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J Am Dent Assoc, Vol 136, No 7, 1023-1032.
© 2005 American Dental Association
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TRENDS

JADA Continuing Education

The prevalence of alcohol, cigarette and illicit drug use and problems among dentists



GEORGE A. KENNA, Ph.D., R.Ph. and MARK D. WOOD, Ph.D.


   ABSTRACT
TOP
 ABSTRACT
SAMPLE AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. Primarily on the basis of qualitative data, use of alcohol and illicit drugs has been speculated to be higher among dentists. The authors conducted a study to assess self-reported substance use by dentists and compare these data with those regarding physicians and the general population (GP).

Methods. A total of 113 dentists (65.3 percent) and 104 physicians (63.4 percent) from a northeastern state responded to a seven-page self-report survey during the summer of 2002. The survey assessed health care professionals’ alcohol, cigarette and drug use; consequences of use; disciplinary occurrences and treatment; and professional and social influences.

Results. Although about twice as many physicians as dentists reported heavy alcohol use, a greater number of dentists reported heavy episodic alcohol use over the past year and past month, as well as having more alcohol-use problems than physicians. Roughly twice as many physicians and three times the GP reported using anxiolytics than did dentists. More dentists than physicians reported past-year, but not past-month, minor opiate use. While more dentists reported being in social situations in which they were offered alcohol, more physicians reported being offered alcohol by pharmaceutical companies at various functions.

Conclusions. Contrary to previous speculation, there is little evidence from the prevalence data the authors analyzed for this report to suggest that dentists are at a greater risk of developing alcohol- or other drug-use problems than is the GP.

Practice Implications. While the findings of this study do not suggest that substance use is more prevalent among dentists, educational institutions and state organizations still must be vigilant in educating, monitoring and encouraging dentists to voluntarily receive treatment.

Key Words: Alcohol; drugs; cigarettes; substance use; substance abuse

Substance (alcohol, cigarette and illicit drug) use and abuse have been recognized as areas of concern among dental professionals.1,2 As determined from qualitative data,3,4 a number of dentists—like their patients and other health care professionals5–9—use alcohol, tobacco and other potentially addicting drugs, thus potentially jeopardizing themselves, their practices and, most importantly, the public. While these data are highly informative for delineating important correlates of use, prevalence data for alcohol, cigarette and drug use by dentists are virtually unknown, and, as noted by Hankes and Bissell,10 what data exist are questionable in their generalizability.10

There is little evidence that dentists are at a greater risk of developing alcohol-or other drug-use problems than is the general public.

Much of the available information pertaining to dentists has been based largely on a review article,11 a retrospective analysis of treatment-seeking or professionally censured dentists,12 a study with uncorrected multiple analyses,13 or qualitative studies.3–5,14 In particular, qualitative studies based on clinical samples of dentists may lead to overestimating dentists’ substance dependence and raising unfounded concerns about their substance use. While these studies have provided valuable insights into the clinical processes of substance use and abuse by dentists, they nonetheless are limited with respect to methodological rigor and generaliz-ability to dentists at large.

Substance abuse rates among dentists have been characterized to be higher than those reported in the general population (GP).11,12 Clarke and colleagues,12 citing previous findings,14 deduced that chemical dependency may be more prevalent among dentists; they estimated the percentage of alcohol and drug dependence in dentists to be 15 to 18 percent. Chiodo and Tolle11 similarly suggested that dentists were at a higher risk of reporting greater substance abuse than the GP. They concluded that the literature consistently reported higher rates of chemical dependency in health care providers. Actually, the 15 to 18 percent estimate initially cited by Hedge14 was consistent with combined substance abuse-dependence data for the GP at the time15 and, therefore, does not support this characterization. As also reported for physicians,16 this incongruity illustrates the lack of dependable data that question whether dentists are indeed at increased risk of developing alcohol or drug dependence.

The primary aim of our study was to obtain methodologically sound and current prevalence data so as to better inform the dental profession about data that may direct future initiatives related to substance use by dentists. A secondary aim of our study was to compare substance use among dentists with a sample of physicians and the public at large using data collected from a statewide survey, as well as general population data available from the National Survey on Drug Use and Health (NSDUH).17 To provide a more complete substance abuse outcomes-related topography, we also included prevalence data focusing on the consequences of substance abuse and putative social and professional influences that may facilitate or contribute to substance use by dentists.

In this article, we use a number of specialized terms that often have other "everyday" meanings. To minimize confusion, we define "drug use" as the intake of a licit substance (used without a prescription or for reasons other than intended) or illicit substance, and we define "drug abuse" as "the intake of a chemical substance under circumstances or at dosage levels that significantly increase risks of harm, whether or not the substance is licit or illicit."18 In addition, we define "alcohol use" as alcohol being consumed during the specified period assessed in the survey and "alcohol abuse" as a pattern of problem drinking that may result in health consequences, social problems or both.


   SAMPLE AND METHODS
TOP
 ABSTRACT
 SAMPLE AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Measures. Substance use. We used items based on the National Household Survey on Drug Abuse19 and other surveys of health care professionals20–23 to assess health care professionals’ self-reported substance use. Consistent with these surveys, we defined "heavy episodic use" of alcohol as consuming five or more drinks containing alcohol during one episode at least once during the specified timeframe (year or month) and "heavy alcohol use" as heavy episodic use five or more times during the past month.

We compared past-year and past-month use of drugs with similar items assessed in the GP in 2002.17 In our study, we specified that the phrase "use of prescription drugs" meant the drug use was "on your own, without authorization, or for use other than intended or prescribed." The prescription drug classes (with trade name examples) we assessed included stimulants, major opiates, minor opiates, anxiolytics (for example, alprazolam), sedative-hypnotics, inhalants (for example, nitrous oxide), tranquilizers, barbiturates and miscellaneous drugs such as butorphanol or tramadol. The "street drugs" we assessed included marijuana, cocaine, hallucinogens and "designer drugs" such as 3,4-methylene-dioxymethamphetamine (known commonly as "Ecstasy"). In view of low base rates assessed in a much larger sample,22 we did not assess heroin and steroid use.

Alcohol and drug dysfunction. A set of items assessed lifetime minor and major consequences of use called "dysfunctions," first as a result of alcohol use and then of drug use.21 An example of a main question stem assessing minor alcohol-related dysfunction was "Has your alcohol or drug use ever caused you to ...". One of the multiple answer choices was "get behind in your work?". An example of a question assessing major dysfunction was "have an auto accident or other kind of accident?"; the response options ranged from "never" to "often."

Disciplinary occurrences and treatment. We assessed self-reported consequences resulting from alcohol and drug use, along with disciplinary outcomes and treatment sources.23

Professional and social influences. Consistent with previous research,24,25 we used a set of questions to assess the impact of social influences such as friends, acquaintances and pharmaceutical companies on alcohol and drug use during the past year. We asked study participants how many times in the past year they had been in situations in which they were either given, bought or offered a drink by friends, colleagues or sales-people or offered or asked for prescription drugs.

Procedure and survey response. After we received approval by the institutional review board (IRB) of a small northeastern state university, 30 health care professionals, representing multiple health care fields, pilot tested a questionnaire. After we made minor changes to the questionnaire and received IRB reapproval, we administered a seven-page self-report survey during the summer of 2002.

The sample consisted of all licensed dentists, nurses, pharmacists and physicians in a small northeastern state during 2002 (state name withheld per IRB request), whose names and contact information were supplied by the state’s department of health, which is responsible for overseeing all boards of registration for each health care profession. We stratified the addresses supplied by the department of health by ZIP codes to represent all regions of the state. Based on the population of each health care group in the state, we created a random sampling of health care professionals by choosing every nth person on each group’s list. The sample frame was 671 dentists, 1,369 pharmacists, 3,424 physicians and 15,181 nurses. The total number of participants we anticipated that we needed to obtain the targeted final sample of health care professionals was 748: 178 dentists, 188 nurses, 186 pharmacists and 196 physicians (95 percent confidence level with ± 10 percent sampling error). Other than demographics, we present only data relevant to dentists and physicians.

The survey asked participants how many times in the past year they were either given, bought or offered a drink or were offered or asked for prescription drugs.

Using validated self-report mail survey methods,26 we sent 748 health care professionals chosen from the sample frame an introductory letter explaining the purpose of the survey. At regularly specified intervals over an eight-week period, we mailed them a survey packet that included a consent form for them to indicate their agreement to participate, as well as a guarantee from us ensuring the participants’ anonymity and confidentiality. As a token of appreciation, we sent $1 to all health care professionals in the first wave of surveys. After we mailed the introductory letter, we sent subsequent mailings (a possibility of three surveys and two follow-up postcards) only to those who did not respond to the previous mailings. We sent the final survey to the remaining nonrespondents using priority mail.

After we removed the 51 people who could not be contacted, the subject pool after the three waves was 697, with 479 usable responses. For all health care professions combined, the response rate to the survey was 68.7 percent, with 113 (65.3 percent) dentists and 104 (63.4 percent) physicians responding. Considering the sensitive nature of the survey, the level of response was consistent with those of the most methodologically rigorous studies of health care professionals.22–24

Overall, dentists were slightly older than physicians (Table 1Go). Except for a slight underrepresentation of women in dentistry, the final sample was consistent with demographic information provided by the state for dentists and physicians (20 percent and 26 percent, respectively). The majority of dentists and physicians were white, non-Hispanic and married. Dentists and physicians replied that they were in a solo (53 percent and 26 percent, respectively) or group (38 percent and 27 percent, respectively) practice, with most dentists specializing in general dentistry (74 percent), pediatric dentistry (8 percent) or oral and maxillofacial surgery (7 percent), while physicians reported working in many specialties.


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  		TABLE 1 DEMOGRAPHICS OF HEALTH CARE PROFESSIONALS WHO RESPONDED TO THE SURVEY (n = 479).

 
Data analyses. We scanned the surveys into a database and imported the data into a statistical software program (Statistical Analysis System, Version 8.2, SAS Institute, Cary, N.C.) for data analysis. The initial data analysis phase consisted of a series of preliminary analyses and logical groupings of variables for further analysis. We used normal probability plots to identify far outliers (that is, two standard deviations from the mean); however, we found none. The variables we used in our analyses met the guidelines for skew and kurtosis.27 We used t tests for group difference significance tests between dentists and physicians, and we conducted {chi}2 analyses on prevalence data. We used logistic regression, analysis of variance and bivariate correlation to examine nonresponse.


   RESULTS
TOP
 ABSTRACT
 SAMPLE AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
We examined the data as a function of the three waves of response to assess for response bias (that is, to determine if any relationships existed between the various substance use measures and timing of the response to the survey). Putatively, nonresponders might resemble those who respond in the last wave more than those who respond in the earlier waves. The analysis by wave, therefore, provides one basis for evaluating whether the nonresponder group includes a higher proportion of substance users than the responder group.28,29 Our analysis found no evidence of higher substance use among third-wave responders and, therefore, no indication of a nonresponse bias.

Prevalence of alcohol, cigarette and drug use. Past-year and past-month prevalence rates of alcohol, cigarette and drug use are reported in Table 2Go for dentists, physicians and the GP. NSDUH17 assesses substance use in the GP and also includes broader descriptors defining drug categories such as the use of pain relievers and tranquilizers. We considered the clinical sophistication of the respondents to this survey and inquired about more specific use of minor and major opiates, as well as anxiolytics and barbiturates (for example, phenobarbital). For comparisons with the GP data,17 we used the closest available age groupings (aged 50–54 years for alcohol and cigarettes and 26 years and older for illicit drugs) to the dentists and physicians in our study, who had a mean age of almost 50 years. We provide these rates as approximate comparisons and recognize the weakness of not having precise age-matched cohorts.


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  		TABLE 2 PREVALENCE OF PAST SUBSTANCE USE FOR DENTISTS, PHYSICIANS AND THE GENERAL POPULATION IN 2002.

 
Alcohol was the most widely used substance for all groups, with lifetime use by 96.5 percent of dentists, 92.3 percent of physicians and 88 percent of the GP. Data in Table 2Go indicate that not only did a significantly greater number of dentists than physicians report heavy episodic use of alcohol over the past year ({chi}2 = 6.041, P ≤ .01), they also reported a significantly higher average mean number of drinks per month (t = 2.32215, P ≤ .05). Table 2Go also shows that heavy episodic use and, in particular, heavy alcohol use by people aged 50 to 54 years were reported more by the GP than by dentists. Likewise, though more dentists than physicians reported past-year and past-month cigarette use, these figures were substantially less than those reported by the GP. Though not significant, past-year and past-month marijuana use was reported by more dentists than physicians or the GP.

Dentists and physicians most frequently reported using anxiolytics and opiates among all of the prescription drug classes. A notable, though not a significant, difference was that almost twice as many physicians as dentists and three times the GP aged 50 to 54 years as dentists reported using anxiolytics. More dentists than physicians reported past-year, but not past-month, minor opiate use. Though this rate was less than reported by the GP, one must keep in mind that we assessed the rates for minor and major opiate use separately. When we considered both together, we found that opiate use by dentists exceeded the past-year prevalence reported by the GP. Neither group reported past-year use of inhalants, which included nitrous oxide on the survey; however, though not shown, 13.3 percent of dentists and 5.8 percent of physicians reported lifetime use of inhalants.

Lifetime use of drugs for illicit reasons or for reasons other than prescribed (including marijuana) by both dentists (60.1 percent) and physicians (59.6 percent) exceeded the rate reported by people aged 50 to 54 years in the GP (51.1 percent). Total past-year and past-month illicit drug use rates by both groups of health care professionals also exceeded those reported by the GP. While past-year and past-month drug use was reported by about 50 percent more dentists than physicians, the majority of this use involved marijuana.

Alcohol and drug dysfunction. Table 3Go displays a number of minor and major dysfunctions related to alcohol or drug use or abuse by dentists and physicians. In addition to listing separate dysfunctions, we provide subtotals for one or more minor dysfunctions related to alcohol or drugs and one or more major dysfunctions related to alcohol or drugs. We summed up these minor and major dysfunctions to give total percentages that reported one or more of any type of dysfunction, called "some alcohol or drug dysfunction." In general, dentists reported having more individual problems related to alcohol use than did physicians; however, none of these differences was significant. Relative to specific minor alcohol dysfunctions, "worry that you might be using too much or too often" was the problem most frequently reported by both dentists and physicians. On the other hand, a greater number of dentists than physicians reported that at least once, alcohol use had caused them to "call in sick or late for work." In total, while twice as many dentists as physicians reported having major dysfunctions, this finding was not significant. However, a significantly greater proportion of dentists than physicians reported having combined minor and major alcohol-related dysfunctions ({chi}2 = 8.261, P ≤ .01).


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  		TABLE 3 LIFETIME PREVALENCE OF MINOR AND MAJOR DYSFUNCTIONS RELATED TO ALCOHOL OR DRUG USE.*

 
Except for the response category "call in sick or late for work," more physicians than dentists reported having drug-related problems in every category, though the reported rates were low for both groups. As with alcohol, worrying about too much drug use was the primary concern for both groups of health care professionals. When we examined the compilation of dysfunctions, we found that more physicians than dentists reported having one or more minor, major and some drug-related dysfunctions.

Disciplinary occurrences and treatment. Table 4Go displays total percentages for perceived use and abuse of alcohol and illicit drugs. More than appropriate alcohol use was reported by 29.2 percent of dentists at some time during their lives. As with many other alcohol-use measures, fewer physicians than dentists reported that they had ever used alcohol more than they would consider appropriate. Perhaps reflecting drug access, fewer dentists than physicians reported using drugs more than would be considered appropriate. With the exceptions of receiving out-patient treatment for drug or alcohol problems and successfully stopping drug or alcohol use on their own, few respondents acknowledged that they had sought treatment or been subjected to a disciplinary investigation or referral as a result of substance use. None of the survey respondents reported they had been disciplined by the state or forced to change employment because of a substance-related problem.


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  		TABLE 4 LIFETIME PREVALENCE OF CONSEQUENCES OF ONLY ALCOHOL, ONLY DRUG OR BOTH ALCOHOL AND DRUG USE AND ABUSE.

 
Professional and social influences. We combined the responses of greater than once or twice during the past year to generate the percentages presented in Table 5Go (page 1030). More dentists reported they were more often in social situations in which friends or colleagues offered them alcohol than were physicians. On the other hand, significantly more physicians than dentists reported that pharmaceutical companies offered them alcohol at various continuing education functions ({chi}2 = 38.551, P ≤ .001). Roughly one in eight physicians and dentists reported that they were asked for psychoactive prescription drugs by nonpatients and colleagues. Only physicians reported using samples of psychoactive drugs, and more physicians than dentists acknowledged writing prescriptions for psychoactive drugs for their own use.


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  		TABLE 5 PAST-YEAR PREVALENCE OF PROFESSIONAL INFLUENCES ON ALCOHOL OR DRUG USE.

 

   DISCUSSION
TOP
 ABSTRACT
 SAMPLE AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
There is little evidence from the data we present to suggest that dentists are at a greater risk of reporting greater alcohol or drug use than is the GP. Although total past-year and past-month illicit drug use by dentists exceeded rates reported by the GP, these rates were almost exclusively due to marijuana use. Furthermore, the total drug use rates for the GP 50 to 54 years of age category we used for comparison purposes17 is conservative; using the 45 to 49 years of age category would double the total illicit drug use rates. The total illicit drug use rate for 50-year-olds most likely lies somewhere in between the rates for the two age groups. Assessing substance use prevalences for comparably age-matched samples in the GP would be a methodologically superior approach in future studies.

As in the rest of society, alcohol abuse appears to be the most notable substance-use issue facing dentistry. In a retrospective study of the treatment records of 2,015 health care professionals in Maryland’s treatment program, researchers found that dentists, in addition to physicians, were more likely to be exclusively abusing alcohol.30 By just about every major alcohol-use measure used in our study, dentists were more likely to consume, abuse and report problems from alcohol than were physicians. When compared with the GP, however, the prevalence of heavy episodic use and heavy alcohol use were less, suggesting that dentists were, at most, no more likely to develop a problem with alcohol than were people in the GP.

Consistent with previous findings, data suggest that physicians have a distinctive pattern of drug use that includes primarily minor opiates and anxiolytics.22 In contrast to physicians, in our study dentists were more likely to use marijuana than were physicians or the GP. On the other hand, except for marijuana, anxiolytics and to some degree opiates, most drug use rates for dentists were exceeded by prevalence rates from the GP. Most dentists do not have access to or require many other drugs such as sedatives, major opiates or barbiturates in their practices. While Clarke and colleagues12 suggested that nitrous oxide poses a particular hazard for dentists, no past-year or past-month inhalant use by dentists in our sample was reported.

Some factors that may be related to differential drug use rates reported by dentists that we considered included the sex ratio of the sample, as well as the subjects’ incomes and their social influences. First, we considered that alcohol-use differences among dentists may be related to the fact that more dentists are men, who typically report greater alcohol consumption than women.31 While the majority of dentists in our study were male (85.3 percent), almost as many physicians were male (73.9 percent). Furthermore, we found no statistical difference between the sexes on past-month alcohol consumption. Previous findings suggest there tend to be fewer sex differences in drinking between men and women as a function of increased socioeconomic status (SES).32 Furthermore, problem drinking among female medical school students and among male medical school students is approximately the same by the end of medical school.33

Second, while Hughes and colleagues22 suspected that alcohol use was more prevalent in physicians than in the GP owing to physicians’ higher SES, the results of our study do not entirely support this conclusion. While past-year prevalence of alcohol use may be related to higher SES, our findings suggest that heavy episodic use and heavy alcohol use may be more prevalent among the GP than among health care professionals, as the GP has, on average, less education and lower incomes than dentists or physicians. That is, while dentists may drink more heavily than physicians, by comparison with the GP, most appear to drink in moderation. In a review of several surveys performed in the United States, Knupfer32 noted that people with a higher SES were more likely to drink alcohol and to drink more frequently, but they were more likely to drink moderate amounts of alcohol. Moreover, a consistent relationship between incidence of alcohol problems and lower SES also has been reported.34

Dentists reported that during the past year they were offered alcohol by friends and colleagues more often than did physicians. Social factors in concert with other risk factors might significantly facilitate alcohol use by dentists. Heath35 suggested that an underlying social structure defines and shapes a relationship between alcohol use, alcohol involvement (activities in which use of alcohol use by a group is a central social theme) and group membership. The findings from our study suggest that modest support for a social component combined with other biopsychosocial factors contributes to a higher prevalence and rate of alcohol use by dentists.

As a result of their alcohol or drug involvement, only a small number of dentists (1.8–2.7 percent) reported that they had received either formal or informal treatment or had sought help of some type. These rates are low when compared with similar data (7.9 percent lifetime) for physicians.22 As noted by Hughes and colleagues,22 this type of measure is methodologically weak, as there is a tendency for some respondents to deny they may have a substance-abuse problem.

Repeated requests to the state board of examiners in dentistry to obtain public information regarding the specific number of substance-related disciplinary actions by the state were unsuccessful. We subsequently obtained data on disciplinary actions for any reason.36 While these data suggest the 10-year prevalence rate to be somewhat less than 3.4 percent, the rates of substance use and dependence could be higher than the actual number of cases resulting in disciplinary action because of self-initiated treatment.

While we effectively implemented well-validated methods for obtaining a representative sample with which to compare dentists and physicians,29 some limitations of our study must be kept in mind when considering the findings. A 68.7 percent response rate was robust compared with other similar studies performed with health care professionals,21–23 but about 31 percent of the sample did not respond. This means there was a chance that the alcohol use or abuse histories of those health care professionals who did not respond were in some way different from those who did. Although the response rate in our study suggests good generalizability, we drew the sample from a single, northeastern state, limiting the generalizability to the broader population. Alcohol and drug use rates have been known to vary by geographic location, with substance use generally higher in the Northeast.17,20 Also, many of the drugs we assessed in our study are controlled substances of which unprescribed use constitutes an illegal activity. This question becomes even more relevant to health care professionals, who also must abide by the Controlled Substances Act.37 The sensitivity of collecting such data makes reliability and validity a concern. Surveys on drugs in which questions are asked about socially disapproved and illegal behaviors may generate inaccurate reporting and bias in survey estimates. Underreporting has been found to vary as a function of more recent assessment and more highly stigmatized drugs.38 Although we included a guarantee assuring anonymity and confidentiality with each survey mailed, the data presented by this study probably are representative of a conservative estimate of substance use by dentists and physicians.

Most, if not all, states now recognize that dentists and other health care professionals respond positively to treatment for substance abuse disorders39 and have impaired-provider programs in place.10 While the findings of our study do not support the previous conclusion that substance use and abuse is more prevalent in dentists, state organizations should remain vigilant in monitoring and encouraging substance-impaired dentists to voluntarily seek treatment. Early intervention for dentists, as well as other health care professionals, is key to lessening the potential detrimental outcomes that often occur from substance use, abuse and dependence.3 Ultimately, since most health care professionals receive little training about the dynamics of addiction, too many remain vulnerable.4 A comprehensive program involving a combination of approaches is essential to combat potential substance impairment beginning in dental school.40 Education addressing the nature, causes and prevention of substance dependence are needed for all programs. Improving how people think of chemical dependency might change the paradigm that chemical impairment is something other than a brain disease41 and, in turn, alter the stigma that health care professionals and others associate with this mental health disorder.42 A program that seeks to change attitudes and awareness of the problem might include enhancing dental practitioners’ understanding of the disease characteristics and neurobiochemical processes, incorporating discussions in dental school that are intended to humanize substance abuse by people, identifying organizations or programs from which dentists can seek assistance, requiring that dental students have exposure to Alcoholics Anonymous or Narcotics Anonymous meetings, dispelling the myth of immunity to alcohol and other drug addictions, and exposing students to recovering chemically dependent dental professionals.2,10

Additional information on and confidential resources for treatment from the Dentist Well-Being Program, ADA Council on Dental Practice can be obtained on ADA.org at "www.ada.org/prof/resources/topics/wellbeing.asp".


   CONCLUSION
TOP
 ABSTRACT
 SAMPLE AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
Previous speculation suggests that rates of alcohol and illicit drug use by dentists are higher compared with those of the GP. The primary aim of our study was to quantify these rates compared with those of physicians and the GP. Compared with physicians, dentists were more likely to report heavy episodic alcohol use and use of marijuana. Contrary to previous speculation, however, there is little evidence from the prevalence data in our study to suggest that dentists may be at a greater risk of developing alcohol or other drug problems than is the GP.


   FOOTNOTES
 

Dr. Kenna is a postdoctoral fellow, Community Health, Center for Alcohol and Addiction Studies, Box G-BH, Brown University, Providence, R.I. 02908, e-mail "George_Kenna{at}Brown.edu". Address reprint requests to Dr. Kenna.


Dr. Wood is an associate professor, University of Rhode Island, Department of Psychology and the Cancer Prevention Research Center, Kingston.


The authors wish to thank Alvin Swonger, Ph.D., and Janet Kulberg, Ph.D., for comments on survey design and interpretation; John Femino, M.D., for his invaluable assistance in the pilot study phase, study design and interpretation of the data; and Allison Trinkoff, Ph.D., R.N., of the University of Maryland for sharing her survey design.


Requests for copies of the survey used in the study described in this article should be sent to Dr. Kenna.


   REFERENCES
TOP
 ABSTRACT
 SAMPLE AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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