James C. Turner, MD University of Virginia Past President, American College Health Association Adrienne Keller, PhD. University of Virginia National Social Norms Institute Leading causes of mortality among American college students at 4-year institutions.

Disclosures This project received no specific grant funds from either the University of Virginia or the American College Health Association. The co-investigators are all salaried employees of their respective institutions/organizations. The American College Health Association is a non-profit professional association. This study was commissioned by JCT while President of the American College Health Association. The University of Virginia Department of Student Health has received grants and/or gifts from Merck, GSK, NCAA, Anheuser Busch Foundation, Gordie Foundation, Clay Foundation, and the CDC. None of these entities specifically contributed resources to this project.

ACHA College Student Mortality Rates No published study of college student mortality rates among multiple institutions since No existing data regarding leading causes of mortality among 18 million college students. Student deaths uncommon, tragic, newsworthy. ACHA conducted a survey of 1154 institutions regarding deaths Aug 1, 2009-May 31, four year schools responded representing 1.36M enrolled year old students.

ACHA College Student Mortality Rates Sources of death information: o Dean of students (33%) o Student health/counseling services (26.3%) o Campus security (15%) o Registrar (8.4%) o Central administration (7.2%) o Public affairs (6.6%) o Miscellaneous (3.5%)

Table 1. Comparison of enrollment of year olds in sample schools vs. in all 4 year institutions, by gender, institutional control, Census Bureau region and urbanization. ENROLLMENT (18-24 year olds)* SAMPLEPOPULATION numberpercentnumberpercent By Gender males640, % % females720, % % Total % By Institutional Control public % % private % % Total % % By Census Bureau Region Region 1: Northeast % % Region 2: Midwest % % Region 3: South % % Region 4: West % % Territories % % Total % % By Urbanization Large urban % % Small urban/Suburban % % Rural % % Other/Not assigned406.03%00 Total % %

Table 1. Comparison of enrollment of year olds in sample schools vs. in all 4 year institutions, by gender, institutional control, Census Bureau region and urbanization. ENROLLMENT (18-24 year olds)* SAMPLEPOPULATION numberpercentnumberpercent By Gender males640, % % females720, % % Total % By Institutional Control public % % private % % Total % % By Census Bureau Region Region 1: Northeast % % Region 2: Midwest % % Region 3: South % % Region 4: West % % Territories % % Total % % By Urbanization Large urban % % Small urban/Suburban % % Rural % % Other/Not assigned406.03%00 Total % %

Table 2. Comparison of enrollment of undergraduates among sample and all undergraduates by ethnicity.* RACE/ETHNICITY Undergraduates in all 4 Year Institutions Undergraduates in Sample Schools NPercent N white6,982,69260%979,51869% black1,253,62611%114,5928% Hispanic1,176,29410%88,5206% Asian/Pacific716,9156%95,4837% American Indian/Alaska Native 94,6951%10,2311% Non-resident alien560,1585%43,6013% Unknown843,0067%84,2196% 2 or more560,1585%5,6870% Total11,627, %1,421,851100% * Ethnicity is not available for age groups, but is available by enrollment in undergraduate or graduate/professional programs. Comparison limited to undergraduate populations.

Table 2. Comparison of enrollment of undergraduates among sample and all undergraduates by ethnicity.* RACE/ETHNICITY Undergraduates in all 4 Year Institutions Undergraduates in Sample Schools NPercent N white6,982,69260%979,51869% black1,253,62611%114,5928% Hispanic1,176,29410%88,5206% Asian/Pacific716,9156%95,4837% American Indian/Alaska Native 94,6951%10,2311% Non-resident alien560,1585%43,6013% Unknown843,0067%84,2196% 2 or more560,1585%5,6870% Total11,627, %1,421,851100% * Ethnicity is not available for age groups, but is available by enrollment in undergraduate or graduate/professional programs. Comparison limited to undergraduate populations.

Methodology Annualized data Ten month data converted to twelve months Imputation to estimate alcohol as factor 49% of all vehicular deaths assumed related to alcohol (Hingson et al. JSAD 2009) 38% of all non-vehicular accidents assumed related to alcohol (Hingson et al. JSAD 2009)

Table 3. Mortality rates for year olds at 4 year institutions (n=157) Category of DeathNumber Imputed Cases 12 months Sample nRate/ % CI for rate Predicted Rate/ Reference LowerUpper Vehicular Injury 78941,361, CDC- WISQARS Non-Alcohol Related* 40481,361, Alcohol Related* 38461,361, Hingson et al Suicide 70841,361, CDC- WISQARS Non-traffic injury44531,361, CDC- WISQARS Non-Alcohol Related**27321,361, Alcohol Related** 17201,361, Hingson et al Unknown 34411,361, CDC- WISQARS Cancer 22261,361, to 5.4***NCI Homicide671,361, CDC- WISQARS DOE Total *Cases of alcohol related injury are imputed from the number of vehicular injury using 49% alcohol related. 6 **Cases of alcohol related injury are imputed from the number of non-traffic injury using 38.5% alcohol related. 6 *** NCI provides mortality rates for general population ages and only. Range reflects two age groups year old general population year old college students +++ All four year colleges all incidents of murder (includes students and nonstudents).

Table 3. Mortality rates for year olds at 4 year institutions (n=157) Category of DeathNumber Imputed Cases 12 months Sample nRate/ % CI for rate Predicted Rate/ Reference LowerUpper Vehicular Injury 78941,361, CDC- WISQARS Non-Alcohol Related* 40481,361, Alcohol Related* 38461,361, Hingson et al Suicide 70841,361, CDC- WISQARS Non-traffic injury44531,361, CDC- WISQARS Non-Alcohol Related**27321,361, Alcohol Related** 17201,361, Hingson et al Unknown 34411,361, CDC- WISQARS Cancer 22261,361, to 5.4***NCI Homicide671,361, CDC- WISQARS DOE Total *Cases of alcohol related injury are imputed from the number of vehicular injury using 49% alcohol related. 6 **Cases of alcohol related injury are imputed from the number of non-traffic injury using 38.5% alcohol related. 6 *** NCI provides mortality rates for general population ages and only. Range reflects two age groups year old general population year old college students +++ All four year colleges all incidents of murder (includes students and nonstudents).

Table 3. Mortality rates for year olds at 4 year institutions (n=157) Category of DeathNumber Imputed Cases 12 months Sample nRate/ % CI for rate Predicted Rate/ Reference LowerUpper Vehicular Injury 78941,361, CDC- WISQARS Non-Alcohol Related* 40481,361, Alcohol Related* 38461,361, Hingson et al Suicide 70841,361, CDC- WISQARS Non-traffic injury44531,361, CDC- WISQARS Non-Alcohol Related**27321,361, Alcohol Related** 17201,361, Hingson et al Unknown 34411,361, CDC- WISQARS Cancer 22261,361, to 5.4***NCI Homicide671,361, CDC- WISQARS DOE Total *Cases of alcohol related injury are imputed from the number of vehicular injury using 49% alcohol related. 6 **Cases of alcohol related injury are imputed from the number of non-traffic injury using 38.5% alcohol related. 6 *** NCI provides mortality rates for general population ages and only. Range reflects two age groups year old general population year old college students +++ All four year colleges all incidents of murder (includes students and nonstudents).

Table 3. Mortality rates for year olds at 4 year institutions (n=157) Category of DeathNumber Imputed Cases 12 months Sample nRate/ % CI for rate Predicted Rate/ Reference LowerUpper Vehicular Injury 78941,361, CDC- WISQARS Non-Alcohol Related* 40481,361, Alcohol Related* 38461,361, Hingson et al Suicide 70841,361, CDC- WISQARS Non-traffic injury44531,361, CDC- WISQARS Non-Alcohol Related**27321,361, Alcohol Related** 17201,361, Hingson et al Unknown 34411,361, CDC- WISQARS Cancer 22261,361, to 5.4***NCI Homicide671,361, CDC- WISQARS DOE Total *Cases of alcohol related injury are imputed from the number of vehicular injury using 49% alcohol related. 6 **Cases of alcohol related injury are imputed from the number of non-traffic injury using 38.5% alcohol related. 6 *** NCI provides mortality rates for general population ages and only. Range reflects two age groups year old general population year old college students +++ All four year colleges all incidents of murder (includes students and nonstudents).

Table 3. Mortality rates for year olds at 4 year institutions (n=157) Category of DeathNumber Imputed Cases 12 months Sample nRate/ % CI for rate Predicted Rate/ Reference LowerUpper Vehicular Injury 78941,361, CDC- WISQARS Non-Alcohol Related* 40481,361, Alcohol Related* 38461,361, Hingson et al Suicide 70841,361, CDC- WISQARS Non-traffic injury44531,361, CDC- WISQARS Non-Alcohol Related**27321,361, Alcohol Related** 17201,361, Hingson et al Unknown 34411,361, CDC- WISQARS Cancer 22261,361, to 5.4***NCI Homicide671,361, CDC- WISQARS DOE Total *Cases of alcohol related injury are imputed from the number of vehicular injury using 49% alcohol related. 6 **Cases of alcohol related injury are imputed from the number of non-traffic injury using 38.5% alcohol related. 6 *** NCI provides mortality rates for general population ages and only. Range reflects two age groups year old general population year old college students +++ All four year colleges all incidents of murder (includes students and nonstudents).

Summary of Mortality Rates/100K years old 4-Year institutions Leading causes –Suicide (6.18, CI ) –Non-Alcohol vehicular (3.51, CI ) –Alcohol related vehicular (3.37, CI ) –Non-alcohol non-traffic injury (2.39, CI ) –Cancer (1.94, CI ) –Alcohol related non-traffic injury (1.49, CI ) –Homicide (0.53, CI )

Mortality Rates by Demographic Characteristics Males had a significantly higher rate of suicide than females (OR 4.43, CI ) No differences by institutional control (public vs. private) or Census Bureau Regions in mortality rates for suicide, alcohol vehicular and non-traffic injuries. Rural schools had higher rates of alcohol related vehicular accidents than large urban schools (OR 1.96, CI ) and small urban/suburban schools (OR 2.99, CI ).

Limitations Does not constitute a probability sample of schools (only those schools with access to the data, or willingness to respond to the survey participated). Slight over-representation of males, whites, large urban locations, and public schools may contribute to different mortality rates. No standardized methodology for tracking and reporting student deaths. Imputation of alcohol-related deaths.

Limitations Despite limitations, mortality rates are similar to published data: –Suicide (Schwartz. JACH ) –Alcohol-related vehicular deaths in Virginia (Turner et al. JACH ) –Cancer (Altekruse et al. SEER cancer statistics ) –Homicide (US DOE Post Secondary Education. Campus safety and security statistics )

Comments First mortality study of college students since Suicide 47% lower and alcohol related deaths 60-76% lower than same-aged general population. –Effective education, detection, and intervention –Accessible medical and counseling services –Less driving –Socioeconomic status –Morbidity related to alcohol still a critical public health issue Homicide 97% lower than predicted rate for general population. –Campus security and crime prevention –Behavior intervention teams

Comments Campuses may afford much safer and protective environments than previously recognized. Further study needed to replicate findings and assess contributory factors. Future epidemiologic data needs to be campus generated. –Estimates from national population statistics may not account for environmental factors or interventions. Suicide prevention needs more attention. Powerful statement about the public health value of college health, counseling, security, and other student support services.

Thanks to the American College Health Association and to E. Victor Leino, PhD, Director of Research.