essay on prevention of alcohol

Preventing Excessive Alcohol Use

Excessive alcohol use is responsible for about 178,000 deaths in the United States each year 1 and $249 billion in economic costs in 2010. 2 Excessive alcohol use includes

• Binge drinking (defined as consuming 4 or more alcoholic beverages per occasion for women or 5 or more drinks per occasion for men).
• Heavy drinking (defined as consuming 8 or more alcoholic beverages per week for women or 15 or more alcoholic beverages per week for men).
• Any drinking by pregnant women or those younger than age 21.

The strategies listed below can help communities create social and physical environments that discourage excessive alcohol consumption thereby, reducing alcohol-related fatalities, costs, and other harms.

The Community Preventive Services Task Force Recommendations

The Community Preventive Services Task Force, an independent, nonfederal, volunteer body of public health and prevention experts, recommends several evidence-based community strategies to reduce harmful alcohol use. Learn more about the Community Guide’s findings .

Recommendations

• Regulation of Alcohol Outlet Density External Alcohol outlet density refers to the number and concentration of alcohol retailers (such as bars, restaurants, liquor stores) in an area. 3
• Increasing Alcohol Taxes External Alcohol taxes may include excise, ad valorem, or sales taxes, all of which affect the price of alcohol. Taxes can be levied at the federal, state, or local level on beer, wine or distilled spirits. 4
• Dram Shop Liability External Dram shop liability, also known as commercial host liability, refers to laws that hold alcohol retail establishments liable for injuries or harms caused by illegal service to intoxicated or underage customers. 5
• Maintaining Limits on Days of Sale External States or communities may limit the days that alcohol can legally be sold or served. 6
• Maintaining Limits on Hours of Sale External States or communities may limit the hours that alcohol can legally be sold or served. 7
• Electronic Screening and Brief Intervention (e-SBI) External e-SBI uses electronic devices (e.g., computers, telephones, or mobile devices) to facilitate delivery of key elements of traditional screening and brief interventions. At a minimum, e-SBI involves screening individuals for excessive drinking, and delivering a brief intervention, which provides personalized feedback about the risks and consequences of excessive drinking. 8
• Enhanced Enforcement of Laws Prohibiting Sales To Minors External An enhanced enforcement program initiates or increases compliance checks at alcohol retailers (such as bars, restaurants, and liquor stores). 9

Recommended against

• Privatization of Retail Alcohol Sales External The privatization of retail alcohol sales refers to the repeal of government (such as state, county, or city) control over the retail sales of one or more types of alcoholic beverages. 10

US Preventive Services Task Force Recommendation

The U.S. Preventive Services Task Force (USPSTF) is an independent panel of non-Federal experts in prevention and evidence-based medicine and comprises primary care providers. The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services and develops recommendations for primary care clinicians and health systems.

• Screening and Brief Intervention for Excessive Drinking in Clinical Settings External Screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings can identify people whose levels or patterns of alcohol consumption do not meet the criteria for alcohol dependence, but place them at increased risk of alcohol-related harms. 11

How Can I Contribute to the Prevention of Excessive Alcohol Use?

Everyone can contribute to the prevention of excessive alcohol use.

• Choose not to drink too much yourself and help others not do it.
• Check your drinking , and learn more about the benefits of drinking less alcohol .
• If you choose to drink alcohol, the Dietary Guidelines for Americans  recommends that adults of legal drinking age can choose not to drink, or to drink in moderation by limiting intake to  2 drinks or less in a day for men or 1 drink or less in a day for women , on days when alcohol is consumed. 12
• Support effective community strategies to prevent excessive alcohol use, such as those recommended by the Community Preventive Services Task Force External .
• Not serve or provide alcohol to those who should not be drinking, including people under the age of 21 or those who have already drank too much.
• Talk with your healthcare provider about your drinking behavior and request counseling if you drink too much.

States and communities can:

• Implement effective prevention strategies for excessive alcohol use, such as those recommended by the Community Preventive Services Task Force External .
• Enforce existing laws and regulations about alcohol sales and service.
• Develop community coalitions that build partnerships between schools, faith-based organizations, law enforcement, health care, and public health agencies to reduce excessive alcohol use.
• Routinely monitor and report the prevalence, frequency, and intensity of binge drinking (whether or not adults binge drink, how often they do so, and how many drinks they have if they do).
• Centers for Disease Control and Prevention. Alcohol-Related Disease Impact (ARDI) website.  Accessed February 29, 2024.
• Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RD. 2010 national and state costs of excessive alcohol consumption . Am J Prev Med 2015; 49(5):e73–e79.
• Campbell CA, Hahn RA, Elder R, Brewer R, Chattopadhyay S, Fielding J, et al. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms   [PDF-445KB].  Am J Prev Med.  2009;37(6):556–69.
• Elder RW, Lawrence B, Ferguson A, Naimi TS, Brewer RD, Chattopadhyay SK, et al. The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms  [PDF-665KB].   Am J Prev Med  2010;38(2):217–29.
• Rammohan V, Hahn RA, Elder R, Brewer R, Fielding J, Naimi TS, et al. Effects of dram shop liability and enhanced overservice law enforcement initiatives on excessive alcohol consumption and related harms: two Community Guide systematic reviews  [PDF-569KB].  Am J Prev Med  2011;41(3):334-43.
• Middleton JC, Hahn RA, Kuzara JL, Elder R, Brewer R, Chattopadhyay S, et al. Effectiveness of policies maintaining or restricting days of alcohol sales on excessive alcohol consumption and related harms  [PDF-674KB].  Am J Prev Med  2010;39(6):575–89.
• Hahn RA, Kuzara JL, Elder R, Brewer R, Chattopadhyay S, Fielding J, et al. Effectiveness of policies restricting hours of alcohol sales in preventing excessive alcohol consumption and related harms  [PDF-735KB].  Am J Prev Med  2010;39(6):590–604.
• Tansil KA, Esser MB, Sandhu P, Reynolds JA, Elder RW, Williamson RS, et al. Alcohol electronic screening and brief intervention: a Community Guide systematic review  [PDF-605KB].  Am J Prev Med  2016;51(5):801–11.
• Elder RW, Lawrence B, Janes G, Brewer RD, Toomey TL, Hingson RW, et al. Enhanced enforcement of laws prohibiting sale of alcohol to minors: systematic review of effectiveness for reducing sales and underage drinking.  Transportation Research E-Circular. 2007;Issue E-C123:181-8. (Access full text article from the issue, Traffic Safety and Alcohol Regulation: A Symposium [PDF-2MB]).
• Hahn RA, Middleton JC, Elder R, Brewer R, Fielding J, Naimi TS, et al. Effects of alcohol retail privatization on excessive alcohol consumption and related harms: a Community Guide systematic review   [PDF-322KB].  Am J Prev Med.  2012;42(4):418-27.
• US Preventive Services Task Force. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Recommendation Statement Website . Accessed April 19, 2022.
• U.S. Department of Agriculture and U.S. Department of Health and Human Services. 2020 – 2025 Dietary Guidelines for Americans . 9th Edition, Washington, DC; 2020.
• Dietary Guidelines for Alcohol
• Resources to Support States and Communities

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• Open access
• Published: 07 November 2021

How to prevent alcohol and illicit drug use among students in affluent areas: a qualitative study on motivation and attitudes towards prevention

• Pia Kvillemo   ORCID: orcid.org/0000-0002-9706-4902 1 ,
• Linda Hiltunen 2 ,
• Youstina Demetry 3 ,
• Anna-Karin Carlander 4 ,
• Tim Hansson 5 ,
• Johanna Gripenberg 1 ,
• Tobias H. Elgán 1 ,
• Kim Einhorn 4 &
• Charlotte Skoglund 1 , 4  

Substance Abuse Treatment, Prevention, and Policy volume  16 , Article number:  83 ( 2021 ) Cite this article

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The use of alcohol and illicit drugs during adolescence can lead to serious short- and long-term health related consequences. Despite a global trend of decreased substance use, in particular alcohol, among adolescents, evidence suggests excessive use of substances by young people in socioeconomically affluent areas. To prevent substance use-related harm, we need in-depth knowledge about the reasons for substance use in this group and how they perceive various prevention interventions. The aim of the current study was to explore motives for using or abstaining from using substances among students in affluent areas as well as their attitudes to, and suggestions for, substance use prevention.

Twenty high school students (age 15–19 years) in a Swedish affluent municipality were recruited through purposive sampling to take part in semi-structured interviews. Qualitative content analysis of transcribed interviews was performed.

The most prominent motive for substance use appears to be a desire to feel a part of the social milieu and to have high social status within the peer group. Motives for abstaining included academic ambitions, activities requiring sobriety and parental influence. Students reported universal information-based prevention to be irrelevant and hesitation to use selective prevention interventions due to fear of being reported to authorities. Suggested universal prevention concerned reliable information from credible sources, stricter substance control measures for those providing substances, parental involvement, and social leisure activities without substance use. Suggested selective prevention included guaranteed confidentiality and non-judging encounters when seeking help.

Conclusions

Future research on substance use prevention targeting students in affluent areas should take into account the social milieu and with advantage pay attention to students’ suggestions on credible prevention information, stricter control measures for substance providers, parental involvement, substance-free leisure, and confidential ways to seek help with a non-judging approach from adults.

Alcohol consumption and illicit drug use are major public health concerns causing great individual suffering as well as substantial societal costs [ 1 , 2 ]. Early onset of substance use is especially problematic since the developing brain is vulnerable to the effects of alcohol and drugs, increasing the risk of long-term negative effects, such as harmful use, addiction, and mental health problems [ 3 , 4 , 5 , 6 ]. Short-term consequences of substance use include intoxication [ 5 , 7 ], accidents [ 8 [, academic failure [ 9 ], and interaction with legal authorities [ 10 ], which calls for effective substance use prevention in adolescents and young adults. Such prevention interventions may be universal, targeting the general population, e.g., legal measures and school based programs, or selective, targeting certain vulnerable at-risk groups, i.e., subsections of the population [ 11 ]. Selective prevention can be carried out within a universal prevention setting, such as health care or school, but also be delivered directly to the group which it aims to target, face-to-face or digitally [ 12 , 13 , 14 , 15 ].

The motives to use substances are governed by a number of personal, social and environmental factors [ 16 ], ranging from personal knowledge, abilities, beliefs and attitudes, to the influence of family, friends and society [ 17 , 18 , 19 , 20 ]. Cooper and colleagues [ 21 ] have previously identified a number of motives for drinking, i.e., 1) enhancement (drinking to maintain or amplify positive affect), 2) coping (drinking to avoid or dull negative affect), 3) social (drinking to improve parties or gatherings), and 4) conformity (drinking due to social pressure or a need to fit in). Similar motives for illicit drug use have been found by e.g. Kettner and colleagues, who highlighted the attainment of euphoria and enhancement of activities as prominent motives for use of psychoactive substances among people using psychedelics in parallel with other substances [ 22 ], along with Boys and colleagues [ 23 , 24 , 25 ], who reported on changing mood (e.g., to stop worrying about a problem) and social purposes (e.g., to enjoy the company of friends) as motives for using illicit drugs among young people. Additionally, the authors found that the facilitation of activities (e.g., to concentrate, to work/study), physical effects (e.g., to lose weight), and the managing of the effects of other substances (e.g., to ease or improve) motivated young people to use illicit drugs.

Prior research has repeatedly shown that low socioeconomic status is a risk factor for substance use and related problems [ 26 , 27 , 28 ]. However, recent research from Canada [ 29 ], the United States [ 30 , 31 , 32 ], Serbia [ 33 ], Switzerland [ 34 ], and Sweden [ 35 ] suggest that high socioeconomic status too is associated with excessive substance use among young people, although for other reasons [ 29 , 30 , 31 , 32 , 33 , 34 ]. Previous research has highlighted two main explanations for excessive substance use among young people in families with high socioeconomic status; i) exceptionally high requirements to perform in both school and leisure activities and ii) absence of adult contact, emotionally and physically, due to parents in resourceful and affluent areas spending a lot of time on their work and careers [ 36 , 37 ]. In addition to these explanations, high physical and social availability due to substantial economic resources and a social milieu were substance use is a natural element, may enable extensive substance use among economically privileged young people [ 30 , 38 , 39 ].

In parallel with identification of various groups at risk for extensive substance use, a growing number of young people globally abstain from using substances [ 1 , 40 , 41 ]. By analyzing data derived from a nationally representative sample of American high school students, Levy and colleagues [ 40 ] found an increasing percentage of 12th-graders reporting no current (past 30 days) substance use between 1976 and 2014, showing that a growing proportion of high school students are motivated to abstain from substance use. However, while this global decrease in substance use among adolescents is mirrored in Swedish youths, in particular alcohol use, a more detailed investigation shows large discrepancies across different socioeconomic and geographic areas. Affluent areas in Sweden stand out as breaking the trend, showing increasing alcohol and illicit drug use among adolescents [ 42 , 43 ].

To date, we lack in-depth knowledge of why youths in affluent areas keep using alcohol and illicit drugs excessively. Furthermore, despite implementation of various strategies and interventions over the last decades [ 14 , 44 , 45 , 46 , 47 , 48 ], we have yet no clear guidelines on how to effectively prevent substance use in this specific group, although the importance of parents’ role for preventing substance use in privileged adolescents has been highlighted in a recent study [ 29 ]. Moreover, despite the fact that attitudes are assumed to guide behavior [ 49 , 50 ] and consequently the reception and effects (behavior change) of prevention interventions, the knowledge about affluent adolescents’ attitudes toward current substance use prevention interventions remains limited. To our knowledge, the only study exploring adolescents’ attitudes to substance use prevention was carried out among Spanish adolescents who participated in “open-air gatherings of binge drinkers”. The study concerned adolescents irrespective of their economic background and revealed positive attitudes to restrictions for drunk people [ 19 ]. Thus, extended knowledge on what motivates young people in affluent areas to excessively use substances, or abstaining from using, as well as their attitudes to prevention is warranted.

In the current study, we aim to explore motives for using, or abstaining from using, substances among students in affluent areas. In addition, we aim to explore their attitudes to and suggestions for substance use prevention. The findings may make a valuable contribution to the research on tailored substance use prevention for groups of adolescents that may not be sufficiently supported by current prevention strategies.

A qualitative interview study was performed among high school students in one of Stockholm county’s most affluent municipalities. The research team developed a semi-structured interview guide (supplementary Interview guide) covering issues regarding the individual’s physical and mental health, extent of alcohol and illicit drug use, motives for use or abstinence, relationships with peers and family, alcohol and drug related norms among peers, family and in the society, and attitudes towards strategies to prevent substance use. Examples of interview questions are: How would you describe your health? Which are the main reasons why young people drink, do you think? How do you get hold of alcohol as a teenager?

What do you know about drug use among young people in Municipality X? How would you describe your social relationships with peers in and outside Municipality X?

The study was approved by the Swedish Ethical Review Authority (dnr. 2019–02646).

Study setting

Sweden has strict regulations of alcohol and illicit drugs compared to many other countries [ 45 , 46 ]. Alcohol beverages (> 3.5% alcohol content by volume) can only be bought at the Swedish Alcohol Retailing Monopoly “Systembolaget” by people 20 years of age or older, or at licensed premises (e.g., bars, restaurants, clubs), at the minimum age of 18 years. The use of illicit drugs is criminalized. The study was carried out in a municipality with 45% higher annual median income than the corresponding figure for all of Sweden, along with the highest educational level among all Swedish municipalities, i.e., 58% of the population (25 years and over) having graduated from university and hold professional degrees, as compared with the national average of 26%. Furthermore, only 6.1% of the inhabitants receive public assistance, compared to a national average of 13.4% [ 51 ].

Recruitment

Purposive sampling was used to recruit students from the three high schools located in the selected municipality. Contact was established by the research team with the principals of the high schools that agreed to participate in the study. Information and invitation to participate in the study was published on the schools’ online platforms, visible for parents and students. Students communicated their initial interest in participating to the assistant principal. Upon consent from the students, the assistant principal forwarded mobile phone numbers of eligible students to the research team. Also, students from other schools in the selected municipality were asked by friends to participate and upon contact with the research team were invited to participate. Forty students signed up to take part in the study, of which 20 were finally interviewed, representing four schools (three in the selected municipality and one in a neighbor municipality). Before the interview, informed consent was obtained by informing the students about confidentiality arrangements, their right to withdraw their participation and subsequently asking them about their consent to participate. The consent was recorded and transcribed along with the following interview. Twenty students who had initially signed up were excluded after initial consent due to incorrect phone numbers or if the potential participants were not reachable on the agreed time for participation. The reason for terminating the recruitment after 20 interviewees was based on the fact that little or no new information was considered to occur by including additional participants.

Participants

The final sample consisted of 20 students. Background information of the participants is presented in Table  1 . The group included eleven girls and nine boys between 15 and 19 years of age. Seven participants attended natural sciences/technology/mathematic programs and 13 attended social sciences/humanities programs. Twelve participants lived in the socioeconomically affluent municipality where the schools were located and eight in neighboring municipalities. The sample included three abstainers and 17 informants who were using substances, the latter referring to self-reported present use of alcohol and/or illicit drugs (without further specification). Additionally, 18 of the participants reported that at least one of their parents had a university education.

During April–May 2020, semi-structured telephone interviews with the students were conducted by five of the authors (PK, YD, AKC, TH, CS). The interviewers had continuous contact during the interview process, exchanging their experiences from the interviews and also the content of the interviews. After 20 interviews had been conducted, it was assessed that no or little new information could be obtained by additional interviews and the interview process was terminated. The interviews, on average around 60 min long, were recorded on audio files and transcribed verbatim.

Qualitative content analysis, informed by Hsieh & Shannon [ 52 ] and Granheim & Lundman [ 53 ], was used to analyze the interview material. To increase reliability of the analytic process, a team based approach was employed [ 54 ], utilizing the broad expertise represented in the research team and the direct experience of information collected from the five interviewers.

The software NVivo 12 was utilized for structuring the interview data. Initially, one of the researchers (PK) read all the interviews repeatedly, searching for meaningful units which could be grouped into preliminary categories and codes, as exemplified in Table 2 . During the process, a preliminary coding scheme was developed and presented to the whole research team. After discussion, the coding scheme was slightly revised. Following this procedure, a second coder (CS) applied the updated coding scheme along with definitions (codebook) [ 54 ], coding all the interviews independently. Subsequent discussions between PK, YD and CS, resulted in an additionally revised coding scheme. This scheme was utilized by PK and another researcher (LH), who had not been involved in the interviewing or coding, coding all of the interviews independently. The agreement between the coders PK and LH was high and a few disagreements solved through discussion. No change in the codes was necessary and the research team agreed on the coding scheme as outlined in Fig.  1 .

Final coding scheme

The interview material generated three main categories, six subcategories and 27 codes. The results are presented under headings corresponding to the identified subcategories, since they are directly connected to the aim of the study. Content from the main category “External factors” is initially presented to illustrate the context in which the students form their motivation to use or abstain from using substances, as well as their attitudes towards prevention.

External factors

The external factors found in the interview material concerned wealth, availability of alcohol and other substances, parental norms and peer norms. Informants living in the affluent municipality described an expensive lifestyle with boats, ski trips, summer vacations abroad, and frequent restaurant visits, in contrast to informants from other areas who described a more modest lifestyle. These differences were further accentuated by informants’ descriptions of large villas in the affluent municipality, where students can arrange parties while the parents go to their holiday homes. Some informants further pointed to the fact that people in this municipality easily can afford to buy illicit drugs, increasing the availability.

The reason why they do it [use illicit drugs] in [the affluent municipality] is because the parents go away, which make it easier to have parties and be able to smoke grass at home, and also because they can afford it .

Parents’ alcohol norms seemed to vary between families, but most informants described modest drinking at home, with parents consuming alcohol on certain occasions and sometimes when having dinner. However, several informants described that they as minors/children were offered to taste alcohol from the parents’ glasses. Most of the informants meant that their parents trust them not to drink too much when partying.

They [my parents] have said to me that drinking is not good, but that they understand if I drink, sort of.

Both parents’ and peers’ norms appear to influence substance use among the students, The impression is that there is an alcohol liberal norm in the local society among adults as well as among adolescents.

If you want to have a social life in community X, then it is very difficult … you almost cannot have it if you don’t drink at parties.

Motives for using substances

Confirming that both alcohol and illicit drugs are frequently used among students in the current municipality, a number of motives for substance use were expressed by the participants. The most prominent motive appeared to be a desire to feel a part of the social milieu and to attain or maintain high social status, with fear of being excluded from attractive social activities and parties if abstaining from substance use. The participants indicated that you are expected to drink alcohol to be included in the local community social life, claiming that this applied to the adult population as well. Alcohol consumption and even intoxication are perceived to be the norm in the students’ social life and several of the participants noted that abstainers risk being considered too boring to be invited to parties.

The view is that you cannot have fun without alcohol and therefore, you don’t invite sober people.

There seemed to be a high awareness of one’s own as well as peers’ popularity and social status. Participants evaluated peers as high or low status, fun or boring, claiming that trying to be cool and facilitate contact with others motivates people to use substances. High status students are, according to some participants, frequently invited to parties where alcohol and other substances are easily accessible.

I would say that our group of friends has more status. [… ] You know quite a few [people] and you are invited to quite a lot of parties. You can often evaluate the group of friends, i.e. their status, based on which parties they are invited to. […] Some [groups of friends] only drink alcohol and some even take drugs and drink alcohol.

Some differences in traditions and norms between schools was discerned, with certain schools being especially known for high alcohol consumption and drug use procedures when including new students in the school-community. One of the participants described fairly extensive norm violations, with respect to the law, on these occasions, e.g., strong peer pressure to drink alcohol and use illicit drugs, combined with humiliation of new students, careless driving under the influence of substances with other students in the car, and “punishment” by future exclusion from social events of those who don’t participate at these occasions. On the other hand, already popular, or more senior students, appear to be able to abstain from substance use on occasions without being questioned or risk social exclusion. High self-esteem and a firm approach when occasionally saying no to substances is often respected according to the participants. To avoid peer pressure to use alcohol or illicit drugs, the participants suggested acceptable excuses, such as school duties, bringing your moped or car to the party, having a sports activity or work the day after, or having plans with your parents or extended family during the weekend.

Apart from peer influence, several students expressed hedonistic motives, such as enjoying a nice event or simply to have fun.

If you want a little extra fun, then you take drugs.

Apart from social enhancement motives for using substances, some students reported that relaxing from academic pressure or rewarding oneself after an intense period of studying motivates them to use substances. Almost every participant expressed high academic ambitions. One participant who claimed to be very motivated to study expressed drinking due to stress, as illustrated in the extract below:

You study a lot and you are stressed over school. Then it can be very nice to go out and drink and you can forget everything else for a few hours. […] So it can be a “stress reliever” in that way.

Yet another participant explained that academic failure had previously made her use substances to comfort herself. Coping with mental health problems, such as depression, was also stated as a reason for substance use. Moreover, some participants reported that they use ADHD (Attention Deficit Hyperactivity Disorder) medication to be able to study more intensively.

Motives for abstaining from using substances

A number of motives for totally or temporarily abstain from substance use were put forward by the students, such as a wish to be healthy, keep control and avoid embarrassment, influence of parents, academic pressure, sports ambitions or simply lack of interest. Lack of interest in alcohol and drugs was expressed foremost by those attending natural sciences programs and those who totally abstained from substance use.

I attend the engineering program and I don’t think the interest in alcohol and parties is as present as it might be on social sciences programs.

Fear of health consequences was predominantly related to abstaining from illicit drugs, but also alcohol. Motives for abstaining from alcohol included perceived risk of being addicted, due to relatives having alcohol problems (heredity), and taking medicine, for example ADHD medicine, since combining alcohol and medication was perceived as risky. Some students had observed friends getting “weird” or “laze” after using illicit drugs, which made them hesitant to use such substances themselves. With regard to parental norms, most parents were by the participants reported to be “normal drinkers” themselves and quite relaxed about their teens’ alcohol consumption. This applied to both the parents of older teens and minors. However, many of the participants reported that their parents would be upset and disappointed if they found out that their child used illicit substances, which motivated some of them to abstain. Reasons for abstaining from substance use included academic strivings, sports performance ambitions, driving, or other activities requiring sobriety, which the students referred to as socially acceptable reason to abstain from substance use. Prioritizing studies over partying was explicitly expressed as the primary motive to abstain by some of the participants.

We are a group of five or six who come from other municipalities. […] We don’t party and such things and we may be seen as a bit boring. But we are a little more responsible and we are more motivated to study than the others in the class.

A wish to save money and reluctance to support the illegal drug production were also mentioned as reasons to abstain from substance use, however to a lesser extent.

Universal prevention viewed as attractive or feasible

With regard to substance information interventions, some students wanted detailed information about different substances’ physical and psychological effects. The participants emphasized the importance of credible sources or persons providing the information, mentioning researchers, young medical students and even parents as credible sources of information. Individuals who had experience of substance use were also suggested.

You have to tell the facts in a way that makes us want to listen. With the help of various spokespersons who have been involved in it, for example.

Several students stressed the importance of being able to identify with the person sending the message and suggested influencers as plausible sources. Someone who is difficult to relate to was given as an example of a non-credible, as the following excerpt shows:

They shouldn’t take a heroin addicts who talk about having found Jesus, because I do not think it would touch the children or touch the young. You have to somehow find … someone that can relate to the young people.

As for universal prevention, the students also suggested intensified legal measures for companies and people providing young people with alcohol or drugs.

For example, make it difficult for young people to have access to alcohol [...], allocate more time as a police officer to catch the drug dealers.

Both alcohol and illicit drugs were reported as easily accessible. Students can obtain alcohol via social media platforms, such as Instagram and Snapchat, where “liquor cars” market themselves and offer home delivery. In addition, older siblings or peers and even some parents were, according to the informants, providing minor students with alcohol. The main way to access illicit drugs is via parties where older students offer drugs to younger peers. Access to prescription drugs was also reported.

Several of the participants agreed that parental involvement is constructive for substance use prevention. Many of them reported having supportive and caring parents involved in their lives, but at the same time referring to friends’ parents as being more absent, resulting in extensive partying in large homes without parental control. Some students reported that parents don’t realize to what extent youths are using substances and that the parents should pay even more attention to what their children do.

I think [parents should be] keeping track, good track of the kids […] . Keeping track of what they are doing and ask them how they feel and things, I think that helps.

In line with leisure activities as a reason to abstain from substance use, some participants suggested that social activities other than partying could be a way of preventing substance use, as expressed by one participant when asked about plausible ways to prevent substance use.

Find a sport or friend that you train with […] instead of going to a party,

Talking about their leisure activities, the participants expressed joy and that these activities made them relax while being social.

The leisure interests, like working out and hanging out with friends, is relaxing and in contrast to the everyday in some way .

Universal prevention viewed as inappropriate

Several of the participants expressed great skepticism towards traditional universal preventive strategies, such as lectures by teachers, social workers or researchers. Some teachers were perceived as ignorant and unengaged, lecturing about substances only by duty.

The teachers have been a bit like ‘now we’re going to talk about drugs […] and then you have fifteen minutes and they say something like ‘here we are a drug free and smoke and tobacco free school’, and no one obeys.

Some students also doubted that the information provided from school and society is true, suspecting exaggerated report on harm, and that they prefer information from social media platforms such as Youtube or other online sources.

It feels like the information we get in school is a bit exaggerated, a bit made up for us […] A bit like this, ‘now we’ll get the young people to stop’.

Selective prevention viewed as attractive or feasible

In circumstances where students are worried about their own or peers’ substance use, participants stressed the need for a way to connect with local authority, health care or other support anonymously, without being registered in medical records or being reported to the authorities. Moreover, the participants emphasized the importance of a non-judging approach from professionals when they reach out to students at risk of excessive substance use.

If you wonder about something or if you are worried about something, then you should be able to turn to adults without being yelled at and know that you are getting positive feedback like ‘I understand you’ and ‘how can we fix this?’

Selective prevention viewed as inappropriate

As indicated above, help-seeking seemed to be counteracted by fear of being recorded in medical records or in the criminal registries. One participant mentioned an incident where a student, caught smoking marijuana, was prosecuted and that this student’s life had been severely affected with cancellation of planned studies abroad and rejection of driving license application. These consequences had, according to the participant, resulted in the student “giving up” and selling illicit alcohol to other students instead of trying to strive for a good future life. Admitting that such an incident can serve as a warning to other students, the fear of consequences is, according to the participant, still an obstacle to seeking help.

People don’t really know what to do when they see their friends do it [use substances]. You don’t want to tell on them, because they are afraid that if it is written down somewhere, then everything can be ruined.

Also, parents were by the participants reported as being reluctant to seek help for their children, because of fear of the reporting of their child’s behavior or crime to authorities, with subsequent negative consequences.

Parents do not dare either because they don’t want it to be about their children. I know some parents who have found drugs in their children’s rooms, but do not want to ruin [future prospects] for them.

The current study aimed to explore motives for using or abstaining from using substances, including alcohol, among students in affluent areas, as well as their attitudes to and suggestions for substance use prevention.

Summary of results

The motives for using substances among the students are associated with social aspects as.

well as own pleasure and coping with stressful situations. The most prominent motive appears to be a desire to feel a part of the current social milieu and to attain or maintain high social status within the peer group. Several of the students expressed fear of being excluded from attractive social activities if abstaining from substance use, although some meant that they were not interested in substances and didn’t care if they were perceived as boring, and also had found a small group of friends with whom they socialized. Motives for abstaining, apart from lack of interest, included academic ambitions, activities requiring sobriety, parental influence, and a wish to stay healthy. The students expressed negative attitudes towards current information-based prevention as well as problems with using selective prevention interventions due to fear of being registered or reported to the authorities. Students’ suggestions for feasible universal prevention concerned reliable information from credible sources, stricter substance control measures, extended parental involvement, and social leisure activities without substance use. Suggestions regarding selective prevention were guaranteed confidentiality and non-judging encounters when seeking help due to substance use problems.

Comparison with previous research

Children of affluence are generally presumed to be at low risk for negative health outcomes. However, the current study, in accordance with other recent studies [ 29 , 55 ], suggest problems in several domains including alcohol and drug use and stress related problems, even if the cause of these problems cannot be determined based on our interview study. Previous explanations for extensive substance use among affluent young people have been exceptionally high-performance requirements in both school and in leisure activities, and absence of emotional and physical adult contact, resulting from parents in affluent areas spending a lot of time on their jobs and careers [ 30 , 56 , 57 , 58 ]. These explanations can be viewed in the light of Cooper and colleagues’ [ 21 ] as well as Boys and colleagues’ [ 23 , 24 , 25 ] previously identified coping motive for substance use. Coping appears among affluent young people as a central motive for substance use, i.e., coping with performance requirements and perhaps with negative affects due to parents’ absence. In the current study, however, social motives, including conformity, i.e., using substances due to social pressure and a need to fit in [ 21 , 23 , 24 , 25 ] appears to be the most prominent motive, supporting the social learning theory which proposes that behavior can be acquired by observing and imitating others and by rewards connected to the behavior [ 16 , 59 ]. Interestingly, a small group of participants, especially from natural sciences programs, resisted the general pressure to use substances and found a social context of a few friends with whom they socialized without striving for high social status in the larger social context. The wish to be included in the social life and achieve high social status within the peer group was described as a central motive for substance use among a majority of the students, along with fear of being excluded if abstaining. Previous research show that high socioeconomic status is a protective factor for substance use disorder among adults [ 60 ], but among young people it may be the opposite. High status appears to be an important risk factor for the use of substances, at least among those striving for higher status. The students report that they, to achieve high status, must attend parties and at least drink alcohol. After achieving high status, which has resulted in frequent invitations to parties, students then may pose an even higher risk of excessive alcohol and drug use. In line with previous studies, results show that individuals with larger social networks, which has shown to be an indicator for social status among young, also drink more [ 35 , 61 ]. However, status can also act as a protective factor. Individuals with higher status have, according to the interviewees, slightly more room for maneuver to temporarily say no to substances at a party, without being pressured or ashamed. Nevertheless, several of the interviewees reported that they have to choose between using substances or being excluded from desirable social activities, as abstainers are considered “boring”. The results further show that alcohol and other drugs are popular among affluent youth and the information from the participants indicate that the students perceive substance use to be under control. One possible explanation is that high affluence can contribute to a sense of control over one’s life [ 62 ]. Although previous studies show that young people from affluent areas drink more, the risk of developing alcohol problems is still greater among young people who grow up in more disadvantaged areas [ 57 ]. Why this is the case is unclear. There is a widespread belief that affluent youngsters have plenty of social and financial resources in the family and thus receive the right help (e.g., psychotherapy) when they have problems [ 62 ], which could explain why they do not develop alcohol problems. However, research also shows that parents in affluent areas seek less help than others when their children are troubled [ 30 , 63 ], partly due to difficulties in accepting and revealing problems within the family [ 62 ]. In the current study, the informants expressed doubts about the possibility to be guaranteed confidentiality when seeking help, which may mean that there are concerns among both children and parents about the risk of losing status and a good reputation if seeking help for substance use problems. Consequently, there is a risk that any substance use problems will not be noticed in this group [ 62 ].

Previous research indicates that academic pressure may promote substance use [ 56 , 64 ]. However, in the current study academic pressure, due to high ambitions, was reported both as a reason for using substances and abstaining, the former to cope with stress or relax, the latter to maintain a sharp intellect and receive high grades. Moreover, previous research has demonstrated an association between pressure from extracurricular activities or “over scheduling” and negative outcomes among affluent students ( 39 ). In the current study, this did not stand out as a critical vulnerability factor. Instead, students reported extracurricular and leisure activities as relaxing and fun and an accepted reason to abstain from substance use while still attending activities where peers were using substances.

With regard to adult or parental contact, previous research shows that mental health and substance use among adolescents in socioeconomic affluent areas are associated with parents’ lack of reaction to teenage substance use (i.e. liberal, allowing attitudes and minor or no repercussions on discovering use) and parents’ lack of knowledge of their teens’ activities [ 30 ]. In our study, the students reported that their parents do not generally react with punishment due to their child’s alcohol consumption. However, the participants thought that parents probably should react more condemningly due to illicit drug use, if revealed. The Swedish criminalization of illicit substance use [ 46 ] may influence parents to adopt stricter norms with regard to their children’s illicit substance, because of the consequences for revealed substance use that may occur in the Swedish context. Also, parents in the current study were reported as being reluctant to seek help for their children out of fear of negative consequences that may affect their children. This result is in line with previous research, showing that concern about admitting problems in their children is elevated among affluent parents [ 30 ], mentioned above. In the current study, the participants further reported closeness to their parents and that their parents cared about how they spent their time. That said, some parents of wealthy peers were reported as being more absent, resulting in extensive partying in large homes without parental control. Previous research has shown the nature of family relationships and perceptions of closeness to be important protective factors for adolescent mental health [ 56 ], and this seems to apply to the students in the current study.

The students’ attitudes to current substance use prevention, aimed to increase students’ knowledge, are to a large extent negative. Information provided in school were reported as exaggerated and uninteresting. Instead, students suggested interventions focusing on credible sources of reliable information, such as from people with personal adverse experiences of substance use and people whom they can identify with. Whether people with own experience of substance use are credible or helpful in a more objective way can be disputed, but the students seem to put their trust in them rather than other persons. This result is partly in line with previous research on school-based programs in general, suggesting that the role of the teacher (the one who deliver the information) is central and that the use of peer leaders can be successful in engaging the students who receive the message [ 65 , 66 ]. Some informants in the current study meant that the teachers in school were ignorant and unengaged, lecturing about substances only by duty, which of course can be problematic for the sense of credibility among those receiving the information. Previous research has demonstrated that for older adolescents, a social influence approach can increase the effectiveness of alcohol and drug prevention interventions, as can health education, basic skills training and the inclusion of parental support [ 67 ]. Again, this research applies to adolescents in general and not to affluent youth specifically.

Interestingly, the students also suggested stricter regulations on substances with intensified legal measures for those providing substances. Positive attitudes to limiting access of alcohol for drunk people have previously been shown in a Spanish study among adolescents participating in an open-air gatherings of binge drinkers [ 19 ]. The positive attitude to stricter regulations for those providing substances is interesting in the light of the students’ desire for a non-judging approach when having to seek help for own substance use, as described below. Previous research, however, supports strict policy measures to decrease availability as an effective measure for substance use prevention in the general population [ 68 ]. The students further suggested increased parental control and activities and venues which can be attended without using substances, for example sporting/training with friends. Leisure activities without substance use have recently been offered to e.g., adolescents in general in an Icelandic prevention strategy [ 69 ], however more research is needed to see if this kind of prevention is attractive also for large groups of affluent students as an alternative to parties and whether it also appears to be effective in reducing substance use in this group. Clearly, some affluent students without ambitions to receive high social status do find socialization without using substances attractive, as shown in the current study. With regard to selective prevention, the students were critical of the current risk of being reported to parents, registered within medical records or reported to the authorities if turning to professionals for support for substance use problems. They claimed that this circumstance serves as a massive counteracting force to seek help at an early stage for oneself or for peers and that the possibility of reaching out anonymously is essential for taking the first step in seeking help. Moreover, the adolescents in this study call for an open and non-judging approach when turning to health care staff, parents or other adults, which is in line with so called Motivational Interviewing, a non-judging approach aimed to enhance motivation to change by exploring and resolving ambivalence about e.g., substance-related behaviors [ 70 ], which has shown promising results with regard to reduction of alcohol consumption among young people [ 71 ].

Strengths and limitations

The current study has a number of strengths. Firstly, we were able to recruit both male and female students between 15 and 19 years of age, living inside the affluent community as well as in neighboring municipalities, which provided us with a broad base of the students’ social context. Secondly, we included informants using substances as well as abstainers, increasing the possibility to get a broad view of motives to use or abstain from using substances among affluent youth. Thirdly, the research group has extensive experience in qualitative analysis as well as working with adolescents and young adults with mental health problems, including alcohol and drug consumption or abuse. However, our study must also be viewed in the context of some limitations. Students with more severe health or psychosocial problems may have refrained from participating, biasing the results towards adolescents of more stable psychosocial functioning. Moreover, interview studies are always vulnerable for social desirability bias due to a potential desire to give socially acceptable answers [ 72 ]. However, the possibility to terminate participation at any time, along with the circumstance that most of the interviewers are health care professionals, thereby used to handle secrecy in consultation situations, may have decreased the risk of desirability bias in the current study.

Several of the motives guiding substance use behavior among young people in general also seem to apply to affluent youth. A desire to feel a part of the current social milieu and to attain or maintain high social status within the peer group were reported as prominent motives for substance use among affluent students in the current study. Given that the social milieu is crucial for the substance use behavior in this context, future research on substance use prevention targeting this group could with advantage pay attention to suggestions on prevention strategies given by the students. Students’ suggestions include reliable prevention information from credible sources, stricter substance control measures targeting those providing substances, parental involvement, leisure activities without substance use, and confidential ways to seek help, involving a non-judging approach from professionals and other adults.

Availability of data and materials

Collected data will be available from the Centre for Psychiatry Research, a collaboration between Karolinska Institutet and Region Stockholm, but restrictions apply to their availability, as they were used under ethical permission for the current study, and so are not publicly available. However, data are available from the authors upon reasonable request and with permission from the Centre for Psychiatry Research.

Abbreviations

attention deficit hyperactivity disorder

natural sciences/technology/mathematic programs

social sciences/humanities programs

Stockholm prevents alcohol and drug problems

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Acknowledgements

We would like to thank all the participating students for making this study possible.

The work was funded by the Alcohol Research Council of the Swedish Alcohol Retailing Monopoly (grant no. 2018–0010). The funding body had no role in study design, data collection, analysis, data interpretation or writing the manuscript. Open Access funding provided by Karolinska Institute.

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Department of Social Studies, Linnaeus university, Växjö, Sweden

Linda Hiltunen

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Liljeholmstorget 7, 117 63, Stockholm, Sweden

Youstina Demetry

Department of Neuroscience, Uppsala University, Uppsala, Sweden

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Contributions

PK contributed to conceptualization, methodology, investigation (data collection), data curation, formal analysis, writing original draft, review & editing, funding acquisition. LH contributed to conceptualization, methodology, data curation, formal analysis, validation, review & editing. YD contributed to project administration, methodology, investigation (data collection), data curation, formal analysis, validation, review & editing. AC contributed to investigation (data collection), review & editing. TH contributed to investigation (data collection), review & editing. JG contributed to conceptualization, methodology, review & editing, funding acquisition. TE contributed to conceptualization, methodology, review & editing. KE contributed to review & editing. CS contributed to conceptualization, methodology, investigation (data collection), data curation, formal analysis, review & editing, funding acquisition, supervision. All authors approved the submitted manuscript version.

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Correspondence to Pia Kvillemo .

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The study was performed in accordance with the Declaration of Helsinki and was approved by the Swedish Ethical Review Authority (dnr. 2019–02646).

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Kvillemo, P., Hiltunen, L., Demetry, Y. et al. How to prevent alcohol and illicit drug use among students in affluent areas: a qualitative study on motivation and attitudes towards prevention. Subst Abuse Treat Prev Policy 16 , 83 (2021). https://doi.org/10.1186/s13011-021-00420-8

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How to Prevent Alcoholism

In This Article

Key takeaways.

• Alcohol addiction or alcohol abuse can lead to long-term physical and mental health complications
• You can prevent alcohol addiction with moderate drinking and professional treatments
• Alcohol can affect people differently, because of this there is no single way to prevent addiction
• If you start to notice physical and mental side effects from alcohol abuse, consider seeking medical attention
• Various treatment options are available to help you recover from addiction and stay sober

Can You Prevent Alcohol Abuse?

Yes, you can prevent alcohol abuse. However, alcohol has different effects on everyone. Because of this, there’s no single way to prevent alcoholism.

Drinking patterns vary depending on factors such as:

• Environment

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Tips for Preventing Alcohol Abuse & Addiction in Adults

If you are struggling with alcohol, the following tips will help you create healthy drinking habits and prevent alcohol use disorder ( AUD ).

Drink Moderately or Practice Low-Risk Drinking

The Dietary Guidelines for Americans recommend non-drinkers abstain from alcohol completely. If you've already started drinking, limit yourself to 1 drink a day for women or 2 drinks a day for men. 8

You can also practice low-risk drinking. Limit your intake to 7 drinks per week for women or 14 for men.

According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), only 2 out of 100 drinkers within these limits develop AUD. 4

Monitor Your Drinking

Whether you drink alone or with others, drink within the recommended limits. One way to do this is to alternate drinking with other activities. For example, you can:

• Talk to people
• Drink water in between drinks
• Substitute alcohol with non-alcoholic drinks

Before you grab a drink, ask yourself why you are doing it. Do not drink alcohol if you feel any negative emotions.

Drinking to cope with sadness or stress will sometimes cause you to consume more alcohol than usual. This can lead to alcohol dependence and long-term alcohol abuse. 9,10

Avoid Triggers

A trigger can be any place, person, object, or situation that urges you to drink alcohol. Learning to recognize your triggers is important in alcohol prevention.

Here are some ways you can avoid them:

• Do not attend gatherings or celebrations where there is alcohol
• Stay away from people who drink heavily or encourage you to drink
• Do not store alcohol at home or keep a stock of it
• Replace alcohol with non-alcoholic drinks and healthy foods
• Avoid people and situations that remind you of past trauma
• Do not live in places that provide easy access to alcohol, such as nearby bars
• Learn healthy coping mechanisms to prevent emotional drinking

Avoiding triggers can be difficult. If you are constantly exposed to triggers, consider moving to an alcohol-free environment, such as a halfway house .

Get Support

Having people who support you is a great way to reinforce your alcohol prevention strategies. They can help you:

• Regulate your drinking
• Avoid triggers
• Create healthy coping mechanisms
• Hold you accountable if you drink
• Call healthcare professionals in case of emergencies

Get Professional Help

BetterHelp can connect you to an addiction and mental health counselor.

How to Prevent Underage Drinking

As a parent or family member, here are some ways to prevent alcohol use in teenagers:

• Encourage teens to feel confident about turning down alcohol
• Speak openly and honestly about drinking and its risks
• Establish boundaries on what will happen if a teen drinks
• Monitor your alcohol at home so you can tell if they have been drinking
• Do not allow them to go to parties without a chaperone
• Set a rule that it is unacceptable to consume alcohol at home
• Encourage healthy relationships with peers who do not drink
• Set a good example with responsible alcohol consumption
• Enroll your child in alcohol prevention programs

The main consequence of underage drinking is that it causes impulsive behavior. This often increases the risk of: 

• Sexual assault
• Alcohol overdose
• Premature death

Studies show that people who start drinking in their teenage years are at higher risk of developing alcohol use disorder (AUD) in adulthood. 12 Because of this, it's important to help them as early as possible.

Preventing Harmful Alcohol Use in Older People

Alcohol use disorders are less common in older adults. But with nearly half of those aged 65 and over still drinking, alcohol consumption is still associated with age-related risks.

Older people have a lower tolerance for alcohol. They can suffer from alcohol-related harm even if they drink within the recommended limits.

To help them avoid harmful alcohol use, involve healthy and safe approaches and seek help from family members and health professionals. 

Here are some ways you can reduce the harmful consequences of alcohol among older adults:

• Ensure they do not mix alcohol with over-the-counter (OTC) and prescription drugs.
• If they have pre-existing health conditions, limit or stop their alcohol intake.
• Watch out for triggers that may cause them to drink excessively.
• Provide support.

Phone, Video, or Live-Chat Support

BetterHelp provides therapy in a way that works for YOU. Fill out the questionnaire, get matched, begin therapy.

When Should You Get Help for You or Your Loved One?

AUD can affect anyone, regardless of age. Knowing the early signs of alcoholism can help you prevent it.

Signs and symptoms of alcoholism include:

• Drinking alcohol alone or hiding one's drinking
• Needing to increase consumption to achieve the same effect
• Decreasing appetite and gradual weight loss
• Lack of personal hygiene
• Decreasing function at work or school
• Becoming angry when confronted about their alcohol misuse

If you experience these or know someone who does, don’t hesitate to seek professional treatment and advice. Doctors and healthcare providers can help you explore harm reduction programs and assist with staging interventions if needed.

How Is Alcohol Addiction Diagnosed?

You’ll start by seeing your primary healthcare provider. If they think you have a problem with alcohol, you’ll be referred to a mental health provider.

You may go through assessments and examinations that include:

• Asking you about your drinking habits
• Alcohol screening and brief interventions
• Lab and image testing
• Psychological evaluations 

Treatment Options for AUD

If you have a drinking problem or alcohol addiction, various treatment options can help you recover and stay sober. However, alcohol affects people differently, and so does treatment.

Consult a doctor or health professional to help find the right treatment program for your needs. Available treatment options for AUD include:

• Medical detox : Medically supervised detox used to avoid harmful withdrawal symptoms
• Inpatient treatmen t: Involves checking yourself into a rehab facility for 24-hour medical supervision
• Outpatient treatment : A treatment program where people are allowed to leave the rehab facility
• Dual-diagnosis treatment : A treatment program that treats any co-occurring condition alongside alcohol use disorder
• Cognitive behavioral therapy (CBT) : A short-term therapy technique that explores the link between thought patterns and addiction
• Partial hospitalization program (PHP) : A treatment program where you stay at a rehab facility for a day and return home at night
• Support groups : Provide a much-needed community to help maintain sobriety after treatment

Preventing Excessive Alcohol Use

Alcohol is a psychoactive substance with immediate effects on the brain. Repeated use can change the way your brain functions and cause alcohol addiction . 3 Preventing alcoholism can help you avoid long-term, life-altering consequences. 

Excessive alcohol use or alcoholism can lead to: 1,2

• Alcoholic liver disease
• Heart disease
• Disabilities
• Social or relationship problems
• Work or school problems
• Mental health problems

Before you take on alcohol prevention, you should examine your relationship with alcohol. Doing so will help determine whether you have a mild or severe alcohol problem.

How to Tell if You Drink Too Much

Take note of how many drinks you typically consume and how often you drink in a day, week, and month. If you drink excessively, you may have an alcohol problem among the following:

• Binge drinking: 4 or more drinks for women in 2 hours or 5 or more drinks for men 
• High-intensity drinking: Alcohol consumption that is 2 or more times than binge drinking levels
• Heavy drinking: 3 or more drinks a day or at least 8 drinks per week for women or 4 or more drinks a day or at least 15 drinks per week for men

Heavy, high-intensity, and binge drinking are signs you drink too much alcohol. Any type of alcohol use in pregnant women and adolescents below 21 is also considered excessive. 4,5

What's Next?

• What Is Rehab Like?
• Why Call an Addiction Hotline?
• How to Sober Up
• Tapering off of alcohol

Get matched with an affordable mental health counselor

Related Articles

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Medically Reviewed by: Paul

Alcohol Detox: 9 Things to Consider

Medically Reviewed by: Annamarie Coy

Relapse Prevention: Strategies to Avoid Triggers

Methadone vs. Suboxone

What Is the Jellinek Curve in Addiction and Recovery?

Peyote Statistics on Usage and its Legal Status

• " Harmful use of alcohol ." World Health Organization Eastern Mediterranean Regional Office.
• " Alcohol Abuse Statistics ." The National Center for Drug Abuse Statistics, 2023.
• U.S. Department of Health and Human Services. " Biology of Addiction: Drugs and Alcohol Can Hijack Your Brain ." News in Health, 2015.
• " Drinking Patterns and Their Definitions ." Alcohol Research: Current Reviews, 2018.
• Centers for Disease Control and Prevention. " Excessive Alcohol Use ." National Center for Chronic Disease Prevention and Health Promotion, 2022.
• Harding et al. “ Underage Drinking: A Review of Trends and Prevention Strategies. ” American Journal of Preventive Medicine, 2016.
• Patrick, M., and Azar, B." High-Intensity Drinking ." Alcohol Research: Current Reviews, 2018.
• U.S. Department of Health and Human Services. " 2015–2020 Dietary Guidelines for Americans ." Office of Disease Prevention and Health Promotion, 2015.
• Merrill, J., and Thomas, S. " Interactions between Adaptive Coping and Drinking to Cope in Predicting Naturalistic Drinking and Drinking Following a Lab-Based Psychosocial Stressor ." Addictive Behaviors, 2012.
• Turner et al. “ Self-medication with alcohol or drugs for mood and anxiety disorders: A narrative review of the epidemiological literature. ” Depression and Anxiety, 2018.
• Kelly et al. " The relationship of social support to treatment entry and engagement: The Community Assessment Inventory ." Substance Abuse, 2010.
• U.S. Department of Health and Human Services. " Alcohol Facts and Statistics ." National Institute on Alcohol Abuse and Alcoholism, 2023.

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• Alcohol Detox: 9 Things to Consider If you're looking for information on alcohol detox, you'll want...
• Relapse Prevention: Strategies to Avoid Triggers Relapse is sometimes seen as an inevitable part of addiction...
• Methadone vs. Suboxone Here's a look at the benefits and side effects of...
• What Is the Jellinek Curve in Addiction and Recovery? Learn about the Jellinek Curve, a graph that plots alcohol...
• Peyote Statistics on Usage and its Legal Status Peyote (Lophophora williamsii) is a small, spineless cactus containing a...

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• 1 McCusker Centre for Action on Alcohol and Youth, Curtin University, GPO Box U1987, Perth, WA 6845, Australia.
• 2 National Drug Research Institute, Curtin University, Bentley, WA 6102, Australia.
• PMID: 24739773
• DOI: 10.1071/HE14001

Preventing alcohol-related harm presents a range of challenges including those related to political will, competing interests with disproportionate resources, and embedded drinking cultures. On the other hand there are opportunities for health promotion, including clear evidence on both the extent of the problem and evidence-based responses and growing community support for action. Australian researchers continue to contribute substantially to the international evidence base on alcohol, generating evidence for translation into effective programs and producing policy-relevant research on which action and advocacy can be based. Successes in other public health areas also provide useful models for public health approaches to alcohol. Those engaged in health promotion have often been required to do a lot with a little, including communicating health messages on a range of themes, countering industry activities that are contrary to good public health and involvement in policy development. Coalition approaches to alcohol related harm, including links with groups outside health, have recently gained momentum and show much potential. Alcohol issues are now firmly on the agenda of the public and decision-makers, and the alcohol industry has expressed clear concern at current levels of activity. This paper will consider briefly the nature of the challenge; evidence-based approaches; achievements and developments thus far; challenges and obstacles; and the role of health promotion and the health promotion workforce.

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Parenting to prevent childhood alcohol use.

Drinking alcohol undoubtedly is a part of American culture, as are conversations between parents and children about its risks. Alcohol affects people differently at different stages of life—for children and adolescents, alcohol can interfere with normal brain development. Alcohol’s differing effects and parents’ changing role in their children’s lives as they mature and seek greater independence can make talking about alcohol a challenge. Parents may have trouble setting concrete family policies for alcohol use. And they may find it difficult to communicate with children and adolescents about alcohol-related issues.

Research shows, however, that teens and young adults do believe their parents should have a say in whether they drink alcohol. Parenting styles are important—teens raised with a combination of encouragement, warmth, and appropriate discipline are more likely to respect their parents’ boundaries. Understanding parental influence on children through conscious and unconscious efforts, as well as when and how to talk with children about alcohol, can help parents have more influence than they might think on a child’s alcohol use. Parents can play an important role in helping their children develop healthy attitudes toward drinking while minimizing its risk.

Alcohol Use by Young People

Underage drinking has been declining but is still a serious public health issue. The percentage of teenagers who drink alcohol is slowly declining, but numbers are still quite high. About 23.1% of adolescents report drinking by 8th grade, and about 36.7% report being drunk at least once by 12th grade. 1

Parenting Style

Accumulating evidence suggests that alcohol use—and in particular binge drinking—may have negative effects on adolescent development and increase the risk for alcohol-related problems later in life. 2,3  This underscores the need for parents to help delay or prevent the onset of drinking as long as possible. Parenting styles may influence whether their children follow their advice regarding alcohol use. Every parent is unique, but the ways in which each parent interacts with their children can be broadly categorized into four styles:

• Authoritarian parents typically exert high control and discipline with low warmth and responsiveness. For example, they respond to bad grades with punishment but let good grades go unnoticed.
• Permissive parents typically exert low control and discipline with high warmth and responsiveness. For example, they deem any grades at all acceptable and fail to correct behavior that may lead to bad grades.
• Neglectful parents exert low control and discipline as well as low warmth and responsiveness. For example, they show no interest at all in a child’s school performance.
• Authoritative parents exert high control and discipline along with high warmth and responsiveness. For example, they offer praise for good grades and use thoughtful discipline and guidance to help improve low grades. 4

Regardless of the developmental outcome examined—body image, academic success, or substance misuse—children raised by authoritative parents tend to fare better than their peers. 5  This is certainly true when it comes to the issue of underage drinking, 6  in part because children raised by such parents learn approaches to problem solving and emotional expression that help protect against the psychological dysfunction that often precedes alcohol misuse. 7  The combination of discipline and support by authoritative parents promotes healthy decision making about alcohol and other potential threats to healthy development. 8

Some parents wonder whether allowing their children to drink in the home will help them develop an appropriate relationship with alcohol. According to most studies this does not appear to be the case. In a study of sixth, seventh, and eighth graders, researchers observed that students whose parents allowed them to drink at home and/or provided them with alcohol experienced the steepest escalation in drinking. 9  Other studies suggest that adolescents who are allowed to drink at home drink more heavily outside of the home. 10  In contrast, adolescents are less likely to drink heavily if they live in homes where parents have specific rules against drinking at a young age and also drink responsibly themselves. 11  Parental provision of alcohol serves as a direct risk factor for alcohol misuse, as is the case when parents provide alcohol for parties attended or hosted by their adolescents. Collectively, the literature suggests that permissive attitudes toward adolescent drinking, particularly when combined with poor communication and unhealthy modeling, can lead teens into unhealthy relationships with alcohol.

Regardless of what parents may teach their children about alcohol, some genetic factors are present from birth and cannot be changed. Genes appear to influence the development of drinking behaviors in several ways. Some people, particularly those of Asian ancestry, have a natural and unpleasant response to alcohol that helps prevent them from drinking too much. Other people have a naturally high tolerance to alcohol, meaning that to feel alcohol’s effects, they must drink more than others. Some personality traits are genetic, and those, like impulsivity, can put a person at risk for alcohol misuse. Mental health conditions may be influenced by genes and increase the risk for alcohol use disorder (AUD). Finally, having a parent with AUD increases a child’s risk for developing alcohol-related problems of their own. 12

Do Teens Listen?

Adolescents do listen to their parents when it comes to issues such as drinking and smoking, particularly if the messages are conveyed consistently and with authority. 5  Research suggests that only 19% of teens feel that parents should have a say in the music they listen to, and 26% believe their parents should influence what clothing they wear. However, the majority—around 80%—feel that parents should have a say in whether they drink alcohol. Those who do not think that parents have authority over these issues are four times more likely than other teens to drink alcohol and three times more likely to have plans to drink if they have not already started. 5

Whether teens defer to parents on the issue of drinking is statistically linked to how parents parent. Specifically, authoritative parents—those who provide a healthy and consistent balance of discipline and support—are the most likely to have teenagers who respect the boundaries they have established around drinking and other behaviors. However, adolescents exposed to permissive, authoritarian, or neglectful parenting are less influenced by what their parents say about drinking. 5

Research suggests that, regardless of parenting styles, adolescents who are aware that their parents would be upset with them if they drank are less likely to do so, highlighting the importance of communication between parents and teens as a protective measure against underage alcohol use. 13

What Can Parents Do?

Parents influence whether and when adolescents begin drinking as well as how they drink. Family policies about adolescent drinking in the home and the way parents themselves drink are important. For instance, if you choose to drink, always model responsible alcohol consumption. But what else can parents do to help minimize the likelihood that their adolescent will choose to drink and that such drinking, if it does occur, will become problematic? Studies 14  have shown that it is important to:

Talk early and often, in developmentally appropriate ways, with children and teens about your concerns—and theirs—regarding alcohol. Adolescents who know their parents’ opinions about youth drinking are more likely to fall in line with their expectations.

Establish policies early on, and be consistent in setting expectations and enforcing rules. Adolescents do feel that parents should have a say in decisions about drinking, and they maintain this deference to parental authority as long as they perceive the message to be legitimate. Consistency is central to legitimacy.

Work with other parents to monitor where kids are gathering and what they are doing. Being involved in the lives of adolescents is key to keeping them safe.

Work in and with the community to promote dialogue about underage drinking and the creation and implementation of action steps to address it.

Be aware of your state’s laws about providing alcohol to your own children.

Never provide alcohol to someone else’s child.

Children and adolescents often feel competing urges to comply with and resist parental influences. During childhood, the balance usually tilts toward compliance, but during adolescence, the balance often shifts toward resistance as teens prepare for the autonomy of adulthood. With open, respectful communication and explanations of boundaries and expectations, parents can continue to influence their children’s decisions well into adolescence and beyond. This is especially important in young people’s decisions regarding whether and how to drink—decisions that can have lifelong consequences.

For more information, please visit:  niaaa.nih.gov .

1  Miech RA, Johnston LD, Patrick ME, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future National Survey Results on Drug Use, 1975-2022. Secondary School Students. Table 1: Trends in lifetime prevalence of use of various drugs in grades 8, 10, and 12. Ann Arbor (MI): Institute for Social Science Research, University of Michigan; 2023 [cited 2023 Jul 19]. Available from: https://www.monitoringthefuture.org/wp-content/uploads/2022/12/mtf2022table01.pdf .    

2  Grant BF, Dawson DA. Age at onset of alcohol use and its association with DSM–IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. J Subst Abuse. 1997;9:103–10. PubMed PMID: 9494942

3  Squeglia LM, Jacobus J, Tapert SF. The influence of substance use on adolescent brain development. Clin EEG Neurosci. 2009;40(1):31–8. PubMed PMID: 19278130

4  Baumrind D. Parental disciplinary patterns and social competence in children. Youth Soc. 1978;9:238–276.

5  Jackson C. Perceived legitimacy of parental authority and tobacco and alcohol use during early adolescence. J Adolesc Health. 2002;31(5):425–32. PubMed PMID: 12401429

6  Simons-Morton B, Haynie DL, Crump AD, Eitel SP, Saylor KE. Peer and parent influences on smoking and drinking among early adolescents. Health Educ Behav. 2001;28(1):95–107. PubMed PMID: 11213145

7  Patock-Peckham JA, Morgan-Lopez AA. College drinking behaviors: Mediational links between parenting styles, parental bonds, depression, and alcohol problems. Psychol Addict Behav. 2007;21(3):297–306. PubMed PMID 17874880

8  Steinberg L, Lamborn SD, Dornbusch SM, Darling N. Impact of parenting practices on adolescent achievement: Authoritative parenting, school involvement, and encouragement to succeed. Child Dev. 1992;63(5):1266–81. PubMed PMID: 1446552

9  Komro KA, Maldonado-Molina MM, Tobler AL, Bonds JR, Muller KE. Effects of home access and availability of alcohol on young adolescents’ alcohol use. Addiction. 2007;102(10):1597–1608. PubMed PMID: 17854336

10  van der Vorst H, Engels RC, Burk WJ. Do parents and best friends influence the normative increase in adolescents’ alcohol use at home and outside the home? J Stud Alcohol Drugs. 2010;71(1):105–14. PubMed PMID: 20105420

11  van der Vorst H, Engels RC, Meeus W, Dekovic M. The impact of alcohol-specific rules, parental norms about early drinking and parental alcohol use on adolescents’ drinking behavior. J Child Psychol Psychiatry. 2006;47(12):1299–1306. PubMed PMID: 17176385

12  Schuckit MA. An overview of genetic influences in alcoholism. J Subst Abuse Treat. 2009;36(1):S5–S14. PubMed PMID: 19062348

13  Foley KL, Altman D, Durant RH, Wolfson M. Adults’ approval and adolescents’ alcohol use. J Adolesc Health. 2004;35(4):e17–e26. PubMed PMID: 15830441

14  Office of the Surgeon General. The Surgeon General’s call to action to prevent and reduce underage drinking: a guide to action for families. Washington, DC: U.S. Department of Health and Human Services, 2007 [cited 2021 Jan 8]. Available from:  https://www.hhs.gov/sites/default/files/underage-drinking-family-guide.pdf . 

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Alcoholism Prevention: How to Avoid Becoming an Alcoholic

Last Updated: August 7, 2019

In the United States, approximately 14 million people fall under the criteria for severe alcohol use disorders (AUD). On average, more than 88,000 deaths annually are attributed to alcoholism. This makes alcohol prevention a priority.  

The financial cost of alcohol abuse is astronomical. The Centers for Disease Control and Prevention put the amount at more than $200 billion per year. Most of these costs (40%) are borne by the federal state and local governments. Therefore, prevention of alcohol abuse can save the economy a lot of resources.

Other than the financial cost, excessive consumption of alcoholic drinks has implications for health care costs, aggression and violence, and family upbringing.

Table of contents

• How much drinking is too much?
• What are the risk groups to target in alcohol prevention?
• How to prevent alcoholism?
• What are the alcoholism prevention laws and regulations?
• When to seek professional help?

Drinking Levels: How Much is Too Much

A standard drink contains 14.0 grams or 0.6 ounces of pure alcohol. 12 ounces of beer contains approximately 5% alcohol content while 5 ounces of wine contains 12% alcohol content. On the other hand, distilled spirits such as rum, vodka, gin, and whiskey have the highest content at 40% alcohol in 1.5 ounces.

There are two broad levels of drinking: excessive drinking and moderate drinking. Excessive drinking is further categorized into heavy drinking, binge drinking, and any drinking by minors (under age 21) and pregnant women.

The most common form of excessive drinking and one of the early signs of alcoholism is binge drinking. Taking 4 or more drinks in a single occasion for women and 5 or more drinks for men, constitute binge drinking. There is a strong positive correlation between binge drinking and alcoholism. Most people targeted in alcoholism prevention fall in this category.

Heavy drinking means 8 or more drinks per week for women and 15 or more for men. Taking one drink per day and two drinks per day for women and men respectively is classified by the Dietary Guidelines for Americans as moderate drinking.

Risk Groups to Target in Alcohol Prevention

The potential causes and risk factors associated with alcoholism have been the subject of studies done on ways to prevent alcoholism. Data analyzed shows a multiplicity of factors influencing alcohol abuse.

Alcoholism can impact anyone irrespective of gender, personal beliefs, ethnicity, age, or body type. However, the following groups have been identified as being at a higher risk hence the focus of prevention interventions.

People with Low Esteem

Low levels of self-esteem can be a catalyst for  alcohol addiction . Feelings of inadequacy, inferiority, worthlessness, and hopelessness can push you to alcoholism as a form of emotional escape. Low self-esteem occurs when your mental impression of your ideal-self differs from your actual self. Once the mind registers this escape route, it becomes difficult to avoid alcohol.

Professionals

One of the greatest underlying causes of alcoholism in the United States is work-related stress. In addition, some professions revolve around alcohol, require people to network socially outside of the office, or have irregular work shift hours, thus posing a challenge to the prevention of alcoholism.

Statistics reported by the Substance Abuse and Mental Health Services Administration reveals that mining, construction, and accommodation services have the highest incidences of alcoholism. The rates stood at 17.5%, 16.5%, and 11.8% respectively.

People with Mental Disorders

There is well-documented evidence that shows a strong relationship between mental disorders such as depression, bipolar, anxiety, and panic disorders and alcohol abuse.

The National Comorbidity Survey shows that more than 40% of bipolar sufferers and about 20% of depression sufferers either abuse or are dependent on alcohol.  Most of these people turn to alcoholism as a coping mechanism for their illnesses.

Drug Abusers

If you are a drug abuser, it becomes difficult to avoid alcohol abuse. When individuals abuse drugs, their tolerance levels increase. This means for them to experience the same or higher desirable effects, they must up their intake or include another substance. Most drug abusers find it difficult to prevent alcohol abuse.

Families with a Drinking History

People coming from a family with a history of diagnosable alcoholic problems are more at risk of becoming alcoholics. On average, children born to alcohol-dependent parents have a 300% greater chance of developing a problematic pattern of drinking compared to the rest.

Alcoholism is more of a behavioral condition. The position of the family in early childhood development is important in instilling social behavior and values. Alcoholic parents tend to be a great influence on their children and lack the moral authority to teach them ways to avoid alcohol.

Practical Tips to Prevent Alcoholism

If you are already into drinking, preventing the urge and ultimately stopping, can be a challenge. However, there are strategies and routines on how to prevent alcoholism you can adapt to cut back and eventually stop drinking altogether.

Recognize Triggers

Internal and external triggers such as places, people, times of day, positive emotions, and negative emotions like frustration can leave you craving a drink . Recognizing these triggers is one way how to avoid alcohol. Move away from certain places, change the company, or switch to something else.

Don’t Keep Alcohol at Home

Access to alcohol increases the likelihood of drinking. Fully-stocked liquor cabinets and half-drunk bottles of wine can set off your drinking triggers . If there is no social purpose, keep alcoholic drinks out of your house. In fact, you can substitute with other drinks such as tea, water, and lemonade.

Engage in Other Activities

Instead of spending time in bars, look for other joints where there are non-drinking activities. You can take a walk, watch a movie or pick up a sport as a strategy on how to avoid drinking alcohol.

Cut Down on the Number of Drinks

Stopping alcoholism is a gradual process that takes time. You should start by cutting down on the drinks you take per day or week. Work on a practical prevention schedule and have an accountability partner. The best way on how to avoid alcohol poisoning is by taking water in between your drinks.

Build a Social Support Network

Alcoholism Prevention Laws and Regulations

In the United States, the debate on how to avoid alcoholism is far from over. Federal state and local governments have put in measures to reduce alcohol abuse and the resulting consequences. Policy interventions such as zero tolerance laws, raising the minimum legal drinking age, warning labels, rehabs for alcoholics , and administrative license revocation laws are already in place.

Community-based interventions and prevention measures such as the Saving Lives Program, Life Skills Training, and Alcohol Misuse Prevention Study have proved effective. With the right information and training on how to prevent alcohol abuse, individuals can put their drinking under control.

When to Seek Professional Help

Alcoholism is a disorder that needs professional support during treatment and recovery. Depending on the  stage of alcoholism , therapists can help families share the mental and emotional burden of supporting alcohol abuse family members.

By attending therapy and alcohol treatment program , alcoholics can regain control over their lives including their habitual drinking and live productive lives once again. If alcoholism has overwhelmed a person that can’t find the support they need, there are professionals to talk to.

Dr. Gregory Okhifun

Medical Reviewer

Dr. Okhifun is a passionate medical doctor, with over five years’ experience as a general practitioner. His passion for medical education led to his journey in medical writing. He has a wealth of experience writing for hospitals and medical centers, health organizations, telemedicine platforms, wellness organizations, medical tourism publications, addiction websites, and websites focused on nutrition and nutraceuticals. He also serves as medical coordinator and content writer for Gerocare Solutions, for which he also volunteers as a health advisor/consultant for the elderly. Dr. Okhifun enjoys traveling, meditation, and reading.

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Home — Essay Samples — Nursing & Health — Alcohol Abuse — The Impact of Alcohol Abuse: Causes, Effects, and Solutions

The Impact of Alcohol Abuse: Causes, Effects, and Solutions

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Why Are Older Americans Drinking So Much?

The pandemic played a role in increased consumption, but alcohol use among people 65 and older was climbing even before 2020.

By Paula Span

The phone awakened Doug Nordman at 3 a.m. A surgeon was calling from a hospital in Grand Junction, Colo., where Mr. Nordman’s father had arrived at the emergency room, incoherent and in pain, and then lost consciousness.

At first, the staff had thought he was suffering a heart attack, but a CT scan found that part of his small intestine had been perforated. A surgical team repaired the hole, saving his life, but the surgeon had some questions.

“Was your father an alcoholic?” he asked. The doctors had found Dean Nordman malnourished, his peritoneal cavity “awash with alcohol.”

The younger Mr. Nordman, a military personal finance author living in Oahu, Hawaii, explained that his 77-year-old dad had long been a classic social drinker: a Scotch and water with his wife before dinner, which got topped off during dinner, then another after dinner, and perhaps a nightcap.

Having three to four drinks daily exceeds current dietary guidelines , which define moderate consumption as two drinks a day for men and one for women, or less. But “that was the normal drinking culture of the time,” said Doug Nordman, now 63.

At the time of his 2011 hospitalization, though, Dean Nordman, a retired electrical engineer, was widowed, living alone and developing symptoms of dementia. He got lost while driving, struggled with household chores and complained of a “slipping memory.”

He had waved off his two sons’ offers of help, saying he was fine. During that hospitalization, however, Doug Nordman found hardly any food in his father’s apartment. Worse, reviewing his father’s credit card statements, “I saw recurring charges from the Liquor Barn and realized he was drinking a pint of Scotch a day,” he said.

Public health officials are increasingly alarmed by older Americans’ drinking. The annual number of alcohol-related deaths from 2020 through 2021 exceeded 178,000, according to recently released data from the Centers for Disease Control and Prevention : more deaths than from all drug overdoses combined.

An analysis by the National Institute on Alcohol Abuse and Alcoholism shows that people over 65 accounted for 38 percent of that total. From 1999 to 2020, the 237 percent increase in alcohol-related deaths among those over age 55 was higher than for any age group except 25- to 34-year-olds.

Americans largely fail to recognize the hazards of alcohol, said George Koob, the director of the institute. “Alcohol is a social lubricant when used within the guidelines, but I don’t think they realize that as the dose increases it becomes a toxin,” he said. “And the older population is even less likely to recognize that.”

The growing number of older people accounts for much of the increase in deaths, Dr. Koob said. An aging population foreshadows a continuing surge that has health care providers and elder advocates worried, even if older people’s drinking behavior doesn’t change.

But it has been changing . The proportions of people over 65 who report using alcohol in the past year (about 56 percent) and the past month (about 43 percent) are lower than for all other groups of adults. But older drinkers are markedly more likely to do it frequently, on 20 or more days a month, than younger ones.

Moreover, a 2018 meta-analysis found that binge drinking (defined as four or more drinks on a single occasion for women, five or more for men) had climbed nearly 40 percent among older Americans over the past 10 to 15 years.

What’s going on here?

The pandemic has clearly played a role. The C.D.C. reported that deaths attributable directly to alcohol use, emergency room visits associated with alcohol, and alcohol sales per capita all rose from 2019 to 2020, as Covid arrived and restrictions took hold.

“A lot of stressors impacted us: the isolation, the worries about getting sick,” Dr. Koob said. “They point to people drinking more to cope with that stress.”

Researchers also cite a cohort effect. Compared to those before and after them, “the boomers are a substance-using generation,” said Keith Humphreys, a psychologist and addiction researcher at Stanford. And they’re not abandoning their youthful behavior, he said.

Studies show a narrowing gender divide, too. “Women have been the drivers of change in this age group,” Dr. Humphreys said.

From 1997 to 2014, drinking rose an average of 0.7 percent a year for men over 60, while their binge drinking remained stable. Among older women, drinking climbed by 1.6 percent annually, with binge drinking up 3.7 percent.

“Contrary to stereotypes, upper-middle-class, educated people have higher rates of drinking,” Dr. Humphreys explained. In recent decades, as women grew more educated, they entered workplaces where drinking was normative; they also had more disposable income. “The women retiring now are more likely to drink than their mothers and grandmothers,” he said.

Yet alcohol use packs a greater wallop for older people, especially for women, who become intoxicated more quickly than men because they’re smaller and have fewer of the gut enzymes that metabolize alcohol.

Seniors may argue that they are merely drinking the way they always have, but “equivalent amounts of alcohol have much more disastrous consequences for older adults,” whose bodies cannot process it as quickly, said Dr. David Oslin, a psychiatrist at the University of Pennsylvania and the Veterans Affairs Medical Center in Philadelphia.

“It causes slower thinking, slower reaction time and less cognitive capacity when you’re older,” he said, ticking off the risks.

Long associated with liver diseases, alcohol also “exacerbates cardiovascular disease, renal disease and, if you’ve been drinking for many years, there’s an increase in certain kinds of cancers,” he said. Drinking contributes to falls, a major cause of injury as people age, and disrupts sleep.

Older adults also take a lot of prescription drugs, and alcohol interacts with a long list of them. These interactions can be particularly common with pain medications and sleep aids like benzodiazepines, sometimes causing over-sedation. In other cases, alcohol can reduce a drug’s effectiveness.

Dr. Oslin cautions that, while many prescription bottles carry labels that warn against using those drugs with alcohol, patients may shrug that off, explaining that they take their pills in the morning and don’t drink until evening.

“Those medications are in your system all day long, so when you drink, there’s still that interaction,” he tells them.

One proposal for combating alcohol misuse among older people is to raise the federal tax on alcohol, for the first time in decades. “Alcohol consumption is price-sensitive, and it’s pretty cheap right now relative to income,” Dr. Humphreys said.

Resisting industry lobbying and making alcohol more expensive, the way higher taxes have made cigarettes more expensive, could reduce use.

So could eliminating barriers to treatment. Treatments for excessive alcohol use, including psychotherapy and medications, are no less effective for older patients , Dr. Oslin said. In fact, “age is actually the best predictor of a positive response,” he said, adding that “treatment doesn’t necessarily mean you have to become abstinent. We work with people to moderate their drinking.”

But the 2008 federal law requiring health insurers to provide parity — meaning the same coverage for mental health, including substance use disorders, as for other medical conditions — doesn’t apply to Medicare. Several policy and advocacy groups are working to eliminate such disparities.

Dean Nordman never sought treatment for his drinking, but after his emergency surgery, his sons moved him into a nursing home, where antidepressants and a lack of access to alcohol improved his mood and his sociability. He died in the facility’s memory care unit in 2017.

Doug, whom his father had introduced to beer at 13, had been a heavy drinker himself, he said, “to the point of blackout” as a college student, and a social drinker thereafter.

But as he watched his father decline, “I realized this was ridiculous,” he recalled. Alcohol can exacerbate the progression of cognitive decline, and he had a family history.

He has remained sober since that pre-dawn phone call 13 years ago.

City of Alexandria, VA

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City of Alexandria Recognizes National Alcohol Awareness Month: Community Meeting Announced

Alexandria, Va.- In recognition of National Alcohol Awareness Month, the Substance Abuse Prevention Coalition of Alexandria (SAPCA) is hosting a series of activities throughout April.  SAPCA invites youth, parents and caregivers, and all community members to join in the following prevention efforts and awareness activities:

• Attend SAPCA's Spring Community Meeting on  April 25 from 6-7:30 p.m.  via Zoom to learn about the latest youth substance use data trends and discuss action items to address these trends.  Register to attend .
• Visit the Del Pepper Community Resource Center (4850 Mark Center Dr.) to view displays of student artwork promoting the benefits of a drug-free lifestyle. These displays feature the winning designs for the fall 2023 Red Ribbon Week poster contest. Artwork will be displayed on the lobby level and on the fifth floor beginning April 16.
• Join SAPCA for the presentation of a proclamation recognizing April as Alcohol Awareness Month on April 24 at 7 p.m. at City Hall (401 King St.). Winners of the Red Ribbon Week poster contest will also be recognized.
• Check out SAPCA's  "I don't drink because..."  campaign. Alexandria City High School students created videos to encourage youth to be alcohol free. The videos reinforce the social norm that most youth in Alexandria do not drink alcohol, a trend to get behind.

SAPCA provides tools and resources for residents to engage youth and initiate conversations about the dangers of alcohol and other substances, healthy decision making, avoiding risky behaviors, responding to peer pressure, resources for treatment and recovery and more. The City also provides a Resource Directory for Alexandria’s Youth and Young Adults .

Sign up for SAPCA’s e-newsletter , follow SAPCA on Facebook and Twitter , and visit SAPCA’s website alexandriava.gov/SAPCA to stay informed about upcoming events and ways to get involved in local efforts t o prevent youth substance use and misuse .

For media inquiries, please contact  Emma Beall, SAPCA Coordinator, at  [email protected] , 703.746.3670,

For reasonable disability accommodation, contact Maurice Tomdio at [email protected] , or call 571.384.5244, Virginia Relay 711. If you prefer communication in another language, free interpretation and translation services are available; please email [email protected] or call 703.746.3960.

Alexandria at 275: Celebrate Alexandria's 275th birthday from April through September at alexandriava.gov/ALX275 .

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• PMC10305038

Interventions to prevent alcohol use: systematic review of economic evaluations

Long khanh-dao le.

PhD, Health Economics Group, School of Public Health and Preventive Medicine, Monash University, Australia

MHE, Health Economics Group, School of Public Health and Preventive Medicine, Monash University, Australia

Mary Lou Chatterton

PharmD, Health Economics Group, School of Public Health and Preventive Medicine, Monash University, Australia

Joahna Kevin Perez

Oxana chiotelis.

MHE, Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Deakin University, Australia

Huong Ngoc Quynh Tran

Marufa sultana.

PhD, Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Deakin University, Australia

Natasha Hall

Yong yi lee.

PhD, Health Economics Group, School of Public Health and Preventive Medicine, Monash University, Australia; School of Public Health, The University of Queensland, Australia; and Policy and Epidemiology Group, Queensland Centre for Mental Health Research, Australia

Cath Chapman

PhD, Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Australia

Nicola Newton

Matt sunderland, maree teesson, cathrine mihalopoulos, associated data.

For supplementary material accompanying this paper visit http://doi.org/10.1192/bjo.2023.81.

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

Alcohol use is a leading risk factor for death and disability worldwide.

We conducted a systematic review on the cost-effectiveness evidence for interventions to prevent alcohol use across the lifespan.

Electronic databases (EMBASE, Medline, PsycINFO, CINAHL and EconLit) were searched for full economic evaluations and return-on-investment studies of alcohol prevention interventions published up to May 2021. The methods and results of included studies were evaluated with narrative synthesis, and study quality was assessed by the Drummond ten-point checklist.

A total of 69 studies met the inclusion criteria for a full economic evaluation or return-on-investment study. Most studies targeted adults or a combination of age groups, seven studies comprised children/adolescents and one involved older adults. Half of the studies found that alcohol prevention interventions are cost-saving (i.e. more effective and less costly than the comparator). This was especially true for universal prevention interventions designed to restrict exposure to alcohol through taxation or advertising bans; and selective/indicated prevention interventions, which involve screening with or without brief intervention for at-risk adults. School-based interventions combined with parent/carer interventions were cost-effective in preventing alcohol use among those aged under 18 years. No interventions were cost-effective for preventing alcohol use in older adults.

Conclusions

Alcohol prevention interventions show promising evidence of cost-effectiveness. Further economic analyses are needed to facilitate policy-making in low- and middle-income countries, and among child, adolescent and older adult populations.

Alcohol use is a leading risk factor for death and disability worldwide, especially in young adults. 1 The Global Burden of Disease study found that alcohol use is associated with substantial health loss, particularly in males. 1 Importantly, the attributable burden of alcohol use increases monotonically with increasing alcohol consumption. Addressing alcohol-related harms is therefore a global public health priority. 2 There are a variety of interventions designed to prevent alcohol use at the population level (i.e. upstream interventions, such as tax increases or advertising bans) and the individual level (i.e. downstream interventions, such as school-based interventions). To facilitate successful and sustainable scale-up of effective interventions and innovative service delivery strategies, decision makers require evidence on an intervention's cost and cost-effectiveness in addition to its effect on alcohol use and associated harms. Evaluating costs alongside the health effects of alcohol prevention and control strategies is required to determine their value-for-money credentials.

The burden of alcohol use disorders is exacerbated by its comorbidity with other substance use and mental health disorders. For example, a third of adults with opioid use disorder have an alcohol use disorder. 3 Depression and anxiety are also most commonly associated with alcohol, 4 with a third of people living in the UK reporting having both a psychiatric disorder and a comorbid alcohol use disorder. 4 , 5

A previous review has identified 27 studies published between 2006 and 2016 that have examined economic evaluations of alcohol prevention interventions. 6 Over half of the studies adopted a healthcare perspective, evaluating interventions over a 5-year time horizon. Most studies analysed healthcare costs, as well as costs attributable to government, social care, criminal justice, law enforcement and individual out-of-pocket payments. The studies evaluated a range of interventions, with the most common interventions comprising screening and brief interventions (SBIs), followed by upstream interventions such as tax increases, advertising restrictions and limiting retail sales. Only two school-based interventions were identified. However, this review primarily focused on economic evaluations of public health interventions and identifying methodological issues, rather than interpreting the cost-effectiveness results of broad preventive interventions for alcohol use in decision-making contexts. The evidence of economic benefit has grown rapidly since the previous review, necessitating an update. Importantly, there is also increasing evidence of economic evaluations targeting multiple health-related risk factors, including alcohol. Evidence on multifactorial prevention interventions were not included in the previous review.

This study aims to conduct a systematic review of the evidence for the cost-effectiveness of interventions to prevent alcohol use across the lifespan. This review used narrative synthesis to evaluate the methods of published economic evaluations and the quality of the literature. A key focus of this review was to summarise the cost-effectiveness evidence for alcohol prevention interventions and to identify knowledge gaps, challenges and opportunities for future research. Alcohol use often co-occurs with other substance use and mental/physical health conditions. As such, this review also evaluated studies assessing the cost-effectiveness of preventive interventions targeting multiple health-related risk factors alongside alcohol use.

Search strategy

The current review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines 7 and was registered on the International Prospective Register of Systematic Reviews Databases (PROSPERO; identifier CRD42020147386). The protocol was amended to include additional researchers and selecting on of the Drummond checklist as the tool for quality assessment. Searches were done to identify journal articles through electronic databases hosted on the EBSCOhost platform (i.e. EMBASE, Medline, CINAHL, PsycINFO and EconLit libraries) on 1 August 2019; with an updated done on 5 May 2021. The search strategy included economic evaluation terms; prevention or treatment terms; and terms related to alcohol, smoking, illicit drug use and substance use disorders. No date restrictions were applied during literature retrieval. Grey literature were excluded to narrow the focus on rigorous, peer-reviewed evidence. Unlike pharmaceutical products, many mental health prevention and treatment interventions are not subject to formal health technology assessment requirements. Manual searches were also conducted with the Tufts Cost-Effectiveness Analysis registry, a comprehensive database containing over 10 000 cost-effectiveness studies. 8 Further details of the search strategy are presented in the Supplementary Material available at https://doi.org/10.1192/bjo.2023.81 .

Study selection

All citations were imported into a web-based systematic review software, Covidence (Veritas Health Innovation, Melbourne, Australia; www.covidence.org ), which facilitated the identification and removal of duplicates. Title and abstract screening, full-text screening, data extraction and quality assessment were done independently by any two reviewers (J.F., L.K.-D.L., M.L.C., J.K.P., O.C., H.N.Q.T., M. Sultana, N.H.). Disagreements and discrepancies were resolved by a third reviewer (L.K.-D.L., M.L.C.). Studies were only included if they were full economic evaluations that compared two or more interventions in terms of their costs and outcomes.

Different economic evaluation frameworks can be used to assess the cost-effectiveness of healthcare interventions and programmes. Three commonly used frameworks include cost-effectiveness analysis (CEA), cost–utility analysis (CUA) and cost–benefit analysis (CBA). All of these frameworks measure costs in monetary terms, but differ in how outcomes are measured. For instance, outcomes are measured in CEA by using clinically meaningful units, e.g. the proportion who use alcohol, point improvements on a scale of alcohol-associated harms. The main units of outcome in CUA are generic health indices that combine measures of health-related quality of life (morbidity) and the length of life (mortality). Quality-adjusted life-years (QALYs) and disability-adjusted life-years (DALYs) are both commonly used generic health indices. In CBA, the most widely used framework beyond the health sector, all outcomes are valued in monetary terms. It follows that CBA necessitates the monetary valuation of health-related outcomes. Return-on-investment (ROI) analysis is also a commonly used partial economic evaluation framework that was included in this review. ROIs are typically a reduced form of CBA, where only the costs and cost offsets that can be attributed to healthcare interventions or programmes are considered compared with CBA, which often evaluates a wider set of health and non-health outcomes.

Economic evaluation studies can take the form of trial-based economic evaluations where the economic evaluation is conducted alongside a clinical trial. Alternatively, model-based economic evaluations synthesise multiple data sources to simulate the costs and outcomes that would occur under a scenario where an intervention is implemented versus some counterfactual scenario. All four economic evaluation frameworks (CEA, CUA, CBA and ROI) were included in this systematic review. Partial economic evaluations, cost studies, reviews, expert opinions, qualitative studies, conference papers, dissertations, book chapters and articles not in English were excluded. Studies were classified as alcohol prevention if they evaluated interventions focused on the prevention of alcohol use or the reduction of excessive alcohol use. Studies that targeted either the general population or the at-risk drinking population were included.

The mental health intervention spectrum described by Mrazek and Haggerty was used to classify prevention interventions into three types: universal, selective and indicated prevention. 9 Universal prevention interventions target the whole population (e.g. school-based prevention). Selective prevention interventions target a subgroup of the population who are at risk for harmful alcohol use and/or binge drinking. Indicated prevention interventions target people who binge drink and/or consume harmful levels of alcohol, but do not have an alcohol use disorder or alcohol dependence. Studies were excluded if they included treatment interventions that target people diagnosed with an alcohol use disorder or alcohol dependence.

In summary, study inclusion criteria were full economic evaluations (e.g. CEA, CBA and CUA) or ROI studies aimed at prevention of alcohol use or reduction of excessive alcohol use. Exclusion criteria were partial economic evaluations and cost studies, reviews, expert opinions, qualitative studies, conference papers, dissertations, book chapters or artiwcles not in English.

Data extraction

This study used a data extraction framework that was adapted from several previous reviews of economic evaluations and the review guideline developed by the Joanna Briggs Institute (JBI). 10 , 11 Data extraction was completed in Microsoft Excel version 15.0 for Windows and independently performed by any two reviewers (J.F., L.K.-D.L., M.L.C., J.K.P., O.C., H.N.Q.T., M. Sultana, N.H.). Any discrepancies in data extraction were resolved by a third reviewer (J.F., J.K.P.), who was not involved in the initial extraction. Data were extracted on the target population, intervention(s) and comparator, economic evaluation framework, study design, perspective, time horizon, reference year, discount rates, currency, cost categories, outcomes measured and cost-effectiveness findings. There were no data extraction issues that warranted contacting the authors of included studies. However, if studies did not report an economic reference year, then it was assumed that the reference year was 2 years before the year of publication. To allow comparisons of value across studies, the reported intervention costs and ratios were converted into 2019 US dollars, using the EPPI-Centre cost conversion online tool. 12

Synthesis of study findings

Results were presented for the following age groups: children and adolescents (<18 years), adults (18–65 years) and older adults (>65 years). A meta-analysis was not conducted because of the substantive heterogeneity observed between studies in relation to the population, intervention, comparator, outcome and economic evaluation frameworks. We employed narrative synthesis together with a dominance ranking framework to synthesise study methods and findings. The dominance ranking framework presents the distribution of interventions across three decision criteria (i.e. favour, unclear decision or reject an intervention). This framework was adapted from the guideline developed by the JBI. 10 Two reviewers (J.F., L.K.-D.L.) conducted the dominance framework classification. Dominance ranking was based on the results reported by the studies, and traffic light colour coding was used to indicate implications for decision makers. ‘Red’ signifies study results where routine adoption of the intervention is likely to be less favoured or rejected by decision makers (i.e. costs are higher and the intervention is less effective). ‘Green’ denotes study results that suggest an intervention is potentially very acceptable or favourable to decision makers (i.e. has better health outcomes and lower costs). ‘Yellow’ signifies study results that do not provide a clear-cut decision for decision makers (i.e. the intervention is ‘more effective and more costly’ or it is ‘less effective and less costly’). In this case, some form of financial or clinical trade-off is required. Willingness-to-pay thresholds can be used here to determine whether the intervention is cost-effective and represents value for money.

Quality assessment

Reporting and quality assessment was completed with the Drummond ten-point checklist. 13 Despite planning to use the Quality of Health Economic Studies (QHES) tool, we ultimately opted to use the Drummond ten-point checklist because it can be applied to both trial- and model-based economic evaluations (the QHES is only applicable to model-based evaluations). Two independent reviewers were involved in the quality assessment of included studies. Conflicts were resolved by a third reviewer (J.F., L.K.-D.L., M.L.C.). There are 33 sub-items attached to the ten overarching Drummond criteria, which can be answered as ‘yes’, ‘no’ and ‘cannot tell’. 13 Items that were relevant but did not have sufficient information to judge ‘yes’ or ‘no’ were marked with ‘cannot tell’. Reporting and quality assessment were completed in Microsoft Excel, with two reviewers independently assessing the quality of included studies. To limit inconsistencies in assessment, the authors met to discuss and assess two identified studies (a trial-based and a model-based economic evaluation). An average score was calculated to gauge the quality of the studies. ‘Yes’ answers were assigned a score of 1; ‘no’ answers were assigned a score of 0 and ‘cannot tell’ were assigned a score of 0.5. Studies that scored at least 9 were considered of good quality, studies that scored 6 to <9 were considered of fair quality, 14 and studies scoring <6 were deemed poor quality, but were still presented to show the entirety of the available evidence. Quality assessment was also discussed narratively to describe the characteristics of identified studies. Post-quality assessment internal consistency was measured with the Kuder–Richardson Formula 20 (KR20). For each study, a binary entry (0 for conflict or 1 for agreement) was used to represent independent quality assessment. A KR20 coefficient ranges from 0 to 1, with a score closer to 1 indicating high internal consistency.

A total of 5674 articles were identified during the literature search. After removing duplicates and title and abstract screening, 488 articles remained for full-text deliberation. There were 364 articles remaining after full-text screening. Of these, 57 studies met the inclusion criteria for the prevention of alcohol use ( Fig. 1 ). The main reasons for exclusion were as follows: being outside the scope of the review (e.g. prevention of other substances or substance use disorder treatments), did not meet the criteria of a full economic evaluation, incorrect disease population, incorrect study designs or publication type, and wrong or no outcomes. Hand searching further identified 12 studies. The reasons for missing out on the 12 articles identified through hand searching were exclusion through screening ( n  = 2) and from combining the concepts within the search strategy ( n  = 10). There were 34 model-based evaluation studies, 28 trial-based evaluations and seven studies that included both model- and trial-based economic evaluations. The economic evaluation frameworks comprised CEA ( n  = 21), CUA ( n  = 18), CBA ( n  = 9) and ROI ( n  = 4). There were also studies that used multiple economic evaluation frameworks, including CBA plus CEA ( n  = 4) and CEA plus CUA ( n  = 13). Sixty-one studies were for the general or adult population, and the remaining studies involved children ( n  = 7) or older adults ( n  = 1). Further details of included economic evaluations are found in Table 1 .

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram.

Data extraction of included economic evaluations

CEA, cost-effectiveness analysis; RCT, randomised controlled trial; GBP, Great British Pound; GP, general practitioner; PFBA, personalised feedback and brief advice; eBI, electronic brief intervention; CUA, cost–utility analysis; NHS, National Health Service; PSS, personal social services; QALY, quality-adjusted life-year; ICER, incremental cost-effectiveness ratio; WTP, willingness to pay; USD, US dollars; STD, sexually transmitted disease; CBA, cost–benefit analysis; SA, sensitivity analysis; AUDIT, Alcohol Use Disorders Identification Test; SF-12, 12-item Short-Form Survey; SBI, screening and brief intervention; SBIRT, screening, brief intervention and referral to treatment; AUD, Australian dollars; DALY, disability-adjusted life-years; WHO; World Health Organization; CER, cost-effectiveness ratio; AUDIT-C, Alcohol Use Disorders Identification Test; MIFB, motivational interviewing with feedback; EQ-5D, Euro-QoL five dimension; CBT, cognitive–behavioural therapy; ROI, return on investment; %CDT, carbohydrate-deficient transferrin; RCQ, Readiness to Change Questionnaire; CORE-LD, Clinical Outcomes in Routine Evaluation; USAF, United States Air Force; BAC, blood alcohol concentration; CAD, Canadian dollar; ASSIST, Alcohol, Smoking, and Substance Involvement Screening Test; EQ-5D-3L, European Quality of Life 5 Dimensions 3 Level Version; FASD, foetal alcohol spectrum disorder; NMB, net monetary benefit.

Children, adolescents and young adults

Trial-based economic evaluations.

Six economic evaluations were done alongside randomised controlled trials (RCTs) of preventive interventions targeting children, adolescents and young adults. One evaluation also incorporated economic modelling. 15 Intervention settings varied from school-based to family-based to e-health. The time horizons of the trial-based economic evaluations ranged from 4 months to 5 years. All studies were set in high-income countries, with the majority of the studies located in the USA ( n  = 3). The perspectives that were adopted included societal ( n  = 2) and healthcare sector ( n  = 2).

One school-based intervention for adolescents and their parents/carers was found to be cost-saving in reducing alcohol use and binge drinking episodes compared with education as normal. 16 Electronic brief intervention (eBI) and personalised feedback with brief advice (PFBA) were evaluated against screening only; with screening dominating eBI and PFBA not being cost-effective compared to screening. 17 A web-based game with feedback on alcohol awareness targeting adolescents aged 15–19 years was more effective and more costly compared with care as usual, with an incremental cost-effectiveness ratio (ICER) of $83 per reduction of one glass of alcohol or $192 per reduction of binge drinking occasion per 30 days. 18 A community mobilisation strategy to reduce youth substance use, delinquency, violence and other problem behaviours was cost-saving compared with a control community, with a benefit–cost ratio of $8.22 per dollar invested. 19 A teenage prevention programme had a 90% probability of being cost-effective compared with attention control, using a willingness-to-pay threshold of $118 per dollar invested. 20

Model-based economic evaluations

Two model-based economic evaluation studies were included for children, adolescents and young adults. 15 , 21 Both studies used a societal perspective, with one study using a 5-year time horizon and the other using a lifetime time horizon. The two studies separately evaluated a family-based intervention, a parenting-only intervention and an intervention involving alcohol screening and counselling visits. The family-based intervention, which was about parenting skills with child involvement, produced a benefit–cost ratio of $9.60 per dollar invested, whereas the parenting-only intervention had a benefit of $5.85 per dollar invested when compared with minimal contact. 15 The alcohol screening intervention plus the provision of counselling to youth identified at high risk of alcohol harms over 5 years would be cost-effective under the willingness-to-pay threshold of $978 047 per life-year saved compared with standard care, if programme efficacy was estimated at 5.6%. 21

The review identified 30 trial-based evaluations targeting adults. Twenty-one evaluations were conducted alongside RCTs, with the remainder conducted alongside non-RCT studies. Most studies were conducted in high-income countries such as the USA ( n  = 15), followed by the UK ( n  = 7), Australia ( n  = 2) and The Netherlands ( n  = 2). Only two studies were conducted in low- and middle-income countries, including India and Thailand. 22 , 23 CEA ( n  = 11) was commonly used followed by combinations of multiple frameworks ( n  = 8), CBA ( n  = 4), CUA ( n  = 4) and ROIs ( n  = 3). Most studies adopted perspectives from societal ( n  = 5), healthcare sector ( n  = 5) or both ( n  = 5), with time horizons ranging from 6 weeks to 6 years.

Economic evaluations conducted alongside RCTs evaluated several interventions, including brief intervention or brief advice ( n  = 11), motivational interviewing and/or counselling ( n  = 5), and internet/computer-based interventions ( n  = 3). Evaluations of brief interventions reported ICERs of $0.40 to $303 per reduction in drinks per week 24 – 26 and a benefit–cost ratio of $39 per dollar invested. 27 The results of brief advice varied from being not cost-effective when compared with health and lifestyle leaflet, 28 to having benefit–cost ratios of $5.6 (at 6 months) 29 and $39 (at 12 months) 30 per dollar invested compared with a control group. Motivational interviewing or counselling reported a range of CEA results, from being dominated (i.e. more costly and less effective) when compared with assessment only, 31 to cost-saving when compared with enhanced usual care. 22 Motivational interviewing was found to be dominant (i.e. less costly and more effective) compared with minimal intervention. 32 Incorporating a patient's significant other into motivational interviewing (SOMI) had benefit–cost ratios of $4.23 (societal) and $5.13 (healthcare) per dollar invested when compared with motivational interviewing only. 33 Web-based alcohol interventions reported ICERs ranging from being dominated when compared with minimal intervention, to $393 616 per QALY gained against measurement only. 34 – 36

Economic evaluations done alongside non-RCT studies involved study designs such as pre–post, quasi-experimental and retrospective. Evaluated interventions included work-based interventions ( n  = 3); brief intervention ( n  = 2); screening, brief intervention and referral to treatment (SBIRT) ( n  = 2); a health promotion programme called the Integrated Management of Alcohol Intervention Program (i-MAP) and a community programme. The work-based interventions generated mixed ROI ratios ranging from no cost-savings 37 to $3.92 38 for every dollar spent, and a benefit:cost ratio of 26:1 39 when compared with doing nothing. Different delivery methods for brief intervention were evaluated against usual care, with no impact on outcomes found. 40 Another evaluation compared brief intervention (one to five sessions from 5 min to 1 h) against brief treatment (five to 12 1-h sessions intended for patients with higher risk factors) and reported that brief intervention was not better in terms of reducing the probability of using any alcohol, but was better in reducing the proportion using alcohol to intoxication, days of alcohol use and days of alcohol use to intoxication. 41 SBIRT was found to be cost-saving compared with usual care, 42 with a 21% reduction in healthcare costs and significant reductions in 1-year emergency department visits compared with usual emergency services use. 43 The health promotion intervention i-MAP generated an ROI ratio of 2:1, 23 and the community-based or multicomponent alcohol prevention programme was found to be cost-saving in terms of addressing violent crime. 44

There were 33 model-based economic evaluations, including an RCT study 35 that modelled a longer time horizon and a pre–post study 42 utilising Monte Carlo simulation. Most evaluations were conducted in high-income countries, including the USA ( n  = 8), Australia ( n  = 6), Canada ( n  = 4), the UK ( n  = 4), Denmark ( n  = 2), The Netherlands ( n  = 2), Estonia ( n  = 1) and Italy ( n  = 1). Low- and middle-income countries included Kenya ( n  = 1) and Thailand ( n  = 1). There was also one evaluation conducted in a European context and two studies that used a global context. Most studies involved CUA ( n  = 13), followed by CEA ( n  = 7), CBA ( n  = 3) and ROI ( n  = 1). Nine studies used a combination of different economic evaluation frameworks. The majority of studies adopted a health sector perspective ( n  = 17) and nine studies adopted a societal perspective. Almost half of the studies used a lifetime time horizon ( n  = 15).

The majority of the model-based interventions included upstream interventions such as policy and taxation ( n  = 15). Most CEAs of policy and taxation found that it generated cost-savings. 45 – 48 Studies that adopted the CUA framework reported results that were cost-saving when compared with doing nothing. 49 – 51 Brief intervention, SBI and SBIRT were the second-most modelled interventions ( n  = 17). Modelling indicated that brief intervention and SBI were cost-effective. 51 – 66 Cognitive–behavioural therapy showed cost-savings, 67 and motivational interviewing was cost-effective under a willingness-to-pay threshold of $50 000 per QALY. 68

The models identified in this review were primarily multistage life table models, with or without a preceding decision tree. Individual-based models such as microsimulation and Monte Carlo simulation were also used, whereas simpler decision tree models were less common. Multistage life tables were used to estimate the incidence, prevalence, remission and mortality of alcohol-related diseases and injuries based on population life tables. These models can predict the demographic consequences derived from introducing new interventions (because of changes in the key parameters of incidence, prevalence remission or mortality). 66 The changes in alcohol use affect the mortality and prevalence of alcohol-related diseases (e.g. liver failure), as well as the mortality and incidence of alcohol-related injuries (e.g. road accidents). These reductions then influence overall rates of mortality and disability in the population. 51 The most commonly used multistage life table models included the model developed for the Adverse Childhood Experiences Prevention study, 66 the Sheffield Alcohol Policy Model, 61 the Chronic Disease Model 69 and the model developed for the WHO-CHOICE study. 55 Each multistage life table model applied potential impact fractions (PIFs) to estimate treatment effects. The PIF is an epidemiological measure of effect that calculates the proportional change in average disease incidence, prevalence or mortality after a change in the population distribution of a risk factor exposure. 70 , 71

There was substantial heterogeneity between the different models on the number of health conditions attributable to alcohol use. The most comprehensive models covered up to 22 health conditions attributable to alcohol use. 61 Non-communicable diseases (NCDs) were the most common conditions, followed by alcohol-related injuries. Alcohol dependence/alcohol use disorders were the only mental disorders included in existing models.

Model-based economic evaluations of interventions to prevent multiple risk factors, including alcohol use

Four studies evaluated preventive interventions that included multiple risk factors, including alcohol use. Cadilhac et al 72 modelled a hypothetical cohort to evaluate the cost–benefit of feasible reductions in six common risk factors over a lifetime (without decay). These risk factors include tobacco smoking, inadequate fruit and vegetable consumption, excessive alcohol use, high body mass index, physical inactivity and intimate partner violence. Cadilhac et al corrected the joint effects by using the joint population attributable risk fraction that was outlined in the 2003 Australian Burden of Disease and Injury study 73 and by the World Health Organization. 74 This formula is based on the assumption that health risks are independent. 74 Results showed that reducing these risk factors saved 2334 million Australian dollars for the 2008 Australian adult population (or 4022 million in 2019 US dollars).

A pre–post study conducted in the USA showed that the Health Risk Management programme to reduce ten risk factors in workers (i.e. poor eating habits, physical inactivity, tobacco use, excessive alcohol use, high stress, depression symptoms, high blood pressure, high total cholesterol and high blood glucose) would produce a return of $2.03 per dollar invested within 1 year of follow-up. 75 Growth curve modelling of a company health promotion and lifestyle programme was evaluated for the benefit of reducing rates of obesity, high blood pressure, high cholesterol, tobacco use, physical inactivity and poor nutrition over a 6-year time horizon. Despite having no effect on average alcohol consumption, the programme showed a return of $3.92 per dollar spent when all benefits were accounted for. 38 A recent economic evaluation alongside a trial conducted by Kruger et al found that within the 6-month follow-up, a theory-based online health behaviour intervention implemented in university was not cost-effective in reducing unhealthy eating, physical inactivity, binge drinking and smoking. 35 However, by extrapolating the efficacy of the intervention over a lifetime and rolling out the intervention to other universities, the intervention became cost-effective, with an ICER of £1545 ($2493) per QALY gained. This result is well below the UK willingness-to-pay threshold of £20 000 (around $28 653) per QALY gained.

Older adults

Only one study was found for older adults with excessive alcohol use. Although this CBA reported lower healthcare and societal costs favouring the intervention group, it also showed no significant differences in costs between the intervention and control groups. 76

Quality assessment results.

There were 26% of conflicts registered out of a possible 2277 pairings from the 33 quality assessment sub-items. Post-assessment internal consistency was calculated and resulted in a KR20 coefficient of 0.76, which indicates acceptable internal consistency. Most studies (84%) were fair ( n  = 43) or good ( n  = 15) quality. Only two economic evaluations done alongside trials, Kuklinski et al 19 and Tanaree et al, 23 met all ten points of the quality checklist. Less than half of the studies lacked a clear description of the competing alternatives, relevant costs and consequences because of non-inclusion or non-reporting of capital costs. Most studies did not adequately present and discuss study results in terms of implementation, generalisability and future directions. Further details are presented in Table 2 .

Quality assessment of included economic evaluations

Colour grading of cost-effectiveness results

Figure 2 presents a summary of the classification for different interventions graded based on their results and grouped as either likely to be rejected, favoured or unclear from a decision-making perspective. Half of the interventions were found to be cost-saving for the prevention of alcohol use and 84% of studies were rated as either fair (53%) or good (32%) quality. Most interventions were delivered to adults or the general population, except for four interventions targeting children and their parents and one intervention for older adults. Specifically, universal prevention strategies restricting access to alcohol through taxation or advertising bans and selective/indicated prevention through screening with or without brief intervention accounted for most of the studies.

Cost-effectiveness summary of interventions. SBI, screening and brief intervention; SBIRT, screening, brief intervention and referral to treatment.

Another 35% of interventions were categorised as ‘unclear’ because they produced improved health outcomes at a higher cost. Two-thirds of economic evaluations were fair quality, followed by studies rated as good (17%) or poor (17%) quality. Most interventions restricted exposure to alcohol through taxation with or without advertising bans for general populations or selective/indicated prevention through screening with or without brief intervention for targeting adults.

A total of 14% of interventions from the economic evaluations were categorised as ‘reject’ (i.e. less effective and more costly). Around a quarter of these studies were good quality, and two-thirds were fair quality.

Several interventions show cost-effectiveness results with a high degree of uncertainty, meaning that they comprise cost-effectiveness evidence that simultaneously indicate ‘favour’, ‘unclear’ and ‘reject’ decisions. These mixed results were affected by the variance around the choice of study elements. This suggests that a particular intervention may be acceptable or not appropriate in certain situations or contexts. For example, in universal interventions, both breath testing and brief advice had varying cost-effectiveness results. The ‘favour’ judgement for breath testing was from a modelling study showing cost-savings when compared with doing nothing. 45 However, two other studies modelled both breath testing and brief advice against different comparators, with one comparing both with current situation 77 and the other using taxation as the comparator. 56 In the first study, both breath testing and brief advice had more costs and less DALYs compared with current situation in the Estonian population. 77 In the second, a global regional modelling study, brief advice had cost-effectiveness results ranging from ‘favour’ in some regions (because it was dominant) to ‘reject’ in other regions (because it was dominated by taxation). 56 The study reported that generally, both interventions incurred higher costs than taxation. In terms of DALYs, regions with higher levels of heavy alcohol use lean toward taxation being more effective, whereas breath testing and brief advice are more effective in regions with less prevalence of heavy alcohol use. 56

In terms of ‘indicated’ interventions for adults, motivational interviewing showed cost-effectiveness judgements ranging from ‘favour’ to ‘reject’. SOMI reported ‘favour’ judgement from a positive cost–benefit ratio in both healthcare and societal perspectives when compared with standard motivational interviewing. Standard motivational interviewing reported ‘unclear’ cost-effectiveness results compared with standard care. 68 Two motivational interviewing studies reported ‘reject’ results because it was dominated by motivational interviewing with feedback 31 and by the intervention Motivational Assessment Program to Initiate Treatment (MAPIT). 78 Motivational interviewing studies that used societal perspectives were judged ‘favour’ or ‘unclear’, whereas ‘reject’ cost-effectiveness results were found from narrower provider and probationary system perspectives.

In ‘selective’ interventions, web-based health promotion had both ‘unclear’ and ‘reject’ judgements. A study reported cost-effectiveness results for web-based health promotion judged as ‘unclear’ because of higher costs and higher utilities for the intervention compared with doing nothing, in a population of university students. The analysis was over 6-month and lifetime time horizons, and only used intervention and rollout expenses for costs. 35 In another study, web-based intervention was compared with minimal intervention. Reported results were mixed with ‘unclear’ judgement for CEA (lifestyle factor score improvement outcome) and ‘reject’ judgement for CUA. This evaluation was from a societal perspective and over a 2-year time horizon for the people with computer and internet access with basic internet literacy. 36

The current review provides an update on the cost-effectiveness evidence for the prevention of alcohol use across the lifespan. The number of studies included in this review is nearly two and a half times more than those included in a previous review. 6 Most of the cost-effectiveness evidence has been evaluated for interventions targeting adults. There were limited economic evaluations of interventions targeting children, adolescents and older adults. Furthermore, most studies were conducted in high-income countries, particularly using trial-based economic evaluations. Less cost-effectiveness research has been undertaken in low- and middle-income countries. Half of the evidence estimated that preventive interventions for alcohol use were cost-saving. The interventions frequently found to be cost-saving were ‘universal’ prevention, consisting largely of increasing the price of alcohol via taxation or reducing exposure to alcohol via advertising bans. Most of these interventions were compared against doing nothing or having no policy in place. Selective/indicated prevention, such as screening with or without brief intervention, was also found to be cost-saving when compared with doing nothing. It is also encouraging that school-based interventions, with and without interventions for parents (selective prevention), were found to be cost-saving, albeit in a limited number of studies. However, it is important to note that it is difficult to determine which intervention is the optimal choice, given that little evidence was established to compare different interventions within a single-study context. In terms of study quality, most studies included in this review had fair to good quality.

The results of this review provide important economic evaluation evidence to support the implementation of alcohol prevention interventions at a population level. However, it should be noted that although economic evaluation offers a useful format (with one concise indicator) for decision-making, it is not a perfect instrument. In particular, results across different economic evaluations are not comparable because of the variations in methodology, such as how utility scores for calculating QALYs were measured (differences in outcome measurement tool used) or the context in which the intervention was conducted. Other implementation considerations, such as equity, feasibility, sustainability and acceptability, may not be adequately addressed by economic evaluations. Therefore, even if there is clear evidence of effectiveness or cost-effectiveness, it does not necessarily guarantee intervention uptake.

The conflicting cost-effectiveness findings observed across several interventions were the result of substantive variations in study design. These variations limit the ability to conduct any prospective meta-analysis, highlighting a limitation of economic evaluations. Chisholm et al effectively demonstrated this issue where differences in study design or data inputs from different countries resulted in varying cost-effectiveness estimates. 56 In their evaluation, alcohol taxation was-cost saving in the USA and European countries; however, it was found to be more effective and more costly in African and Asian countries, with ICERs under a willingness-to-pay threshold of $50 000 per DALY. 56 Therefore, it is important that policy decisions be aided by adequate, context-specific research to determine which interventions can be considered value for money.

The paucity of cost-effectiveness studies on alcohol prevention among children and adolescents is in stark contrast to the literature on the cost-effectiveness of mental health promotion and prevention, where most of the existing research has focused on children, adolescents and youth. 79 Prevention of alcohol use in adolescents is important given that early use of alcohol predicts frequent drinking, leading to future alcohol-related harms. 80 Furthermore, the frequency of adolescent drinking is also predictive of substance use problems in adulthood. Further research is urgently needed to establish the value-for-money credentials of interventions to prevent or delay alcohol use in this age group.

Trial-based economic evaluations primarily evaluated indicated prevention interventions, whereas model-based economic evaluations primarily evaluated universal prevention interventions. This is sensible because universal preventive interventions are expected to have broad effects that may take years to be realised and are difficult to properly evaluate in a trial. Furthermore, model-based economic evaluations can estimate the long-term effects of alcohol use, including its effects on NCDs. Ideally, it is important to capture the full breadth of long-term effects produced by alcohol prevention interventions over the life course. However, the effect of prevention interventions over the long term becomes more uncertain, as extrapolating the longer-term effects of an intervention typically necessitates the use of assumptions that are not based on empirical evidence. Furthermore, the effects of intervention have been found to attenuate over time in long-term follow-up studies.

This review also included economic evaluations evaluating multiple risk factors, including alcohol use. However, only four studies were found that focused on combined alcohol use and risk factors for physical health conditions (e.g. obesity or NCDs). There is currently no evidence on the cost-effectiveness of preventive interventions for alcohol use and risk factors for mental health conditions. Given the high prevalence of comorbidity between alcohol use disorder, other drug use disorders and mental disorders, 81 further research should explore the impact of interventions on risk factors for both physical and mental health conditions.

This review has several limitations. Only peer-reviewed articles published in the English language were included, which may have contributed to the lack of studies conducted in low- and middle-income countries. It is also common for economic evaluations, especially ROI studies, to be published in grey literature rather than in the academic literature, potentially limiting the studies identified. In addition, the involvement of multiple reviewers in screening and extraction may have resulted in inconsistencies. Meta-analysis was also not possible given the high level of methodological heterogeneity in the populations, interventions, comparators and outcomes, as well as economic evaluation frameworks across included studies. Furthermore, the majority of cost-effectiveness evidence supported the prevention of alcohol use, raising concerns of publication bias. Alternatively, a strength of this review is the use of a dominance ranking framework to summarise and provide recommendations for policy and practice. 79

In conclusion, this study found that prevention interventions for alcohol use are promising and likely provide good value for money. These findings will be of value to policy makers and other stakeholders interested in preventing alcohol use and/or excessive alcohol use. Nevertheless, policy decisions should still be aided by adequate, context-specific research on possible prevention interventions, to determine whether such interventions would be value for money. Future economic analyses are needed for low- and middle-income countries, as well as for children, adolescents and older adults. Moreover, research on cost-effectiveness with longer follow-up is also required, as it is uncertain whether the modelled longer-term effects of interventions will, in fact, be realised.

Supplementary material

Data availability, author contributions.

L.K.-D.L., J.F., M.L.C. and C.M. conceptualised the study and wrote the original draft of the manuscript. L.K.-D.L., J.F., J.K.P., O.C., H.N.Q.T., M. Sultana and N.H. were responsible for data curation. L.K.-D.L. and J.F. conducted formal analysis and data visualisation. C.M., C.C., N.N., T.S., M. Sunderland and M.T. were responsible for funding acquisition. L.K.-D.L., M.L.C., C.M., C.C., N.N., T.S., M. Sunderland and M.T. conducted the study investigation and provided supervision. L.K.-D.L., J.F., M.L.C., C.M. and Y.Y.L. were responsible for the study methodology. L.K.-D.L., J.F. and M.L.C. were responsible for project administration. L.K.-D.L., M.L.C., C.M., C.C., N.N., T.S., M. Sunderland, M.T. and Y.Y.L. were responsible for data validation. L.K.-D.L., J.F., J.K.P., O.C., H.N.Q.T., M. Sultana, N.H., C.M., C.C., N.N., T.S., M. Sunderland, M.T. and Y.Y.L. reviewed and edited the manuscript.

This review was funded by the National Health and Medical Research Council (NHMRC) Centre for Research Excellent PRevention and Early intervention in Mental Illness and Substance usE (PREMISE) under grant number APP1134909, which was awarded to M.T., N.N., C.M., T.S. and C.C. The funder was not involved in any part of this publication. L.K.-D.L. is funded by the Alfred Deakin Postdoctoral Research Fellowship.

Declaration of interest

Understanding the New ATF Firearm Dealership Regulations

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• Public Safety & Justice Reform

Local elected officials play a crucial role in ensuring public safety and regulatory compliance within their communities. With the Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) recently finalizing amendments to the firearm dealership regulations under 27 CFR Part 478, it is imperative for local government leaders to understand the implications of these changes and how they can effectively support enforcement and community awareness.

Overview of the Revised Regulations

The ATF’s final rule significantly broadens the definition of ‘engaged in the business’ for firearm dealers. This revision is part of implementing the Bipartisan Safer Communities Act, which was supported by the NLC.

What Local Elected Officials Need to Know:

1. Expanded Definition of Firearm Dealership

• The new rule defines dealers as those intending to “predominantly earn a profit” from the sale of firearms rather than needing to prove it as their primary livelihood. This change aims to encompass a wider array of individuals and entities under the requirement for licensing, including those selling online or at gun shows.

2. Implications for Licensing and Compliance

• Elected officials should ensure that local law enforcement and regulatory bodies are aware of the expanded criteria for who should be licensed as a firearm dealer. Enhanced training and resources may be necessary to manage compliance checks and licensing processes effectively.
• Understanding the broader definition of “purchase” and “sale,” which now includes any exchange of value (e.g., bartering goods, services, or even controlled substances for firearms), is crucial for properly identifying unlicensed transactions.

3. Enhancing Public Safety and NICS Enhancement

• The rule mandates more rigorous background checks by increasing the number of transactions that must go through licensed dealers. This supports NLC’s longstanding policy , which calls for the federal government to expand and enhance the National Instant Criminal Background Check System (NICS) and require anyone selling or transferring a gun to verify records through an authorized federal firearms licensee (FFL) to ensure the buyer is not a prohibited person.
• Local leaders can support public safety by promoting awareness of these requirements among community members and potential firearm purchasers.
• Engaging with community stakeholders, including local businesses and firearm dealers, to educate them about the new regulations and the importance of compliance can help prevent illegal firearm sales and ownership.

4. Support for Former Licensees

• The rule outlines procedures that former licensees must follow when liquidating their inventory. Local governments might need to assist in monitoring and facilitating these processes to ensure that firearms are not disposed of improperly or illegally.

5. Effective Date and Enforcement

• The rule takes effect 30 days after its publication in the Federal Register. Local officials should coordinate with law enforcement to update local ordinances and enforcement practices to align with the new federal regulations.
• It may be beneficial to establish local task forces or working groups to address the specific needs and challenges related to firearm dealership regulations in the community.

For local elected officials, the ATF’s updated firearm dealership regulations present an opportunity to strengthen community safety protocols and ensure that all firearm transactions within their jurisdictions meet the latest federal standards. By proactively adopting local enforcement practices and engaging with the community to promote awareness and compliance, local leaders can play a pivotal role in preventing unlawful firearm sales and enhancing public safety.

Additional Resources

National League of Cities Applauds Senate Passage of Bipartisan Gun Violence Prevention Legislation

500+ Local Leaders from All 50 States Sign National League of Cities’ Letter to Congress Urging Immediate Action to Prevent Gun Violence

Cities Push Forward to Address Community Gun Violence and Mental Health 

About the author.

Yucel (u-jel) Ors is the Director of Public Safety and Crime Prevention at the National League of Cities.

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• Tony McCright, Jr.

Effects of Alcohol Consumption Essay

Introduction, nursing intervention.

Alcohol consumption can have various effects on the people who consume it. The effects may be social, psychological, physiological and medical. Some alcoholic brands (like wine) may have positive effects on our health while others (like spirits) may have negative effects. The duration in which a person consumes alcohol determines the intensity of the negative effects of alcohol on the person. One negative effect of alcohol is the damage of body organs like the liver and the colon, when consumed for a long period of time (Cooper, 2000).

Alcohol is categorized as a depressant due to its ability to slow down the nervous system thereby reducing sensitivity to pain through inducement of sleep like feeling. Some of the immediate impacts of alcohol misuse include lack or loss of one’s awareness, distortion of reality, loss of coordination of the brain activities and one’s motor skills (Toppness, 2011). When used for a long time, it leads to addiction, as well as social and economic irresponsibilities by the addicted individuals (Toppness, 2011).

Research has shown that alcohol consumption is a risk factor to colon cancer. However, the type of alcohol brand matters. While wine may have positive impacts in preventing colon cancer, hard liquor like spirits have been found to increase the chances of alcoholics developing colon cancer. Prolonged alcohol consumption also leads to colon irritation, which in turn leads to diarrhoea and constipation (Toppness, 2011). This can make the individuals lose their appetite and become malnourished. Such individuals may end up being socially and economically irresponsible, which may further lead to depression. The depressed individuals become prone to suicide because their thinking and reasoning becomes impaired, and to them, life loses meaning.

Patients who are addicted to alcohol consumption need to be shown love and care not rebuke and contempt. This is one aspect of the nursing profession and other professions like social work. We should show them love and care through talking to them in a courteous manner, and showing them that they are able to come out of their situation.

Many alcohol addicts have their symptoms as adaptive. This means that they develop or acquire some behaviour which helps them cope with the problems they are facing; one such behaviour is alcohol consumption, which later develops into alcohol misuse or abuse. For example, some may assume or think that other people hate them because they are poor or are of low social status. This is an external pressure to them, and in order for them to safeguard their ego, they engage in alcohol consumption in order to cope in staying with the people who hate them. Our intervention should therefore be centred on behaviour and attitude change.

We should show them that alcohol consumption is not the solution to their problems and help them gain the courage to face life the way it is. We should help them acquire new behaviours which are not depended on alcohol. For instance, they could be helped to boost their people’s skills, their confidence as well as improve on their hygiene, which would boost their self-esteem. These interventions could be done in a community setting or at their homes. In severe cases of addiction, they should be taken to rehabilitation, where they could be helped to recover from withdrawal symptoms.

Even though alcohol can have many negative effects on our bodies, it is a good component of our diet when used properly in the right quantities and frequencies. For instance, it makes our meals complete apart from being used as a social drink. Alcohol consumption therefore becomes dangerous to us and our bodies when we misuse it. Alcohol consumption is regarded as a risk factor in causing colon cancer because it causes diarrhoea and inflammation of the colon. The link is however not clearly established and therefore the need for more research to establish the relationship between alcohol consumption and colon cancer (Hales, 2008).

Cooper, D.B. (2000). Alcohol Use. Abingdon OX14 1AA: Radcliffe Publishing.

Hales, D. (2008). An Invitation to Health. New York: Cengage Learning.

Toppness, H. (2011). Alcohol Effects on the Colon. Web.

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Bibliography

IvyPanda . "Effects of Alcohol Consumption." March 26, 2022. https://ivypanda.com/essays/effects-of-alcohol-consumption/.

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