Goal 3: Develop and Improve Strategies To Prevent Alcohol Misuse, Alcohol Use Disorder, and Alcohol-Related Consequences
People begin drinking for different reasons and at different points in their lives, have different risk and protective factors, and vary in their susceptibility to the negative effects that may result from drinking too much. The stage of life at which a person is exposed to alcohol is an important moderator of alcohol misuse and the consequences associated with it, and it is a key consideration in designing and implementing preventive interventions.
Many people first begin using alcohol during adolescence, and the prevalence of drinking and binge drinking increases dramatically during this time, peaking in the early 20s. (See “Alcohol Use Across the Lifespan.”) Not only are adolescents at increased risk of injuries and accidents while under the influence, but those who begin drinking before age 15 are four times more likely to report symptoms of alcohol use disorder (AUD) at some point in their lives compared to those who wait until they are 21 or older.34 Moreover, preclinical and clinical research indicates that alcohol exposure during adolescence can affect brain development and compromise cognitive function in both the short and long term. In light of the adverse consequences associated with adolescent drinking, a key objective is to prevent, or at least delay, the onset of drinking among youth.
Young adults are also vulnerable to alcohol misuse and its consequences. This time of life is marked by burgeoning independence and a transition into more adult roles, including, for many, the pursuit of a college degree or the beginning of a career in the military or civilian workforce. Each year, more than 5,000 18- to 24-year-olds die from unintentional injuries related to alcohol.35 Binge and extreme binge drinking are particularly troubling, as they increase risks for blackouts, alcohol poisoning, sexual assault and sexually transmitted diseases, poor academic performance, and developing AUD.
There are special considerations facing older adults who drink. Midlife is the time when individuals with AUD are most likely to seek alcohol treatment, and when many of the pathological health consequences associated with chronic alcohol misuse emerge, including alcoholic liver disease, alcoholic cardiomyopathy, neurodegeneration, acute and chronic pancreatitis, and kidney failure. Older adults are more sensitive than younger people to the sedative effects of alcohol, as well as to the effects of alcohol on reaction time, balance, attention, and driving skills. Adults older than age 65 are more likely than younger people to take medications, and combining alcohol with certain medications increases the potential for injuries and other adverse health effects. Alcohol-interactive medications are also metabolized more slowly as one ages, creating a larger window of time for potential negative interactions. Many older adults also have poor dietary intake due to a multitude of problems, including depression, problems chewing, and poor appetite, which can result in higher blood alcohol content when they do drink.
Developmental factors are not the only consideration in designing preventive interventions. A person’s genetic makeup, health status, demographic and cultural background, and individual life experiences are also important factors, as is the broader sociocultural context in which one lives. This may include alcohol-related policies, community attitudes toward alcohol use, and exposure to social media. Such individual and environmental determinants, as well as interactions among them, affect the likelihood that a person will misuse alcohol, develop AUD, or suffer adverse alcohol-related outcomes.
NIAAA will continue to support research to translate basic behavioral science findings into individual-, family-, and community-level interventions to prevent alcohol misuse and its myriad adverse consequences. NIAAA is particularly interested in supporting the development of culturally appropriate interventions for at-risk groups; interventions to reduce alcohol-related violence, sexually transmitted diseases, overdose, and adverse medication interactions; and interventions that capitalize on electronic health technologies as a means of broadening their reach.
To advance these goals, NIAAA will pursue the following objectives:
Objective 3a: Promote universal screening and brief intervention for alcohol and other substance use
Regular screening for alcohol misuse is a key prevention strategy, and the U.S. Preventive Services Task Force recommends that primary care clinicians screen adults for alcohol use. Studies show that most patients do not object to being screened, that they are open to hearing advice, and that those who screen positive for heavy drinking or AUD show some motivational readiness to change. Moreover, adult screening in primary care is effective at reducing alcohol misuse, though additional research is needed to evaluate its effectiveness in other settings and with diverse populations. Screening is also an important tool for delaying the onset of drinking among youth. To facilitate youth alcohol screening, NIAAA developed Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide. The guide is designed to help primary care providers identify 9- to 18-year-olds who are at risk for alcohol use, are using alcohol, or have AUD, and to intervene as appropriate. It introduces a two-question screening tool and an innovative youth alcohol risk estimator to help clinicians overcome time constraints and other common barriers to alcohol screening and brief interventions.
To further encourage alcohol screening and brief intervention, NIAAA will support research and related initiatives to:
- Evaluate NIAAA’s youth alcohol screening guide in primary care settings, emergency departments, juvenile justice settings, and schools, and for youth who have chronic health conditions.
- Adapt and evaluate adult alcohol screening and brief intervention for various settings and populations, including underrepresented minorities, pregnant women, seniors, individuals engaged with the justice system, and individuals with chronic illnesses.
- Develop and evaluate methods for administering alcohol screening and brief intervention along with screening and brief intervention for other addictive substances, including tobacco and marijuana.
Objective 3b: Develop, evaluate, and promote effective strategies for preventing alcohol misuse, alcohol use disorder, and related consequences for individuals at all stages of life
Individuals operate within many different social systems, including families, peer groups, schools, workplaces, community groups, and broader sociocultural environments. Each of these systems exposes a person to numerous influences that may confer risk for or protection from alcohol problems. A large body of evidence shows that both individual and environmental interventions can be effective at preventing alcohol-related harm. For example, among college students, a group to which considerable attention has been devoted, some of the most effective individual-level strategies include providing students with personalized feedback about their alcohol use in comparison with use by their peers, and training students to monitor and assess their alcohol consumption, identify personal drinking cues, develop alcohol refusal skills, and manage stress. Effective environmental interventions for college students include restricting happy hours and alcohol price promotions, banning Sunday alcohol sales, enforcing minimum drinking age laws, and increasing the cost of alcohol.
To help colleges and universities identify interventions appropriate for their campuses, NIAAA created CollegeAIM—the College Alcohol Intervention Matrix—in conjunction with leading college alcohol researchers. CollegeAIM is a comprehensive, easy-to-use tool that rates nearly 60 individual- and environmental level interventions based on factors such as effectiveness, cost, and ease of implementation. It allows officials to identify strategies most likely to reduce drinking and its harmful consequences; see how their current strategies compare with other options; find new, research-based strategies to consider; and select a combination of approaches that meets the needs of their students and campus.
Despite the availability of effective preventive strategies, the prevalence of alcohol misuse remains unacceptably high. Existing interventions do not work for—nor do they reach—every individual. For example, interventions designed for college students may not be effective for young adults who are not in school—a group for which few preventive interventions have been specifically designed. Likewise, those designed for working-age adults may not be effective for retirees. The desired outcomes of prevention programs may also vary by group. Whereas maintaining alcohol levels at or below the low-risk guidelines established by NIAAA may be an appropriate outcome for many healthy adults, those with chronic diseases, such as human immunodeficiency virus (HIV), or those at risk for adverse alcohol medication interactions may be advised to drink less or not at all. These examples point to the need for a broader menu of preventive interventions. They also underscore the importance of designing evaluations to assess whether an intervention is equally effective for different groups, identifying the variables mediating and moderating subgroup effects, and adapting evidence-based interventions—or designing new ones—for the groups and communities in which they will be delivered.
To prevent alcohol misuse, including binge and extreme binge drinking, and its consequences for diverse populations across the lifespan, NIAAA will support research to:
- Develop and evaluate strategies to prevent and reduce alcohol misuse among young adults, including those in the military, the civilian workforce, and college.
- Assess the impact of NIAAA’s CollegeAIM in preventing and reducing alcohol misuse in college students.
- Use CollegeAIM as a model for disseminating evidence-based information on preventing and treating alcohol-related harms for noncollege populations
- Develop and evaluate interventions to prevent and reduce alcohol misuse during pregnancy.
- Develop and evaluate interventions to prevent and reduce alcohol misuse by older adults.
- Develop and evaluate culturally appropriate, evidence-based interventions for preventing alcohol misuse in diverse communities.
- Evaluate the effectiveness and implementation of interventions to reduce HIV transmission and improve HIV medication compliance and overall health outcomes by reducing alcohol misuse among people with HIV
- Evaluate the effectiveness and implementation of new policies and other environmental interventions for preventing alcohol misuse and related problems.