1. Policy Approaches to Reduce Binge Drinking and Impaired Driving Toben F Nelson, ScD Division of Epidemiology and Community Health University of Minnesota

2. Learning Objectives: Describe the problem of underage drinking within a public health perspective Describe the value of adopting a public health perspective to combat underage drinking Identify the ways that a public health perspective is unique Identify a menu of public health / policy options to reduce underage drinking

3. Alcohol Misuse Injuries Liver disease Violence, Sexual Assault Unintended Pregnancies Cardiovascular disease Alcohol Use Disorders RISK FACTOROUTCOME Child Neglect GI cancers, GI disorders Crime, legal costs Lost productivity, absenteeism

4. PERSON CONSUMPTION CONSEQUENCE(S) Consequences of Alcohol Probabilistic relationship By drinking event By drinker PREVENTION HARM REDUCTION

5. Underage drinking is part of a larger societal problem with alcohol 3 rd leading cause of preventable death in the US –4,500 under 21 –79,000 adults Youth tend to drink like the adults around them The causes are the same The solutions the same too…

6. Binge Drinking among Current Drinkers Naimi et al., JAMA, (2003)

8. Percentage of High School Students Who Reported Binge Drinking * Had five or more drinks of alcohol in a row within a couple of hours on at least 1 day during the 30 days before the survey. 11.5% - 21.8% 21.9% - 23.9% 24.0% - 25.1% 25.2% - 30.7% No Data State Youth Risk Behavior Surveys, 2009

9. Minnesota has a problem Underage >60 alcohol-attributable deaths annually Mostly acute conditions –Motor vehicle crash –Homicide / Suicide General population >1,100 alcohol-attributable deaths annually Both acute and chronic conditions –Abuse/Dependence –Liver disease Source: Alcohol-Related Disease Impact (ARDI) CDC

10. Ronald Reagan signs national minimum legal drinking age bill, July 1984 “…raising that drinking age is not a fad or an experiment. It's a proven success. Nearly every State that has raised the drinking age to 21 has produced a significant drop in the teenage driving fatalities.” -President Ronald Reagan Policy Success

11. Effects of Minimum Drinking Age Laws Review of 241 published analyses 1960-2000 135 were of high quality Outcomes –Alcohol consumption (n=33) –Traffic crashes (n=79) –Other (n=23) Wagenaar & Toomey, 2002

12. Effects of Minimum Drinking Age Laws Alcohol consumption (n=33) Higher MDLA – Lower Consumption (n=11; 33%) Higher MDLA – Higher Consumption (n=1; 3%) Traffic crashes (n=79) Higher MDLA – Fewer Traffic Crashes (n=46; 58%) Higher MDLA – More Traffic Crashes (n=0; 0%) Other (n=23) Higher MDLA – Fewer Alcohol-related problems (n=8; 35%) Higher MDLA – More Alcohol-related problems (n=0; 0%) Wagenaar & Toomey, 2002

13. Annual lives saved by 21 MLDA Based on an average decline in deaths of 13% when individual states raised the MLDA 890 lives saved in 2006 Total lives saved - more than 25,000

14. Source: The Monitoring the Future Study, the University of Michigan

15. Underage Drinking in the U.S. 10.8 million youth ages 12-20 years in the U.S. reported past-month drinking in 2004, and 7.4 million reported past- month binge drinking. 5,400 children under 16 years start drinking every day in the U.S. On average, 12-17 year olds report they began drinking at age 14 years. Source: Substance Abuse Mental Health Services Administration, National Survey on Drug Use and Health, 2005

16. Deaths and YPLL among Youth <21 due to Exposure to Excessive Drinking 4,500 alcohol-attributable deaths 274,000 YPLL (60 yrs lost/death) >95% of deaths and YPLL involved binge drinking. 1 of 4 deaths among males and 1 of 6 deaths among females age 15 to 20 years. Three-fourths of the deaths involved young men. CDC: ARDI Web Site (www.cdc.gov/alcohol), 2007www.cdc.gov/alcohol

17. Onset of drinking Early start (before age 15) associated with: –Alcohol use –Other substance use –Alcohol-related health and social consequences –Abuse, Dependence, Alcoholism … in adulthood

18. Grant J Stud Alcohol (1997)

19. Long ‐ Term Effects of Minimum Drinking Age Laws on Past ‐ Year Alcohol and Drug Use Disorders Alcoholism: Clinical and Experimental Research Volume 33, Issue 12, pages 2180-2190, 23 SEP 2009 DOI: 10.1111/j.1530-0277.2009.01056.x http://onlinelibrary.wiley.com/doi/10.1111/j.1530-0277.2009.01056.x/full#f2 Volume 33, Issue 12, http://onlinelibrary.wiley.com/doi/10.1111/j.1530-0277.2009.01056.x/full#f2

20. Surgeon General’s Recommendations Enforce all policies and laws against underage drinking and publicize these efforts Gain public support for enforcing underage drinking laws Source: Office of the US Surgeon General (2007)

21. Some Distinctions between Public Health and Medicine Public HealthMedicine FocusPopulationsIndividuals EthicPublic ServicePersonal Service EmphasisPrevention, Community Health Promotion Diagnosis & Treatment, Patient Care InterventionsEnvironment, Behavior, Medical Care Medical Care H Fineberg, Harvard School of Public Health, 1990 http://www.hsph.harvard.edu/about.html

22. The Strategy of Prevention An example

23. The Prevention Paradox Greatest risk health harms among extreme drinkers. HOWEVER, few extreme - many “moderate” drinkers. “Moderate” drinking also carries risks Vast majority of health harms in a community arise from moderate or low consumption. Greatest health gains from incrementally moving majority. Rose (1985); Rose (1992)

24. Risk of injury, by usual number of drinks (past 30 days) Weitzman & Nelson (2004)

25. Evidence for findings regardless of: consumption measure –Usual drinks –Drinking frequency –Frequency of drunkenness Negative social/health consequence –14 different outcomes –Only the risk trajectory varied The Prevention Paradox Weitzman & Nelson (2004); Wechsler & Nelson (2006 )

26. The Prevention Paradox “A prevention measure that brings large benefits to the community affords little to each participating individual” Geoffrey Rose, 1998

27. High-risk & Population Approaches High-risk: change extreme, high-risk individuals, treatment Population: change majority, the conditions that shape everyone’s behavior.

28. High-Risk Approach Advantages Intervention tailored/targeted to the individual Clear benefits (when achieved) to the individual Intuitive Disadvantages Difficult & costly to ID “at- risk” Effects palliative, temporary Low odds success Modest benefit to the population

29. Population Approach Advantages Large population benefits Broad target audience Longer lasting effects Disadvantages May limit personal freedoms Resistance from invested parties Counter-intuitive

30. High-Risk & Population Approaches Not Mutually Exclusive You Can Do Both

31. Social Ecology of Drinking What are some mutable factors that can shift the population distribution?

33. Underage drinking Adult drinking Environmental Conditions

34. Integrated theory of drinking behavior Public Policy & Institutional Policies/Structures Legal Availability Formal Social Controls Economic Availability Physical Availability Individual Risk Factors Drinking Behavior Alcohol-related Problems Adapted from Wagenaar & Perry, 1994 Problems that stem from alcohol use are primarily a function of availability

35. Public Health Triad AgentHost Environment

36. Knowledge Attitudes Intentions Skills Pricing Composition Labeling Packaging PersonDrug Advertising/ Promotion Physical Context Availability Sociocultural Context Institutions Legal Sanctions Key Influencers Drug-Related Problems Environment Torjman (1986)

37. Intervening to Reduce Alcohol- related Motor Vehicle Crashes Source: NEW SLIDE Alcohol- Related MV Death DWI Arrest/ Conviction Alcohol- Related MV Injury Alcohol- Related MV Crash Alcohol- Impaired Driving Binge Drinking Any Drinking Regulating price Regulating access Altering the drinking context Advertising content control Education and persuasion Drinking driver countermeasures Treatment and early intervention

38. Assessing the State Alcohol Policy Environment in the United States

40. Percentage of High School Students Who Reported Binge Drinking * Had five or more drinks of alcohol in a row within a couple of hours on at least 1 day during the 30 days before the survey. 11.5% - 21.8% 21.9% - 23.9% 24.0% - 25.1% 25.2% - 30.7% No Data State Youth Risk Behavior Surveys, 2009

41. Policy Environment Youth Alcohol Pattern -5+ (binge) drinking -Freq. 5+ drinking -Current drinking -Freq. current drinking -Drinking/Driving Youth-Specific Policies Adult Alcohol Pattern -5+ (binge) drinking -Freq. 5+ drinking -Heavy drinking -Total drinks -Current drinking Adult-Oriented (i.e., population-based) Policies

42. http://www.epi.umn.edu/alcohol