Scientific background and explanation of rationale

Adolescence is a period in which young people experiment with alcohol and establish use behaviours, and, as they age, the amount and frequency of use increases.¹ There is some evidence to suggest that earlier initiation of drinking is associated with later problematic misuse of alcohol (e.g. Bonomo et al.² and DeWit et al.³), although systematic review has highlighted weaknesses in the evidence base for this.⁴ The complexity of the relationship between earlier use and later problems is confounded by factors such as parental drinking and problem behaviours and/or behavioural disinhibition (e.g. Donovan et al.⁵) and, accordingly, some authors have concluded that earlier initiation is better characterised as a marker of general risk proneness than as a causal influence.⁶ However, there is stronger evidence to suggest that earlier age of self-reported drunkenness and the establishment of regular alcohol drinking is associated with a greater risk of adult alcohol-related problems.⁴ Other acute and long-term consequences of heavy alcohol use in young people are evident, and these adversely impact on health, educational achievement, societal cohesion, criminality, welfare and well-being.^7,8 There are also clear geographic differences in the burden that alcohol places on the population, and these are closely associated with other major indicators of ill health and health inequalities (e.g. Public Health England⁹). Indeed, differences in alcohol use and the consequences of alcohol use are thought to be one of the major determinants of health and social inequalities.^10,11

Prevalence of alcohol use in the UK

The consumption of alcohol by those under the age of 18 years remains a public health concern in the UK. Evidence continues to suggest that, although the proportion of adolescents drinking alcohol across the UK has declined in recent years, those who do drink appear to be consuming more on each occasion.^12–18 Although this may be true at a national level, regional variations in drinking patterns also exist.^14,16,19 In comparison with the rest of the UK, drinking prevalence and excessive weekly drinking among adolescents has increased in Northern Ireland (NI) in recent years.¹⁵ The results of the most recent Young Persons’ Behaviour and Attitudes Survey²⁰ show that, of those who had ever drunk a full alcoholic drink (not just had a sip or taste), 56% had done so by the age of 13 years and 84% had done so by the age of 15 years. This is in comparison with 32% of 13-year-olds and 70% of 15-year-olds in Scotland reporting lifetime consumption of a full drink.²¹ This does suggest a greater degree of alcohol use overall in NI than in Scotland (period prevalence). However, when comparing lifetime drunkenness in Scotland and NI, figures show that 39.3% of 11- to 16-year-olds in NI report lifetime drunkenness²⁰ compared with 44% of 13-year-olds and 70% of 15-year-olds in Scotland.²¹

Consequences of drinking

Adolescents are much more vulnerable than adults to the adverse effects of alcohol because of a range of physical and psychosocial factors that often interact (e.g. Newbury-Birch et al.⁷). These adverse effects include (1) neurological factors due to changes that occur in the developing adolescent brain after alcohol exposure (e.g. Windle et al.,²² Zeigler et al.²³ and Witt²⁴); (2) cognitive factors due to the psychoactive effects of alcohol, which impair judgement and increase the likelihood of accidents and trauma (e.g. Rodham et al.²⁵); (3) social factors that arise from a typically high-intensity drinking pattern that leads to intoxication and risk-taking behaviour (e.g. Ellickson et al.⁸ and MacArthur et al.²⁶); and (4) physiological factors resulting from a typically lower body mass and less efficient metabolism of alcohol (e.g. Windle et al.²² and Zucker et al.²⁷). Physiological factors are compounded by the fact that young people have less experience of dealing with the effects of alcohol than adults, and that have fewer financial resources to help buffer the social and environmental risks that result from drinking alcohol.²⁸

Parental influence on young people’s drinking

Family factors are important in determining the nature and extent of adolescent alcohol use. These relate not only to the structure of families but also to family cohesion, family communication about issues such as substance use, parental modelling of behaviour (e.g. parental use of substances or rules on substance use), family management, parental monitoring/supervision, parent/peer influences and availability of alcohol in the family home.¹⁶ For example, it has been argued that a trusting relationship between adolescents and their parents with open expression of ideas and feelings is an important factor in the reduction of health risk behaviours (e.g. Bahr et al.²⁹ and Riesch et al.³⁰). Moreover, parent–child communication processes have been proposed to mediate the effects of risk factors on problematic behaviour³⁰ and better family communication processes have been shown to be protective against negative alcohol-related outcomes in young people.^31–35

The rapid escalation in the numbers of lifetime users and levels of use throughout adolescence is mirrored by the progressive detachment of adolescents from their parents and an increase in parental tolerance of adolescent drinking behaviour.³⁶ Although there are significant shifts in attachments of adolescents from parents to peers, there is still evidence that the influence of parents is considerable up to later adolescence and into early adulthood.³⁷ In a review of current evidence, Gilligan et al.³⁸ classified the environmental factors that determine adolescents’ propensity to engage in risky drinking as (1) social and (2) peer or family/parental. In the case of the latter, children are exposed to and learn about alcohol from an early age.³⁸ There has been much debate regarding the extent (if at all) to which parental tolerance of adolescent supervised drinking in the home, and by extension parental supply of alcohol to their children, can reduce heavier drinking and result in greater responsibility in terms of alcohol use. Young people’s drinking behaviours are said to be affected by their parents’ attitudes towards this behaviour and by parental supervision of their drinking (e.g. van der Vorst et al.³⁶), and parents often supply alcohol to their children, believing that it teaches them responsible drinking.³⁹ However, the risk arising from parental supply of alcohol is not well understood, and there is little evidence to support this as a harm-reducing practice.³⁸ In fact, although there is evidence suggesting that parental disapproval of drinking and limiting the supply of alcohol reduce adolescent drinking behaviour,^36,40 some have suggested that parental supply of alcohol may reduce barriers to drinking, encouraging more frequent drinking and consumption of greater amounts of alcohol and even promoting a progression to unsupervised drinking.⁴¹

Perceived parental approval of drinking has been linked to heavy drinking among high school and college students (e.g. Abar et al.⁴²). In support of the argument that permitting drinking at home promotes drinking in other contexts, van der Vorst et al.⁴³ reported that adolescents who were permitted to drink at home were also more likely to drink outside the home and to report more alcohol-related problems over a 2-year period than those who were not permitted to drink at all. In a survey of around 12,000 15- to 16-year-olds in the UK, Bellis et al.⁴⁴ reported that among those identifying any measure of unsupervised consumption, or heavy or frequent drinking, there was a significantly greater likelihood of alcohol-related violence, regretted sex or forgetting things after drinking. Furthermore, those reporting any measure of unsupervised consumption were also more likely to drink frequently and to drink heavily.⁴⁴ Livingston et al.,⁴⁵ in a 1-year follow-up of young women making the transition from high school to college, reported that those who were allowed to drink at home, either at meals or with friends, reported more frequent heavy episodic drinking (HED) at college, but those allowed to drink with friends reported the heaviest drinking episodes at both time points. However, in one Dutch longitudinal study, van der Vorst et al.⁴³ reported no differences in progression to problem drinking among young people whose parents provided high or low levels of supervision of alcohol use.

Universal interventions for preventing alcohol-related problems

Reviews of effective school-based universal alcohol prevention programmes for adolescents have failed to consistently identify interventions that are well designed, well implemented and properly evaluated (e.g. Jones et al.,⁴⁶ Foxcroft and Tsertsvadze,^47–49 Nation et al.,⁵⁰ Faggiano et al.⁵¹ and Spoth et al.⁵²). Foxcroft and Tsertsvadze,^47–49 in their reviews of school-based universal interventions, were unable to recommend any single prevention initiative. However, one conclusion, which is consistent in all reviews, is that prevention interventions that effectively develop social skills appear to be superior in their impact to those that seek to enhance only knowledge (e.g. Foxcroft and Tsertsvadze,^48,49 Nation et al.⁵⁰ and Faggiano et al.⁵¹). In the absence of substantial evidence on particular programmes, guidance issued by the National Institute for Health and Care Excellence (NICE)⁵³ in 2007 called for partnership working between schools and other stakeholders in efforts to prevent misuse. NICE also suggested that school-based interventions should aim to increase knowledge about alcohol, to explore perceptions about alcohol use and to help develop decision-making skills, self-efficacy and self-esteem. In family settings, universal prevention typically takes the form of supporting the development of parenting skills including parental support, nurturing behaviours, establishing clear boundaries or rules and parental monitoring.⁴⁷ Social and peer resistance skills, the development of behavioural norms and positive peer affiliations can also be addressed with these types of approaches. Most of the studies included in Foxcroft and Tsertsvadze’s 2011 Cochrane review⁴⁷ of family-based alcohol prevention activities reported positive effects on behaviour and, although these tended to be small, they were generally consistent and persisted into the medium to longer term.

School-based alcohol education programmes in the UK for those aged < 18 years have predominantly been classified as universal, as they have been typically targeted at all pupils regardless of screened or perceived level of alcohol-related risk.⁵⁴ Outcomes assessed in universal prevention programmes have included those related to quantity and frequency of alcohol use (e.g. period prevalence, frequency of drunkenness, HED), as well as harms associated with consumption.⁴⁸ With respect to this last set of outcomes, harms can arise both from the actions of the drinker (e.g. accidents, health problems) and from the drinking of others (e.g. drunk driving, violence). Universally targeted alcohol prevention programmes (e.g. McBride et al.,⁵⁵ Newton et al.⁵⁶ and Vogl et al.⁵⁷) that aim to reduce harms associated with alcohol may, therefore, provide messages of harm reduction rather than focus on abstinence. In addition to aiming to reduce alcohol-related harm through reducing consumption, these types of programmes aim to reduce those direct and indirect harms reported by those recipients who continue to drink.

Introduction to the intervention components of STAMPP

The Steps Towards Alcohol Misuse Prevention Programme (STAMPP) combined a school-based alcohol harm reduction curriculum and a brief parental intervention that is designed to support parents in setting family rules around drinking. Chapter 2 (see Intervention) provides further information on the development, delivery and content of the intervention.

The classroom component of STAMPP is the School Health and Alcohol Harm Reduction Project (SHAHRP), which is an example of a universally targeted classroom intervention. It combines a harm reduction philosophy with skills training, education and activities designed to encourage positive behavioural change.^55,58 It is a curriculum-based programme delivered in two phases over a 2-year period, and is described by its developers as having an explicit harm reduction goal. The development of the SHAHRP is described by Farringdon et al.⁵⁹ It was originally developed in the 1990s in Western Australia, and the core components of the intervention were based on a systematic literature review of effective substance use education. The curriculum was written by practising teachers (with experience of developing student-centred learning approaches), with the assistance of research academics, and underwent piloting, evaluation and further development processes. Key evidence-based features of the programme include (according to the formative evaluation of the SHAHRP):⁵⁹

• social inoculation (phase 1 of the intervention, delivered prior to alcohol initiation)
• relevance to drinking trajectories of recipients (i.e. phase 2 of the intervention, introducing harm reduction, is implemented after pupils are most likely to have initiated alcohol use)
• core intervention (phase 1) with booster sessions (phase 2)
• experientially focused and based on the drinking experiences of young people
• skills based with normative components
• incorporation of utility knowledge about alcohol use.

Includes specialist training of programme deliverers (e.g. teachers)

In the original Australian programme evaluation,⁵⁵ which compared the intervention group with the control group receiving education as normal (EAN), the intervention group reported significantly less alcohol use: a difference in quantity of 31.4%, 31.7% and 9.2% at 8, 17 and 32 months after baseline, respectively; and significant differences in reports of hazardous drinking, defined as consuming more than two (female)/four (male) standard drinks (10 g of alcohol) per occasion, once per month or more often at 8 months (25.7%) and 17 months (33.8%) after baseline but not at the 32-month follow-up (4.2%). Intervention students also reported significantly greater knowledge at the 8-month follow-up, and this was maintained at the 20-month follow-up but not at 32 months. In addition, there was a significant difference between the study groups in the number of self-reported harms they experienced from their own use of alcohol after both phases of the intervention. This was maintained 17 months after the intervention but not at the final follow-up at 32 months. Finally, the intervention group developed significantly better alcohol-related attitudes (attitudes that supported less harmful alcohol-related behaviours) from first follow-up at 8 months, and this was maintained to the 32-month follow-up point.

A previous investigation of the SHAHRP utilising a non-experimental design was conducted in NI by some of the current STAMPP investigators,⁶⁰ and found that, after appropriate adaptation (e.g. normative epidemiological facts updated, timings of lessons altered), participation in the SHAHRP was associated (across 32 months of follow-up) with benefits for pupils. Between-group comparison showed that intervention pupils reported significantly fewer alcohol-related harms over time, and, when drinking behaviour trajectories were modelled using latent class growth modelling, intervention pupils were significantly more likely than pupils receiving EAN to be members of those latent classes that reported less increase in drinking over time, that had a larger increase in alcohol knowledge and healthy attitudes, and that were more likely to report a smaller increase or no increase at all in alcohol-related harms.

The parental component of STAMPP was developed by the trial team and was based on earlier work by Koutakis et al.,⁶¹ who found that giving advice to parents about setting strict rules around alcohol consumption reduced drunkenness and delinquency in 13- to 16-year-olds in Sweden (the Örebro Prevention Programme). The original Swedish intervention was based on empirical evidence that suggested that lower levels of youth alcohol drinking were associated with stricter parental attitudes against youth alcohol use and involvement in structured, adult-led activities. Similarly, permissive parental attitudes towards children’s alcohol use have been shown to be better predictors of offspring alcohol use than parents’ own use.⁶² However, the original Swedish programme was relatively intensive (six 20-minute standardised presentations and discussion given to parents of 13- to 16-year-olds during regular school-based parent–teacher meetings) and so Koning et al.^63,64 adapted this intervention further (a single parents evening) and combined it with a school-based alcohol curriculum (the Dutch Healthy School and Drugs programme). They found that this combined intervention was associated with a significantly reduced rate of frequency of drinking or weekly drinking, and this was partly mediated by changes in parental rules and attitudes towards alcohol (i.e. stricter rules and attitudes were developed).

Explanation of rationale

Given the prevalence of underage drinking in the UK, the reported problems, costs and harms associated with this behaviour and the lack of a robust UK evidence base for universal alcohol prevention interventions, this work aimed to investigate an adapted form of the evidence-based SHAHRP^55,60 in a culturally appropriate and curriculum consistent manner in the NI and Glasgow/Inverclyde post-primary school settings. Furthermore, considering the strong links between family behaviours and young people’s substance use, the effect of introducing a parental component to the core SHAHRP curriculum was examined.

Specific objectives

Chapter summary: introduction to the research

Although alcohol use in the general population of young people is falling in the UK, there are regional differences, and those who initiate use early, are regular drinkers or report early drunkenness are more likely to experience adverse outcomes or a greater number of years of ill health. The responses to young people’s alcohol use have traditionally focused on school-based educational approaches, although general population policies, such as restrictions on marketing and pricing increases, are also likely to affect consumption. However, the evidence base for school-based universal alcohol interventions (i.e. those that target a whole population, regardless of level of risk) is weak and, although some skills-based approaches have been shown to produce changes in different indicators of alcohol use, effect sizes are often small and the longevity of the intervention effect is limited. Other research has shown that family factors are an important determinant of young people’s alcohol use. For example, in those families in which there is good communication and authoritative rules on alcohol are in place, young people are less likely to drink. In keeping with the literature on school-based interventions, however, there are few family-based programmes that have found significant reductions in indicators of alcohol use and alcohol harm.

This research sought to determine the effectiveness of a programme, STAMPP, that is a school-based alcohol harm reduction curriculum with a brief parental intervention designed to support parents/carers in setting family rules around drinking. We examined whether or not STAMPP was effective in reducing HED and self-reported harms related to recipients’ own use of alcohol. The programme rationale was that stricter parental/carer rules and attitudes towards alcohol would reinforce learning and skills development in the classroom. The classroom component, SHAHRP, was a universally targeted curriculum that combines a harm reduction philosophy with skills training, education and activities designed to encourage positive behavioural change. It was delivered in two phases over a 2-year period and was adapted from an original Australian programme in an early study,⁵⁵ with the assistance of education and prevention specialists. The brief intervention delivered to intervention pupils’ parent(s)/carer(s) comprised a short, standardised presentation delivered at specially arranged evenings on school premises. The presentation included an overview of the Chief Medical Officer (CMO)’s guidelines for drinking in childhood,⁶⁵ information on alcohol prevalence in young people, corrected (under)estimates of youth drinking rates and highlighted the importance of setting strict family rules around alcohol. The presentation was followed by a brief discussion on setting and implementing authoritative family rules on alcohol. All intervention pupils’ parents/carers were followed up by a mailed leaflet, whether or not they attended the parents’ evening, which provided a summary of the key information delivered in the evening and coincided with phase 2 of the classroom intervention.