# Presentation: 293547

## Effectiveness of Interventions to Reduce Adolescent Alcohol Use and Alcohol-impaired Driving from the Community Guide

**Ruth A. Shults and Randy W. Elder**
**Centers for Disease Control and Prevention**

**Notes:**
Welcome and thanks.

## Disclaimer

- The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.

## Why Use Evidence-Based Practices?

- Resources are tight ... and getting tighter
- Increasing pressure to be accountable
- Gap between scientists and decision-makers -- priorities, language and approaches
- Increasing pressure to embrace “evidence-based” methods

## The Benefits

- Reliability – move us beyond experience and anecdote
- Synthesis (1) – streamline enormous amounts of data
- Synthesis (2) – reconcile or explain variable results
- Transparency – reduce bias and make assumptions explicit

## Goals of the Community Guide

**Systematic review of literature**
**Evidence-based recommendations**
**Highlight important knowledge gaps**

**Notes:**
The first goal is to provide a systematic review of the literature, using standardized methods for selecting and evaluating studies.  CDC staff are conducting the reviews.

These findings are reviewed by a separate, non-federal task force of injury prevention experts—this is the Task Force on Community Preventive Services.  The Task Force makes recommendations for implementing interventions based on the strength of evidence for effectiveness.

In cases for where there aren’t enough qualifying studies to evaluate the effectiveness of an intervention, the goal is to highlight these gaps in knowledge.

## Community Guide “Basics”

**Systematic reviews of literature**
**By researchers, methodologists, and practitioners**
**Evidence based recommendations**
**Based on the evidence by an impartial,  independent, non-federal Task Force**
**Effectiveness is measured in terms of demonstrated health outcomes **
**Changes in attitudes, knowledge or intentions do not qualify as health outcomes**

**Notes:**
Teams of Researchers, methodologists, and practitioners perform systematic reviews of literature
An independent, non-federal group makes recommendations based on the evidence

## Community Guide Topics

| Risk Behaviors | Specific Conditions |
| --- | --- |
|  Tobacco Use*
 Alcohol Abuse/Misuse
 Other Substance Abuse
 Poor Nutrition*
 Inadequate Physical Activity*
 Unhealthy Sexual Behaviors |  Vaccine Preventable Disease*
 Pregnancy Outcomes*
 Violence* 
 Motor Vehicle Injuries*
 Mental Health/Depression
 Cancer*
 Diabetes*
 Oral Health*
 Obesity* |
| The Environment |  |
|  Sociocultural Issues* |  |

- *Currently Available

**Notes:**
And here you see a listing of all of the topics that will eventually be reviewed.  The asterisked ones have been completed and are available online.  And, the book containing these reviews has been published recently—The Guide to Community Preventive Services, Volume 1. 

The topics are divided into three sections.  The first, changing health risk behaviors, specific conditions (MV injuries and violence are here), and environmental issues. 

## Who Is the Audience?

**People who plan, fund, or implement public health services and policies for communities and health care systems **
**Public health departments**
**Health care systems**
**Schools**
**Government **
**Businesses**
**Community organizations**

## Steps in Conducting Systematic Reviews 

**Develop conceptual framework**
**Search for and retrieve evidence**
**Rate quality of evidence**
**Summarize evidence**
**Translate strength of evidence into recommendation**
**Disseminate findings and recommendations**

**Notes:**
There are five steps in the methods used to develop the Community Guide, all of which have explicit rules.  The methods paper was published in the AJPM in January 2000.
I’ll say a few words about each of these steps, using some examples from the MV reviews.

The steps are: (refer to slide)

## Summarizing the Evidence

**For each intervention:**
**Number of studies**
**Quality (Design + Execution)**
**Consistency of effect**
**Effect Size**

**Notes:**
Step 4) Summarizing the evidence for each intervention: 
Once all of the qualifying studies of a particular intervention had been reviewed, we summarized the evidence.  We considered: 1) the number and quality of the studies; 2) consistency of the findings across the studies; 3) the effect size.

## Evidence for Effectiveness

**Strong**
**Sufficient**
**Insufficient**

**Notes:**
Based on that summary information, we rated the evidence for effectiveness as:  strong; sufficient; or insufficient.

## Alcohol-impaired Driving Reviews	

| Intervention | Primary Outcome | Summary Effects | Task Force Recommendation |
| --- | --- | --- | --- |
| Minimum  Legal Drinking Age Laws 
MLDA (age 21) | Crashes | -12% to 
-16% | Recommended
(Strong Evidence) |
| Low BAC Laws for Young Drivers | Crashes | -11% to 
-17% | Recommended
(Sufficient Evidence) |
| Server Intervention | Intoxicated Patrons | -33% | Recommended under certain conditions
(Sufficient Evidence) |
| School-based Instructional Programs | Drinking and Driving | -0.10 SD | Insufficient Evidence |
|  | Riding with Drinking Drivers | -0.18 SD | Recommended
(Sufficient Evidence)
 |

**Alcohol-impaired Driving Reviews****	**

**Notes:**
Note—the ranges of effects provided reflects stratification of outcome variables, usually according to crash severity 
All crash outcomes are for alcohol-related crashes
* Recommended with caveats (may only be effective under certain conditions)

## Alcohol-impaired Driving ReviewsContinued

| Mass media campaigns | Recommended 
(strong evidence) |
| --- | --- |
| Sobriety checkpoints | Recommended
(strong evidence) |
| 0.08% BAC laws | Recommended 
(strong evidence) |
| Multifaceted community-based  | Recommended under certain conditions
(sufficient evidence) |
| Ignition interlock programs | Recommended under certain conditions
(sufficient evidence) |
| Designated driver promotion programs | Insufficient Evidence |

## School-based Health Promotion ProgramsIntervention Definition

- Health promotion programs that:
- Provide information
- Teach critical life skills
- Attempt to change perceptions of normative behavior
- Such programs may:
- Focus on drinking and driving or on alcohol abuse in general
- Be delivered to individual classes or to the broader student body
- Include changes in institutional policy, but not be primarily policy-based

**Notes:**
School-based health promotion programs attempt to prevent alcohol-impaired driving and riding with alcohol-impaired drivers by providing students with information, teaching them critical life skills, or attempting to change their perceptions of normative behavior. 

These programs may focus solely on drinking and driving or may encompass general alcohol education. They can be delivered to individual classes or to a broader population of students.

Some of these programs may also incorporate changes in institutional policies, but we didn’t evaluate health promotion programs that were solely policy-based (for instance, programs to limit the availability of alcohol to college students)

## Specific Interventions

- Activities addressed:
- Instructional programs (classroom)
- Peer organizations (e.g., SADD)
- Social norming campaigns (college)
- Settings
- Elementary School (not covered)
- Middle School
- High School
- College

**Notes:**
School-based health promotion is a fairly broadly defined concept and it subsumes several fairly distinct interventions that it may be appropriate to consider separately for recommendations.

The most common intervention involves educational curricula related to alcohol abuse or alcohol-impaired driving – these can vary greatly with respect to their underlying theories of behavior change, modality of presentation, and length, among other things

Another school-based intervention involves the implementation of peer organizations dedicated to preventing alcohol-impaired driving, with Students Against Drunk Driving, also known as Students Against Destructive Decisions being a typical example 
– peer organizations attempt to both raise awareness of the problem and attempt to change the environment to highlight alternatives to drinking and driving and alcohol consumption in general

Social norming campaigns are another type of intervention that is commonly implemented in educational institutions to reduce high-risk drinking and its consequences such as alcohol-impaired driving – the underlying theory is that people’s drinking patterns are affected by their perceptions of their peer’s typical drinking patterns, and that people tend to overestimate their peers’ alcohol consumption. Social norming campaigns attempt to correct these misconceptions, thus reducing high-risk drinking and its consequences.

## Analytic Framework: School-Based Health Promotion Programs

**School-based Health Promotion**

**Change in Attitudes Intentions**

**Development of  Refusal and Other Skills**

**Knowledge of consequences of/alternatives to drunk driving**

**Change in**
**Perceived Social **
**Norms**

**Peer Influences**

**Notes:**
School-based health promotion interventions generally attempt to foster behavior change through three pathways:

 They may try to impart Knowledge and awareness of the consequences of and alternatives to alcohol-impaired driving or riding with drinking drivers – in some cases they may go a step beyond this and actually provide alcohol-free events as alternatives to situations where drinking and driving is likely
 They may also foster skill development, most commonly focusing on refusal skills
 And they can also attempt to change perceived social norms

School-based education interventions typically focus on the first two goals,
Social norms marketing campaigns focus on the third, 
And peer organizations attempt to address all three

Changes in these three areas would be expected to foster positive changes in attitudes and intentions regarding drinking and driving or riding with drinking drivers, have a protective effect against harmful peer influences, and foster beneficial peer influences

Decreasing the targeted risk behaviors and ultimately decreasing fatalities and injuries from alcohol-related crashes

## Outcome Measures

- Alcohol-related crashes
- Self-reports of:
- Alcohol-impaired driving
- Riding with an alcohol-impaired driver
- Intent to drink and drive or ride with alcohol-impaired driver (non-recommendation)

**Notes:**
Because of the nature of this intervention and the population it targets, we needed to expand the outcomes that we evaluated beyond objective population-based data on alcohol-related crashes and alcohol-impaired driving

Most of the studies we reviewed evaluated the interventions using self-reported data, and these data needed to be adapted to the age of the population targeted:

Many studies evaluated self-reports of alcohol-impaired driving, but a large segment of this population does not drive;
So riding with an alcohol-impaired driver is also a commonly evaluated variable – this is the only variable that kids who don’t drive can control to affect their chances of being in an alcohol-related crash
Finally, for people in the youngest age groups we evaluated, there may be few instances when they are even offered a ride with a drinking driver, so we decided to include studies evaluating the intent to drink and drive or to ride with a drinking driver, although we don’t believe that this outcome meets the standards for a recommendation outcome

## Characteristics of Instructional Programs

- Effectiveness assessed
- in 5 countries, rural and urban schools
- in schools with varied demographics
- Programs varied in
- length (from 1 to 12 sessions)
- focus (emphasis on alcohol misuse vs. driving varied)
- Most included interactive components

## Peer Organizations 

- Two studies of their effectiveness noted that peer organizations produced some beneficial effects
- Neither study found that peer organizations were associated with a significant decrease in drinking and driving or riding with a drinking driver
- Insufficient evidence to recommend due to the small number of available studies

## Social Norming Campaigns

- Attempt to reduce perceived pressures to consume excessive quantities of alcohol by correcting students’ tendencies to overestimate the normative alcohol consumption of peers
- Findings from the 2 qualifying studies
- 25% reduction (p = 0.18) in the number of drivers with positive blood alcohol concentrations (BACs) and a 50% reduction (p = 0.21) in those with BACs above 0.08%
- intervention associated with a self-reported increase use of designated drivers (p < .05) and a decrease in drinking and driving (p < .05)
- Insufficient evidence to recommend due to the small number of available studies

**Newman, 1992**

**Wilkins, 2000**

**D’Amico, 2002**

**Harre, 1998**

**Klepp, 1995 **

**Sheehan, 1996 **

**Shope, 2001**

**Study **

- Boys

- Risk Skills

- DARE

- Girls

**Instructional Programs ****Self-Reported Outcomes**

**Notes:**
Here is a summary figure for the self-reported outcomes with drinking and driving in red and riding with a drinking driver in yellow.
The green represents a composite outcome for both driving and riding. The studies are arranged in ascending order of sample size, and design quality is designated by the Gs and Ls next to the author names.

The median change in self-reported drinking and driving was -.10 standard deviation for the pure measures and -.05 when the D’Amico results are included

For riding with drinking drivers, the median change is -.38 for the pure measures and -.07 with the D’Amico results included. 
So the results are clustered fairly close to zero for drinking and driving, but we have a couple of quite positive results for riding with drinking drivers. 

To give you a sense of context, an effect size of .3 to .6 is generally considered moderate. In this data set .2 standard deviations generally translates to about a 7% change in self-reported behavior, but these Likert data tend to have fairly high variance, so that magnitude of change wouldn’t typically be significant.  

How you interpret the D’Amico results may play a role in whether you view the results for the RWDD outcome as consistent or sufficient for a recommendation, so I’d like to give you the team’s perspective on two relevant issues

First, we think it would be reasonable to discount the DARE results due to the fact that it is known to be an ineffective program and because it has very limited relevance for alcohol-impaired driving. I’ve marked the DARE result with a dotted line to indicate that it is questionable whether it belongs in the evidence base.
Second, it probably makes sense to consider the mixed AID/RWDD outcome in the same class as RWDD, given that RWDD is the more frequently reported and thus is likely to have more influence on the variance in the results.

The upshot if you accept those two premises would be that the median effect size for RWDD is -.14, with a range from -.01 to -.73.

## Conclusions – Instructional Programs

- Drinking and driving:
- Insufficient evidence due to inconsistent outcomes
- Riding with drinking drivers:
- Recommended based on sufficient evidence
- 5 studies, 4 of greatest design quality
- Evidence consistent
- Effect size sufficient

**Notes:**
It seems clear that there is insufficient evidence for a recommendation based on the Alcohol-impaired driving outcomes – there is no consistent beneficial effect evident in these data

The outcomes for riding with drinking drivers are in more of a grey area

We have 4 studies that provide data on RWDD itself, and an additional 1 that evaluated RWDD in combination with AID;
 and 4 of the studies were of greatest design quality and fair execution, so this number is potentially sufficient for a recommendation

So the questions you need to address are whether the evidence is consistent and the effect size is sufficient for a recommendation. 

You may also want to consider the issue of decay, but I would like to point out that for RWDD, this issue may not be as straightforward as it was for tobacco, given that every time a person chooses not to ride with a drinking driver, there is a potential health benefit.

## Points to Ponder 

- Is it important for programs to have a theoretical foundation?
- Should programs target high-risk individuals?
- Content and delivery—are some approaches more effective than others?
- Peer and media resistance skills
- Interactive format
- Combine school- and community-wide components with policy changes (e.g., Project Northland)

## Overview of Community GuideAlcohol Initiative

## Contributors

- Randy Elder
- Gail Janes
- Briana Lawrence
- Bob Brewer
- Tim Naimi
- Ralph Hingson
- Stephen Wing
- Traci Toomey
- Tom Babor
- John Higgins-Biddle
- Jonathan Fielding

- CDC
- CDC
- CDC
- CDC
- CDC/IHS
- NIAAA
- SAMHSA
- U of Minnesota
- U of Connecticut
- U of Connecticut
- Task Force on Community Preventive Services

**Notes:**
These are the members of our Coordination Team, who have helped to guide this review.  It includes representatives of CDC’s Alcohol Activity, liaisons with federal agencies that focus on alcohol-related activities, academicians, and a Task Force representative.

## Prevention of Excessive Drinking and Related Harms: Logic Model

- Interventions

- Community
- Environment

- Family
- Factors

- Individual
- Factors

- Demand

- Access &
- Availability

- Excessive
- Drinking

- Academic

- Economic

- Legal

- Social

- Morbidity
- Mortality

## Effectiveness of EnhancedEnforcement of the Retail Sale of Alcohol to Minors

## Intervention Definition

- Compliance checks using “decoys”
- Implemented by or coordinated with
- law enforcement
- alcohol regulators
- Legal or administrative sanctions for noncompliant establishments

**Notes:**
On this slide, I’ve listed the components of the enforcement activities that were included in the reviewed studies.  All studies included a surveillance component, which involved compliance checks in which minors or youthful looking adults attempt to purchase alcohol from on-premise or off-premise retail establishments.   These visits were implemented by or coordinated with either local law enforcement or the local liquor licensing board.
In all studies, the enforcement component involved legal or administrative sanction, consistent with local statute, for establishments found to be noncompliant.
(If asked, can mention others:  community mobilization activities and policy changes such as changes to the types of sanctions, and zoning restrictions on the outlet density, but note that slide #6 also provides this information) 

## Implementation

- Enforcement
- Varied in intensity and duration
- Media component
- Mass media (radio, television, local press)
- Small media (letters to retail establishments)

**Notes:**
As in most reviews, despite fairly stringent inclusion criteria, there was variation across studies in the approach to implementation.
The enforcement component varied across studies in intensity and duration.  We defined intensity as the proportion of a community’s retail establishments that were targeted and the likelihood of repeat visits to a given establishment, and duration as the period of time over which the intervention was applied.
I will present data on the variation of effect with duration, but we had insufficient data to allow a systematic review of the relationship between intensity and effect. 
Most, although not all studies included a media component to broadcast information about the program.  In those studies that did include a media component, the nature of the media advocacy campaigns variously  included mass and small media.  Where mass media was employed, it involved both paid and earned media.  Small media campaigns included two studies that sent letters to all establishments within the sampling frame, advertising their initiative.  

## Implementation Context

- Often part of a broader community-based effort targeting underage or excessive drinking, which may include:
- Community coalitions
- Training in responsible beverage service
- Changes in alcohol-related policy

**Notes:**
Lastlly, our reviewed studies included 5 multicomponent studies, where the enforcement component was part of a broader, community-based effort to target underage or excessive drinking.  The additional components included community coalitions, which often included community mobilization efforts to encourage increased enforcement; training in responsible beverage service; and changes in alcohol-related policy.  

## Analytic Framework

**enforcement **
**of laws prohibiting **
**provision of alcohol **
**to minors**
**(MLDA)**

- Consumption

- Harmful
- Consequences

- Actual and
- perceived
- threat of
- detection and
- punishment

- Willingness
- to provide
- alcohol to
- minors

- Access via
- targeted
- providers

- Acquisition
- via
- alternative
- channels

- Social norms re: gravity
- of underage drinking

- Demand

**Analytic Framework**

**Notes:**
This is our analytic framework.  We postulate that the intervention works through both changes in social norms, and changes in the actual and perceived threat of detection and punishment.  As the level of concern about detection grows among retailers, we suggest that willingness to provide alcohol to minors will decrease, which will drive down access and hence, decrease both consumption and its harmful consequences.  However, we note that, as access via retailers becomes increasingly more constrained, some portion of underage consumers may simply move to alternative sources, thereby limiting the ultimate impact of the intervention on consumption.  
Lastly, we note that changes in social norms, which may support the decision to enhance enforcement, can also independently change demand, and work in concert with the enhanced enforcement component to limit the willingness of both targeted retailers and alternative sources to provide alcohol to minors, thereby reinforcing the downward pressure on consumption.    

## Outcome Measures

- Consumption: frequency and/or quantity of  alcohol consumed
- Self-reported alcohol consumption
- Self-reported binge drinking
- Access: completed buy attempts
- Proportion of buy attempts that result in alcohol purchase

**Notes:**
We will provide data on two recommendation outcomes:  consumption is our primary outcome, and we will present data on changes in the frequency and/or quantity of alcohol consumed, overall and in the form of binge drinking.

In addition, we will provide data on changes in access to alcohol by minors.  This outcome is defined as the proportion of buy attempts that result in an alcohol purchase, as assessed by underage (or underage-appearing) decoys.  We propose that changes in access can be viewed as an acceptable proxy for changes in consumption and, in the next three slides, we will discuss the strengths and weaknesses of this premise.  

## Outcome: Completed Buy Attempts

**Outcome: Completed Buy Attempts**

**Preusser 1994 (60%)**

**Barry 2004 (28%)**

**Scribner 2001 (89%)**

**Wagenaar 2004 (-)**

**Grube 1997 (35%)**

**Wallin 2004 (45%)**

_**Study (Baseline Rate)**_

**Perry 2002 (49%)**

**Wagenaar 2000 (56%)**

**Median = –42%**

**Notes:**
Note to self:  need some indicator of significance/error bars on this slide
Here is the scatter plot of all 10 data points from the eight reviewed studies.  For each study, we’ve provided the relative percent change in completed buy attempts associated with enhanced enforcement of laws barring alcohol sale to minors, and the baseline level of compliance.  The median response was a 42% relative decrease  in completed buy attempts.   The interquartile range varies from -17% to -57%.
When we looked at this graphic, we thought the results might suggest a bimodal distribution, and wondered if they were correlated with the intensity of the intervention, in terms of the percentage of retailers within the experimental community that received compliance checks, and/or the number of repeat compliance checks to a given retailer over the course of the experimental period.  
Unfortunately, many of the studies did not provide sufficient information to allow a systematic review of this issue, but to the extent we were able to examine it, the size of the relative effect did not appear to be a function of the intensity of the intervention.
I’d also like to point out that the top five studies are multicomponent studies, all of which, with the exception of Wallin, involved multiple communities.  In two of these studies – Wagenaar (2000) and Perry - individual experimental communities tailored the specific elements of their enforcement activities to meet their needs and not all experimental communities opted for an enhanced enforcement initiative, as I mentioned in an earlier slide.   Wallin is our sole foreign study – it is Swedish – and Wallin, Preusser, Scribner and Barry, at the bottom, targeted single communities.     
Lastly, I would like to note that Wagenaar (2004) reported the establishment level effect of the intervention, whereas the other studies reported the average level of compliance across all establishments in the experimental community.  

## Completed Buy Attempts by Follow-up Time: Sustainability of Effect 

**r = -0.179**
**p > 0.05**

**Notes:**
I’ve mentioned the variation of effect with intensity of the intervention; in this slide, we examined the relationship between effect and duration of follow-up, to determine whether there was evidence of attenuation of effect over time, in the the continued presence of the intervention.  There was no evidence of a linear relationship between effect and follow-up time, as evidenced by the correlation coefficient which was not significantly different from 0.  The effect of this intervention seems to persist relatively unchanged, as long as the intervention remains in place.

## Completed Buy Attempts: Sustainability of Effect

**Completed Buy Attempts: ****Sustainability of Effect**

**Follow-up time (months)**

**Percent Decrease in Completed Buy Attempts**

**47%**

**56%**

**57%**

**Preusser, 1994: Off-premises establishments**

**Notes:**
In the same vein, the study of Preusser, who examined the effect of an enhanced enforcement campaign in Denver over a 10 month period, corroborates the conclusions from the previous slide – that the maximal effect develops quickly and persists, at least up to 10 months, so long as the intervention remains in place.    

## Binge Drinking in Past 2–4 Weeks

| Study | Group | Measure | Baseline | Percent Change |
| --- | --- | --- | --- | --- |
| Barry, 2004 |  Grades 9–12  | Binge drinking in past month (%) | 32%1 | –16%
(p<0.051) |
| Wagenaar, 2000
 | Grade 12

Aged 18–20 yrs | Binge drinking in past 2 wks (%)

Binge drinking in past 2 wks (%) | 31%

31% | –5%(NS)

2%(NS) |
| Perry, 2002 | Grades 9–12  | Binge drinking frequency
(Likert scale)
 | 1.6/
3 weeks2 | -6%2
(p< 0.05) |

**1**** p-value based on change in intervention group**
**2 ****Conservative estimates based on 7-point Likert scale scores (baseline = 1.6; net absolute change = -0.09)**

**Notes:**
The same three studies also provided data on changes in the frequency and intensity of binge drinking, assessed by self-report.  
As in the preceding slide, the first two studies express the effect size as relative percent change from baseline.  In these studies, the effect of enhanced enforcement of laws prohibiting the sale of alcohol to minors varied from a 2% increase in frequency of binge drinking, to a 16% decrease, although none of these values achieved statistical significance at p < 0.05.  
As before, Perry assessed the effect of the intervention on 9th graders in the control and experimental communities at baseline, and then again, 3 years later. As seen with 30 day consumption, binge drinking increased in intensity in both groups, although the rate of increase among 12th graders in the experimental communities was 50% less than the rate of increase among twelfth graders in the control communities.  This difference was significant at p < 0.05. 

## Other Benefits and Harms

- Consumption of other substances
- May increase if reduced availability of alcohol leads to substitution
- May decrease if substance consumption is secondary to drinking episodes or to drinking-centered lifestyles

**Notes:**
There are relatively few harms associated with this intervention.  One of the more concerning potential harms is the possibility that minors may substitute other harmful substances for the alcohol that now requires more time and energy to acquire.  However, consumption of other addictive or otherwise harmful substances may also decrease, if their consumption is secondary to drinking episodes, or drinking-centered lifestyles. 
One author also mentioned the potential harm to businesses, but we have not listed this as a potential harm, since providing alcohol to minors is an illegal activity, and the negative impact on businesses of curtailing illegal activities is not generally of concern from a public health perspective.

## Applicability

- Types of communities studied
- Small towns and urban settings
- All geographic regions of the US
- Sweden
- Types of establishments studied
- On-premises
- Off-premises
- Other points of variance across studies
- Combination with other interventions
- Variance in intensity of intervention
- Baseline rates of sales to minors

**Notes:**
Although only eight studies met our inclusion criteria for this review, they covered a relatively broad range of settings and protocols.  The effectiveness of enhanced enforcement of laws limiting sale of alcohol to minors was assessed in on- and off-premise establishments in small towns and in urban settings, in all geographic regions of the US and in one non-US setting – Sweden. 

Studies also varied in the local groups that were involved in drafting and implementing the intervention – we required that each study involve either local law enforcement or liquor board members, but many also engaged community action groups.  Some communities implemented an enhanced enforcement campaign alone, and others combined it with responsible beverage training, and changes in local liquor policy. 

Lastly, as we’ve already noted, the intensity of the intervention also varied across studies, as a function of the number of establishments visited in a given community, and the number of return visits to a given establishment.  

This intervention was deemed to be significantly effective at countering underage access across all settings and variations in implementation. 

## Barriers to Implementation

- Lack of community support
- Lack of support from regulatory and law enforcement agencies
- Opposition by retailers

**Notes:**
There are several potential barriers to implementation of this intervention, that are worthy of note.  Perhaps of greatest importance, community support is a requirement for successful implementation of this community-based intervention.  

In addition, and perhaps as a corollary to the first bullet, the support of the community must include the support of regulatory and law enforcement agencies, without which this initiative could not go forward.  If, however, the community supports a campaign of enhanced enforcement, it can attempt to spur enforcement action by independently launching a surveillance program and publicizing the results.  We reviewed one study in which this approach was taken.

Lastly, the community retailers must be at least nominally supportive of the initiative.  If the retailers actively lobby against any program of enhanced enforcement, particularly in small towns, it can prove a formidable barrier to implementation.     

## Conclusion

- Enhanced enforcement of laws prohibiting sale of alcohol to minors substantially increases likelihood of retailer compliance with existing MLDA laws, but
- Minors may seek alcohol from alternative sources, thereby reducing ultimate impact on consumption
- Few studies evaluated alcohol consumption

**Notes:**
So, in conclusion, [read the text of the slide].  

## Task Force Recommendation

- 	The Task Force recommends enhanced enforcement of laws prohibiting sale of alcohol to minors, on the basis of sufficient evidence of effectiveness in limiting underage alcohol purchases.  Further research will be required to assess the degree to which these changes in retailer behavior affect underage drinking.

## Where to go for Community Guide Results

-      **www.thecommunityguide.org**

## Points to Ponder School-based Programs

- Is it important for programs to have a theoretical foundation?
- Should programs target high-risk individuals?
- Content and delivery—are some approaches more effective than others?
- Peer and media resistance skills
- Interactive format
- Combine school- and community-wide components with policy changes (e.g., Project Northland)

## Points to Ponder Enhanced Enforcement of Retail Sales

- To what extent do these programs reduce underage drinking?
- By themselves?
- When implemented with other programs/policies that reduce demand and access from other sources?
- What intensity of enforcement is necessary to change retailer behavior?
- Is this intervention cost-effective?