Prevention of Underage Drinking Problems

1
Prevention of Underage Drinking Problems
Ralph Hingson, ScD Director, Division of
Epidemiology and Prevention Research National
Institute on Alcohol Abuse and Alcoholism Prevent
ing Underage Alcohol Use A National Meeting of
the States Sponsored by the Interagency
Coordinating Committee for the Prevention of
Underage Drinking October 31, 2005
2
(No Transcript)
3
Magnitude of Alcohol Problems on U.S. College
Campuses
Dr. Margaret Jonathan
Travis Moore Levy
Stedman
Hingson et al. (2002) J. Studies on Alcohol
4
(No Transcript)
5
Interventions

• Individually oriented
• Family
• School
• Environmental
• Comprehensive Community Interventions

6
Brief Motivational Alcohol Intervention in a
Trauma Center

• 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

Source Gentilello Annals of Surgery, 1999
7
Brief Motivational Alcohol Intervention in a
Trauma Center

• Results
• 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

Source Gentilello Annals of Surgery, 1999
8
Brief Alcohol Intervention for Older Adolescents

• 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
• Brief intervention group had
• ¼ drinking and driving occasions
• Fewer moving violations 3 vs. 23
• ¼ alcohol related injuries

Source Monti et al. J. Consulting and Clinical
Psychology (1999)
9
Fifteen Studies Provide Strong Support for the
Efficacy of This Approach Among College Students

• Barnett et al. 2004
• Borsari and Carey (in press)
• Labrie 2002
• Gregory 2001
• LaChance 2004
• Murphy et al. 2001
• Murphy et al. 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, 2005 In Review)
10
Implementation Gap

• Fewer than
• ½ of pediatricians screen all adolescents for use
  of alcohol and drugs
• ¼ screen for drinking and driving.
• Pediatric Medical Care Providers considerably
  underdiagnose alcohol use, abuse, and dependence
  among patients ages 14-18.
• 1.5 million 12-17 year olds need alcohol
  treatment
• Only 216,000 14 received treatment

Sources American Academy of Pediatrics, 1997
Wilson, Sheritt, Gates, Knight Pediatrics, 2004
National Household Survey on Drug Use and Health,
2003
11
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
12
Family Interventions Iowa Strengthening
Families Program

• Goals
• Improve parent/child relations
• Strengthen family communication skills
• Increase child coping skills
• Implementation
• 7 sessions at school
• 13 hours total
• Parent and child separately and together

13
Family Interventions

• A randomized controlled trial with families of
  6th graders
• Iowa Strengthening Families Program (ISFP) (206
  families)
• Preparing for Drug Free Years Program (PDFYP)
  (221 families)
• Control (221 families)

Lifetime Drunkenness Through 6 Years Past
Baseline Logistic Growth Curve
Trajectory for ISFP Condition
Trajectory for Control Condition
72
0
6
18
30
48
Months
Source Spoth, Redmond, Shin J Consulting
Clinical Psychology (2001, 2004)
14
School Based Programs

• Programs that rely primarily on increasing
  knowledge about consequences of drinking are not
  effective.
• Effective Programs
• Are based on social influence models
• Include norm setting
• Address social pressures to drink and teach
  resistance skills
• Include developmentally appropriate information
• Include peer-led components
• Provide teacher training
• Are interactive
• School only program effects are generally small
• Less effective with students who initiate
  drinking prior to grades 5 or 6

Source NIAAA, Alcohol and Development in Youth
A Multidisciplinary Overview
15
School Based Life Skills Program

• Junior High- 30 sessions, most in Year 1
• Curricula
• Drug Information
• Alcohol/Drug Resistance Skills
• Self Management Skills
• General Social Skills
• Results
• Beneficial Effects
• Alcohol Tobacco Use
• Through High School, Not After

Sources Botvin et al. J. Consulting and
Clinical Psychology (1990) JAMA
(1995) Addictive Behaviors (2000)
16
Combined Family Interventions School Based
Life skills Program

• Randomized controlled trial of 7th graders from
  36 rural
• schools
• ISFP Plus Life Skills Training (n549)
• Life Skills Training Only (n517)
• Control (n453)

• Results 2 ½ Years Later
• Weekly drunkenness rate among intervention
  students 1/3 lower
• Strengthening Family plus Life Skills (p.03)
• Life Skills Training (p.08)

Conclusion Family and school interventions
combined are more effective than school
interventions only
Source Spoth, et al Psychology of Addictive
Behaviors (In Press)
17
Environmental Approaches
18
Drinking Trends AmongHigh School Seniors,
1975-2003
Federal 21 drinking age
Drinking age 21 in all States
Source Monitoring the Future, 2004
19
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
20
Legal Drinking Age Changes

• CDC reviewed 49 studies published in scientific
  journals
• Alcohol-Related Traffic Crashes
• - Increased 10 when the drinking age was
  lowered
• - Decreased 16 when the drinking age was raised

Source Shults et al., American Journal of
Preventive Medicine, 2001
21
Cumulative Estimated Number of Lives Saved by the
Minimum Drinking Age Laws 1975-2003
Source National Highway Traffic Safety
Administration
22
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

23
Source Grant and Dawson J. Substance Abuse
(1997)
24
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 respondents life
• - during the year prior to the survey

25
Micheal Timothy Wilder
26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
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
30
Why Are These Findings Important?

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

Source Centers for Disease Control and
Prevention
31
Why Are These Findings Important?
Alcohol is involved over 50,000 injury deaths
annually
Over half under age 44
Source G. Smith et. al 1999
32
(No Transcript)
33
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
34
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
35
Proportion of Teen Fatal Crashes
Involving Single Vehicles at Night Before and
After Zero Tolerance Laws for Youth
Comparison
Zero Tolerance
Percent
Before
After
Before
After
1
21
SVNF 1439 1079 1150
717 Fatal Crashes 4597
3400 3637 2851
Source Hingson, Heeren, Winter, 1994
36
(No Transcript)
37
States with Primary Safety Belt Laws

• Primary Law

As of July 2004, 21 states, DC and Puerto Rico
have primary safety belt laws. New Hampshire is
the only state that has no adult safety belt law
38
Increase Price of Alcohol

• 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 (Kenkel, 1993)
• Robberies
• Rapes
• Liver cirrhosis mortality
• See Cook Moore, 1993 Cook Tauchen, 1982
  Ruhm, 1996

39
Restricting Alcohol Licenses

• Density of alcohol outlets is associated with
• - Higher alcohol consumption
• - Violence
• - Other crime
• - Health problems

• Sources Ornstein Hanssens, 1985 Gliksman
  Rush, 1986 Gruenewald et.al, 1993
  Scribner et.al., 1995 Stitt and
  Giacopassi, 1992 Chaloupka Wechsler, 1996

40
Is Passing Laws Enough?
41
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
42
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

43
Successful Comprehensive Community Interventions

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

44
Project Northland

• Intervention to prevent or reduce alcohol use
  among 6, 7, and 8th grade students
• School Education Programs (general program
• each grade)
• Parent Involvement
• Peer Participation
• Community task forces to engage citizens
• Compliance Checks
• Server Training
• Ordinances

Source Perry C. et al. American Journal of
Public Health, 1996 Perry C. et al. Health
Education Research, 2002.
45
Project Northland

• Results
• 3 Years Later
• Drinking 50 lower among baseline non-drinkers
• (5 vs 10)
• Lower rates of cigarette and marijuana use
• Monthly and weekly drinking 20-30 lower
• among entire sample
• Grades 11 12
• Fewer Northland students drink 5
• 80 reduction in youth ability to purchase
• alcohol (Off Sale)

46
Communities Mobilizing for Change

• Interventions to Reduce Availability
• Merchants record underage buy attempts
• Beer kegs prohibited at University Homecoming
• Policies to discourage motels from permitting
  underage drinking parties
• Security at high school dances
• Model local ordinances to restrict underage
  access to alcohol
• Compliance checks

Source Wagenaar et al., J. Studies on Alcohol,
2000
47
Communities Mobilizing for Change

• Results
• -17 increase in outlets checking age ID
• -24 decline in bar and restaurant sales
• -25 decrease in the proportion of 18-20 year
  olds
• attempting alcohol purchase
• -17 decline in the proportion of older teens
• providing alcohol to younger teens
• -7 decrease in the percent under 21 who drank
• -14 decline in alcohol traffic injuries,
  drivers 18-20

Source Wagenaar et al., J. Studies on Alcohol,
2000
48
Community Trials

• Intervention
• Reduce youth alcohol availability
• Drinking and driving enforcement
• Alcohol outlet density reduction
• Community mobilization media
• Advocacy
• Responsible alcohol service
• Results
• Self reported DWI cut in half
• 10-11 decrease in single vehicle night crashes
• 43 decrease in emergency department alcohol
  related assault admissions

Mountain of Beer
Source Holder et al., JAMA (2000)
49
A Matter of Degree

• Intervention Components
• 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

Source Weitzman et al. American Journal of
Preventive Medicine. 2004
50
A Matter of Degree

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

Source Weitzman et al. American Journal of
Preventive Medicine 2004
51
Fighting Back Program

• First Community Program to combine
• Environmental interventions to limit alcohol
  availability
• Efforts to increase substance abuse treatment

Source Hingson et al. Injury Prevention (2005)
52
Fighting Back Program Selected Interventions

• Limit Alcohol Availability
• Youth access compliance check surveys
• Responsible beverage service training
• Monitoring and closing problem liquor outlets
• Bill board restrictions
• Expand Treatment
• Sales tax increase for expanded treatment
• New treatment programs- courts, jails, health
  care
• agencies, public housing
• Emergency department screening/brief
  interventions
• New inpatient, outpatient and recovery programs

Source Hingson et al. 2005
53
Fighting Back - ResultsGreater Relative
Reduction in Alcohol-Related Fatal Crashes VS
Fatal Crashes with Zero BAC
Courtney Birch
Communities Kansas City, MO, Milwaukee, WI, San
Antonio, TX, Santa Barbara, CA, and Vallejo, CA
54
Conclusions

• Research indicates reductions in Underage
  Drinking and Related Problems can be achieved
  with Interventions that focus on
• - Individuals
• - Families
• - Schools
• Environmental Changes
• Interventions targeting multiple levels are more
  effective
• Comprehensive community interventions address
  underage drinking at multiple levels

55
Conclusions

• Community Level Interventions can include
• - Coordination of multiple city departments
• - Clear measurable objectives and strategic
  plans
• Combine education and enforcement
• Treatment programs
• - Use of data to plan and evaluate
• Involvement of private citizens
• Youth involvement (be inclusive)

56
(No Transcript)
57
(No Transcript)
58
(No Transcript)
59
(No Transcript)
60
(No Transcript)
61
(No Transcript)
62
Acknowledgements

• NIAAA staff who assisted with this presentation
• Rachel Goutos
• Vivian Faden, Ph.D.

63
Panel Discussion

• Moderator
• Faye Calhoun, Sc.D.
• Deputy Director
• National Institute on Alcohol Abuse and
  Alcoholism
• Panelists
• Harold Holder, Ph.D
• Senior Research Scientist
• Prevention Research Center
• John Knight, MD
• Associate Professor of Pediatrics, Harvard
  Medical School
• Director, Center for Adolescent Substance Abuse
  Research, Children's Hospital, Boston
• Kelli A. Komro, MPH, Ph.D.
• Associate Professor, Department of Epidemiology
  and Health Policy Research
• Institute for Child Health Policy, University of
  Florida