One Finger Points, Three Point Back- Sarah M. Ragsdale

An estimated 6-percent of middle-aged men abuse alcohol – nearly four times greater than women and twice the rates of just one decade prior (37, 38). Due to the social, economic and physical effects of alcohol abuse, the public health community must improve its strategies to reduce the prevalence of alcohol abuse among all populations. Specifically, many criticisms of the public health community’s strategies to reduce alcohol consumption among middle-aged men are presented. The public health community has failed to adequately measure the problem, study the populations at-risk and intervene effectively. Population stigmatization and confusion result from the individualistic approaches to interventions among middle-aged men.


Failure to Measure

The first major limitation of the public health community’s approach to address the problem of alcohol abuse exists in the existing definitive measures of the problem. The problem of alcohol abuse is largely defined in terms of overall consumption and other quantitative measures. Healthy People 2010 “set the national objective for reducing per capita alcohol consumption to no more than 1.96 gallons ethanol, … a decrease of 12.5 percent, or about 3 percent per year from 2006 through 2010” (1). It is problematic to measure alcohol abuse by per-capita consumption or overall deaths by alcohol-related diseases because population-level measures do not allow for the detections of “subtle and complicated relationships,” which can lead to underreporting (2 p. 163); therefore, requiring flawed individual assessments.

Addressing the first point, when alcohol epidemiologists measure alcohol in the aggregate of per-capita consumption or deaths by cirrhosis of the liver, only correlation, not causality, can be inferred. Relying on the “three primary sources” of alcohol data (death certificate data, the Fatal Accident Reporting System, and the National Hospital Discharge Survey) limits understanding of the problem (3). Although defined as objective, data from death certificates present inherent flaws as “sympathetic certifiers” of the cause of death may enter non-alcohol-related codes to protect the individual’s reputation (3). This often leads to underestimates of the problem’s true prevalence in all populations.

Due to the limitations of data collected in terms of overall consumption or deaths, additional individual-level data must be collected to understand possible relationships. Of six national surveillance studies sponsored by the Centers for Disease Control (CDC), all assess only volume consumed in a given time frame (5). This is problematic because, again, alcohol consumption measurements are often in terms difficult for all consumers to relate and self-quantify. Using a graduated frequency scale of mean consumption per day, week or month proves to be less effective than other approaches, which impacts accuracy of reports (6). The primary method for data collection is what the National Institute of Alcohol Abuse and Alcoholism (NIAAA) sadly describes as the “newer and improved” approach of self-reported questionnaires. These flawed assessments further contribute to the failure to definitively measure alcohol abuse. Surveys, in their effort to quantify the problem, are often skewed by limited sample sizes, increased margins of error, failures to properly sample minority populations, underestimate consumption and under-sample heavy drinkers (3). Marks discusses the problem of “inappropriateness in framing the questions” (4, p. 15) as yet another threat to the study of this public health problem.

Failure to Study the Population

Not only has the public health community failed to develop definitive measures of the problem of alcohol abuse, it has failed to study the root causes of the problem among populations, including middle-aged men. This failure results from the reliance on quantitative and biomedical models to study treatment and prevention, virtually ignoring possible qualitative and social science approaches.

According to the NIAAA’s suggestions for improving treatment and prevention in the middle-aged population, new research opportunities should focus on developing new medications for craving control and organ injury prevention (8). They note most research on the topic has “focused on how alcohol damages body tissues,” and they secondarily note “research shows that a variety of factors—both biological and social— influence an individual’s response to therapy” (8). Focusing greater attention on biologic factors over social factors in research presents the missed opportunity to employ the social sciences (8).

The NIAAA discusses the overlook of social science methods in its strategic plan by outlining the need to “identify biological factors and contextual social factors that contribute to the decisional process to change drinking behavior as part of the transitional process from alcohol dependence to recovery” and “increase understanding of the role of social context in promoting positive change in drinking behavior” (9). Although this suggestion is slightly better, it still does not address primary prevention as it incorporates social science techniques in response to relapse alone. The NIAAA also notes “naturalistic, qualitative and longitudinal studies can identify factors influencing natural history and disease course, in order to inform more explanatory studies” (9). The idea of contextualizing risk factors is supported by Link, et al when they advocate for a shift in the assessment of public health problems as “social factors have received far less attention” and suggest “fundamental causes” and “social patterning” of disease (10, p. 80).

According to Marks, “health is a “multivariate construct that lends itself to interdisciplinary approach” (4, p. 10) therefore, understanding alcohol abuse from a social perspective, allows for more effective study of target populations particularly. The NIAAA “recognizes the need to support research that focuses on client populations as well as research on the aggregate population” (11). Doing so, according to the NIAAA, “could provide meaningful insight to guide the development of more effective strategies to change individual behavior to improve health” (11). However, when studying specific populations, alcohol researchers have focused much effort on underage drinking and college student drinking patterns, making the middle-aged population much less of a priority (34). The reasons for this are complex. It appears the public health community views alcohol abuse as a socially and environmentally modifiable “risky behavior” during youth (9); however, when the population ages, it is seen as chronic or genetic - only modifiable by drug treatment and therapy (12). With such frame, focus naturally gravitates toward the development of treatments as opposed to interventions. If alcohol abuse is viewed in the same context as HIV, it is clear that “there is an epidemic beneath the epidemic we know about” (13, p. 69) as the public health community has failed to understand the root social causes of alcohol abuse among middle-aged men.

Failure to Intervene

The public health community’s individualist approach to alcohol abuse among middle-aged men is reflected in the measurement and study of the problem as well as the approaches to intervene. Since “the goal of public health research is to provide a scientific basis for the development of effective strategies to improve health status” (7, p. 1175), it is not surprising public health has over looked alcohol abuse at the social-level resulting in population confusion and stigmatization.

Social-level interventions

The NIAAA discusses in its strategic plan many methods to reduce alcohol abuse among middle-aged men, focusing on drug treatment and individual behavior change (9). The NIAAA advocates for various models including the Transtheoretical Model (Stages of Change), Cognitive-Behavioral Therapy, and Motivational Enhancement (9), but makes no mention of various social theories and approaches. Although many structural-level policies exist to combat underage and college student drinking, few exist that specifically target middle-aged or male populations (34). The same can be said for community-level social interventions. Of the six “effective” prevention programs the NIAAA lists, zero target adult populations (34).

Confusion

Public health professionals have historically plagued the community with mixed messages on many primary prevention fronts resulting in public confusion. Don’t have sex before marriage, but if you do, use a condom. Don’t use drugs, but if you do, recycle your needles. Don’t drink underage, but once you are of age, go for it. Don’t drink and drive, but if you don’t drive, then drink. Alcohol is bad for you, but alcohol is good for you. How is the public to synthesize this information? The CDC defines heavy drinkers as consuming one or more drinks daily (14), while Men’s Health Magazine reports alcohol to be “fine in moderation” (15) and “the recommended safe intake for men is around three units of alcohol a day. That is 21 units per week.” (16). Although Men’s Health is not a peer-review scientific magazine, it is accessible and accepted by many adult men who may internalize it guidelines over the CDC fact sheets. The popular media messages and some scientific data are clearly counter to the messages from public health organizations which often declare alcohol as unsafe in any quantity or frequency.

Public health organizations have received criticism for exaggerations of risks associated with alcohol abuse, leading some to be classified as neo-prohibitionist. The Center on Addiction and Substance Abuse (CASA) was sharply criticized by representatives from the American Beverage Licensees and the Chronicle of Higher Education by its efforts to “paint the most alarming picture possible" (17) resulting in “denounce(ing of) responsible consumption (of alcohol) with half-baked advocacy disguised as real research." (18). The Washington Times criticized Mothers Against Drunk Drivers (MADD) in much of the same way by declaring that MADD's "ongoing push to compel states to adopt ever-lower standards for being legally drunk‚ is becoming a prohibitionist jihad driven by hysteria, not medical reality" (19). Even the American Medical Association (AMA) is not free of criticism as many question the rationale for never rejecting their resolution in support of prohibition in the 1920s (17).

Stigmatization

Stigmatization is a side effect of the public health community’s alarming alcohol messages as well as the individualistic frame of alcohol abuse. Alcohol abusers were “viewed more harshly” by peers than even the heavily stigmatized mentally ill according to one study’s findings (20). Stigmatization is further illustrated by the skewing of death records by “sympathetic certifiers” as mentioned previously. The same study noted that if the individual is viewed as responsible for their alcohol abuse problem, their peers tended to place blame and viewed them as “dangerous” and “feared and avoided them” (20).

This is even more problematic when alcohol abuse is considered with mental illness. The mentally ill are already marginalized, which compounds barriers to treatment of mentally ill alcohol abusers. As noted in tobacco research which concludes “these people are already stigmatized by their underlying psychiatric condition - Adding the further burden of the stigma associated with smoking makes it even harder for them to achieve the wellness that they and their families seek” (21 p. 2286). One study concluded that “those in treatment for alcohol or drug problems are frequently and disproportionately marginalized” (25). Just as was shown in smoking research the “risk of the marginalization of smoking is that it further isolates the group of people with the highest rates of smoking – persons with mental illness, problems with substance abuse, or both” (21). Cohen, et al describe social isolation as a health risk “comparable to the risks associated with cigarette smoking, high blood pressure and obesity and is robust even after controlling for these and other traditional risk factors” (40). Hence, it is no surprise as result that 42-percent of alcohol addicts had “bad opinion of health services” (25) resulting in missed treatment and intervention opportunities.

Conclusion

Public health practitioners can be our own worst enemy when it comes to assessing and preventing public health problems. In the case of alcohol abuse, the public health community has failed to adequately measure and the problem through failed epidemiologic measures and assessment methods. The public health community’s failed intervention and communication strategies have further confused, stigmatized and negatively impacted the screening and treating of alcohol abuse among middle-aged men.

Silver Lining:
Public Health Solutions to a Public Health Failure

In light of the many existing criticisms of the public health community’s strategies to reduce alcohol abuse among middle-aged men, several solutions are possible. In order to address the epidemiological problem of flawed definitive measures of alcohol consumption and abuse, improvements to data collection measures are necessary. Next, techniques from social epidemiology are necessary to address the failure to study the underlying reasons for alcohol abuse. Finally, the failure to develop successful interventions is addressed through approaches from Social Network Theory and Social Marketing Theory, which address the individual-level bias and stigma associated with alcohol abuse in this population.

Failure to Measure - Solutions

In order to address the failure to definitively measure alcohol abuse, the very epidemiologic approaches of assessment require improvement. The first proposal is to improve the way consumption data is collected on individuals. The second is to look at the overall social effects of alcohol abuse.

Since population-level data can lead to the underreporting of alcohol abuse, individual-level assessments are necessary to understand and define the scope of the problem. Strunin addresses many of the problems associated with the public health community’s methods to collect data on alcohol abuse when noting “valid reports of drinking has been controversial in alcohol studies” (30). She points out that many estimates of alcohol abuse “rely on accuracy of self-report data” that can “deny or deliberately deceive reports of behavior” (30); however, much can be done to improve instruments of measurement.

One improvement is to use improved questionnaires to fill in the knowledge gaps of consumption data. Some suggested improvements to questionnaires from the literature range from using diary methods and improving survey questions and their ordering (27, 28, 29). Another improvement that Strunin and others note is the use of beverage-specific measures (6, 30). The most compelling improvement from her work is the use of “multidisciplinary approaches” and “ethnographic interviewing and other qualitative methods in assessing alcohol use” (30). This approach is particularly useful to measure specific populations such as middle-aged men.

By focusing on measures such as volume of ethanol consumed and death by cirrhosis of the liver, the public health community misses other big picture strategies to measure the problem of alcohol abuse. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) lists “social problems resulting from alcohol abuse” as an “area of interest” but underscores that researchers rely on “more objective sources” (3). However, many quantifiable social problems result from alcohol abuse in the middle-aged population including failure of work obligations, legal problems, divorce, marital violence, child abuse and other crimes (26). Although it is difficult to develop measures of association, the failure to examine social effects to measure alcohol abuse among populations is clearly a missed opportunity to assess population-specific alcohol consumption.

Failure to Study - Solutions

With solutions to correct the public health community’s failure to develop definitive measures to effectively assess alcohol abuse, it is important to improve the strategies in studying the root causes of alcohol abuse among middle-aged men. The present methods in studying the individual risk factors for alcohol abuse can be improved by the conceptualization of risk factors in the social epidemiologic approach.

The NIAAA reports many causes of alcohol abuse among middle aged men including a gene influencing consumption (31), depression (32) anxiety (33) and family history (34). These conclusions ignore many social factors, which is not surprising as they result from the heavy reliance on the biomedical model. They also possibly result from the Type III error of epidemiology by “providing the right answer to the wrong question” (7). This error results from the “discrepancy between the questions being asked and the methods used to address the question” (7, p. 1175). The “evident” failure of epidemiologists to recognize many social factors (35. p. 110) results from what Schwartz lists as “value-laden considerations” that “limit the realm of inquiry” (7, 1175). This error, however, can be minimized by replacing this individualistic risk factor epidemiology with social epidemiology.

To combat “biomedical individualism,” social epidemiology studies social determinants as root causes of disease (36, p. 22). Instead of adjusting for social factors in the analysis phase of study design as possible confounders, social factors are the “focus of analysis” (36 p. 22). In order to review possible social risk factors, cultural context would first need to be assessed through both anthropologic and epidemiologic approaches. Then, social networks would be reviewed to map relationships and normative behavior among alcohol abusive individuals to identify a possible “core group” (36). Next, neighborhood effects would be studied to view the interaction of social networks in their cultural and geographic context – paying attention to poverty, marginalization, social isolation, etc. Finally, social capital would be measured. After reviewing social factors, structural risk factors require analysis. Adequate structural analysis would review demographic changes, violence and discrimination, legal structures and policy enforcement (36).

Failure to Intervene – Solutions

Along with the failure to study and definitively measure alcohol abuse, the public health community has failed to develop social-level interventions for alcohol abuse among middle-aged men. Confusion and stigmatization of the population result from this failure. This can be corrected in two ways. The first is to employ social-level techniques including Social Network Theory. The second is to use Marketing Theory to disseminate accurate information to the public, reduce stigmatization of the population, and change social norms.

Social Network Theory

The goal of social epidemiology is to reveal the underlying social networks that influence behavior. Once these are revealed, the Social Network Theory can be applied to develop social-level interventions. The effects of social networks are illustrated in research on smoking cessation. In the predominantly middle-aged population studied, researchers found that smokers quit “in concert” (41). Isolated individuals did not influence decisions to quit smoking, but rather it was social ties to other smokers and non-smokers (41). If results translate to the same population of alcohol abusers then specific social networks can be studied and successfully intervened upon.

Marketing Theory

Ether defines social networks as predictors of the “formation of public opinions” (39); therefore, marketing to specific social networks effectively alters social norms and attitudes. This is important for alcohol abuse among middle-aged men because “social networks can be especially important in the construction of a person’s reputation” (39). As discussed previously, barriers to treatment result from the stigmatization and social isolation of the population so a shift in perception of reputation can reduce stigmatization.

Aside from reducing the stigmatizing effects of alcohol abuse among middle-aged men, marketing theory accomplishes health behavior change because media is “a major source of patterned social expectations about the social organization of specific groups in modern society.” (42). The basic idea is to make a promise to mass media consumers and support that promise with visual images and a consistent message. If applied correctly, this strategy will identify what the population aspires to be and will offer that to them.

Marketing theory views groups differently than a collection of individuals based on group dynamics. DeFleur and Ball-Rokeach note the individual-level treatment interventions such as those suggested by NIAAA offer a “very incomplete picture of the human condition” because human beings act in an “intensely social nature.” (42, p. 219). This allows for the idea that groups of middle-aged men can be affected at the same time through a mass media message. Due to the group focus, it recognizes the many layers of influence on the individual. This addresses the flaw of the NIAAA models as they “fail to account for real-world cognition” (4, p. 8) by falsely assuming an internal locus of control and free choice. They also assume that behavior is “not restrained by political or social factors” (4, p. 8) many of which are portrayed through mass media. People are powerfully influenced by “accumulated exposure to media content” as “indirect influences on culture and society” (42, p. 206).

Conclusion

The failures of the public health community to address alcohol abuse among middle-aged men are clear; however, the solutions are promising. This paper does not suggest tossing out the window current epidemiologic approaches to measuring and studying the problem in this population, but does present clear opportunities to incorporate the social sciences and qualitative approaches. Theories with roots at the social level offer promising solutions to the failed individualist intervention attempts.


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MADD Gone Mad: How Focusing on Alcohol Prohibition has deterred the group from Drunk Driving Prevention - Christopher Wilterdink

INTRODUCTION

Alcohol’s presence, availability, and potential for abuse make it a significant public health concern, especially when used in excess and in combination with other activities and behaviors, such as motor vehicle use and operation. In 2006, there were 13,470 fatalities in crashes involving an alcohol-impaired driver (BAC of .08 or higher) – 32 percent of total traffic fatalities for the year (1). While it is true that drunk driving deaths have decreased 35 percent since the early 1980s when MADD was formed, it continues to be an issue of significant concern (2). In fact, there were 12,998 drunk driving deaths in 2007, a figure that has remained relatively constant since the year 2000, according to the NHTSA (3). In this respect, alcohol abuse and drunk driving remain prominent public health issues that need to continue to be addressed.

MADD, or Mothers Against Drunk Driving, is a non-profit organization founded in 1980 in Irving, Texas by Candace Lightner, whose daughter was killed by a drunk driver. The organization’s original mission includes stopping drunk driving and underage drinking, and offering support to those affected by drunk driving including victims and their families (4). Undoubtedly, MADD has played a pivotal role in reducing drunk-driving deaths by more than 13,000 since the organization’s inception, through a combination of traffic safety regulations and victims’ rights legislation (5). However, the group’s mission since the mid 1990s has fundamentally changed to one focused on alcohol prohibition rather than stopping drunk driving. In 2002, Lightner told the Washington Times: "MADD has become far more neo-prohibitionist than I had ever wanted or envisioned ... I didn't start MADD to deal with alcohol. I started MADD to deal with the issue of drunk driving.” (6) By focusing on drinking rather than drunk driving, the group has lost sight of its original purpose, thereby failing to address both underage drinking and drunk driving as effectively as is necessary. In this paper, I will demonstrate why MADD has failed to continue to address the drunk driving issue using social and behavioral sciences as support by examining the group’s goals, initiatives, and methods with which they approach this significant public health problem.

ARGUMENTS

1. MADD data and reports repeatedly focus on the severity and susceptibility of individuals to the dangers of alcohol use and drunk driving accidents by using inaccurate statistics, targeting social drinkers and ignoring other related factors to drinking behavior.

MADD manipulates the Health Belief Model in their promotional and advertising materials in order to misrepresent the drunk driving and under aged drinking problems as more severe than they are in actuality, thus using fear as a vehicle for making more young people feel susceptible to alcohol-related car crashes (7). Furthermore, by approaching people as individuals rather than groups who may act in concert, the intervention fails to target the individuals who continue to violate the traffic safety regulations the group was instrumental in passing. Arguably one of MADD’s biggest victories has been lowering the legal limit from .10 to .08. However, research shows that over two-thirds of alcohol related crashes are caused by individuals whose blood alcohol level is over .14 and the average fatal accident is caused by individuals whose blood alcohol level is above .17. According to the National Institute in Alcoholism, those individuals with a blood alcohol level this high are 480 times as likely to have an accident as those individuals who have had nothing to drink (8). The majority of drunk driving accidents that continue to occur annually happen under these circumstances, with significantly impaired drivers. Furthermore, the U.S. Government Accountability Office reviewed all the statistical data and concluded "the evidence does not conclusively establish that .08 BAC laws by themselves result in reductions in the number and severity of crashes involving alcohol." (9) On a related note, MADD will not discuss the fact that using a cell phone while driving is actually more dangerous than having a blood alcohol level of .08 (10). By focusing on the blood alcohol limit, MADD fails to address to target those individuals who are most susceptible to accidents, those with BACs of nearly double the legal limit, and admit to the presence of other contributing factors to accidents and fatalities.

Other factors that MADD overlooks with respect to alcohol-related motor vehicle deaths are fatigue, drug use, inexperience in driving, road rage, speeding, poorly lit roads, and failure to use safety belts (11). By ignoring these other factors, MADD again relies on the Health Belief Model, assuming that individuals operate within a vacuum in which environmental factors play no role, which is clearly false. While some of MADD’s efforts have focused on seat belt use, these interventions assume that people who have been drinking will act rationally and decide to put on a seatbelt. However, if they have decided that driving while intoxicated is a sound decision, then their judgment can clearly not be relied on to when it comes to buckling up.

MADD’s Public Relations Department also uses misrepresented statistical evidence in order to make the drunk driving problem appear more severe than it actually is (see end of this paragraph for citation). In addition, research clearly states that by repeatedly doing a certain task after drinking, like driving home after being at one’s favorite bar, can lead to the development of a form of adaptation referred to as "learned" or tolerance. This tolerance reduces the impairment caused by the alcohol, thus enabling one to drive home safely. However, if any unexpected changes were to occur, this learned tolerance would be negated (12). When MADD reports alcohol related motor vehicle fatalities, these figures include deaths where pedestrians, passengers, or third parties could have been drinking, thus inflating the number of deaths caused by drunk drivers themselves. The Insurance Institute for Highway Safety reports that MADD exaggerates the problem, referring to it as a “growing epidemic” (13).

MADD exaggerates the severity of the effects of alcohol use among young adults in order to make alcohol less appealing to young adults (an issue also addressed by the 3^rd argument in this paper). A MADD ad campaign targeted at under-aged drinkers linked alcohol use to weight-gain, rape, STDs, and drug use, behaviors that are far more influenced by group behavior, dynamics, and other circumstances than the use of alcohol. In this way, MADD also manipulates the Theory of Reasoned Action by considering the importance of social norms (14). The stigmas attached with these behaviors are far more severe than drinking. One MADD statistic states that underage drinkers are 50 times as likely to use cocaine as non-drinkers, a statement not founded in any formal research (15). Additionally, a former MADD officer Ralph Hingson produced inaccurate reports, including one where he estimated that alcohol kills 1,400 college students annually, even though there is evidence suggesting that this figure is a gross overestimation (16). This research was used by MADD without mentioning that Hingson was employed by MADD, thereby raising questions regarding its validity (17).

2. MADD’s efforts to curb drunk driving accidents are impeded by the organization’s bureaucracy, a lack of services for drunk drivers, and a lack of acknowledgment of individual community and MADD chapter needs, which are reflective of the drinking behaviors of those populations.

MADD spends nearly twice as much as the AIP recommends for fundraising, and these efforts do not go to the communities that are in greatest need, but rather to fund the agency’s bureaucracy, through higher employee salaries and increased benefits (18). In Canada, while the group reports that over 83% of its resources go into programs, actually only 19% do, because MADD counts professional fundraisers as charitable work, claiming that they make their pitch about drunk-driving to their potential donors (19). On the U.S. side, unlike other nation-wide non-profit organizations, MADD does not allow its local chapters to keep all of the money they raise. In one case, the Las Vegas MADD chapter raised over $29,000 locally, turned this sum over to the national office as required, and then received a check for $1.29 as their share (20).

Also important to consider is the way that MADD frames the issue of drunk driving and drinking in general as a law and regulation issue rather than a social behavior issue that varies from state to state. One of MADD’s more famous promotional materials is the State Progress Report, where it rates states according to the prevalence of drunk driving fatalities and comparing them to one another (21). The reasons that MADD cites as to why a particular state may or may not have done poorly is generally due to the strength / presence of interlock laws and use of sobriety checkpoints, not the social norms regarding drinking behavior in the region, resources available for repeat DUI offenders and the presence of interventions targeted at youth and high risk populations. In fact, the three states that MADD gives the worst marks to on the State Progress Report, Wisconsin, South Caroline and Montana, all average more than 30 gallons of alcohol consumed per person per year, far exceeding the national average (22). But surprisingly enough, even in a rural state like Wisconsin, there are 6 local MADD chapters. Unfortunately, the majority of their volunteer opportunities are with victim services, fundraising efforts, and court volunteering. The activism related opportunities require training, developed by the national MADD office, and are therefore not tailored to the needs of individual communities (23).

Interlock laws require repeat DUI offenders to use ignition interlock devices when mandated to do so by a judge. These devices require the user to blow into the device before turning on their vehicle, which will not start if their BAC is above .025 (24). The interlock laws passed, in addition to other drunk-driving legislation, are the only contact that MADD has with drunk drivers outside of the courtroom. However, for victims of drunk driving accidents, they offer support services including a hotline, online chatting, and legal assistance to ensure that the drunk driving offender receives the maximum penalty. In addition to serving justice, MADD should provide support services for drunk driving offenders and work with local communities to provide transportation alternatives whenever possible.

MADD pledges local community support through the local chapters established throughout the country. However, the geographic distribution of these chapters, in addition to the lack of diversity among local MADD members does not address the segments of the population most likely to drink underage or to drive while drunk. In a survey of local MADD chapters, it was revealed that most of the chapters’ officers are white, married, educated women, often the mothers and relatives of victims of drunk driving accidents (25). Furthermore, as Dr. Weed, a sociology professor at the University of Texas states, their “agenda for local activism resembles a moral crusade in that public awareness and youth education” (26). He argues that they primarily believe that individual responsibility and stricter laws are the keys to solving the drunk driving issue – not looking at the influences of group and social dynamics that engender the alcohol abuse behavior.

What is flawed in this approach is that these women do not represent the minority populations at risk for drunk driving that do not live in their community / belong to their social class, nor can they always effectively reach out to the opposite gender. In fact, accounting for gender differences alone, a 1995 study stated, “Twenty-nine percent of male drivers involved in fatal motor vehicle crashes had BAC's of 0.01 percent or greater, compared with 15 percent of female drivers” (27). While these women may be able to reach out to the men in their community, MADD chapters are often far removed and isolated from the male populations at highest risk for alcohol abuse and thus at higher risk for drunk driving accidents, like Native American males (28). For example, in South Dakota, a state that MADD ranks among the top 10 with the highest prevalence of drunk driving accidents, the only MADD chapter is located in Butte County, which is in the western part of the state (29, 30). This chapter is far removed from the expansive Native American Indian reservations located in the northern part of the state, where the majority of the Native American males are concentrated (31).

Drinking behaviors also differ by race among adolescent and underage drinkers. According to a study by the Center for Substance Abuse Treatment, the three groups with highest prevalence of binge drinking within the past thirty days are White (46%), Hispanic (40%) and Black (19%) (32). What is so provocative about these numbers is that the underage binge drinking rate is highest in the same racial group as that of local MADD chapter officers, suggesting that MADD may not be as effective an intervention as reported and that there are other factors at work. The importance of socioeconomic status of underage drinkers, access to alcohol, social acceptance and rates of car ownership should not be overlooked as they often are by MADD (33). By approaching alcohol abuse as a population wide epidemic and ignoring the social factors at work in specific regions, ethnicities, and subgroups, MADD fails to achieve real change at a community level.

3. By arguing for prohibition of drinking for underage individuals, MADD fails to accept the reality of drinking prevalence, and fails to fully educate adolescents about alcohol use and its effects.

As MADD’s founder noted in the quote given in the introduction, the organization has become more focused on alcohol itself than on drunk driving. As a result, the group has clearly articulated that it is unacceptable to drink at all when underage (34). By linking drinking to poor achievement in school, depression, suicide, and pregnancy, MADD frames the negative consequences of drinking such that any consumption of alcohol would seem dangerous. However, according to a national survey of U.S. college and university students, “93% of students never received a lower grade for drinking too much and 90% have never damaged property or pulled a false alarm while drinking" (35). These figures are enlightening, considering the fact that almost half (48%) of all alcohol use at colleges and universities is done by underage individuals (36). What is even more illuminating about this data is that binge drinking rates are actually higher among more educated individuals (37). These findings, while striking, also point to possible statistical inaccuracies and the presence of bias and confounding in many of the studies related to alcohol use.

MADD states that adolescent drinking behavior is most highly influenced by children’s parents, thus emphasizing the need for parents to properly educate their children regarding the dangers of alcohol. A MADD pamphlet for parents states “For many parents, the riskiest thing they did in their youth was play spin the bottle. Today young people are taking much bigger risks with a bottle – a beer bottle and its no game” (38). However, the proportion of adolescents between the ages of 12 and 17 that has consumed alcohol within the last month has dropped from 50% in 1979 to 19% in 1998, according to the government’s National Household Survey on Drug Abuse (39). This data demonstrates that parents are more likely to have consumed alcohol while underage than their children, thus highlighting the need for alcohol education efforts among parents. What this data also points to is a widespread prevalence of underage drinking that has decreased significantly.

Labeling theory shows that by portraying widespread drinking and the reckless behavior associated with it as a growing epidemic, as MADD does, that it becomes a self-fulfilling prophecy, and adolescents become more likely to drink solely because they believe that so many other people are doing it (40). Abusive drinking behavior increases because of the importance of social norms, especially among teenagers and young adults (41). Research has indicated that by providing adolescents with accurate information about alcohol abuse and addressing misconception can lower alcohol abuse rates according to a study in the journal, Preventive Medicine (42). MADD reports in their underage drinking fact sheet that “In 2006, about 10.8 million young people aged 12 to 20 (28.3 percent) reported drinking alcohol in the last month” (43). According to labeling theory, these staggering statistics act more to promulgate the message of widespread underage drinking than to prevent it. In a Newton study, it was found that by conducting surveys on college campuses to address perceived behavioral norms by publishing results about people’s actual drinking behavior demonstrated a 54% decrease in alcohol related injuries to others (44).

By stigmatizing alcohol, and associating it with and leading to the use of illegal drugs like cocaine and marijuana as MADD does, they only reinforce the negative label that alcohol has been given. Instead of stigmatizing the substance all together, MADD needs to recognize that it is the abuse of alcohol that causes the drunk driving fatalities that the group originally set out to stop. Rather than providing children with reasons not to drink, as MADD suggests parents do, the organization needs to tell parents to give their kids all of the information about alcohol, including how to drink it safely, thereby enabling them to make informed decisions armed with that knowledge. A 1996 study comparing abstinence-only alcohol education programs to those that provide moderate alcohol use as an option has shown those programs advocating for responsible use rather than no use at all are far more successful (45).

CONCLUSION

MADD’s failure to continue to address the drunk driving problem stems from their recent focus on alcohol prohibition rather than drunk driving itself. The legislation the group has helped to pass, including Interlock-ignition laws and other traffic safety laws proved to be instrumental in lowering the rates of both alcohol-influenced traffic accidents and fatalities. However, the continued high prevalence of drunk driving and high numbers of yearly deaths caused by drunk driving show that MADD’s focus on improved legislation, victim advocacy and extensive fundraising have not been enough to eliminate this very serious problem. This failure is caused by not only not considering all the factors that influence drinking behaviors, but also by not reaching out to those who continue to drive while drunk, most of them over double the legal limit. The organization’s growth has driven them away from the community level support upon which they were founded, and has deterred them from opening new chapters in areas whose populations are most affected by drunk driving incidents, and increasing the amount of resources and support given to those communities where MADD chapters already exist.

A more effective public health intervention to address underage drinking and drunk driving would not be focused on alcohol prohibition but rather on an interdisciplinary approach, relying on the social and behavioral sciences to examine all the factors that influence drinking behavior, especially among those segments of the population with highest alcohol abuse prevalence rates. By removing the stigma associated with alcohol use, treating it as a separate issue from other drugs and redefining adolescent social norms, public health can effectively address the alcohol abuse issue that leads to reckless behaviors. Focusing on an abstinence only approach is unrealistic and misleading because it deprives adolescents of information regarding how to use alcohol safely and under what circumstances. A more realistic and successful approach would be to provide people with accurate information regarding alcohol, enabling them to make the informed choice whether to abstain or not. In order to reach out to underage drinkers and of age alcohol abusers, community support must be available to provide people with transportation alternatives and to help not only drunk driving victims, but drunk drivers themselves. Renewed attention must be paid to the behavior actually in question and which directly causes the fatalities: driving while intoxicated and not alcohol as a substance, which can be consumed safely when done in moderation.

ALTERNATIVE INTERVENTION DESCRIPTION

An alternative proposal to address the drunk driving problem will need to return to MADD’s original mission, to stop drunk driving and underage drinking, and offering support to not only drunk driving victims and families as MADD has done, but to offenders as well (46). By returning to the drunk driving issue, rather than focusing on alcohol prohibition, the new intervention will specifically work at significantly reducing the 12,998 drunk driving deaths occurring in 2007 alone (47). I will demonstrate why an alternative intervention will effectively address the drunk driving issue using social behavioral science principles and theories, taking into consideration some of the most crucial factors that shape underage drinking and drunk driving behavior.

The proposed intervention, Families for Responsible Drinking Behavior (FRDB), will be a network of local organizations that strive to promote community level change, by reducing drunk driving fatalities and traffic accidents and encouraging safer drinking behaviors, especially among adolescents and underage drinkers. Social network theory argues that health behavior is determined by one’s social network, so by targeting networks of people in which binge drinking and drunk driving behavior is acceptable, the intervention will reach out to those individuals at highest risk for drunk driving fatalities (48). By acknowledging the social norms associated with drinking behavior, this intervention will not target the consumption of alcohol, but rather the setting in which it occurs and the other related behaviors that when combined with drinking, prove to be dangerous, like motor vehicle use (49). Most important is that FRDB approaches drunk driving at a group level, rather than relying on individual level factors like those of the Health Belief Model (50).

With these social behavioral principles in mind, the practical operations of the new anti-drunking driving organization are described in the following sections that delineate how FRDB addresses the flaws in MADD’s approach to the public health problem.

ARGUMENTS

1. MADD data and reports repeatedly focus on the severity and susceptibility of individuals to the dangers of alcohol use and drunk driving accidents by using inaccurate statistics, targeting social drinkers and ignoring other related factors to drinking behavior.

Families for Responsible Drinking Behavior approaches drinkers as groups of people who may act in concert, thereby targeting the individuals who continue to violate drunk driving laws and traffic regulations. Research shows that over two-thirds of alcohol related crashes are caused by individuals whose blood alcohol level is .14 and the average fatal accident is caused by individuals whose blood alcohol level is above .17 (51). With Social Network Theory in mind, FRDB will reach out to these groups of people by examining where they fit within their social circle, what group attitudes are towards binge drinking and whether there are other contributing factors like family history of alcoholism, employment status and education level (52).

FRDB members will volunteer to drive a federally subsidized free shuttle service for any patron that local bar and restaurant owners deem to have had too much to drink, and advertise when the shuttle will be running and where it is available. In addition, FRDB will work with legislators for stricter laws regarding contributing factors to alcohol-related motor vehicle accidents, like highway safety, safety belt use, and cell phone use. However, FRDB acknowledges that drunk individuals act irrationally with respect to these contributing factors as well, and will work with law enforcement to increase patrolling, which both law research has shown to be more effective than the sobriety checkpoints that MADD advocates (53). This approach will target the most dangerous drivers at highest risk for motor vehicle accidents rather than the population at large.

Through promotional materials and advertising, FRDB will accurately represent statistical evidence to show the actual severity of the drunk driving problem, doing its best to make the issue still relevant without referring to it as a “growing epidemic” (54). Furthermore, the group will target under-age drinkers by linking alcohol abuse with negative health effects, like liver, heart, and kidney disease (55). By focusing on alcohol abuse rather than just use, adolescents will be more inclined to consider how much they are drinking rather than whether or not they are at all. FRDB will take into consideration the importance of social norms, part of the Theory of Reasoned Action, by linking moderate alcohol consumption with a positive outcome, like relaxation and socialization after a tough week of papers, tests and work (56). By taking into consideration group level behaviors and dynamics, targeting repeat DUI offenders rather than social drinkers, and providing accurate alcohol related statistics and information to young drinkers, FRDB places alcohol use in its proper context while still presenting it as a significant public health concern.

2. MADD’s efforts to curb drunk driving accidents are impeded by the organization’s bureaucracy, a lack of services for drunk drivers, and a lack of acknowledgment of individual community and MADD chapter needs, which are reflective of the drinking behaviors of those populations.

Families for Responsible Drinking Behavior, while a nation-wide organization, is principally a network of local FRDB chapters that, as the name suggests, aim at providing family-like support and activism for drunk driving victims and offenders. These local chapters are allowed to keep 75% of the money they raise. The remaining 25% goes to the national office in Washington, D.C. where that money is used to fund research regarding drunk driving prevalence and accident statistics and provide additional resources for those chapters whose serve areas with the highest rates of drunk driving, like Wisconsin, South Carolina, and Montana (57). FRDB’s activities on a local and national level are monitored by a group of individuals elected by their FRDB chapter to ensure that fundraising money goes to drunk driving prevention efforts, not group members. Fundraising efforts play an integral role in the success the group is able to have, but the funds need to stay at a local level to effectively promote community-wide change.

FRDB, because it is places so much emphasis on individual chapters, frames the issue of drunk driving as a social behavior issue that is different in every state and region (58). Regions and communities cited as having high numbers of drunk driving fatalities would not only receive more funds and be targeted as areas where stricter laws and regulations should be enacted, but would also receive more resources for repeat DUI offenders, including support services like online chats, legal assistance and counseling. Rather than focusing solely on victim services, the program will reach out to drunk driving offenders by offering a hotline they can call if they need a ride home, and FRDB members could volunteer for different shifts to help get these drunk drivers out of the driver’s seat and safely home. In addition, FRDB could work with local town parks and recreation departments to sponsor board game nights, dances, potluck dinners and other activities so people who do not drink do not feel marginalized either, and all local residents have access to forms of recreation besides drinking.

In order to acknowledge that drinking behavior varies by race and gender, local FRDB chapters will have leadership teams comprised of individuals of different background, socioeconomic status, and ages, advocating adolescent participation as well. These leadership teams will be responsible for reaching to the different segments of the population, with activism efforts specifically catered for different drunk driving risk groups. With Social Marketing Theory in mind, for adolescents for example, FRDB efforts could try to sell to them the idea of success, that comes with drinking moderately, responsibly, and in a way that does not endanger their academic pursuits and future opportunities (59). By selling the idea of a happy family to middle-aged binge drinkers, it forces them to think about their family before they drink too much or get behind the wheel.

Male representation in the FRDB chapters is essential, since they are almost twice as likely as female drivers to be involved with alcohol-related fatal motor vehicle accidents (60). While white, married, educated women are pivotal in spearheading efforts for drunk driving victims, underage binge drinking rates are highest in the areas where these women live, suggesting that both men and adolescents are needed to successfully combat the issue (61). In addition, part of the national FRDB office’s efforts need to include identifying areas not served by FRDB, starting new local chapters there, especially if they are at higher risk for alcohol abuse and drunk driving fatalities. Part of the FRDB efforts in South Dakota for example could include outreach programs to the Native American Reservations, whose male populations are highly susceptible to binge drinking, and thus worthy of greater attention and efforts (62). By offering services for drunk drivers, acknowledging individual community and FRDB chapter needs, the group strives to promote local change with national support and base their interventions around the drinking behaviors of these populations. Alcohol use is not a population wide epidemic, it is a public health problem influenced by social factors that vary among states and population sub-groups.

3. By arguing for prohibition of drinking for underage individuals, MADD fails to accept the reality of drinking prevalence, and fails to fully educate adolescents about alcohol use and its effects.

FRDB recognizes that underage drinking is prevalent and occurs despite minimum age drinking laws. Therefore, FRDB adolescent interventions need to remain focused on drunk driving rather than alcohol. By describing the negative consequences of drunk driving, like losing one’s friends, wrecking you or your parents’ car, and not remembering social gatherings because you were unconscious, FRDB frames drunk driving as something negative under any circumstances by keeping in mind what matters most to underage drinkers, their friends and family (63). Some data shows that binge drinking rates are higher among more educated individuals, including under-aged college students (64). Therefore, FRDB will also have local chapters, called Students for Responsible Drinking Behavior (SRDB), similar to the MADD spin off, Students Against Destructive Decisions, formerly known as Students Against Driving Drunk. SADD, like MADD also no longer focuses primarily on drunk driving, thereby limiting their efficacy in this area (65). Local SRDB chapters will work with area colleges to provide transportation services from off-campus housing or bars back to campus, as well as working with resident assistants living in the dormitories to provide alcohol education sessions for students and support services for alcohol abusers.

Because adolescent drinking behavior is most highly influenced by children’s parents, special educational efforts need to be taken in order to promote responsible drinking among this segment of the population so that their children will not see alcohol as off-limits in all circumstances, but rather able to be enjoyed in moderation. For that reason, FRDB will work with prenatal clinics and doctors to encourage safe drinking behaviors among parents after children are born and provide support services for those parents who abuse alcohol themselves or want to educate their children about alcohol use and its effects. Parents then become an additional resource for their children, and by offering support rather than prohibiting alcohol use, they work to change social norms by encouraging moderation, with the understanding that they will also provide support and further education if their children do drink too much.

Labeling theory shows that by portraying widespread drinking and the reckless behavior associated with it as highly prevalent then adolescents become more likely to drink because they believe that so many other people are doing it (66). Research has demonstrated that by providing adolescents with accurate information about alcohol abuse and addressing misconceptions can lower alcohol abuse rates (67). Therefore, FRDB would work with researchers to publish results about people’s actual drinking behavior in both college newspapers and other magazines read by adolescents, which has been shown to result in a decrease in alcohol related injuries to others (68).

If stigma theory is to be used by FRDB, than it should be done with drunk driving and not alcohol itself (69). However, stigmatizing this behavior could result in it becoming more attractive or appealing for adolescents. Regardless, the group needs to encourage parents to provide children with information about alcohol, how to drink it safely, and enable them to make informed decisions about how they will choose to use it. Alcohol-related public health programs that have advocated for responsible use rather than taking an abstinence only approach to alcohol have been demonstrated to be far more effective (70). By presenting drinking in moderation and abstaining both as acceptable alternatives, FRDB prepares young people to make either choice, knowing that they will always have community support if they need it.

CONCLUSION

In order to effectively address the drunk driving problem, Families for Responsible Drinking Behavior challenges dogma by changing beliefs about alcohol as a substance, its consumption, and education regarding its use. By presenting alcohol as neither a positive or negative, there are no positive or negative stigmas attached to it, and it is seen as neither forbidden or encouraged. Furthermore, by tolerating consumption of alcohol, FRDB acknowledges its presence in social settings while still remaining adamantly against its abuse. Finally, with respect to alcohol education, FRDB argues that it be done both at home and in social settings like school, and while children are still young, so they see their parents’ positive example of moderate and responsible drinking (71). MADD’s recent efforts have failed make any significant strides in reducing the number of drunk driving deaths, a figure that has remained relatively constant since 2000, according to the NHTSA. (72) This is because they have invested more money time and energy on the same individual level approaches they have for the last 25 years, in addition to showing a new focus against alcohol use altogether. By taking into consideration group level factors and dynamics, social norms, accounting for irrational behavior, and utilizing behavior and social science principles, Families for Responsible Drinking Behavior can effectively address the drunk driving problem by focusing on community level change by targeting and offering support for those groups at highest risk for alcohol abuse.

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5. Ibid, 4.

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9. Ibid, 2.

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14. Fishbein M., & Azjen I. (1975). Beliefs, attitudes, intentions, and behavior. Boston: Adison-Wesley

15. MADD over the edge? Advocacy group heats up the rhetoric as drunk driving statistics continue to fall. Alcohol Issues Insights, 1999, 16(6)

16. Hingson, R., et al. Magnitude of alcohol-related morbidity, mortality, and alcohol dependence among U.S. college students between the ages of 18 and 24. Journal of Studies on Alcohol, 2002, 63(2), 136-144

17. Ibid, 16.

18. Boland, Michael. Missouri University Regional American Campus and Alcohol Conference, St. Louis, MO, October 24-26, 2004.

19. Recksiedler, Dean. MADD stops fundraising over controversy. Vancouver News 1130 December 13, 2006;

20. MADD Money. Investigative report., K5 News, Seattle, Wa., n.d.

21. http://www.madd.org/getattachment/12293f6f-4a16-4caa-8c85-2b6735f9c7ca/State-Progress-Report.aspx

22. http://www.time.com/time/2007/america_numbers/alcohol.html

23. http://www.maddwisconsin.org/localdirectory/localdirectory.htm

24. http://www.nmshtd.state.nm.us/upload/images/Traffic_Safety/Ignition_Interlock-Facts.pdf

25. Weed, Frank J. “Grass-Roots Activism and the Drunk Driving Issue: A Survey of MADD Chapters” Law & Policy. Vol.9, Issue 3. 2008 Baldy Center for Law and Social Policy. P.259-278

26. Ibid, 25.

27. National Highway Traffic Safety Administration (NHTSA). Traffic Safety Facts 1994: A Compilation of Motor Vehicle Crash Data from the Fatal Accident Reporting System and the General Estimates System. Washington, DC: NHTSA, August 1995.

28. National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert: Alcohol and Minorities No. 55 January 2002.

29. http://www.madd.org/getattachment/12293f6f-4a16-4caa-8c85-2b6735f9c7ca/State-Progress-Report.aspx

30. http://www.alcoholfreechildren.org/en/states/sd.cfm?doc_id=223

31. http://www.nps.gov/history/nagpra/documents/resmap.htm

32. http://www.icpsr.umich.edu/SAMHDA/NTIES/NTIES-PDF/SHEETS/121_binge_drinking.pdf

33. A multilevel analysis of the relation of socioeconomic status to adolescent depressive symptoms: does school context matter? . The Journal of Pediatrics , Volume 143 , Issue 4 , Pages 451 - 456 E . Goodman

34. http://www.madd.org/getfile/2ebe207e-b1d8-44c5-b192-f125fb96c97c/Underage-Drinking-Fact-Sheet_FINAL081908.aspx

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37. 2000 Rhode Island Behavioral Risk Factor Surveillance System

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39. Substance Abuse and Mental Health Services Administration. The 1998 National Household Survey on Drug Abuse. Washington, D.C.: SAMHSA, 1999, Table 14. Available at www.samhsa.gov.

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42. Hansen, William B, and Graham, J. W. Preventing alcohol, marijuana, and cigarette use among adolescents: Peer pressure resistance training versus establishing conservative norms. Preventive Medicine, 1991, 20

43. The Substance Abuse and Mental Health Services Administration (SAMHSA). 2006 National Survey on Drug Use andHealth (2006).

44. Haines, Michael P. A Social Norms Approach to Preventing Binge Drinking at Colleges and Universities. Newton, MA: Higher Education Center for Alcohol and Other Drug Prevention, p. 4.

45. Hanson, David J. Alcohol Education: What We Must Do. Westport, CT: Praeger, 1996.

46. Ibid, 4.

47. Ibid, 3.

48. Freeman, Linton. 2006. The Development of Social Network Analysis. Vancouver: Empirical Pres, 2006; Wellman, Barry and S.D. Berkowitz, eds., 1988. Social Structures: A Network Approach. Cambridge: Cambridge University Press.

49. DeFleur, M. L. & Ball-Rokeach, S. (1989). Theories of mass communication (5th ed.). White Plains, NY: Longman.

50. Ibid, 7.

51. Ibid, 8.

52. Ibid, 48.

53. http://www2.potsdam.edu/hansondj/DrivingIssues/1103163004.html

54. Ibid, 13.

55. http://www.healthchecksystems.com/alcohol.htm

56. Ibid, 14.

57. Ibid, 33.

58. Baars, B. (1988), A Cognitive Theory of Consciousness, Cambridge: Cambridge University Press.

59. Kotler, P, Zaltman, G. Social marketing: an approach to planned social change. J Market. 1971;35:3-12

60. Ibid, 27.

61. Ibid, 33.

62. Ibid, 28.

63. Ibid, 58.

64. Ibid, 37.

65. http://www.sadd.org

66. Ibid, 40.

67. Ibid, 42.

68. Ibid, 44.

69. Heatherton, Kleck, Hebl & Hull, The Social Psychology of Stigma, The Guilford Press, 2000.

70. Ibid, 45.

71. Guthrie, R. S. Abstinence and Alcohol Use Among Senior Students Enrolled in Seventh-Day Adventist Academies. Unpublished M.S. thesis, University of Wisconsin - LaCrosse, 1986, pp. 11 and 79; Hanson, David J. Preventing Alcohol Abuse: Alcohol, Culture, and Control. Westport, CT: Praeger, 1995, pp. 45-50.

72. Ibid, 3.