Prevention of Underage and College Drinking Problems

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Prevention of Underage and College Drinking
Problems

• Ralph Hingson, Sc.D.
• US Department of Education
• National Meeting on Alcohol and Other Drug Abuse,
  and Violence Prevention
• Indianapolis, IN
• October 5, 2005

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Purpose

• Assess magnitude of alcohol related health
  problems among college students
• Drunk driving
• Heavy drinking
• Alcohol-related traffic deaths
• Unintentional non-traffic deaths
• Other health problems
• Examine research on interventions to reduce
  college drinking problems

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Magnitude of Alcohol Problems on U.S. College
Campuses
Hingson et al. (2002) J. Studies on Alcohol
Dr. Margaret Jonathan
Travis Moore Levy
Stedman
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Annual Review of Public Health
Brad McCue www.brad21.org
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Data Sources Examined

• Fatality Analysis Reporting System (FARS)
• National Highway Transportation and Safety
  Administration (NHTSA)
• Mortality Statistics Centers for Disease Control
  (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, 3329 19-25

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National Surveys

• National Household Survey on Drug Abuse 1999,
  2002
• Harvard School of Public HealthCollege Alcohol
  Survey (CAS) 1999, 2001
• CDC National College Youth Risk Behavior Survey
  (1995)

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Change in percent binge drinking and driving
under the influence among 18-24 year
olds1999-2002
Persons ages 18-24 1999 2002 Change Past month
binged 5 at least once


College 41.7 43.2 4 Non-College 36.5
39.8 9 Drove under the influence
in past year College
26.5 31.4 18 Non-College
19.8 25.7 30
Source National Household Survey on Drug Use and
Health
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Changes in Alcohol Related Injury Deaths college
and non-college 18-24 year olds 1998-2001
1998 2001 Percent Change Total Per Pop. Percent Change Total Per Pop.
All Alcohol Related Injury Deaths
College 1,550 1,700 9 6
Source FARS, CDC, Smith et al. 1995
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Change in Numbers of College Students 18-24
Experiencing Alcohol Problems1999-2001
1999 2001 Binge 5 Drinks
3.6 million 3.8 million Drove under influence
2.3 million 2.8 million Injured under
influence of alcohol 588,000 599,000 Assaulted
by another college student 730,000 690,000
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
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Alcohol Related Behaviors and Consequences of
18-24 Year Olds in the U.S. 2001
College 3.8 million 2.8 million 1,700
Non College 7.6 million 4.5 million 3,700
Total 11.4 million 7.3 million 5,400

• Drank 5 on an occasion past month
• Past year drove under the influence of alcohol
• Died of alcohol-related unintentional injury

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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

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CDC Youth RiskBehavior Survey 2003

• 28 of high school students start to drink before
  age 13.
• They are 7 times more likely by age 17 to binge
  frequently (5 or more drinks/6 or more times per
  month).
• There are over 1 million frequent bingers in high
  school.

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Youth Risk Behavior Survey2003

• Frequent binge drinkers compared to abstainers in
  high school were much more likely to

• Ride with a drinking driver
• Drive after Drinking
• Never wear safety belts
• Carry weapon
• Carry gun
• Be injured in a fight
• Be injured in a suicide attempt

• Be forced to have sex
• Had sex with 6 or more partner
• Have unprotected sex
• Been or gotten someone pregnant
• Use Marijuana
• Used Cocaine
• Ever injected drugs

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Youth Risk Behavior Survey2003

• Frequent binge drinkers compared to abstainers in
  high school were much more likely in the past
  month to
• Drink at school 31 vs. 0
• Use marijuana at school 29 vs. 1
• Earned mostly Ds and Fs in 13 vs. 4
• school within the past year

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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

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Interventions

• Individually oriented
• Environmental
• Comprehensive Campus/ Community Interventions

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GentilelloBrief Motivational Alcohol
Intervention in a Trauma CenterAnnals of
Surgery, 1999

• 46 of injured trauma center patients age 18 and
  older screened positive for alcohol problems.
• Half (N336) randomly allocated to receive 30
  minute brief intervention to reduce risky
  drinking and offers links to alcohol treatment

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GentilelloBrief Motivational Alcohol
Intervention in a Trauma CenterAnnals of
Surgery, 1999

• 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

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Brief Alcohol Intervention for Older Adolescents
J. Consulting and Clinical Psychology Monti et
al. (1999)

• 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 MI SC
Drinking and driving 62 85 SC had 4 times more drinking and driving occasions
Moving Violations 3 23
Alcohol-related injury 21 50 SC had 4 times more alcohol-related injury
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Fifteen Studies Provide Strong Support for the
Efficacy of This Approach Among College Students

• Barnett et al. 2004
• Boresian et al. In Press
• Labrie 2002
• Gregory 2001
• LaChance 2004
• Murphy and Colleagues 2001
• Murphy and Colleagues 2004

• Marlatt, 1998
• Anderson et. Al., 1998
• Larimer, 2000
• DAmico Fromme 2000
• Dimeff, 1997
• Aubrey, 1998
• Monti, 1999
• Baer, 2001

Source Larimer and Cronce (2002, In Review)
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• 19 of College Students 18-24 met DSM IV
  Alcohol Abuse or Dependence Criteria
• 5 of them sought treatment in the past year
• 3 thought they should seek help but did not
• Source National Epidemiologic Study of Alcohol
  Related Conditions 2002

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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
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Environmental Approaches
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Drinking Trends AmongHigh School Seniors,
1975-2003
Federal 21 drinking age
Drinking age 21 in all States
Source Monitoring the Future, 2004
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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
5,244
Non Alcohol Related Fatalities
?38
3,781
2,738
2,115
Alcohol Related Fatalities
?60
Source U.S. Fatality Analysis Reporting System
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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
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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
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Legal Drinking Age Changes

• CDC reviewed 49 studies published in scientific
  journals
• Alcohol-Related Traffic Crashes
• - Increased10 when the drinking age was lowered
• - Decreased 16 when the drinking age was raised

Source Shults et al., American Journal of
Preventive Medicine, 2001
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Cumulative Estimated Number of Lives Saved by the
Minimum Drinking Age Laws, 1975-2003
Source National Highway Traffic Safety
Administration
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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

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Source Grant and Dawson (1997) J. Substance
Abuse
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PurposeTo 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 respondents life
• - during the year prior to the survey

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Micheal Timothy Wilder
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Figure 2 Ever in a Physical Fight While or
After Drinking According to Age of Drinking
Onset, National Longitudinal Alcohol
Epidemiologic Survey
Odds Ratio and Confidence Intervals
Age Started Drinking
Plt.001
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 respondents period of heaviest
drinking
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Why Are These Findings Important?

• Injuries are the leading cause of death among
  youth 1-34
• Unintentional injuries 1 1-44
• Intentional injuries 2 8-34

Source CDC
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Why Are These Findings Important?
Alcohol is involved over 50,000 injury deaths
annually
40 unintended injury deaths 39,000
47 Homicides 8,000
29 Suicides 8,500
Over half under age 44
Source G. Smith et. al 1999
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Legislation to Reduce AlcoholRelated Traffic
Deaths

• Legal drinking age of 21 All States
• Criminal per se laws All States
• Administrative license revocation 40 States
• Mandatory assessment and treatment
  32 States
• Primary enforcement safety belt 21 States
• Zero tolerance for drivers under 21 All
  States
• .08 Criminal per se BAC level All States

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BAC and Impairment
Concentrated Attention, Speed Control, Braking,
Steering, Gear Changing, Lane Tracking, Judgement
Tracking, Divided Attention, Coordination, Compreh
ension, Eye Movement
Simple Reaction Time, Emergency Response
Choice Reaction Time

• Key driving functions are impaired at levels as
  low as .02-.04.

Source National Highway Traffic Safety
Administration
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Relative Risk of Fatal CrashDrivers Age 16-19
and 20 As a function of BAC
16-19 y.o.
20 y.o.

• The risk of fatal crash increases more with each
  drink among young drivers than drivers age 20 and
  older.

Source Simpson, H. 1989
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Increased Risk of Driver Single Vehicle Crash
Death at Blood Alcohol Concentration of .08 -
.10 Relative to Sober Drivers
Male Relative Risk
Age 16-20 51.4
21-34 13.4
35 11.4
Female Relative Risk
Age 16-20 14.9
21-34 13.4
35 11.4
Source (Zador P., Krawchuck S., Voas R., J.
Studies on Alcohol, 2000)
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Proportion of Teen Fatal Crashes Involving
Single Vehicles at Night Before and After Zero
Tolerance Laws for Youth
Comparison
Zero Tolerance
1
Percent
Before
After
Before
After
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SVNF 1439 1079
1150 717 Fatal Crashes 4597
3400 3637 2851
Conclusion If all states adopted Zero
Tolerance laws there would be 375-400 fewer
fatal crashes each year involving drivers
under 21.
Source Hingson, Heeren, Winter, 1994
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Hingson, Heeren, Winter AJPH (1996).08 Laws

• .08 Law Comparison Date .08
  Analysis
• States States Law Effective Period
• Utah Idaho August 1983 Aug.
  1976 July 1991
• Oregon Washington November
  1983 Nov. 1976 Oct. 1991
• Maine Massachusetts August 1988 Aug.
  1984 July 1993
• California Texas January 1990 Jan. 1986
  Dec. 1993
• Vermont New Hampshire July 1981 July 1990
  June 1993

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Results

• .08 law states experienced significant declines
  in the proportion of fatal crashes with drivers
  with BACs of
• .08 ? 16
• .15 ? 18
• All .08 law states also had Administrative
  License Revocation (ALR)
• 16 post law declines in .08 law states were
  greater than the 6 9 declines attributed to
  ALR laws in national studies

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Hingson, Heeren, and Winter 1996 American Journal
of Public Health

• Conclusion
• .08 laws, in combination with ALR, reduce the
  proportion of fatal crashes involving drivers
  with blood alcohol levels at .08 or higher and
  .15 or higher.
• After subtracting 6-9 alcohol related fatal
  crash declines associated with ALR, we projected
  that if all states adopted .08 laws, 500-600
  fewer fatal crashes would occur each year.

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Center for Consumer-Freedom.com
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Key ABI Arguments

• - .08 law a feel good law that will not reduce
  alcohol-related traffic deaths
• - .08 laws target social drinkers, not high BAC
  offenders over ½ drivers in alcohol-related
  fatal crashes have BACs above .15
• - MADD prohibitionist .08 first step down
  slippery slope (Impairment begins with 1st
  drink proves it)

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• - MADD more concerned with raising money than
  reducing traffic deaths
• - Hingson 1996 study of .08 laws flawed
• Compared California with Texas, not a nearby
  state
• Other comparisons preferable, e.g. Mythical
  State, Michigan, Ohio, Pennsylvania (Scopatz,
  1998)
• Not possible to separate effects of .08 laws from
  ALR
• Clinton relied too heavily on Hingson study
• - .08 laws will clog courts with new cases and
  fill jails
• - This will cost
• - Every year the majority of states considering
  .08 laws defeat them
• - A 120 pound woman would reach .08 after 2
  drinks she would lose her license, be called a
  criminal and face jail time

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Ten studies have been conducted in the U.S. that
examined multiple states that adopted .08 Per Se
Laws

• Johnson Fell (1995)
• Hingson, Heeren, Winter (1996)
• Apsler et. al. (1999)
• Voas, Tippetts, Fell (2000)
• Hingson, Heeren, Winter (2000)
• Dee (2001)
• Shults et al. (2001)
• Eisenberg (2003)
• Bernat et al. (2004)
• Tippetts et al. (2005)
• Every study found significant reductions in fatal
  crash measures involving drinking drivers

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Ross and Geri Goughler
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Is Passing Laws Enough?
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Potential Process of Change After a Drinking Age
Increase
Police and Enforcement
General Legal Deterrence
Legal Drinking Age Increase
Reduction In Drinking Driving After Drinking
Court Enforcement
Fatal and Night Fatal Crash Reductions
Public Education Who - Minors - Alcohol
Outlets What - Reasons for Law - Enforcement
Changes in Public Perception about Alcohol
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• How can you further reduce alcohol-related
  traffic deaths
• and injuries in your community?

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Increase Price of Alcohol

• Heaviest drinkers may be less affected
• Moderate drinkers most affected (average
  consumption level)
• Manning, 1995
• 1 price increase leads to 1.19 decrease in
  consumption among moderate drinkers

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• 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 1 price increase leads
  to .7 decrease in drunk driving for males, .8
  decrease for females (Kenkel, 1993)
• Robberies
• Rapes
• Liver cirrhosis mortality
• See Cook Moore, 1993
• Cook Tauchen, 1982
• Ruhm, 1996

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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

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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

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Successful Comprehensive Community Interventions

• Saving Lives Program Hingson (1996)
• Project Northland Perry (1996)
• Communities Mobilizing for Change Wagenaar (2002)
• Community Trials Holder (2000)
• A Matter of Degree Weitzman (2004)
• Clapp et al. (2005)
• Fighting Back Hingson (2005)

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• Goals Reduce
• Drunk Driving
• Related Traffic Risks eg. speeding, not wearing
  safety belts, running red lights

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Saving Lives ProgramProgram Components

• School based education
• Community awareness-public education
• Increased police enforcement
• Business for safety
• Alcohol beverage server education
• Community task forces key public and private
  sector community leaders
• Full-time coordinator Mayors office
• Encourage local initiatives
• Evaluation feedback

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Saving Lives vs. Rest of Mass. 5 Pre Program
Years Compared to 5 Program Years

• PreProgram Program Change
• Fatal Crashes 178 120 ?
  25
• Fatal Crashes Involving Alcohol 69
  36 ?42
• Fatally Injured Drivers with 49
  24 ?47
• Positive BAC
• Fatal Crashes Involving Speeding 68
  33 ?27
• Pedestrian Fatalities
  45 33 ?18
• Drivers in Fatal Crashes 98
  45 ?39
• Age 15-25

plt0.05
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A Matter of Degree (AMOD)Weitzman et al.
American Journal of Preventive Medicine. 2004

• 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

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A Matter of Degree (AMOD)Weitzman et al.
American Journal of Preventive Medicine. 2004

• AMOD achieved reductions among college students
  in
• Binge drinking
• Driving after drinking
• Alcohol related injuries
• Being assaulted by other drinking college students

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Fighting Back Program
Hingson et al., Injury Prevention (2005)

• Limit Alcohol Availability
• Compliance check (sting) surveys to reduce youth
  alcohol access
• Responsible service trainings
• Enact ordinances e.g. prohibit public
  consumption, sales of large beer bottles or
  fortified wine
• Monitor problematic liquor outlets (shut down if
  needed)
• Voluntary merchant covenants not to sell to
  minors or intoxicated persons
• Restricting bill board campaigns
• Convening city-wide task forces

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• Expand Treatment Services
• Increase public funds for treatment (city wide
  anti drug sales tax)
• Referral and public awareness campaigns regarding
  existing treatment services
• Create or expand new treatment or after care
  programs within existing organizations (e.g.
  courts, jails, persons, health care agencies,
  public housing)
• Initiating emergency department screening, brief
  interventions and referral
• Drug courts mandating treatment
• Opening new treatment or after care facilities
  (e.g. outpatient, inpatient, recovery residences)
• Convening a treatment provider task force

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Greater Relative Reduction in Alcohol-Related
Fatal Crashes VS Fatal Crashes with Zero BAC
Pooled Effects BAC .01 VS Zero BAC BAC .08 VS Zero BAC BAC .15 VS Zero BAC
5 FB sites VS controls 22 P.01 20 Plt.001 17 P.02

3 FB sites targeting entire communities VS controls 31 Plt0.001 36 Plt.001 39 P.003

Communities Kansas City, MO, Milwaukee, WI, San
Antonio, TX, Santa Barbara, CA, and Vallejo, CA
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Courtney Birch
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Conclusions

• Efforts to reduce underage drinking and drunk
  driving have focused state level legislative
  change
• - Legal drinking age 21
• - Criminal Administrative Per Se Laws
• - Increased Penalties
• - Lower legal BAC

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Conclusions

• Alcohol-Related Traffic Fatalities can also be
  reduced by attention to
• - Speeding
• - Running Red Lights
• - Failure to Yield to Pedestrians
• - Failure to Wear Safety Belts

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Conclusions

• Community Level Interventions can also reduce
  alcohol-related traffic deaths and other types of
  alcohol related injuries
• - Coordination of multiple city departments
• - Clear measurable Objectives and Strategic
  Plans
• Combine Education and Enforcement
• Include Treatment Program
• - Use Data to Plan and Evaluate
• Involve Private Citizens Be Inclusive
• Involve Youth

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NIAAA Rapid Response to College Drinking Grants

• Clemson University
• Fordham University
• Loyola Marymount University
• Minnesota State University
• Northeastern University
• North Dakota State University
• Ohio State University
• State University of New York Albany

• University of Central Florida
• University of Michigan
• University of Rhode Island
• University of San Diego
• University of Virginia
• University of Wisconsin Milwaukee
• Western Washington State University