The ASAM Principles of Addiction Medicine 5th Edition

21. Environmental Approaches to Prevention: A Community-Based Perspective

Andrew J. Treno, PhD, Paul J. Gruenewald, PhD, Joel W. Grube, AB, MS, PhD, Robert F. Saltz, PhD, and Mallie J. Paschall, PhD

CHAPTER OUTLINE

■  SCOPE OF THE PROBLEM

■  “ENVIRONMENTAL” VERSUS “INDIVIDUAL” APPROACHES TO PREVENTION

■  DOMAINS OF ENVIRONMENTAL PREVENTION

■  SEVEN EFFICACY TRIAL CASE STUDIES

■  MULTICOMPONENT ENVIRONMENTAL APPROACHES CONSIDERED

■  THE EMERGENCE OF ECOLOGIC RESEARCH

■  THE LOGIC OF ENVIRONMENTAL PREVENTION

■  ENVIRONMENTAL PREVENTION AND THE ROLE OF THE MEDICAL PROFESSIONALS

At the conclusion of prohibition in 1933, states in the United States were challenged to establish regulations over production, distribution, and sales of alcohol to reduce crime related to illegal sales and to protect the public health. States could choose to continue prohibition, prohibit sales by beverage type (beer, wine, or spirits), exclude sales on specific days or times (e.g., Sunday sales), restrict sales to certain outlets (e.g., restaurants), or monopolize aspects of production, wholesale distribution, and retail sales by beverage type. States determined the regulatory conditions under which alcohol could be sold (or not) and so also determined, in large part, the social, economic, physical, and legal environments for use. Thus, the grand experiment of prohibition was followed by another less grand but perhaps more important experiment, the progressive deregulation of alcohol sales by all states in the United States. Over the subsequent 80 years, every state deregulated sales, enabled sales in more social contexts, lowered beverage taxes and prices, increased numbers of outlets, and lowered legal restrictions on use. Crimes related to illegal production and distribution were essentially eliminated, but deregulation was accompanied by an increase in many other public health problems (13). Nonetheless, with the creation of large and profitable alcohol markets, continued deregulation is actively pursued as a goal by the beverage and social hosting industries to this day (4).

Although state laws and regulations affect the environments in which alcohol can be sold and used, the impacts of deregulation are felt almost exclusively at local community and neighborhood levels: A change in state regulations on special use permits may allow your town to have a “summer wine festival,” adding a new social context for use. State alcohol taxes do not keep up with inflation, so the real price for a beer at the corner store is reduced every year. Restrictions on numbers of outlets may limit those in your county but allow overconcentrations in some neighbor-hoods. Legal consequences of sales to minors may be considerable but not enforced by local police. For this reason, many communities want to push back against deregulation and use community resources to decrease neighborhood problems related to substance use. And it is at the community level that, from a practical perspective, physicians can act to reduce the impacts of expanding environments for the use of alcohol and other addictive substances (now including marijuana). With a focus upon the impacts of secondhand smoke on nonsmokers, young adults, and infants, important gains have been made in reducing or restricting environments in which tobacco use is possible (5). Similar gains can be made with regard to alcohol and other drug use. Communities can intervene in and take control of many aspects of drug using environments for the reduction of use, consequences, and disorders. These programs can be effective and complement treatment efforts.

In this chapter, we will outline some effective environmental approaches to the prevention of alcohol problems with a focus upon what can be done to ameliorate these problems in community settings. While environmental prevention efforts to reduce tobacco and other substance use have been pursued in earnest over the past decade (6), much can be learned from a focus on alcohol. After a statement of the scope of the problem, we will distinguish environmental approaches from other approaches for prevention among youth and adults. We will review the growing scientific bases for these prevention efforts. We will then summarize current knowledge and best practices for community prevention efforts aimed at youth and adult drinkers.

SCOPE OF THE PROBLEM

Alcohol-involved problems are a serious public health issue. Total annual alcohol-related deaths in the United States for 2001 were estimated at about 75,000 persons per year, representing roughly 2.3 million years of potential life lost (7,8). This figure has changed little in more recent estimates by the Center for Disease Control and Prevention (9). Alcohol-related motor vehicle crashes account for many of these deaths. About 32% of traffic crashes involve alcohol impairment and, despite declines in traffic fatalities, 33,808 people died in 2009 due to alcohol-involved traffic crashes (10,11), and 12% of people aged 12 and older reported driving while under the influence of alcohol at least once in the past year (12). Additional alcohol-related deaths are due to a variety of related injury risks. Depending upon the drinker’s body weight, gender, and drinking experience, alcohol in sufficient quantity alters motor skills, reaction time, and judgment (13,14) and increases the risk of injury to the drinker and to others (15). Alcohol use is involved in a substantial percentage of injuries caused by falls, drownings, and burns (16,17). In a widely cited 2008 review of emergency room studies, Cherpitel and Ye concluded that “no safe level of consumption appears to exist in relation to injury risk” (18).

Alcohol use is also involved in violence and crime. Approximately 2.7 million alcohol-involved violent victimizations occur each year (19), many related to violence between partners (20). It has been estimated that alcohol is involved in between 28% and 43% of violent injuries (21) and 47% of homicides (22). Much of the violence associated with drinking takes place among young people between the ages of 15 and 29, and this sadly includes high rates of both interpersonal violence (23) and suicide (24). Approximately 24% of suicides involve alcohol intoxication in excess of 0.08% BAC (25), and alcohol is involved in about 27% of hospital discharges recording the survival of a suicide attempt (26).

Not surprisingly, direct medical care costs associated with organ damage and injuries related to alcohol use are quite substantial, about $26.3 billion a year, with lost productivity due to hospitalization and recovery accounting for an additional $87.6 billion (27). Crimes attributable to alcohol have been estimated to cost $84 billion a year (28), more than twice the estimated $38 billion attributable to illegal drugs. Alcohol-related injuries are estimated to cost employers $28.6 billion a year (29). An estimated 16% of alcohol sales to underage drinkers leads to an estimated 3,170 deaths and 2.6 million other injury events with an estimated cost of $61.9 billion (30). Finally, alcohol use is a major problem in the US work force, linked to increased medical costs, workers’ compensation claims, sick leave/ absenteeism, accidents, early retirement, and loss of productivity (31,32).

“ENVIRONMENTAL” VERSUS “INDIVIDUAL” APPROACHES TO PREVENTION

Both prevention and treatment are needed to reduce alcohol problems and related costs in community settings—the former to reduce use and prevent unhealthy use before they begin and the latter to treat disorders once established. Unfortunately, treatment alone cannot effectively reduce use, disorders, and problems related to alcohol. The activities of commercial alcohol markets ensure that a large pool of susceptible drinkers remain at risk for disorders—a portion of these drinkers progress to disorders; a minority seek or are entered into treatment; and relapse rates after treatment are high. The consequence of these dynamics is that treatment alone would have to be nearly universally applied and very effective to substantially reduce alcohol use disorders in drinking populations (33). A more significant concern than the limited effectiveness of treatment, however, is that most alcohol-related problems, and the lion’s share of health care and social costs related to alcohol use, arise among the low risk (so-called “moderate drinkers") who do not exceed drinking limits or meet criteria for an alcohol use disorder (18). Treatment is not an option for these drinkers, and prevention efforts are essential to reduce problems due to alcohol use before disorders are established (34).

Many different educational prevention programs have been implemented that attempt to educate people about alcohol effects and problems related to use, encourage people to abstain from use, or encourage the development of social supports that discourage problematic use. On the whole, these programs have been shown to have limited success (35,36). A narrow focus on educational programs to the exclusion of other alternatives, incomplete conceptual models of program effects, poor program or policy designs, and inadequate research and evaluation plagued evaluation of these programs for some years (37,38). More recently, although preventive educational interventions have been shown to be successful in reducing or delaying alcohol use among young people (39), critical reviews have concluded that there is little convincing evidence that these programs by themselves lead to long-term reductions in use (40,41). It is unreasonable to expect that educational approaches alone can have a substantial and lasting impact on drinking problems when people are immersed in an environment in which alcohol is readily available and heavily marketed (42).

Environmental approaches to prevention take an alternative approach, acknowledging that alcohol-related problems result from interactions between individuals in many different social, economic, and community environments (4345) and that some features of these environments can be easily, and sometimes inexpensively, changed for the benefit of community members (46). These approaches have been developed to complement educational approaches and have been shaped into programs that communities can implement and that do not require direct intervention with specific individuals (4750). While differing somewhat in details, these programs have shared a common heritage of policy, regulatory, and enforcement interventions that attempted to reduce problems related to substance abuse by changing the economic, physical, or social environment in which alcohol or drugs are obtained or used (51,52). The focus on “communities,” such as neighborhoods within cities or cities themselves, recognizes that interventions at this level are likely to be most effective. It is at the geographic levels of neighborhoods and cities that most “community systems” bear upon alcohol use, abuse, and problems (43). Community systems are those formal and informal political and social institutions in a community that support and can be used to prevent alcohol-related problems; these include alcohol distribution systems, police enforcement, and treatment and medical facilities.

Environmental approaches contrast sharply with educational approaches in at least five respects: First, environmental approaches seek to change components of community systems that support substance use–related problems. These may include changes in functions of formal institutions (e.g., reducing hours and days of sale of alcohol), but may also include efforts to change informal systems (e.g., by making social hosts legally responsible for providing alcohol to underage drinkers). Individual educational approaches may encourage individual resistance to or desistance from use, but do not attempt to alter the formal or informal structures that enable use. Second, media’s efforts in environmental prevention are generally intended to motivate gatekeepers to pursue activities that are extensions of their normal efforts (e.g., law enforcement) or increase public awareness of prevention efforts (e.g., the availability of safe ride programs) to mobilize for structural and system change. Individual educational approaches target individuals to encourage individual behavior change (e.g., “just say no"). Third, rather than targeting at-risk individuals, environmental approaches target broader alcohol and drug environments and affect populations of users and nonusers alike. Thus, a workplace intervention may alter workplace policies toward alcohol, reduce use at the workplace, and provide greater safety for everyone (53). Since nonabusers often suffer collateral damage from alcohol and drug abuse (54,55), everyone benefits, and everyone is affected by the program. Fourth, individual educational approaches attempt to reduce the individual demand for drugs, whereas environmental approaches often focus on the supply side of substance use. Environmental efforts may include enforcement actions to reduce youth purchases of alcohol (56), drug interdiction (57), efforts to target risks specifically related to sales (e.g., responsible beverage service [RBS] programs) (58), safe needle programs (51), and efforts to change drug distribution to ameliorate problem “hot spots” (59). Fifth, as a final distinction, environmental approaches often focus on problems related to acute rather than chronic use, including motor vehicle crashes, injuries, and violence. Medical conditions related to use, like liver cirrhosis, are the outcome of long periods of heavy consumption unmitigated by environmental or social circumstance. Problems related to illegal drug markets, such as drug-related crime (60), or alcohol markets, such as alcohol-related crashes (59), on the other hand, are affected by current “acute” use and can be prevented without affecting use. Thus, an RBS program may reduce sales to intoxicated persons in bars and subsequently reduce drunken driving (58), but need not have an overall effect on drinking to be effective.

DOMAINS OF ENVIRONMENTAL PREVENTION

Environmental prevention programs act in four domains: the physical, the social, the economic, and the legal. Prevention programs may alter physical access by affecting proximity to sources of alcohol, drugs, and tobacco. College dormitories may prohibit alcohol in dorm rooms, college administrators may eliminate the sale of tobacco through vending machines, and public markets for illegal drugs may be disrupted by matrix enforcement programs. Environmental prevention programs may alter social access by affecting the social networks that encourage and enable distribution of these substances. They may alter social access to alcohol by restricting social activities at which alcohol is served (e.g., during on-campus celebrations), reduce social access to tobacco, and moderate social access to illegal drugs by establishing and enforcing drug-free zones in a community. Prevention interventions may alter economic access by increasing the real costs of alcohol, drugs, and tobacco through taxation minimum pricing, or regulating hours of sale, and changing the economic geography of availability. Laws may be enacted to decrease sales to minors or reduce the amount of alcohol an individual may legally consume prior to driving through restrictions on legal blood alcohol contents.

The four domains of environmental influence also interact in their effects upon alcohol and drug problems. For example, the physical, social, economic, and legal availability of alcohol (represented by outlets, use by others, beverage prices, and the laws regulating such) intersect at places where alcohol problems occur. For example, the presence of other drinkers at outlets exposes the patrons of a bar to both social influences for drinking and much greater risks of violence (61). Prices for alcoholic beverages at bars are much greater than at off-premise establishments, changing both the nature of drinking at bars and its relationship to problem outcomes, such as driving while intoxicated and alcohol-related crashes (62). The drinking patterns of others at these establishments influence the behaviors of drinking groups, as by encouraging much greater levels of intoxication (63). Parallel arguments can be constructed for illegal drugs. Concentrated use of illegal drugs (e.g., in and around crack houses) is associated with substantial degrees of crime and elevated rates of disease (51,64). Prices of illegal drugs may be influenced by drug interdiction efforts (modestly), but certainly affect the distribution of drug purchases (64). Favored drugs for abuse change as social access is restructured by enforcement efforts or other changes in informal social systems that support drug distribution.

SEVEN EFFICACY TRIAL CASE STUDIES

The past two decades have seen the intensive development of community-based environmental prevention and intervention programs. Community-based environmental prevention researchers moved from establishing that environmental prevention programs “work” to asking questions as to “what works,” “for whom,” and “why?” Different communities have different environmental structures and needs and different problems and concerns, each requiring some adaptation of program foci in the different domains of environmental prevention. The current challenge is how to develop and field a framework that adapts the logic of environmental prevention to the very different needs of communities. This process may be illustrated by considering seven efficacy trial case studies.

The Saving Lives Project

The Saving Lives Project, conducted in six communities in Massachusetts, was designed to reduce alcohol-impaired driving and related problems such as speeding. Programs were designed locally and involved a host of activities, including media campaigns, business information programs, speeding and drunk-driving awareness days, speed watch telephone hotlines, police training, high school peer-led education, Students Against Drunk Driving chapters, and college prevention programs. The program evaluation involved a quasi-experimental design with five communities serving as controls. While the control communities were slightly more affluent than the experimental sites, they had similar demographic characteristics, rates of traffic citations, and fatal crashes. The study found that Saving Lives cities experienced a 25% decline in fatal crashes when compared to the rest of Massachusetts (i.e., from 178 crashes to 120), a 42% reduction in fatal motor vehicle crashes within the experimental communities, a 47% reduction in the number of fatally injured drivers who tested positive for alcohol, and an 8% decline in crash injuries among 15- to 25-year-olds. In addition, there was a decline in self-reported driving after drinking (specifically among youth). The greatest fatal and injury crash reductions occurred in the 15-to-25-year-old age group (65).

The CMCA Project

The Communities Mobilizing for Change on Alcohol (CMCA) project was designed to reduce access to alcohol among the youth under the legal drinking age of 21. The project was composed of five core components intended to influence (a) community policies, (b) community practices, (c) youth alcohol access, (d) youth alcohol consumption, and subsequently (e) youth alcohol problems. Although the project clearly was communitywide in terms of the institutions involved, it was focused on youths under 21 years old. The CMCA project recruited 15 communities in Minnesota and western Wisconsin, matched them on size, state, proximity to a college or university, and baseline data from an alcohol purchase survey, and then randomly assigned members of each pair to intervention or control groups (66). The CMCA project hired a part-time local organizer from within each community who was responsible for community organizing activities that activated the community members, who would, in turn, select interventions designed to influence underage access to alcohol. The interventions that could be selected included a broad array of programs that affect youth access: underage decoy purchase operations in alcohol outlets, citizen monitoring of outlets selling to youths, keg registration, sponsorship of alcohol-free events for youth, policy action to shorten hours of sale for alcohol, implementation of RBS training programs, and development of educational programs for youth and adults. The experimental sites were free to shape these interventions to fit their own ends. Evaluation data were collected at baseline and at about 30 months after the interventions began. Results showed that merchants increased the frequency of checks for age identification, reduced sales to minors, and reported more care in controlling sales to youths. A telephone survey of 18- to 20-year-olds showed reductions in attempts to purchase alcohol, reduced levels of alcohol use, and reduced propensity to provide alcohol to other teens. In addition, the project found a statistically significant decline in drinking-and-driving arrests among 18- to 20-year-olds and disorderly conduct violations among 15- to 17-year-olds in the CMCA cities compared to the controls (66).

The Community Trials Project

The Community Trials (CT) project was a five-component community-level intervention conducted in three experimental communities matched to three control communities (46) in California and South Carolina. Intervention components of the project were designed to reduce alcohol-related harm among all persons in the three experimental communities. The outcomes assessed in the project represented five primary sources of acute injury and harm related to alcohol use: injuries and fatalities related to drinking and driving, violence, drowning, burns, and falls. The design of each intervention component was based on prior scientific evidence and intended to affect different aspects of community systems underlying use, abuse, and problems in community settings. The five intervention components were as follows: (a) a “Media and Mobilization” component to develop community organization and support for the goals and strategies of the project; (b) a “Responsible Beverage Service” component to reduce service to intoxicated patrons at bars and restaurants; (c) a “Sales to Youth” component to reduce underage access; (d) a “Drinking and Driving” component to increase enforcement activities related to driving while intoxicated (DWI) offenses; and (e) an “Access” component to reduce the availability of alcohol. The final evaluation of the project covered key problem areas through data collected in a large population survey and from archival sources and emergency departments. Comparison of the effects of the interventions on relative risks of injury outcomes between matched communities showed significant reductions in nighttime injury crashes (10%) and in crashes in which the driver was found by police to “have been drinking” (6%). Assault injuries observed in emergency departments declined by 43%, and all hospitalized assault injuries declined by 2%. Analyses of the survey data showed a 49% decline in episodes of driving after “having had too much to drink” and a 51% decline in self-reports of driving when “over the legal limit.” Importantly, although the drinking population increased slightly in the experimental sites over the course of the study, there was a significant reduction in problematic alcohol use; the average number of drinks per occasion declined by 6%, and the variance in drinking patterns (an indirect measure of heavy drinking) declined by 21% (46).

The Sacramento Neighborhood Alcohol Prevention Project

The primary goal of the Sacramento Neighborhood Alcohol Prevention Project (SNAPP) was to implement and evaluate neighborhood-level interventions intended to reduce youth and young adult access to alcohol, risky drinking, and associated problems, particularly in low-income, ethnically diverse neighborhoods. SNAPP represented an extension of the CT project in that it posed three basic questions. First, could an environmental approach be tailored to the unique needs of economically and ethnically diverse populations? Second, could environmental strategies address the problem of intentional injuries (i.e., assaultive violence) in the context of more economically and ethnically diverse settings? Finally, could these more specifically tailored interventions be implemented at the neighborhood level? To address these questions, SNAPP set as its goal the reduction of alcohol access, drinking, and related problems in two low-income, predominantly ethnic minority neighborhoods, focusing on individuals between ages 15 and 29.

SNAPP implemented five interventions, including a mobilization component, a community awareness component, a Responsible Beverage Service (RBS) component, an underage-access law enforcement component, and an intoxicated-patron law enforcement component. These were fielded in one area of the city early in the project and fielded in another similar area about 2 years later. To mobilize the neighborhoods in support of the overall project goals and interventions, project lead agencies worked with collaborative advisory committees, composed of members drawn from each of the two geographical areas and that worked to ensure intervention implementation and fidelity to project design. The community awareness component intended to increase awareness of the problems associated with youth and young adult drinking to catalyze support for community mobilization efforts. Activities included neighborhood presentations of research findings and local statistics related to underage and problematic drinking to parents and other community groups, distribution of informational flyers and brochures, and youth participation as volunteers in data collection activities related to neighborhood alcohol availability. The RBS component was designed to help retailers develop policies and train staff to reduce alcohol sales to minors and intoxicated persons. This component increased compliance with existing alcohol policies by obtaining sponsorship and support from local and state hospitality organizations, providing manager and server training for all on- and off-premise licensed alcohol outlets in the selected neighborhoods using a standard curriculum, developing a process to increase enforcement of existing laws regarding service to intoxicated customers, and obtaining endorsement of RBS from neighborhood bodies and organizations. The underage-access enforcement component focused on increasing actual and perceived enforcement of laws prohibiting alcohol sales to minors and was accomplished by working with neighborhood police to increase the number of off-premise sting operations. Other efforts were designed to parallel those of the on-premise intervention. Letters from the local police were sent to all premises in and around the study sites informing them that stepped-up enforcement of laws regarding sales to intoxicated patrons and minors would become a regular police activity.

The project evaluation showed that the neighborhood interventions led to an estimated reduction of 3.9% in police calls related to assaults and a 33.4% reduction in emergency medical system (e.g., ambulance) responses related to motor vehicle crashes in the first relative to the second intervention site. Subsequently, the project found an estimated reduction of 36.5% in police calls related to assaults and an estimated reduction of 37.4% in emergency medical system responses related to assaults in the second intervention site over preintervention levels (67).

The Operation Safe Crossing Project

The goal of the Operation Safe Crossing project was to implement and evaluate a large drunk-driving enforcement program at the US/Mexican border to reduce the number of youths crossing the border to drink in the city of Tijuana (across the border from the large metropolitan area of San Diego, California). The intervention activities for this project included both enforcement of drinking and driving laws through the use of sobriety checkpoints near the border and enforcing laws barring youth from reentering the United States without parents or other adult guardians through special patrols conducted about every 60 days. Data from a border breath test survey were used to dramatize the problem and gain public support for action. The data were also used to help design the enforcement effort and measure progress in reducing the cross-border drinking problem. Analysis of data from this pre–poststudy involved observations on more than 2 million pedestrians returning from Tijuana. The Operation Safe Crossing program appeared to reduce the number of late-night crossers by 31.6% relative to rates before the intervention. In addition, the proportion of pedestrians with blood alcohol concentrations at 0.08 declined by 29%, and there was a decline in the number of 16- to 20-year-olds who had been drinking and were involved in automobile crashes relative to other drivers of the same age group who had not been drinking and crashed (68).

The Safer California Universities Project

The aim of this project was to determine whether environmental prevention strategies targeting specific off-campus settings would reduce the incidence of student intoxication on college campuses. Fourteen large public universities were recruited to participate in the project; campuses were matched on campus and community characteristics; and one member of each pair was randomly assigned to the intervention condition. The intervention campuses implemented five environmental interventions: (a) nuisance party enforcement operations to reduce problems related to off-campus parties, (b) minor decoy operations at on- and off-premise outlets to reduce underage sales and sales to intoxicated persons, (c) police roadside checkpoints testing for intoxicated drivers, (d) development of social host ordinances to discourage provision of alcohol to underage drinkers in social gatherings, and (e) the use of campus and local media to increase the visibility of all these environmental strategies. Significant reductions in the incidence and likelihood of intoxication at off-campus parties and bars/restaurants were observed among intervention campuses compared to controls. A lower likelihood of intoxication was also observed among intervention campuses for the last time students drank at an off-campus party, a bar or restaurant, or another (undesignated) setting. No increase in intoxication appeared in any setting, a sign that heavy drinking and intoxication were not displaced to other drinking contexts. Finally, stronger intervention effects were observed at those intervention campuses with the highest intensity of implementation (69).

Reducing Youth Access to Alcohol Project

As noted previously, alcohol prevention programming has traditionally focused on school-based educational that have focused on information-based approaches. Unfortunately, evaluation of these efforts has produced mixed results. This is particularly problematic since research has clearly indicated that alcohol is readily available to young people from a variety of retail and social sources. The Oregon Reducing Youth Access to Alcohol Project incorporated a mix of law enforcement and other community-based activities. The Reducing Youth Access to Alcohol intervention was initiated as a collaborative effort involving researchers, local community actors, and the Addictions and Mental Health Division (AMHD) of Oregon’s Department of Health and Human Services. The five specific program programs included (a) community mobilization, (b) a reward and reminder program, (c) media advocacy, (d) enforcement, and (e) coordination and community outreach.

The study design involved 36 Oregon communities defined by public school districts that participated in the annual in-school Oregon Healthy Teens surveys of 8th and 11th grade students. Communities were randomly assigned to intervention and control conditions. Because of limited resources, the interventions were implemented consecutively in two cohorts of communities. During the initial stage of project interventions, project staff and community prevention coordinators secured community support and endorsement for the project. Specific mobilization activities included presentations highlighting local underage drinking data, education to increase awareness of the risks associated with underage alcohol consumption, and highlights of proposed project activities. In each intervention community, as a part of the Reward and Reminder Program, off-premise outlets in each community were visited by young-appearing buyers who reinforced proper alcohol ID checking practices and provided constructive feedback to clerks, managers, and owners when proper ID checking procedures were not followed. In the weeks preceding these visits, merchant education visits were conducted to each alcohol outlet. The Media Advocacy component included a series of newspaper articles and community/school newsletters focusing on topics such as county-specific underage drinking statistics, underage drinking during prom and graduation, the dangers of underage drinking at home, social host liability, and project law enforcement activities. Enforcement activities included compliance checks, which were completed once per year for 2 years in each of the off-premise alcohol outlets in the project communities, along with shoulder tap operations, third-party purchase surveillance, enforcement of minor in possession laws, DWI enforcement, and controlled party dispersal. Throughout the program, staff and coalition members worked with key stakeholders in each community to ensure program implementation.

Evaluation data consisted of student surveys administered annually to 11th grade students along with underage purchase surveys. For evaluation purposes, four primary outcome measures were identified. These included measures of any prior 30-day alcohol use, prior 30-day binge drinking, and perceived availability to alcohol for the student survey and “successful” purchases from the purchase survey. Statistically significant effects were found for the underage sales outcome measure. Additional analyses showed that enforcement activities, which varied considerably between sites, had a moderating effect on both 30-day drinking and underage binge drinking (70). Specifically, significant reductions in these outcomes were observed in communities with the highest levels of implementation. No changes were observed in communities with only modest levels of implementation.

MULTICOMPONENT ENVIRONMENTAL APPROACHES CONSIDERED

These seven prevention intervention studies differed along a number of dimensions. Each was targeted to a slightly different population, implemented in different sites, involved a different implicit or explicit model of program effects, targeted different outcomes, used different evaluation tools (be they in-school surveys or roadside survey data on alcohol-related crashes), and ultimately produced findings with somewhat different implications for program development and future research. That said, each was characterized by a common set of core scientific characteristics. Specifically, each involved careful collection of baseline data, targeted a well-defined community-level problem, involved long-term implementation and monitoring, and produced a final intervention evaluation documenting success in reducing targetted problems. More substantively, each was comprehensive and multicomponent, addressed the specifics of the local alcohol environment based on prior research and relied on local personell for implementation. Importantly, each demonstrated, across a variety of research and community settings, the potential impact of interventions targeting physical, economic, social, and legal aspects of the alcohol environment on drinking and alcohol-related problems. Clearly, this history demonstrates that environmental prevention can work. “What works?” and “Why it works?” remain important questions.

THE EMERGENCE OF ECOLOGIC RESEARCH

One of the side benefits of these projects has been the development of a set of core research findings suggestive of directions in which environmentally based prevention science might be directed. These projects were, indeed, efficacy trials for environmental preventive interventions, but efficacy trials “with a twist” so to speak. Each manipulated with some success different components of complex community systems related to drinking and the emergence of drinking problems. Each produced fundamental research findings on the mechanisms of success and failure and unintended consequences that environmental preventive interventions can have in community settings. Each has guided the field toward more direct ecologic studies of alcohol-related problems. Still, further ecologic studies are needed to develop a deeper understanding of how community systems work. Through a better understanding of the processes and relationships that generate alcohol- and other drug-related problems, improved intervention strategies can be developed.

Despite the demonstrated effectiveness of environmentally based preventive interventions, much empirical research and efficacy testing remains to be done. To date, most approaches that study relationships between alcohol environments and alcohol problems rely upon statistical evaluations of empirical correlations to elucidate plausible person-environment interactions. In this sense, we are in the first stage of truly ecologic studies. We have moved from demonstrating that environmental interventions are effective to considering which are the most effective. Yet, careful studies of the mechanisms that make them work have not been conducted. The causal status of arguments based on correlational data can be strengthened by longitudinal analyses that identify the same associations over time. However, without a convincing theoretical statement of plausible mechanisms that relate observed environmental measures to outcomes (i.e., a stated mechanism by which greater outlet densities lead to more neglect and abuse) and without accompanying empirical tests of these mechanisms, the causal processes that support these correlations remain unknown. Tests of unique predictions from social ecologic models (e.g., that the time heavy-drinking parents spend either intoxicated or drinking outside the home reduces parental monitoring and leads to child neglect) are required. Moreover, it is clear that such studies would need to incorporate individual-level data (e.g., surveys) into analyses that have typically relied on aggregate-level data. The ultimate goal is to state and test strong social ecologic theories about alcohol-related problems such as drinking and drunken driving, intimate partner violence and alcohol, parental alcohol use and child abuse and neglect, and the relationships of community policy and enforcement activities to underage drinking.

To summarize, a number of important points should be noted. First, almost all of the interventions reviewed above have to do with regulating availability, punishing or deterring at risk drinkers, or enforcing other alcohol controls. This rather primitive view, while consistent with overall effects, ignores those situations where such approaches are likely to fail (e.g., other problems related to the social uses of alcohol). Second, by maintaining an individual focus, traditional approaches ignore the broader economic and community structures that support alcohol problems. Specifically, the social and commercial distribution of alcohol in communities may distort social systems in specific ways that may lead to great harm. In developing and developed countries, where commercialization of distribution and sales is championed by commercial or social interests, these distortions can be quite excessive, leading to much harm (and the institutionalization of systems that produce and maintain harm). Third, careful consideration should be given to the roles outlets play in producing problems. Here, at least three theories present themselves, each with different implications for prevention policy. First, outlets may cause problems through their effect on consumption levels. In this case, the target of policy interventions is appropriately to be found in the regulation of the alcohol that flows through them. Second, outlets may serve as places where problems “congregate” as a result of the concentration of drinkers into drinking cultures and environments with generally permissive norms regarding the expression of aggression. In this case, alcohol would appear to be somewhat secondary, and attention would need to be focused on more general policing of establishments and the development of policies designed to thwart the development of such “subcultures of violence.” Finally, outlets might simply be markers of social pathology. Outlets may simply concentrate in low-income areas where political opposition to their development is absent or ineffectual. Unfortunately, given our current state of knowledge, we are only beginning to put together a suitable ecologic explanatory framework.

THE LOGIC OF ENVIRONMENTAL PREVENTION

Even as we continue to build a registry of effective prevention strategies, we are faced with the awareness that research in the most efficient ways to implement those strategies is sorely lacking. Conventional approaches are too often very slow and labor intensive. One approach to facilitate implementation is the use of a logic model to drive even the earliest phases of a community intervention to reduce alcohol problems. This approach has evolved from experience with Holder’s Community Trials project (46), the Sacramento Neighborhood Alcohol Prevention Project (SNAPP) (67), and the Safer California Universities Project (69). Figure 21-1 shows an example developed to address underage drinking. The model summarizes an extensive literature review of factors related to differences in community prevalence of underage drinking (see http://www.pire.org/logicmodels.htm). The diagram is used in the very first meeting of the community task force or coalition and guides assessment, planning, and implementation of activities more directly than current practice in technical assistance. Evidence-based interventions can be laid over the diagram to show how they work to reduce the problematic outcome. Thus, this “logic model” is not simply a codification of the “inputs” and “outputs” of a program or intervention (as logic models are usually defined), but is instead of synthesis of research, a theory of change, and (eventually) an action plan, all built on the same simple “platform.”

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FIGURE 21-1 Summary of literature review of factors related to differences in community prevalence of underage drinking.

Conventional practice provides materials and menus of intervention options to community groups with little guidance for tying them into a synergistic whole. A logic model, by contrast, is far more prescriptive and, in our experience, thereby greatly appreciated by community members. It is used to communicate what the set of relevant prevention strategies are, and how they are meant to work together. It draws borders around what kind of assessment and process data need to be collected and what decisions need to be made in planning. The logic model identifies what kinds of people or agencies should be recruited for the intervention, which diverges from the notion that a large group of stakeholders should be recruited as a first step. Instead, the approach is to recruit others for specific components of the intervention (rather than being asked to take part in monthly meetings).

In sum, the logic models clarify the partnership between researchers and community members by drawing attention to what research recommends be done and what local expertise recommends about how to accomplish it. It leads communities to focus more on objectives than process, moves the community quickly through assessment and planning so members can be engaged in the action phase sooner, and, finally, keeps everyone focused on community-level outcomes.

ENVIRONMENTAL PREVENTION AND THE ROLE OF THE MEDICAL PROFESSIONALS

Although environmental prevention is typically cast in contrast to medical treatment, its relevance to medical practice broadly conceptualized can be substantial in a number of ways. Perhaps, the most obvious way is the “gatekeeper” function served by medical practitioners relative to prescription drugs. Medical practitioners as a part of their social function regulate access to prescription drugs on a daily and patient by patient basis. Although prescription medications do often circulate through social networks, such access relies heavily on the cooperation of medical personnel who provide access by writing prescriptions. Given the current problems associated with certain prescription medicines related to “doctor shopping,” prescription sharing, and patients receiving multiple prescriptions for the same drugs or drugs whose combined use is counterindicated, the role of medical professionals is substantial. Also, medical professionals may lobby their professional associations for the endorsement of “best practices” around such prescription-related practices. Even more globally, medical professionals are in a unique position to impact the communities by advocating for healthier environments. Thus, one may argue that at all levels of community systems, from the actual settings of clinical practices to the boards that govern medical practices, to macrostructures that govern community structures and ultimately produce observed health outcomes, the potential role of medical practitioners is substantial.

ACKNOWLEDGMENTS

This work was supported by NIAAA grant P60-AA06282 (Environmental Approaches to Prevention).

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