1. 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

2. 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

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

8. Annual Review of Public Health Brad McCue www.brad21.org

9. 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, 33:29 19-25

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

11. Change in percent binge drinking and driving under the influence among 18-24 year olds 1999-2002 Persons ages 18-2419992002Change Past month binged 5+ at least once College 41.7 43.2 +4% Non-College36.539.8+9% Drove under the influence in past year College 26.531.4+18% Non-College 19.825.7+30% Source: National Household Survey on Drug Use and Health

12. Changes in Alcohol Related Injury Deaths college and non-college 18-24 year olds 1998-2001 19982001Percent Change Total Per Pop. All Alcohol Related Injury Deaths College1,5501,700+ 9%+ 6% Source: FARS, CDC, Smith et al. 1995

13. Change in Numbers of College Students 18-24 Experiencing Alcohol Problems 1999-2001 1999 2001 Binge 5+ Drinks 3.6 million3.8 million Drove under influence 2.3 million2.8 million Injured under influence of alcohol 588,000599,000 Assaulted by another college student730,000690,000 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

14. Alcohol Related Behaviors and Consequences of 18-24 Year Olds in the U.S. 2001 Drank 5+ on an occasion past month Past year drove under the influence of alcohol Died of alcohol-related unintentional injury 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

15. 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

16. CDC Youth Risk Behavior 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.

17. Youth Risk Behavior Survey 2003 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

18. Youth Risk Behavior Survey 2003 Frequent binge drinkers compared to abstainers in high school were much more likely in the past month to: Drink at school31% vs. 0% Use marijuana at school29% vs. 1% Earned mostly D’s and F’s in 13% vs. 4% school within the past year

20. 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

21. Interventions Individually oriented Environmental Comprehensive Campus/ Community Interventions

22. Gentilello Brief Motivational Alcohol Intervention in a Trauma Center Annals of Surgery, 1999 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

23. Gentilello Brief Motivational Alcohol Intervention in a Trauma Center Annals 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

24. 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 monthsMISC Drinking and driving62%85%SC had 4 times more drinking and driving occasions Moving Violations3%23% Alcohol-related injury 21%50%SC had 4 times more alcohol-related injury

25. 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 Boresian et al. In Press Labrie 2002 Gregory 2001 LaChance 2004 Murphy and Colleagues 2001 Murphy and Colleagues 2004 Source: Larimer and Cronce (2002, In Review)

26. 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

27. 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

28. Environmental Approaches

29. Drinking Trends Among High School Seniors, 1975-2003 Source: Monitoring the Future, 2004 Federal 21 drinking age Drinking age 21 in all States

30. 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

31. 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

32. 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

33. 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

34. Cumulative Estimated Number of Lives Saved by the Minimum Drinking Age Laws, 1975-2003 Source: National Highway Traffic Safety Administration

35. 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

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

37. 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

38. Micheal Timothy Wilder

42. Figure 2: 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

43. 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

44. Why Are These Findings Important? Source G. Smith et. al 1999 40% unintended injury deaths 39,000 47% Homicides8,000 29% Suicides8,500 Alcohol is involved over 50,000 injury deaths annually Over half under age 44

45. Legislation to Reduce Alcohol Related 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

46. 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%.

47. 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.

48. Increased Risk of Driver Single Vehicle Crash Death at Blood Alcohol Concentration of.08% -.10% Relative to Sober Drivers MaleRelative Risk Age 16-2051.4 21-3413.4 35+11.4 FemaleRelative Risk Age 16-2014.9 21-3413.4 35+11.4 Source: (Zador P., Krawchuck S., Voas R., J. Studies on Alcohol, 2000)

50. Proportion of Teen Fatal Crashes Involving Single Vehicles at Night Before and After Zero Tolerance Laws for Youth SVNF 1439 1079 1150 717 Fatal Crashes 4597 3400 3637 2851 1% 21% Source: Hingson, Heeren, Winter, 1994 Percent ComparisonZero Tolerance BeforeAfterBeforeAfter Conclusion: If all states adopted Zero Tolerance laws there would be 375-400 fewer fatal crashes each year involving drivers under 21.

53. Hingson, Heeren, Winter – AJPH (1996).08 Laws.08 Law ComparisonDate.08% Analysis States StatesLaw EffectivePeriod Utah IdahoAugust 1983 Aug. 1976 – July 1991 Oregon Washington November 1983 Nov. 1976 – Oct. 1991 Maine MassachusettsAugust 1988Aug. 1984 – July 1993 California TexasJanuary 1990Jan. 1986 – Dec. 1993 Vermont New HampshireJuly 1981July 1990 – June 1993

54. Results:.08 law states experienced significant declines in the proportion of fatal crashes with drivers with BAC’s 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

55. 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.

57. Center for Consumer-Freedom.com

58. 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 1 st drink” proves it)

59. - 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

63. 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

64. Ross and Geri Goughler

67. Is Passing Laws Enough?

69. 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

70. How can you further reduce alcohol-related traffic deaths and injuries in your community?

71. 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

72. 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

73. 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

74. 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

75. 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)

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

77. Saving Lives Program Program 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 Mayor’s office Encourage local initiatives Evaluation feedback

89. Saving Lives vs. Rest of Mass. 5 Pre Program Years Compared to 5 Program Years PreProgram Program Change Fatal Crashes178 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 *p<0.05

90. 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

91. 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

92. Fighting Back Program Hingson et al., Injury Prevention (2005) Limit Alcohol Availability: 1.Compliance check (sting) surveys to reduce youth alcohol access 2.Responsible service trainings 3.Enact ordinances e.g. prohibit public consumption, sales of large beer bottles or fortified wine 4.Monitor problematic liquor outlets (shut down if needed) 5.Voluntary merchant covenants not to sell to minors or intoxicated persons 6.Restricting bill board campaigns 7.Convening city-wide task forces

93. Expand Treatment Services: 1.Increase public funds for treatment (city wide anti drug sales tax) 2.Referral and public awareness campaigns regarding existing treatment services 3.Create or expand new treatment or after care programs within existing organizations (e.g. courts, jails, persons, health care agencies, public housing) 4.Initiating emergency department screening, brief interventions and referral 5.Drug courts mandating treatment 6.Opening new treatment or after care facilities (e.g. outpatient, inpatient, recovery residences) 7.Convening a treatment provider task force

94. Greater Relative Reduction in Alcohol- Related Fatal Crashes VS Fatal Crashes with Zero BAC Pooled EffectsBAC.01%+ VS Zero BAC BAC.08%+ VS Zero BAC BAC.15%+ VS Zero BAC 5 FB sites VS controls 22% P=.0120% P<.00117% P=.02 3 FB sites targeting entire communities* VS controls 31% P<0.00136% P<.00139% P=.003 Communities: Kansas City, MO, *Milwaukee, WI, San Antonio, TX, *Santa Barbara, CA, and *Vallejo, CA

95. Courtney Birch

96. 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

97. 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

98. 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

105. 1.Clemson University 2.Fordham University 3.Loyola Marymount University 4.Minnesota State University 5.Northeastern University 6.North Dakota State University 7.Ohio State University 8.State University of New York Albany 9.University of Central Florida 10.University of Michigan 11.University of Rhode Island 12.University of San Diego 13.University of Virginia 14.University of Wisconsin – Milwaukee 15.Western Washington State University NIAAA Rapid Response to College Drinking Grants