Brief interventions in doctors' offices and emergency rooms, coupled with environmental strategies that address alcohol consumption and marketing on a community-wide basis, can delay the onset of alcohol use and prevent binge drinking, according to experts who spoke at the annual medical/scientific conference of the American Society of Addiction Medicine (ASAM).Ralph Hingson, Sc.D., chair of the Social and Behavioral Sciences Department at the Boston University School of Public Health, said that research has shown that the younger a person is when they first start drinking, the more likely they are to become dependent upon alcohol at some point in their lifetime.
Early onset of drinking also can lead to problems other than dependence. Hingson's own research has demonstrated a link between early-onset drinking and an elevated risk of unintentional injuries, drunk driving, and involvement in alcohol-related motor-vehicle crashes. And in a forthcoming study to be published in the journal Pediatrics, Hingson and colleagues conclude that children who start drinking prior to age 14 are seven times more likely to engage in an alcohol-related fight over their lifetime than individuals who start drinking at age 21.
Physicians can play a critical role in counseling their young patients about the consequences of starting to drink, said Hingson. Research shows that such brief interventions can be highly effective. For instance, when trauma patients injured while under the influence of alcohol were told of the risks of drinking and advised of treatment resources, they reported consuming an average of 21 fewer drinks per week a year later, according to a study led by Larry Gentilello, M.D., of the Univeristy of Washington and published in the Annals of Surgery in 1999.
Gentilello's study group also experienced a 47-percent reduction in new injuries, 48 percent fewer hospitalizations, and 23 percent fewer DUIs. "Catching these people at a teachable moment had a recognizable impact on behavior," Hingson noted, adding that between 10 and 30 percent of patients who receive counseling in a general or primary-care setting will change their drinking behavior.
Norman Wetterau, M.D., an assistant professor of family medicine at the University of Rochester School of Medicine and a practicing physician with Tricounty Family Medicine in Dansville, N.Y., said primary-care physicians need to:
- ask patients about their alcohol and other drug use
- ask patients what they think about their use
- provide both written and oral information
- connect patients with treatment resources, as needed
- connect patients with community groups for teens (which he says is especially good prevention for socially isolated nonusers and experimenters whose friends are using)
Environmental prevention also can prevent drinking problems associated with early onset of use, Hingson said. For example, long-term studies have shown that people who grew up in states with age-21 drinking laws drank less between ages 21 and 25 than those who grew up in states where the drinking age was lower than 21.Richard Yoast, director of the Robert Wood Johnson Foundation National Alcohol Program at the American Medical Association, said the power of the environmental-change model lies in its ability to create a new standard of behavioral expectations around drinking and other drug use. "It makes it easier to do the right thing," said Yoast.
By changing laws and community standards, community groups -- which can and should include participation from doctors and medical organizations -- can create policies that are long-lasting and require minimal maintenance.
Unfortunately, said Yoast, the alcoholic-beverage industry actively works against some of the key facets of environmental prevention, including price controls, enforcement of liquor laws, and curbs on availability. "The alcohol industry has wiped out alcohol prevention in the federal government, alcohol taxes have not kept pace with inflation, and the number of outlets is up while enforcement has not kept pace," he said. "By and large, the information people get about alcohol is through alcohol advertising."
The challenge of delay first use of alcohol and preventing underage drinking is especially acute at America's colleges, where Yoast says an increasing number of freshmen are showing up with established alcohol problems. In one study, 74 percent of college students who reported binge drinking also said they had binged in high school. "That's a marked change over the last 20 years," said Yoast.
The focus of most prevention efforts -- including those promulgated by the alcohol industry -- focuses strictly on changing individual behavior. "But that's backwards," said Yoast. "Youth don't control prices, taxes, or distribution laws."
Yoast charges that the alcohol industry, which sells $5.5 billion worth of its products to college students annually, has little real interest in comprehensive strategies that shift the focus from individual to collective responsibility for drinking problems. "Frequent bingers consume 64 percent of alcohol on campus," he said. "When the beverage industry says it is targeting moderate drinkers, that's nonsense. Bingers is where the sales are."
Local action on college alcohol problems often is stymied because state laws trump local action, and the alcohol industry influences the creation and enforcement of state laws, said Yoast. Despite such obstacles, a number of partnerships between colleges and communities have sprung up nationally to deal with the issue of underage drinking.
Through the A Matter of Degree initiative, for example, 10 communities and schools have worked together to address issues such as bar density, alcohol advertising, pricing, attitudes toward drinking, law enforcement, recruitment issues (such as promoting the institution as a "party school"), campus policies, media messages and norms, non-alcohol alternative activities, and industry sponsorship and promotion.
Such efforts have helped to break down hostility between schools and their communities, and resulted in some changes, such as the University of Florida banning bars from handing out promotional leaflets on campus. Other schools have put parental-notification policies in place or banned alcohol at certain sports and social events, while college towns have moved to boost enforcement and ban drink specials, Yoast said.
Doctors Play Key Role in Underage-Drinking Prevention. Original feature article, Join Together Online (www.jointogether.org), May 14, 2001.
Boston University School of Public Health 
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