Social exchange of cigarettes by youth.

OBJECTIVE: This study seeks to determine the magnitude, nature, and correlates of social exchange of cigarettes among youth who smoke. DESIGN: Cross sectional survey. SETTING: Schools in 29 Minnesota communities. PARTICIPANTS: All students in grades 8, 9, and 10 (ages 13-16 years) in each participating school. The parent/child response rate for the survey was 90%. Analyses included 4124 respondents who smoked at least one cigarette in the month before the survey. OUTCOME MEASURES: Social exchange scale, consisting of 16 items assessing aspects of social provision and acquisition of cigarettes. RESULTS: Almost 90% of youth in this study had obtained a cigarette from, and about 75% of them had provided cigarettes to, another teen in the prior month. Daily smokers provided to more teens and provided more often than those who smoked less than daily. Daily smokers also reported having more social sources, both teens and adults, than lighter smokers, and were more likely to have both bought from and sold cigarettes to other teens (p < 0.0001 for all comparisons between daily and less than daily smokers). In a multivariate analysis, social exchange was associated with grade, whether siblings and friends smoke, level of smoking, age of smoking initiation, parental influences and community norms about teen smoking, and buying cigarettes. CONCLUSIONS: Social provision and acquisition of cigarettes among teens are widespread, reciprocal behaviours. Parental and community expectations about smoking influence social exchange, possibly by providing opportunities or barriers for social smoking. Commercial and social availability are not mutually exclusive; rather social exchange extends the reach of commercial sources.

Project ARM: alcohol risk management to prevent sales to underage and intoxicated patrons.

Clear policies and expectations are key to increasing responsible service of alcohol in licensed establishments. Few training programs focus exclusively on owners and managers of alcohol establishments to reduce the risk of alcohol service. Project ARM: Alcohol Risk Management is a one-on-one consultation program for owners and managers. Participants received information on risk level, policies to prevent illegal sales, legal issues, and staff communication. This nonrandomized demonstration project was implemented in five diverse bars. Two waves of underage and pseudo-intoxicated purchase attempts were conducted pre- and postintervention in the five intervention bars and nine matched control bars. Underage sales decreased by 11.5%, and sales to pseudo-intoxicated buyers decreased by 46%. Results were in the hypothesized direction but not statistically significant. A one-on-one, outlet-specific training program for owners and managers is a promising way to reduce illegal alcohol sales, particularly to obviously intoxicated individuals.

Public opinion on alcohol policies in the United States: results from a national survey.

We surveyed the U.S. non-institutionalized population age 18+ on opinions regarding 23 alcohol control policies (N = 7,021). The cooperation rate among contacted households was 70% and the overall response rate was 54%. Results showed high levels of public support for most alcohol control policies. Over 80% support restrictions on alcohol use in public places, such as parks, beaches, concert venues, and on college campuses. Eighty-two percent support increased alcohol taxes, provided the funds are used for treatment or prevention programs. Over 60% support alcohol advertising and promotion restrictions, such as banning billboard advertising, banning promotion at sporting events, or banning liquor and beer advertising on television. Multivariate regression analyses indicated significant relationships between alcohol policy opinions and a variety of sociodemographic, political orientation, and behavioral measures. However, the absolute differences in alcohol policy support across groups is small. There is a strong base of support for alcohol control policies in the U.S., and such support is found among whites and ethnics of color, young and old, rich and poor, and conservatives, moderates, and liberals.

Effects of coping on health outcome among women with gastrointestinal disorders.

BACKGROUND: Studies have shown that the nature and quality of coping may positively or negatively affect health outcome; however, this relationship has not been well studied among patients with gastrointestinal (GI) disorders. OBJECTIVES: The primary objective was to study the effect of different coping strategies on the health outcome of women with GI disorders and how these coping strategies may modify the effects of education, GI disease type, neuroticism, and abuse severity on health outcome. METHODS: We followed 174 patients in a referral GI clinic for 12 months to assess their health status as a derived variable of daily pain, bed disability days, psychological distress, daily dysfunction, number of visits to physicians, and number of surgeries and procedures. We obtained at baseline their GI diagnosis (functional vs. organic), neuroticism score (NEO Personality Inventory), sexual and/or physical abuse history, and scores on two coping questionnaires. Regressions analyses were used to determine the relative effect of the coping measures on health outcome and their modifying effects on education, GI disease type, neuroticism, and abuse severity. RESULTS: A higher score on the Catastrophizing scale and a lower score on the Self-Perceived Ability to Decrease Symptoms scale (Coping Strategies Questionnaire) predicted poor health outcome. Less education, a functional GI diagnosis, a higher neuroticism score, and greater abuse severity also contributed to poor health status. However, the effect of GI disease type and neuroticism on health outcome was significantly reduced by the coping measures. CONCLUSIONS: Maladaptive coping (eg, catastrophizing) and decreased self-perceived ability to decrease symptoms may adversely affect health outcome and may modify the effect of GI disease type and neuroticism on health outcome.

Policy evaluation research. Measuring the independent variables.

The purpose of this article is to evaluate the accuracy of three methods used to obtain policy data: (a) government agency surveys, (b) secondary sources, and (c) historical legal research. Changes in laws were identified for all 48 contiguous states for the period 1968 to 1994. Legal research is most accurate for well-established laws that have consistent legal descriptions across nearly all states. Laws that are recently enacted, adopted by only a few states, and treated in a legally inconsistent manner across states require a multistage data collection method to identify accurate policy change information.

Communities mobilizing for change on alcohol (CMCA): effects of a randomized trial on arrests and traffic crashes.

AIMS: We previously reported effects of the CMCA intervention in reducing social and commercial access to alcohol by youth, and reducing alcohol use by 18-20-year-olds. This paper reports on effects of CMCA on arrests and car crashes. DESIGN: CMCA was a group-randomized trial that implemented and evaluated a community-organizing effort to change community policies and practices to reduce youth access to alcohol. Seven Midwestern communities were randomly assigned to the intervention condition and eight communities were assigned to the control condition. INTERVENTION: For 2.5 years, a part-time community organizer worked in each of the seven intervention communities with local public officials, enforcement agencies, alcohol merchants, the media, schools and other community groups to reduce youth access to alcohol. MEASUREMENT: We collected annual arrest and quarterly traffic crash data for the years 1987-1995, providing a 6-year baseline and 3 years of data during the intervention. Data were stratified into two target age groups (15-17 and 18-20) and a control group (age 21 and over). Analyses used random-coefficient models because we had repeated observations for each unit of assignment in a group-randomized trial with heterogeneous trends across communities. FINDINGS: We observed net declines in the intervention communities for all arrest and traffic crash indicators. The decline was statistically significant for DUI arrests among 18-20-year-olds and approached significance for DUI arrests and disorderly conduct violations among 15-17-year-olds. CONCLUSIONS: Together with previously published results from this study, the results reported here suggest that a community-organizing approach to limit youth access to alcohol may be effective, at least for selected end-points and subgroups. We conclude that this approach may be useful, but that a longer intervention period is required to increase effectiveness.

Alcohol home delivery services: a source of alcohol for underage drinkers.

OBJECTIVE: This study describes the use of alcohol home delivery services by underage drinkers, and characteristics of grocery and liquor stores that deliver alcohol. The availability of alcohol home delivery services across the United States is also described. METHOD: Individuals surveyed were from 15 small- and medium-sized midwestern communities. Of all enrolled 12th graders, 83.5% (N = 4,487) responded, and of a randomly selected cohort of 18- to 20-year-olds, 93.9% (N = 1,721) responded. All grocery stores that sold alcohol and liquor stores in the corresponding communities were invited to participate in the study and 124 (92.5%) of those businesses completed surveys regarding outlet characteristics and practices. Data for the surveys were based on a nested cross-sectional design with individual respondents nested within the 15 communities. RESULTS: Purchases of delivered alcohol were made by 10% of 12th graders and 7.3% of 18- to 20-year-olds within the past year; 20.2% of outlets delivered alcohol. Using bivariate analyses, purchasing delivered alcohol was associated with male gender, high-risk drinking (drinking five or more drinks on an occasion), more recent and more frequent drinking. Providing delivery services was more common among outlets selling keg beer and/or single servings. Multivariate analyses revealed positive associations between purchasing delivered alcohol and male gender for the 12th graders, and high risk and more recent drinking for both the 12th graders and 18- to 20-year-olds. For outlets, selling keg beer was positively associated with providing delivery services. A separate survey indicated that home delivery services appear to be available in many areas of the country. CONCLUSIONS: Home delivery is a previously unidentified source of alcohol for underage drinkers that could be curtailed with effective alcohol policies.

Communities mobilizing for change on alcohol: outcomes from a randomized community trial.

OBJECTIVE: Communities Mobilizing for Change on Alcohol (CMCA) was a randomized 15-community trial of a community organizing intervention designed to reduce the accessibility of alcoholic beverages to youths under the legal drinking age. METHOD: Data were collected at baseline before random assignment of communities to intervention or control condition, and again at follow-up after a 2.5-year intervention. Data collection included in-school surveys of twelfth graders, telephone surveys of 18- to 20-year-olds and alcohol merchants, and direct testing of the propensity of alcohol outlets to sell to young buyers. Analyses were based on mixed-model regression, used the community as the unit of assignment, took into account the nesting of individual respondents or alcohol outlets within each community, and controlled for relevant covariates. RESULTS: Results show that the CMCA intervention significantly and favorably affected both the behavior of 18- to 20-year-olds (effect size = 0.76, p<.01) and the practices of on-sale alcohol establishments (effect size = 1.18, p<.05), may have favorably affected the practices of off-sale alcohol establishments (effect size = 0.32, p = .08), but had little effect on younger adolescents. Alcohol merchants appear to have increased age-identification checking and reduced propensity to sell to minors. Eighteen- to 20-year-olds reduced their propensity to provide alcohol to other teens and were less likely to try to buy alcohol, drink in a bar or consume alcohol. CONCLUSIONS: Community organizing is a useful intervention approach for mobilizing communities for institutional and policy change to improve the health of the population.

Methadone in the treatment of chronic nonmalignant pain: a 2-year follow-up.

OBJECTIVE: To examine the longitudinal use of methadone in a pain clinic. DESIGN: Follow-up study of 40 patients initially treated with methadone and re-evaluated 2 years later, comparing those maintained on methadone with those who were switched to other opioids. SETTING: Pain clinic at a university hospital. RESULTS: The 14 patients (35%) who stayed on methadone for the duration of the study, had higher employment rates (P <.05) and higher functional ratings (P <.02) than those on other opioids. Side effects were the most common reason (33.4%) for discontinuation of methadone. Dose escalation occurred in 11 of 14 patients (78.6%). CONCLUSIONS: Chronic pain patients may be safely and effectively treated with methadone. Those not responding or tolerating methadone may be benefited by treatment with other opioids.

Alcohol sales to pseudo-intoxicated bar patrons.

OBJECTIVES: Many establishments serve alcoholic beverages to obviously intoxicated patrons despite laws against such sales. To guide the development of interventions to reduce these illegal alcohol sales, this study used actors feigning intoxication to determine whether servers recognized obvious signs of intoxication and to assess the tactics servers used when dealing with intoxicated patrons. METHODS: Male actors ages 30 to 50 acted out signs of obvious intoxication as they attempted to purchase alcoholic beverages. If served during the first attempt, these pseudo-intoxicated buyers made second purchase attempts during the same visit. Observers accompanied the actors; after each visit, actors and observers recorded the servers' behavior and comments. RESULTS: Alcoholic beverages were served to actors portraying intoxicated patrons at 68% of first purchase attempts and 53% of second purchase attempts (62% of a total of 106 purchase attempts). The most common refusal technique was a direct refusal (68% of refusals), made with either no excuse or with reference to the actors' apparent intoxication level. Servers' second most commonly used refusal technique was offering alcohol-free beverages, such as coffee or water (18% of refusals). CONCLUSIONS: Further research is needed to determine why servers who recognize intoxication serve alcoholic beverages and what training, outlet policies, and external pressures are needed to reduce illegal alcohol sales to obviously intoxicated patrons.

Policy options for prevention: the case of alcohol.

Reducing the availability of alcohol through alcohol control policies such as excise taxes and the minimum legal drinking age has been effective in reducing a wide range of alcohol-related problems, including traffic crashes, liver cirrhosis, and violence. Alcohol control policies may be classified into two overlapping categories--public and institutional policies. Some policies such as alcohol server training may be either mandated by governmental jurisdictions or voluntarily adopted by individual institutions, which include alcohol retail establishments, other businesses, worksites, schools, colleges/universities, law enforcement agencies, religious institutions, insurance agencies, and alcohol producers. Public policies may be mandated by national, state/provincial, or local governments to regulate where, when, and how alcohol is sold and consumed. This paper describes the wide array of public and institutional policies available to reduce alcohol-related problems. Summaries of research evaluating specific alcohol control policies are provided when available.

Qualitative assessment of training programs for alcohol servers and establishment managers.

OBJECTIVE: In an attempt to reduce the societal burden associated with alcohol-related problems such as underage drinking and drunk driving, some local communities and state governments mandate training programs for employees of establishments that serve or sell alcoholic beverages. This study was designed to assess the available training programs for employees and managers and to identify states that either mandate training programs or encourage them by reducing establishments' legal liability. METHODS: Training programs were identified through the Internet, key informants, and the research literature. Three researchers independently rated each of 22 local and national programs across 10 categories. In addition, the authors surveyed alcoholic beverage control agencies and legislative research bureaus in the 50 U.S. states. RESULTS: The results show that training programs are not standardized and vary widely in content, use of behavior change methods, and production quality. Most programs targeted waitstaff and bartenders. Only one program exclusively targeted owners and managers. CONCLUSIONS: National standards must be developed for training programs for servers, managers, and owners.

Relationships among alcohol availability, drinking location, alcohol consumption, and drinking problems in adolescents.

We examined relationships among perceived alcohol availability, drinking location, alcohol consumption, and drinking problems. Subjects were 3,372 adolescent drinkers, ages 16-18, who participated in the Communities Mobilizing for Change on Alcohol Project baseline survey. Mixed-model regression was employed to identify predictors of alcohol consumption and drinking consequences. Perceived alcohol availability was significantly associated with higher levels of alcohol consumption for males. Drinking in a public location with higher levels of alcohol consumption for females. Results underscore the importance of youth alcohol assessibility.

Impact of sexual and physical abuse dimensions on health status: development of an abuse severity measure.

OBJECTIVE: Despite the abundant literature showing a relationship of sexual and/or physical abuse history with poor health status, few studies provide evidence about which dimensions of abuse may have a worse impact on health. In female patients with gastrointestinal (GI) disorders, the present study aims to identify which dimensions of abuse history (eg, number of perpetrators, injury) might predict poor current health status, in order to develop an empirically based severity of abuse measure. METHODS: Of a sample of 239 female patients from a referral gastroenterology clinic, this paper primarily focuses on 121 women with a past history of contact sexual abuse (N = 99), and/or life threatening physical abuse (N = 68). RESULTS: Among those with a sexual abuse history, 24% of current health status was explained by serious injury during abuse (p = .0006), victimization by multiple perpetrators (p = .03), and being raped (p = .09). Among the physically abused, rape (in addition to life threat) (p = .0001), and multiple life-threatening incidents (p = .002) explained 39% of the variance in overall health. Among the women with a sexual and/or physical abuse history, the experience of rape, serious injury during sexual abuse, and multiple life-threatening incidents explained one fourth of the variance in current health status. Based on these three dimensions of abuse, we created an abuse severity measure which explained about one fourth of the variance in health status among the subgroup with abuse history, and among the entire clinic sample. CONCLUSIONS: Given the high prevalence of abuse in referral practice, and the potential health impact of previous abuse, it is important that history taking include details concerning the abuse experience. The severity of abuse measure developed in this paper should prove useful for both research and clinical practice.

Why and in what context adolescents obtain alcohol from adults: a pilot study.

Four focus groups involving 26 male and female high school seniors were conducted to provide insight into the context and settings in which alcohol is provided to youth, and why some youth choose certain sources of alcohol over others. Adults over the age of 21 years were the most common source of alcohol used by participants. Participants believe that it was less risky to ask an older adult to purchase alcohol than to attempt to buy it themselves. Few restrictions were placed on youth when alcohol was provided by an older adult. Youth may seek certain alcohol sources when they perceive that alcohol is available and risks of obtaining it are low.

Environmental predictors of drinking and drinking-related problems in young adults.

We examined relationships among drinking norms, peer alcohol use, alcohol availability, drinking location, alcohol consumption, and drinking-related problems among young adult drinkers. The specific objectives of our study were to assess the relative contribution of normative and physical environmental factors to drinking and drinking consequences. Subjects were 3,095 young adults, aged eighteen to twenty years old who participated in the Communities Mobilizing for Change on Alcohol Project baseline survey. Alcohol consumption (i.e., number of drinks on the last occasion) and drinking consequences served as dependent variables. Multiple linear regression was used to identify predictors of alcohol consumption, and logistic regression was employed to identify predictors of drinking consequences. Drinking norms and peer alcohol use were positively related to alcohol consumption and to drinking consequences. Drinking in a public setting was positively related to alcohol consumption, but not to drinking-related problems. Findings suggest that policies and programs that alter the normative and physical environment surrounding drinking may reduce alcohol consumption and subsequent problems in young adults.

Changing the relationship among nurses' knowledge, self-reported behavior, and documented behavior in pain management: does education make a difference?

An educational program designed to change knowledge in order to change pain management practices and patient outcomes was offered to nurses who provide day-to-day care to patients with cancer in communities in a predominantly rural state. A quasi-experimental time-series design was used to measure the effectiveness of the program in changing nurse knowledge, attitude and behavior, and to evaluate the relationships between the outcomes. Data were collected from nurses (N = 29) and patient charts before (N = 209) and after (N = 163) the program. Nurses' knowledge increased, but the change was not statistically significant; the mean percent of correct answers on the three subtests were different and differences persisted throughout the study. Nurses believed that patients should be "pain free." Documentation of behaviors, for example, practice activities, occurred infrequently and showed little change until 6 months after the program. Increase in documentation of pain-intensity ratings, pain location, number of sites of pain, presence of confusion, anxious or depressed mood, sleep, nausea and vomiting, constipation, and general activity were noted. Documentation of the use of a propoxyphene-containing analgesic decreased; increase in the use of hydromorphone methadone and transdermal fentanyl was noted. Analysis of the relationships between correct responses to nurse knowledge questions and documentation of behavior provided interesting, statistically insignificant results that need to be reexamined in future research. Future programs should emphasize analgesic dosing and calculation of equianalgesic doses. Current practices in chart documentation may provide incomplete information regarding change in practice behaviors; more detailed documentation of pain management practices is needed. Nurses who participated in the program anecdotally reported feelings of increased credibility and effectiveness. Although change in behavior is slow to occur, education does make a difference.

Characteristics, policies and practices of alcohol outlets and sales to underage persons.

OBJECTIVE: A recent study found that many alcohol outlets sold alcohol to youthful-appearing study confederates. This article expands upon that work by exploring the linkages between the policies, practices and characteristics of outlets and their propensity to sell alcohol to persons under the legal drinking age. METHODS: Data on alcohol outlets are from a telephone survey of 100 establishments located in 28 communities in northeastern Minnesota that hold off-sale licenses for the sale of distilled spirits and/or full strength beer and wine. Alcohol purchase attempts were conducted in each outlet to provide a measure of propensity to sell alcohol to underage persons. Youthful-appearing study confederates conducted three separate purchase attempts in each outlet. Multiple linear regression was used to estimate the effects of outlet characteristics and policies on the purchase success rate. RESULTS: Bars were less likely than liquor stores or bar/liquor stores to sell to study confederates. Having a manager on the premises at all times was associated with a 15% lower purchase success rate in bars. Requiring formal training of bar staff involved in alcohol sales was associated with a 19% lower purchase success rate. No outlet characteristics or practices were associated with the purchase success rate in liquor stores and bar/liquor stores. CONCLUSIONS: These results underscore the importance of research and intervention focusing on alcohol outlet policies and practices that affect the propensity to sell alcohol to persons under the legal drinking age.

Project Northland: outcomes of a communitywide alcohol use prevention program during early adolescence.

OBJECTIVES: Project Northland is an efficacy trial with the goal of preventing or reducing alcohol use among young adolescents by using a multilevel, communitywide approach. METHODS: Conducted in 24 school districts and adjacent communities in northeastern Minnesota since 1991, the intervention targets the class of 1998 (sixth-grade students in 1991) and has been implemented for 3 school years (1991 to 1994). The intervention consists of social-behavioral curricula in schools, peer leadership, parental involvement/education, and communitywide task force activities. Annual surveys of the class of 1998 measure alcohol use, tobacco use, and psychosocial factors. RESULTS: At the end of 3 years, students in the intervention school districts report less onset and prevalence of alcohol use than students in the reference districts. The differences were particularly notable among those who were nonusers at baseline. CONCLUSIONS: The results of Project Northland suggest that multilevel, targeted prevention programs for young adolescents are effective in reducing alcohol use.

Sources of alcohol for underage drinkers.

OBJECTIVE: We assessed the extent to which various sources of alcoholic beverages are used by early, middle and older teenagers, the extent to which teenagers perceive alcohol to be available from different sources and factors related to use of alternative sources. METHOD: Ninth graders (n = 2,269), twelfth graders (n = 2,377) and youth aged 18-20 (n = 1,738) were surveyed in 15 upper-midwestern communities using a nested cross-sectional design. Analyses were based on mixed-model regressions, with both the individual and community treated as random effects, taking into account the intraclass correlation for each dependent variable. Analyses focused on current (last 30 day) drinkers to avoid recall bias for drinking events in the distant past. RESULTS: A person aged 21 or over was the most common source of alcohol for current drinkers in all three age groups; 46% of 9th graders, 60% of 12th graders and 68% of those aged 18-20 obtained alcohol from a person age 21 or older for their last drinking occasion. A person under age 21 was the second most prevalent source for 9th and 12th graders (29% of each group obtained alcohol from someone under age 21 for their last drinking occasion). A commercial outlet was the second most prevalent source for those aged 18-20 (14% obtained alcohol directly from an outlet for their last drinking occasion). CONCLUSIONS: Perceived availability, binge drinking and several demographic characteristics were independently related to source of alcohol used, and age interacted with several factors in predicting source of alcohol. We conclude that increased attention to sources of alcohol used by youths would facilitate efforts to reduce underage drinking.