1. Prevention of Underage Drinking Problems Prevention of Underage Drinking Problems Ralph Hingson, ScD Director, Division of Epidemiology and Prevention Research National Institute on Alcohol Abuse and Alcoholism Preventing Underage Alcohol Use: A National Meeting of the States Sponsored by the Interagency Coordinating Committee for the Prevention of Underage Drinking October 31, 2005

2. N ational I nstitute on A lcohol A buse and A lcoholism

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

4. N ational I nstitute on A lcohol A buse and A lcoholism

5. Interventions  Individually oriented  Family  School  Environmental  Comprehensive Community Interventions

6. 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

7. 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

8. 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 35-40 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 occasions –Fewer moving violations 3% vs. 23% –¼ alcohol related injuries Source: Monti et al. J. Consulting and Clinical Psychology (1999)

9. 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. 2004  Borsari and Carey (in press)  Labrie 2002  Gregory 2001  LaChance 2004  Murphy et al. 2001  Murphy et al. 2004 Source: Larimer and Cronce (2002, 2005 In Review )

10. 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 14-18.  1.5 million 12-17 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

11. N ational I nstitute on A lcohol A buse and A lcoholism Insurers’ Liability for Losses Due to Intoxication As of January 1, 2004 28 States and DC allow with holding of medical reimbursement if injured under the influence

12. 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

13. 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 6183048 72 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)

14. 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 models –Include norm setting –Address social pressures to drink and teach resistance skills –Include developmentally appropriate information –Include peer-led components –Provide teacher training –Are 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

15. 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)

16. 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 (In Press) 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)

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

18. N ational I nstitute on A lcohol A buse and A lcoholism Drinking Trends Among High School Seniors, 1975-2003 Source: Monitoring the Future, 2004 Federal 21 drinking age Drinking age 21 in all States

19. N ational I nstitute on A lcohol A buse and A lcoholism Trends in Alcohol Related and Non Alcohol Related Traffic Fatalities persons 16-20 U.S. - 1982-2004 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

20. 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

21. N ational I nstitute on A lcohol A buse and A lcoholism Cumulative Estimated Number of Lives Saved by the Minimum Drinking Age Laws 1975-2003 Source: National Highway Traffic Safety Administration

22. 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

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

24. 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

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

26. N ational I nstitute on A lcohol A buse and A lcoholism

29. 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

30. 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 #1 1-44  Intentional injuries #2 8-34 Source: Centers for Disease Control and Prevention

31. 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

32. N ational I nstitute on A lcohol A buse and A lcoholism

33. 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.02-.04%.

34. N ational I nstitute on A lcohol A buse and A lcoholism Relative Risk of Fatal Crash Drivers Age 16-19 and 20+ as a function of BAC 16-19 y.o. 20+ y.o. Source: Simpson, H. 1989 The risk of fatal crash increases more with each drink among young drivers than drivers age 20 and older.

35. 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 1439 10791150 717 Fatal Crashes 4597 34003637 2851 1% 21% Source: Hingson, Heeren, Winter, 1994 Percent ComparisonZero Tolerance BeforeAfterBeforeAfter

36. N ational I nstitute on A lcohol A buse and A lcoholism

37. 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

38. 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) –Robberies –Rapes –Liver cirrhosis mortality See: Cook & Moore, 1993; Cook & Tauchen, 1982; Ruhm, 1996 Increase Price of Alcohol

39. 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

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

41. 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

42. 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 –Education –Media advocacy –Community organizing and mobilization –Environment policy change –Heightened enforcement

43. 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)

44. 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 program each grade) each grade) –Parent Involvement –Peer Participation –Community 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.

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

46. 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

47. 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 18-20 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 18-20 Source: Wagenaar et al., J. Studies on Alcohol, 2000

48. 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 half –10%-11% decrease in single vehicle night crashes –43% decrease in emergency department alcohol related assault admissions “Mountain of Beer” Source: Holder et al., JAMA (2000)

49. 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

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

51. 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)

52. 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

53. 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 16-20 5 FB sites vs controls 22%P=.0126%P=.08

54. 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

55. 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)

56. N ational I nstitute on A lcohol A buse and A lcoholism

62. Acknowledgements NIAAA staff who assisted with this presentation  Rachel Goutos  Vivian Faden, Ph.D.

63. N ational I nstitute on A lcohol A buse and A lcoholism Panel Discussion Moderator Faye Calhoun, Sc.D. Deputy Director National Institute on Alcohol Abuse and Alcoholism Panelists Harold Holder, Ph.D Senior Research Scientist Prevention Research Center John Knight, MD Associate Professor of Pediatrics, Harvard Medical School Director, Center for Adolescent Substance Abuse Research, Children's Hospital, Boston Kelli A. Komro, MPH, Ph.D. Associate Professor, Department of Epidemiology and Health Policy Research Institute for Child Health Policy, University of Florida