On a June evening in Johannesburg, colleagues and friends gathered at the annual meeting of the Kettil Bruun Society to celebrate and pay tribute to ARG Senior Scientist Cheryl Cherpitel. Cheryl was the recipient of the 2023 Jellinek Memorial Fund Award for outstanding contribution to the advancement of knowledge on alcohol/alcoholism in the category of epidemiology and population studies. The award recognizes Cheryl’s decades-long research in alcohol use and injury and her collaborations with, and mentorship and training of, researchers across the globe.
Recently, we sat down with Cheryl to talk about the award, how she got started, and the direction her research has taken. We also chatted about the significance of her contributions to science and the impact of her work on the global health community.
Our senior communications specialist, Diane Schmidt, spoke to her from Victoria, BC.
Back to the Start
Diane Schmidt: First, thanks so much for spending time with me today. To begin, let’s talk about how you got into epidemiology and research. I understand you started as a nurse.
Cheryl Cherpitel: That’s right—I was a nurse. And I was a nurse because my mother was a nurse, her sisters were nurses, my cousin was a nurse, and my great grandmother was a midwife. So I came from this long history of female health workers, and of course, I was going to be a nurse. But I really wasn’t that happy with nursing. Two or three years after getting my nursing degree, I went back to do my master’s in public health at Berkeley. As part of the degree requirements, I had to do field work and that took me to Appalachia in Kentucky.
While I was in Kentucky, I noticed how differently alcohol was used than in California. There were these dry counties, and people had to go to other areas to purchase alcohol, and if the police thought you had more alcohol on you than you could drink on your own, they would arrest you. Despite the dry areas and enforcement, I noticed people seemed to have more drinking problems than what I saw in California.
At that point, I didn’t know anything about alcohol research or regional variations.
After that, I lived in Mississippi for a while, and again, I noticed how alcohol was regulated with half of the counties being dry. Also, Mississippi was the last state in the US to repeal prohibition in 1966 and it had a more conservative approach to alcohol regulation.
It was when I was in Mississippi that I decided to go back to do my doctorate, and because of my experiences in the South, I decided to look at regional variations in alcohol use. Tied into that, fetal alcohol syndrome had just been recognized, but all the studies on women drinking during pregnancy had been done on the west and east coasts. I thought we should do something in the South.
I had my dissertation planned even before I applied for my doctoral program. When I was accepted into the program, I received the National Research Service Award fellowship, which is given on an individual basis on the merit of your proposal. But the year before I started the program, being interested in regional variations, I was introduced to Robin Room at the Alcohol Research Group, which at the time, was the Social Research Group—that was the fall of 1979. So when I began my doctoral program, I became an unofficial predoc of ARG because my fellowship was administered through UCSF rather than UC Berkeley.
I finished my dissertation and all the coursework in three-and-a-half years. As an aside, the fellowship committee was concerned that I was being too ambitious, wanting to finish the research in four years (laughs)—and a whole year of that work was spent collecting data on drinking during pregnancy among more than 400 women in Mississippi, each of who were interviewed twice during pregnancy.
Research in the ER
After that, I worked briefly at a county health department, but while I was there, ARG contacted me to see if I wanted to lead an emergency department study that was part of their Center grant. This was to be done as part of the Community Epidemiology Laboratory, which was a series of studies done in Contra Costa County, looking at alcohol, alcohol problems, and treatment aspects in the health and social service system that were not part of the mainstream medical system. The emergency room was one of these settings, and because I successfully collected data in Mississippi, and because of my nursing background I would be viable in the ER, they thought I’d be able to do the study.
However, there had only been one other study in the ER and that was done in 1969 so we weren’t sure we could do it. Because of this, we decided to do a dry run, conducting a study at, what was then called, the San Francisco General Hospital, and it was really, a trial by fire. We collected data around the clock for two months over very major holidays and events—Christmas, New Years, Valentine’s Day, the Super Bowl and a Grateful Dead concert—all of which brought people into the emergency room. We had a 75% response rate and collected data on about 1900 patients on their alcohol use, both injured and non-injured so we could compare.
That was successful, so we went ahead and did the three-hospital study in Contra Costa County. I then decided, it would also be good to collect data from the three Kaiser Permanente hospitals which would then give us a total representative sample of ER patients in Contra Costa County. We also had general population data from Contra Costa County so we could look at some similar variables to see what was really going on with alcohol and injury in the ER population.
I wrote an R01 grant to fund these analyses and was successful and that was the very first R01 that ARG received.
Back then, things were so different. I remember I was at a meeting outside of Warsaw, Poland, and I received a call from NIAAA because Council had met and they were concerned about my statistical analysis and they wanted me to fix it up a little bit—I mean, the personal touch was beyond belief!
That’s for sure! That definitely doesn’t happen anymore [laughs].
ER Studies Expand Across the Globe
After our San Francisco study, in 1985, the first international conference on alcohol and injury was held in Ontario, Canada, supported by WHO and NIAAA and other Canadian institutions. There, I made connections with people globally. Following that, Mexico wanted to do a study in eight emergency rooms, which they did, and I provided the training. Spain was interested, so I wrote a small grant to a funding agency to support their training. Italy was interested and NIAAA came up with some funding for that, and meanwhile, Poland did a study as did Argentina, Canada, and Australia.
What was exciting was from these studies, we were developing a very interesting dataset.
Was your role to train people to conduct these kinds of studies?
Yes, I would go to each of the countries and train people on how to collect the data using the same instrument, the same questionnaire, the same methodology.
I called this collection of studies the Emergency Room Collaborating Analysis Project (ERCAP). At that point, we had about eight countries involved, and given what we were finding in the emergency room, I thought it would be good to try to screen people for alcohol problems. That’s when I became interested in measurement in terms of evaluating some of the screening instruments that were available. Some of these instruments were fairly lengthy and not really feasible in the ER setting, so I evaluated items from instruments in a number of places, such as Poland, Mexico and various locations in the US, and was able to look globally and cross-nationally to identify the smallest set of items that were most effective, sensitive and specific in identifying alcohol use disorders. That became known as the Rapid Alcohol Problems Screen (RAPS).
Before we dive into RAPS, can you talk a little about your findings from the ER studies?
We found that alcohol was very prominent in ER admissions, although, interestingly, in the San Francisco General sample, they thought about half the people who come into the ER were drunk or have alcohol on-board, but it turned out, if you look at individual people, it wasn’t nearly that high—the staff kept seeing the repeaters. The two main measures were to breathalyze people as they came in and ask them whether they drank before the event, and we found rates, I think San Francisco General was one of the highest, of 35 or 36% reported drinking before the event and about 15-18% were BAC positive. It differed, of course, by country and region.
The Development of RAPS and Brief Intervention Assessment
So, let’s talk about the RAPS as it’s being used around the world. You developed this measure to make it faster to assess people in ER settings, is that right?
That’s right. I evaluated the four items—remorse, amnesia, perform (did you not do things you would ordinarily do because of alcohol use), and starter (taking a drink in the morning when you first get up)—and it turns out that the first item, remorse, picks up the majority of people who would be positive (80%). This means that you could ask just one question about remorse—and if someone responds “yes”, you wouldn’t have to ask the other three questions.
Based on my work in the emergency room—both the screening and epidemiology studies—NIAAA invited me to be on the clinical and treatment subcommittee for the initial review group. This was the first time someone from ARG served on a review committee.
What did you focus on after the ER studies and development of RAPS?
After that, I became interested in brief intervention in the emergency room as well—first you assess then you do brief intervention. I received funding for two brief intervention studies.
Several years before, we’d collected epidemiology data in Warsaw and Sosnowiec in southern Poland—the latter having a high rate of drinking among ER attendees—and went back there to do a brief intervention study. The second study was done among Mexican American young adults attending the ER in El Paso, Texas.
Those were interesting studies because we found a high prevalence of heavy episodic drinking and the brief intervention had not been evaluated for this type of drinking before.
What did the brief intervention look like?
We used the Brief Negotiated Interview (BNI). The way it works is, once the person tests positive and agrees to participate in the study, you ask their permission to talk with them about their drinking. It’s really a small conversation, maybe about 10 minutes, and you talk about the pros and cons of drinking, you give them a readiness ruler to see how ready they might be to change, and what the barriers to change are, then at the end of this dialogue, you come to a negotiated agreement as to what they plan to do. For example, someone might say, I’m not going to stop at the bar on my way home from work anymore. It’s a written prescription that the person takes home with them.
Were you able to do any follow up with participants afterward?
Yes. We did a three month and 12-month follow up.
What did you find?
We found the brief intervention is effective even as long as 12 months out. Interestingly, it’s sometimes thought that maybe the screening acts like a brief intervention because you’re asking people about their drinking, so you don’t really have a good control group.
In our studies, we did a randomized control trial with three arms: people who were screened only, people who were screened and assessed—assessment involved gathering more detail about their drinking patterns and problems—and people who were screened, assessed and received the intervention.
Our results showed that people who were assessed looked good at three months with improvements similar to the people who also had the intervention, but by 12 months, they had deteriorated. The people who were only screened didn’t show any difference.
It makes sense that you’d use a brief intervention in this context because it seems to me that you’re capturing folks who have had an incident possibly because of their drinking or their drinking contributed to the incident in some way, at an almost golden moment when an intervention might stick.
That’s how it was seen—like a golden opportunity—and I think it has been, however, when we looked at some interaction terms in the data, whether the person attributed their injury to alcohol, that was significant but not as large as I had anticipated.
What was your next step?
In 2000, the World Health Organization (WHO) became interested in the ER work, and used my instrument to do a study in 12 countries. I helped them do training for that and then I thought it would be wonderful to add those 12 datasets to the eight countries I already had data for, so I wrote another R01, which was funded in 2002. It carried on for 18 years. It must be one of the longest R01s. It just ended in 2020.
That must be an incredibly rich dataset.
It was! Then in 2005, I decided to write a conference grant to fund a meeting in Berkeley on new knowledge on alcohol and injury in emergency rooms. I received funding and we had about 50 people attend from about 20 countries. And we paid for them to come. The Pan American Health Organization (PAHO) was involved and WHO supported people in attending, and of course, NIAAA. We ran it like a Kettil Bruun meeting.
What an amazing opportunity for people from around the world to come together for one purpose—to bring everyone together to share their work.
Exactly. We definitely got a lot of mileage out of it because we were able to come up with recommendations for future research, and I wrote subsequent grants based on these recommendations.
On Becoming Director of the WHO Collaborating Center on Alcohol and Injury
In 2008, PAHO decided they wanted to do studies on alcohol and injury so we collected data in six Central, South and Latin American and Caribbean countries. Based on the work with WHO and PAHO, PAHO asked if I would apply to become a WHO/PAHO collaborating center, which I did. We received that in 2011.
And you kept that role for over a decade, too. So what did it mean to be the director of the WHO Collaborating Center for Alcohol and Injury?
There’s no money attached and it’s mostly seen as a status symbol. However, it’s there to support WHO and PAHO with their initiatives and the work they want to do. The collaborating center helps to support these initiatives and institutions.
I have to say, it was thrilling to go to the WHO headquarters, especially being a nurse. To me, WHO is the epicenter of public health in the world. It was thrilling.
You went for meetings?
The first time I went, I was invited to do a session on alcohol and injury. And I’ve been several times since, and every time, it’s still so thrilling to be there.
Other Significant Contributions
Your work on alcohol and injury has really moved the research forward and has benefited so many people around the world. I’m also curious about your other work—you’ve published studies on measuring blood alcohol content. Do you want to speak about that research?
We did some analysis of BAC, trying to better correlate how much a person had to drink and the timing from the event and what their BAC would be. The idea is that, just because you have someone come into the ER and test positive on a breathalyzer test and you have some kind of qualitative reading, every person is different, and you don’t have full information to determine the causal association. For instance, when we ask people if they were drinking six hours before the injury, some people may have been drinking, but it may have been only one drink six hours ago, and we all know that’s not going to do anything. We wanted to determine how best to measure and determine correlation.
We also did some work on the criteria for the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), and some of our work was very useful in looking at the criteria and which worked and which were not so important.
More recently, WHO asked us to do some analysis of our data on a single episode of drinking and risk of injury. That was very interesting. We found that a very high prevalence of people weren’t heavy drinkers, weren’t alcohol dependent, weren’t frequent drinkers, and didn’t have an alcohol use disorder, they just had this one drinking episode which led to injury. Now that has become a new diagnostic code in the ICD.
That’s incredible! What is it called?
I believe it’s called ‘a single episode of harmful use’.
I should also mention that in 2004, NIAAA invited me to be on the National Advisory Council, which was quite an honor.
I don’t think anyone else at ARG has had that honor?
What does it mean to be on the Council?
Four times a year, we would travel to NIAAA for two and a half days and we would have all the grants before us, and we’d approve them. Sometimes there might be an issue, but mostly we were rubber-stamping the grants. It was very interesting. There was a group of twelve of us, and they were great colleagues in the field, and some of the NIAAA staff would come, and when someone rotated off the council, they’d do a presentation of their work. It was really a wonderful experience, especially compared with being on the review group, which is a lot of hard work!
I bet! What came after your work with PAHO?
Well, PAHO became interested in studies on alcohol and road traffic injuries, so we started work on that. We trained in six countries but only got data from two because of the pandemic. In fact, I was training in the last place—Suriname—and that was in March 2020, when I got a call from PHI asking what I was doing traveling at this time (laughs).
What happened to the study?
We trained the people, but we lost touch after that and now too much time has lapsed for follow up. There’s also been a change to the PAHO alcohol and drug advisor and I’m not sure of the new person’s priorities—it might not be alcohol and injuries.
The pandemic really had a big impact on field work as your experience demonstrates—a lot of research got shut down. Can you also speak to your work in Canada, with the Center for Addiction Research in British Columbia?
Yes, we did ER studies in Victoria and Vancouver, and they were very similar to the other studies. It was very interesting to work with another research group.
Because I lived in Vancouver and worked in a center at St. Paul’s Hospital, I’m curious about the differences between Victoria and Vancouver. St. Paul’s was where the folks from the Downtown Eastside would go for emergency care.
Right. St. Paul’s had a very high prevalence of alcohol-related violence and alcohol-related injuries compared with The Royal Jubilee in Victoria.
So, Cheryl, what are you up to these days in terms of your work? I know you’ve been traveling and sharing your research.
I have more work to do with a group in Portland, Oregon who received funding from the Insurance Institute for Highway Safety to do a study on alcohol and other drug use and motor vehicle injury using the same methodology that we’ve used previously. We’re still writing papers on that study.
And what we’re finding, along with the studies in Victoria and Vancouver, is that cannabis on its own doesn’t contribute much to injuries. However, coupled with alcohol, it is contributing significantly to injuries. We also found that people who smoke cannabis tend to drink a lot more alcohol than people who don’t smoke—the risk of injury is very high when alcohol and cannabis are combined.
The other study that I’m working on is looking at alcohol and pancreatitis. It’s a case-crossover study where people are their own controls. We’re collecting data at three or four sites in the US, including Los Angeles, Philadelphia and Cleveland, and we’re trying to see if there is an association between acute alcohol use and acute pancreatitis, or is it that a person’s long term alcohol use is causing the pancreatitis. We’re following participants over time and interviewing them to see what’s going on. We’re still doing data collection.
What it Means to Win the Jellinek
Okay, so let’s talk about the Jellinek Award. You went to South Africa to receive the award and the award was presented to you by Robin Room. That seems like such a nice circle now that I know Robin is the one who brought you to ARG.
Yes, it was so appropriate, so lovely. It was very sweet. I was very honored.
Well, as others have said to you, it is so deserved and overdue. Your career has really pushed alcohol and injury research forward, along with assessment and intervention with your measure being used in so many countries around the world. It’s a huge legacy.
It’s always a little shocking when people come up to me and say that they’ve read my paper and comment on it. I often think that we write these papers, but does anyone really read them? But they do! That’s always very rewarding.
Often, because the work that we do is at a population health level, it doesn’t always filter down to what’s happening on the ground. But your work does and I hope you know how much you and your research mean to so many people, especially those of us who’ve had the privilege to call you a colleague and friend—and how much you mean to all of us at ARG.
Thank you. I would also like to add, and you might be interested in this because you’re a woman, that only 15% of Jellinek awardees have been women.
Oh, that’s a terrible statistic!
Yes, it is terrible! [laughs] I didn’t say that in my acceptance speech, but what I did say was that there was a picture that a colleague showed everyone at the last Kettil Bruun meeting—it was of the meeting held in Poland in 1986 that I mentioned before—when I was first starting out. There were only 19 people there and only three were women, and I was one of those three. And of those 19 people, five have been recipients of the Jellinek Award. When I said that at the award ceremony, I looked out at the audience and now they are mostly women, and I said, I think we’ve come a long way. People cheered.
That’s great to see this kind of change happen. But thinking about it from that perspective, you’ve really helped pave the way for women.
I received the Jellinek Award for my ER work, but also for being an international collaborator and mentor. It was never my intention, but I guess I did.
Whether you intended to or not, you were in there, making room for those who came after you.
I suppose so.
There are so many things to thank you for, Cheryl. But I’ll start by thanking you for spending this time with me, for your generosity in sharing, and of course, for the work itself and its impact on the world. You’re a treasure. Thank you.
This has been wonderful. Thank you.
Read More About Cheryl’s Work
Acute Alcohol Consumption Causes Higher Injury Risk for Women then Men
RAPS Helps Clinicians Assess Patients in the ER
US-Mexico Border Project Wraps Up with Significant Results
Low and Moderate Drinkers are not Immune from Injuries
Stricter Alcohol-Related Policies Associated with Fewer Injuries
White Moderate Drinkers are a Higher Risk of Alcohol-Related Injuries
Cherpitel Directs the WHO/PAHO Collaborating Center