Magnitude and Prevention of Underage and College Drinking Problems Magnitude and Prevention of Underage and College Drinking Problems Washington, DC February 15, 2006 February 15, 2006 Ralph Hingson, ScD National Institute on Alcohol Abuse and Alcoholism CADCA National Conference

N ational I nstitute on A lcohol A buse and A lcoholism Underage Drinking and Prevention U.S.A.

N ational I nstitute on A lcohol A buse and A lcoholism Alcohol is the Drug of Choice Among Adolescents Source: Monitoring the Future, 2004 Percent Using in Past Month Grade

N ational I nstitute on A lcohol A buse and A lcoholism Adolescents Drink Less Frequently Than Adults, But Drink More Per Occasion Source: SAMHSA National Survey on Drug Use and Health 2003 Drinking days/ month Usual # drinks/ occasion Underage 12-17Adult 26 and older

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CDC Youth Risk Behavior Survey 2003 N= 15,240 School Response 81%, Student Response 83% U.S. Student Pop. Grades ,267,000 U.S. Student Pop. Grades ,267,000  28% of high school students start to drink before age 13  By age 17 they are 7 times more likely to binge frequently (5 or more drinks/ 6 or more times per month)  There are over 1 million frequent bingers in high school  Over 2 million age are frequent binge drinkers (NHSDUH 2003)

N ational I nstitute on A lcohol A buse and A lcoholism Youth Risk Behavior Survey 2003 Frequent binge drinkers compared to abstainers in high school were much more likely in the past 30 days to Frequent binge drinkers compared to abstainers in high school were much more likely in the past 30 days to Ride with a drinking driver 80% vs. 13% Drive after Drinking61% vs. 0% Never wear safety belts18% vs. 5% Carry weapon45% vs. 10% Carry gun24% vs. 3% Be injured in a fight17% vs. 2% Be injured in a suicidal attempt10% vs. 1%

N ational I nstitute on A lcohol A buse and A lcoholism Youth Risk Behavior Survey 2003 Frequent binge drinkers compared to abstainers in high school were much more likely to Frequent binge drinkers compared to abstainers in high school were much more likely to Be forced to have sex22% vs. 5% Had sex with 6 or more partners32% vs. 3% Use condoms last time had sex56% vs. 65% Been or gotten someone pregnant13% vs. 2%

N ational I nstitute on A lcohol A buse and A lcoholism Youth Risk Behavior Survey 2003 Frequent binge drinkers compared to abstainers in high school were much more likely to have in the past month Frequent binge drinkers compared to abstainers in high school were much more likely to have in the past month Used marijuana71% vs. 6% Used cocaine26% vs. <1% Ever injected drugs15% vs. <1%

N ational I nstitute on A lcohol A buse and A lcoholism Youth Risk Behavior Survey 2003 Frequent binge drinkers compared to abstainers in high school were much more likely in the past month to: Frequent binge drinkers compared to abstainers in high school were much more likely in the past month to: Drink at school31% vs. 0% Use marijuana at school29% vs. 1% Earned mostly D’s and F’s in 13% vs. 4% school within the past year

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United States 2002 Underage Drinking Related Injury Deaths Persons Under Traffic crash deaths* 1,143 drinking drivers under other persons under other persons under persons older than persons older than Other unintentional injury deaths** 1900 alcohol related homicides/suicides _____ 35% of homicides 11% of suicides*** 5,555 * NHTSA ** CDC 33% alcohol related *** Percentage Reported by Levy et al. Cost of Underage Drinking OJJ DP, 1999

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Dr. Margaret Jonathan Travis Moore Levy Stedman Magnitude of Alcohol Problems on U.S. College Campuses Hingson et al. (2002) J. Studies on Alcohol

N ational I nstitute on A lcohol A buse and A lcoholism Annual Review of Public Health Brad McCue

N ational I nstitute on A lcohol A buse and A lcoholism Data Sources Examined  Fatality Analysis Reporting System (FARS, NHTSA)  Mortality Statistics (CDC)  US Census Bureau Population Statistics  College Enrollment Data US Department of Education  Smith, et al. Fatal Non-Traffic Injuries Involving Alcohol: A Meta Analysis, Annals of Emergency Medicine 1999, 33:  National Household Survey on Drug Abuse 1999, 2002  Harvard School of Public Health College Alcohol Survey (CAS) 1999, 2001

N ational I nstitute on A lcohol A buse and A lcoholism Change in percent binge drinking and driving under the influence among year olds Persons ages Change Past month binged 5+ at least once College % Non-College % Drove under the influence in past year College % Non-College % Source: National Household Survey on Drug Use and Health

N ational I nstitute on A lcohol A buse and A lcoholism Changes in Alcohol Related Injury Deaths college and non-college year olds Percent Change Total Per Pop. All Alcohol Related Injury Deaths College College1,5501, % + 6% Source: FARS, CDC, Smith et al. 1995

N ational I nstitute on A lcohol A buse and A lcoholism Change in Numbers of College Students Experiencing Alcohol Problems Binge 5+ Drinks 3.6 million 3.8 million Drove under influence 2.3 million 2.8 million Injured under influence of alcohol 588,000599,000 Assaulted by another college student730,000690,000 Sex assault/date rape 82,400 97,000 Full time 4 year college students 6.1 million 6.4 million Change of +4.5% Sources: College Alcohol Survey, National Household Survey on Drug Use and Health

N ational I nstitute on A lcohol A buse and A lcoholism Alcohol Related Behaviors and Consequences of Year Olds in the U.S College College Non College Total Total  Drank 5+ on an occasion past month 3.8 million 7.6 million 7.6 million 11.4 million  Past year drove under the influence of alcohol 2.8 million 4.5 million 4.5 million 7.3 million  Died of alcohol-related unintentional injury 1,700 1,700 3,700 3,700 5,400 5,400

N ational I nstitute on A lcohol A buse and A lcoholism College Alcohol Study The younger college students were when first drunk, the more likely they will experience in college:  Alcohol Dependence  Drive after drinking  Alcohol related injury  Unplanned and unprotected sex after drinking Source: Hingson, Heeren, Winter. J. Studies on Alcohol 2003, Pediatrics 2003

N ational I nstitute on A lcohol A buse and A lcoholism Conclusion In the U.S. there is an urgent need to expand and improve prevention, screening and treatment programs and policies to reduce alcohol related harm –Persons under 21 –Among college students –Persons of similar ages not in college

N ational I nstitute on A lcohol A buse and A lcoholism Interventions  Individually oriented  Family  School  Environmental  Comprehensive Community Interventions

N ational I nstitute on A lcohol A buse and A lcoholism Brief Motivational Alcohol Intervention in a Trauma Center  46% of injured trauma center patients age 18 and older screened positive for alcohol problems.  Half (N=336) randomly allocated to receive 30 minute brief intervention to reduce risky drinking and offers links to alcohol treatment Source: Gentilello Annals of Surgery, 1999

N ational I nstitute on A lcohol A buse and A lcoholism Brief Motivational Alcohol Intervention in a Trauma Center Results:  Reduced alcohol consumption by an average 21 drinks per week at 1 year follow up  47% reduction in new injuries requiring treatment in ED  48% reduction in hospital admissions for injury over 3 years  23% fewer drunk driving arrests Source: Gentilello Annals of Surgery, 1999

N ational I nstitute on A lcohol A buse and A lcoholism Brief Alcohol Intervention for Older Adolescents Brief Alcohol Intervention for Older Adolescents  94 ED patients, mean age 18.4, injured after drinking  Half randomly allocated to a minute motivational intervention to reduce drinking and related risky behaviors such as DWI Results at six months:  Brief intervention group had ¼ drinking and driving occasions¼ drinking and driving occasions Fewer moving violations 3% vs. 23%Fewer moving violations 3% vs. 23% ¼ alcohol related injuries¼ alcohol related injuries Source: Monti et al. J. Consulting and Clinical Psychology (1999)

N ational I nstitute on A lcohol A buse and A lcoholism Fifteen Studies Provide Strong Support for the Efficacy of This Approach Among College Students  Marlatt, 1998  Anderson et. Al., 1998  Larimer, 2000  D’Amico & Fromme 2000  Dimeff, 1997  Aubrey, 1998  Monti, 1999  Baer, 2001  Barnett et al  Borsari and Carey (in press)  Labrie 2002  Gregory 2001  LaChance 2004  Murphy et al  Murphy et al Source: Larimer and Cronce (2002, 2005 In Review )

N ational I nstitute on A lcohol A buse and A lcoholism  Fewer than –½ of pediatricians screen all adolescents for use of alcohol and drugs –¼ screen for drinking and driving.  Pediatric Medical Care Providers considerably underdiagnose alcohol use, abuse, and dependence among patients ages  1.5 million year olds need alcohol treatment  Only 216,000 14% received treatment Wilson, Sheritt, Gates, Knight Pediatrics, 2004; National Household Survey on Drug Use and Health, 2003 Sources: American Academy of Pediatrics, 1997; Wilson, Sheritt, Gates, Knight Pediatrics, 2004; National Household Survey on Drug Use and Health, 2003 Implementation Gap

N ational I nstitute on A lcohol A buse and A lcoholism 19% of College Students met DSM IV Alcohol Abuse or Dependence Criteria 5% of them sought treatment in the past year 5% of them sought treatment in the past year 3% thought they should seek help but did not 3% thought they should seek help but did not Source: National Epidemiologic Study of Alcohol Related Conditions 2002

N ational I nstitute on A lcohol A buse and A lcoholism Insurers’ Liability for Losses Due to Intoxication As of January 1, States and DC allow with holding of medical reimbursement if injured under the influence

N ational I nstitute on A lcohol A buse and A lcoholism Family Interventions Iowa Strengthening Families Program Family Interventions Iowa Strengthening Families ProgramGoals:  Improve parent/child relations  Strengthen family communication skills  Increase child coping skills Implementation:  7 sessions at school  13 hours total  Parent and child separately and together

N ational I nstitute on A lcohol A buse and A lcoholism Family Interventions Source: Spoth, Redmond, Shin J Consulting Clinical Psychology (2001, 2004) Trajectory for ISFP Condition Trajectory for Control Condition 0 Months Lifetime Drunkenness Through 6 Years Past Baseline: Logistic Growth Curve A randomized controlled trial with families of 6th graders:  Iowa Strengthening Families Program (ISFP) (206 families)   Preparing for Drug Free Years Program (PDFYP) (221 families)   Control (221 families)

N ational I nstitute on A lcohol A buse and A lcoholism School Based Programs  Programs that rely primarily on increasing knowledge about consequences of drinking are not effective.  Effective Programs : Are based on social influence modelsAre based on social influence models Include norm settingInclude norm setting Address social pressures to drink and teach resistance skillsAddress social pressures to drink and teach resistance skills Include developmentally appropriate informationInclude developmentally appropriate information Include peer-led componentsInclude peer-led components Provide teacher trainingProvide teacher training Are interactiveAre interactive  School only program effects are generally small  Less effective with students who initiate drinking prior to grades 5 or 6 Source: NIAAA, Alcohol and Development in Youth: A Multidisciplinary Overview

N ational I nstitute on A lcohol A buse and A lcoholism School Based Life Skills Program Junior High- 30 sessions, most in Year 1 Junior High- 30 sessions, most in Year 1Curricula: Drug Information Alcohol/Drug Resistance Skills Self Management Skills General Social Skills Results: Beneficial Effects Alcohol & Tobacco Use Through High School, Not After Through High School, Not After Sources: Botvin et al. J. Consulting and Clinical Psychology (1990); JAMA (1995); Addictive Behaviors (2000)

N ational I nstitute on A lcohol A buse and A lcoholism Combined Family Interventions & School Based Life skills Program Results: 2 ½ Years Later  Weekly drunkenness rate among intervention students 1/3 lower –Strengthening Family plus Life Skills (p=.03) –Life Skills Training (p=.08) Conclusion: Family and school interventions combined are more effective than school interventions only Source: Spoth, et al Psychology of Addictive Behaviors (2005) Randomized controlled trial of 7 th graders from 36 rural schools:  ISFP  ISFP Plus Life Skills Training (n=549)   Life Skills Training Only (n=517)   Control (n=453)

N ational I nstitute on A lcohol A buse and A lcoholism Environmental Approaches Environmental Approaches

N ational I nstitute on A lcohol A buse and A lcoholism Drinking Trends Among High School Seniors, Source: Monitoring the Future, 2004 Federal 21 drinking age Drinking age 21 in all States

N ational I nstitute on A lcohol A buse and A lcoholism Frequency of use of any alcoholic beverage during the last 12 months: Students age 15- ESPAD 2003 Comment: Of 35 European nations only Turkey has a lower percentage of 15 year olds who drank alcohol in the past year than the United States

N ational I nstitute on A lcohol A buse and A lcoholism Frequency of being drunk in last 12 months: Students age 15- ESPAD 2003 Comment: Of 35 European countries 31 had a higher percentage of 15 year olds than in the U.S. who reported being drunk in the past year

N ational I nstitute on A lcohol A buse and A lcoholism Trends in Alcohol Related and Non Alcohol Related Traffic Fatalities persons U.S US MLDA Age 21 Law MLDA 21 in All 50 States 3,781 2,738 2,115 5,244 ↑ 38% ↓ 60% Non Alcohol Related Fatalities Alcohol Related Fatalities Source: U.S. Fatality Analysis Reporting System

N ational I nstitute on A lcohol A buse and A lcoholism Legal Drinking Age Changes  CDC reviewed 49 studies published in scientific journals  Alcohol-Related Traffic Crashes: - Increased 10% when the drinking age was lowered - Decreased 16% when the drinking age was raised Source: Shults et al., American Journal of Preventive Medicine, 2001

N ational I nstitute on A lcohol A buse and A lcoholism Cumulative Estimated Number of Lives Saved by the Minimum Drinking Age Laws Source: National Highway Traffic Safety Administration

N ational I nstitute on A lcohol A buse and A lcoholism 10 Reasons for Legal Drinking Age of 21  Alcohol-related traffic fatalities and injuries  Other unintentional injuries (falls, drownings, burns)  Homicide and assault  Sexual assault  Suicide  STDs, HIV/AIDS  Unplanned pregnancy  Alcohol dependence  Teen drug use  Poor academic performance

N ational I nstitute on A lcohol A buse and A lcoholism Source: Grant and Dawson J. Substance Abuse (1997)

N ational I nstitute on A lcohol A buse and A lcoholism Purpose To assess whether an earlier drinking onset is related to:  Unintentional injuries under the influence of alcohol  Motor vehicle crashes because of drinking  Physical fights after drinking - ever in the respondent’s life - during the year prior to the survey

N ational I nstitute on A lcohol A buse and A lcoholism Micheal Timothy Wilder

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Ever in a Physical Fight While or After Drinking According to Age of Drinking Onset, National Longitudinal Alcohol Epidemiologic Survey Controlling for age, gender, black, non hispanic, Hispanic, other, education, marital status, current, past, never smoke current, past, never use drugs, family history of alcoholism, current, past, never alcohol dependent, frequency drank 5+ during respondent’s period of heaviest drinking Odds Ratio and Confidence Intervals P<.001 Age Started Drinking

N ational I nstitute on A lcohol A buse and A lcoholism Why Are These Findings Important? Injuries are the leading cause of death among youth 1-44  Unintentional injuries #  Intentional injuries # Source: Centers for Disease Control and Prevention

N ational I nstitute on A lcohol A buse and A lcoholism Why Are These Findings Important? Source G. Smith et. al 1999  40% unintended injury deaths39,000  47% Homicides 8,000  29% Suicides 8,500 Alcohol is involved over 50,000 injury deaths annually* * Over half under age 44

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BAC and Impairment Concentrated Attention, Speed Control, Braking, Steering, Gear Changing, Lane Tracking, Judgement Tracking, Divided Attention, Coordination, Comprehension, Eye Movement Simple Reaction Time, Emergency Response Choice Reaction Time Source: National Highway Traffic Safety Administration  Key driving functions are impaired at levels as low as %.

N ational I nstitute on A lcohol A buse and A lcoholism Relative Risk of Fatal Crash Drivers Age and 20+ as a function of BAC y.o. 20+ y.o. Source: Simpson, H The risk of fatal crash increases more with each drink among young drivers than drivers age 20 and older.

N ational I nstitute on A lcohol A buse and A lcoholism Proportion of Teen Fatal Crashes Involving Single Vehicles at Night Before and After Zero Tolerance Laws for Youth SVNF Fatal Crashes % 21% Source: Hingson, Heeren, Winter, 1994 Percent ComparisonZero Tolerance BeforeAfterBeforeAfter

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States with Primary Safety Belt Laws As of July 2004, 21 states, DC and Puerto Rico have primary safety belt laws. New Hampshire is the only state that has no adult safety belt law Primary Law

N ational I nstitute on A lcohol A buse and A lcoholism  Younger heavier drinkers more affected than older heavier drinkers Kenkel, 1993 Godfrey, 1997 Chaloupka & Wechsler, 1996 Sutton & Godfrey, 1995  Higher prices reduce alcohol related problems Motor vehicle fatalities (Kenkel, 1993)Motor vehicle fatalities (Kenkel, 1993) RobberiesRobberies RapesRapes Liver cirrhosis mortalityLiver cirrhosis mortality See: Cook & Moore, 1993; Cook & Tauchen, 1982; Ruhm, 1996 Increase Price of Alcohol

N ational I nstitute on A lcohol A buse and A lcoholism Restricting Alcohol Licenses Density of alcohol outlets is associated with - Higher alcohol consumption - Violence - Other crime - Health problems Ornstein & Hanssens, 1985; Gliksman & Rush, 1986; Gruenewald et.al, 1993; Scribner et.al., 1995; Stitt and Giacopassi, 1992; Chaloupka & Wechsler, 1996 Sources: Ornstein & Hanssens, 1985; Gliksman & Rush, 1986; Gruenewald et.al, 1993; Scribner et.al., 1995; Stitt and Giacopassi, 1992; Chaloupka & Wechsler, 1996

N ational I nstitute on A lcohol A buse and A lcoholism Is Passing Laws Enough?

N ational I nstitute on A lcohol A buse and A lcoholism Potential Process of Change After a Drinking Age Increase Legal Drinking Age Increase Police and Enforcement Court Enforcement General Legal Deterrence Public Education Who - Minors - Alcohol Outlets What - Reasons for Law - Enforcement Changes in Public Perception about Alcohol Reduction In Drinking & Driving After Drinking Fatal and Night Fatal Crash Reductions

N ational I nstitute on A lcohol A buse and A lcoholism Comprehensive Community Interventions  Involve multiple departments of city government and private citizens  Use multiple program strategies EducationEducation Media advocacyMedia advocacy Community organizing and mobilizationCommunity organizing and mobilization Environment policy changeEnvironment policy change Heightened enforcementHeightened enforcement

N ational I nstitute on A lcohol A buse and A lcoholism Successful Comprehensive Community Interventions  Project Northland Perry (1996)  Communities Mobilizing for Change Wagenaar (2002)  Community Trials Holder (2000)  A Matter of Degree Weitzman (2004)  Fighting Back Hingson (2005)  Saving Lives Program Hingson (1996)  Clapp et al. (2005)

N ational I nstitute on A lcohol A buse and A lcoholism Project Northland  Intervention to prevent or reduce alcohol use among 6, 7, and 8 th grade students School Education Programs (general programSchool Education Programs (general program each grade) each grade) Parent InvolvementParent Involvement Peer ParticipationPeer Participation Community task forces to engage citizensCommunity task forces to engage citizens  Compliance Checks  Server Training  Ordinances Source: Perry C. et al. American Journal of Public Health, 1996; Perry C. et al. Health Education Research, 2002.

N ational I nstitute on A lcohol A buse and A lcoholism Project Northland Results: 3 Years Later Drinking 50% lower among baseline non-drinkersDrinking 50% lower among baseline non-drinkers (5% vs 10%) (5% vs 10%) Lower rates of cigarette and marijuana useLower rates of cigarette and marijuana use Monthly and weekly drinking 20-30% lowerMonthly and weekly drinking 20-30% lower among entire sample among entire sample Grades 11 & 12 Fewer Northland students drink 5+Fewer Northland students drink 5+ 80% reduction in youth ability to purchase80% reduction in youth ability to purchase alcohol (Off Sale) alcohol (Off Sale)

N ational I nstitute on A lcohol A buse and A lcoholism Communities Mobilizing for Change  Interventions to Reduce Availability: –Merchants record underage buy attempts –Beer kegs prohibited at University Homecoming –Policies to discourage motels from permitting underage drinking parties –Security at high school dances –Model local ordinances to restrict underage access to alcohol –Compliance checks Source: Wagenaar et al., J. Studies on Alcohol, 2000

N ational I nstitute on A lcohol A buse and A lcoholism Communities Mobilizing for Change : Results: -17% increase in outlets checking age ID -24% decline in bar and restaurant sales -25% decrease in the proportion of year olds attempting alcohol purchase attempting alcohol purchase -17% decline in the proportion of older teens providing alcohol to younger teens providing alcohol to younger teens -7% decrease in the percent under 21 who drank -14% decline in alcohol traffic injuries, drivers Source: Wagenaar et al., J. Studies on Alcohol, 2000

N ational I nstitute on A lcohol A buse and A lcoholism Community Trials Intervention:   Reduce youth alcohol availability   Drinking and driving enforcement   Alcohol outlet density reduction   Community mobilization & media   Advocacy   Responsible alcohol serviceResults: Self reported DWI cut in halfSelf reported DWI cut in half 10%-11% decrease in single vehicle night crashes10%-11% decrease in single vehicle night crashes 43% decrease in emergency department alcohol related assault admissions43% decrease in emergency department alcohol related assault admissions “Mountain of Beer” Source: Holder et al., JAMA (2000)

N ational I nstitute on A lcohol A buse and A lcoholism Program Components  School based education  Community education  Increased police enforcement  Business for safety  Alcohol beverage server education  Community task forces – key public and private sector community leaders  Full-time coordinator Mayor’s office  Encourage local initiatives  Evaluation feedback

N ational I nstitute on A lcohol A buse and A lcoholism Saving Lives vs. Rest of Mass. 5 Pre Program Years Compared to 5 Program Years *p<0.05 Pre-Program ProgramChange Fatal Crashes ↓ 25%* Fatal Crashes Involving Alcohol 6936 ↓ 42%* Fatally Injured Drivers with Positive BAC 4924 ↓ 47%* Fatal Crashes Involving Speeding 6833 ↓ 27%* Pedestrian Fatalities 4533 ↓ 18%* Drivers in Fatal Crashes Age ↓ 39%*

N ational I nstitute on A lcohol A buse and A lcoholism A Matter of Degree  Intervention Components: –College/ Community Partnerships –Environmental strategies to reduce drinking problems: –Keg registration –Mandatory responsible beverage service –Police wild party enforcement –Substance free residence halls –Advertising bans Source: Weitzman et al. American Journal of Preventive Medicine. 2004

N ational I nstitute on A lcohol A buse and A lcoholism A Matter of Degree Results:  Achieved reductions among college students in Binge drinkingBinge drinking Driving after drinkingDriving after drinking Alcohol related injuriesAlcohol related injuries Being assaulted by other drinking college studentsBeing assaulted by other drinking college students Source: Weitzman et al. American Journal of Preventive Medicine 2004

N ational I nstitute on A lcohol A buse and A lcoholism Fighting Back Program First Community Program to combine:  Environmental interventions to limit alcohol availability  Efforts to increase substance abuse treatment Source: Hingson et al. Injury Prevention (2005)

N ational I nstitute on A lcohol A buse and A lcoholism Fighting Back Program Selected Interventions Limit Alcohol Availability  Youth access compliance check surveys  Responsible beverage service training  Monitoring and closing problem liquor outlets  Bill board restrictions Expand Treatment  Sales tax increase for expanded treatment  New treatment programs- courts, jails, health care agencies, public housing agencies, public housing  Emergency department screening/brief interventions  New inpatient, outpatient and recovery programs Source: Hingson et al. 2005

N ational I nstitute on A lcohol A buse and A lcoholism Fighting Back - Results Greater Relative Reduction in Alcohol-Related Fatal Crashes VS Fatal Crashes with Zero BAC Communities: Kansas City, MO, Milwaukee, WI, San Antonio, TX, Santa Barbara, CA, and Vallejo, CA Courtney Birch Pooled Effects BAC.01%+ BAC.01%+ vs Zero BAC vs Zero BACDrivers All Ages FB sites vs controls 22%P=.0126%P=.08

N ational I nstitute on A lcohol A buse and A lcoholism Conclusions  Research indicates reductions in Underage Drinking and Related Problems can be achieved with Interventions that focus on - Individuals - Families - Schools -Environmental Changes  Interventions targeting multiple levels are more effective  Comprehensive community interventions address underage drinking at multiple levels

N ational I nstitute on A lcohol A buse and A lcoholism Conclusions  Community Level Interventions can include - Coordination of multiple city departments - Clear measurable objectives and strategic plans -Combine education and enforcement -Treatment programs - Use of data to plan and evaluate -Involvement of private citizens -Youth involvement (be inclusive)

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Acknowledgements NIAAA staff who assisted with this presentation  Rachel Goutos