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Brief Intervention

I. Learning Objectives

  • A. Participants will increase their knowledge of brief intervention treatment.
  • B. Participants will increase their knowledge of the evidence that supports the use of brief intervention in student health settings.
  • C. Participants will increase their skills in conducting brief talk therapy.

II. Chronology

  • A. 20-to 40-minute large group lecture using a sub-sample of about 30 slides.
  • B. 10- to 20-minute demonstration role-play.
  • C. 10- to 20-minutes for participants to practice role-plays.

III. Training Materials

Overview

Brief alcohol interventions are time-limited counseling strategies that focus on changing behavior and increasing treatment compliance. Brief interventions are primarily used to reduce alcohol use in non-dependent, non-addicted drinkers. The goal of brief intervention is to help students reduce their alcohol use to low-risk levels or to facilitate referral to alcohol treatment programs for students who are not able to reduce or stop drinking on their own. This module is designed for busy primary care clinicians with limited time to work with students. These interventions are designed for use in high-volume settings such as student health clinics, urgent care settings, and general primary care settings.

Brief intervention is a specific clinical protocol that is primarily clinician-directed and focused on convincing patients in one or two brief visits to reduce their drinking. Based on motivational interviewing techniques (see Module 4 of this curriculum) and a harm reduction paradigm, clinicians focus on helping students cut down and reduce their alcohol use. Studies have found that as many as 50% of persons are willing to work with their physician or health care provider to reduce their alcohol use (Fleming, 2002).

Brief intervention is not used exclusively for the treatment of alcohol problems; in fact, these counseling strategies are widely used by primary care providers, counselors, and other health care professionals to alter patient behavior. This method is routinely used to help individuals change dietary habits, stop smoking, reduce HIV risk, and take medications as prescribed. The following information is a very brief review of the evidence that supports the implementation of brief intervention in student health settings. Reports in the NIAAA 10th Special Report to the U.S. Congress on Alcohol and Health [PDF] (Fleming, 2000), the NIAAA journal Alcohol Research & Health (Fleming, 1997), and an article prepared for the NIAAA college drinking committee (Larimer and Cronce, 2002) provide a more comprehensive review of the subject.

What is Brief Intervention?

This curriculum recommends the utilization of the following protocol to conduct brief interventions with college students:

4 step Brief Intervention diagram
[D]

1. Conduct an assessment:

"Tell me about your drinking." "What do you think about your drinking?" "What do your friends think about your drinking?" "Have you ever done something you regret while you were drinking?" " Have you had any problems at school or with your friends related to your alcohol use?" "Have you ever been concerned about how much you drink?" "Are you interested in changing how much you drink?"

2. Provide direct, clear feedback:

"As your clinician/provider/therapist, I am concerned about how much you drink and how it is affecting you." "The car accident was probably a direct result of your alcohol use." "You reported an unwanted sexual encounter the last time you got drunk." " You reported to me that you flunked an exam because you were so hung over." "While you may think you drink less than your friends, you are drinking at a high-risk level that could cause serious health problems if you continue." "Contrary to common belief, most students do not drink the way you do."

3. Establish a treatment contract through negotiation and goal setting:

"You need to reduce your drinking. What do you think about cutting down to three to four drinks 1-2 times per week?" "If you can cut down, you can still have fun and go to parties. However, cutting down to 3-4 drinks over an evening will significantly reduce your risk of getting into trouble with your alcohol use." " If you can't cut down, then you may have a very serious problem with your drinking. I would like you to use these diary cards to keep track of your drinking over the next two weeks. We will review these at your next visit."

4. Apply behavioral modification techniques (optional if time allows):

"Here is a list of situations when people drink and sometimes lose control of their drinking. Let's talk about ways you can avoid these situations." (See the intervention workbook at the end of this module for examples).

5. Ask patients to review a self-help booklet (optional but very helpful):

"I would like you to review this booklet and bring it with you at your next visit. It would be very helpful if you could complete some of the exercises in the book." (See workbook)

6. Set up a continuing care plan for nurse/health educator/social worker reinforcement phone calls and clinic visits:

"I would like you to schedule a follow-up appointment in one month so we can review your diary cards and I can answer any questions you might have. I will also ask one of the nurses to call you in two weeks. When is a good time for the nurse to call?"

In addition to the above six steps, there are a number of techniques that clinicians can use to increase the efficacy of brief intervention:

  • A. Provider empathy and body language are powerful change agents. Many studies have shown that one of the strongest predictors of change is related to the empathy of the counselor or therapist.
  • B. Creating a safe protective environment is another key element, especially for women. Many students drink to relieve stress, anxiety and fears. Students are reluctant to share these fears and concerns with clinicians, especially if they have had embarrassing or dangerous experiences while drinking or at parties.
  • C. Developing mutual trust and respect is an important aspect of the clinician-patient relationship that can lead to risk-taking in terms of revealing sensitive or painful memories.
  • D. Creating cognitive dissonance and dealing with a patient's ambiguity toward change is another effective strategy. Students want to be accepted and to be cool. However, throwing up all over one's friends is not a pleasant experience for anyone. Being loud and abusive does not lead to respect or acceptance among other students. Pointing out the obvious adverse effects associated with heavy drinking can lead to students questioning their use of alcohol
  • .
  • E. Other tools include self-monitoring diary cards. Monitoring alcohol use can surprise students as to their level of use.
  • F. Self-help booklets and referring patients to reading materials can lead to behavioral change. These booklets may be useful to some students who are ready to change. While information alone is not an effective change agent, specific methods on how to change can be very helpful.
  • G. Many patients respond to stories about persons who have changed their alcohol use, especially if delivered by a recovering peer. Peer counseling can be an effective method to help students change their behavior in a student health center. Having a peer counselor available in the student health center can greatly facilitate the ability of a primary care provider to effect behavioral change.
  • H. Asking a patient to bring his/her roommate, partner, or close friend with them is another technique that can supplement brief intervention.

Does Brief Intervention Work?

There have been over 70 studies reported in the literature testing the efficacy of brief intervention. Brief intervention studies to reduce alcohol use and alcohol-related harm have been one of the most active areas of research in the alcohol field. These studies have primarily been conducted in Western Europe and North America. Six of these brief intervention motivational interview trials have focused on college-aged populations. Three of these studies were conducted in medical care settings-one in a student health center, one in the emergency department, and one in an alcohol treatment program. One study conducted in primary care settings included a large sample of young adults and is included in this review.

In addition to the classic brief motivational intervention studies, there have been a number of studies focused on reducing alcohol use in individual students, utilizing a number of techniques that overlap with brief intervention and motivational interviewing. Other interventions with college students have included:

  • Educational/information interventions;
  • Values clarification programs;
  • Normative education programs;
  • Cognitive-behavioral skills-based programs;
  • Alcohol focused skills training programs; and
  • Intensive treatment programs.

For information on these other interventions, the author refers readers to Larimer and Cronce (2002) which can be found in Supplement 14 of the Journal of Alcohol Studies.

Below is a detailed review of 7 brief intervention studies that are applicable to student health settings.

Study 1

Baer (1992) conducted a study with 132 college students at the University of Washington. Subjects were assigned to one of three groups: alcohol skills group therapy, alcohol skills self- help booklet, and one-hour feedback. There was significant pre- post-reduction in alcohol use in all three groups. Limitations of the study included the absence of a no-intervention control group and poor follow-up rates. The study was conducted in a research setting rather than in a clinical setting.

Study 2

Marlatt (1998) conducted a trial with a sample of 348 high-risk freshman identified prior to starting school. Students willing to participate were either assigned to a no-intervention control group or the intervention group. The intervention group received written feedback, personalized feedback one-year post-randomization, and written feedback two years post-randomization. Students assigned to the intervention group reported lower levels of alcohol use and fewer alcohol-related adverse events. The study used the Rutgers Alcohol Problem Index to measure alcohol events. While the study was not conducted in a student health center, the methods may be applicable to clinical settings.

Study 3

Borsari and Carey (2000) replicated portions of the work of Marlatt in a sample of 60 students recruited from a psychology class. Students received a similar intervention as the one developed at the University of Washington (Dimeff, 1999,) with the difference that the intervention was delivered over a few weeks rather than over 2 years. Students (n=29) assigned to the intervention group reported lower levels of alcohol use 6 weeks post-intervention compared to the no-intervention control group.

Study 4

Larimer and colleagues (2000) recruited 296 students from 12 fraternities and sororities and randomly assigned these students to brief motivational intervention or no-intervention control group. The intervention was conducted by a research therapist. The intervention group reported reduced alcohol use from 15.5 to 12 standard drinks per week, while the control group increased alcohol use from 14.5 to 17 drinks per week. There were minimal differences reported in women sorority members. This lack of effect in the women may be related to the small sample size. The generalizability of this study to primary care student health settings is not clear.

Study 5

A study conducted in a student health setting recruited a sample of 41 students in a college center waiting room (Dimeff, 1997). Seventeen students were randomly assigned to a computerized personalized feedback report that was reviewed with the students by their student health clinicians. The 24 subjects in the control group received a brief computerized assessment without feedback. The subjects exposed to the computerized feedback reported decreased drinking and had fewer negative consequences at follow-up. This is the only study reported in the literature that was conducted in a student health clinic where a primary care provider participated in the intervention.

Study 6

Monti and colleagues (1999) tested the efficacy of brief intervention in the emergency department setting with young adults ages 18 and 19. Ninety-four subjects were randomized to an intervention group or usual emergency department care. The intervention consisted of a single counseling session delivered by a research therapist. Subjects were followed for three months. The intervention group reported a reduction in alcohol-related injuries, traffic violations, and drinking and driving events. However, there was no difference in alcohol use between the control and intervention groups at the follow-up. While the model requires the presence of a counselor or therapist available to the emergency department staff on short notice, the intervention model may work in a student health center.

Study 7

The largest brief intervention trial conducted in primary care settings with a large sample of young adults was Project TrEAT - A Trial of Early Alcohol Treatment (Fleming 1997, 2002). Project TrEAT was started in 1992 with 48-month follow-up interviews completed in the fall of 1998. Subjects were recruited in the office waiting rooms of sixty-four family physicians from 17 clinics located in Southern Wisconsin. Over 17,695 adults ages 18-64 completed a screening instrument while waiting to see their primary care physician for a routine appointment. Twenty-four hundred and fifty subjects screened positive for high-risk problem drinking. A total of 774 patients remained eligible following a research interview and were randomized to "usual care" or "brief intervention." A total of 225 young adults (ages 18-30) participated in the trial.

The intervention was delivered by the patient's family physician in the context of a general office visit. This is in contrast to the majority of the trials list above where a research therapist delivered the intervention. The intervention consisted of four parts. There were two face-to-face brief interventions and two nurse follow-up phone calls. The face-to-face physician intervention utilized a scripted workbook that the patient worked on at home between visits (a modified version of this workbook is contained in Appendix A). Diary cards were used to monitor the patient's alcohol use. The workbook included a review of their overall health factors, a list of alcohol-related adverse effects, a graph of the prevalence of alcohol use disorders, contracting methods using a prescription blank, and cognitive behavioral exercises. The face-to-face interventions were conducted in 10-15 minutes, depending on the physician and the patient's responsiveness to the intervention.

Of the 774 subjects enrolled in the trial, 723 completed the 12- month follow-up interview (93.4% follow-up rate) and 83% completed the 48-month follow-up. The trial had complete or partial follow-up data on 98% of the subjects. The major alcohol use outcome variables were average drinks per week, binge drinking, excessive drinking, hospital days, emergency department visits, legal events, and costs. Patient self-report, family member report, medical records, claims data, and Department of Transportation and arrest data were used to assess the major outcomes of interest.

Project TrEAT found large decreases in all alcohol-use variables in all groups at 6, 12, 24, 36 and 48-month follow-up. There were significant differences between the experimental and control groups at each follow-up period. The intervention group reduced its alcohol use 20-40% more than the control group. There were also significant reductions in utilization events, legal events, and costs. These differences were similar across all age groups, including the young adults in the sample.

Chart Percent Drinking Excessively in Past Week [D]

Chart Mean Number of Drinks in Past 7 Days (n=774) [D]

Chart Number of Binge Drinking Episodes: Past 30 Days [D]

Chart Percent Doing Any Binge Drinking in Past Month [D]

Summary

There are a number of positive conclusions, listed below, that can be reached about the use of brief interventions in college clinics and other health settings from these studies. However, many important questions remain for research. These include whether the observed effects last beyond 12 months, and whether they diminish over time. Brief interventions have also not yet been proven to be effective in various ethnic groups.

Conclusion 1: Changes in Alcohol Use

Brief intervention talk therapy delivered by primary care providers, nurses, therapists, and research staff can decrease alcohol use for at least one year in non- dependent drinkers in primary care clinics, managed care settings, hospitals, and research settings (Bien, 1993; Kahan, 1995; WHO, 1996; Wilk, 1997; Fleming, 1997, 1999, 2000, 2002; Marlatt, 1998; Ockene, 1999; Gentilello, 1999). In positive trials, reductions in alcohol use varied from 10-30% between the experimental and control groups. One trial demonstrated sustained reductions in alcohol use over 48 months.

Conclusion 2: Effects by Gender

The effect size for men and women is similar (Wallace, 1988; WHO, 1996; Fleming, 1997; Ockene, 1999). A recent 48-month follow-up study of 205 women ages 18-40 who participated in Project TrEAT found sustained reductions in alcohol use (Manwell, 2000). This study also found significant reductions by women who received brief intervention and became pregnant during the 48-month follow-up period compared to women from the control group who became pregnant. There remains insufficient evidence on the efficacy of brief intervention with pregnant women (Chang, 1999).

Conclusion 3: Effects by Age

The effect size for persons over the age of 18 is similar for all age groups including students (Wallace, 1988; WHO, 1996; Fleming, 1997, 1999b; Marlatt, 1998; Ockene, 1999; Monti, 1999).

Conclusion 4: Reductions in Health Care Utilization

Brief intervention can reduce health care utilization (Kristenson, 1983; Israel, 1996; Fleming, 1997, 2000, 2002; Gentilello, 1999). Fleming's Project TrEAT and Kristenson found reductions in emergency room visits and hospital days. Gentilello found reductions in hospital readmissions for trauma. Israel reported reductions in physician office visits.

Conclusion 5: Reductions in Alcohol-Related Harm

Brief intervention can reduce alcohol-related harm. A number of studies found a reduction in laboratory tests such as GGT levels (Kristenson, 1983; Wallace, 1988; Nilssen, 1991; Israel, 1996), sick days (Kristenson, 1983; Chick, 1985), drinking and driving (Monti, 1999); and accidents and injuries (Gentillelo, 1999; Fleming, 2000).

Conclusion 6: Reductions in Cost

Brief intervention may reduce health care and societal costs. An analysis of 48- month outcome data for Project TrEAT indicated a benefit-cost ratio of 3.8 to 1 for health care costs and 39 to 1 for societal costs (Fleming, 2002). Cost estimates performed by Holder (1995) using indirect data reported a cost savings of 1.5 to 1.

Conclusion 7: Intervention Delivered by a Patient's Physician May be More Powerful

Brief intervention may have a more powerful effect if delivered by the patient's personal physician or provider. While there have been no direct comparisons between type of provider, the strongest trials had the patient's personal physician and nurse deliver the intervention (Wallace, 1988; Anderson, 1992; Fleming, 1997, 1999, 2002; Ockene, 1999).

Conclusion 8: Three to Four Contacts Minimum For Reduction in Alcohol Use

Based on a number of trials, the minimum number of brief intervention contacts required to achieve a reduction in alcohol use is 3-4. These can include screening and assessment, a 10-15 minute counseling session, and a follow-up phone call. The length of the intervention appears to be less important than the number of contacts (Cordoba, 1998).

Conclusion 9: Non-traditional Settings Offer Promise

Non-traditional settings such as the workplace, dental offices, adult education centers, social service agencies and pharmacies offer significant promise for screening and brief intervention. A study conducted in 67 work sites in Australia suggests that employees will participate in alcohol screening and brief intervention if they are incorporated into lifestyle-based interventions (Richmond, 1995).

As stated earlier, while many questions remain, brief intervention is an important tool for the health professional working with college students. Trained personnel should be available to administer this intervention to college students in need on campus and in community clinic settings.

Guidelines for Using Brief Intervention

  • All students who drink above recommended limits of alcohol use should receive brief intervention.
  • Students who are resistant or who fail brief intervention may have a more serious problem than first suspected and should be referred to an alcohol treatment specialist.
  • Change is a long-term process, not a single event. Physicians may have to speak with students on many occasions before they are ready to change behavior.

Appendix A of this module contains an intervention workbook based on Project TrEAT specifically designed for college students.

References

Anderson, P., & Scott E. (1992); "The Effect of General Practitioners' Advice to Heavy Drinking Men;" British Journal of Addiction, 87, 891 900.

Baer, J.S., Marlatt, G.A., Kivlahan, D.R., Fromme, K., Larimer, M.E., & Williams, E. (1992); "An Experimental Test of Three Methods of Alcohol Risk Reduction With Young Adults;" Journal of Clinical. Psychology, 60, 974-979.

Bien, T.H., Miller, W.R., & Tonigan, J.S. (1993); "Brief Interventions for Alcohol Problems: A Review;" Addiction, 88, 315 335.

Bosari, B., & Carey, K.B. (2000);" "Effects of a Brief Motivational Intervention With College Student Drinkers;" Journal of Clinical. Psychology, 68, 728-733.

Burge, S.K., Amodei, N., Elkin B., Catala, S., Andrew, S.R., Lane, P.A., & Seale, J.P. (1997); "An Evaluation of Two Primary Care Interventions for Alcohol Abuse Among Mexican American Patients;" Addiction, 92, 1705 1716.

Chang, G., Wilkins Haug, L., Berman, S., & Goetz, M.A. (1999); "Brief Intervention for Alcohol use in Pregnancy, Randomized Trial;" Addiction. 94, 1499-1508.

Chick, J., Lloyd, G., & Crombie, E. (1985); "Counseling Problem Drinkers in Medical Wards: A Controlled Study;" British Medical Journal of Clinical Research Education, 290, 965 967.

Cordoba. R, Delgado, M.T., Pico, V., Altisent, R., Fores, D., Monreal, A., Frisas, O., & Lopez del Val, A. (1998); "Effectiveness of Brief Intervention on Non-Dependent Alcohol Drinkers (EBIAL): A Spanish Multi-Centre Study;" Journal of Family Practice, 15, 562-568.

Dimeff, L.A. (1997); "Brief Intervention for Heavy and Hazardous College Drinkers in a Student Primary Care Setting;" Ph.D. dissertation, Seattle, WA: University of Washington.

Dimeff, L.A., Baer, J.S., Kivlahan, D.R., & Marlatt, G.A. (1999); Brief Alcohol Screening and Intervention for College Students (BASICS): A Harm Reduction Approach, New York: Guilford Press.

Fleming MF. (1997); "Strategies to Increase Alcohol Screening in Health Care Settings;" Alcohol Health & Research World, 21, 340 347.

Fleming, M.F., Barry, K.L., Manwell, L.B., Johnson, K., & London, R. (1997); "Brief Physician Advice for Problem Alcohol Drinkers. A Randomized Controlled Trial in Community Based Primary Care Practices;" Journal of the American Medical Association, 277, 1039 1045.

Fleming, M.F., Manwell, L.B., Barry, K.L., Adams, W., & Stauffacher, E.A. (1999); "Brief Physician Advice for Alcohol Problems in Older Adults: A Randomized Community Based Trial;" The Journal of Family Practice, 48, 378 384.

Fleming, M.F., & Manwell, L.B. (1999); "Brief Intervention in Primary Care Settings. A Primary Treatment Method for At-Risk, Problem, and Dependent Drinkers;" Alcohol Research Health, 23, 128-137.

Fleming M.F. (2000); "Screening and Brief Intervention in the U.S. Health Care System;" In: 10th Special Report to the U.S. Congress on Alcohol & Health, from the Secretary of Health and Human Services. Washington DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism.

Fleming, M.F., Mundt, M.P., French, M.T., Manwell, L.B., Stauffacher, E.A., & Barry, K.L. (2000); "Benefit Cost Analysis of Brief Physician Advice With Problem Drinkers in Primary Care Settings;" Medical Care, 38, 7-18.

Fleming, M.F., Mundt, M.P., French, M.T., Manwell, L.B., & Stauffacher, E.A. (2002); "Project TrEAT, A Trial for Early Alcohol Treatment: 4 Year Follow Up;" Alcohol, Clinical and Experimental Research, 26, 36-43.

Gentilello, L.M., Rivara, F.P., Donovan, D.M., Jurkovich, G.J., Daranciang, E., Dunn, C.W., Villaveces, A., Copass, M., & Ries, R.R. (1999); "Alcohol Interventions in a Trauma Center as a Means of Reducing the Risk of Injury Recurrence;" Annals of Surgery, 230, 473-480.

Holder, H.D., Miller, T.R., & Carina, R.T. (1995); Cost Savings of Substance Abuse Prevention in Managed Care; Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention (CSAP) Publication. Rockville, MD

Israel, Y., Hollander, 0., Sanchez Craig, M., Booker, S., Miller, V., Gingrich, R., & Rankin, J.G. ( 1996); "Screening for Problem Drinking and Counseling by the Primary Care Physician Nurse Team;" Alcoholism, Clinical and Experimental Research, 20, 1443 1450.

Kahan, M., Wilson, L., & Becker, L. (1995); "Effectiveness of Physician Based Interventions With Problem Drinkers: A Review;" Canadian Medical Associate Journal, 152, 851 859.

Kristenson, H., Ohlin, H., Hulten Nosslin, M.B., Trell, E., & Hood, B. (1983); "Identification and Intervention of Heavy Drinking in Middle Aged Men: Results and Follow-Up of 24-60 Months of Long Term Study With Randomized Controls; Alcoholism, Clinical and Experimental Research, 7, 203 209.

Larimer, M.E., Anderson, B.K., Baer, J.S., & Marlatt, G.A. (2000); "An Individual in Context: Predictors of Alcohol Use and Drinking Problems Among Greek and Residence Hall Students;" Journal on Substance Abuse;11, 53-68.

Larimer, M., & Cronce, J. (2002); "Identification, Prevention and Treatment: A Review of Individual-Focused Strategies to Reduce Problematic Alcohol Consumption by College Students;" Journal of Alcohol Studies, Supplement 14, 148-163.

Manwell, L.B., Fleming, M.F., Mundt, M.P., Stauffacher, E.A., & Barry, K.L. (2000); "Treatment of Problem Alcohol Use in Women of Childbearing Age: Results of a Brief Intervention Trial;" Alcohol Clinical and Experimental Research, 24, 1517-1524.

Marlatt, G.A., Baer, J.S., Kivlahan, D.R., Dimeff, L.A., Larimer, M.E., Quigley, L.A., Somers, J.M, & Williams, E. (1998); "Screening and Brief Intervention for High-Risk College Student Drinkers: Results From a 2-Year Follow-Up Assessment;" Journal Consult Clinical Psychology, 66, 604 615.

Monti, P.M., Colby, S.M., Barnett, N.P., Spirito, A., Rohsenow, D.J., Myers, M., Wollard, R., & Lewander, W. (1999); "Brief Intervention for Harm Reduction With Alcohol-Positive Older Adolescents in a Hospital Emergency Department;" Journal Consult Clinical Psychologist, 67, 989-994.

Nilssen 0. (1991); "The Tromso Study: Identification of and a Controlled Intervention on a Population of Early-Stage Risk Drinkers;" Preventive Medicine, 20, 518 528.

Ockene, J.K., Adams, A., Hurley, T.G., Wheeler, E.V., & Hebert, J.R. (1999); "Brief Physician- and Nurse Practitioner-Delivered Counseling for High-Risk Drinkers: Does it Work?" Archives of Internal Medicine. 159, 2198-2205.

Richmond, R., Heather, N., Wodak, A., Kehoe, L., & Webster, L. (1995); "Controlled Evaluation of a General Practice-Based Brief Intervention for Excessive Drinking;" Addiction, 90, 119 132.

Wallace, P., Cutler, S., & Haines, A. (1988); "Randomized Controlled Trial of General Practitioner Intervention in Patients With Excessive Alcohol Consumption;" British Medical Journal, 297, (6649), 663 668.

Wilk, A.L., Jensen, N.M., & Havighurst, T.C. (1997); "Meta Analysis of Randomized Control Trials Addressing Brief Interventions in Heavy Alcohol Drinkers;" Journal of General Internal Medicine, 12, 274 283.

World Health Organization Brief Intervention Study Group. (1996); "A Cross-National Trial of Brief Interventions With Heavy Drinkers;" American Journal of Public Health, 86, 948 955.

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Historical document
Last reviewed: 9/23/2005


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