Harms from a partner's drinking: an international study on adverse effects and reduced quality of life for women

BACKGROUND

Partners of heavy drinking individuals can be detrimentally affected as a result of their partner's drinking.

OBJECTIVES

The aim of this study was to identify the proportion of heterosexual intimate partner relationships with a heavy drinking male that resulted in reported alcohol-related harm and to investigate the impact of this on well-being in 9 countries.

METHODS

This study used survey data from the Gender and Alcohol's Harm to Others (GENAHTO) Project on Alcohol's Harm to Others in 9 countries (10,613 female respondents, 7,091 with intimate live-in partners). Respondents were asked if their partners drinking had negatively affected them as well as questions on depression, anxiety, and satisfaction with life.

RESULTS

The proportion of partnered respondents that reported having a harmful heavy drinking partner varied across countries, from 4% in Nigeria and the US to 33% in Vietnam. The most consistent correlate of experiencing harm was being oneself a heavy episodic drinker, most likely as a proxy measure for the acceptability of alcohol consumption in social circles. Women with a harmful heavy drinking partner reported significantly lower mean satisfaction with life than those with a partner that did not drink heavily.

CONCLUSIONS

Harms to women from heavy drinking intimate partners appear across a range of subgroups and impact on a wide range of women, at least demographically speaking. Women living with a heavy drinking spouse experience higher levels of anxiety and depression symptoms and lower satisfaction with life.

Hazardous drinking and exposure to interpersonal and community violence on both sides of the U.S. -Mexico border

Objective

Different patterns of heavy drinking occur by country and proximity to the U.S. Mexico border. Few studies describe the impact of violence on drinking between countries and along the border.

Methods

Survey data is from U.S. Mexican origin adults living in Texas and Mexican border and non-border cities, N=4,796. Participants were asked about alcohol consumption, interpersonal physical violence (IPV) and exposure to community violence. Monthly hazardous drinking (5+/4+ for men/women) was the primary outcome. Multivariate logistic regression model comparisons identified best predictors.

Results

In the U.S. hazardous drinking was associated with past year IPV (OR_adj=2.5; 1.8-3.5) and community violence (OR_adj=1.4; 1.1-1.8). In Mexico, IPV (OR_adj=3.9; 2.0-7.4) and border proximity (OR_adj=0.5; 0.4-0.8) were associated with hazardous drinking but not community violence.

Conclusion

Hazardous drinking is associated with IPV in both countries, but violence did not explain border hazardous drinking differences where they existed in Mexico.

Evaluation of the SCA instrument for measuring patient satisfaction with cancer care administered via paper or via the Internet

Background: Patients’ perspectives provide valuable information on quality of care. This study evaluates the feasibility and validity of Internet administration of Service Satisfaction Scale for Cancer Care (SCA) to assess patient satisfaction with outcome, practitioner manner/skill, information, and waiting/access.

Patients and methods: Primary data collected from November 2007 to April 2008. Patients receiving cancer care within 1 year were recruited from oncology, surgery, and radiation clinics at a tertiary care hospital. An Internet-based version of the 16-item SCA was developed. Participants were randomised to Internet SCA followed by paper SCA 2 weeks later or vice versa. Seven-point Likert scale responses were converted to a 0–100 scale (minimum–maximum satisfaction). Response distribution, Cronbach’s alpha, and test–retest correlations were calculated.

Results: Among 122 consenting participants, 78 responded to initial SCA. Mean satisfaction scores for paper/Internet were 91/90 (outcome), 95/94 (practitioner manner/skill), 89/90 (information), and 86/86 (waiting/access). Response rate and item missingness were similar for Internet and paper. Except for practitioner manner/skill, test–retest correlations were robust r = 0.77 (outcome), 0.74 (information), and 0.75 (waiting/access) (all P < 0.001).

Conclusions: Internet SCA administration is a feasible and a valid measurement of cancer care satisfaction for a wide range of cancer diagnoses, treatment modalities, and clinic settings.

Are lifetime abstainers the best control group in alcohol epidemiology? On the stability and validity of reported lifetime abstention

Lifetime abstainers have often been recommended as the comparison group in alcohol epidemiology. The objective of this study was to provide insight into the validity and stability of lifetime abstention by using data derived from the National Alcohol Survey, a national probability survey of US households conducted in 1984, and its 2 follow-up surveys conducted in 1990 and 1992. Results indicated that more than half (52.9%; all proportions were weighted to represent the US population) of those who reported never having a drink of any alcoholic beverage in the 1992 survey reported drinking in previous surveys. Depending on assumptions, this difference may result in an underestimation of alcohol-attributable mortality of 2%-15% in men and 2%-22% in women. Sociodemographic factors differentiated those who consistently reported lifetime abstention across surveys from the rest of the study population. Results suggest that using reported lifetime abstainers as a sole comparison group is problematic, especially if reporting is based on 1 measurement only. Establishing multiple measurement points and including irregular lifetime light drinkers with lifetime abstainers as the comparison group are recommended for future epidemiologic studies.

Public alcohol policy: current directions and new opportunities

Alcohol policy has been shown to have an impact on the incidence and prevalence of alcohol "addiction," or alcohol use disorders (AUDs), as currently defined by the International Classification of Diseases, volume 10, or by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. We will mainly use the term "addiction" to depict a state involving loss of control over intense urges to consume alcohol, even at the expense of adverse consequences. This definition goes beyond pure "physiological dependence." We will use the term AUD when referring to statistics based on the above-described definitions. In this overview we identify the pathways in the relationship between alcohol policy and addiction, present the empirical evidence, and draw conclusions. Special emphasis will be put on treatment policy.

Ways of measuring drinking patterns and the difference they make: experience with graduated frequencies

This paper reviews methodological issues in assessing volume and pattern of alcohol consumption. It focuses on three measures developed at the Alcohol Research Group (ARG) to assess frequencies of drinking in a graduated series of quantity intervals, called the graduated quantity-frequency (QF) approach. The three measures include two reference periods, 30 days and 12 months, and use three distinct ways of assembling the graduated QF data. The Cahalan-Treiman 30-day measure, developed for self-administered mail surveys, targets daily amounts of beverage alcohol, with thresholds asked in ascending order. The other two measures use descending quantity ranges. The Knupfer Series (KS) asks for three beverage-specific quantity levels. The Graduated Frequencies (GF) measure assesses intake of combined alcohol with five levels. Both are available in face-to-face and telephone formats. All three measures inquire about consumption in the metric of "drinks," defined within the form or interview; each is useful for estimating volume and pattern of consumption. Methodological studies with the GF include comparisons with other measures, between- and within-subject interview comparisons, and qualitative protocol analyses designed to examine cognitive response processes. Uses for each measure are considered, and recommendations are made for improvement and more thorough specification of drinking patterns.

Dimensions of alcohol-related social and health consequences in survey research

Dimensions of alcohol-related social and health consequences are approached from two different perspectives. First, classical approaches with factor analytic techniques are used to empirically determine the dimensionality of item batteries intended to measure harm. Second, a closer look is taken at theoretically underlying dimensions of social and health consequences and their association with alcohol consumption. Using as empirical material data from the US national survey of males aged 21-59 (N3) conducted in 1969, the following specific questions are discussed: (1) What are the underlying dimensions of alcohol-related social and health consequences? (2) How should the relation between alcohol consumption and consequences best be assessed (in terms of epidemiological traditions or social constructivist traditions)? (3) How can we best incorporate the time perspective into modeling the relationship between alcohol consumption and consequences? A first attempt is made to develop practical guidelines for future research on handling these problems.

Average volume of alcohol consumption, patterns of drinking, and all-cause mortality: results from the US National Alcohol Survey

The objective of this study was to investigate the effects of an average volume of alcohol consumption and drinking patterns on all-cause mortality. The sample (n = 5,072) was drawn from the 1984 National Alcohol Survey, representative of the US population living in households. Follow-up time was until the end of 1995, with 532 people deceased during this period. The authors found a significant influence of drinking alcohol on mortality with a J-shaped association for males and an insignificant relation of the same shape for females. When the largest categories of equivalent average volume of consumption were divided into people with and without heavy drinking occasions, serving as an indicator of drinking pattern, this differentiation proved important in predicting mortality. Light to moderate drinkers had higher mortality risks when they reported heavy drinking occasions (defined by either eight drinks per occasion or getting drunk at least monthly). Similarly, when the category of exdrinkers was divided into people who did or did not report heavy drinking occasions in the past, people with heavy drinking occasions had a higher mortality risk. Finally, indicating alcohol problems in the past was related to higher mortality risk. Results emphasized the importance of routinely including measures of drinking patterns into future epidemiologic studies on alcohol-related mortality.

Reports of alcohol-related harm: telephone versus face-to-face interviews

OBJECTIVE

To assess the effect of mode of administration in alcohol surveys (telephone vs face-to-face interviews), prevalence rates of self-reported harms due to alcohol were compared for two datasets with equivalent measures.

METHOD

Two national alcohol surveys were used: the 1990 Warning Labels Survey, in which random digit dialing was used to generate a sample of 2,000 adults interviewed by telephone, and the 1990 National Alcohol Survey (face-to-face interviews), a probability sample of U.S. adults living in households (N = 2,058). Both surveys included identical items on five areas of alcohol-related harm, yielding one composite index of any harm reported in the last 12 months that was compared between the two surveys for current drinkers.

RESULTS

After controlling for demographic characteristics and alcohol use, the telephone survey yielded significantly higher rates of alcohol-related health harm, work harm and "any harm" as compared to the in-person survey. The interaction between heavier drinking (five or more drinks during 1 day, weekly or more often) and method of data collection was significant for health harm and any harm. Respondents in the telephone survey who drank 5+ less than weekly were more likely than those interviewed in person to report health harm due to alcohol use; those in the telephone survey who drank 5+ weekly or more often were more likely to report any harm.

CONCLUSIONS

Possible explanations for differences between the surveys include anonymity and fewer social desirability issues associated with telephone surveys, as well as potentially differing cognitive requirements in telephone versus face-to-face interviews.

Methods for evaluating policy changes in alcohol services

Policy research assesses how outside forces affect alcohol treatment services. In this primer, we examine a range of effective methods that can be brought to bear by researchers and address the issues involved in conceptualizing and conducting studies of policy formation, implementation and policy implications. Because there is no single superior methodology for studying policy change, researchers have relied on five broad methodologies for studying policy context, formation, change and implications. We provide specific examples of each approach, addressing the following issues: data sources and samples; the problems, challenges, strengths, and limitations of the approach; and whether (and how) the method has been used in the alcohol field. The five methods are archival studies; key informant studies; ethnographic and observational studies; surveys; and meta-analyses. The strongest research designs in alcohol services research often combine methods and sources to get different vantage points on questions about policy change.

Effects of telephone versus face-to-face interview modes on reports of alcohol consumption

AIMS AND DESIGN

In order to assess the effects of survey modality on alcohol consumption estimates, data from two surveys using different interview modes (face-to-face and telephone) were compared on several alcohol measures.

SETTING AND PARTICIPANTS

Face-to-face survey data were drawn from the 1990 National Alcohol Survey, while the telephone data came from the 1990 Warning Labels Survey. Both surveys used a probability sampling of the US adult general population in the 48 contiguous states.

MEASUREMENTS

Measures of alcohol use derived from an identical "graduated frequencies" series included estimates of any drinking in the past 12 months, overall volume, and heavy (5+) drinking days.

FINDINGS

Abstention rates did not differ by survey mode, nor did distributions of alcohol consumption by volume and reported frequency of drinking five or more drinks in a day. Multiple regression models including demographic-mode interaction terms were used to examine how mode effects might differ across demographic subgroups. Lower income respondents were under-represented in the telephone sample, and were associated with lower reports of volume and 5+ days, compared to respondents in the face-to-face mode.

CONCLUSIONS

The results suggest that although there are few differences in alcohol consumption estimates by interview mode, telephone samples may need to be supplemented or estimates adjusted by income level in order to attain equivalent results.

Trends in social consequences and dependence symptoms in the United States: the National Alcohol Surveys, 1984-1995

OBJECTIVES

Given the decline in alcohol use in the United States since the 1980s, the purpose of this study was to assess shifts in self-reported social consequences of alcohol use (and 5 consequences subscales) and dependence symptoms from 1984 to 1995.

METHODS

This study used data from 3 national alcohol surveys based on household probability samples of current drinkers (adults) in 1984, 1990, and 1995; samples sizes were 1503, 1338, and 1417, respectively.

RESULTS

Overall, few changes in prevalence of social consequences or dependence symptoms were found. Significantly lower prevalence rates of 2 consequences subscales (accidents/legal problems and work problems) were reported between 1984 and 1990, but prevalence rates did not change for any of the scales from 1990 to 1995.

CONCLUSIONS

This stability in alcohol-related outcomes despite reductions in alcohol consumption may be a result of cultural shifts in which problem amplification occurs in "drier" historical periods. Furthermore, rates of alcohol-related problems may be approaching their lowest limit and may not be readily influenced by any additional decreases in alcohol consumption.

A 10-year national trend study of alcohol consumption, 1984-1995: is the period of declining drinking over?

OBJECTIVES

Data from the 1984, 1990, and 1995 National Alcohol Surveys were used to investigate whether declines shown previously in drinking and heavy drinking across many demographic subgroups have continued.

METHODS

Three alcohol consumption indicators--current drinking (vs abstaining), weekly drinking, and weekly heavy drinking (5 or more drinks in a day)--were assessed for the total US population and for demographic subgroups.

RESULTS

Rates of current drinking, weekly drinking, and frequent heavy drinking, previously reported to have decreased between the 1984 and 1990 surveys, remained unchanged between 1990 and 1995. Separate analyses for each beverage type (beer, wine, and spirits) and most demographic subgroups revealed similar temporal patterns.

CONCLUSIONS

Alcohol consumption levels, declining since the early 1980s, may reach a minimum by the 21st century. Consumption levels should be monitored carefully over the next few years in the event that long-term alcohol consumption trends may be shifting.

Beer drinking accounts for most of the hazardous alcohol consumption reported in the United States

OBJECTIVE

Patterns and correlates of hazardous drinking, defined as occasions in which five or more drinks were consumed in a day, were compared for wine, beer and distilled spirits.

METHOD

From a probability sample of the U.S. adult household population, 2,817 respondents who had consumed at least one drink in the previous year were selected for analysis.

RESULTS

The results show that, in the U.S., beer accounts for the bulk of alcohol consumed by the heaviest drinkers. Beer also accounts for a disproportionate share of hazardous drinking. Logistic regression analyses revealed that drinkers who consume beer in a hazardous fashion at least monthly are more likely to be young, male and unmarried, and less likely to be black than are other drinkers. Hazardous beer consumption is more predictive of alcohol-related problems than hazardous consumption of wine or spirits.

CONCLUSIONS

Three potential explanations for the results are considered: advertising, beer-drinking subcultures and risk compensation. Additional research is urged in order to better specify the causal role of these and other factors in hazardous beer drinking.

Alcoholic beverage choice, risk perception and self-reported drunk driving: effects of measurement on risk analysis

AIMS

The present study examined effects of measurement on risk curve analysis in an application involving prediction of frequency and indicator measures of drunk driving with beverage-specific alcohol consumption and risk perception measures.

DESIGN AND PARTICIPANTS

From a 1995 in-person survey of the US adult household population (response rate = 77%) the responses of 1260 adult drivers who reported any drinking in the prior year were selected for analysis. Regression and graphical techniques were used to investigate relationships between drinking pattern, beverage choice, perception of risks of drinking before driving, and frequency of drunk driving.

MEASUREMENTS

Self-reported drunk driving (occurrence) was measured by a question assessing driving after drinking enough to be in trouble if stopped by the police within the prior 12 months; those affirming this (n = 191) were asked how many times they did so (frequency). Alcohol consumption was assessed by beverage and in combination. Risk perception was assessed as a factor score from three correlated measures. Demographic variables included age, ethnicity, education and income.

FINDINGS

Controlling for demographics, heavy beer consumption (p < 0.01) more than heavy wine (NS) or liquor/spirits (p < 0.05) intake was strongly predictive of risk perception. A regression analysis showed a significant interaction between heavy beer consumption and perceived risk (p < 0.001) in predicting reported frequency of drunk driving, after controlling for heavy beer consumption (p < 0.05), total alcohol consumption and risk perception (both ps < 0.001). No interactions were important in equivalent models predicting dichotomous occurrence. Graphic analysis showed the shape of the risk curve is altered when frequency of drunk driving is taken into account rather than simple occurrence.

CONCLUSIONS

Individuals' underestimation of beer's intoxicating effects, compared to other alcoholic beverage types, helps explain beer's over-representation in drinking driving violation reports. There is a need for creative public health campaigns designed to inform young men of beer's alcohol content and associated risks.

Coverage of beverage alcohol issues in the print media in the United States, 1985-1991

OBJECTIVES

This study assessed the portrayal of alcohol-related issues in the print media in the United States during the 7-year period bracketing implementation of the US alcohol warning label act in November 1988.

METHODS

All articles that appeared from 1985 to 1991 in 5 national newspapers and that were indexed as dealing with beverage alcohol were identified. Content analysis of a 15% sample of these articles allowed an in-depth assessment of the conceptualization of alcohol in the US print media.

RESULTS

A slight decrease in articles related to alcoholism was offset by an increase in articles about the more general health-related effects of alcohol. The warning label act received little attention. Most articles portrayed alcohol neutrally or negatively, using information from government sources.

CONCLUSIONS

Portrayal of alcohol in the US print media has changed in recent decades. A general shift noted as early as the 1960s has increasingly emphasized public health issues and deemphasized clinical aspects of alcoholism. This has been accompanied by a continuing shift away from a biopsychological definition of alcohol-related behavior to a definition stressing external environmental factors.

The role of alcohol in physical assault perpetration and victimization

OBJECTIVE

This study examines the influence of lifetime alcohol use and drinking-in-the-event on the risk of physical assault perpetration and victimization while controlling for the effects of additional demographic and personality characteristics known to be associated with violence or alcohol use.

METHOD

Secondary analyses were performed on data collected for the 1990 National Alcohol Survey, which included in-person interviews with 2,058 adults (58% female) residing within the 48 contiguous United States.

RESULTS

Approximately 11.5% of the sample reported having committed a physical assault, and 16.6% of the respondents reported having been the victim of a physical assault, since the age of 12 years. Gender, age, education, lifetime drinking history and an interaction between age and impulsivity were associated with physical assault perpetration. Marital status, impulsivity, and life-time drinking history were associated with physical assault victimization. Analyses performed on the subsample of individuals reporting a physical assault indicated that drinking-in-the-event by both the perpetrator and victim was associated with men's, and not women's, experiences.

CONCLUSIONS

The results support a strong and stable relationship between alcohol use and physical assault. Previous findings regarding men and alcohol-related aggression are supported, but the results contradict past conclusions pertaining to alcohol and women's victimization.

Public opinions on alcohol policy issues: a comparison of American and Canadian surveys

AIMS

To study international and within country differences with regard to views by the general public on alcohol policy topics, describe associations with socio-demographic characteristics and drinking practices, and contrast opinions with variations in actual policies.

DESIGN, SETTING, SUBJECTS

Large-scale cross-sectional household surveys were conducted in Canada (n = 11,550) and the United States (n = 4004) in 1989-90, involving representative samples of adults aged 18 and older.

MEASURES

Eleven alcohol policy topics were examined: alcohol taxes; hours of off-premise sale; legal drinking age; alcohol sales in corner stores; government advertising against alcohol; warning labels on alcohol products; alcohol advertising on TV; industry sponsorship or cultural or sports events; efforts to prevent service to drunken customers; prevention and education; and treatment.

FINDINGS

Even after controlling for drinking levels and respondent characteristics, policy measures that control physical or economic access to alcohol are not as strongly supported as those that provide information or focus on the heavy drinker. There was greater polarization of opinion within both countries for policy items relating to promotion of alcohol or control of physical, demographic or economic access, and virtually no polarization with regard to items such as curtailing service to drunken customers or providing information or treatment. In the jurisdiction with less restrictive measures on a particular policy, there seems to be greater public support for curtailing access to alcohol and, in some instances, more restrictive policies are associated with lower support for increasing restrictions.

CONCLUSION

Public opinion data are an important resource in determining whether actual policies are compatible with the views of those affected by them. Disjunctions between research on the most effective policy interventions and views by the public point to special agenda for information dissemination and prevention initiatives.

Assessment methods for alcohol consumption, prevalence of high risk drinking and harm: a sensitivity analysis

BACKGROUND

There are no standardized ways to assess alcohol consumption in epidemiological studies. The main objective of the present study was to compare three widely used methods for assessing alcohol consumption with respect to resulting prevalence estimates for high risk drinking and harm as defined by morbidity and mortality indicators.

METHODS

A within-subjects design was used to compare a quantity frequency, a graduated frequency, and a weekly drinking recall measure. Data consisted of a representative sample of 3961 adult residents of the province of Ontario, Canada, who participated in a multi-wave cross-sectional survey between 1990-1994. Cross-tabulation, Spearman correlation, and standard methodologies for prevalence-based cost-of-illness studies were used.

RESULTS

The graduated frequency measure consistently yielded higher estimates of the prevalences of high risk drinking and harm. Differences were marked on all indicators, but were most pronounced for harmful drinking as defined by consuming an average of >60 g pure alcohol per day for males, and >40 g per day for females. Prevalence estimates of harmful drinking were almost five times higher for graduated frequency versus weekly drinking measures, and almost three times higher for graduated frequency versus quantity frequency measures.

CONCLUSIONS

The characteristics of different measures of alcohol consumption should be considered in future research in epidemiology.

Who drinks most of the alcohol in the US? The policy implications

OBJECTIVE

The concentration of alcohol consumption in the U.S. among the heaviest drinkers is analyzed with data from two recent probability samples of the adult population.

METHOD

Pooled data from four national telephone surveys (N = 7,049; 4,784 drinkers) with uniform methodology are used for the primary analysis, and data from an in-person national household survey (N = 2,058; 1,308 drinkers) are used for confirmatory analysis. Each survey systematically measured self-reported alcohol consumption during the prior year using a "graduated frequencies" approach designed to capture drinking at a series of amount-per-day levels.

RESULTS

The two studies produced very similar estimates: the top 2.5% of drinkers by volume account for 27% and 25% of the nation's total self-reported alcohol consumption in the telephone and in-person surveys, respectively; the top 5% account for 42% and 39%; and the top 20% of drinkers account for 89% and 87% in each survey, respectively. Men were overrepresented at the highest volumes, contributing about 76% of the country's total reported consumption. Similarly, young adults aged 18 to 29 are disproportionately represented in the heaviest drinking levels; constituting 27% of the population, they account for about 45% of overall adult drinking.

CONCLUSIONS

The bulk of the alcohol reported drunk in the U.S. is consumed by a relatively small population of very heavy drinkers. Prevention policies implied by this concentration include strengthening of social norms discouraging heavy consumption, restricting marketing practices that target heavy drinkers, and implementing measures to reduce consumption by the heaviest drinkers.

Measuring treatment philosophy: a scale for substance abuse recovery programs

The assessment of the philosophy that guides substance abuse treatment programs has been a difficult subject to approach by those working in treatment research. Differing treatment philosophies are generally represented by multi-dimensional theoretical constructs that do not easily lend themselves to assessment by quantitative means. In the U.S., substance abuse treatment programs have been suggested as fitting into a disease (or medical) model, a social learning (or psychological) model, or a social community model in designing a treatment regime for clients. This paper presents a Social Model Philosophy Scale (SMPS) to classify the extent to which a given treatment program follows a social model approach to treatment. The final version of the SMPS (available from the first author) contains 33 questions for use in residential programs, divided into six conceptual domains: physical environment, staff role, authority base, view of substance abuse problems, governance, and community orientation. Overall internal reliability is high (alpha = .92), with subscale alphas ranging between .57 and .79. Test-retest analyses showed that the information obtained from the SMPS is consistent across time, administrators, and respondents. In addition, the SMPS is brief and easy to administer. Methodology used in item creation and final item selection is reported. Although not designed to distinguish philosophies other than social model, early results suggest that the SMPS may also be used to classify other program philosophies.

Prevalence, trends, and incidence of alcohol withdrawal symptoms: analysis of general population and clinical samples

Analyses of the prevalence and incidence of withdrawal symptoms in the general population can provide an estimate of the frequency of alcohol dependence in the population. Similar analyses in people who are being treated for alcoholism or alcohol-related problems can identify the need for and specific types of treatment required for these populations. Three national surveys found that the prevalence of withdrawal symptoms was relatively low in the general population and has remained stable over the past 15 years. The likelihood of experiencing withdrawal symptoms increased with increasing alcohol consumption. No differences in the prevalence of withdrawal symptoms existed among ethnic groups in the general population. In a sample of patients undergoing alcoholism treatment, the prevalence of withdrawal symptoms generally was high, with lower rates among blacks than among whites and Hispanics. The prevalence of withdrawal symptoms in people undergoing treatment after being convicted of driving under the influence fell between that of the general population and that of the treatment sample.

Situational norms for drinking and drunkenness: trends in the US adult population, 1979-1990

Drinking depends on time, place, situation and personal characteristics. Patterns and trends in situational drinking norms (subjective levels of acceptable consumption for various situations) for US adults are reported. Results are based on eight comparable normative questions from national household surveys conducted in 1979 (n = 1772), 1984 (n = 5221 including Hispanic and black oversamples) and 1990 (n = 2058). Across years and population subgroups, a correspondence in ordering of situations on acceptability of drinking and of drunkenness was found. There were contrasting secular trends in the acceptability of drunkenness in different situations: drinking "enough to feel the effects" became more acceptable when at home but less acceptable in several other situations, particularly for men at a bar. For a decreasing percentage of respondents of both genders, it remains more acceptable for men than women to drink in bars, but gender norms in such "wetter" situations were converging by 1990. Men remain more accepting of drinking (but not drunkenness) for "dryer" situations such as when driving, but the trend is towards reduced acceptance. Multiple regression models predicting "acceptance of drinking" and "acceptance of drunkenness" scores showed fair stability in explanatory variables over time, with drinking level and conservative Protestant affiliation (drinking) or age (drunkenness) the major contributors.

The role of health consciousness in predicting attention to health warning messages

PURPOSE

Guided by information processing theory and the health belief model, this paper considers the relationship between health consciousness among the general population and attention to environmental health warnings about alcohol consumption. Mechanisms of exposure to three dominant types of impersonal alcohol-related health messages in the environment are explored.

DESIGN

Cross-sectional survey using telephone interview data.

SUBJECTS

A representative nationwide sample of adults was interviewed in 1993 (n = 1026), with a response rate of 63%.

MEASURES

Key variables include exposure to warning labels on alcoholic beverages, to point-of-sale posters, and to advertisements in the media, as well as respondents' alcohol consumption, health problems (indicative of salience of health warnings), and level of health consciousness assessed by items tapping concern with nutrition and seeking information on health topics.

RESULTS

In the total sample, over a third had seen a warning label or poster and almost all had seen an advertisement about the risks associated with alcohol consumption in 1993. Survey respondents scored very high on five individual items that make up the health consciousness scale introduced here, with 69% endorsing all items. The scale demonstrated good internal reliability (alpha = .70) and was significantly correlated (p < .01) with not enjoying getting drunk and with usually reading product warning labels, suggesting construct validity. Yet the hypothesized strong relationships between health consciousness and attention to health warnings about drinking were not observed; nor was salience of messages a predictor of recall. Importantly, high proportions of underage drinkers and young adults at elevated risk for drinking problems are reached by container warning label messages. Mechanisms of exposure recall vary based on message source, with "container label recall" associated with heavier drinking, younger age, and purchasing patterns; "poster recall" associated with purchasing and health consciousness; and "advertisement recall" associated with heavy consumption and younger age.

CONCLUSIONS

These results are contrary to predictions from skeptics of broad-based informational interventions, who argue that only the already-health conscious are attentive to health warnings about the risks of alcohol consumption. These data suggest that the label is reaching intended target audiences, especially younger people, males, and heavier alcohol consumers. Future research in predicting attention to impersonal health warnings in the environment should continue to improve the assessment of constructs such as salience and health consciousness, and should further test the applicability of available theoretical models. Subsequent research should also consider additional measures to tap mechanisms of exposure to impersonal health messages to enable a better understanding of the population that is not being reached by such public health interventions.

Risk functions for alcohol-related problems in a 1988 US national sample

To assess the relationship of alcohol use and three types of alcohol-related problems (ICD-10 dependence syndrome, work problems and drunk driving), risk curves were developed for average number of drinks per day during last year (volume) and number of days drinking five or more drinks during one day (5+). Using data from the 1988 National Health Interview Alcohol Supplement, risk curves were derived from data on 22,102 current drinkers who consumed at least 12 drinks in the last year. The emphasis in this analysis was on the proportion of drinkers at lower levels reporting different types of problems. The results indicate that even at lower levels of drinking (volume averaging one or fewer drinks/day) there is considerable risk for drunk driving and less risk for work problems and alcohol dependence. The risk for all types of problems at lower and moderate levels of drinking was significantly higher for respondents who had five or more drinks during one day in the last year. These findings underscore the importance of examining risk (physical and social) at lower levels of drinking and for using both overall volume and heavier quantity per occasion drinking measures when assessing risk for any alcohol-related problem.

Selection bias in national surveys due to screening: implications from a county general population survey

National alcohol surveys using face-to-face interviews, such as the US 1988 National Health Interview Survey Alcohol Supplement and the 1990 US National Alcohol Survey, for reasons of efficiency often use screener items to identify individuals who are likely to have experienced alcohol-related problems and only those individuals are chosen to respond to a list of alcohol-related problem questions. The consequence of screening is that only a subset of the current drinkers have complete data on such items. This paper examines the bias introduced by the exclusion of cases with incomplete information due to screening. Data from a regional general population survey were used to investigate possible bias due to screening because it included the screening questions used in NHIS and NAS but did not screen on those items. Risk curves and estimated probabilities from logistic regressions of three alcohol dependence symptom items and two problem indices were compared by gender across three subsamples: (1) all current drinkers (without screening); (2) those who passed the screener item for the NHIS and (3); the NAS, respectively. Results indicate that the effect of the screener items on the estimated prevalence of the measures concerned are minimal, supporting the practice, judiciously applied, when greater survey efficiency is required.

Drinking problems and self-reported criminal behavior, arrests and convictions: 1990 US alcohol and 1989 county surveys

Use of general population surveys in addition to institutional samples is critical to disentangling the relationship between criminal behavior and alcohol problems or use of illicit drugs. Local area studies can be useful but generalizability of their results is seldom studied. Data from recent US national (n = 2058) and county (n = 3069) general population surveys are used to examine the role of alcohol problem and drug use history in predicting self-reported criminal behavior, arrest and conviction within a logistic regression framework. In the national and county surveys controlling for age, gender, income, marital status, employment, education, race and drug use, lifetime drinking problems significantly predicted current criminal behavior (odds ratios 1.3 and 1.5, respectively) with slightly stronger relationships noted in equivalent models predicting arrest (odds ratios 1.7 and 1.8) and conviction (odds ratios 1.7 and 1.6). Relationships between alcohol, drugs and criminal behavior/justice variables are discussed. Parallels between US and county results suggest that findings from intensive, articulated analyses of community-level population and institutional surveys may be cautiously generalized beyond their geographic locus.

First effects of warning labels on alcoholic beverage containers

Health warning labels are now required on alcoholic beverage containers in the United States. This study addresses who has seen these labels and respondents' reported changes in relevant knowledge, attitudes and behavior. Random samples of adults in the general population of the United States were interviewed by telephone 6 months prior to and 6 months after the enactment in November 1989 of the warning label law (N = 2006 and 2000, respectively). Six months after introduction of warning labels, over one fifth of the respondents reported having seen the labels. Greater proportions of key target groups, such as heavy drinkers and young men at risk for drunk driving, reported seeing the warnings. No statistically significant changes in knowledge of the health risks included on the labels were detected, but we found that knowledge levels for two non-included potential warnings had declined somewhat. After controlling for demographics and alcohol consumption, respondents who probably saw the warning labels were significantly more likely to report several behaviors indicative of heightened awareness of, and caution regarding, the hazard of drinking and driving and of drinking during pregnancy, hazards that are both included on the warning labels.

Alcohol-related cognitions: do they predict treatment outcome?

Relationships have been reported between alcohol-related cognitions and a range of demographic, drinking behavior, and drinking problem variables. There has been speculation that such cognitions might help predict treatment outcome. We investigated the ability of one class of alcohol-related cognitions--motivations (specifically, reasons for limiting drinking)--to predict the outcomes of a secondary prevention program. Heavily drinking university men were randomly assigned to three groups with different intensities of self-regulation training. Data from the combined sample (n = 40) were analyzed, since outcomes did not differ significantly by treatment level. Four motivation factors, alcohol consumption variables, and alcohol-related problems were assessed pre and posttreatment. Multiple regression analyses were used to assess the ability of pretreatment motivations to predict change on selected outcome measures. Two motivational factors were found significantly and differently related to program outcomes. Implications of these findings for future research and treatment effectiveness are discussed.

Screening for depression in primary care clinics: the CES-D and the BDI

The present study was undertaken to examine the utility of the Center for Epidemiological Studies-Depression (CES-D) scale and the Beck Depression Inventory (BDI) as screening instruments for primary care clinic patients. We examined: 1) patients' willingness to complete the scales; 2) the level of agreement between the screening instruments and DSM-III diagnosis of Major Depressive Episode, based on the NIMH Diagnostic Interview Schedule (DIS); 3) the effect on detection rates of raising the cut-off score for each depression screen; and 4) the factor structure of the CES-D in our primary care sample versus findings from general population studies. The CES-D and BDI performed comparably as depression screening instruments. Both produced too many false positives when standard (low) cut-off scores were applied. However, when straight cut-off scores were used, results suggested that either the CES-D or BDI might assist physicians in reliably detecting depressed patients, without an overload of false positives. Comparison of our findings with those from other studies suggest that depression screening instruments may be particularly helpful with older primary care patients. The CES-D factor analysis highlights the need to look more closely at the relevance of positive affect to the detection, diagnosis, and treatment of depressive disorders in primary care practices.

Violent behavior and length of psychiatric hospitalization

The relationship between violent behavior and length of hospitalization was studied in a retrospective chart review of 253 patients admitted to a university-based acute inpatient unit. Violent behavior was defined as physical attacks on persons or fear-inducing behavior before admission or during initial hospitalization, and its value as a predictor of length of stay was assessed in multiple regression analyses that also included 20 demographic and clinical variables. Violence per se was not an important predictor of length of stay, but violence associated with a diagnosis of schizophrenia was an important predictor. Schizophrenic patients who physically attacked others shortly after admission were more likely to have an extended stay than other patients. The study demonstrates the importance of considering clinically meaningful patterns, such as the interaction between diagnosis and violent behavior, when predicting length of stay.

Reasons students give for limiting drinking: a factor analysis with implications for research and practice

Dimensions of cognitions associated with self-regulation of alcohol consumption were studied using a 22-item Reasons for Limiting Drinking (RLD) scale in a student survey of nine universities. Data on 2,482 drinkers were factor analyzed using several methods in split halves and the total sample. Four interpretable factors accounting for 39% of the common variance were consistently found. Based on core content, these subjective motivational factors were labeled self-control, upbringing, self-reform and performance. Reliability analysis was used to construct subscales to assess these factors. Subscales had adequate internal reliability (alphas = .66-.73) for brief research scales. Relationships between the RLD subscales and between these subscales and selected demographic, alcohol-consumption and problem indicators are summarized. Based on these results and an application in a prevention experiment with heavily drinking students, the niche for such "reasons" measures in participant screening and program evaluation is discussed.

Factor structure of a brief symptom checklist for acute psychiatric inpatients

A 36-item symptom checklist (the HSCL-36) was assembled and assessed based on previous factor-analytic research with the Hopkins Symptom Checklist-90 (HSCL-90), which had focused on outpatients. Acute psychiatric inpatients (N = 243) completed the HSCL-36 after admission to a university hospital. The responses were factor analyzed using a principal axis extraction. Varimax rotation yielded six interpretable factors, for which factor-based subscales were derived. Five of the six subscales were found to be reliable using coefficient alpha. Results are compared with studies that used self-report symptom checklists with outpatients. Future directions for research are discussed.

Predictors of violence in civilly committed acute psychiatric patients

The authors investigated the relationship between community violence and violence in the hospital for patients hospitalized through emergency civil commitment. The medical charts of 238 patients involuntarily admitted to a university-based acute inpatient unit were reviewed for evidence of violence during the 2 weeks before commitment and the first 72 hours of hospitalization. Patients who were violent in the community were more likely to be violent in the hospital. A discriminant function analysis was used to identify the combination of information concerning community violence and patient background characteristics that most efficiently predicted which patients were violent during emergency commitment.

Quantity per occasion and consequences of drinking: a reconsideration and recommendation

Research and methodological analyses having implications for measurement of patterns of consumption of alcohol are reviewed. The importance of estimating quantity per occasion, especially maximum, in addition to average volume of intake when investigating consequences of alcohol abuse is established. Problems with commonly used indicators of styles of consumption are identified and a new Volume-Maximum Index overcoming a number of these is proposed. Initial results having a bearing on construct validity are summarized, based on a 2-year longitudinal survey of university students. Several applications for such an indicator are discussed, with particular attention to evaluating prevention and treatment programs for young problem drinkers.

Average, binge and maximum alcohol intake in healthy young men: discriminant function analysis

Blood samples and data on alcohol consumption, diet, exercise, smoking and drug use were collected from 89 undergraduate men affiliated with Greek houses. This population has previously been identified as one that consumed large amounts of alcohol among university undergraduates. Energy and nutrient intake from foods, exercise and drug use (except caffeine) were not different between those reporting consuming more than or less than 1 oz of alcohol per day. Multiple discriminant analysis using a panel of 35 blood tests correctly classified all subjects according to their self-reported intake of more than or less than 2 oz of alcohol per day; 96% were classified correctly at a cut point of 1.5 oz per day. Correct classification was 96-99% using a measure of binge consumption (quantity-frequency of heavy drinking). When maximum number of drinks per occasion was used in the discriminant function, 90-92% were correctly placed. Discriminant analysis based on a panel of common blood tests appears to be a promising technique to identify young drinkers who consume high amounts of alcohol.

The role of client satisfaction in evaluating university counseling services

Though ubiquitously used for evaluating university counseling services, client satisfaction assessment has been hampered by inadequate instrumentation. Systematic use of a short form of the Client Satisfaction Questionnaire (CSQ) in one such center over the past 5 years is described, together with strategies to ensure maximal accuracy and utilization of results. Several method factors were investigated. Optional respondent identification was not found to reduce response rate or increase reported satisfaction compared to anonymity, while a substudy obtaining very high response suggested bias from nonresponse to the routine survey (response rate = 40%) was not great. The CSQ was found to have excellent psychometric properties and many advantages for use in student service settings. Relationships between satisfaction and a number of other variables such as demographics, precounseling expectancies, problem type and severity, counselor differences, and duration of counseling are reported. Ways such findings were incorporated in service planning are briefly discussed.

Changing patterns of substance use on campus: a four-year follow-up study

In 1969 and 1973, 598 and 474 randomly selected students at a large midwestern university reported their present and past use, and extent of use of substances taken without medical prescription. Ten of the 18 substances showed a significant increase in percentage of users over time with greatest increases for marijuana, hashish, and alcohol. These three plus tobacco are those substances most used by students and used most frequently. Other substances are used by less than 7 per cent presently and by less than 4 per cent on an often or regular basis. The percentage of tobacco users has not diminished, but smokers report lower frequencies of use in 1973. Single undergraduates reported highest percentage of substance users, and sex differences were not evident. Methodological issues in survey research on substance use are discussed as well as implications for substance educational programming.