On the 27th November, ERAB (The European Foundation for Alcohol Research) and its American Associate the ABRMF (The Foundation for Alcohol Research) launched their jointly produced report ‘Underage Drinking: A Report of Drinking in the Second Decade of Life in Europe and North America’ at a meeting in the European Parliament in Brussels, Belgium. The meeting brought together alcohol education programme deliverers and specialists to discuss the findings and recommendations regarding initiatives that are showing signs of being effective in reducing underage drinking.
The meeting was opened by Michael Huebel, Head of Unit - Health Determinants, DG Sanco who spoke of the chronic disease epidemic of non-communicable diseases - which are wholly preventable. Excess alcohol consumption, together with unhealthy diet, physical inactivity and smoking is a key cause.
Heubel stated that the EU would take account of a worldwide policy approach with the UN and WHO. He reiterated the aims of the Alcohol Health Forum and its continuing strategy to inform, educate and raise awareness of the risks of excessive alcohol consumption and consumption guidelines, with a view to changing norms in society. He cited successes of the Forum in moving towards an enforcement age of 18 across Europe.
Mr Huebel stated DG Sanco’s position: “The general consensus is that while an individual education action on its own might not be very effective, education clearly has its place as part of a comprehensive approach to address alcohol related harm”.
He referred to a project which was funded through EU/US cooperation funds on alcohol and young people, that is yet to be updated via: www.eurocare.org/eu_projects/eu_usa_dialogue. Outlying the key priorities regarding alcohol and underage drinking, its consensus statement can be viewed here.
Professor Helene White compared and contrasted underage use of alcohol in Canada and the US against that of the EU. The legal drinking age is 18 or 19 in Canada and 21 in the US, against 16 or 18 in the EU. She drew attention to low frequency but high quantity trends in consumption seen in Norway and Sweden, and both high frequency and high consumption levels in Denmark in particular, as well as more regular but low consumption levels in countries such as Italy. Rates of underage drinking and intoxication are notably lower in the US.
The authors split consumption styles for underage drinkers into intoxication cultures - as found in Eastern Europe, Canada, Sweden, Denmark and Finland, versus non intoxication cultures - where underage drinking may occur quite frequently, but at low doses among under 18s such as Italy, Portugal and Greece. Helen White explored the trends seen in ESPAD and the HSBC studies covered in AIM May and June editions in detail (www.aim-digest.com/digest/pdigest/digest.htm).
Trends in 16 year olds rates of excessive consumption from the ESPAD study 1999 - 2011
Trends in underage drinking and intoxication across the EU are largely downwards, with a couple of notable exceptions, Spain and France, but still remain higher than the US, for example. Professor White asked the hypothetical question as to why this might be. She cited easy access to alcohol by underage drinkers as a key factor in most countries across the EU - 78% of underage drinkers say it is easy to get alcohol if they want it. Could it also be due to more prevention progress, societal norms or having a higher drinking age in the US?
Professor Reinout Wiers explored the risk and protective factors for underage drinkers.
His work looks at the elements that affect a young person’s decision to drink including their personality and genetic vulnerability. Elements affecting the age of onset of drinking include genetics, cognitions and post onset. Factors affecting the amount drunk include - societal (religion, laws and customs) and interpersonal issues such as peer group (risk) and parental monitoring (protective). Parents who were strict, but kind, showed better outcomes for adolescents. Parents who were good role models and set boundaries could help delay the age of onset. Injunctive norms were described as when teens presume a perceived peer approval of drinking and so are more likely to engage. Descriptive norms are perceived beliefs of how much and how often everyone drinks.
Genetic risk is explained by hereditary impulsivity as well as physiological reaction to alcohol - i.e. if a negative effect is not encountered and it is pleasurable then inexperienced drinkers are more likely to continue and drink again - this involves what is known as a triggered reaction (memory associations). Hence, a combination of genes, the environment and reactions all play a part. Risks in personality that can lead to an escalation in drinking are those who are anxious or feel helpless/ vulnerable as they may feel alcohol helps them cope.
Wiers described the effect of the early onset of drinking as like being on a horse and not knowing how to ride it - younger individuals are not yet in control of their impulses or reactions and the rider needs to learn through maturity how to control the ride. Wiers believes that adult supervised alcohol use contributes to earlier onset of drinking, so it is better for parents to say no. Parents can help by being supportive, monitoring effectively and encouraging communication. Societal issues include the quality of the neighbourhood, legal issues such as the availability of alcohol and whether legal drinking ages are enforced, religion and advertising can influence positive perceptions of alcohol.
Professor Sherry Stewart compared US and EU alcohol education style approaches. US programmes tend to have abstinence as a goal, whereas EU strategies tend to focus on harm reduction and raising age of onset of the first drink.
Universal prevention - target all children
Selective prevention - is aimed at high risk groups
Indicated prevention - is for adolescents showing signs of alcohol use problems
School based approaches are deemed to show the most consistent effect as they ensure a captive audience. They must be tailored to different age groups and levels of experience. School approaches are usually class based and universal.
Social influence approach:
This approach looks to influence peer pressure or media conceptions and has a parental element. It focuses on teaching resistance skills and seeks to strengthen coping skills. It involves normative education as well as resistance skills training with a special focus on learned behaviour and personal factors such as low self esteem, anxiety and normative beliefs.
Stewart discussed the issues of whether selective approaches could be stigmatising (taken out of class for sessions). Additionally there is the issue of how do you screen effectively for risk takers?
Stewart also pointed to the fact that only 15% of programmes currently used in schools are properly evidence based, most are delivered or purchased from providers.
Multiple component programmes
There is little evidence at present to suggest that a parental and school approach is more effective, probably as parents are notoriously hard to engage at school level. The authors made many recommendations, some of which are overleaf.
RECOMMENDATIONS REGARDING THE ROLE OF PARENTS AND FAMILIES
Parents should provide effective parental monitoring, consistent rule setting, and clear communication about alcohol.
Parents should consistently disapprove of binge/heavy drinking.
In most instances, except perhaps family or religious gatherings, parents should avoid providing alcohol to adolescents.
Parents should maintain an active involvement with the activities of their children, including helping direct their selection of a peer group.
Parents should be encouraged to monitor their children’s social media sites, especially for their alcohol content.
Parents should avoid modelling heavy drinking or intoxication.
In selecting alcohol prevention programmes, it should be kept in mind that parent-based programmes can be effective in preventing or reducing alcohol use in young people and that the most effective parent-based programmes emphasise active parental involvement as well as development of competence, self-regulation, and parenting skills.
In selecting an alcohol prevention programme, family-based prevention programmes should be considered. Although their effects are small, their effects are generally consistent and persisting, and even small effects can be important from a public health perspective.
In countries with more liberal alcohol policies and lower legal drinking ages, parental programmes should be combined with other evidence-based programmes.
RECOMMENDATIONS FOR SCHOOL PROGRAMMES
Policy makers and service deliverers should attempt to deliver programmes that have been shown to be evidence-based within a cultural and social context that closely matches the context in which they wish to deliver that particular programme.
Small modifications to programme delivery methods and content should always be tested, considering the potential for iatrogenic effects in alcohol prevention.
It is best to deliver alcohol prevention in sequential and developmentally appropriate stages.
Normative feedback, especially for high school students, should be provided in the context of a comprehensive approach to skill development.
Universal interventions should not be exclusively delivered by police or other authority figures.
Prevention programmes should use an interactive delivery style.
Targeted school-based prevention programmes should be introduced in the early adolescent years, ideally before initial exposure to alcohol.
Selective interventions should be targeted toward at-risk groups, particularly those with personality or behavioural traits that put them at-risk for alcohol use disorders and for whom targeted interventions have been shown to be effective. Other at-risk groups have been identified, but should only be targeted in prevention with programmes that have an evidence base for those particular populations.
Strategies such as personalised feedback designed to correct misperceived norms for both high school and college students should not be used as a method to prevent onset of drinking and are indicated as a method to reduce drinking in those who have already begun to drink, particularly those who drink more heavily.
Researchers and practitioners should consider adapting evidence-based programmes for use on the Internet, but more research is needed in both Europe and North America before this becomes standard practice (see research recommendations below).
When disseminating an efficacious alcohol prevention programme, it is very important to attend to intervention fidelity including adequate training and supervision of those delivering the intervention.
As it has been shown that school staff can be trained to effectively deliver evidence-based universal (e.g. Life Skills Training/ Unplugged) and selective (e.g. Personality-targeted) programmes, we recommend public investment in broader dissemination of training in these and other evidence-based practices.
Greater investment in comparative effectiveness and cost effectiveness research will guide policy makers to develop effective strategies for broader dissemination of alcohol prevention.
An international system for evaluating and disseminating evidence-based practices in alcohol prevention should be made available to the public and maintained by a research organisation that is neutral with respect to theoretical approaches to prevention, yet experienced with respect to reviewing and synthesising the evidence base.
RECOMMENDATIONS REGARDING MULTI-COMPONENT PROGRAMMES
When selecting an alcohol prevention programme, it should be kept in mind that multi-component interventions for alcohol misuse prevention in young people can be effective, although generally speaking, interventions with multiple components are no more effective than those with a single component.
However, there is some limited evidence from one study that both parents and children should be targeted simultaneously in multi-component interventions in countries with more liberal alcohol policies and lower legal drinking ages.
RESEARCH ON RISK AND PROTECTIVE FACTORS
Better controlled studies are needed for regional and cross-national comparisons to understand the influence of parental supervised alcohol use within the family setting on underage drinking in different cultural/drinking contexts.
More quantitative and qualitative research is needed to compare risk and protective factors and their association with drinking outcomes across European and North American countries.
More research utilising “natural experiments” (e.g., adoption studies, twin studies, longitudinal studies of samples experiencing important secular changes) is needed to clarify the causal status of several risk factors.
More research is needed on both implicit and explicit alcohol-related cognitions in adolescents to determine the causal status of these cognitive processes in youth.
Controlled, experimental studies are needed within naturalistic settings, such as those relating exposure to alcohol-related content in films/movies with adolescent drinking.
Research is needed on the effects of social media and, in particular, the practice of posting alcohol-related messages by underage people (on Facebook, Twitter, etc.).
More research comparing peer-led versus professionally-led interventions is needed to clarify their relative effectiveness in different situations, and what factors might moderate their effectiveness.
More research should evaluate the use of web-based adaptations of evidence-based programmes for adolescents and parents, with an emphasis on evaluating their behavioural outcomes.
More research should evaluate web-based adaptations of evidence-based training programmes for teachers and providers.
More research should evaluate the use of social media and other technologies to promote youth access to evidence-based interventions.
Research is needed to evaluate the use of social media and the Internet to better disseminate knowledge and guidelines for evaluating the evidence in support of prevention programmes and policies.
More research should systematically evaluate the cultural and policy-level contexts that may enhance or interfere with the impact of evidence-based programmes.
More work is needed to further investigate the effectiveness of parent-based alcohol prevention programmes, especially in different cultures.
Future work should examine cross-cultural similarities and differences in the efficacy of multi-component interventions involving both school- and family-based components in preventing or decreasing alcohol use in adolescents.
There is a need for additional studies that attempt to enhance the efficacy of school-based programmes by including broader community components such as media, community services, and alcohol retailer involvement within a multi-component intervention.
Research has demonstrated that both implicit and explicit alcohol-related cognitions are malleable in adults with promising outcomes, but hardly any research has been done in adolescents. More research is needed on this topic to develop new intervention strategies to moderate drinking in this age-group.
More data are needed on the health-economics of alcohol prevention programmes with youth to help guide policy makers around improving young people’s access to effective intervention programmes.