What are some of the key characteristics of evidence-based environmental prevention strategies for youth alcohol and tobacco use prevention? Can they help guide our current planning to address the use of e-cigarettes and marijuana use?
Environmental prevention strategies (EIs) targeting tobacco smoking and alcohol use when enforced, have been shown over time to be very effective at preventing substance use, especially among youth.[1] The prime foci or outcomes expected from evidence-based EIs are to:
· target norms;
· restrict availability, especially for youth;
· develop regulations which constitute the laws, rules and polices that relate to not only to availability but also to:
o costs,
o parameters for production,
o the codification of norms relating to the behavior itself; and,
· establish enforcement criteria to ensure that effective prevention strategies are carried out as intended.
Such interventions provide an evidence-based framework for allowing legal and safe access to adults at the same time for preventing access to such substances for children and youth.
While most of the research on the effectiveness of environmental strategies has involved alcohol and tobacco policy, more recently, cannabis for medical use has become legal in 35 states and the District of Columbia in the U.S. Similarly, the use of e-cigarettes among youth has increased even at a time when the rates of cigarette use have decreased among this group.[2]. We can credit the creation and enforcement of environmental prevention strategies for the success noted in smoking trends among youth.
Can these strategies be applied to the prevention of cannabis and e-cigarette use among adolescents? For youth we must underscore that the issue is not the legal status of psychoactive substances but, rather, the impact of these substances on the developing brains of youth that can affect their physical and mental health. Research has also shown negative consequences for early first use of alcohol and tobacco, including addiction and chronic illnesses.
What are some of these effective prevention strategies?
The following is a list of common environmental interventions that have been shown to be effective in reducing access and availability of alcohol and tobacco as well as their consumption resulting in decreased harm consequences associated with their use:
· Establishing a minimum age for purchasing alcohol and tobacco; and for drinking alcohol and smoking/using tobacco
· Instituting taxation and other pricing strategies;
· Training in responsible selling and serving practices;
· Putting advertising and promotion restrictions in place;
· Limiting the physical availability of alcohol (e.g., hours of sale, number of retail outlets);
· Other “place-based” strategies such as zoning restrictions of vendors near schools; and
· Instituting and enforcing drink-driving laws.
All of these efforts require clear communication about the policy or regulations as well as the consequences for noncompliance; cooperation of businesses and the training of servers and security staff; and the monitoring of enforcement strategies.
Description of Evidence-Based Environment Interventions
Below are descriptions of these interventions.
Minimum age laws set a minimum legal age for purchasing and using substances. As an example of minimum purchase age, in the U.S., a person must be 21 years old in order to buy alcohol and 18 in order to buy tobacco. In addition, 21 States have established age 21 as the minimum age for the consumption of tobacco, in 2 States the minimum ages are 18 and 19 while in the remaining States there is no minimum age for smoking. The minimum age for the consumption of alcohol is 21 across the United States. There is good evidence that setting minimum purchase and use ages helps to prevent or reduce substance use among youth.
Price strategies are another important and effective environmental intervention. Research has shown that when the purchase price for alcohol and tobacco is increased, the consumption of these substances goes down, not only among youth but also adults. Increasing alcohol taxes has been associated with reducing consumption and correspondingly, decreases in motor vehicle fatalities and liver cirrhosis. Another example of a pricing strategy is to firmly set a minimum purchase price for alcohol and tobacco, and to avoid or restrict reduced price specials for those substances. The overall goal is to keep prices high enough to decrease consumption. This is particularly effective with youth who have limited resources for purchasing substances.
Responsible beverage service training is designed to help businesses who sell and serve alcohol to follow the laws and reduce the likelihood of selling to minors or to intoxicated customers. It includes training for store clerks, bartenders and servers to implement specific strategies to:
● Check birthdates through official documentation (e.g., driver’s license) to confirm that a customer meets the minimum legal age to purchase alcohol;
● Implement proven effective strategies when refusing to sell to someone who is underage; and
● Recognize when someone is obviously showing signs of intoxication, and to enhance the
skill set needed to refuse serving that person more alcohol.
Physical limits on use. Similarly, establishing tobacco-free zones (beaches, parks, buildings, schools, restaurants and other entertainment venues, etc.) has been shown to not only reduce access to smoking products but also to establish norms about tobacco use. The findings show that smoke-free policies can lead to substantial and sustained reductions in tobacco smoking in public places while also leading to high levels of support by the public and subsequent reductions in smoking.
Enforcement is Essential
Evidence-based policies are only as effective as the level of enforcement that is instituted. Therefore, effective enforcement strategies are a necessary component of evidence-based environmental interventions. Examples of enforcement strategies that have been found to be effective include:
· Decoy operations where “underage decoys” work with law enforcement officers to attempt to purchase alcohol or tobacco. Businesses that sell to this minor, are then fined but also at risk of losing their licenses to sell these products,
· Roadside sobriety checkpoints are another enforcement strategy. This strategy has reduced the incidence of alcohol or drug use and driving, and
· Penalties imposed for other types of violations by suppliers and consumers, such as bars or restaurants serving alcohol to obviously intoxicated patrons or arresting someone for smoking in a public building where smoking is banned.
Instituting evidence-based environmental prevention strategies also provide opportunities for various sectors of a community to interact in achieving common goals regarding reductions in youth use of substances like alcohol and tobacco and perhaps now cannabis and e-cigarettes. Such community-based and collaborative opportunities reinforce the importance of prevention and norms about the use of these substances for youth.
[1] International Standards for Drug Use Prevention. UNODC. 2013; 2018. [2] Youth and Tobacco Use | CDC