Lessons from Project Northland
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Lessons From Project Northland Preventing Alcohol Problems During Adolescence Carolyn L. Williams, Ph.D., and Cheryl L. Perry, Ph.D. Project Northland, an ongoing community trial aimed at reducing alcohol use and alcohol- related problems among adolescents, is nearing completion. The project combines individual- based strategies to encourage adolescents not to use alcohol with community-based strategies to both reduce alcohol availability and modify community attitudes concerning youth drinking. Project Northland has developed prevention programs and followed the same group of adolescents from sixth grade to high school graduation. This article discusses the rationale for this type of program, elements of the adolescents’ social environment targeted for change, the unique challenges of working with high school students compared with younger adolescents, and areas for future research. KEY WORDS: community based prevention; prevention program; prevention strategy; adolescent; AOD availability; attitude toward AOD; prevention of AODR (alcohol and other drug related) problems; underage drinker; socioenvironmental factors; junior high school student; high school student; youth culture; harm reduction policy; literature review hroughout the history of the gests that a third era of temperance (i.e., “you first had a glass of beer or United States, public opinion may be under way. Additional evi- wine, or a drink of liquor such as T concerning alcohol use has dence to support this shift in American whiskey, gin, scotch, etc.”) at age 15 oscillated from toleration to disapproval, attitudes toward alcohol includes the and the average annual consumption reinstatement of age 21 as the legal CAROLYN L. WILLIAMS, PH.D., is of alcohol has risen and fallen in drinking age in all States by the mid- an associate professor and Cheryl L. accordance with this pattern. Current 1980s and ongoing public activism, Perry, Ph.D., is a professor in the annual per person alcohol consump- beginning in the mid-1970s, supporting Division of Epidemiology, School tion among adults in the United States tougher drunk-driving laws. of Public Health, University of is only about one-third of what it was Despite overall lower alcohol con- Minnesota, Minneapolis, Minnesota. in the early 19th century (Musto sumption in the United States, American 1996). Along with other indications, youth drink more at younger ages. Project Northland is funded by a 15-percent drop in adult alcohol One study found that only 9 percent National Institute on Alcohol Abuse consumption since its most recent of respondents born between 1919 and Alcoholism grants R01–AA08596 peak around 1980 (Musto 1996) sug- and 1929 reported first using alcohol and R01–AA10719. Vol. 22, No. 2, 1998 107 or younger, compared with 33 per- during adolescence. Data from the researchers (e.g., Holder et al. 1997; cent of those surveyed who were born 1992 National Longitudinal Alcohol Wagenaar and Perry 1995). between 1971 and 1975 (Johnson Epidemiologic Survey of 27,616 and Gerstein 1998). Many youth drinkers and former drinkers found drink alcohol regularly. In a 1995 that people who started drinking Adolescents’ Social survey, 25 percent of 8th graders, 39 before age 15 were four times more Environment: Targets for percent of 10th graders, 51 percent likely to become alcohol dependent at Comprehensive Prevention of 12th graders, and 68 percent of some point during their lives, compared college students reported drinking at with those who had initiated drinking Current prevention efforts tend to be least once during the 30 days prior to at age 20 or older (40 percent versus comprehensive and to target factors in being surveyed (Johnston et al. 1996). 10 percent) (Grant and Dawson 1997) the adolescents’ social environment In addition, the survey results suggest (see the Epidemiologic Bulletin, pp. that are known to affect underage that many young drinkers consume 144–150). Similarly, the number of peo- drinking (Botvin and Botvin 1992; multiple drinks per drinking occa- ple who experienced alcohol abuse in Dusenbury and Falco 1995; Hansen sion. Fifteen percent of 8th graders, their lifetime increased as the age of 1993). Figure 1 illustrates aspects of 24 percent of 10th graders, 30 percent drinking onset decreased (Grant and adolescents’ social environment that of 12th graders, and 40 percent of Dawson 1997).1 An earlier British can be the targets of prevention college students reported consuming study that followed a sample of young efforts.2 The most immediate social five or more drinks in a row at least people from ages 16 to 23 (Ghodsian environment for a given adolescent once in the 2 weeks before the survey and Power 1987) found that those generally consists of parents, siblings, (Johnston et al. 1996). youth who drank the most in quantity and best friends. The next ring The widespread and often heavy and frequency at age 16 were the includes larger peer groups, which alcohol use by adolescents are associ- most likely to drink heavily at age 23. may vary by setting (e.g., friends at ated with significant morbidity and More specifically, 16-year-old males school, on sports teams, or at religious mortality (e.g., Chassin and DeLucia who reported drinking the week prior institutions); teachers; other relatives; 1996) that are not confined to the to the survey were nearly four times and other important adults in an ado- group of more extreme users. In fact, more likely to report heavy drinking lescent’s life (e.g., coaches, religious because the general population (i.e., more than 50 drinks of alcohol advisors, or other youth group leaders). includes more light and moderate in 1 week) at age 23, compared with The outer ring includes the broader drinkers than heavy drinkers, the for- those who reported being abstinent at community of business (e.g., alcohol mer experience more alcohol-related age 16 (15 percent versus 4 percent). merchants, including neighborhood problems as a group, even though as A recent behavioral genetics study merchants, and major employers in individuals they are at less risk than suggests that social and environmental the region) and community leaders as heavier drinkers (National Institute factors are more important than genetic well as local and national government on Alcohol Abuse and Alcoholism influences in delaying drinking until leaders (ranging from school superin- [NIAAA] 1994). This finding has age 16. Rose and colleagues (in press) tendents and police chiefs to mayors tended to shift the focus of prevention conducted a population-based study and the governor), with the top of the efforts away from the identification of that was able to identify all the twins outer ring reserved for mass media problem drinkers toward the prevention born in Finland between 1975 and and advertising. Project Northland of alcohol use during adolescence 1979 and to enroll them sequentially targeted each ring of the adolescents’ (Wagenaar and Perry 1995). in the study when they reached age social environment. Project Northland is the largest 16. The study included 2,711 total Much of the popular youth cul- community trial in the United States pairs of twins born over the 5-year ture—frequently cited by parents, to focus on the prevention of alcohol period and demonstrated that remain- other adults, and youth as among the use and alcohol-related problems ing abstinent from alcohol until age primary reasons for an adolescent’s among adolescents. Using the exam- 16 was clearly linked to nongenetic use of alcohol, tobacco, and other ple of Project Northland, this article influences. Abstinence rates were drugs—is developed primarily in the describes a comprehensive approach influenced by sibling interaction that combines individual-based strate- effects, parental drinking patterns, 1Lifetime alcohol dependence and abuse were defined gies to encourage adolescents not to and contextual features of the region. using standard criteria from the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual use alcohol with community-based Rose and colleagues suggested that of Mental Disorders, Fourth Edition (APA 1994). strategies to both reduce alcohol avail- regional features may include vari- ability and modify community ables such as local alcohol sales, ease 2Figure 1 has been modified from the version used attitudes regarding underage drinking. of underage access to alcohol, and by Perry in her expert testimony in the 1998 Epidemiologic studies demonstrate exposure to public drinking or intoxi- tobacco trial in Minnesota (State of Minnesota and Blue Cross and Blue Shield of Minnesota v. Philip the importance of delaying the onset cation, issues that have been identified Morris, Inc.; R.J. Reynolds Tobacco Company; of drinking and reducing alcohol use as intervention targets by prevention Brown & Williamson Tobacco Corporation et al.). 108 Alcohol Health & Research World Lessons From Project Northlands outermost ring of a young person’s interpersonal influences (i.e., the first strated effectiveness (Dusenbury and social environment (i.e., mass media, two rings in figure 1). Even then, Falco 1995). The table on page 110 advertising, and businesses that target interventions with families have been lists the key components of effective peer-group identity to encourage limited (Dusenbury and Falco 1995; prevention programs identified by youth to engage in various behaviors). Wechsler and Weitzman 1996). Dusenbury and Falco and how they For example, advertisements, rock Interventions