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

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

Dr. Margaret Jonathan Travis

Moore Levy Stedman

Magnitude of Alcohol Problems on U.S. College Campuses

Hingson et al. (2002) J. Studies on Alcohol

Annual Review of Public Health

Brad McCuewww.brad21.org

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

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)

Change in percent binge drinking and driving under the influence among 18-24 year olds

1999-2002

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

Changes in Alcohol Related Injury Deaths college and non-college 18-24

year olds 1998-2001

1998 2001 Percent Change

Total Per Pop.

All Alcohol Related Injury Deaths

College 1,550 1,700 + 9% + 6%

Source: FARS, CDC, Smith et al. 1995

Change in Numbers of College Students 18-24 Experiencing Alcohol Problems

1999-2001

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

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

College3.8 million

2.8 million

1,700

Non College7.6 million

4.5 million

3,700

Total11.4 million

7.3 million

5,400

College Alcohol StudyThe 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

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.

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

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 D’s and F’s in 13% vs. 4%school within the past year

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

Interventions

• Individually oriented

• Environmental

• Comprehensive Campus/ Community Interventions

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 (N=336) randomly allocated to receive 30 minute brief intervention to reduce risky drinking and offers links to alcohol treatment

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

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

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)

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

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

Environmental Approaches

Drinking Trends AmongHigh School Seniors, 1975-2003

0102030405060708090

100

Perc

en

t

Yearly

Monthly

5+ Drinks

Source: Monitoring the Future, 2004

Federal 21 drinking age

Drinking age 21 in all States

Trends in Alcohol Related and Non Alcohol Related Traffic Fatalities persons 16-20 U.S.

1982-2004US MLDA Age 21 Law

MLDA 21 in All 50 States

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

5500

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

Num

ber

of F

atal

ities

3,781

2,738

2,115

5,244

↑38%

↓60%

Non Alcohol Related Fatalities

Alcohol Related Fatalities

Source: U.S. Fatality Analysis Reporting System

Frequency of use of any alcoholic beverage during the last 12 months: Students age 15- ESPAD 2003

0

10

20

30

40

50

60

70

80

90

100

Austri

a

Belgiu

m

Bulgar

ia

Croat

ia

Cypru

s

Czech

Rep

.

Denm

ark

Estoni

a

Faroe

Isl.

Finla

nd

France

Germ

any

Greec

e

Green

land

Hungar

y

Icel

and

Irela

nd

Isle

of M

anIta

ly

Latvi

a

Lithuan

iaM

alta

Nether

lands

Norway

Polan

d

Portu

gal

Roman

ia

Russi

a

Slova

k Rep

.

Slove

nia

Sweden

Switzer

land

Turkey

Ukrai

neUK

Spain

USA

Pe

rce

nt

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

Frequency of being drunk in last 12 months: Students age 15- ESPAD 2003

0

10

20

30

40

50

60

70

80

90

100

Austri

a

Belgiu

m

Bulgar

ia

Croat

ia

Cypru

s

Czech

Rep

.

Denm

ark

Estoni

a

Faroe

Isl.

Finla

nd

France

Germ

any

Greec

e

Green

land

Hungar

y

Icel

and

Irela

nd

Isle

of M

anIta

ly

Latvi

a

Lithuan

iaM

alta

Nether

lands

Norway

Polan

d

Portu

gal

Roman

ia

Russi

a

Slova

k Rep

.

Slove

nia

Sweden

Switzer

land

Turkey

Ukrai

neUK

USA

Pe

rce

nt

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

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

Cumulative Estimated Number of Lives Saved by the Minimum Drinking Age Laws, 1975-2003

12,35713,15213,968

14,816 15,66716,513

17,35918,22019,121

20,04320,970

21,88722,798

0

5,000

10,000

15,000

20,000

25,000

1975-1991

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Source: National Highway Traffic Safety Administration

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

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

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 respondent’s life

- during the year prior to the survey

Micheal Timothy Wilder

Figure 2: Ever in a Physical Fight While or After Drinking According to Age of Drinking Onset, National Longitudinal

Alcohol Epidemiologic Survey

4.10

3.203.50

2.90

2.30

1.50

2.00

1.50

1.00

0

1

2

3

4

5

6

<14 14 15 16 17 18 19 20 21+

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

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

Why Are These Findings Important?

Source G. Smith et. al 1999

•40% unintended injury deaths

39,000

•47% Homicides 8,000

•29% Suicides 8,500

Alcohol is involved over 50,000 injury deaths annually

Over half under age 44

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

BAC and Impairment

.10

.09

.08

.07

.06

.05

.04

.03

.02

.01 BAC

Concentrated Attention, Speed Control,Braking, Steering, Gear Changing, Lane Tracking, Judgement

Tracking, Divided Attention, Coordination,Comprehension, Eye Movement

Simple Reaction Time, Emergency ResponseChoice Reaction Time

Source: National Highway Traffic Safety Administration

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

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

0 .015-.049 .050-.079

Blood Alcohol Concentration (mg%)

Rel

ativ

e R

isk

of F

atal

Cra

sh

Relative Risk of Fatal CrashDrivers 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.

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)

Proportion of Teen Fatal Crashes Involving Single Vehicles at Night

Before and After Zero Tolerance Laws for Youth

31.3 31.7 31.6

25.1

0%

10%

20%

30%

40% Comparison

ZeroTolerance

SVNF 1439 1079 1150 717Fatal Crashes 4597 3400 3637 2851

1%

21%

Source: Hingson, Heeren, Winter, 1994

PercentComparison Zero Tolerance

Before After Before After

Conclusion: If all states adopted Zero Tolerance laws there would be 375-400 fewer fatal crashes each year involving

drivers under 21.

Hingson, Heeren, Winter – AJPH (1996).08 Laws

.08 Law Comparison Date .08% AnalysisStates 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

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

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.

Center for Consumer-Freedom.com

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)

- 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

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

Ross and Geri Goughler

Is Passing Laws Enough?

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

How can you further reduce alcohol-related traffic deaths

and injuries in your community?

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

• Younger heavier drinkers more affected than older heavier drinkers

Kenkel, 1993Godfrey, 1997Chaloupka & Wechsler, 1996Sutton & 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, 1993Cook & Tauchen, 1982Ruhm, 1996

Restricting Alcohol LicensesDensity 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

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

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)

Goals: Reduce

•Drunk Driving

•Related Traffic Risks eg. speeding, not wearing safety belts, running red lights

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 Mayor’s office• Encourage local initiatives• Evaluation feedback

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

*p<0.05

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

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

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

Limit Alcohol Availability:1. Compliance check (sting) surveys to reduce youth

alcohol access2. Responsible service trainings3. Enact ordinances e.g. prohibit public consumption,

sales of large beer bottles or fortified wine4. Monitor problematic liquor outlets (shut down if

needed)5. Voluntary merchant covenants not to sell to minors

or intoxicated persons6. Restricting bill board campaigns7. Convening city-wide task forces

Expand Treatment Services:1. Increase public funds for treatment (city wide anti

drug sales tax)2. Referral and public awareness campaigns regarding

existing treatment services3. 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 treatment6. Opening new treatment or after care facilities (e.g.

outpatient, inpatient, recovery residences)7. Convening a treatment provider task force

Greater Relative Reduction in Alcohol-Related Fatal Crashes VS Fatal Crashes

with Zero BACPooled 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% P<.001

17% P=.02

3 FB sites targeting entire communities* VS controls

31% P<0.001 36% P<.001 39% P=.003

Communities: Kansas City, MO, *Milwaukee, WI, San Antonio, TX, *Santa Barbara, CA, and *Vallejo, CA

Courtney Birch

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

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

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

1. Clemson University2. Fordham University3. Loyola Marymount

University4. Minnesota State

University5. Northeastern University6. North Dakota State

University7. Ohio State University8. State University of New

York Albany

9. University of Central Florida

10. University of Michigan11. University of Rhode

Island12. University of San Diego13. University of Virginia14. University of Wisconsin

– Milwaukee15. Western Washington

State University

NIAAA Rapid Response to College Drinking Grants