Chapter 3 Preview

As discussed in earlier chapters, the misuse of alcohol and drugs and substance use disorders has a huge impact on public health in the United States. In 2014, over 43,000 people died from a drug overdose, more than in any previous year on record² and alcohol misuse accounts for about 88,000 deaths in the United States each year (including 1 in 10 total deaths among working-age adults).⁴ The yearly economic impact of alcohol misuse and alcohol use disorders is estimated at $249 billion ($2.05 per drink) in 2010⁶ and the impact of illicit drug use and drug use disorders is estimated at $193 billion-figures that include both direct and indirect costs related to crime, health, and lost productivity.⁷ Over half of these alcohol-related deaths and three-quarters of the alcohol-related economic costs were due to binge drinking. In addition, alcohol is involved in about 20 percent of the overdose deaths related to prescription opioid pain relievers.⁶

Substance misuse is also associated with a wide range of health and social problems, including heart disease, stroke, high blood pressure, various cancers (e.g., breast cancer), mental disorders, neonatal abstinence syndrome (NAS), driving under the influence (DUI) and other transportation-related injuries,^8,9 sexual assault and rape,^10,11 unintended pregnancy, sexually transmitted infections,¹² intentional and unintentional injuries,¹³ and property crimes.¹⁴

Given the impact of substance misuse on public health and the increased risk for long-term medical consequences, including substance use disorders, it is critical to prevent substance misuse from starting and to identify those who have already begun to misuse substances and intervene early. Evidence-based prevention interventions, carried out before the need for treatment, are critical because they can delay early use and stop the progression from use to problematic use or to a substance use disorder (including its severest form, addiction), all of which are associated with costly individual, social, and public health consequences.^6,15-17 This chapter will demonstrate that prevention can markedly reduce the burden of disease and related costs. The good news is that there is strong scientific evidence supporting the effectiveness of prevention programs and policies.

This chapter uses the term evidence-based interventions (EBIs) to refer to programs and policies supported by research. The chapter discusses the predictors of substance use initiation early in life and substance misuse throughout the lifespan, called risk factors, as well as factors that can mitigate those risks, called protective factors. The chapter also includes a system of categorizing prevention strategies defined by the Institute of Medicine (IOM).¹⁸ This discussion is followed by a review of rigorous research on substance use initiation and misuse prevention programs that have demonstrated evidence of effectiveness. The chapter continues with a review of the rigorous research on the effectiveness and population impact of prevention policies, most of which are associated with alcohol misuse, as there is limited scientific literature on policy interventions for other drugs. Detailed reviews of these programs and policies are in Appendix B - Evidence-Based Prevention Programs and Policies. The chapter then describes how communities can build the capacity to implement effective programs and policies community wide to prevent substance use and related harms, and concludes with research recommendations.

Why We Should Care About Prevention

Beginning in the twentieth century, the major illnesses leading to death shifted from infectious diseases, such as tuberculosis and infections in newborns, to noncommunicable diseases, such as heart disease, diabetes, and cancer. This shift was a result of effective public health interventions, such as improved sanitation and immunizations that reduced the rate of infectious diseases, as well as increased rates of unhealthy behaviors and lifestyles, including smoking, poor nutrition, physical inactivity, and substance misuse. In fact, behavioral health problems such as substance use, violence, risky driving, mental health problems, and risky sexual activity are now the leading causes of death for those aged 15 to 24.¹⁹

To effectively prevent substance misuse, it is important to understand the nature of the problem, including age of onset. Although people generally start using and misusing substances during adolescence, misuse can begin at any age and can continue to be a problem across the lifespan. As seen in Figure 3.1, likelihood of substance use escalates dramatically across adolescence, peaks in a person's twenties, and declines thereafter. For example, the highest prevalence of past month binge drinking and marijuana use occurs at ages 21 and 20, respectively. Other drugs follow similar trajectories, although their use typically begins at a later age.²⁰ Early substance misuse, including alcohol misuse, is associated with a greater likelihood of developing a substance use disorder later in life.^21,22 Of those who begin using a substance, the percentage of those who develop a substance use disorder, and the rate at which they develop it, varies by substance.

Figure 3.1

Past-Month Alcohol Use, Binge Alcohol Use, and Marijuana Use, by Age: Percentages, 2015 National Survey on Drug and Health (NSDUH). Note: Binge alcohol use is defined as drinking five or more drinks (for males) or four or more drinks (for females) on (more...)

It is important to note that the vast majority of people in the United States who misuse substances do not have substance use disorders.^20,23 Nonetheless, substance misuse can put individual users and others around them at risk of harm, whether or not they have a disorder. Also, early initiation, substance misuse, and substance use disorders are associated with a variety of negative consequences, including deteriorating relationships, poor school performance, loss of employment, diminished mental health, and increases in sickness and death (e.g., motor vehicle crashes, poisoning, violence, or accidents).^15-17 It is therefore critical to prevent the full spectrum of substance misuse problems in addition to treating those with substance use disorders.

Preventing or reducing early substance use initiation, substance misuse, and the harms related to misuse requires the implementation of effective programs and policies that address substance misuse across the lifespan. The prevention science reviewed in this chapter demonstrates that effective prevention programs and policies exist, and if implemented well, they can markedly reduce substance misuse and related threats to the health of the population. However, evidence-based programs and policies are underutilized. For example, studies have found that many schools and communities are using prevention programs and strategies that have little or no evidence of effectiveness.^24,25 In fact, underuse of effective prevention programs and policies was the impetus for the creation of Communities That Care (CTC), a prevention service delivery system that promotes healthy youth development, improves youth outcomes, and reduces substance use and other problem behavior.²⁶

At the policy level, research shows that higher alcohol prices reduce alcohol misuse and related harms (e.g., alcohol-related motor vehicle crashes),^27-31 and taxes are one component of price. As of January 1, 2015, 42 states had a beer excise tax of less than $0.50 per gallon, while only four states had an excise tax more than $1.00 per gallon (Table 3.4).^32,33

Table 3.4

Status of Selected Evidence-Based Strategies in States for Preventing Alcohol Misuse and Related Harms.

Risk and Protective Factors

Longitudinal research has identified predictors of substance use and other behavioral health problems that are targets for preventive interventions.^34-36 Risk and protective factors influence the likelihood that a person will use a substance and whether they will develop a substance use disorder.

Risk and protective factors become influential at different times during development, and they often relate to physiological changes that occur over the course of development or to factors in a person's environment—for example, biological transitions such as puberty or social transitions such as attending a new school, parental divorce or military deployment, or graduation.³⁷ These factors can be influenced by programs and policies at multiple levels, including the federal, state, community, family, school, and individual levels.^38-41 Targeted programs implemented at the family, school, and individual levels can complement the broader population-level policy interventions, and assist in reducing specific risk factors (Table 3.1) and promoting protective factors (Table 3.2). Although there are exceptions, most risk and protective factors associated with substance use also predict other problems affecting youth, including delinquency, psychiatric conditions, violence, and school dropout. Therefore, programs and policies addressing those common or overlapping predictors of problems have the potential to simultaneously prevent substance misuse as well as other undesired outcomes.^42-44

Table 3.1

Risk Factors for Adolescent and Young Adult Substance Use.

Table 3.2

Protective Factors for Adolescent and Young Adult Substance Use.

Some risk and protective factors appear to have consistent effects across cultural and gender groups, although low-income and disadvantaged populations are generally exposed to more risk factors, including risk factors within the environment, and to fewer protective factors than are other groups in the population. However, research has shown that binge drinking is more common among individuals in higher income households as compared to lower income households.⁴⁵ This has implications for the types of prevention programs and policies that might be most successful with disadvantaged populations. Despite the similarities in many identified risk factors across groups, it is important to examine whether there are subpopulation differences in the exposure of groups to risk factors.

Types of Prevention Interventions

The IOM has described three categories of prevention interventions: universal, selective, and indicated.¹⁸ Universal interventions are aimed at all members of a given population (for instance, all children of a certain age); selective interventions are aimed at a subgroup determined to be at high-risk for substance use (for instance, justice-involved youth); indicated interventions are targeted to individuals who are already using substances but have not developed a substance use disorder. Communities must choose from these three types of preventive interventions, but research has not yet been able to suggest an optimal mix. Communities may think it is best to direct services only to those with the highest risk and lowest protection or to those already misusing substances.¹⁰⁰ However, a relatively high percentage of substance misuse-related problems come from people at lower risk, because they are a much larger group within the total population than are people at high-risk. This follows what is known as the Prevention Paradox: “a large number of people at a small risk may give rise to more cases of disease than the small number who are at a high risk.”¹ By this logic, providing prevention interventions to everyone (i.e., universal interventions) rather than only to those at highest risk is likely to have greater benefits.³

One advantage of a properly implemented universal prevention intervention is that it is likely to reach most or all of the population (for example, school-based interventions are likely to reach all students). Targeted (selective and indicated) approaches are likely to miss a large percentage of their targets, but they provide more intensive services to those who are reached. Because the best mix of interventions has not yet been determined, it is prudent for communities to provide a mix of universal, selective, and indicated preventive interventions.

Evidence-based Prevention Programs

This section identifies universal, selective, and indicated prevention programs that have been shown to successfully reduce the number of people who start using alcohol or drugs or who progress to harmful use. Inclusion of the programs here was based on an extensive review of published research studies. Of the 600 programs considered, 42 met criteria to be included in this Report. Studies on programs that included people who already had a substance use or related disorder were excluded. The review used standard literature search procedures which are summarized in detail in Appendix A - Review Process for Prevention Programs.

The vast majority of prevention studies have been conducted on children, adolescents, and young adults, but prevention trials of older populations meeting the criteria were also included. Programs that met the criteria are categorized as follows: Programs for children younger than age 10 (or their families); programs for adolescents aged 10 to 18; programs for individuals ages 18 years and older; and programs coordinated by community coalitions. Due to the number of programs that have proven effective, the following sections highlight just a few of the effective programs from the more comprehensive tables in Appendix B - Evidence-Based Prevention Programs and Policies, which describe the outcomes of all the effective prevention programs. Representative programs highlighted here were chosen for each age group, domain, and level of intervention, and with attention to coverage of specific populations and culturally based population subgroups. It is important to note that screening and brief intervention (SBI) and electronic SBI for reducing alcohol misuse have been recognized as effective strategies for identifying and reducing substance misuse among adults, but these are discussed in detail in Chapter 4 -Early Intervention, Treatment, and Management of Substance Use Disorders as effective early intervention strategies.^103-106

Programs for Older Adults

Only two studies showed preventive effects on alcohol use in older adults.^174,175 One is Project Share, which showed reductions in heavy drinking among those aged 60 and older. Project Share provided personalized feedback to at-risk older drinkers, which included a personalized patient report, discussion with a physician, and three phone calls from a health educator.¹⁷⁴ A second study, the Computerized Alcohol-Related Problems Survey (CARPS) assessed personalized reports of drinking risks and benefits accompanied with education for physicians and patients aged 65 and older. The study found a significant decrease in alcohol misuse, including reductions in the quantity and frequency that older individuals reported drinking.¹⁷⁵

Economics of Prevention

The Washington State Institute for Public Policy developed a standardized model using scientifically rigorous standards to estimate the costs and benefits associated with various prevention programs. Benefit-per-dollar cost ratios for EBIs ranged from small returns per dollar invested to more than $64 for every dollar invested. These estimates are illustrated below in Table 3.3.

Table 3.3

Cost-Benefit of EBIs Reviewed by the Washington State Institute for Public Policy, 2016.

Evidence-based Community Coalition-based Prevention Models

Community-based prevention programs can be effective in helping to address major challenges raised by substance misuse and its consequences. Such programs are often coordinated by local community coalitions composed of representatives from multiple community sectors or organizations (e.g., government, law enforcement, health, education) within a community, as well as private citizens.

These coalitions work to change community-level risk and protective factors and achieve community-wide reductions in substance use by planning and implementing one or more prevention strategies in multiple sectors simultaneously, with the goal of reaching as many members of the community as possible with accurate, consistent messages. For example, interventions may be implemented in family, educational, workplace, health care, law enforcement, and other settings, and they may involve policy interventions and publicly funded social and traditional media campaigns.^{28,74,177-179}

A common feature of successful community programs is their reliance on local coalitions to select effective interventions and implement them with fidelity. An important requirement is that coalitions receive proactive training and technical assistance on prevention science and the use of EBIs and that they have clear goals and guidelines. Technical assistance can be provided by independent organizations such as Community Anti-Drug Coalitions of America (CADCA), academic institutions, the program developers, or others with expertise in the substance misuse prevention field. Three examples of effective community-based coalition models are provided below.

Evidence-based Prevention Policies

This section primarily discusses the evidence of effectiveness for policies to reduce alcohol misuse, as well as the more limited body of scientific literature on the effectiveness of policies to prevent the misuse of prescription medications, including pain relievers, tranquilizers, stimulants, and sedatives.

Policies to Reduce Alcohol Misuse and Related Problems

Research has shown that policies focused on reducing alcohol misuse for the general population can effectively reduce alcohol consumption among adults as well as youth, and they can reduce alcohol-related problems including alcohol-impaired driving.^190,191 In addition to discussing a number of effective population-level alcohol policies, this section will also describe policies designed specifically to reduce drinking and driving and underage drinking.

Price and Tax Policies

Evidence indicates that higher prices on alcoholic beverages are associated with reductions in alcohol consumption and alcohol-related problems, including alcohol-impaired driving. Several systematic reviews have linked higher alcohol taxes and prices with reduction in alcohol misuse, including both underage and binge drinking.^{28,31,72,192-197} One 2009 review examined 1,003 separate estimates from 112 studies.⁷² The authors concluded, “We know of no other prevention intervention to reduce drinking that has the numbers of studies and consistency of effects seen in the literature on alcohol taxes and prices.” Similarly, a 2010 review of 73 taxation studies found “consistent evidence that higher alcohol prices and alcohol taxes are associated with reductions in both alcohol misuse and related, subsequent harms.”³¹ For example, a study found that the price elasticity of binge drinking among individuals aged 18 to 21 was -0.95 for men and -3.54 for women, meaning that a 10.0 percent increase in the price of alcohol is expected to decrease binge drinking by 9.5 percent among men and 35.4 percent among women in that age group.¹⁹⁸

The effectiveness of increasing alcohol taxes as a strategy for reducing alcohol misuse and related problems has also been acknowledged outside the United States.²⁸ For example, a 2009 World Health Organization (WHO) review stated that “when other factors are held constant, such as income and the price of other goods, a rise in alcohol prices leads to less alcohol consumption” and “[p]olicies that increase alcohol prices delay the time when young people start to drink, slow their progression towards drinking larger amounts, and reduce their heavy drinking and the volume of alcohol drunk on each occasion.”¹⁹² Additionally, studies have found that increasing alcohol taxes is not only cost effective but can result in a net cost savings (i.e., the savings outweigh the costs of the intervention).

Policies that Affect Access to and Availability of Alcohol

Policies Affecting Alcohol Outlet Density

Research suggests that an increase in the number of retail alcohol outlets in an area—called higher alcohol outlet density—is associated with an increase in alcohol-related problems in that area, such as violence, crime, and injuries.^177,199,200 Four longitudinal studies of communities that reduced the number of alcohol outlets showed consistent and significant reductions in alcohol-related crimes, relative to comparison communities that had not reduced alcohol outlet density.^199,201-203 Although no studies have explicitly analyzed the cost-benefit ratio of this intervention, research suggests that the costs of limiting the number of alcohol outlets is expected to be much smaller than the societal costs of alcohol misuse.¹⁷⁷

Commercial Host (Dram Shop) Liability Policies

Commercial host (dram shop) liability allows alcohol retailers—such as the owner or server(s) at a bar, restaurant, or other retail alcohol outlet—to be held legally liable for harms resulting from illegal beverage service to intoxicated or underage customers.²⁰⁴ In a systematic review, 11 studies assessed the association between dram shop laws and alcohol-related health outcomes.²⁰⁵ The review found a median reduction of 6.4 percent (range was 3.7 percent to 11.3 percent) in alcohol-related motor vehicle fatalities associated with these policies. Two studies on the effects of these laws did not find reductions in binge drinking.

Policies to Reduce Days and Hours of Alcohol Sales

A review of 11 studies of changing days of sale (both at on-premise alcohol outlets such as restaurants and bars, and off-premise outlets such as grocery, liquor, and convenience stores) indicated that increasing the number of days alcohol could be sold was associated with increases in alcohol misuse and alcohol-related harms, while reducing days alcohol is sold was associated with decreases in alcohol-related harms.²⁰⁶ Similarly, a review of 10 studies (none conducted in the United States) found that increasing hours of sale by two or more hours increased alcohol-related harms, while policies decreasing hours of sale by at least two hours reduced alcohol-related harms.²⁰⁷ One study found that lifting a ban on Sunday sales of alcohol led to an estimated 41.6 percent increase in alcohol-related fatalities on Sundays during the period from 1995 to 2000, equating to an additional cost of more than $6 million in medical care and lost productivity per year in one state.²⁰⁸ Banning sales of alcohol on Sundays has been recognized as a cost-effective strategy.

State Policies to Privatize Alcohol Sales

The privatization of alcohol sales involves changing from direct governmental control over the retail sales of one or more types of alcohol, and allowing private, commercial entities to obtain alcohol licenses, typically to sell liquor in convenience, grocery, or other off-premise locations. A systematic review of studies evaluating the impact of privatizing retail alcohol sales found that such policies increased per capita alcohol sales in privatized states by a median of 44.4 percent. Studies show that per capita alcohol sales is known to be a proxy for alcohol misuse.^209,210

Policies to Reduce Drinking and Driving

Since the early 1980s, alcohol-related traffic deaths in the United States have been cut by more than half (Figure 3.2). It has been estimated that reductions in driving after drinking prevented more than 300,000 deaths during this time period.²¹¹ In fact, declines in traffic deaths due to reductions in drinking and driving have exceeded declines from the combined effects of increased use of seat belts, airbags, and motorcycle and bicycle helmets.²¹² From 1982 to 2013, alcohol-related traffic deaths decreased by 67 percent, whereas non-alcohol-related traffic deaths decreased by only 14 percent.²¹³

Figure 3.2

Alcohol- Versus Non-alcohol-related Traffic Deaths, Rate per 100,000, All Ages, United States, 1982-2013. Source: Adapted from Hingson and White, (2014).

Several policies and law enforcement approaches have been found to reduce rates of drinking and driving and related traffic crashes, injuries, and deaths within the general population, among both youth and adults. These DUI policies and enforcement approaches create deterrence by increasing the public's awareness of the consequences of drinking and driving, including the possibility of arrest. Some of these strategies include:

• 0.08 percent criminal per se legal blood alcohol content (BAC) limits, meaning that no further evidence of intoxication beyond a BAC of 0.08 percent is needed for a DUI case;^214-221 and
• Sobriety checkpoints.^222-224

Other proven DUI prevention strategies fall under the rubric of indicated interventions as they target drivers who have been convicted of DUI to reduce recidivism:²²³

• Lower legal blood alcohol limits for people convicted of DUI;^217,223
• Mandatory ignition interlock laws for all convicted offenders, including first offenders;^223,225,226
• Mandatory assessment and treatment of persons convicted of DUI;²²³
• DUI courts;²²³
• Continuous 24/7 alcohol monitoring of persons with one or multiple DUI charges;²²³ and
• Vehicle impoundment or immobilization.²²³

The Implications of Drinking-Oriented and Driving-Oriented Policies to Reduce Harms

An examination of state-level data on 29 alcohol control policies in all 50 states from 2001-2009²²⁷ divided those policies into two mutually exclusive groups: (1) drinking-oriented policies, intended to regulate alcohol production, sales, and consumption, raise alcohol taxes, and prevent sales to minors; and (2) driving-oriented policies, which are intended to prevent an already intoxicated person from driving. State data on impaired driving from more than 12 million adults during the even years of 2002 through 2010 were evaluated, and four results were reported, two of which are presented here:

• First, the review found that drinking-oriented policies were slightly more effective in reducing impaired driving than driving-oriented policies, though both types of policy changes were independently associated with lower levels of impaired driving.
• Second, drinking-oriented policies appeared to exert their effects by reducing binge drinking, which in turn was associated with a lower likelihood of impaired driving. The authors concluded that most states may have a greater opportunity for adopting and aggressively implementing drinking-oriented policies to reduce overall harms, although there is a need to strengthen driving-oriented policies as well.

Overall, these findings support the importance of implementing a comprehensive range of alcohol policies to effectively reduce alcohol misuse and related harms, including strengthening both drinking-oriented policies and driving-oriented policies.

Policies to Reduce Underage Drinking

Raising the Minimum Legal Drinking Age

Before 1984, only 22 states had a MLDA of 21. To reduce DUIs, Congress passed the National Minimum Drinking Age Act, which threatened to withhold a portion of states' federal highway construction funds if states made the purchase or public possession of alcoholic beverages legal for those under the age of 21. By 1988, all states had adopted age 21 as the MLDA. In the 1982 Monitoring the Future annual national survey of middle and high school students, 71.2 percent of high school seniors reported that they drank in the past 30 days and 42 percent reported binge drinking in the past 2 weeks.²²⁸ In 2014, these same statistics were 37.4 percent and 19 percent respectively (Figure 3.3).²¹³ These declines may be partially attributable to the MLDA²¹⁴ along with other policy and behavior-change interventions occurring at the same time.

Figure 3.3

Trends in 2-Week Prevalence of 5 or More Drinks in a Row among 12th Graders, 1980-2015. Note: The first vertical bar indicates institution of the MLDA 21 policy change in 7 states in 1984. The second vertical bar indicates federal passage of the MLDA (more...)

Many studies have shown the benefits of raising the MLDA. A Community Guide review found that raising the MLDA reduced crashes among drivers aged 18 to 20 by a median of 16 percent:²¹⁵ A finding replicated in a prospective analysis of the National Highway Traffic Safety Administration's (NHTSA's) Fatality Analysis Reporting System (FARS) examining the ratio of drinking to non-drinking drivers aged 20 and younger. The analysis statistically adjusted for zero tolerance laws, graduated licensing restrictions (e.g., provisional licenses for new drivers that include restrictions on driving at night or with any measurable alcohol in their systems), use/lose laws, administrative license revocation, 0.08% BAC per se laws, per capita beer consumption, unemployment rate, vehicle miles traveled, frequency of sobriety check points, number of licensed drivers, and the ratio of drinking to non-drinking drivers in fatal crashes ages 26 and older.²¹⁴ An additional analysis examined national alcohol-related fatal traffic crash data before and after states raised the MLDA to 21. Before those laws were instituted, 61 percent of drivers aged 16 to 20 had a positive BAC compared with 33 percent following institution of those laws.²²⁹ These analyses showed general declines in alcohol-related fatal crashes across age groups, but the declines were highest for drivers aged 16 to 20. Comparing the declines across ages is useful because these older drivers were not the main focus of the MLDA changes.

An extensive review concluded that raising the MLDA to 21 has been directly associated with less frequent drinking, less heavy drinking, and fewer alcohol-related traffic fatalities in the age groups targeted by the law.¹⁷⁸ More specifically, NHTSA estimates that raising the MLDA to 21 may have prevented 30,323 traffic deaths since 1975.²³⁰

MLDA Compliance Checks

As a complement to the MLDA laws, research has shown the importance of repeated compliance check surveys on alcohol sales to people younger than age 21. These compliance check surveys monitor the percentage of attempts to buy alcohol that result in a sale to a person appearing to be younger than age 21. Alcohol outlet owners are informed in writing whether or not they were observed selling alcohol to underage-appearing individuals, told about the penalties for selling to minors, which can include fines or license suspension, and informed that the surveys will be repeated. A review identified several studies that found these compliance check surveys reduce the percentage of underage alcohol buying attempts and sales of alcohol to youthful-looking decoys by more than 40 percent.¹⁸⁷ This strategy is an effective way to reduce alcohol consumption by minors and can be implemented in conjunction with population level alcohol policies.

Zero Tolerance Laws

All 50 states have passed laws making it illegal for persons younger than age 21 to drive with any measurable BAC. These laws, called zero tolerance laws, were instituted because of the higher fatal crash risk among drivers younger than age 21^215,231 and because of studies showing that lowering the drinking age below age 21 was related to increases in fatal crashes.²³² Another study examined the first eight states to implement zero tolerance laws, comparing each with a nearby state that did not enact such a law.²³³ Examining an equal number of years before and after these laws changed, researchers found 20 percent fewer alcohol-related traffic crash deaths in the targeted age groups within the zero tolerance states compared to nearby states without these laws. Similarly, a more recent examination of Monitoring the Future survey data for high school seniors in 30 states before and after adoption of zero tolerance laws found that after the laws were enacted, a 19 percent decline in driving after drinking occurred as well as a 23 percent decline in driving after five or more drinks.²³⁴

Use/Lose Laws

Use/lose laws allow states to suspend a person's driver's license for underage alcohol violations. An examination of the Youth Risk Behavior Surveillance System survey data by state (statistically adjusted to account for state differences in age, gender, race, ethnicity, and other factors) from 1999 to 2009 found past-month drinking declined after use/lose laws were instituted.²³⁵ The study also found that after these laws were instituted, survey respondents were half as likely to report driving after drinking compared with before the laws were instituted.

Criminal Social Host Liability Laws

Criminal state social host liability laws require law enforcement to prove intent to provide alcohol to underage guests. Specifically, “social host” refers to adults who knowingly or unknowingly host underage drinking parties on property that they own, lease, or otherwise control. With social host ordinances, law enforcement can hold adults accountable for underage drinking through fines and potentially criminal charges. More than 30 states have some form of social host liability laws. To see the effect of these laws, researchers examined rates of alcohol consumption, binge drinking, and DUI between 1984 and 2004 from the annual Behavioral Risk Factor Surveillance System. They also looked at data from the FARS from 1975 to 2005 on alcohol-related versus non-alcohol-related fatal traffic deaths among those aged 18 to 20. After controlling for the state's legal drinking age, several drinking laws, and socioeconomic factors, social host liability laws were independently associated with declines in binge drinking (3 percent), driving after drinking (1.7 percent), and alcohol-related traffic deaths (9 percent).²³⁶

Civil Social Host Liability Laws

In contrast to state-level criminal social host ordinances, city- or county-level civil liability ordinances allow for a lower burden of proof but still deter underage drinking parties. Through civil social host liability laws, adults can be held responsible for underage drinking parties held on their property, regardless of whether they directly provided alcohol to minors. To date, more than 150 cities or counties have social host liability ordinances in place. The research on this strategy is still emerging, but findings currently show that social host liability reduces alcohol-related motor vehicle crashes as well as other alcohol-related problems.^28,237

Proposals for Reductions in Alcohol Advertising

Although evidence of a causal relationship is lacking, research has found an association between increased exposure to marketing and increased alcohol consumption among youth.⁷⁷ For example, one study found that for every additional advertisement seen by youth per month, they drank one percent more, while for every additional dollar per capita spent on alcohol advertising in a youth's media market, they drank three percent more.²³⁸ Typically, these studies have not controlled for other factors known to influence underage drinking, such as parental attitudes and drinking by peers. Further, studies have yet to determine whether reducing alcohol marketing leads to reductions in youth drinking. One study estimated that a 28 percent decrease in alcohol marketing in the United States could lead to a decrease in the monthly prevalence of adolescent drinking from 25 percent to between 21 and 24 percent.²³⁹ A separate study of alcohol advertising bans concluded that “there is a lack of robust evidence for or against recommending the implementation of alcohol advertising restrictions.”²⁴⁰

Prevention Interventions for Specific Populations

An important consideration in any assessment of the overall effectiveness of EBIs is whether and to what extent they work with specific populations, such as Blacks or African Americans, Hispanics or Latino/as, Asians, American Indians or Alaska Natives, Native Hawaiians or Other Pacific Islanders, veterans, or lesbian, gay, bisexual, and transgender (LGBT) populations. The EBIs described in this chapter have been purposely selected because many have been implemented, tested, and found to be effective in diverse populations. It should be noted that while prevention policies have shown impacts for the entire population, and a number of prevention programs at each developmental period have shown positive outcomes with a mix of populations, most studies have not specifically examined their differential effects on racial and ethnic subpopulations. Studies finding significant prevention effects across multiple population subgroups include LifeSkills Training, keepin' it Real, Nurse Family Partnership, Raising Healthy Children, Good Behavior Game, Classroom-Centered Intervention, Fast Track, SODAs City, I Hear What You're Saying, Project Chill, Positive Family Support, Coping Power, Project Towards No Drug Abuse, Communities That Care, Project Northland, and Project STAR.

The following programs were found to be equally effective in White and specific racial and ethnic minority populations: Fast Track, which is equally effective for White and Black or African American adolescents, LifeSkills Training, which is equally effective with White and Black or African American and Hispanic or Latino adolescents, and keepin' it REAL, which is equally effective with White and Hispanic or Latino adolescents. In addition, some interventions developed for specific populations have been shown to be effective in those populations, i.e., Strong African American Families, Familas Unidas for Hispanics or Latinos, Bicultural Competence for American Indian or Alaska Natives, and PROSPER for rural communities.

Maximizing Prevention Program and Policy Effectiveness

Although a variety of prevention policies and programs have been shown to reduce substance misuse and consequences of use, many are underutilized. Additionally, many programs are not currently being implemented with sufficient quality to effectively improve public health. For example, although it is difficult to collect data on this issue, research suggests that few family-serving agencies are using EBIs to address child behavioral and emotional problems,^280,281 and surveys of school administrators indicate that only 8 to 10 percent report using EBIs to prevent substance misuse.^282,283 Additionally, research has shown that untested or ineffective prevention programs are used more often than EBIs,^282,283 and, when they are used, EBIs are often poorly implemented, do not serve large numbers of participants, and are not sustained.^284,285 For example, family-based EBIs are often delivered with less intensity and/or to different types of participants than specified by program developers.²⁸⁶ School officials have reported low rates of implementation fidelity, including failure to deliver all required lessons, content, and activities; to use the required materials; to employ the recommended instructional strategies; to target the appropriate students with lessons; and/or to ensure that all teachers receive training.^{24,283,284,287,288} EBIs that are poorly implemented tend to have weak or no effects on participants.^272,289-296 For example, in one study, the LifeSkills Training program delivered in middle and junior high schools has shown significant, long-term effects on Grade 12 students' alcohol and marijuana use only among students whose teachers delivered at least 60 percent of the required material.²⁹²

Research demonstrates that building prevention infrastructure; activating federal, state, local, and tribal stakeholders; ensuring collaboration; and helping communities select, implement, and sustain EBIs²⁹⁷ is possible and can be done effectively. For example, one large-scale study provided schools and various human service agencies with training and technical assistance to replicate nine EBIs rated as “Model” by the Blueprints for Healthy Youth Development.²⁶⁸ That study indicated that when provided with ongoing support, 74 percent of sites successfully implemented these systems.²⁹⁸ Evaluations of PROSPER and CTC, which provide community coalitions with prevention infrastructure to choose EBIs that addressed their needs and to implement the chosen EBIs with fidelity, have shown that communities using these delivery systems implement EBIs with high fidelity and sustain them over time.^299-304 In addition, evaluations showed that CTC communities reached more participants with more EBIs compared with communities that did not use this prevention infrastructure support system.^302,303 These and other studies indicate that prevention infrastructure can be generated by taking the actions discussed in the section on Improving the Dissemination and Implementation of Evidence-based Programs later in this chapter.

Additionally, strengthening state and local public health capacity will help to increase the surveillance and monitoring of risk and protective factors and substance misuse by adolescents and adults in the general population, including persons who drink to excess but are not dependent on alcohol. It is important to educate and raise awareness about the public health burden of substance misuse and effective program and policy interventions for preventing and reducing substance use across the population.

Improving the Dissemination and Implementation of Evidence-based Programs

The emerging field of dissemination and implementation research seeks to identify ways to increase the use and high-quality implementation of evidence-based programs and address challenges to implementation. This research indicates that the key to achieving significant gains in public health, including reductions in substance use initiation and substance misuse, is to build prevention infrastructure at the local level.^305-307 This means increasing awareness of EBIs among community leaders, service providers, and local citizens. It also means providing tools to help communities select and use EBIs that will be feasible to implement and relevant for their populations.^308-310 When agencies and staff are unaware of, do not support, or lack the ability to select and implement appropriate EBIs with quality, then dissemination, implementation, and sustainability will be hindered.^285,311-313 In contrast, when local systems and agencies learn more about the effectiveness of prevention interventions, have a culture and climate that supports innovation and the use of EBIs, and have the budget and skills needed to plan for and monitor the implementation of EBIs, then effective dissemination and implementation will be fostered.^{294,311,312,314-318}

Coalition-based systems have been developed to assist communities in building these capacities, and when tested in randomized trials, these systems have been shown to improve community capacity for effective prevention; increase dissemination, implementation, and sustainability of EBIs; and produce community-wide reductions in youth substance use.³²⁴ An important feature of these systems is the provision of community coalitions with multiple training workshops and ongoing technical assistance. Just as organizations require technical assistance to ensure high-quality implementation of specific EBIs, coalitions need technical assistance to support and develop their prevention capacities.^325-328 Each community model has different steps that outline their process; the following four steps are one example of how to build broader implementation of evidence-based prevention.

Recommendations for Research

Although much has been learned in prevention research over the past four decades, much remains to be understood. Future research should develop and evaluate new prevention interventions, both programs and policies, and continue to assess the effectiveness of existing interventions about which little is known. This research will help guide the field toward strategies with the greatest potential for reducing substance misuse and related problems.

Research also is needed to examine the effectiveness of screening and brief interventions for alcohol use in adolescents and for drug use in adolescents and adults; the combinations of evidence-based alcohol policies that most effectively reduce alcohol misuse and related harms; the public health impact of policies to reduce drug misuse; and the effectiveness of strategies to reduce marijuana misuse, driving after drug use, and simultaneous use of alcohol and drugs. In addition, the public health impact of marijuana decriminalization, legalization of medical marijuana, and legalization of recreational marijuana on marijuana, alcohol, and other drug use, as well as policies to reduce prescription drug misuse, should be monitored closely.

Research is needed to develop and test new prevention interventions, both policies and programs, to fill gaps in existing EBIs and to meet emerging public health needs across the lifecourse.

Given that racial and ethnic minority communities are often disproportionately affected by the adverse consequences of substance misuse, culturally-informed research should be conducted to examine ways to increase the cultural relevance, engagement, and effectiveness of prevention interventions for diverse communities. Additionally, studies of these interventions should be replicated and examined to determine the impact of prevention interventions for different cultural groups and contexts.

Consistent standards for evaluating interventions, conducting replication trials, and reporting the results should be developed. Examples of such standards have been developed by the Society for Prevention Research and the United Nations Office on Drugs and Crime.^{26,357,362-368} Studies evaluating the effectiveness of interventions for reducing substance misuse should collect data over extended periods of time to track the long-term effects of these interventions on persons of all ages. The impact of environmental interventions on substance misuse should also be followed for at least a year beyond the end of the period of intervention support. The field needs to develop a consensus on standardization of methods of cost-benefit analysis, and increase research on cost-effectiveness evaluations of prevention EBIs.

Evidence is also needed to develop improved strategies for intervention in primary health care settings to prevent the initiation and escalation of adolescent substance use. More research is also needed on linking screening with personalized interventions, improved strategies for effective referral to specialty treatment, and interventions for adolescents that use social media and capitalize on current technologies. Research should also consider the optimal conditions for bringing effective prevention interventions to scale, develop consensus on standardization of methods for cost-benefit analysis, and increase research on cost-effectiveness evaluations of prevention EBIs.

Surveillance of risky drinking, drug use, and related problems needs to be improved. All drivers in fatal crashes should have their blood alcohol content tested and be tested for drug use. All unintentional and intentional injury deaths, including overdoses, should be tested for both alcohol and drugs. Surveillance surveys need to add questions about simultaneous alcohol and drug use and questions about the maximum quantities consumed in a day and frequency of consumption at those levels. Efforts are needed to increase surveillance of the second-hand effects of alcohol and drug use, such as assaults, sexual assaults, motor vehicle crashes, homicides and suicides, and effects of substance use on academic and work performance. Efforts are needed to expand surveillance beyond national and state levels to the level of local communities.

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