Communities Mobilizing for Change on Alcohol:

Objective: Communities Mobilizing for Change on Alcohol (CMCA) was a randomized 15-community trial of a community organizing intervention designed to reduce the accessibility of alcoholic beverages to youths under the legal drinking age. Method: Data were collected at baseline before random assignment of communities to intervention or control condition, and again at follow-up after a 2.5year intervention. Data collection included in-school surveys of twelfth graders, telephone surveys of 18to 20-year-olds and alcohol merchants, and direct testing of the propensity of alcohol outlets to sell to young buyers. Analyses were based on mixed-model regression, used the community as the unit of assignment, ook into account he nesting of individual respondents or alcohol outlets within each community, and controlled for relevant covariates. Results: Results show that the CMCA intervention significantly and favorably affected both the behavior of 18to 20-year-olds (effect size = 0.76, p < .01) and the practices of on-sale alcohol establishments (effect size = 1.18, p < .05), may have favorably affected the practices of off-sale alcohol establishments (effect size = 0.32, p = .08), but had little effect on younger adolescents. Alcohol merchants appear to have increased ageidentification checking and reduced propensity to sell to minors. Eighteento 20-year-olds reduced their propensity to provide alcohol to other teens and were less likely to try to buy alcohol, drink in a bar or consume alcohol. Conclusions: Community organizing is a useful intervention approach for mobilizing communities for institutional and policy change to improve the health of the population. (J. Stud. Alcohol 61: 85-94, 2000) N 1997, over half (53%) of U.S. high school seniors re.ported having drunk alcohol in the past 30 days, and 31% reported having consumed five or more drinks on at least one occasion in the previous 2 weeks (Johnston et al., 1997). Among college students, drinking rates are even higher (Wechsler et al., 1995). Use of alcoholic beverages by youths significantly increases risk for a range of health and social problems, including traffic crashes, assault, suicide, drowning, recreational injuries and early unprotected sex (Baker et al., 1992; Hayward et al., 1992; Leigh, 1990; Roizen, 1982, 1993; Stall et al., 1986). As a result, states and communities continue to seek ways to effectively prevent teenage drinking and its damaging sequelae. Most programmatic interventions to reduce youth drinking and its consequences have focused on reducing the demand for alcohol by youths, traditionally through schoolbased programs. Programs from the 1960s to mid-1980s used information-based and affective-change strategies, and were found to be ineffective (Moskowitz, 1989). More recently, programs based on the social influences model have emerged, teaching specific drug use resistance skills or more Received: September 23, 1997. Revision: June 23, 1998. *The CMCA project was funded by the National Institute on Alcohol Abuse and Alcoholism and the Center for Substance Abuse Prevention under grant R01-AA90142 (Alexander C. Wagenaar, principal investigator). 85 general ife skills. Some of these programs have shown beneficial effects, although effects often decay after program implementation ends, and successful programs require intense implementation and dozens of sessions across multiple years (Botvin et al., 1995; Ellickson and Bell, 1990; Perry and Kelder, 1992). Widely disseminated programs currently in use throughout the country, such as DARE, are not effective (Clayton et al., 1996; Dukes et al., 1996; Ennett et al., 1994). There is also a substantial literature on the effects of reducing the supply of alcohol. For example, increasing the legal age for purchase or consumption of alcohol from 18 to 21 significantly reduced youth drinking and alcohol-related casualties such as traffic crashes (Wagenaar, 1993). Reducing the availability of alcohol via increasing the excise tax, and thereby increasing retail prices, has a significant effect on alcohol consumption; this effect is particularly large for youths, given the high level of price elasticity among teenage drinkers (Chaloupka et al., 1998, in press; Grossman et al., 1994). Recently, encouraging results have appeared for community-based alcohol interventions. Project Northland was a 28-community randomized trial with social-influencesmodel school curricula implemented in sixth through eighth grade, supplemented with peer leadership, parent education and community task forces (Perry et al., 1996). Results showed significantly lower prevalence of alcohol use after 3 years of intervention, with the effects most notable among 86 JOURNAL OF STUDIES ON ALCOHOL / JANUARY 2000 those who were nonusers of alcohol at baseline. Effects decayed after the intervention was no longer active (Perry et al., 1998). Consequently, the second phase of Project Northland currently underway is focused more directly on community action to reduce the supply of alcohol to teenagers. Finally, a 5-year quasi-experimental prevention trial implemented in three communities has recently been completed. The goal of this effort was to specifically reduce alcohol-related injuries. Results indicate significant reductions in alcohol sales to minors and alcohol-involved traffic crashes, and no demonstrated effects on sales to intoxicated patrons or other broader measures of alcohol availability (Holder et al., 1997). Intervention design and implementation The Communities Mobilizing for Change on Alcohol (CMCA) project was a randomized community intervention trial testing a community organizing intervention designed to reduce youth access to alcohol. The project sought o reduce the number of alcohol outlets that sell to young people; reduce the availability of alcohol to youths from noncommercial sources uch as parents, siblings and older peers; and reduce community tolerance of underage drinking and adult provision of alcohol to youths. The project organized for action through public institutions uch as city councils, schools and enforcement agencies, and private institutions uch as alcohol merchants, business associations and the media. Details on the theoretical foundations and design of the CMCA project are available elsewhere (see Wagenaar et al., 1994; Wagenaar and Perry, 1994). During the first phase of the intervention period, the organizers completed a total of 1,518 one-on-one meetings with leaders and citizens from diverse sectors of the community. The one-on-ones were designed to help the organizers deepen their understanding of the community, its history, culture and networks of power and influence. They also helped build personal and political relationships with diverse citizens in the community; gain an understanding of individuals' commitments, interests and views; and identify individuals for recruitment into the core leadership group or a broader set of community activists. During this initial stage, the organizers also conducted a detailed review of extant alcohol control policies, procedures and enforcement practices in their communities. During the second phase, a local core leadership group, called a strategy team, and larger base of active citizens was developed, again reflecting diverse sectors of each community. As the organizers worked to build a base of support, media advocacy efforts (Wallack et al., 1993) resulted in rapid increases in media coverage of CMCA specifically (a total of 97 articles published), as well as increasing coverage of alcohol issues more generally (from 5,152 column inches in 1993 to 7,084 column inches in 1995). Finally, there were many changes in specific policies, procedures and practices in the CMCA communities during the intervention phase of the project. Intervention implementation and intermediate outcomes are reported in Wagenaar et al., 1999. Research design Method The CMCA project employed a randomized community trial design for most of its outcome measures and a multiple time-series design for the remainder (Wagenaar et al., 1994). Seven socially and geographically distinct upper midwestern communities were randomly assigned to receive the intervention, with eight others randomly assigned to serve as controls. Baseline surveys were conducted in each community among a number of targeted groups and repeated 3 years later. In addition, a multiple time-series design was superimposed on the community trial such that the outcomes for the multiple time-series design were collected from the same communities, but the outcome variables were measured at many more points in time both prior to and after the onset of the intervention program. Description of communities The community was defined based on geography, consisting of a city and its surrounding school district. All communities had a school district that included all the areas within the incorporated city plus surrounding areas outside the city limits. This unit was such a size that the intervention could feasibly be implemented in seven communities. In addition, the school district represented a cohesive social unit, especially for youths. Finally, secondary data of interest were available at the level of the school district, city and county. All school districts in Minnesota and western Wisconsin were screened for: ninth-grade nrollments of at least 200, no participation in other major alcohol-related studies or programs, at least 25 miles distance from other eligible communities, and concentration of students in three or fewer municipalities. In addition, we excluded the MinneapolisSt. Paul metropolitan area and, importantly, excluded cities with preexisting projects or special efforts to address youth drinking (e.g., communities with CSAP Parmership grants). Twenty-four districts were identified that met these criteria and were invited to participate in the study. To participate, district officials had to agree to random assignment to the intervention or control condition and to allow access to ninthand twelfth-grade students for the baseline and follow-up school surveys. Fifteen of the 24 eligible districts agreed to participate in the study; the most common reason for refusal was recent participation in another survey that included items on alcohol use. The 15 communities had an average population of 20,836 (range = 8,029 to 64,797). Three of the communities were home to a 4-year college and the average distance to the University of Minnesota was 90 miles (ranging from 18 to 240 miles). There were on average 35 on-sale