Epidemiology and Policy Prevention of Underage Drinking Terry Sterling Ralph Hingson, Sc.D., M.P.H. Director, Division of Epidemiology and Prevention Research National Institute on Alcohol Abuse and Alcoholism

Need to test all injury deaths under age 21 for alcohol

Consequences of Underage Drinking: United States Nearly 5,000 unintentional injury deaths 1,527 alcohol-related traffic crash deaths Poor academic performance Potential cognitive deficits Unplanned and unprotected sex after drinking Physical and sexual assaults Higher tobacco and drug use Hangovers Poisoning/overdoses (400/year; ↑58% 2006-2010) Second-hand effects to others Source: Surgeon General’s Call to Action, 2007

Sources: Zeigler et al, Prev Med, 2005; Squeglia et al, Clin EEG Neurosci, 2009; Squeglia et al, J Stud Alcohol Drugs, 2012; Norman, Drug & Alcohol Depend, 2011

Source: Grant and Dawson (1997) J. Substance Abuse z 37 Source: Grant and Dawson (1997) J. Substance Abuse z

Interventions Individually-Oriented Family School Web-Based Environmental/ Policy Comprehensive Community Interventions

Alcohol: Trends in 2-Week Prevalence of 5 or More Drinks in a Row among College Students vs. Others 1-4 Years Beyond HS, 1980-2013 Federal 21 Drinking Age Drinking Age 21 in all states Full-time College Students Others 1-4 Yrs. Past HS 12th Graders 2013 Source: Monitoring the Future, 2014

Non-Alcohol-Related ↓ 34% Alcohol- vs. Non-Alcohol-Related Traffic Fatalities, Rate Per 100,000, Ages 16-20, United States, 1982-2014 U.S. MLDA Age 21 law MLDA 21 in all 50 states 25.58 (n=5,244) Non-Alcohol-Related ↓ 34% 8.89 (n=1,896) 13.36 (n=2,738) Alcohol-Related ↓ 80% 5.17 (n=1,102) Sources: U.S. Fatality Analysis Reporting System, 2016; U.S. Census Bureau, 2016

Fell et al., Impact of 20 Underage Drinking Laws, J Stud Alcohol and Drugs, 2016 Methods: Examined the ratio of drinking to non-drinking drivers in the U.S. in all states from 1982-2012 using the Fatality Analysis Reporting System data Used structural equation modeling to compare drivers ≥age 20 versus 26+ Controlled for: per capita beer consumption per se 0.10 and 0.08% laws Results Nine underage drinking laws produced significant declines in alcohol-related traffic deaths involving drivers under age 21 – administrative license revocation – seat belt laws

Fell et al. (continued) Results (cont.) Law Percent Fake ID support -11.9 Possession of alcohol -7.7 Purchase of alcohol -4.2 Use/lose -7.9 Zero tolerance -2.9 Age of bar tender ≥21 -4.1 State responsible for beverage service -3.8 Dram shop liability -2.5 Social host laws -1.7 Collectively, the 9 laws prevent 1,135 deaths per year 210 more lives would be saved annually if all states passed these laws

Is Passing Laws Enough? 56-scan

Potential Process of Change After a Drinking Age Increase Police and Enforcement General Legal Deterrence Legal Drinking Age Increase Reduction In Drinking & Driving After Court Enforcement Alcohol-Related Fatal Crash Reductions Public Education Who - Minors - Alcohol Outlets What - Reasons for Law - Enforcement Changes in Public Perception about Alcohol

Comprehensive community interventions address college age and underage drinking at multiple levels - Coordinate multiple city departments - Clear measurable Objectives and Strategic Plans Combine Education and Law Enforcement Include screening and early interventions - Use Data to Plan and Evaluate Involve Private Citizens – Be Inclusive Involve Youth

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) Fighting Back, Hingson (2005) Sacramento Neighborhood Prevention, Treno, (2007) State Coalitions to Reduce Underage Drinking, Wagenaar (2007) Neighborhoods Engaging with Students (NEST), Saltz (2009) College community program, McCartt et al. (2009) Communities That Care, Hawkins et al. (2009) Safer California Universities, Saltz et al. (2010) Study to Prevent Alcohol Related Consequences (SPARC), Wolfson et al. (2011)

Conclusions Research indicates reductions in underage and college age drinking and related problems can be achieved with interventions that focus on - Individuals - Families - Schools - Environmental Changes/Legislation - Community Interventions targeting multiple levels are more effective

Number of Alcohol- vs. Non-Alcohol-Related Traffic Fatalities, Ages 16-20, Massachusetts, 1982-2015 U.S. MLDA Age 21 law MLDA 21 in all 50 states 107 (Rate/100K=20.1) Alcohol-Related ↓ 93% in Rate/100K 50 (Rate/100K=9.4) 14 (Rate/100K=2.9) Non-Alcohol-Related ↓ 70% in Rate/100k 2015 7 (Rate/100K=1.5) Sources: U.S. Fatality Analysis Reporting System, 2016; U.S. Census Bureau, 2016