IJE Advance Access originally published online on June 6, 2005
International Journal of Epidemiology 2005 34(4):758-761; doi:10.1093/ije/dyi099
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Cochrane Column |
Cochrane Column
South African Cochrane Centre, Medical Research Council, PO Box 19070, Tygerberg 7505, South Africa. E-mail: taryn.young{at}mrc.ac.za
The Cochrane Collaboration (http://www.cochrane.org) is an international, non-profit organization that prepares and disseminates up-to-date systematic reviews on the effects of healthcare interventions in order to help people make well-informed decisions. Systematic reviews have been introduced in recent years to reduce biases characterizing traditional (informal) literature reviews. They aim to answer focused healthcare questions by systematically identifying and evaluating all relevant research studies and synthesizing their results.
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In this and future issues of the IJE, we will highlight a Cochrane systematic review of relevance to public health, asking the authors of the review to produce a summary and commission commentaries from relevant individuals. The aim of the Column is to bring this information to a wider audience, and to stimulate debate on relevance, feasibility, and acceptability. We are particularly keen to focus on the relevance to, or lack of evidence for, low-income and middle-income countries.
If you are interested in contributing to the Cochrane Column or The Cochrane Collaboration, contact me at the South African Cochrane Centre.
Longer-term primary prevention for alcohol misuse in young people: Cochrane systematic review
Worldwide, 5% of all deaths of young people between the ages of 15 and 29 are attributable to alcohol use. In 2000 the World Health Organization, together with the UK Alcohol Education and Research Council (AERC), commissioned an update of the original systematic review, done in 1995 and reported in Addiction1, this time under the auspices of the Cochrane Drugs and Alcohol Collaborative Review Group. The aim of this Cochrane review was to identify and summarize rigorous evaluations of psychosocial and educational interventions aimed at the primary (or universal) prevention of alcohol misuse by young people aged up to 25 years, especially over the longer-term (>3 years).
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Methods |
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 Top Methods Results and discussionConclusionsReferences |
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A comprehensive search of 22 databases and recursive checking of bibliographies for randomized and non-randomized controlled trials and interrupted time series studies were carried out. Only those studies that reported objective or self-reported measures of alcohol use and misuse were eligible for inclusion. After rejecting studies that neither met the inclusion criteria nor had major methodological shortcomings, 56 studies were selected for inclusion in the systematic review.
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Results and discussion |
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TopMethodsResults and discussionConclusionsReferences |
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Of the 56 studies, 20 studies showed evidence of ineffectiveness. No firm conclusions about the effectiveness of prevention interventions in the short-term and medium-term were possible because of methodological shortcomings with many studies. Of the studies that reported longer-term evaluations, there were often higher levels of attrition and a lack of an intention-to-treat (ITT) analysis, therefore threatening the validity of the results. After contacting the authors of longer-term studies and also making some conservative assumptions we were able to re-analyse the results of three longer-term evaluations that reported effective or partially effective results. In the ITT analysis, the Strengthening Families Program (SFP10-14)2 showed promise as an effective prevention intervention. The number needed to treat (NNT) for the SFP10-14 over 4 years for three alcohol initiation behaviours (alcohol use, alcohol use without permission, and first drunkenness) was nine (for all three behaviours) (Table 1). One study3 also highlighted the potential value of culturally focused skills training over the longer-term (NNT = 17 over 3.5 years for 4+ drinks in the last week), although only one outcome measure was reported and therefore available for ITT re-analysis, leading to the possibility of a presentational bias. The ITT results for the Life Skills Training Programme4 were less convincing.
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Conclusions |
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The Cochrane review concluded that: (i) The SFP10-14 shows promise but needs to be evaluated on a larger scale and in different settings to confirm current results; (ii) Culturally focused interventions require further development and rigorous evaluation, including cost-effectiveness assessment; (iii) Further research is needed to identify important alcohol misuse outcome measures (indicators), as there is currently no clear understanding of which outcome measures are important predictors of alcohol misuse, morbidity, and mortality in later life; and (iv) An international register of alcohol and drug misuse prevention interventions should be established and criteria agreed for rating prevention intervention in terms of safety, efficacy and effectiveness.
The full text of the Cochrane Review is available in The Cochrane Library. Foxcroft DR, Ireland D, Lister-Sharp DJ, Lowe G, Breen R. Primary prevention for alcohol misuse in young people. The Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD003024 [GenBank] . DOI: 10.1002/14651858.CD003024. This version first published online: 22 July 2002 in Issue 3, 2002.
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References |
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1 Foxcroft DR, Lister-Sharp D, Lowe G. Alcohol misuse prevention for young people a systematic review reveals methodological concerns and lack of reliable evidence of effectiveness. Addiction 1997; 92:531–37.[CrossRef][ISI][Medline]
2 Spoth RL, Redmond C, Shin C. Randomized trial of brief family interventions for general populations: adolescent substance use outcomes 4 years following baseline. J Consult Clin Psychol 2001; 69:627–42.[CrossRef][ISI][Medline]
3 Schinke SP, Tepavac L, Cole KC. Preventing substance use among native american youth three-year results. Addict Behav 2000; 25:387–97.[CrossRef][ISI][Medline]
4 Botvin GJ, Baker E, Dusenbury L, Botvin EM, Diaz T. Long term follow-up results of a randomised drug abuse prevention trial. JAMA 1995; 273:1106–12.[Abstract]
Commentary: Studies are scientifically weak and few from developing countries
Alcohol and Drug Abuse Research Group, Medical Research Council, Private Bag X385, Pretoria, 0001, South Africa
This review is relevant and timely for South Africa, where alcohol misuse is a major public health concern and prevention interventions are implemented in the absence of evidence on their effectiveness. However, its usefulness for informing public health practitioners, preventionists, and other related workers on the effectiveness of interventions for young people in South Africa is limited owing to methodological weaknesses in the reviewed studies and its disappointing findings about the effectiveness of alcohol misuse intervention programmes in general.
The authors of the review suggest that the overall poor quality of the existing evaluation research prevents its results from being conclusive. The review employed a narrative style owing to the extreme heterogeneity in the designs, interventions, and outcome measures of the 56 included studies. Moreover, with 84% of the evaluations having been conducted in the USA, and only two in developing countries, its relevance to non-USA settings is unclear. These limitations would suggest a need to ensure that: (i) potential research flaws are minimized before studies are funded and initiated; (ii) more stringent criteria are used to evaluate articles (reporting randomized controlled trials) that are being considered for publication in scientific journals; and (iii) greater priority is given to research on identifying and overcoming logistical, practical, and ethical barriers to conducting high-quality evaluation research on alcohol and other drug misuse among young people.
The review's findings about the effectiveness of many of the evaluated prevention programmes for alcohol misuse are not very promising. Often short-term or medium-term gains of programmes are not maintained in the longer-term. No differences in outcomes associated with generic and alcohol-only programmes were apparent. For a handful of studies there was some evidence of long-term effectiveness of certain intervention programmes. One example was a family-focused programme involving parenting skills training for parents and communication, peer, and emotional management-type skills training for adolescents. The authors also pointed to the cost-effectiveness and other advantages of multi-targeted community interventions and stressed a need to concentrate on culturally focused interventions.
After more than two decades of evaluation research many intervention programmes for young people's alcohol misuse still seem not to show much promise. Are appropriate risk factors being targeted and relevant protective factors being strengthened in order to reduce young people's vulnerability to misusing alcohol? Is there a need to re-conceptualize and re-design interventions to improve the current rates of success?
The review cannot be used to inform practitioners, policymakers, and educators about the likely effectiveness of specific prevention programmes for young people in South Africa. However, certain findings suggest that comprehensive interventions will have better outcomes than the more popular, easier, cheaper to implement, individually focused educational and psychosocial programmes. The reviewers suggest a framework according to which programmes that may be recommended for alcohol misuse prevention should meet the criteria of safety, effectiveness, and efficacy. When considering such programmes for implementation in a new setting it is probably also essential to first establish the cultural appropriateness of that programme for the new setting.
Commentary: Why not increase the price of alcohol?
Alcohol and Drug Service, St Vincent's Hospital, Darlinghurst, NSW, 2010, Australia
A summary of Cochrane reviews (and protocols) of relevance to health promotion and public health can be viewed on the Cochrane Health Promotion and Public Health website: http://www.vichealth.vic.gov.au/cochrane/
It may seem disappointing that this meticulous review of such a self-evidently important subject could find so few of the papers published on it meeting acceptable scientific standards. Yet this is a common finding in Cochrane reviews. Readers may also be disappointed that the efficacy of so few interventions has been suitably demonstrated. More importantly, the reviewers found strong evidence that other interventions should not be considered further.
Many of the strategies that are effective in preventing alcohol-related problems in the general population are equally effective in younger populations. Some are even more effective in this population. Increasing the price of alcohol relative to income is the single intervention best supported by evidence of effectiveness and this is even more important in younger populations. Younger populations have smaller discretionary income and are, therefore, more sensitive to price increases. Also, an even higher proportion of alcohol consumption in younger drinkers is accounted for by alcohol consumed at high risk of harm.
Young drivers account for a disproportionate share of road crash deaths and injuries, especially alcohol-related crashes. In some countries in recent years, road crash deaths and injuries have been reduced substantially. This was achieved by a wide range of general and alcohol-specific measures including car safety belts, random breath testing, probationary driving licenses with reduced blood alcohol limits, raised minimum legal drinking age, improved street lighting and signage, and improved design of vehicles and roads.
Readers who despair that only relatively few interventions were found to be strongly supported by evidence of effectiveness in this review should take comfort from the fact that the review presented only part of a much larger picture.
Alcohol consumption has been increasing steadily for many years (from a low baseline) in many developing countries, especially in Asia and the Pacific. Although developing countries account for 
80% of the global population, we have few studies from these countries. The conclusions that apply to developed countries may not be as relevant, or may not apply at all, in developing and transitional countries.
In general, the incidence of alcohol-related problems is closely related to per capita consumption. This is because as much as 80% of the alcohol consumed by a community is drunk at risk of acute or chronic harm. Reducing alcohol consumption, especially that proportion consumed at high risk of harm, should be the primary focus of prevention efforts. This is a difficult task as the alcohol beverage industry often accounts for a sizeable proportion of the national economy and often has considerable political influence. Many governments rely heavily on revenue from alcohol and are, therefore, often reluctant to embrace fiscal and other controls no matter how strong the evidence of effectiveness. Governing and opposition political parties are often grateful recipients of donations from the industry. Therefore in the short-term, the kinds of interventions canvassed in this review are often the only interventions that can be implemented.
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