Full Text PA-92-101


NIH GUIDE, Volume 21, Number 30, August 21, 1992

P.T. 34

  Health Care Economics 

PA NUMBER:  PA-92-101

National Institute on Alcohol Abuse and Alcoholism


Alcohol abuse and alcoholism are major problems in the United States,
and costs related to alcohol misuse are a significant economic issue.
The purpose of this Program Announcement (PA) is to make clear the
continued interest of the National Institute on Alcohol Abuse and
Alcoholism (NIAAA) in supporting additional, high-quality research on
economic and socioeconomic aspects of the prevention, treatment, and
epidemiology of alcohol-related problems.

Alcohol is directly and indirectly responsible for approximately
100,000 deaths annually in the U.S.  A significant proportion of
alcohol-related deaths are due to traffic fatalities.  About one-half
of the approximately 6,000 vehicle crash fatalities in 1987 involved
alcohol (National Highway Traffic Safety Administration (NHTSA), 1988).
Deaths from cirrhosis and other diseases of the liver account for
another substantial proportion of alcohol-related deaths.
Alcohol-related cirrhosis constitutes the ninth largest cause of death
among Americans and kills more than 10,000 persons annually.  Alcohol
use is also implicated in homicide, suicide, and death from non
vehicular injuries.

Morbidity related to alcohol use is also widespread and costly.  Heavy
drinking is a direct cause of psychiatric, neurological, nutritional,
and cardiac diseases.  In addition, alcohol use is a contributing
factor in pneumonia, diabetes, hypertension, and several types of
cancer.  More than 1.4 million persons were treated for alcohol abuse
and dependence during fiscal year 1987 (DHHS, 1990(b)).  In 1990, an
estimated 15 million adult Americans had either alcohol dependence or
alcohol abuse according to DSM-III criteria (Williams et al., 1989).

The costs associated with these conditions are substantial.  In 1985,
the total economic costs associated with alcohol abuse were estimated
at more than $70.3 billion.  This included lost work days and earnings
of $27.4 billion and nearly $24 billion in productivity foregone as a
result of premature alcohol-related mortality (Rice et al., 1990).

Many of the research topics of interest to economists are germane to
research on alcohol abuse and alcoholism.  These include the factors
influencing supply and demand, the financing and reimbursement
mechanisms for prevention and treatment services, the costs of illness,
and the cost effectiveness of alternative prevention and treatment
programs.  In these areas, the methodologies and analytic techniques
familiar to economists may be applied to the study of alcohol-related

Although this PA emphasizes research opportunities in prevention and
treatment, NIAAA would also welcome economic studies that bear on
epidemiologic issues.  For example, investigators could examine
relationships between variations in economic conditions and rates of
alcohol use and abuse.  Indicators of economic conditions could include
rates of employment and unemployment, income levels and earnings, the
proportion of women in the labor force, and other appropriate measures.
Indicators of alcohol consumption and problems can be derived from
national surveys and morbidity and mortality record systems.  Relevant
data bases maintained by the NIAAA are described in Appendix I of this
PA.  This PA is a revised version of a 1988 announcement titled
"Research on Economic and Socioeconomic Issues in the Prevention,
Treatment, and Epidemiology of Alcohol Abuse and Alcoholism."


The Public Health Service (PHS) is committed to achieving the health
promotion and disease prevention objectives of "Healthy People 2000,"
a PHS-led national activity for setting priority areas (DHHS, 1990(a)).
This PA, Research on Economic and Socioeconomic Aspects of Alcohol
Abuse, is related to the priority areas of decreasing morbidity and
mortality that are associated with the drinking of alcohol.  Prevention
strategies that may have a potential to contribute toward such
reductions include:  interventions that reduce the incidence and
prevalence of alcohol abuse among adolescents; interventions that
reduce motor vehicle crashes and fatalities associated with alcohol
use; interventions involving the use of administrative driver's license
suspensions or similar penalties for DWI offenders; and interventions
involving statutory restrictions on alcoholic beverage promotions
targeted at youth.  Potential applicants may obtain a copy of "Healthy
People 2000" (Full Report:  Stock No. 017-001-00474-0 or Summary
Report:  Stock No. 017-001-00473-1) through the Superintendent of
Documents, Government Printing Office, Washington, DC 20402-9325
(telephone:  202-783-3238).


Applications may be submitted by domestic and foreign non-profit and
for-profit organizations, public and private, such as universities,
colleges, hospitals, laboratories, units of State and local
governments, and eligible agencies of the Federal Government.  Women
and minority investigators are encouraged to apply.  Foreign
institutions are not eligible to apply for the First Independent
Research Support and Transition (FIRST) award.


Research support may be requested through applications for a research
grant (R01), Small Grant (R03), or FIRST Award (R29).  Specialized
announcements for the FIRST Award program (R29) and the Small Grant
program (R03) are available from the National Clearinghouse for Alcohol
and Drug Information, P.O. Box 2345, Rockville, MD 20852, telephone
(301) 468-2600 or 1-800-729-6686.

Applicants for research grants may request support for up to five
years, Small Grants are limited to two years, and FIRST Award
applicants must request five years of support.  FIRST and Small Grants
are not renewable, but applications may be submitted for R01 support to
continue research on the same topics.

Annual awards will be made, subject to continued availability of funds
and progress achieved.

Terms and Conditions of Support

Grant funds may be used for expenses clearly related and necessary to
conduct research projects, including direct costs that can be
specifically identified with the project and allowable indirect costs
of the institution.  Funds may not be used to establish, add a
component to, or operate a treatment, rehabilitation, or
prevention/intervention service program.  Support for research-related
treatment, rehabilitation, or prevention services and programs may be
requested only for costs required by the research.  These costs must be
justified in terms of research objectives, methods, and designs that
promise to yield generalizable knowledge and/or make a significant
contribution to theoretical concepts.

Grants must be administered in accordance with the PHS Grants Policy
Statement (Rev. October 1990).


No specific set-aside funds are being allocated by the NIAAA for this
program at this time.  Applications received in response to this PA
will compete with others assigned to the NIAAA for funding.  The amount
of funding available will depend on appropriated funds, quality of
research applications, and program priorities at the time of the award.
In FY 1992, 29 grants relating to this program area, including new and
continuation grants, were funded for approximately $6 million.


Economic considerations often have a strong direct or indirect effect
on the levels of alcohol consumption and on the levels of
alcohol-related problems.  The price and availability of alcoholic
beverages, for example, have been shown to affect alcohol consumption,
morbidity, and mortality.  Advertising by the alcohol industry supports
a significant share of prime-time television, but the effects of
advertising on alcohol use and abuse still are not clear.

Public information campaigns, alone or in combination with more
personalized approaches, may be used to prevent alcohol problems, but
the cost-effectiveness of such intervention strategies should be more
firmly established.  Risk-taking behavior may be conceptualized in
economic terms according to rational and quasi-rational models of
decision-making.  Costs, as well as other social policy considerations,
affect the choice of strategies for deterring drinking and driving and
the ways such interventions are implemented.

These themes are further elaborated below.  In addressing these issues,
prospective researchers are strongly urged to draw upon the expertise
of economists and other scientists experienced in research on the
prevention of alcohol problems.  This may supplement the applicants'
own expertise.

A.  Price and Availability

Previous Studies

The price and availability of alcoholic beverages appear to be related
to levels of alcohol consumption and alcohol related problems.
Specifically, research indicates that variations in alcoholic beverage
prices are related to per capita alcohol consumption (Atkinson,
Gomulka, and Stern, 1990; Coate and Grossman, 1988; Grossman, Coate,
and Arluck, 1987; Heien and Pompelli, 1989; Ornstein and Levy, 1983;
Ornstein and Hanssens, 1985; Nelson, 1990), traffic crashes and
fatalities (Phelps, 1988; Cook, 1981; Saffer and Grossman, 1987(a);
Saffer and Grossman, 1987(b)), and cirrhosis mortality rates (Cook,
1981; Cook and Tauchen, 1982).  Moreover, constraints on the
availability of alcoholic beverages have been statistically associated
with lower consumption and problem levels (Glicksman and Rush, 1986;
Room, 1984; Rush, Glicksman and Brook, 1986; Ornstein and Hanssens,

Conceptually, price and availability are related phenomena. From an
economic perspective, restrictions on availability may be interpreted
as increases in the "full price" paid by the buyer (Grossman, 1988).
This full price includes the effort and resources expended in
purchasing alcohol, in addition to the money price.  Social scientists
operating from other perspectives have sometimes conceptualized the
economic availability of alcohol as one of several dimensions of
availability.  For example, Smart has distinguished economic
availability from physical availability, which he defines as "specific
alcohol-control measures employed except for price;"  subjective
availability, which he defines as "individual differences in how
accessible people feel alcohol is to them;" and social availability,
which he defines as "availability within small social or family groups"
(Smart, 1980, p. 124).  Though economists and other social scientists
may disagree on how the components of availability should be defined or
how they are related, both seem to share a recognition that price and
non-price factors are closely related.

Taxation is the principal policy mechanism for influencing the price of
alcoholic beverages.  Taxes on alcohol appeared early in this Nation's
history and have always been an important source of revenue.
Conceptual approaches to setting the proper level of alcohol taxes have
centered on various arguments including:  that heavy drinkers should
pay for the external costs (see footnote 1 below) of excessive
consumption (user fee), that tax levels should be set so as to reduce
the level of alcohol-related problems (public health promotion), that
tax rates may send inappropriate price signals if the price is less
than the marginal social cost of consumption (economic efficiency),
that taxes should be adjusted to some historical standard so as to
compensate for the effects of inflation (historical precedent), and
that taxes across beverage categories should be uniform per unit of
ethanol (beverage equality) (Cook, 1988; Cordes et al., 1990; Manning
et al., 1989; Pogue and Sgontz, 1989; DHHS, 1989).

A consideration in setting tax policy for any one beverage is the
degree of beverage substitution that might be expected (Heien and
Pompelli, 1989; Ornstein and Levy, 1983).  Therefore, the cross-price
elasticities (see footnote 2 below) for alcoholic beverages are
important considerations in establishing tax policy.  Also important is
the potential substitution of illegal drugs (such as marijuana) for
alcohol if alcohol taxes are increased substantially.

Whether or not various subgroups within the population have different
price elasticities for the purchase of alcoholic beverages should also
be understood.  Such knowledge is important for evaluating the economic
efficiency and efficacy of alternative tax policies.  Heavier drinkers
might not exhibit the same price responsiveness as lighter drinkers.
This is a fundamental consideration in arguments about the economic
efficiency of a given alcohol tax proposal (Pogue and Sgontz, 1989;
Cook and Tauchen, 1982).  To the extent that alcohol problems are not
evenly distributed through the population, but instead tend to be
concentrated among certain groups (such as the concentration of DUI
casualties among young men), differences in price elasticity by age,
gender, or other demographic characteristics may have important
implications for the efficacy of taxes in reducing certain problems.

Research on availability has kept pace with research on price.
Availability restrictions may be aimed either at reducing alcohol
consumption or at confining that consumption to drinking contexts and
environments thought to be relatively less problems prone.

Footnote 1.  Costs imposed on third parties other than the buyer and
seller, such as the damages sustained by non drinking accident victims
or the health care costs borne by the taxpayers.

Footnote 2.  The proportion by which consumption of one commodity
changes in response to a 1-percent increase in the price of another
commodity, other things remaining constant. For example, an increase in
beer consumption that might occur if the price of wine were raised.

The range of availability restrictions that could be studied include
such approaches as:  total prohibition of sales by local option (Dull
and Giacopassi, 1988); restriction of sales to State-run outlets
(Colon, 1982; Holder and Wagenaar, 1991; Mulford and Fitzgerald, 1988;
Ornstein and Hanssens, 1985; Wagenaar and Holder, 1991; Fitzgerald and
Mulford, 1992; Nelson, 1990; Zardkoohi and Sheer, 1984; Smith, 1982;
Swidler; 1986); restrictions on the sale of liquor by the drink (Blose
and Holder, 1987(a); Blose and Holder, 1987(b); Holder and Blose,
1987); restrictions on days and hours of sale (Smart and Adlaf, 1986;
Smith, 1987; Smith, 1988); restrictions on alcohol sales in combination
with other business activities (such as alcohol sales at gas stations)
(Wagenaar and Farrell, 1989); limitations on the density of alcohol
outlets in a geographic area (Glicksman and Rush, 1986; Rush et al.,
1986; Colon, 1982; Godfrey, 1988); and planning and zoning restrictions
that govern the proximity of alcohol outlets to schools, churches,
residences, and other types of land-use (Wittman and Hilton, 1987).

Youth are a sub-population of particular interest with regard to
alcohol availability.  Recent research has concentrated on the
advisability of raising the minimum drinking age (GAO, 1987; Wagenaar,
1986).  Much less is known about the patterns and mechanisms of youth
access to alcohol, and how these patterns might suggest improvements in
the enforcement of minimum age laws.

Availability issues are also of substantial interest in minority
communities.  Low-income, inner-city neighborhoods often have
relatively high densities of alcohol outlets, which may contribute to
the levels of alcohol-related problems in these communities (Kerbs,

Research Needs

NIAAA encourages studies that are likely to advance current knowledge
in the areas outlined above.  Central to this purpose would be studies
of the effects of price increases and availability controls on rates of
alcohol consumption and alcohol-related problems.  Other studies might
address such topics as:  variations in price and income elasticities
among demographic subgroups (especially youth and minorities) and among
different types of drinkers (heavy, moderate, and light), beverage
substitution effects (including the substitution of cheaper for more
expensive brands within the same beverage type as well as the
substitution across beverage types), and the potential for substitution
between alcohol and other drugs.

Further research on alcohol taxation is also needed.  Theoretical
studies might examine issues such as:  (a) the appropriate or optimal
level of alcohol taxation; (b) the effects of tax policies on industry
pricing and marketing behavior; and (c) the implications of alternative
tax structures (e.g., ad valorem vs. per unit taxes, equalization of
taxes per unit of ethanol, or state vs. federal taxation) for
considerations of efficiency, fairness, and public health.  Empirical
analyses might also address any of these areas, as well as issues such
as:  (a) the extent to which increased taxation of alcoholic beverages
leads to reductions in alcohol consumption, heavy drinking, or alcohol
problems; (b) the importance of public health considerations among the
factors leading to the enactment of particular tax policies; (c) the
incidence of potential regressivity of alcohol taxes; and (d) the
long-term effects of alcohol taxes on factors such as educational
attainment and labor market behavior.

Studies of the effectiveness of various availability restrictions
(either singly or in combination) would help in understanding their
utility as prevention tools.  Analysts may wish to take into
consideration the possibility that, in addition to the formal existence
of any set of restrictions, the vigor of enforcement may also be an
important factor in reducing alcohol-related problems (Janes and
Gruenewald, 1991).

With regard to youth, two areas of study seem especially promising.
Studies of patterns of youth access to alcohol could contribute to
better enforcement of the minimum drinking age, lead to a more richly
detailed understanding of the cultural mores surrounding youthful
drinking, and contribute to the design of improved prevention programs
for youth.  Another area of promise involves studies of the effects of
drinking patterns at younger ages on subsequent educational attainment,
labor market participation, and career development.

Studies of the behavior underlying alcohol use also have an important
role to play.  These may include studies of the consumption decisions
of alcohol-dependent individuals, studies of economic models of
addictive behavior, and studies of motivations and cognitions
surrounding alcohol use.

A methodological priority in economic studies of price and availability
is improving the quality and availability of micro data sets that can
be used to support economic analyses.  Existing survey data sets have
been found useful for such analyses to the extent that they contain
detailed data on alcohol consumption, household and individual income,
and labor force participation (Coate and Grossman, 1988; Grossman et
al., 1987; Heien and Pompelli, 1989; Manning et al., 1989).  The survey
data sets used most often have been the panel component of the
Monitoring the Future study, the Epidemiologic Catchment Area Study,
the National Health and Nutrition Examination Survey, the National
Household Interview Survey, and the National Longitudinal Survey of
Youth.  The identification and utilization of additional data sets that
could support such analyses would be of value to the field.

To date, most price and availability studies using micro data have been
secondary analyses.  Applicants are encouraged to consider moving
beyond this stage by proposing to conduct surveys that are explicitly
designed to support economic analyses.  This would yield data sets with
variables more closely tailored to the needs of such analyses.  For
example, the simple family income items present in many surveys could
be superseded by a more detailed set of items that identify the
respondent's income, the amount of income that comes from wages and
salaries, and the amount of income that is received as transfer
payments.  Applicants are encouraged to consider the formation of
research teams that include both individuals with expertise in survey
research and individuals with expertise in economic analysis.

On the price side, recent studies have tended to use data provided by
the American Chamber of Commerce Research Association (American Chamber
of Commerce Researchers Association, 1991; Nelson, 1990) or Federal
excise tax data (taken as a proxy for price).  Other price data have
been drawn from liquor industry sources (DISCUS and Jobson's Liquor
Handbook).  Research that identifies and utilizes additional sources of
price data would be of great value to the field.

B.  Advertising and Mass Media

Previous Studies

A variety of social science methodologies, including those
traditionally employed by economists, may be used to evaluate the
effects of mass communications in either promoting or preventing
alcohol consumption and in increasing or reducing the problems
associated with it.  Alcohol advertisements encourage a favorable view
of alcohol consumption (Finn and Strickland, 1982; Atkin, 1987; Atkin,
1990; Postman et al., 1987).  A supportive view of drinking is also
embedded in broadcast media programming (Wallack, Grube, Madden, and
Breed, 1990; Hansen, 1988; Kilbourne, 1985).  To the extent that
supportive presentations lead to positive attitudes and to distorted
perceptions of the uses and abuses of alcohol, advertising messages
that contain such supportive presentations would be expected to lead to
increased consumption.  These media effects are most likely to alter or
shape the beliefs and intentions of those youthful viewers who have had
the greatest exposure to alcohol advertisements.  Most studies to date,
however, provide only modest support for this hypothesis (Smart, 1988).
Other studies using econometric and time series analyses of aggregate
data to explore a link between advertising and per capita consumption
and to assess the effects of advertising bans have found weak and
inconsistent advertising effects (Smart, 1988; Saffer, 1991; Makowsky
and Whitehead, 1991).

The mass media also have been used to convey information about the
health hazards associated with alcohol consumption through news
articles, public service messages and, more recently, by "cooperative
collaboration" between TV producers and health promotion experts in
encouraging alternative depictions of alcohol use and consequences.
The goals of these health promotion efforts have been to increase
public knowledge and, ultimately, to reduce alcohol-related problems.
Research on mass media messages, in general, suggests that they are
most likely to be effective when combined with other interventions,
such as organized discussion groups, personalized communications, or
visible enforcement of deterrent laws.  Both the Stanford Heart Study
and Project CRASH illustrate the combined efforts of media and
community mobilization (Blane, 1988; Holder, 1988).

The accumulation of knowledge about the effects of advertising and
media programming has been hampered by widely acknowledged flaws in the
research designs of many studies, as well as by narrow
conceptualizations and data availability limitations.  These
shortcomings indicate the continued need for methodologically sound,
well-executed research that can demonstrate the potential and limits of
mass communications that might affect drinking attitudes and behavior.

Research Needs

Research is needed to determine whether or not there is a clear
connection between advertising and mass media portrayals and alcohol
use by youthful and vulnerable populations and abuse by others.  This
might include:

o  Studies of the impact of advertising on the development of alcohol
expectancies and drinking behavior in youth;

o  Examinations of the relationships between either advertising
expenditures or advertising policies and alcohol sales or problem

o  Analyses of the effects of various marketing activities (e.g.,
promotional efforts, event and team sponsorships) on the drinking
behavior of vulnerable individuals and groups (e.g., underage youth,
women, ethnic minorities);

o  Studies of how the images of alcohol and drinking portrayed in mass
media programming are interpreted, how they affect public understanding
of alcohol problems, and how they affect public responses to prevention
and treatment policies;

o  Examinations of the relationship between the amount of alcohol
advertising in the media and the news coverage of both alcohol and
general health concerns;

o  Studies of the effectiveness or ineffectiveness of both alcohol
"counteradvertising," social marketing, and health promotion messages
and campaigns are needed.  These might address the following issues:

o  The effectiveness of health promotion efforts to alter programming
content regarding the portrayal of alcohol and alcohol-related
behavior.  For example, what has been the impact on attitudes and
behavior related to drinking and/or driving of designated driver

o  What lessons from commercial marketing can be applied by those doing
social marketing with respect to alcohol?  What are the barriers to
effective counteradvertising and health promotion efforts?  How might
these be more effectively addressed?

Health warning labels on containers of alcoholic beverages are another
means of communicating potential hazards associated with alcohol
consumption (Andrews et al., 1990; Mayer et al., 1991; Mazis et al.,
1991).  Studies about the design and effectiveness of warning labels
are encouraged.  These could include:

o  Studies that monitor the long-term impact of these labels among the
population at large and among population groups of interest (such as
young male drivers, women of child-bearing age, ethnic minorities, or
heavy drinkers);

o  Time series analyses of traffic crash rates or birth defect rates
before and after the appearance of the labels;

o  Laboratory studies of the effects of different label design
features, alternative label texts, additional rotating warning
messages, or the rotation of warning messages;

o  Studies of the interaction of warning labels with other preventive
strategies, such as interventions among women of child-bearing age or
school-based education programs.

Studies that might help inform policy-makers about the potential impact
of warning labels placed in alcohol advertisements, statements of
alcohol content on malt beverages and wine coolers, and nutritional
labeling of alcoholic beverages are also encouraged.  Such studies

o  Analyze both the message content and the design of these instruments
for conveying information about alcohol and alcohol-related health

o  Compare the impact of these messages on different population groups
(defined by age, gender, ethnicity, drinking pattern, education, or
other relevant characteristics);

o  Investigate the potential backlash effect that statements of alcohol
content might have (viz., the possible unintended effect that some
drinkers would use the information provided by beverage content
statements to seek out and consume beverages that contain the greatest
concentration of alcohol).  Such studies might use focus groups,
laboratory observations of quasi-naturalistic drinking occasions,
controlled experiments, or other methods.

C.  Risk-Taking Behavior

Previous Studies

Most healthy adolescents engage in some risk-taking behavior. This is
part of the natural exploration, initiative-taking, boundary-setting,
and assertion of independence that is necessary for psychological
development toward adulthood (Erikson, 1950; Baumrind, 1987; Tonkin,
1987).  Some risk taking behaviors, however, contribute relatively
little to normal growth or unnecessarily endanger young persons (Lewis
and Lewis, 1984; Jonah, 1986; Irwin and Millstein, 1986; Konner, 1987;
Dryfoos, 1990; Feldman and Elliot, 1990).  It can be argued that
alcohol overindulgence constitutes a substantial risk without a
sufficient compensating benefit (Tonkin, 1987; Greydanus, 1987).  There
is evidence to suggest that many youth have not balanced the risks and
benefits of alcohol use in ways that are in their best interests
(Fischhoff and Quadrel, in press).
For the purposes of this announcement, risk-taking behavior is defined
as daring to do something that has perceived benefit, but that is
actually dangerous, and in which the actor perceives a risk to
himself/herself.  Acting without an awareness that a risk is involved,
acting without any expectation of benefit, or acting impulsively
without the calculus of potential harm is not considered to be risk
taking behavior.  "Risk" means different things to different people,
and it may be influenced by a wide variety of factors (Konner, 1987;
Tversky and Kahneman, 1981; Slovic et al., 1982; Kahneman and Tversky,

By the age of 10 to 12 and continuing through adolescence, youth enter
a period in which they explore, try on new roles, and seek new
experiences (Erikson, 1950; Baumrind, 1987; Tonkin, 1987).  At this
point, generally speaking, the early adolescents do not have the basis
that adult maturity provides in cognitive reasoning for evaluating the
probabilities of risk (Baumrind, 1987; Irwin and Millstein, 1986;
Piaget and Inhelder, 1958).  Further, peer pressure may override or
distort perception of risks (Lewis and Lewis, 1984).

The use of alcohol in certain situations by adolescents or adults may,
in itself, be considered risk-taking behavior (Baumrind, 1987;
Fischhoff and Quadrel, in press).  It may also act as a factor in the
decision to enter into other risk-taking behaviors such as driving
after drinking, engaging in indiscriminate sex, or experimenting with
illegal drugs (Baumrind, 1987; Tonkin, 1987; Jonah, 1986; Irwin and
Millstein, 1986; Fischhoff and Quadrel, in press).  A better
understanding of the reasons for such risk-taking behavior should
contribute to more well-grounded prevention efforts.

Research Needs

NIAAA is interested in laboratory experiments, longitudinal studies,
survey studies, observational studies, and field studies that identify
the kinds of factors that are involved in risk-taking decisions related
to adolescent alcohol use.

A few suggested examples of research studies that could be funded under
this announcement are as follows:

o  Studies that develop and test models of risk-taking.  These models
might take into account such factors as the cognitive assessment of
risk, the "myth of invulnerability" (Baumrind, 1987; Tonkin, 1987;
Jonah, 1986; Irwin and Millstein, 1986), the limited (real world)
experience or maturity of youth at the various developmental levels
(Erikson, 1950; Baumrind, 1987; Jonah, 1986; Piaget and Inhelder,
1958), the preference for risk or arousal need (Wilde, 1982), and the
probabilities and valences associated with real and perceived benefits
and penalties (Tonkin, 1987; Jonah 1986; Konner, 1987; Tversky and
Kahneman, 1981; Kahneman and Tversky, 1984; Slovic, 1987).

o  Studies that identify the forces that stimulate or suppress
adolescent risk-taking behavior.  These forces might be tested
individually or synthesized into multifaceted models to be tested.  In
this work, cultural differences should be taken into account.  The same
values and decision-making schemes might not apply across ethnic and
socioeconomic subpopulations.

o  Studies that examine the perception of invulnerability among youth
and adults.  This would include the identification of factors that
increase and reduce this perception.  Especially important would be
studies of the interplay between perceptions of invulnerability, risk
taking, and intentions to drink in potentially dangerous situations.

o  Studies that identify situations, conditions, and factors that may
undermine the exercise of good judgment on the part of youth.  Also
needed are studies of considerations that would make not drinking a
more attractive choice to young people.  Where research to date has
focused on teaching "refusal skills" and ways to avoid risk, future
research could address how youth consider the tradeoffs they might be
willing to make regarding alcohol use.

o  Studies that examine how young people estimate the probabilities of
risk associated with alcohol use and how this changes with age.  To
what extent does risk-taking related to alcohol use decrease with age
(the "maturing out" process)?  Is it true that older people are more
likely than younger people to perceive the potential negative outcomes
associated with alcohol use?

D.  Deterring Drinking and Driving

Previous Studies

The effectiveness of an effort to deter drinking and driving has been
attributed to three factors:  the certainty, severity, and swiftness of
the sanction (Ross, 1984).  Many recent changes in laws, enforcement,
and administrative procedures that operate along these principles have
been proposed to enhance deterrence.  These proposed changes represent
natural experiments and provide numerous opportunities for evaluation
(Hingson and Howland, 1990).  Studies exploring the effects of various
policies usually distinguish between general and specific deterrent

Specific deterrence refers to the effects of an intervention (usually
one considered unpleasant or punitive) on the subsequent behavior or
recidivism of the offender.  General deterrence includes the inhibiting
effects of the threat of the sanction or intervention on the rest of
the populace.

Among the recent drinking and driving interventions that focus on
severity of punishment are increases in minimum fines and heavier jail
sentences, particularly for repeat offenders.  Efforts to increase the
certainty of sanctions include such innovations as police roadblocks.

Administrative license revocation is intended to provide punishment
that is both more certain and more swift.  An indirect approach to
deterrence is derived from the civil liability of commercial (and
social) servers of alcoholic beverages.  This liability varies from
State to State, but it has had the general effect of encouraging the
hospitality industry to accept such interventions as server training.

Recent studies provide evidence that some interventions have been
successful in increasing the certainty of punishment for drinking
drivers.  These include "random" safety checks (Homel, 1986), targeted
enforcement (i.e., police patrols focused on times and places where
drinking drivers are most common; Ross, 1987), and installation of an
ignition interlock system in a convicted driver's car (Morse and
Elliott, 1991).  Interventions that attempt to make punishment occur
more swiftly, such as administrative license actions, have also
demonstrated potential deterrent effect (Zador et al., 1988; Nichols
and Ross, 1989).  However, the effectiveness of brief mandatory jail
sentences remains unclear.  Nichols and Ross (1989) reviewed studies
assessing both the general and the specific deterrent effects of jail
sentences.  They found that most of the studies reviewed reported no
specific deterrent effect of jail sentences on driving while
intoxicated (DWI) recidivism; a few, however, reported that brief jail
sentences reduced recidivism.  Their review of the general deterrent
effect of jail concluded that although several studies found mandatory
jail sentences deterred alcohol-impaired driving, other policies such
as license withdrawal and high fines may be more effective and are less
costly than mandatory jail terms.

Research on the effectiveness of multicomponent and alternative
environmental approaches to deter drinking and driving indicates the
preliminary effectiveness of treating drinking and driving as one
aspect of a wider behavior pattern of risky driving which can be
addressed by a community-wide campaign of intensified enforcement and
community education (Hingson et al., 1990).  Several studies have shown
that server training (an alternative environmental approach) is
effective in reducing the amount of alcohol consumed by bar patrons
(Saltz, 1987; McKnight, 1991) without measuring their subsequent
driving behavior.

Studies of youth indicate that teenage drivers and their passengers are
at significantly increased risk of injury and death from an
alcohol-related crash in comparison with older drivers and passengers
(Klitzner, 1988).  Assessments of youth drinking and driving
countermeasures suggest that those which focus on regulatory or
legislative countermeasures have been more effective than educational
strategies focused on altering individual knowledge or attitudes
(Klitzner, 1988).  For example, studies of changes in minimum alcohol
purchase age consistently show that increases in the minimum purchase
age decrease crash involvement (O'Malley and Wagenaar, 1991; Saffer and
Grossman, 1987).

Research on other special populations has identified patterns and
problems related to drinking and driving that diverge from those of the
general population.  The age-adjusted rate for motor vehicle fatalities
among American Indians and Alaskan Natives is 2.3 times higher than the
rate for the general population.  Many factors contribute to this
higher fatality rate, but patterns of alcohol use are regarded as major
contributors (May, 1989).  Blacks and Hispanics also appear to be at
high risk for alcohol-related driving problems, due largely to
involvement in heavy drinking episodes (Howard et al., 1988).  Women
generally drink less and drive less than men; their rates of
alcohol-related driving also are lower.  Recent research, however,
points to evidence that women, particularly those between 18 and 24,
are drinking and driving more frequently than in the past.
Consequently, while rates of DWI arrests and alcohol-related fatal
injuries declined dramatically between 1976 and 1985 for young male
drivers, those of women between 21 and 24 increased substantially
(Popkin, 1991).  Such findings suggest the need for greater attention
to the drinking and driving behavior of these special populations.

Research Needs

A variety of applications for research on the costs and benefits of
deterrence-based drinking and driving interventions are encouraged.
For example, research is needed to determine which types of sanctions,
in which combinations, and at which levels of severity produce the
greatest amounts of both general and specific deterrent effects.  This
research would address questions such as the following: What is the
optimum period for license withdrawal in terms of preventing future
drinking and driving among those punished?  How effective are fines
based on the offender's income level?  What is the minimum level of
driver safety checks needed in order to produce lasting reductions in
the fatal crash rate?  How can the short-term effectiveness of media
campaigns be sustained over time?  How do (a) server training, (b)
designated driver campaigns, (c) provision of alternative means of
transportation, and (d) other prevention activities initiated by some
segments of the alcohol service industry compare with respect to cost
effectiveness?  Also encouraged are studies of how changes in the
evolving judicial system shape and influence the kinds of deterrence
programs that are initiated.

Economic analyses of the costs of deterrence-based interventions are
needed to formulate wise public policy. Appropriate political choices
depend on knowing the costs associated with various choices.  Among the
policy options for which such analyses might be appropriate are:
expanded police patrols, systematic enforcement of availability
limitations, prosecution of drinking and driving cases in court under
various legal rules, and the incarceration of DWI offenders.  These may
be compared to other sanctions such as fines or civil procedures for
the forfeiture of cars driven by offenders.  Other costs that might be
explored are those borne by defendants and their families, such as
insurance premium increases, legal fees, and the costs incurred by
third parties as a result of uninsured driving by those subjected to
license penalties.

Cost-benefit comparisons can be made between various deterrence
programs to see which are most effective and efficient in reducing
drinking and driving (e.g., random safety checks compared with targeted
enforcement).  In addition, deterrence-based programs might be compared
with interventions not explicitly based on the deterrence principle but
which have deterrent potential.  These include availability constraints
(Cook, 1981; Rabow and Watts, 1982), educational programs to help
drivers recognize and act on the symptoms of alcohol impairment in
themselves and others (Thurman, Jackson and Zhao, 1990; Rabow, et al.,
1990), and alcoholism treatment programs for DWI offenders.  In
comparing program types, attention should be paid to their relative
effectiveness and efficiency.  The frequency and circumstances under
which informal interventions occur (i.e., preventing a friend or
acquaintance from driving while intoxicated) also merits consideration.

The evidence of various problems and risk patterns among special
populations suggests the value of studies focused specifically on
racial/ethnic minority, female, and youthful populations.  To reduce
drinking and driving by youth, research might focus on the etiology of
youth drinking as well as testing the effectiveness of programs that
separate drinking from driving (e.g., designated driver).  Research on
other populations needs to (1) determine the full extent of the
drinking and driving problem in each group, (2) explore the extent to
which differences in DWI arrest rates are the result of differential
law enforcement by police, and (3) test the effectiveness of drinking
and driving countermeasures tailored to specific subcultures.  These
might assess public service announcements and health promotion
information in Spanish and/or those using celebrities and ethnic
symbols to convey an anti-drinking and driving message.

Treatment Research Issues

Previous Studies

Treatment services, health policies, reimbursement and management
systems are components in an interdependent, interactive and
continuously evolving system of health care.  Access to and
effectiveness of treatment services for alcoholism and alcohol abuse
are shaped by this larger socioeconomic system of health care.  Of
vital importance to the identification and adoption of appropriate
alcohol treatment services is research on the cost effectiveness and
cost offsets of alternative treatment modalities in different types of
treatment settings and in different patient populations (see, for
example, Apsler and Harding, 1991; Blose and Holder, 1991; Goodman et
al., 1991; Hayashida et al., 1989; Holder and Blose, 1991; Walsh et
al., 1991; Wright and Buck, 1991).  Of equal importance will be
research on the impact of specific reimbursement systems, managed care
systems and/or health policies on the availability and cost
effectiveness of different types of alcohol treatment services
(Institute of Medicine, 1989; Institute of Medicine, 1990; Strumwasser
et al., 1991).

Research Needs

Research is needed in the following areas:

o  Descriptive studies of the existing alcoholism treatment system can
help enhance current knowledge (Institute of Medicine, 1989; Moos et
al., 1990).  Such studies would examine the geographic distribution,
availability, use, and costs of various alcoholism treatment services
and settings.  Treatment services to be studied would include common
modalities provided by publicly funded programs at the local, state,
and federal level as well as privately funded programs.  Among the
modalities that could benefit from additional research attention is
28-day, AA-based rehabilitation (Cook, 1988).  More information is also
needed about such questions as:  How much care is provided outside the
formal alcoholism treatment system; by primary care physicians, for
example, or in non-medical settings such as AA (McCrady and Irvine,
1989)?  Who uses these services?

o  There is need for a typology that would characterize treatment
services according to the nature and duration of the interventions
provided, characteristics of the facility in which they are offered,
and other relevant factors such as the type and range of services.
Such a typology could provide a basis for descriptive studies comparing
the relative costs of various strategies for treatment.

o  Studies that examine the interrelationships among treatment factors,
patient factors, facility characteristics, and treatment costs are also
encouraged (Walsh et al., 1991).  Studies in this area would use the
kinds of data described above to examine differences across geographic
areas and across patients with different characteristics according to
type of treatment and setting (type of facility and characteristics of
the facility, such as inpatient vs. outpatient or hospital-based vs.
freestanding).  The techniques and approaches of industrial
organization economics might also have useful applications to the
analysis of the supply of treatment.  Studies in this area might ask
questions such as:  What differences are there in the type and volume
of services provided to patients with different characteristics?  How
do the services provided by free standing facilities differ from those
provided in hospital based programs?  How does the financing of these
services (e.g., public vs. private) vary across patients and across

o  Studies that focus on the need for alcoholism treatment services and
on determinants of use of or access to these services would also be of
interest.  Existing research suggests that the need for alcoholism
services in the population is far greater than might be assumed on the
basis of current patterns of use.  Only about 15 percent of individuals
with diagnosable alcohol problems receive alcoholism treatment
services.  Research is needed to examine how such factors as severity
of alcohol dependence, ability to pay for treatment (both through a
third party and out of pocket), treatment cost, treatment duration, and
the availability of treatment affect the decision to use alcoholism
treatment services and the type of services sought.  Some specific
questions that might be asked include:

Who seeks what kind of treatment?  What kinds of individuals seek care
in informal as opposed to formal settings, or medical as opposed to
non-medical settings.

Do different geographic areas have different patterns of treatment?
For example, do providers within certain geographic areas tend to use
only inpatient care?

What are the monetary and the non-monetary factors influencing the
willingness to seek treatment, or to seek certain kinds of treatment?
For example, do some patients prefer inpatient treatment because it
removes them from their environment or provides leave from work?

What determines the role of AA in different market areas?  Are AA
services complements or substitutes for other treatment approaches?
Does AA compete with other providers (e.g., are there fewer formal
treatment programs in areas where AA is more dominant)?

How do geographic or market areas differ in the range and variety of
services offered?  How does this range affect the treatment actually
provided and its costs?  If only inpatient treatment is available in an
area, for example, utilization patterns and treatment costs may differ
from those in areas where a wider range of services are offered.

How do employer attitudes toward alcoholism and treatment affect
employees' use of alcoholism services?

To what extent are mental health services substituted for alcoholism
services?  For example, how does the availability of mental health vs.
alcoholism care affect the use of services by patients with dual

o  Studies of the "cost offsets" of treating alcoholism are also of
importance.  Such studies ask whether the costs of alcoholism treatment
are offset by reductions in other health care costs (Blose and Holder,
1991; Goodman et al., 1991).  Because the costs of treatment are often
difficult to determine from available data and the costs of the
untreated condition are even more difficult to measure, proxy measures
of cost (such as number of physician visits or days of work missed) may
be used instead of cost.  An important area of study involves the
dynamics behind observed cost offsets. For example, why do we observe
high medical care costs prior to treatment and low costs afterwards?

o  NIAAA also encourages studies that examine the variable impact of a
treatment intervention's effects on outcome and cost within the context
of specific types of health service systems (e.g., general hospitals,
psychiatric hospitals, free standing alcoholism treatment units).  Such
studies could examine the generalizability of treatment effects from
interventions demonstrated to be efficacious in controlled clinical
trials.  Alternatively, cost analyses can be added to clinical trials
carried out in health system settings that represent services typically
available to the general population.

o  Studies that explore the costs associated with alternative patient
outcomes are encouraged.  Competing demands for relatively limited
health care resources require scrutiny of the cost effectiveness of the
treatment of health care problems, including alcohol-related problems.
Unfortunately, there is at present limited information about the direct
and indirect costs of alcohol-related problems, and limited knowledge
of the clinical outcomes associated with the treatment of these
problems.  Consequently, studies are encouraged that increase our
understanding of the costs associated with alternative patient outcomes
(Holder et al., 1991; Cartwright and Kaple, 1991).  These studies
should control for differences in patient characteristics, clinical
variables, treatment setting, modality, provider characteristics, and
source of payment.

o  Studies of the nature and effects of current strategies for
financing and reimbursing alcoholism treatment and for containing
treatment costs on the organization and delivery of care are also
encouraged.  Reimbursement strategies contain specific incentives for
providers of alcoholism treatment services.  Research is needed on how
alcoholism treatment services are currently funded and how the
incentives contained in current reimbursement and/or managed care
systems affect the provision and use of alcoholism treatment services.
Studies may assess the potential effects of alternative financing,
reimbursement and/or managed care strategies on the organization, cost,
delivery, availability, or outcomes of alcoholism treatment.  Some
specific questions are the following:

What are the determinants of insurance coverage?  What role do factors
like unionization, employee turnover, and employer size play?  How does
adverse selection operate?  How do mandated insurance benefits affect
the utilization of alcoholism treatment services, employee assistance
programs, etc.?

What determines alcoholism benefits in managed care systems?

What services are actually provided?  How is access to these services
managed?  In what way and to what extent do managed care systems reduce
the amount of treatment provided (e.g., number of inpatient treatment
days, number of psychotherapy sessions, or number of types and hours of
service provided)?

What is the impact of specific types of managed care systems on access
to care and on the utilization, cost, and quality of services provided?

How do regional patterns of insurance coverage affect the kinds of
alcoholism services offered?  What determines the relative market
shares of public and private providers and for-profit vs.
not-for-profit providers?  Does provider behavior (e.g., patient mix,
costs, profit margins) vary as the market shares vary?

What is the distribution of alcoholism treatment costs across
individuals, families, third-party payers, employers, etc.?

Who bears the burden?

Can we explain differences in the States' behavior (e.g., variations in
the development of their public programs)? This includes not only
State-funded community treatment programs but also State health
insurance programs like Medicaid.

How does the amount spent on treatment relate to treatment utilization
in publicly funded programs?  Do states that spend more money provide
more treatment?



Applications for grants and cooperative agreements that involve human
subjects are required to include minorities and both genders in study
populations so that research findings can be of benefit to all persons
at risk of the disease, disorder or condition under study:  special
emphasis should be placed on the need for inclusion of minorities and
women in studies of diseases, disorders, and conditions which
disproportionately affect them.  This policy applies to all research
involving human subjects and human materials, and applies to males and
females of all ages.  If one gender and/or minorities are excluded or
are inadequately represented in this research, particularly in proposed
population-based studies, a clear, compelling rationale for exclusion
or inadequate representation should be provided.  The composition of
the proposed study population must be described in terms of gender and
racial/ethnic group, together with a rationale for its choice.  In
addition, gender and racial/ethnic issues should be addressed in
developing a research design and sample size appropriate for the
scientific objectives of the study.

Applicants are urged to assess carefully the feasibility of including
the broadest possible representation of minority groups.  However, NIH
and ADAMHA recognize that it may not be feasible or appropriate in all
research projects to include representation of the full array of United
States racial/ethnic minority populations (i.e., American Indians or
Alaskan Natives, Asians or Pacific Islanders, Blacks, Hispanics).
Investigators must provide the rationale for studies on single minority
population groups.

Applications for support of research involving human subjects must
employ a study design with minority and/or gender representation (by
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to the scientific objectives of the research.  It is not an automatic
requirement for the study design to provide statistical power to answer
the questions posed for men and women and racial/ethnic groups
separately; however, whenever there are scientific reasons to
anticipate differences between men and women, and racial/ethnic groups,
with regard to the hypothesis under investigation, applicants should
include an evaluation of these gender and minority group differences in
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minorities is impossible or inappropriate with respect to the purpose
of the research, because of the health of the subjects, or other
reasons, or if in the only study population available, there is a
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The NIH/ADAMHA funding components will not make awards of grants,
cooperative agreements or contracts that do not comply with this
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will report annually on enrollment of women and men, and on the race
and ethnicity of subjects.

Protection of Human Subjects

The Department of Health and Human Services (DHHS) has regulations for
the protection of human subjects and has developed additional
regulations for the protection of children.  A copy of these
regulations (45 CFR 46, Protection of Human Subjects) and those
pertaining specifically to children are available from the Office for
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questions concerning protection of human subjects in research may be
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which commits the applicant organization to comply with the DHHS
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nonexempt research activities involving human subjects.


Applicants are to use the current version of grant application form PHS
398 (rev. 9/91).  The number and title of this PA, PA-92-101 "Research
on Economic and Socioeconomic Aspects of Alcohol Abuse" must be typed
in item number 2a on the face page of the PHS 398 application form.

Application kits containing the necessary forms and instructions may be
obtained from business offices or offices of sponsored research at most
universities, colleges, medical schools, and other major research
facilities.  If such a source is not available, the following office
may be contacted for the necessary application material:

National Clearinghouse for Alcohol and Drug Information
P.O. Box 2345
Rockville, MD  20852
Telephone:  (301) 468-2600

The signed original and five permanent, legible copies of the completed
application must be submitted to:

Division of Research Grants
National Institutes of Health
Westwood Building, Room 240
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Criteria for scientific/technical merit review of applications for
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and the methodology proposed for collection and analysis of data.

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The review criteria for Small Grants (R03) and FIRST Awards (R29) are
contained in the specialized announcements.


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Assistance, No. 93.273.  Awards are made under the authority of
Sections 301 and 510 of the Public Health Service Act, as amended (42
USC 241 and 290bb).  Federal regulations at 42 CFR Part 52, "Grants for
Research Projects," and Title 45 CFR Parts 74 and 92, generic
requirements concerning the administration of grants, are applicable to
these awards.  This program is not subject to the intergovernmental
review requirements of Executive Order 12372 or Health Systems Agency


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Appendix I


This appendix lists data sources which may be useful to applicants in
designing a study under this announcement.

The Alcohol Epidemiologic Data System (AEDS) prepares periodic reports
in four major areas:

o  Liver Cirrhosis Mortality

o  Trends in Alcohol-Related Fatal Traffic Accidents

o  Apparent Per Capita Alcohol Consumption

o  Alcohol-Related Hospital Discharges

In the first three areas, data are available at the State level.  In
addition, alcohol-related data are available in a "Data Reference
Manual" series.  The publications in this series cover cirrhosis
mortality, hospital discharges, and per capita consumption, plus a
volume entitled "County Alcohol Problem Indicators, 1979-1985."  It
provides data on alcohol-related mortality for counties, States, and
the United States.  AEDS also produces a "Data Catalog" that summarizes
the contents of many national-level data sets useful for alcohol
research.  The catalog and most of these reports are available by
writing AEDS, c/o Cygnus Corporation, Suite 1275, 1400 Eye Street, NW,
Washington, DC 20005.

The U.S. Government's health survey organization, the National Center
for Health Statistics (NCHS), in April 1985, published a valuable
analysis of its data resources related to research on alcohol, drug
abuse, and mental health problems.  Entitled "An Inventory of Alcohol,
Drug and Mental Health Data Available from the National Center for
Health Statistics," it can be obtained from the National Technical
Information Service, document PB 85-226199, or is available in
libraries that carry the NCHS Statistical Report Series.  It is filed
under the subtitle "Programs and Collection Procedures, Series 1, No.

Detailed data on fatal traffic accidents are available from the
National Highway Traffic Safety Administration's (NHTSA) Fatal Accident
Reporting System.  Published reports can be requested from the National
Center for Statistics and Analysis, NHTSA, NRD 30, 400 7th Street, SW,
Washington, DC 20590.  Data tapes are available from DOT Transportation
Systems Center, Attention: John F. Mitchell, DTS 32, Kendall Square,
Cambridge, MA  02442.

Alcoholism treatment data have been collected in census surveys of the
treatment system in the National Drug and Alcoholism Treatment Unit
Surveys conducted in 1979, 1980, 1982, 1987, 1989, and 1990.  Recent
summary reports and access to data tapes are available through the
Alcohol Epidemiologic Data System (AEDS), mentioned earlier.


Through AEDS, the Division of Biometry and Epidemiology (DBE) has
acquired several hundred data sets over the past nine years.

Many of these data sets are from small regional or local surveys with
limited potential for analysis at the national level.

There are, however, a number of national-level data sets that routinely
form the core of AEDS' secondary data analysis efforts.  These data
sets are national surveys of alcohol consumption and abuse, and
national mortality and morbidity statistics.  They include the:

o  National Health and Nutrition Examination Survey I
o  National Health and Nutrition Examination Survey II
o  National Health and Nutrition Examination Survey I, Epidemiologic
Follow-up Study
o  Hispanic Health and Nutrition Examination Survey
o  National Health Interview Survey 1983
o  National Health Interview Survey 1985
o  National Health Interview Survey 1987
o  National Health Interview Survey 1988
o  National Natality Survey and National Fetal Mortality Survey 1980
o  National Maternal and Infant Health Survey 1988
o  Multiple Cause of Death, Mortality Detail 1968-1988
o  National Mortality Followback Survey 1986
o  National Hospital Discharge Survey 1975-1989
o  Fatal Accident Reporting System 1975-1989

With the exception of the Fatal Accident Reporting System (operated by
the National Highway Traffic Safety Administration) and the MEDSTAT
data sets (provided by MEDSTAT Systems, Inc.), all of these data sets
are operated by the National Center for Health Statistics (often with
funding and planning assistance from NIAAA).

This section presents a brief narrative description of each data set.
Each description discusses the data set's sample, key variables (e.g.,
demographic variables) and alcohol related variables.

National Health and Nutrition Examination Survey I (NHANES I)

The NHANES I is a nationwide, multistage, stratified probability sample
of about 24,000 persons 1-74 years old.  Data are weighted to represent
the civilian, non institutionalized population of the 48 contiguous
States, excluding Indian reservations.

Data were collected between April 1971 and October 1975 on the medical
history, examination, diet, and laboratory tests of sample persons.
Demographic data on age, sex, race, ethnicity, education, occupation,
employment status, marital status, income, and language were also

The medical exam portion of NHANES I has four questions related to

o  During the last year, have you had at least one drink of beer, wine
or liquor?

o  How often do you drink?  (Range goes from daily to 2 or 3 times per
year, for those who answered "yes" to question 1 above.)

o  Which do you most frequently drink (beer, wine, liquor)?

o  When you do drink (beer/wine/liquor), how much do you usually drink
over 24 hours?

The 24-hour dietary recall interview codes are for alcohol ingested
during a 24-hour period.  Also, information on caloric value for each
food substance ingested has been included to permit analysis of food
calories, alcohol calories, and percentage of alcohol in the diet.

While the battery of NHANES I interviews, exams, and tests were
administered to persons 1-74 years old, the alcohol consumption data
were collected from persons 12-74 years old.

Previous researchers suggest merging data from the medical exam and
24-hour dietary recall interview to analyze alcohol consumption.  Given
the extensive medical and nutritional data provided in NHANES I, this
data base appears to be useful in associating alcohol consumption with
other nutritional indices and medical characteristics.

National Health and Nutrition Examination Survey II (NHANES II)

The NHANES II is a stratified, multistage, probability sample of the
civilian noninstitutionalized U.S. population.  Approximately 21,000
people between the ages of 6 months and 74 years were interviewed
between 1976 and 1980.

As part of the NHANES series, this survey is designed to monitor the
nutritional status and medical condition of the U.S. population.  Eight
separate survey instruments are used to collect data on medical
history, diet, medication and vitamin usage, and behavior.  Three
subgroups of the population are given special consideration in the area
of nutritional assessment.  These are:  preschool children (6 months -
5 years), the aged (60-74 years), and persons whose income was below
the 1970 poverty level.

Frequency of alcohol consumption and beverage preference are obtained
from the Dietary 24-hour Recall and Dietary Frequency form.  Only
respondents aged 12-74 are asked for this information.

National Health and Nutrition Epidemiologic Follow-up Survey (NHEFS)

Although NHANES I provided a wealth of information on the prevalence of
health conditions and risk factors, the cross sectional nature of the
original survey limits its usefulness for studying the effects of
clinical, environmental, and behavioral factors and in tracing the
natural history of disease.  Therefore, the NHEFS was designed to
investigate the association between factors measured at baseline and
the development of specific health conditions.  This is an important
consideration in determining the long term health effects of behaviors
such as alcohol and tobacco use.

Three waves of the NHEFS have been completed to date:

In the first wave, conducted from 1982-84, data were collected on all
14,407 subjects that were examined at NHANES I.  Detailed data from
personal interviews on health, nutrition, exercise and other behaviors
were collected in addition to standard demographic variables.

The second wave, completed in 1986, collected information by telephone
interviews on changes in the health and functional status since the
last contact with the older members of the NHEFS cohort.  It was
restricted to those subjects who were at least 55 years old at NHANES

Finally, the third wave of the NHEFS was a follow-up of the entire
cohort similar to the 1982-84 survey.  Data on changes in health status
and behavior were obtained primarily through telephone interviews.

Alcohol questions were included in each wave of the follow-up and
covered the following broad topic areas:

o  reasons for not drinking;
o  quantity and frequency of consumption; and
o  lifetime drinking patterns.

All three waves of the NHEFS can be linked to the baseline survey using
individual patient identifying numbers.

Hispanic Health and Nutrition Examination Survey (HHANES)

The HHANES is the first survey in the HANES series targeted
specifically at a U.S. minority.  Data were collected on approximately
12,000 Mexican-Americans, Cuban-Americans and Puerto Ricans between
1982 and 1984.  As part of the HANES series, the purpose of the survey
is to monitor the health and nutritional status of the U.S. Hispanic

The core instrument collects detailed information on medical history,
health problems, nutritional status, and laboratory tests, in addition
to standard demographics.  The Alcohol, Drug Abuse, and Mental Health
Administration sponsored the supplement, which was administered during
the medical exam to persons 12 to 74 years of age.

The alcohol section is composed of 75 questions designed to elicit
information on the quantity, frequency, and volume of consumption,
lifetime drinking patterns, self-classification of drinking type, and
reasons for not drinking currently.  The survey is designed so that
alcohol consumption can be correlated with the health and nutrition
parameters identified by the core instrument.

National Health Interview Survey (NHIS 83) Alcohol/Health Practices

This survey is designed to collect information on health status, health
habits, disabilities, and contacts with health practitioners.
Conducted over several years, the NHIS data provide the largest source
of linked records relating general health status of the U.S. population
with measures of alcohol consumption.

Data were collected in 1983 on approximately 25,000 people age 18 and
above.  The core instrument contains questions eliciting information on
health and behavior practices, doctor services, and dental care.

The alcohol supplement is essentially identical to the HHANES
supplement.  The main differences are that NHIS 83 employs a 2-week
reference period for alcohol consumption questions as opposed to
HHANES' 4-week period; and NHIS 83 includes a series of questions
covering specific alcohol-related problems.

National Health Interview Survey (NHIS 85) Health Promotion and Disease
Prevention Questionnaire

The NHIS 85 continues the focus of previous waves of the NHIS by
collecting data on the health and health care visits of Americans.
Approximately 33,000 people age 18 and older were interviewed in 1985.

As in 1983, alcohol questions are included in a separate questionnaire.
The 1985 alcohol questions are not as detailed as those for 1983.
However, information on lifetime drinking, quantity and frequency of
consumption, reasons for not drinking, and alcohol-related problems is
collected.  For the first time, questions on the public's awareness of
fetal alcohol syndrome are asked on a NHIS instrument.

National Health Interview Survey (NHIS 87) Epidemiology Study

This survey includes basic information (e.g., health status, health
habits, physician visits, and a wealth of demographic information) from
the core questionnaire of the NHIS and various cancer risk factors
(including alcohol) in the Epidemiology Study.

The NHIS 87 Epidemiology study includes questions on acculturation,
food frequency consumption items (over 60 food categories, including
alcohol) smoking habits, other tobacco use, reproduction and hormone
use, family history of cancer, cancer survivorship, occupational
exposures, and relationships and social activities.

Data were collected on 22,080 respondents aged 18 years and older, with
an oversample conducted in Hispanic households.

As part of the section on food frequencies, the alcohol questions in
the NHIS 87 include separate quantity-frequency items on beer, wine,
and liquor.  The beverage-specific items ask the number of times in the
past year each beverage was consumed, the number of drinks consumed
when the respondent drank, and the portion size (small, medium, or
large) of the drink(s).  A final two questions on alcohol ask:  (1) if
there was any period in which the respondent drank 5 or more drinks of
alcoholic beverage almost every day, and (2) how long the period

National Health Interview Survey (NHIS 88) Alcohol Section

Portions of this survey replicate the alcohol questionnaire in the NHIS
83, but the survey is expanded considerably to include questions on the
drinking level of each family member, family history of alcoholism or
problem drinking, and symptoms of alcohol abuse and alcohol dependency.

A randomly selected person 18 years of age or older from each household
in the NHIS sample was asked to respond to the alcohol section.  The
completed number of questionnaires for the alcohol section was 43,809,
a response rate of about 87 percent.

As with the NHIS 83, the alcohol questions in the NHIS 88 are very
detailed, with specific quantity-frequency items on beer, wine and
liquor, along with estimates of total alcohol intake.  Other drinking
behaviors also are examined in detail, including drinking history as
represented by any periods of light, moderate, and heavier drinking
over the respondent's lifetime.  The lifetime and the past-year
prevalence of 41 symptoms of alcohol abuse and alcohol dependency are
asked of current drinkers; lifetime prevalence of these symptoms is
asked of former drinkers.  Also, overall consumption of alcohol in the
past year is asked of all respondents, except lifetime abstainers.
Detailed consumption items are asked of all current drinkers.

National Natality Survey and National Fetal Mortality Survey 1980
(NNS/NFMS 1980)

These two different surveys utilize the same survey instruments and are
designed to enable analyses of high-risk pregnancies.  Data were
collected in 1980 on:  (a) a sample of 9,941 live birth (or fetal
death) certificates; (b) a questionnaire mailed to married mothers; and
(c) questionnaires mailed to 3 types of medical service providers (as
appropriate) -- attendants at delivery, hospital, and radiologic
services.  Data from these surveys include numerous personal,
demographic, health status, health practices, health resources
utilization, and infant status variables.

The questionnaires mailed to the mother contained the following four
alcohol questions:

o  Did mother drink alcoholic beverages during 12 months before
o  Frequency and amount of alcohol consumption before pregnancy?
o  Frequency and amount of alcohol consumption during pregnancy?
o  Kinds of alcoholic beverages consumed (in 7 categories of beer,
wine, liquor, and combinations).

National Maternal and Infant Health Survey (NMIHS) 1988

The 1988 NMIHS is a nationally representative followback survey of
mothers, their prenatal care providers, and their hospitals of delivery
conducted by the National Center for Health Statistics (NCHS).  The
main purpose of the survey is to study some of the factors related to
poor pregnancy outcomes such as maternal smoking, drinking, and drug
use.  It is also useful in assessing  progress towards achieving
maternal and infant health objectives set by the U.S. Department of
Health and Human Services for the year 2000.  The sample consisted of
11,000 women who had live births, 4,000 who had late fetal deaths, and
6,000 who had infant deaths.  Based on information from certificates of
live births, reports of fetal death, and certificates of infant death
in 1988, questionnaires were mailed to mothers irrespective of marital
status.  Prenatal care providers and hospitals of delivery were
contacted after being identified by the mother.  Then information
supplied by mothers, prenatal care providers, and hospitals of delivery
was linked with the vital records to expand knowledge of maternal and
infant health.  This survey includes data on demographic
characteristics, personal characteristics, health status, health
practices, health resources utilization, other pregnancies and
deliveries, and infant status.

The questionnaire mailed to the mother contained the following alcohol

o  Did mother drink any alcoholic beverages during the 12 months before
o  Frequency and amount of alcohol consumption before pregnancy?
o  Frequency and amount of alcohol consumption during pregnancy?
o  Did mother reduce drinking of alcoholic beverages during pregnancy?
o  Reason for reducing drinking of alcoholic beverages during

A Longitudinal Follow-up (LF) of mothers in the survey was planned to
provide information on health and development of low-birth weight
babies, child care and safety, maternal health, maternal depression,
and plans for adoption and foster care.  Data collection for the LF
survey started in January 1991.

Multiple Cause of Death, Mortality Detail, 1968-1988

These tapes contain vital statistics data for both underlying and
multiple causes of death for all deaths occurring during a particular
calendar year.  The tapes include deaths at any time after live birth;
therefore, no fetal deaths have been included.  Demographic variables
include date of death, age, race, sex, and geographic data.

There are specific disease categories under ICD-8 and ICD-9 which are
generally believed to be alcohol related (e.g., alcohol dependence
syndrome and cirrhosis of the liver).  These may be listed for specific
records, as underlying or contributing causes of death.

National Mortality Followback Survey, 1986 (NMFS)

The 1986 NMFS is designed to supplement information obtained from death
certificates with information on important characteristics of the
decedent that may have affected mortality.  These characteristics
include patterns of lifetime behavior, health services experience prior
to death, socioeconomic status, and many other aspects of life that may
affect when and how death occurs.  Data are based on a one percent
sample of deaths in 1986.  The tape consists of records for 18,733
decedents.  The records contain data from death certificates, the
informant survey questionnaire responses, and the facility abstract
record.  Starting with the death records as the sampling frame,
questionnaires were mailed to the next-of-kin addressing lifestyle and
health related variables.  Information from health care facilities in
which the decedent spent one or more nights during the last year of
life was obtained for 12,275 decedents.

Alcohol questions include:  whether the decedent ever had 12 drinks in
his/her lifetime, how often he/she had a drink, and on the days that
the decedent drank, how many drinks he/she had.  In addition to
diagnostic data on cause(s) of death and hospital diagnoses, the
informant was asked whether the decedent ever had cirrhosis of the
liver at any time in his/her life.

National Hospital Discharge Survey (NHDS) 1975-1989

The NHDS collects data from short-stay hospitals throughout the U.S.
excluding military, VA, and institutional hospitals.

Data are collected from the hospital record face sheets of a random
sample of discharges (sample size varies from year to year but is
generally around 220,000 discharges).  Basic demographic data (e.g.,
sex, age, marital status, and geographic location) are collected as
well as medical diagnoses and operations.

Data on four specific alcohol-related diseases, alcohol dependence,
alcohol abuse, alcoholic psychoses, and liver cirrhosis are recorded.
Other conditions with alcohol mentioned as a contributing factor also
can be analyzed.

Fatal Accident Reporting System (FARS) 1975-1990

The FARS is an automated system containing data on all fatal traffic
accidents occurring each year within the 50 States, the District of
Columbia, and Puerto Rico.  To be included, an accident must involve at
least one motor vehicle moving on a roadway customarily open to the
public, and result in the death of a person (occupant of a vehicle or
nonoccupant) within 30 days of the accident.  Data concerning fatal
traffic accidents are  gathered from the State's own source documents
and translated appropriately to codes on standard FARS forms.  The data
sources may include:  police accident reports; State vehicle
registration files; State driver licensing files; state highway
department files; vital statistics documents; death certificates;
coroner/medical examiner's reports; hospital medical reports; and
emergency medical services reports.

Some of the key variables recorded by FARS include age, sex, role in
the accident, injury severity, day of the week and time of day of the
accident, and the number of vehicles involved.

Alcohol involvement in an accident is determined with three variables.
They are:

o  a blood alcohol concentration (BAC) test;
o  the judgment of the investigating officer; and
o  whether DWI charges were filed (variable added in 1982).

MEDSTAT Systems Data Base 1987-1989

NIAAA has contracted with MEDSTAT Systems, Inc., of Ann Arbor,
Michigan, to provide a subset of the MEDSTAT data base, which consists
of more than 180 million health care claims for 5.7 million privately
insured individuals under the age of 65.  To produce the data base,
MEDSTAT contracts with more than 60 large U.S. corporations to collect
information on their employer-based health insurance programs.  Data
are collected from over 100 commercial insurance companies, Blue
Cross/Blue Shield plans, third party administrators, and
self-administered corporations.  (The data base is not a statistically
determined sample and it, therefore, is not nationally representative.)

The subset of the MEDSTAT data base acquired by NIAAA contains
approximately 2 million inpatient and outpatient claim records for
families in which at least one member had an alcohol- or other
drug-related condition or procedure.  Over 40 alcohol- and other
drug-related conditions and procedures are coded in the data base,
including alcoholic psychoses, alcohol dependence syndrome, alcohol
abuse, and liver cirrhosis (with and without mention of alcohol).  The
conditions are recorded on the claim forms with the International
Classification of Diseases, Ninth Edition, Clinical Modification
(ICD-9-CM) codes.  For billing and administrative purposes, the data
base also records conditions and procedures using the following three
coding systems: (1) Diagnosis Related Groups, (2) Current Procedural
Terminology, Fourth Edition, and (3) Health Care Procedure Codes.

In addition to the information on alcohol- and other drug related
conditions and procedures, the data base also contains variables
describing the demographic characteristics of the patients, benefits
plans, clinical treatment, and financial arrangements.

The initial version of the alcohol- and other drug-related conditions
and procedures data tape contains approximately 50,000  inpatient and
2 million outpatient claim records for the years 1987 through 1989.


It is generally accepted that alcohol contributes significantly to
overall morbidity and mortality.  What is unclear, however, is its
precise contribution to these events.  Recent estimates suggest that
alcohol may be involved in 15 to 90 percent of all serious events,
depending on the category of event (Roizen, 1982).  This is an
unacceptably broad range with little practical value for surveillance

To arrive at more specific estimates of alcohol involvement in injury,
illness, and death, the Division of Biometry and Epidemiology regularly
undertakes analyses of a variety of data sets.  The most useful of
these are the several large national data sets described in the
previous section.

Analysis of these data sets enables NIAAA to estimate alcohol's
contribution to morbidity and mortality.  An example is:

o  There were 7.4 alcohol-related traffic deaths per 100,000 population
in 1989.

This discussion has not included all data sets that could potentially
be of use to researchers, but has focused on data sets that are
national in scope and contain alcohol-related data.  Other Federal
agencies as well as State agencies may have additional data resources
that would be of use to researchers.

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