A Systematic Review of Evidence-Based Prevention Approaches for Alcohol Problems with Viability for Military Implementation

Abstract

Introduction:

Hazardous alcohol use in the military exceeds that of the general population and is associated with a host of negative personal, health, social, emotional, and occupational consequences. Prevention is a cost-effective way to reduce problematic drinking. Despite numerous reviews and meta-analyses synthesizing the literature on prevention programs targeting civilians, there is a dearth of such resources specifically targeting active duty service members and other military personnel. The purpose of this systematic review was to summarize existing evidence-based prevention programs that have documented success in reducing the onset of alcohol problems in young adults, emphasizing programs that may be implementable in the U.S. military.

Materials and Methods:

We identified alcohol prevention programs through two methods: we conducted (1) a meta-review of evidence-based prevention programs in clearinghouses and (2) a systematic review of alcohol-prevention evaluations in military settings.

Results:

Integrated results review 6 prevention programs that were identified as a good fit based on inclusion criteria (i.e., universal or selective prevention, administrable to individuals or small groups) with sufficient support for effectiveness. All included programs demonstrate research supporting their application in either active duty or veteran populations.

Conclusions:

This review adds to the literature by synthesizing the current evidence-based prevention programs targeting the onset of alcohol problems, with an emphasis on those programs that have strong potential for successful implementation among military populations. Specific recommendations and considerations for implementation are provided.

A REVIEW OF EVIDENCE-BASED PRIMARY PREVENTION APPROACHES FOR ALCOHOL PROBLEMS WITH VIABILITY FOR MILITARY IMPLEMENTATION

Alcohol misuse is a significant public health concern in both civilian and military populations, leading to direct and indirect negative consequences for affected individuals and their families. Approximately 12.7% of American males and 9.4% of females 18 or older met criteria for alcohol use disorder (AUD) in 2020.¹ The AUDs increase the risk of physical health disorders (e.g., heart disease, liver disease, cancer^2,3) and are both the cause and consequence of mental health disorders (e.g., depression, anxiety, and post-traumatic stress disorder^4,5). The cost to treat AUD and its consequences burdens health care systems.^6,7

Furthermore, negative consequences are found for those with hazardous drinking that does not meet criteria for AUD.^8-11 Hazardous drinking, defined as 4 or more drinks for females or 5 or more drinks for males on any day,¹² has the potential to escalate in severity, frequency, and related impairment. Military hazardous alcohol use exceeds that of the general population. For example, in 2018, the binge drinking prevalences were approximately 16.6%¹³ for civilians and 34% for service members (SMs).¹⁴ The reasons for this are varied. First, SMs’ high levels of alcohol use are more socially acceptable, skewing perceptions of what constitutes excessive alcohol use.¹⁵ Second, SMs lead more stressful lives (e.g., combat situations, demanding training exercises, time away from loved ones, high operations tempos¹⁵); alcohol may be used to manage these stresses, foster social interactions, and build camaraderie. Emerging adulthood (18-25 years of age) is associated with Americans’ peak level of alcohol use¹⁶ and corresponds to SMs’ modal age.

PREVENTION OF ALCOHOL PROBLEMS

Given (1) the scale of alcohol use, (2) the personal and societal costs associated with alcohol misuse, and (3) the limited availability of treatment resources, prevention is the cost-effective way to mitigate harm and reduce future problematic drinking and its consequences. Most individuals with alcohol use problems do not seek care and are not screened for problematic alcohol use even when they encounter the health care system.¹⁷ As such, the implementation of effective and efficient prevention initiatives can help reach individuals with elevated alcohol consumption but who are not yet known to the community or identified as needing intervention.

Prevention can be conceptualized as (1) universal (initiative administered to an entire population); (2) selective (initiative administered to at-risk individuals); and (3) indicated (initiative administered to individuals showing signs of a problem but who have not reached clinical criteria).¹⁸ The U.S. military has attempted universal prevention via alcohol use policies, regulating alcohol sales and pricing at on-installation retailers, “deglamorization” and personal responsibility campaigns, and health promotion programs.¹⁹ More recently, brief interventions targeting the prevention of alcohol problems have been implemented as selective or indicated prevention with both active duty SMs and veterans (e.g., Screening, Brief Intervention, and Referral to Treatment [SBIRT]).^20,21 Additionally, the use of technology (e.g., web-based platforms; virtual delivery of information via phone, email, and videoconferencing) have led to effective ways of reaching large, diverse populations.^22,23

Department of Defense (DoD) spends approximately $665 million annually (in 2024 dollars) on medical expenses related to excessive alcohol use.²⁴ Moreover, research suggests that heavy alcohol consumption negatively impacts readiness by reducing reaction times, visual sensitivity, and efficiency, particularly in young adults.²⁵ As such, prevention of alcohol-related problems and their consequences is of considerable importance to commanders, military leadership, and policymakers. The DoD Instruction 6400.09 Section 3.2 mandates a prevention process (including for alcohol) comprising “data-informed actions.”²⁶ Each service then executes its own compliant strategy. For example, the Department of the Air Force (DAF) Instruction DAFI-44-121 for the Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program requires that “prevention strategies must be comprehensively structured to educate and inform the overall population as well as specifically target higher risk populations.”²⁷

The ADAPT requested this review to empirically guide their prevention efforts by identifying evidence-based (i.e., empirically supported) prevention approaches that successfully reduce the onset of alcohol problems (e.g., binge drinking, alcohol use disorder, alcohol-related incidents) in populations comparable to that of the U.S. military (i.e., predominantly young and male). Prevention initiatives fitting with military substance use prevention (e.g., universal and indicated prevention programs that were cost-sensitive with modest training and calibration requirements) were of special interest.

RATIONALE FOR REVIEW AND GOALS OF THE CURRENT STUDY

Although there are several reviews examining the efficacy of alcohol use prevention initiatives in civilians,^23,28 there are no systematic syntheses of prevention initiatives applicable to and viable within military contexts. Given that many of the interventions described in the extant civilian literature focus on young adults—the time of highest consumption rates and the modal age of SMs—much of what has been proven effective is likely portable for military use. Thus, this review had 3 primary aims, to (1) summarize the state of current evidence-based prevention programs targeting alcohol problems in civilian adults, (2) review the extant literature on the efficacy of prevention initiatives in military populations, and (3) make recommendations for U.S. military substance use agencies to consider implementing for problematic alcohol consumption.

METHOD

Search #1: Meta-Review for Evidence-Based Prevention Programs: Clearinghouses

We identified prevention programs for problems in young adults from 5 clearinghouses (Figure 1). “Alcohol” and “Alcohol Prevention” were used as keywords or filters.

Figure 1.

Meta-review of programs from evidence-based registries. (a) The results First Clearinghouse Database, which identifies evidence-based programs from Blueprints, California Evidence-Based Cleaning House for Child Welfare, CrimeSolutions.gov, Military Family Readliness, National Registry of Evidence-Based Programs and Practices, Social Programs that Work, and Teen Pregnancy Prevention Evidence Review; (b) the Evidence-Based Practices Resource Center (Substance Abuse and Mental Health Services Administration); (c) Evidence-based Reports (U.S. Agency for Healthcare Research and Quality); (d) The Community Guide (U.S. Centers for Disease Control), and (e) Evidence-based Practices for Substance Use Disorders.

Inclusion and exclusion criteria

Inclusion criteria were (1) demonstrated reduction in problematic alcohol-related behavior, (2) designed for, and testing in, emerging adult or adult populations, (3) included alcohol-related behaviors (e.g., number of drinks consumed), and (4) implementable in the military contexts. Exclusion criteria were (1) requiring a substance use disorder diagnosis, (2) targeting individuals under 18, (3) insufficient scientific evidence, (4) alcohol not the primary intervention target, and (5) policy-level, rather than SM-level, change targets (e.g., limiting times when alcohol is sold).

Search #2: Systematic Review of Alcohol-Prevention Evaluations in Military Settings

To ensure we included all alcohol prevention programs implemented in the military, even if they were not represented in the evidence-based clearinghouses, we conducted a literature search using PsychINFO and EBSCO Host databases. Search terms included “alcohol,” “prevention,” and “military or Army or Navy or National Guard or Marines or Air Force.” This also allowed us to identify programs from the evidence-base clearinghouses that have empirical support in military trials. We retained original research papers, official reports, systematic reviews, and meta-analyses and excluded unpublished manuscripts, dissertations, and theses.

Inclusion and exclusion criteria

Inclusion criteria were that studies (1) sampled either active duty SMs or veterans in the United States, (2) intervened with SMs or veterans specifically (rather than a spouse or partner), and (3) targeted alcohol-related behaviors directly. The exclusion criteria included (1) requiring participants to meet criteria for a substance use disorder, (2) conducting the study outside the United States, (3) targeting intervention to outcomes other than alcohol or only including individuals with a particular medical or psychological diagnosis (e.g., HIV, PTSD), (4) program was implemented at the policy level (e.g., enforcement of underage drinking laws).

RESULTS

Search #1: Meta-Review for Evidence-Based Prevention Programs: Clearinghouses

Forty-three programs were identified as meeting the initial clearinghouse search criteria of “alcohol prevention” (see Figure 1 for the PRISMA diagram). Six programs were included in the final review. Basic information about each program (e.g., implementation details, references) can be found in Table 1.

Table 1.

Summary of Prevention Programs Viable for U.S. Military Implementation

Program	Targets	Format	Selected citations	EBP rating	Resources required	Military Application & General Findings
Brief Alcohol Screening and Intervention for College Students (BASICS)	Frequency of alcohol use; Quantity of Alcohol use; Negative consequences of alcohol use	Indicated;Individual, group, inperson, telehealth, feedback only;Originally designed for 1 hour assessment and 1 hour feedback.	36,37,39	Blueprints: Model Plus; Crime Solutions: Effective; OJJDP Model Programs: Effective; SAMHSA: 3.1–3.3	Manual is publicly available.	Battalion Alcohol Skills Intervention Curriculum (BASIC)—U.S. Marine Corps43 Results: Significant improvement in self-reported alcohol-related problems at 3 months post intervention
Targeted Brief Alcohol Interventions for Alcohol Use for Adolescents and Young Adults	Reduction in alcohol consumption; Less days spent drinking; Lower alcohol related problems	Universal, Selective, or Indicated Individual, group, inperson 1–5 sessions, varying length	20	Crime Solutions: Effective;OJJDP Model Programs: Effective	Varies	Alcohol Misconduct Prevention Program—DAF30,32 Results: Decrease in alcohol related incidents in quasi-experimental study.
Alcohol Screening and Brief Intervention/ Alcohol Brief Interventions	Reduced alcohol use Reduced excessive drinking Reduced underage drinking Reduced-alcohol related harms	Universal Individual 1 session, 5–10min	29,22,52-54	What Works for Health: Scientifically Supported SAMHSA: Grade B	Screening and intervention materials available online through the Institute for Research, Education & Training in Addictions (https://ireta.org/resources/sbirt-toolkit/) and SAMHSA (https://www.samhsa.gov/sbirt)	Screening, Brief Intervention, and Referral to Treatment (SBIRT)—Active-duty Military20,57 Results: Reduction in alcohol consumption for participants with higher risk scores.
Alcohol Excessive Consumption: Electronic Screening and Brief Interventions (e-SBI)	Alcohol Consumption Binge Drinking Risky drinking behavior	Universal 1 session At-least partially electronically delivered	59-61	The Community Guide: Scientifically Supported	The Guide to Community Preventive Services	No studies in active-duty SMs.*
Computerized Brief Interventions for Youth Alcohol Use	Reduced alcohol consumption	Universal Fully electronically delivered 1 session, 5–10min	63, 73	Crime Solutions: Effective	Varies	No studies in active-duty SMs.*
Drinker’s Check-Up/College Drinkers Check-Up	Reduction in average daily consumption Reduction in average peak BAC Reduction in alcohol-related consequences Decrease in ambivalence about reducing alcohol use	Indicated Fully electronic 1 session, 35 min. Motivational/feedback approach	64,67	CDC: Promising	Resources available: https://checkupandchoices.com	Drinker’s Check Up—adapted for military. Active-duty SMs from Army, Navy, Air Force, and Marine Corps56,69 Results: Relative to controls, DCU group demonstrated reductions in alcohol consumption and peak BAC; reductions in consumption maintained at 6month follow up.

Note.

^*See Supplement 1 for summary of results in Veterans populations.

Search #2: Systematic Review of Alcohol-Prevention Evaluations in Military Settings

Papers (N = 901) were identified as meeting the initial search criteria (see Figure 2 for the PRISMA diagram). After removing duplicate records, 495 papers underwent a title review; 52 were included for further review. Nine papers were retained; most were military applications of the programs identified in search #1.

Figure 2.

PRISMA flow diagram for systematic review of military prevention programs.

INTEGRATED RESULTS

Brief Alcohol Interventions for Alcohol Use for Adolescents and Young Adults

Brief Alcohol Interventions (BAI) encompass a range of specific programs that target reductions in alcohol consumption in 1 to 5 sessions. Brief Alcohol Interventions can be delivered as universal, selective, or indicated and can be self-administered or provided by a professional (e.g., paraprofessional, medical provider) in a group or one-on-one. A meta-analysis of 185 BAIs reported significant reductions in alcohol use and related problems among young adults (ages 18 to 30) with small effect sizes (alcohol consumption: ḡ= 0.17 and related problems: ḡ = 0.11).²⁹

Military applications

Two quasi-experimental trials assessed an adapted BAI for DAF technical-school trainees. Klesges and colleagues³⁰ used bachelor’s-level paraprofessionals (many of whom were enlisted personnel) to administer a one-session (40-50min) BAI during the first week of technical training that used (1) a motivational interviewing approach³¹ to address common alcohol-related beliefs, (2) psychoeducation about risk factors and harm-reduction techniques, and (3) personalized feedback based on questionnaire responses (specific details are outlined elsewhere).³² Interventionists were (1) trained with a 2-day workshop that included simulated motivational interviewing group sessions, (2) supervised by a psychologist who was a member of the Motivational Interview Network of Trainers, and (3) checked for fidelity via videorecording and feedback.

In combination with the program and random breathalyzer administration, results from 15,898 Airmen (at one base) found baseline to post-test reductions in alcohol-related incidents (i.e., driving under the influence, underage drinking, accidental injuries, crimes against people when drinking, property damage while drinking³²). Li et al.³³ found that for every dollar spent on the intervention, the DAF saved $4.09, including the amount of money recovered from discharges but excluding any additional health benefits (e.g., lower health care utilization). Talcott et al.³² replicated these results at 4 bases (N = 34,318), reporting a 16% baseline to post-test decrease in alcohol-related incidents.

Brief Alcohol Screening and Intervention for College Students (BASICS)

BASICS, originally intended for college students,^34,35 is an indicated prevention program targeting young adults (18-25 years old) with increased risk for problematic alcohol use (e.g., heavy consumption) with over 30 years of research support.³⁶ Implemented at universities in the United States and internationally, BASICS is a BAI that originates from the lengthier Alcohol Skill Training Program (a 6-8 session group cognitive-behavioral therapy program^35,37). It uses a harm-reduction approach³⁸ coupled with motivational interviewing techniques³³ and was originally delivered as two 1-h sessions: assessment and feedback. The assessment portion can be conducted in person or online. The feedback sessions provide personalized feedback about alcohol use, consequences, beliefs about alcohol, and other contextual factors (e.g., alcohol expectancies, protective behavioral strategies.^39-41 In addition to feedback, general psychoeducation around drinking and MI is infused to support patients in making decisions about changing their alcohol use, such as reviewing strategies for harm reduction behaviors (e.g., strategies for limiting or stopping alcohol use and serious harm related to drinking). BASICS can be implemented either in individual or group sessions, via telehealth or in person, and has evidence to support implementing just a feedback session with remote assessment.³⁷ Decades of research support the efficacy of BASICS in reducing alcohol use and its consequences.^40,42 No formal certification or BASICS is needed; however, ongoing feedback and coaching may be necessary to ensure the program is being implemented with fidelity.³⁷

Military application

A version of BASICS⁴³—has been implemented with active duty U.S. Marines. The program was based on brief alcohol skills training conducted with young adults and adolescents,^35,36,44 which is also the foundation of the BASICS college program. Adaptations to the original BASICS program included encouraging unit leadership to actively monitor and reduce risk within their units. Furthermore, the program was conducted in small groups led by unit leaders. Materials were developed through extensive meetings and trials with U.S. Marine Corps personnel, substance use counselors, and experts in the field. Junior enlisted Marines received two 90-min weekly skills sessions (in small groups of 10-12) with six 60-min booster sessions, whereas senior enlisted Marines completed one 90-min session covering intervention program material, facts about alcohol use, and effects within the USMC, and a section on values and support to assist with monitoring risk within the battalion. A trial with 567 male SMs from 2 USMC infantry battalions (with 1 battalion receiving BASIC and the other serving as a control) was followed up with at 3 and 6months post-intervention. Results revealed significant improvement in self-reported alcohol-related problems (e.g., serious consequences resulting from alcohol use, inability to remember things that happened while drinking); however, this improvement was only found at the initial (3 months post-intervention) follow-up.⁴³ Marines rated a web-based intervention as useful and stated that they would recommend the program to others.⁴⁵

BASICS research with civilians demonstrated efficacy in just one-to-two sessions. There is no research comparing this shorter version with the longer Marines version. Furthermore, decreased alcohol consumption was found in a randomized controlled trial (RCT) with 325 veterans from the wars in Iraq and Afghanistan⁴⁶ of personalized feedback only versus alcohol-impact educational information; no significant differences were found between groups.⁴⁶ Thus, the USMC’s more time-intensive alcohol skills training program likely is more time-intensive than necessary.

Alcohol Screening and Brief Interventions/screening, Brief Intervention, and Referral to Treatment

Alcohol Screening and Brief Interventions (SBIs) are another type of BAI, with a focus on providing information regarding alcohol use consequences and increasing patient motivation to change or prevent problematic alcohol consumption in a short session (usually 5-10min but can be up to 1 h).^33,47 Session content includes (1) screening for alcohol use and associated problems, (2) providing feedback on the patient’s behavior, and (3) providing advice and supporting decision-making around behavior change.^48-50 These interventions can be delivered one-on-one in person or via telehealth. Patients determined to be at high risk also receive a referral for additional assessment and treatment.^47,49 A recent systematic review suggests moderate-quality evidence for the short-term impacts of SBIRT in reducing at-risk drinking in emergency departments.⁵¹ The SBIRT serves as a primary prevention intervention to identify risk levels and make referrals/recommendations aligned with that risk, is clinically and economically effective,^52,53 and is most often implemented in primary care. ^49,54

Military application

Several studies have examined the efficacy of SBIRT with active duty SMs.^20,55-57 Reed and colleagues²⁰ conducted a randomized trial of SBIRT to reduce alcohol misuse among 791 AD SMs. Using a parallel, two-group, repeated measures design, participants were randomly assigned to receive SBIRT or usual care (i.e., brochure with alcohol resources).²⁰ Participants were assessed at baseline and 6months follow-up. Four civilian health educators provided the SBIRT treatment, which included a 15- to 30-min session. To facilitate discussion, participants were provided with a pamphlet (i.e., information about alcohol-related risks impacting military career and finances, definition of a standard drink, National Institute on Alcohol Abuse and Alcoholism consumption recommendations, and information on how to develop a plan for limiting). Overall results indicated no significant changes from baseline to post-treatment. However, higher-risk participants (i.e., AUDIT scores >8) reported that they significantly reduced self-reported quantity and frequency of alcohol use and experienced increased self-efficacy; these effect sizes were small.²⁰

Alcohol Excessive Consumption: Electronic Screening and Brief Interventions

The Electronic Screening and Brief Interventions (e-SBIs) are either entirely or partially self-administered and developed to address access to in-person services and reduce provider burden.^58-60 Parts of the traditional screening and brief intervention process are carried out via electronic devices (e.g., phone, computer), and specific designs can vary.^59,60 The e-SBI mirrors traditional SBI by incorporating (1) screening for excessive alcohol consumption and (2) a brief intervention incorporating personalized feedback and motivational interviewing techniques.⁵⁹ Examples of e-SBI include online self-administered assessment, fully computer-automated personalized feedback, or a provider meeting via telephone, video, or chat. The e-SBIs are effective in reducing alcohol consumption and binge drinking.⁵⁹ These results were stronger for those engaging in heavier consumption at baseline.^59,60 Positive results were maintained up to 1-year post-intervention.⁶¹

Military application

No studies have assessed the efficacy/effectiveness of e-SBI in active duty SMs.

Computerized Brief Interventions for Youth Alcohol Use

A computerized brief (5-10min) intervention is a digitally (e.g., via phone, tablet, or computer) delivered prevention program targeting the reduction or elimination of alcohol use in adolescents and young adults.⁶² Components include (1) assessment, (2) feedback, and (33) decision-making. Like the previously reviewed programs, assessment focuses on alcohol risk level and readiness to change. Feedback is both general and personalized depending upon the level of risk identified. Finally, decision-making tools assist participants in identifying goals and creating a change plan or providing additional information if readiness to change is low. Additional resources and referrals are provided if needed. The specific content of computerized brief interventions varies. A meta-analysis of 14 RCTs targeting youth aged 15-25 found that computerized brief interventions (i.e., assessment + feedback vs. control) reduced alcohol consumption in the short-term (SMD: −0.18, 95% CI, −0.29 to 0.08) and in the long term (SMD: −0.17, 95% CI, −0.30 to −0.04).⁶² Although the authors conclude that computerized brief interventions may be cost-effective, increase reach, and successfully reduce alcohol consumption among young people, they also point out methodological limitations, including high attrition, inadequate blinding of assessors and participants, and relatively small sample sizes.⁶²

Military application

There have not been any RCTs in active duty SMs. However, there is evidence of success with veteran populations⁶³ (see supplement for details).

College Drinker’s Check-Up

The College Drinker’s Check-Up (CDCU)—a 35-min, computer-delivered intervention using brief motivational techniques focuses on reducing heavy drinking among college students—is based on the evidence-based Drinker’s Check-Up⁶⁴ for older adults. The program employs (1) personalized feedback, (2) personal responsibility, (3) carefully given advice, (4) a menu of options for change, (5) empathy, and (6) an emphasis on self-efficacy.⁶⁵ Given the focus on at-risk drinkers, CDCU can be implemented as an indicated prevention program. Results of 2 RCTs demonstrated reduced drinking in heavy drinkers compared with controls.⁶⁶ Another study with students living in off-campus housing found significant reductions in alcohol consumption and alcohol-related consequences at 1- and 3-months post-intervention.⁶⁷

Military application

The CDCU has been adapted and tested in military samples. Pemberton et al. tested an adapted version of CDCU—revising the layout, graphics, and multimedia to include vignettes with military personnel and military-specific norms—at 8 military installations (2 from each service).⁵⁶ Participants (N = 3,889) were assigned to either receive the adapted CDCU program, another web-based intervention (i.e., Alcohol Savvy,⁶⁸) or control. The CDCU, compared with the control, group showed reductions in alcohol consumption, heavy episodic drinking, and estimated peak blood alcohol content. Drinking reductions were maintained at the 6-month follow-up. No significant differences in the Alcohol Savvy group were observed. Williams et al.⁶⁹ found that perceived norms significantly mediated the effects of the CDCU, highlighting the importance of this mechanism in prevention programs targeting alcohol reduction.

DISCUSSION

Summary of Findings

Findings from this review indicate a strong evidence base for short-term effects of preventative programs for hazardous drinking. Often, impacts were not maintained, and effect sizes were typically small. In general, the programs identified in this review were not developed specifically for use in military populations (i.e., active duty SMs, veterans), but rather for the general public or, in many cases, university students (e.g., BASICS, CDCU). Nevertheless, each program included in the review demonstrated at least 1 successful military adaptation (with 2 programs studied within veteran populations; see supplement), albeit often with methodological caveats (e.g., lack of control group, small sample size).

Considerations and Recommendations for U.S. Military Prevention Initiatives

Several considerations are conspicuous for military planners considering implementing any of these programs. The evidence base relies primarily on civilian studies and the relevance for military-specific populations should be carefully deliberated. For example, a recent meta-analysis²³ of civilian studies found digitally delivered interventions led to significant reductions, compared with control groups in alcohol use quantity and frequency, as well as heavy episodic drinking. However, because SMs have unique stressors, cultural experiences, and contextual factors (e.g., deployment, lengthy separation from family members and friends⁷⁰), military planners should weigh which might be the best fit for implementation, how a program should be best adapted for SMs, and test the efficacy of their adaptation. This is particularly salient for the reviewed programs, as the impact of psychoeducation and perceived alcohol norms may vary tremendously based on context. Although there may be similarities between college students and young SMs—especially given that approximately 45% of AD military members are college-aged (i.e., 18-25 years old)⁷¹—programs need to be adapted to fit military alcohol consumption, lifestyle, language, and climate.

Social norms campaigns require ongoing assessment to ensure current, relevant information. For example, a social norm campaign developed in 2010 would need to update information about rates of alcohol use if implemented in 2025.

Military planners should weigh the personnel burden to implement many of the programs. For instance, the BASICS program does not require a certification but requires some training to be implemented with fidelity. Although there is a lack of research on best practices for training and supervising providers, ongoing coaching and feedback are recommended.³⁷ Sustainability considerations include the availability of providers and their turnover (e.g., burden of onboarding and training new staff). Many of the reviewed programs use motivational interviewing as a foundation; thus, staff training and skill-maintenance costs and time need to be allocated.

Some research suggests significant savings related to military implementation of brief alcohol prevention programs (see Supplement 1). Moreover, the cost-effectiveness of in-person delivery should be thoroughly deliberated, as some research suggests similar positive impacts for both in-person and web-based delivery modalities.⁷² Web-based programs may increase honesty, reduce socially desirable answering, and may be a more cost-efficient method of reaching a wide range of SMs.⁷³ On the other hand, web-based delivery may reduce completion rates. For example, 2 studies^20,69 of Drinker’s Check-Up found drinking reductions at 1-month postintervention; however, nearly a quarter of the participants failed to complete the program, which took 90min to finish on average.

Additional implementation considerations include when, where, and how to screen SMs for at-risk alcohol use. Will screening be during basic training, tech training, or an annual physical, for example? Will the prevention initiative be command-directed, voluntary, or mandatory? How will SMs be considered for further treatment? Moreover, if a social norms approach is used, how often will data need to be updated? Will the norms need to be specific for subpopulations (e.g., by rank and gender)?

Strengths

This meta/systematic review represents the first attempt to assemble a comprehensive list of viable, evidence-based universal and selective prevention approaches to target the prevention of alcohol problems specific to the U.S. military. The approach allowed us to be flexible and rigorous in our search approach, while providing practical, clear recommendations for the implementation of military alcohol prevention programs.

Limitations

First, the office soliciting this review—DAF’s substance-use response agency—requested a focus on universal and selective prevention. As such, other branches’ substance-use response agencies may have a different (1) emphasis on resource availability, (2) nature of their drug and alcohol prevention and intervention programming, and (3) needs and goals for preventing alcohol problems. We excluded prevention approaches that could not be accomplished universally or administered to individuals and small groups, such as policies and laws aimed to reduce excessive alcohol consumption (e.g., limiting sales) and alcohol-related vehicular accidents (e.g., signs on the highway reminding individuals not to drink and drive). Second, this review is not exhaustive. We excluded dissertations, theses, and unpublished manuscripts.

CONCLUSIONS

This review adds to the literature by synthesizing the current evidence-based prevention programs targeting the onset of alcohol problems, with an emphasis on those programs that have strong potential to be successful in an active duty military setting. Our recommendations may assist military planners in fulfilling DoD and service requirements to implement evidence-based prevention to reduce alcohol problems and related consequences and improve the mental and physical health of SMs. Due to the sparse literature on effective prevention initiatives specifically for active duty SMs, there is still much work to be done to reduce hazardous alcohol consumption, its related problems, and the associated financial and human costs.

Supplementary Material

Supplementary material is available at Military Medicine online.

DATA AVAILABILITY

All data are incorporated into this article and its online supplementary material. All data are freely accessible.