Alcohol misuse is a cause of concern for health services, policy makers, prevention workers, the criminal justice system, youth workers, teachers and parents. Worldwide, 5% of all deaths of young people between the ages of 15 and 29 are attributable to alcohol use. In Europe, one in four deaths of men in the age group 15 to 29 is related to alcohol. In parts of Eastern Europe, the figure is as high as one in three. All in all, 55,000 young people in Europe died from causes related to alcohol use in 1999.
The Annual Report of the Chief Medical Officer of the Department of Health (England and Wales) highlights a worrying trend for teenagers who drink alcohol to consume larger quantities. In 1998, average consumption among 11-15 year-old drinkers was 9.9 units of alcohol a week (1 unit contains 8g. of pure alcohol), compared to 6.0 units a week in 1992. A major European study, also supported by the AERC, has recently provided comparative international data. The European School Survey Project on Alcohol and other Drugs (ESPAD) focussing on 15-16 year olds showed that in the United Kingdom nearly 40% of young people had been drunk by the time they reached 13 years, over one-fifth of students had been intoxicated three times or more during the previous 30 days, and nearly one third of students reported having five or more drinks in a row (binge drinking). In each case the United Kingdom was amongst the worst of the 30 countries studied. The Chief Medical Officer also raised a concern about the increasing number of deaths from chronic liver disease in young people. In the last 30 years of the 20th Century the death rate amongst people aged 35 to 44 years increased 8-fold in men and 7-fold in women; and amongst 25-34 year-olds a four-fold increase was seen over the 30 year period.
This Cochrane Collaboration systematic review of the effectiveness of primary prevention interventions for alcohol misuse in young people, carried out by Professor David Foxcroft and colleagues from the School of Health Care at Oxford Brookes University, had two objectives:
- to identify and summarize rigorous evaluations of psychosocial and educational interventions aimed at the primary prevention of alcohol misuse by young people; and
- to assess the effectiveness of primary prevention interventions over the longer-term (greater than 3 years).
- 56 studies were identified and appraised to be of sufficient quality to be included in the systematic review. The majority (84%) of studies took place in the United States. Of the others, three were Canadian, two British, one Swedish, one Norwegian, one Australian, and one was an international study encompassing Australia, Chile, Norway and Swaziland.
- Only a small number of the many intervention studies found in the literature had been well-designed and adequately evaluated. Fifteen studies reported partially effective short-term (up to 1-year) interventions, that is, the intervention produced some but not all of the desired effects.
- Of the twelve studies reporting medium-term (1-3 years) partially effective interventions, few were convincingly effective, and most were marred by methodological shortcomings. Nineteen studies that carried out a medium-term follow-up found no evidence of intervention effectiveness.
- Over the longer-term, the results of this systematic review point to the potential value of the Strengthening Families Program (SFP) as an effective intervention for the primary prevention of alcohol misuse. The Number Needed to Treat (NNT) for the SFP over 4 years for three alcohol initiation behaviours (alcohol use, alcohol use without permission and first drunkenness) was 9 (for all three outcomes). In other words if 9 people receive the Strengthening Families Programme then one of them will benefit. This compares, for example, with an NNT of 24 for school-based life skills training to prevent one episode of drunkenness six years later.
- Other interventions worth considering are culturally-focused interventions. That is approaches that take account of cultural beliefs, values and norms. Social skills training, for example, would be sensitive to customary rituals such as shaking hands, embracing, and defining appropriate physical proximity across gender and age divides. One study highlighted the potential value of culturally focused skills training over the longer-term (NNT =17 over three-and-a-half years for 4+ drinks in the last week). The Life Skills Training approach (LST) showed less promise.
- For many interventions, however, it is probably reasonable to say that the evidence base does not support their continued use in the primary prevention of alcohol misuse for young people, other than in further research studies.
The Strengthening Families Programme shows promise. The programme covers a range of topics such as making house rules, encouraging good behaviour, handling peer pressure, building family communication and appreciating family members. There are sessions with parents and sessions with children as well as family sessions. Although the results are very positive the programme needs to be evaluated on a larger scale and in different settings to confirm the current results.
Culturally-focused interventions require further development and rigorous evaluation, including cost-effectiveness assessment.
Further research is needed to identify which ways of measuring alcohol use best indicate serious dangers in the short term, and in later life.
An international register of alcohol and drug misuse prevention interventions should be established and criteria agreed for rating prevention intervention in terms of safety, efficacy and effectiveness. This register should be aimed at public health policy makers and prevention workers
Professor David Foxcroft, Diana Ireland & Rosie Breen (Oxford Brooks), Deborah Lister-Sharp (York) with Geoff Lowe (Hull).