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Alcohol Proseminar Alcohol Proseminar Fall, 2002 Fall, 2002

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Alcohol Proseminar. Fall, 2002. Address to the legislature by a 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: - PowerPoint PPT Presentation

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Page 1: Alcohol Proseminar

Alcohol ProseminarAlcohol Proseminar

Fall, 2002Fall, 2002

Page 2: Alcohol Proseminar

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.

Page 3: Alcohol Proseminar

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,

Page 4: Alcohol Proseminar

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.

Page 5: Alcohol Proseminar

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

Page 6: Alcohol Proseminar

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

Page 7: Alcohol Proseminar

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

Page 8: Alcohol Proseminar

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

%

Page 9: Alcohol Proseminar

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

Page 10: Alcohol Proseminar

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

Page 11: Alcohol Proseminar

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

Page 12: Alcohol Proseminar

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

Page 13: Alcohol Proseminar

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 $

Page 14: Alcohol Proseminar

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

Page 15: Alcohol Proseminar

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)

Page 16: Alcohol Proseminar

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

Page 17: Alcohol Proseminar

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

Page 18: Alcohol Proseminar

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

Page 19: Alcohol Proseminar

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

Page 20: Alcohol Proseminar

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

Page 21: Alcohol Proseminar

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?

Page 22: Alcohol Proseminar

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

Page 23: Alcohol Proseminar

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

Page 24: Alcohol Proseminar

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.

Page 25: Alcohol Proseminar

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.

Page 26: Alcohol Proseminar

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

Page 27: Alcohol Proseminar

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.

Page 28: Alcohol Proseminar

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.

Page 29: Alcohol Proseminar

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

Page 30: Alcohol Proseminar

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.”

Page 31: Alcohol Proseminar

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

Page 32: Alcohol Proseminar

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

Page 33: Alcohol Proseminar

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)

Page 34: Alcohol Proseminar

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.

Page 35: Alcohol Proseminar

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

Page 36: Alcohol Proseminar

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

Page 37: Alcohol Proseminar

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

Page 38: Alcohol Proseminar

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

Page 39: Alcohol Proseminar

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

Page 40: Alcohol Proseminar

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

Page 41: Alcohol Proseminar

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

Page 42: Alcohol Proseminar

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

Page 43: Alcohol Proseminar

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

Page 44: Alcohol Proseminar

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

Page 45: Alcohol Proseminar

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)

Page 46: Alcohol Proseminar

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.

Page 47: Alcohol Proseminar

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

Page 48: Alcohol Proseminar

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

Page 49: Alcohol Proseminar

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%

Page 50: Alcohol Proseminar

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.

Page 51: Alcohol Proseminar

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

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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

Page 53: Alcohol Proseminar

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

Page 54: Alcohol Proseminar

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

Page 55: Alcohol Proseminar

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.

Page 56: Alcohol Proseminar

Framework for Alcohol Health Framework for Alcohol Health Services ResearchServices Research

Treatment &Prevention

ClientsFinancing

Population

Outcomes

Cost

Organization

Source: NIAAA, 1997.

Page 57: Alcohol Proseminar

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

Page 58: Alcohol Proseminar

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)

Page 59: Alcohol Proseminar

Interactions Between Clients & Interactions Between Clients & ServicesServices

Client Characteristics:Client Characteristics: DemographicsDemographics ClinicalClinical AccessAccess Belief systemsBelief systems

System System Characteristics:Characteristics: OrganizationOrganization FinancingFinancing

Page 60: Alcohol Proseminar

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.

Page 61: Alcohol Proseminar

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

Page 62: Alcohol Proseminar

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

Page 63: Alcohol Proseminar

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

Page 64: Alcohol Proseminar

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*

Page 65: Alcohol Proseminar

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

Page 66: Alcohol Proseminar

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.

Page 67: Alcohol Proseminar

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.

Page 68: Alcohol Proseminar

Match of Client Needs with Match of Client Needs with ServicesServices

Alcohol and Drug UseAlcohol and Drug Use

MedicalMedical

PsychiatricPsychiatric

SocialSocial

Page 69: Alcohol Proseminar

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

Page 70: Alcohol Proseminar

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.

Page 71: Alcohol Proseminar

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.

Page 72: Alcohol Proseminar

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.