By Tom Fortner
GAINESVILLE, Fla. - Carloads of young people are dusting off the flip-flops, icing down the beer and heading to warmer climes this month for the annual ritual of alcohol-fueled partying known as Spring Break. The participants include many college and high school students under the drinking age who all too often are able to purchase alcoholic beverages illegally.
Now new research shows law enforcement authorities trying to shut off the tap might be wise to step up the patrols year-round, not just in the next few weeks, report University of Florida and University of Minnesota researchers in the current issue of the journal Addiction. Findings from a five-year national study they conducted reveal that police checks of establishments that sell alcohol strongly deter sales to minors, and are even more effective when repeated as often as every three months.
The researchers also found that these checks, in which an underage buyer attempts to purchase alcohol without showing identification and violators are cited, work far better than programs that train staff at bars and restaurants to identify and refuse service to minors.
"We found that enforcement has significant effects, but just like enforcement against any offense, you can't just do it once and think it solves everything," said Alexander C. Wagenaar, Ph.D., a professor of epidemiology and health policy research at UF's College of Medicine. "We have to create an ongoing perception on the part of the managers and owners of these establishments that they have a decent chance of getting caught if they sell to teenagers."
The study was conducted against a backdrop of concern about the use of alcohol by young people on college campuses and elsewhere. Alcohol consumption, often to the point of intoxication, plays a role in a range of negative health consequences, including car crashes, risky sex, assaults, recreational injuries, suicide and alcohol dependence.
"We're looking at a behavior that is a leading cause of death among teenagers and young adults," Wagenaar said. "All major causes of death and injury among teens have a substantial proportion that involve alcohol. So if you narrow down that pipeline flow of alcohol to youth, and attenuate their drinking behavior, the health benefits are large."
In their study, funded by the National Institute on Alcohol Abuse and Alcoholism, Wagenaar and his colleagues evaluated two key strategies used to limit the sale of alcohol to minors - one based on deterrence, the other on compliance. These techniques have been studied before but never in such a controlled way nor over so long a period as in this project, according to the authors.
The study involved 942 establishments that sold alcohol in 20 Midwestern cities. They included locations where alcohol drinks were served on the premises - bars, restaurants and bowling alleys - as well as "off-premise" sales establishments such as liquor, grocery and convenience stores.
Every two weeks, these firms were visited by youthful-looking individuals who attempted to purchase alcohol without providing proof of age. The purchasers were actually 21 or older, but appeared to be younger, as judged by members of a panel working with the authors. Over the course of the study, such purchase attempts were made 7,242 times and alcohol was sold to the pseudo-underage customer in about one out of five encounters.
Wagenaar likened this activity to continually "taking the temperature of the community" with respect to its propensity to sell alcohol to minors.
While these attempted purchases continued, 959 enforcement checks were conducted independently by state or local alcohol enforcement authorities. By obtaining reports of these activities, the researchers could chart their deterrent effect over time via follow-up attempts to purchase at the same establishments.
Law enforcement checks on establishments selling alcohol for off-premise consumption produced an immediate 17 percent decrease in the subsequent likelihood of their selling to minors, said Wagenaar and his colleagues, Traci L. Toomey, Ph.D., and Darin J. Erickson, Ph.D., of the University of Minnesota. That reduction dissipated over time, from 11 percent two weeks after a check to 3 percent after two months. Most of the residual effect disappeared after three months.
A 17 percent decrease is "a substantial effect" for one check, said Wagenaar, noting that many communities perform enforcement checks only once a year or less.
Checks of on-premise establishments yielded even better results, with a 17 percent decrease immediately afterward, diminishing to 14 percent at two weeks and 11 percent at two months.
"This study underscores the potential for enforcement of underage alcohol sales laws to reduce underage access to alcohol," said Ralph Hingson, Sc.D., director of the division of epidemiology and prevention research at the National Institute on Alcohol Abuse and Alcoholism.
On the compliance side, about a third of the intervention establishments voluntarily underwent a formal training program in alcohol risk management at the outset of the study. Yet researchers found that training had virtually no effect on the likelihood of illegal alcohol sales to youth.
"Although it can be part of a comprehensive approach, just training the staff that serve alcohol without an active enforcement effort is not effective," Wagenaar said.
The researchers looked at other influences on an establishment's propensity to sell alcohol. They included media reports of enforcement checks and word-of-mouth communication between businesses.
The study was carried out during a national downward trend in the tendency of alcohol establishments to sell to underage youth. In the early '90s, the rate was 50 percent to 80 percent, Wagenaar said. In the study just completed, it was roughly 20 percent.
"Communities have stepped up enforcement," he said. "There is much more carding going on now than there was in the '80s and '90s. There has been substantial progress, but most communities still pay way too little attention to enforcing the law against sales of alcohol to minors."
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Cure no quick fix for cancer survivors on long road to recovery
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By Melanie Fridl Ross
GAINESVILLE, Fla. - Patients who hear the dreaded words "you have cancer" invariably look forward to the day the doctor tells them "you're cured." But University of Florida researchers say survival often comes at its own price - the mind may need mending even after the body heals.
A national study of cancer patients who underwent bone marrow transplantation reveals cancer diagnosis and treatment has a profound and lasting emotional and physical impact that can persist for decades. In fact, many cancer survivors report lingering sleep and sexual problems, pain, cognitive problems and generally poor physical well-being relative to their healthy peers, said John Wingard, M.D., director of the blood and marrow transplant program and deputy director of the UF Shands Cancer Center for the Gainesville campus. The study was the largest to date to assess long-term quality of life issues among these patients.
"A cure is not necessarily synonymous with total resumption of good health," Wingard said.
Many patients suffer physical complications, such as infections or toxicity from intensive chemotherapy and radiation treatment, he said. And both the patient and the family must often travel to specialized tertiary care centers distant from the home, requiring them to establish a temporary residence for a number of weeks or even months. Their work is disrupted, and they frequently face financial challenges and high health-care costs.
"All of this occurs in the setting of a considerable amount of anxiety about whether the transplant is going to be successful, whether the cancer is going to be controlled, and whether potentially lethal complications will occur during therapy," Wingard said. "The individual and the family are subjected to a pressure cooker of emotions and challenges they need to face."
The findings, published in the Journal of Clinical Oncology, highlight the need for doctors to help their patients cope with the often traumatic experience of fighting cancer and the stresses they live with in its aftermath, Wingard said.
Each year, an estimated 30,000 Americans undergo a bone marrow or peripheral blood stem cell transplant, typically a procedures of last resort. Both types of transplantation aim to restore patients' blood stem cell counts after their own stem cells have been wiped out by high-dose chemotherapy or radiation therapy used to treat cancer. After they are infused into the bloodstream, stem cells take up residence in the bone marrow, where they give rise to the immune system's infection-fighting white blood cells, red blood cells or platelets. Worldwide, about 100,000 people who have undergone a successful transplant are alive, and the number of long-term survivors grows daily.
The study involved 662 patients treated at 40 transplant centers who had breast cancer, acute or chronic leukemia, or lymphoma - among the most common indications for transplantation. Researchers at UF, Northwestern University, the University of Kentucky and the Medical College of Wisconsin interviewed participants by telephone and asked them to describe their quality of life. The patients also completed a series of standardized questionnaires that evaluated their physical health, whether they were depressed or anxious or had other mental health problems, the quality of the support they received from friends and family, and whether they had pain, sleep or sexual problems, fatigue or other ailments. They also were asked about their perceived spiritual well-being. A comparison group of 158 healthy peers completed a similar battery of questionnaires and telephone interviews.
UF researchers found cancer survivors reported large differences in measures of general health, physical function and well-being, depression, cognitive function and fatigue. For example, approximately 30 percent of survivors reported experiencing a constellation of severe symptoms that practitioners commonly consider the basis for a clinical diagnosis of depression. In contrast, only 8 percent of healthy matched controls reported such symptoms. On average, patients were evaluated seven years after transplantation, but some reported deficits that persisted for 20 years.
Others described the post-cancer phase as a time of psychological and interpersonal growth. Researchers say that's because merely surviving puts some problems in perspective. These patients reported the experience strengthened relationships, renewed their appreciation for life, reordered priorities, increased empathy and deepened spirituality.
"One unique facet of this study was that it also looked at good that came out of facing a life-threatening illness," Wingard said. "What we found was that a number of the survivors reported psychological growth and that this positive finding might have leavened some of the losses they experienced. For that reason, many of them, when balancing positives and negatives, felt that their life was better. Some pursued a new career, others found strength in renewing relationships with spouses, family and friends, reassessing what was important to them in life."
Wingard said the study emphasizes the need for physicians to remember that providing emotional support and teaching patients and their families coping skills are often as important as focusing on fixing physical problems. Practitioners also must work on identifyingat-risk patients and families who may need extra attention from the health-care team.
UF researchers are continuing to study threats to patients' sense of well-being and are evaluating their data further to better characterize factors associated with positive health outcomes. Eventually they hope to identify and test ways to help them cope after cancer, boosting quality of life for all involved. That might include something as simple as encouraging patients to periodically write down their deepest thoughts and feelings about their experience as a way to reduce stress and alleviate related symptoms.
The bottom line? "Cure is not the end of the journey," Wingard said. "Survivors continue to travel down the road revisiting some of the experiences they had perhaps months, even years, later. It's important for all of us as family members and friends to be aware of that and to be supportive of individuals who have undergone very traumatic experiences involving their health. Long after a cure is achieved, there may be issues, including stress and depression, that may linger and that still require medical attention."
Despite the vast resources applied in pursuit of a biologic cure - the elimination of cancer - much less attention has been devoted to survivorship issues, including ways to help people resume their lives after successful cancer treatment, said Stephanie Lee, M.D., an assistant professor of medicine at the Dana-Farber/Harvard Cancer Institute in Boston. Physicians have routinely monitored their patients for disease recurrence, she said, but studies suggest they are less skilled at identifying and dealing with late physical complications and emotional or adjustment difficulties.
"The ultimate goal should not only be eradication of cancer, but doing so in a way that leaves no physical, emotional or social complications behind, or at least minimizes them," Lee said. "Dr. Wingard's research confirms what many cancer survivors say: A brush with death may enhance appreciation for life by helping people figure out what is truly important. But this greater appreciation for life may also act as a barrier, or a subtle disincentive, to looking for ways to improve deficits in quality of life. Recognition of these deficits is the first step toward trying to improve things." |
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