policies”
Sources: Ames et al, 2000; Ames et al, 1997; Moore, 1998
Summary and ConclusionsSummary and Conclusions
A wide range of legislative policies at various jurisdictional A wide range of legislative policies at various jurisdictional levels is currently regulating public alcohol commerce and use levels is currently regulating public alcohol commerce and use in the U.S.; over time these evolvein the U.S.; over time these evolve
In the last 20 years, policy analysis and evaluation has In the last 20 years, policy analysis and evaluation has matured, demonstrating efficacy of model programs; matured, demonstrating efficacy of model programs; implementation and effectiveness studies are now underway implementation and effectiveness studies are now underway and are acceleratingand are accelerating
We need both policies that affect all drinkers and targeted We need both policies that affect all drinkers and targeted harm reduction measures aimed at heavy drinkers and harm reduction measures aimed at heavy drinkers and settings in which drinking large quantities is promotedsettings in which drinking large quantities is promoted
Policy development studies reveal opportunities and may Policy development studies reveal opportunities and may improve strategies for enacting evidence-based policiesimprove strategies for enacting evidence-based policies
DefinitionsDefinitions Health Services ResearchHealth Services Research studies the studies the
organization, financing, utilization, costs, organization, financing, utilization, costs, effectiveness, and outcomes of service delivery.effectiveness, and outcomes of service delivery.
Service deliveryService delivery includes alcoholism and includes alcoholism and other substance use treatment, mental health, other substance use treatment, mental health, general medical, emergency room, self-help, general medical, emergency room, self-help, and any other service sectors.and any other service sectors.
Framework for Alcohol Health Framework for Alcohol Health Services ResearchServices Research
Treatment &Prevention
ClientsFinancing
Population
Outcomes
Cost
Organization
Source: NIAAA, 1997.
One-Year Help-SeekingOne-Year Help-Seeking
Individuals with alcohol disorders or problem Individuals with alcohol disorders or problem drinkingdrinking
ECA:ECA: 11% specialty mental health/addictive11% specialty mental health/addictive
services; 8% voluntary support networkservices; 8% voluntary support network NLAES:NLAES: 10%10% RAS:RAS: 7%-10%7%-10%
ECA=Epidemiologic Catchment Area Studies,
NLAES=National Longitudinal Alcohol Epidemiologic Survey,
RAS=Rural Alcohol Study; Regier et al., 1993; Grant, 1996; Booth et al., 2000
Distribution of Problem Drinkers in Distribution of Problem Drinkers in Health & Community AgenciesHealth & Community Agencies
Primary Care Settings
42%
Criminal Justice System
41%
Alcoholism Tx. Facilities
4%Mental Health Tx.
3%
Other Drug Abuse Tx. Facilities
2%
Welfare System8%
Source: Weisner, 1995.
(One California County)(One California County)
Interactions Between Clients & Interactions Between Clients & ServicesServices
Client Characteristics:Client Characteristics: DemographicsDemographics ClinicalClinical AccessAccess Belief systemsBelief systems
System System Characteristics:Characteristics: OrganizationOrganization FinancingFinancing
Client CharacteristicsClient CharacteristicsDemographics: GENDERDemographics: GENDER
Gender Disparities In Help-SeekingGender Disparities In Help-Seeking
Women less likely to enter alcoholism Women less likely to enter alcoholism specialty treatment (not found in NLAES).specialty treatment (not found in NLAES).
Women more likely to seek care in mental Women more likely to seek care in mental health or primary car/general medical settings.health or primary car/general medical settings.
Source: Weisner et al., 1992; Grant, 1996; Kaskutas et al., 1997; Booth et al., 2000.
NLAES=National Longitudinal Alcohol Epidemiologic Survey.
Client CharacteristicsClient CharacteristicsCLINICALCLINICAL
Alcohol use severityAlcohol use severity Psychiatric comorbidityPsychiatric comorbidity Previous treatmentPrevious treatment Alcohol consequencesAlcohol consequences
• # symptoms DSM-IV alcohol use disorder (NLAES)# symptoms DSM-IV alcohol use disorder (NLAES)• Diagnosis of alcohol disorder (NAS, NHIS)Diagnosis of alcohol disorder (NAS, NHIS)• Social consequences of drinking (NAS 1984 F/U, RAS)Social consequences of drinking (NAS 1984 F/U, RAS)
Source: Grant, 1997; Kaskutas et al, 1997; Booth et al., 2000, Hasin & Grant, 1995.
NLAES=National Longitudinal Alcohol Epidemiologic Survey, RAS=Rural Alcohol Study, NAS=National Alcohol Survey, NHIS=National Health Interview Survey
Client CharacteristicsClient CharacteristicsACCESSACCESS
Availability:Availability: availability in the geographic areaavailability in the geographic area
tremendous variation across U.S.tremendous variation across U.S. Accessibility:Accessibility: travel time, driver's license, cartravel time, driver's license, car
longer travel times reduce outpatient longer travel times reduce outpatient useuse
Affordability:Affordability: income, health plan, cost of careincome, health plan, cost of care
NLAES: employmentNLAES: employment
HIP: better insurance coverageHIP: better insurance coverage Acceptability:Acceptability: stigmastigma Accommodation:Accommodation: convenienceconvenience
Source: Penchansky & Thomas, 1981; Fortney et al., 1995; Manning et al., 1996; Grant, 1997; Booth et al., 2000; Fortney & Booth, in press. RAS=Rural Alcohol Study; NLAES=National Longitudinal Alcohol Epidemiologic Survey; HIP=RAND Health Insurance Experiment
Rural/Urban Differences in Rural/Urban Differences in AccessAccess
Income $30.5k $36.2kEmploymentHealth Insurance (any)Perceived Availability Tx 76% 85%Travel Time (minutes) Residential Tx Center 39 25 Self-help Group 22 19 General Medical Provider Mental Health CenterAcceptability Self-help Group 2.0 1.8 Mental Health Counselor Hospital Treatment StigmaAccommodation: Waiting Times p < 0.05
Source: Booth et al., 2000.
Variable Rural Urban
Independent Predictors of Help-Independent Predictors of Help-SeekingSeeking
Demographics Race, Age Female 0.3Access Affordability Accessibility Availability 22 Acceptability Social Support 2.2Clinical Recent Alcohol Dependence 3.3 Social Consequences of Drinking 1.7 Antisocial Personality Disorder Axis I DSM-III-R Disorder Drug Use Chronic Medical Problems 2.1 Prior Alcohol Treatment 4.4
* Booth et al., 2000. OR=odds ratio, listed only when p < 0.05.
Variable OR*
Organization & Financing of CareOrganization & Financing of Care
Organization:Organization: Multiple Systems of CareMultiple Systems of Care Match of Needs with ServicesMatch of Needs with Services
Financing:Financing: Employer-based InsuranceEmployer-based Insurance Publicly Financed ProgramsPublicly Financed Programs Growth of Managed CareGrowth of Managed Care
Policy Makers& RegulatorsPolicy Makers& Regulators
Key Roles in the Alcohol Services Key Roles in the Alcohol Services SystemSystem
Payers• Employers •
• State & Local Governments •• Federal Government •
• Patients •
Payers• Employers •
• State & Local Governments •• Federal Government •
• Patients •
Intermediaries• Managed Behavioral Health Care Organizations •• Integrated Health Maintenance Organizations •
• Managed Indemnity Insurers •
Intermediaries• Managed Behavioral Health Care Organizations •• Integrated Health Maintenance Organizations •
• Managed Indemnity Insurers •
ProvidersProvidersPatients or
ClientsPatients or
ClientsPopulation atRisk
Population atRisk
Source: “Improving the Delivery of Alcohol Treatment and Prevention Services,” NIAAA, 1997.
Locations & Providers of Care:Locations & Providers of Care:Helping With DrinkingHelping With Drinking
90
2232
725
55
17
52
0102030405060708090
Perc
en
t
Locations Providers
The Rural Alcohol Study: 40 service usersThe Rural Alcohol Study: 40 service users
40% >= 1 Location 35% >= 1 Provider
Source: Booth et al., 2000.
Match of Client Needs with Match of Client Needs with ServicesServices
Alcohol and Drug UseAlcohol and Drug Use
MedicalMedical
PsychiatricPsychiatric
SocialSocial
Growth in Managed Care Enrollment, Growth in Managed Care Enrollment, 1988-19961988-1996
HMO18%
PPO/Point of Service
11%
19881988
Conventional71%
Source: Gabel and Hunt, 1996.
HMO33%
PPO25%
Point of Service
16%
Conventional26% 19961996
Impact of Managed CareImpact of Managed Care
Public SectorPublic Sector
§ Massachusetts Medicaid carve-outMassachusetts Medicaid carve-out• Overall expenditures reduced by 22%Overall expenditures reduced by 22%• Substance abuse costs reduced by 48%Substance abuse costs reduced by 48%• Inpatient SA costs reduced 67%Inpatient SA costs reduced 67%• Outpatient SA costs increase 8%Outpatient SA costs increase 8%• Access evidence: mixedAccess evidence: mixed
Source: Callahan et al., 1995; Frank & McGuire, 1997.
Impact of Managed CareImpact of Managed CarePrivate SectorPrivate Sector
§ 1995 Behavioral carve-out:1995 Behavioral carve-out:• 79% inpatient detox followed by care within 30 79% inpatient detox followed by care within 30
daysdays• Higher copayments decreased follow-upHigher copayments decreased follow-up• Per user costs higher for SA compared to MHPer user costs higher for SA compared to MH• SA accounted for only 13% of behavioral health SA accounted for only 13% of behavioral health
care costs/membercare costs/member
§ 1998 Health Care for Communities:1998 Health Care for Communities:• Unmet need defined by no care Unmet need defined by no care LOWERLOWER in MC in MC• Less care or delayed care Less care or delayed care GREATERGREATER in MC in MC
Source: Sturm & Sherbourne, 2000; Schoenbaum et al., 1998; Stein et al., 2000.
ConclusionsConclusions
We need to understand:We need to understand: How to improve help-seeking and How to improve help-seeking and
treatment engagement.treatment engagement. Changes in organization and financing of Changes in organization and financing of
alcohol and other services.alcohol and other services. Community perspective for policy and Community perspective for policy and
program development.program development.