Substance Abuse News

Regular beer—but not light beer or other types of alcohol—appears to be associated with an increased risk of developing psoriasis, according to a report posted online that will be published in the Archives of Dermatology.

“Psoriasis is a common immune-mediated skin disease,” the authors write as background information in the article. “The association between alcohol consumption and increased risk of psoriasis onset and psoriasis worsening has long been suspected. For example, individuals with psoriasis drink more alcohol than individuals without psoriasis, and alcohol intake may exacerbate psoriasis severity.”

Alcohol and Psoriasis

For other diseases, type of alcoholic beverage has been shown to influence risk—for instance, beer confers a larger risk for gout than wine or spirits. To evaluate the association between different types of alcohol and psoriasis risk, Abrar A. Qureshi, M.D., M.P.H., of Brigham and Women’s Hospital and Harvard Medical School, Boston, assessed data from 82,869 women who were age 27 to 44 years in 1991. The women, participants in the Nurses’ Health Study II, reported the amount and type of alcohol they consumed on biennial questionnaires. They also reported whether they had received a diagnosis of psoriasis.

Through 2005, 1,150 cases of psoriasis developed, 1,069 of which were used for analysis. Compared with women who did not drink alcohol, the risk of psoriasis was 72 percent greater among women who had an average of 2.3 drinks per week or more. When beverages were assessed by type, there was an association between non-light beer drinking and psoriasis, such that women who drank five or more beers per week had a risk for the condition that was 1.8 times higher. Light beer, red wine, white wine and liquor were not associated with psoriasis risk.

When only confirmed psoriasis cases—those in which women provided more details about their condition on a seven-item self-assessment—were considered, the risk for psoriasis was 2.3 times higher for women who drank five or more beers per week than women who did not drink beer.

Increased Risk of Psoriasis

“Non-light beer was the only alcoholic beverage that increased the risk for psoriasis, suggesting that certain non-alcoholic components of beer, which are not found in wine or liquor, may play an important role in new-onset psoriasis,” the authors write. “One of these components may be the starch source used in making beer. Beer is one of the few non-distilled alcoholic beverages that use a starch source for fermentation, which is commonly barley.” Barley and other starches contain gluten, to which some individuals with psoriasis show a sensitivity. Lower amounts of grain are used to make light beer as compared with non-light beer, potentially explaining why light beer was not associated with psoriasis risk, they note.

“Women with a high risk of psoriasis may consider avoiding higher intake of non-light beer,” the authors conclude. “We suggest conducting further investigations into the potential mechanisms of non-light beer inducing new-onset psoriasis.”

A brief, motivational talk in the emergency room reduced by half the chances that teenagers would experience peer violence or problems due to drinking, according to a study published Aug. 4 in a theme issue of the Journal of the American Medical Association.

The special issue on violence and human rights includes the work of University of Michigan Health System researchers who immersed themselves at the Hurley Medical Center emergency department, in Flint, Mich., for three years.

Researchers offered help to 726 adolescents, ages 14-18, who reported they experienced aggression or had a drink of beer, wine or liquor at least two or three times in the past year.

Reduction in Aggression

A one-on-one talk with a therapist resulted in a 34 percent reduction in peer aggression. Teens who received only a brochure had a 16 percent drop in aggression over the next three months.

The study showed similar drops in alcohol misuse after teens heard prevention messages delivered by a therapist or while using a role-playing computer program.

“Violence and alcohol use are preventable behaviors and the emergency department can be a key location for reaching high-risk teenagers,” says senior author Rebecca Cunningham, M.D., an emergency room physician and director of the University of Michigan Injury Research Center.

Violence and injuries are the leading causes of deaths among adolescents in the United States and the incidents are often fueled by alcohol. The U-M study showed ED interventions can also reduce alcohol-related problems by as much as 32 percent for six months.

The talks with teens were more complex than a parent talking to a child about the dangers of drinking and how to avoid peer pressure.

“Therapists used motivational interviewing which is well-suited for adolescent development,” says study lead author Maureen Walton, M.P.H., Ph.D., research associate professor in the U-M Department of Psychiatry, Addiction Research Center. “It doesn’t preach or tell teens what to do, but allows adolescents to weigh the pros and cons of their choices in reference to their goals.”

The therapists’ talks with teens also included role play exercises and tools to cope with risky situations that involve drinking or violence and referrals to community services.

Motivational Interviewing

“Most of the adolescents had high aspirations – they wanted to go to college, be a good role model for their younger siblings. They didn’t want to make the mistakes they saw happening around them,” Walton explains. “We talked to them about the discrepancies between their behavior and what they wanted to do with their lives.”

Motivational Interviewing, with proper training, can be used effectively by healthcare providers as well those without a professional healthcare background. Study co-author Stephen T. Chermack, Ph.D, a clinical psychologist and addiction specialist at the U-M Health System and the VA Healthcare System in Ann Arbor, is a member of the Motivational Interviewing Network of Trainers (MINT).

Adolescents in the study reported to the emergency department at Hurley Medical Center between noon and 11 p.m., during the three-year period, September 2006 to September 2009.

All patients completed computerized screening questions regarding alcohol use and violence and were randomized into three groups: a control group receiving a brochure, or one of two groups receiving a 35-minute brief intervention delivered by a computer or a therapist in the emergency room.

Authors say the computer screening worked well with teenagers because of their comfort with using technology. The computer program included animated role playing such as how to handle drinking and driving and conflicts with peers.

High-Risk Youth in the ER

“The study tells us that technology can aid in assisting high-risk youth in busy clinical settings, as well as deliver important prevention messages,” says Cunningham who is also an associate professor of emergency medicine at the U-M Medical School and associate professor of health behavior & health education at the U-M School of Public Health. “Emergency staff are busy and not all hospitals have the resource of a social worker or therapist present at all times in the emergency department.”

The ED can be a prime location for reaching high-risk teenagers since many may skip school, consider themselves too old to go to a pediatrician, yet often do not have a primary care doctor.

“We see the consequences our patients face from violence,” says Cunningham who is part of the team of U-M physicians who work in the Flint emergency department.

“But in addition to treating the immediate wounds from violence, the emergency department can offer opportunities to help the teens we see prevent future problems with alcohol and violence.”

A study published in the scientific journal Addiction shows that the Mexican government’s recent efforts to control the manufacture of methamphetamine have caused a drop in methamphetamine treatment admissions in Mexico and in neighbouring Texas.

In 2005 Mexico began controlling its imports of pseudoephedrine (a precursor chemical used in the manufacture of methamphetamine), and in 2008 it became the first country in North America to ban all imports of pseudoephedrine as well as ephedrine, another important precursor chemical. Researchers estimate that the 2005 import controls caused a 12% drop in voluntary methamphetamine treatment admissions in Mexico, with similar reductions in Texas.

An even larger drop in voluntary admissions occurred following the 2007 closure of a commercial chemical company suspected of illicitly importing more than 60 tons of pseudoephedrine into Mexico. The head of the company fled Mexico but was eventually arrested in the United States. Methamphetamine treatment admissions in Mexico decreased by 56% following the closure of the company, with Texas showing similar results.

Signs of Meth Decline

All decreases in admissions appeared to be specific to methamphetamine, as researchers found no concurrent changes in cocaine, heroin, and alcohol treatment admissions during the same period. The study wound up shortly after the 2008 bans on precursor chemicals came into effect, so researchers weren’t able to examine fully the impact of those bans; however, the researchers noted that treatment admissions in Mexico showed signs of declining in the first few months following the bans.

Says lead researcher James Cunningham, a Fulbright Scholar at The University of Arizona: “These findings constitute the first evidence outside the United States that a country’s precursor chemical controls can have positive public health results both domestically and internationally.”

Standard therapeutic techniques decrease cravings of cigarette smokers by regulating activity in two separate but related areas of the brain, a new study led by a Yale University researcher shows.

Smokers who are taught cognitive strategies, such as thinking about the long-term consequences of smoking, show increased activity in the prefrontal cortex, an area of the brain associated with cognitive control and rational thought. They also show decreased activity in areas of the striatum, an area of the brain associated with drug craving and reward-seeking behavior, according to the paper published online Aug. 2 in the Proceedings of the National Academy of Sciences.

“This shows that smokers can indeed control their cravings, they just need to be told how to do it,” said Hedy Kober, assistant professor of psychiatry at the Yale School of Medicine and lead author of the paper.

Cravings Trigger Relapse

Cravings are the triggers that often lead to relapse in a host of addictions, which carry a staggering economic and social cost. Cigarette smoking alone is responsible for over 400,000 deaths per year in the U.S. (more than all illicit drugs and alcohol combined). Some experts predict that substance abusers should show impairments in areas of the prefrontal cortex, which among other functions helps control emotion. But in smokers at least, this does not appear to be the case. This area of the brain showed increased activity—and smokers reported less intense cravings—when using cognitive strategies.

Cognitive behavioral therapy has been shown to be an effective tool in treating a variety of mental health disorders, including substance use disorders. The new study shows why this approach is effective, Kober said.

“We do not see any impairment in the prefrontal cortex, which suggests the brain is able, when prompted, to recruit control regions to reduce cravings,” Kober said.

Child abuse is a serious problem that affects nearly one million children a year in the United States alone. The American Academy of Pediatrics and the US Department of Health and Human Services classify child abuse into four categories including neglect, physical abuse, sexual abuse, and emotional abuse. None of these categories, however, clearly includes the abusive use of drugs on children. A study soon to be published in the Journal of Pediatrics investigates the malicious use of pharmaceuticals and attempts to shed light on this under-recognized problem.

Dr. Shan Yin from the University of Colorado and the Rocky Mountain Poison Drug Center at Denver Health reviewed cases of pharmaceutical abuse reported to the National Poison Data System between 2000 and 2008. Dr. Yin included reports of the malicious use of alcohol, painkillers, cough and cold medicines, sedatives and sleeping pills, and antipsychotic medicines.

Using Drugs to Subdue Children

Of the more than 1400 cases studied, nearly 14% resulted in moderate to major consequences, including death. Nearly one-half of the abused children were exposed to at least one sedative. An average of 160 cases, including two deaths, was reported each year. Motives and legal findings were unavailable for these particular cases; however, motives for the abusive use of drugs generally are varied, and can include punishment, amusement, or a wish for a break from childcare responsibilities.

This study illustrates the seriousness of the abusive use of drugs administered to children. According to Dr. Yin, “The malicious administration of pharmaceuticals should be considered an important form of child abuse.” He encourages pediatricians and emergency medical personnel to be on the watch for this form of maltreatment, and suggests the use of comprehensive drug screening during the evaluation of a child suspected to be the victim of abuse. Dr. Yin also cautions parents that the “non-therapeutic administration of pharmaceuticals to children can result in serious outcomes, including death.”

Given that Whites are the majority population in the United States, drinking trends for this group tend to determine overall trends in drinking for the country and simultaneously minimize trends and possible risks among Black and Hispanic populations. A study of trends in drinking patterns and amounts drank among Whites, Blacks, and Hispanics from 1992 to 2002 has found a rise in the proportion of drinkers across all three ethnic groups and both genders.

Results will be published in the journal Alcoholism: Clinical & Experimental Research.

Drinking Trends in Ethnic Groups

“Trend analysis is an important part of epidemiological monitoring of drinking and problems in the general population,” said Raul Caetano, professor of epidemiology and regional dean (Dallas) at The University of Texas School of Public Health, as well as the study’s corresponding author. “However, different population groups, such as ethnic groups, can present different trends in drinking and problems and so it is important to investigate trends in different groups and not only in the U.S. general population as a whole.”

“This is the first cross-ethnic alcohol trend analysis to … examine whether alcohol consumption – such as use and heavy drinking – has increased, decreased, or remained stable among Whites, Blacks, and Hispanics in the U.S. from 1992 to 2002,” noted Rhonda Jones-Webb, associate professor in the division of epidemiology and community health at the University of Minnesota School of Public Health.

“Alcohol studies on racial/ethnic minorities such as this are much needed,” Jones-Webb added. “Blacks and Hispanics live in communities where alcohol availability is higher, where there is more exposure to outdoor alcohol advertising, where they have been targeted by special advertising of higher alcohol content beverages – all with fewer personal and community resources to respond to these challenges. Additionally, Blacks and Hispanics are at greater risk for alcohol-related problems such as homicide, which is on the rise in some cities.”

Researchers used data from the 1991-1992 National Longitudinal Alcohol Epidemiologic Survey (n=42,862) and the 2001-2002 National Epidemiologic Study on Alcohol and Related Conditions (n=43,093); both surveys selected respondents 18 years of age and older from the U.S. household population.

Increase in Binge Drinking

“Whites increased their mean number of drinks while Blacks and Hispanics did not,” said Caetano. “There was also a rise in drinking five or more drinks in a day across all three ethnic groups and drinking to intoxication among Whites and Blacks, but this was limited to those reporting such drinking at least once a month. This suggests a polarization in drinking between the two surveys, with those who drank more in 1992 reporting an increase in their drinking in 2002.”

“The results also suggest that while the proportion of Black and Hispanic drinkers increased, the amount of alcohol consumed did not increase among Blacks and Hispanics across the 10-year period,” added Jones-Webb.

“Trends in drinking are linked to a complex web of factors that include how individual drinking is influenced by the drinking of the group to which the individual belongs, as well as personal and other societal changes,” said Caetano. “Changes in the sociodemographic composition of the population such as aging, the influx of immigrant groups, and a decline in mean income level because of economic recessions can all influence trends in drinking and problems.”

In addition, said Jones-Webb, norms regarding drinking seemed to have become more liberal during the 10-year period examined. “This might explain why groups that traditionally do not drink – for example, women and African Americans – may have started to do so.”

Changes in Drinking Trends

“The results in the paper provide a detailed view of how drinking and binge drinking changed in the U.S. between 1992 and 2002,” said Caetano. “National studies such as this are important because they provide information that serves as a backdrop against which the results of other national or local studies can be compared, aiding in the interpretation of findings from these other studies. Trend analyses at the national level can also alert health professionals at the federal level to trends developing in the country, providing a ‘broad-stroke’ national level picture against which many other trends … can be viewed and understood.”

“While there are more drinkers in the population, the rise in the proportion of drinkers does not seem to be triggering a rise in the mean number of drinks consumed per month, at least among Blacks and Hispanics,” added Jones-Webb. “This finding suggests that a diversity of public-health policies are needed to reduce alcohol-related problems among Blacks and Hispanics, including restrictions on alcohol advertising, limiting the overconcentration of liquor stores in poor and minority neighborhoods, regulating high alcohol content beverages, increasing taxes on alcohol, as well as treatment and brief interventions.”

Few colleges and college communities have taken steps to implement recommendations to reduce college student drinking, according to a new study released by researchers from the University of Minnesota School of Public Health. Alcohol consumption by U.S. college students remains a major issue despite a report by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) that detailed the problems associated with student drinking. That report, released in 2002, also outlined strategic recommendations based on the best available science that were designed to help colleges curtail the problem.

Few Colleges Offer Intervention

Toben Nelson, Sc.D., lead author of the study, said the latest research found that only half of the 351 colleges surveyed offered brief intervention programs with documented evidence of effectiveness for students at high risk for alcohol problems. Only a small number (33 percent) of colleges reported that they collaborated with their community on effective alcohol control strategies such as compliance checks to monitor illegal sales, responsible beverage service training, restrictions on alcohol outlets or interventions to address access to low-cost alcohol.

Nearly all colleges offered educational programs, even though the NIAAA report found that by themselves these efforts are ineffective. More than one in five college administrators said they were not familiar with the 2002 NIAAA recommendations.

Curbing Binge Drinking

The latest research – funded by the Substance Abuse Policy Research Program of the Robert Wood Johnson Foundation – in the journal Alcoholism: Clinical and Experimental Research, and comes less than 12 months after University of Minnesota researchers published findings that showed colleges previously identified as “heavy-drinking” have shown little improvement in curbing the binge drinking habits of their students.

“In 2002, there was a great deal of research available to show that heavy drinking was a problem on college campuses. The NIAAA recommendations were designed to help colleges and college communities address that problem,” Nelson said. “Unfortunately, what we’ve found is that little progress in the implementation of the recommendations has been made since they were released.”

Nelson identified a number of possible reasons for the lack of implementation, including strained relationships between communities and college campuses over student drinking, a lack of resources, and staff who are either untrained in the development of community partnerships, or who lack the authority to take meaningful steps forward.

Difficulties Due to Drinking

According to co-author Traci Toomey, Ph.D., a contributor to the development of the 2002 NIAAA recommendations, the latest findings are a source of frustration. “We certainly would have hoped to see more progress among colleges, considering that the NIAAA identified strategies and actions that could lower drinking on college campuses more than six years prior to this study.”

Binge drinking across college campuses remains a problem with a host of associated risks. According to the NIAAA, nearly 600,000 students between the ages of 18 and 24 are unintentionally injured while under the influence of alcohol each year, and 97,000 students are victims of alcohol-related sexual assault or date rape. Nearly one in four college students report academic difficulties that result from their drinking.

In the largest study of its kind, researchers at the Southwest Foundation for Biomedical Research (SFBR) have found that exposure to cigarette smoke can alter gene expression — the process by which a gene’s information is converted into the structures and functions of a cell. These alterations in response to smoking appear to have a wide-ranging negative influence on the immune system, and a strong involvement in processes related to cancer, cell death and metabolism.

Smoking Influences Genes

The scientists indentified 323 unique genes whose expression levels were significantly correlated with smoking behavior in their study of 1,240 people. The changes were detected by studying the activity of genes within white blood cells of study participants.

“Our results indicate that not only individual genes but entire networks of gene interaction are influenced by cigarette smoking,” wrote lead author Jac Charlesworth, Ph.D., in the July 15 issue of the open access journal BMC Medical Genomics. Charlesworth, formerly at SFBR, is now a research fellow at the Menzies Research Institute at the University of Tasmania in Australia.

The study was funded by the National Institutes of Health and the Azar and Shepperd families of San Antonio, ChemGenex Pharmaceuticals and the AT&T Foundation. The study is part of SFBR’s San Antonio Family Heart Study (SAFHS) which includes 40 families in the Mexican American community.

Smoking and Transcriptomics

“Previous studies of gene expression as influenced by smoking have been seriously limited in size with the largest of the in vivo studies including only 42 smokers and 43 non-smokers. We studied 1,240 individuals, including 297 current smokers” Charlesworth said. “Never before has such a clear link between smoking and transcriptomics been revealed, and the scale at which exposure to cigarette smoke appears to influence the expression levels of our genes is sobering”.

“Our results indicate that not only individual genes but entire networks of gene interaction are influenced by cigarette smoking. It is likely that this observed effect of smoking on transcription has larger implications for human disease risk, especially in relation to the increased risk of a wide variety of cancers throughout the body as a result of cigarette smoke exposure,” Charlesworth said.

A new national study reveals that the rate of past month alcohol use (i.e., at least one drink in the past 30 days) among American Indian or Alaska Native adults is significantly lower than the national average for adults (43.9 percent versus 55.2 percent). The study, sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), also shows that American Indian or Native Alaska adults have a rate of past month binge alcohol drinking (i.e., five or more drinks on the same occasion – on at least one day in the past 30 days) well above the national average (30.6 percent versus 24.5 percent). The level of past month illicit drug use was also found to be higher among American Indian or Alaska Native adults than the overall adult population (11.2 percent versus 7.9 percent).

Alcohol Treatment Needed

Among the study’s other significant findings:

• Eighteen percent of American Indian or Alaska Native adults needed treatment for an alcohol or illicit drug use problem in the past year, nearly twice the national average (9.6 percent).
• 1 in 8 (12.6 percent) American Indian or Alaska Native adults who were in need of alcohol or illicit drug treatment in the past year received it at a specialty facility – about the same as the national average (10.4 percent).
• American Indian or Alaska Native adults’ past month substance use rates drop significantly in older age groups – for example, illicit drug use levels drop from 25.4 percent in the 18 to 25 age group to 4.1 percent in those 50 and older. This pattern is also seen in the general adult population.

The study was developed as part of the agency’s strategic initiative on data, outcomes, and quality – an effort to create an integrated data strategy that informs policy makers and service providers on the nature and scope of behavioral health issues. It is one in a series of studies designed to provide more detailed information on substance abuse patterns and treatment needs existing within a wide range of population groups.

Support Services Needed

“Patterns of substance abuse vary somewhat among different segments of our society,” said SAMHSA Administrator Pamela S. Hyde, J.D. “Prevention, treatment and recovery support services are vitally needed within every community. We are using these studies along with on the ground experience to design and provide these services in a way that is accepted by the community and appropriate for individual needs.”

“We appreciate SAMHSA’s support of this study, which provides valuable findings that can be used for more targeted treatment programs and patient screening,” said Dr. Yvette Roubideaux, the Director of the Indian Health Service.

Summertime and the living is easy. But not too easy for parents whose children will head to college in the fall.

University of Rhode Island Psychology Professor Mark Wood, a nationally recognized alcohol researcher, wants parents to be aware that this is a time when teens tend to increase their alcohol consumption.

The URI expert advises parents to monitor their children–know where they are, whom they are with and what they are doing.

Monitoring Means Less Drinking

“This type of monitoring, particularly in combination with an emotionally supportive parenting style, is associated with less drinking and fewer alcohol-related problems across numerous studies,” Wood said.

“It is also important for parents to express clear disapproval of alcohol use and to provide clear and fair consequences associated with breaking the rules. Research shows this combination of factors decreases alcohol use and problems through adolescence and into college,” continued Wood who helps create interventions to reduce alcohol related-harm, particularly among college-age students. Results of his recent study bear this out.

Is Wood advocating that parents become helicopter parents–ones who hover over their children and their problems or experiences, especially when they are in college?

“We live in a era when students are texting and talking to parents, sometimes many times a day. Although the term helicopter parent does have a negative connotation, I think conversations about drinking are good whenever and wherever they occur,” said the researcher.

But is it too late for parents to begin monitoring teenagers after they have already graduated from high school?

“Most American teenagers begin to drink by age 15. By the time they go off to college, most have considerable drinking experience,” explained Wood. “Ideally, parents should be having conversations about alcohol throughout high school. But it’s never too late to begin an ongoing dialogue about drinking with teens.”

There is good reason to be concerned. It’s estimated that more than 1,800 college students die each year in car accidents and more than 750,000 are involved in alcohol related physical or sexual assaults.

Adolescents tend to increase their alcohol use the summer before entering college and during their first semester at college. This is also true of children who have been consistently monitored and emotionally supported. However, these children don’t increase consumption to the levels of kids who didn’t have that kind of parental involvement in high school.

Values, Attitudes and Expectations

“The protective effects that parents exert in high school continue to be influential into college even at a time when the kids have left the home. It’s the internalization of those values, attitudes, expectations that seem to continue to exert an effect,” said Wood.

Wood and his team applied some of their research findings to an intervention to reduce the increases in drinking and the negative consequences that typically occur during matriculation and into college. Results of the study were published in the June 2010 issue of the Journal of Consulting and Clinical Psychology.

In this study, which began in 2004, they recruited and randomly assigned 1,000 incoming freshmen to receive either a Brief Motivational Intervention (BMI) or a parent-based intervention, both, or an assessment-only control. The motivational intervention is considered to be the most effective individual alcohol prevention approach with college students.

In contrast to other BMI studies that have focused on heavier drinkers, the URI study recruited students whether they drank or not. In fact, about 28 percent of the 1,000 students in the study didn’t drink when they came to college.

Students met with an intervention provider who went over a tailored report compiled from information provided by the students about a range of factors, including their alcohol use patterns, consequences associated with use, and family history of alcohol problems. Students were recognized as responsible adults, and weren’t preached to or told not to drink.

Among other things, the report showed the student how his or her drinking compared to others of the same age and gender, correcting misperceptions students have about how much other students are drinking. For example, students often overestimate how much their peers are drinking, and correcting these misconceptions as part of motivational interventions has resulted in lower levels of alcohol use and problems.

Family History of Alcoholism

“A message that we would give a student who told us her father was an alcoholic is that we know that alcohol problems run in families. But it’s also important for you to know that this doesn’t mean that you’re destined to become an alcoholic. It just means that you have an increased risk of drinking problems based on family history,” says Wood.

The message is different with non-drinkers: “Congratulations, you’ve made the safest choice in terms of alcohol use at this point. One of the things we want to tell you is that there are more students like you than you think. We’d like to talk to you about ways that you can continue to make the safe choice around drinking now that you’re in an environment where there is more drinking.”

URI researchers followed up with the students in the spring of their freshman and sophomore years. The team found the intervention was successful for non-drinkers and drinkers. Students who received the BMI were significantly less likely to transition into heavy drinking or begin experiencing alcohol-related problems. For those who were already drinking, the BMI reduced heavy drinking and alcohol problems indirectly by altering students’ misperceptions about alcohol use.