1. FROM GLOBAL TO LOCAL: AN INTRODUCTION TO THE SYMPOSIUM David Jernigan, PhD Johns Hopkins Bloomberg School of Public Health

2. GLOBAL BACKGROUND  Harmful use of alcohol is increasingly recognized as a global public health problem  Alcohol use was responsible for 3.8% of global deaths and 4.6% of global disability in 2004 (Rehm et al., The Lancet, 29 July 2009)  This is nearly equivalent to the harm from tobacco use, even when allowing for potential health benefits of alcohol use  Global strategy on alcohol under development at WHO  Areas of greatest concern:  Alcohol and mortality in Russia  Alcohol and young people

3. The U.S.A. in global context Source: WHO GISAH, as cited in Rehm et al. 2009

4. Death and Disability Attributable to Alcohol Use Among Youth Ages 15-29, 2000 Source: Rehm et al. 2003 % total Deaths Afr D105.90%5605.30%21.10%1291.00% Afr E287.90%1,4698.00%50.90%2571.00% Amr A923.00%1,38828.40%19.50%4019.80% Amr B5235.50%3,99530.80%47.90%6377.80% Amr D517.20%36916.80%13.30%693.70% Emr B24.80%692.40%01.20%100.40% Emr D11.20%1231.60%00.20%160.20% Eur A925.60%1,09824.40%110.20%2376.10% Eur B924.30%66216.90%17.20%1033.10% Eur C4241.00%2,29335.00%519.90%39111.20% Sear B1411.70%83911.30%22.40%1161.80% Sear D265.70%1,6995.30%61.30%3280.90% Wpr A218.40%21415.60%07.00%1108.70% Wpr B3913.70%3,66514.60%74.90%6303.10% WORLD24912.90%18,44413.10%362.20%3,4342.50% Males 15-29Females 15-29 REGIONDeaths (000s)DALYs (000s)% total DALYsDeaths (000s)% total DeathsDALYs (000s)% total DALYs

5. Death and Disability Attributable to Alcohol Use Among Youth Ages 15-29, 2000 Source: Rehm et al. 2003 % total Deaths Afr D105.90%5605.30%21.10%1291.00% Afr E287.90%1,4698.00%50.90%2571.00% Amr A923.00%1,38828.40%19.50%4019.80% Amr B5235.50%3,99530.80%47.90%6377.80% Amr D517.20%36916.80%13.30%693.70% Emr B24.80%692.40%01.20%100.40% Emr D11.20%1231.60%00.20%160.20% Eur A925.60%1,09824.40%110.20%2376.10% Eur B924.30%66216.90%17.20%1033.10% Eur C4241.00%2,29335.00%519.90%39111.20% Sear B1411.70%83911.30%22.40%1161.80% Sear D265.70%1,6995.30%61.30%3280.90% Wpr A218.40%21415.60%07.00%1108.70% Wpr B3913.70%3,66514.60%74.90%6303.10% WORLD24912.90%18,44413.10%362.20%3,4342.50% Males 15-29Females 15-29 REGIONDeaths (000s)DALYs (000s)% total DALYsDeaths (000s)% total DeathsDALYs (000s)% total DALYs

6. Death and Disability Attributable to Alcohol Use Among Youth Ages 15-29, 2000 Source: Rehm et al. 2003 % total Deaths Afr D105.90%5605.30%21.10%1291.00% Afr E287.90%1,4698.00%50.90%2571.00% Amr A923.00%1,38828.40%19.50%4019.80% Amr B5235.50%3,99530.80%47.90%6377.80% Amr D517.20%36916.80%13.30%693.70% Emr B24.80%692.40%01.20%100.40% Emr D11.20%1231.60%00.20%160.20% Eur A925.60%1,09824.40%110.20%2376.10% Eur B924.30%66216.90%17.20%1033.10% Eur C4241.00%2,29335.00%519.90%39111.20% Sear B1411.70%83911.30%22.40%1161.80% Sear D265.70%1,6995.30%61.30%3280.90% Wpr A218.40%21415.60%07.00%1108.70% Wpr B3913.70%3,66514.60%74.90%6303.10% WORLD24912.90%18,44413.10%362.20%3,4342.50% Males 15-29Females 15-29 REGIONDeaths (000s)DALYs (000s)% total DALYsDeaths (000s)% total DeathsDALYs (000s)% total DALYs

7. Death and Disability Attributable to Alcohol Use Among Youth Ages 15-29, 2000 Source: Rehm et al. 2003 % total Deaths Afr D105.90%5605.30%21.10%1291.00% Afr E287.90%1,4698.00%50.90%2571.00% Amr A923.00%1,38828.40%19.50%4019.80% Amr B5235.50%3,99530.80%47.90%6377.80% Amr D517.20%36916.80%13.30%693.70% Emr B24.80%692.40%01.20%100.40% Emr D11.20%1231.60%00.20%160.20% Eur A925.60%1,09824.40%110.20%2376.10% Eur B924.30%66216.90%17.20%1033.10% Eur C4241.00%2,29335.00%519.90%39111.20% Sear B1411.70%83911.30%22.40%1161.80% Sear D265.70%1,6995.30%61.30%3280.90% Wpr A218.40%21415.60%07.00%1108.70% Wpr B3913.70%3,66514.60%74.90%6303.10% WORLD24912.90%18,44413.10%362.20%3,4342.50% Males 15-29Females 15-29 REGIONDeaths (000s)DALYs (000s)% total DALYsDeaths (000s)% total DeathsDALYs (000s)% total DALYs

8. Review of public health findings  The earlier young people start to drink, the worse the alcohol-related consequences:  Alcohol dependence  Traffic crashes  Physical violence after drinking  Other unintentional injuries after drinking (e.g. drowning, falls)  Potential damage to still-developing adolescent brain  Lower chances of success in school  Age of alcohol initiation has long-term influence on health  Bottom line: strong public health interest in delaying onset of drinking

9. Minimum drinking age laws  One of many steps taken by societies to limit alcohol-related harm  EVERY society must take on question of how to control intoxicants and their effects  Minimum drinking age laws only one strategy – cannot be expected to do the whole job  International experience reflects U.S. experience: minimum age laws do affect onset of drinking

10. Age requirement for on- and off- premise purchase of beer and spirits

11. Countries greater than 18  19  Canada (all but Alberta, Manitoba and Quebec)  Republic of Korea  Nicaragua  20  Iceland  Japan  Norway  Sweden  21  Egypt  Indonesia  Micronesia  Palau  USA Source: WHO GAD 2006

12. Recent changes  France:  Moves to increase minimum purchase for alcohol and tobacco from 16 to 18 in 2009  New Zealand (AJPH 2006;96:126–131)  Reduced from 20 to 18 in 1999  Comparing four years before and after the change from 20 to 18, compared to crashes among 20 to 24 year-olds (comparison group), alcohol-involved traffic crashes grew: 14% among 15-17 year-old males 24% among 15-17 year-old females 12% among 18 and 19 year-old males 51% among 18 and 19 year-old females

13. Drinking Ages in Europe  15 – Slovenia  16 – Italy, Malta, Portugal  17 – Greece  18 – Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, France, Germany, Hungary, Ireland, Latvia, Lithuania, Netherlands, Poland, Romania, Russia, Slovakia, Spain, Switzerland, Ukraine, United Kingdom  20 – Iceland, Norway, Sweden

14. Drinking Among 15-16 year-olds: U.S. and Europe, 2007

17. “Extreme drinking worse in U.S.”  Actually, looking at indicator “drunk in past 30 days” 21 countries worse off than U.S., 14 countries better off  Extreme drunkenness worse in U.S.?  15-16 year-olds reporting 10-19 incidents of drunkenness in past 30 days 1 percent of U.S. 10 th graders report this Same percentage as in 14 European countries, including Austria, Italy and Spain

18. Background for this syposium  “Amethyst Initiative” – signed by 130 college presidents and asking for a re-opening of the debate over the federal law withholding 10% of highway funds if states did not implement age 21 alcohol purchase laws  “Rush to judgment” on 21 largely uninformed by public health research  What light can public health research and experience shed on this debate?

19. “Eyeball analyses”  Many shortcomings – much more going on in each country than this cursory analysis can capture  More important to review literature in its entirety – never rely on any single study  Single studies may mis-specify variables to “wash out” effects, e.g. Using 15-24 year-olds as focus of analysis Using all traffic crashes instead of alcohol-related traffic crashes as outcome variable Diluting statistical power by performing state-by-state analyses which increase range of error, involve fitting linear analysis to trends that are by no means linear

20. Goals of this symposium  Key questions:  What can research tell us about drinking among college-aged persons?  What does the research literature suggest are the most effective approaches for reducing alcohol-related harm among college students?  What is our specific situation here in Baltimore?  What can we, as campus and community, do in this city to reduce alcohol-related harm among college students?

21. Structure of the evening  PRESENTATIONS:  What is the situation regarding college drinking in the U.S.A.?  What has public health research told us to date about what will be most effective in reducing alcohol-related harm in college campuses and communities?  What can we learn from experience nearby about reducing alcohol- related harm in campus communities?  What special challenges do we face here in Baltimore?  DISCUSSION:  How can Baltimore benefit from the findings of research literature and experience?  How do we go forward from here?  What partnerships exist and what are needed?  What concrete next steps could be proposed?