National Block Grant Conference 2016 Presentation

The STOP Act State Report on Underage Drinking Laws, Policies and Programs: An Overview

Prevention Strategies and Efforts to Prevent and Reduce Underage Drinking.Jorielle Houston, Ph.D., DirectorDivision of System DevelopmentCenter for Substance Abuse and Prevention

Robert M. Vincent, M.S.Ed.,Public Health Analyst Center for Substance Abuse and Prevention

Building and Sustaining State Behavioral Healthcare Systems, 2016 National Block Grant Conference

Arlington, Virginia, August 11, 2016Albert Melena, DirectorSan Fernando Valley PartnershipSan Fernando, CA

Virgil Boysaw, Jr.Drug Free Community CoordinatorCecil County Health Department, MD

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Alcohol is a factor in the deaths of 4,300 youths in the US per year.

The cost to communities is high.

In 2013, underage drinking cost the U.S. almost $57 billion.Underage Drinking:Understanding the ProblemMotor vehicle crashes (the greatest single mortality risk for underage drinkers)SuicideViolence (e.g., homicides, assaults, and rapes)Unintentional injuries (e.g., burns, falls, and drowning)Brain impairmentAlcohol dependenceRisky sexual activityAcademic problems Alcohol and drug poisoning

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AlcoholDrug of ChoicePercentAlcohol is still the most widely used substance of use among Americans under age 21. In a given month, 10th graders reported:Source: Substance Abuse and Mental Health Services Administration. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health.

Nevertheless, the rates of underage drinking are still unacceptably high, resulting in preventable and tragic health and safety consequences for the nations youth, families, communities, and society as a whole. NSDUH data also show that alcohol continues to be the most widely used substance of misuse among Americas youth and young adultsmore than tobacco or other drugs. ______________________________SAMHSA, Center for Behavioral Health Statistics and Quality. (2015 Sep).Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health(HHS Publication No. SMA15-4927, NSDUH Series H-50). Retrieved fromhttp://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.htm

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AlcoholDrug of ChoicePercentPast substance abuse among 12- to 25-year-olds, 2014

Source: Substance Abuse and Mental Health Services Administration. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health.

Nevertheless, the rates of underage drinking are still unacceptably high, resulting in preventable and tragic health and safety consequences for the nations youth, families, communities, and society as a whole. NSDUH data also show that alcohol continues to be the most widely used substance of misuse among Americas youth and young adultsmore than tobacco or other drugs. ______________________________SAMHSA, Center for Behavioral Health Statistics and Quality. (2015 Sep).Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health(HHS Publication No. SMA15-4927, NSDUH Series H-50). Retrieved fromhttp://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.htm

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Past month alcohol use by 12- to 17-Year-Olds

Alcohol UseAdolescentsSource: Substance Abuse and Mental Health Services Administration. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. 0.25 million2.9 million

2014 data from the NSDUH also show that almost 3 million adolescents used alcohol each month, 1 million binge drank, and a quarter of a million drank heavily. Think about that for a minute. A quarter of a million 12- to 17-year-olds drank heavily (binge drank 5 times during the previous month).

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AlcoholIncreasesAlcohol use markedly increases between ages 17 and 25.Source: Substance Abuse and Mental Health Services Administration. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health.

Now compare the increased alcohol use between ages 17 and 25. By age 21, 2.9 million adolescents are using alcohol each month. By age 25, 20.8 MILLION young adults are using alcohol. That is a 10 fold increase!During that time, binge drinking increases from 1 million to 13.2 million Heavy drinking increases from a quarter of a million to almost 4 million.The risks associated with alcohol use also increase.6

Alcohol use as reported by High School seniorsBy the end of high school, more students will have used alcohol than have not. Alcohol UseHigh SchoolSource: Johnston, L. D., OMalley, P. M., Bachman, J. G., & Schulenberg, J. E. (2015). Monitoring the Future national survey results on drug use: 1975-2014 overview, key findings on adolescent drug use. Ann Arbor, MI: Institute for Social Research, University of Michigan.

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By the end of high school, more students have used alcohol than those who have not. According to results from the 2015 Monitoring the Future survey, in 2014:66 percent of 12th grade students had used alcohol; and50 percent of 12th grade students reported being drunk at least once in their lives. _____________________[2] Johnston, L. D., OMalley, P. M., Bachman, J. G., & Schulenberg, J. E. (2015). Monitoring the Future national survey results on drug use: 1975-2014 overview, key findings on adolescent drug use. Ann Arbor, MI: Institute for Social Research, University of Michigan.

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Alcohol Use, by Race/EthnicitySubstance Abuse and Mental Health Services Administration. (2015). National Survey on Drug Use and Health, 2014.

Alcohol Use Rates, by Race/Ethnicity, Ages 1220, 2014Race/EthnicityCurrent UseBinge UseWhite26.0 percent16.3 percentAmerican Indian/ Alaska Native 21.9 percent14.3 percentHispanic21.2 percent13.1 percentBlack17.3 percent8.5 percentAsian13.5 percent6.7 percent

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The rates of drinking may vary by race or ethnicity. The point to remember is that underage drinking is a universal problem, which we need to address through culturally appropriate measures.

Source: Substance Abuse and Mental Health Services Administration. (2015). National Survey on Drug Use and Health, 2014.

Prevention Is WorkingPast month alcohol use by 12- to 17-year-olds 2004 to 2014Source: Substance Abuse and Mental Health Services Administration. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Table A.7B Tobacco Product and Alcohol Use in the Past Month among Youths Aged 12 to 1717.6%11.5%Any UseBinge UseHeavy Use6.1%1.0%11.1%

2.7%

17.6%

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The good news is that our efforts to reduce underage drinking prevention are working!Data from SAMHSAs 2015 National Survey on Drug Use and Health, or NSDUH, confirm that meaningful progress has been made in reducing underage drinking prevalence over the past decade.Among 12- to 17-year-olds, rates of underage drinking have declined to record lows.

[For both genders: binge drinking- at least five drinks on one occasion during a month; heavy drinking- binge drinking on at least five occasions during a month.]________________________________Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Table A.7B. (HHS Publication No. SMA 15-4927, NSDUH Series H-50). http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.htm

Trends in Alcohol Use amongYouth and Young Adults

Past-month alcohol use by 12- to 20-year-olds

Center for Behavioral Health Statistics and Quality (2015). 2014 National Survey on Drug Use and Health: Detailed Tables.

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Over the past decade, there has been a steady decline in past-month, or current, drinking by adolescents and young adults. We also have seen similar declines in binge and heavy drinking among young people.

However, we should not ignore the slight upticks in past-month use among 16- to 20-year-olds. These changes are important because they both include and affect drinking among college students.

Sources:Center for Behavioral Health Statistics and Quality (2015). 2014 National Survey on Drug Use and Health: Detailed Tables.Johnston, L. D., OMalley, P. M., Miech, R.A., Bachman, J. G., & Schulenberg, J. E. (2014). Monitoring the Future national results on drug use: 2012 overviewKey findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan. From http://www.monitoringthefuture.org//pubs/monographs/mtf-overview2012.pdf (accessed September 3, 2014).Michigan News. (2014). Use of alcohol, cigarettes, and a number of illicit drugs declines among U.S. teens. Ann Arbor: The University of Michigan. From http://www.monitoringthefuture.org/pressreleases/14drugpr_complete.pdf (accessed December 22, 2014).

Underage Drinking in America:Progress and Challenges

About one in ten 18- to 20-year-olds meetscriteria for alcohol dependence or abuse as defined by the DSM-IV.

About one in ten 18- to 20-year-olds meets criteria for alcohol dependence or abuse as defined by the DSM-IV.

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Alcohol Use DisordersSource: Substance Abuse and Mental Health Services Administration. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. 16.3 million10.6 million

2014 data from the NSDUH also show that almost 3 million adolescents used alcohol each month, 1 million binge drank, and a quarter of a million drank heavily. Think about that for a minute. A quarter of a million 12- to 17-year-olds drank heavily (binge drank 5 times during the previous month).

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Alcohol Use Disorders Source: Substance Abuse and Mental Health Services Administration. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health.

2014 data from the NSDUH also show that almost 3 million adolescents used alcohol each month, 1 million binge drank, and a quarter of a million drank heavily. Think about that for a minute. A quarter of a million 12- to 17-year-olds drank heavily (binge drank 5 times during the previous month).

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Underage Drinking in America:Progress and ChallengesBinge drinking (4-5 or more drinks on one occasion) is the most common underage consumption pattern.Binging is engaged in by one-third of 13-year-olds who drink and two-thirds of 18- to 20- year olds who drink.

- Binge drinking (4-5 or more drinks on one occasion) is the most common underage consumption pattern. - Binging is engaged in by one-third of 13-year-olds who drink and two-thirds of 18- to 20- year olds who drink. 14

Significant Progress Has Been Made

Since the minimum legal drinking age (MLDA) was raised to 21 years in all states in 1988, underage drinking and binge drinking have declined.

Epidemiology: progress made

Over the past decade, there has been a steady decline in past-month, or current, drinking by adolescents and young adults. We also have seen similar declines in underage binge and heavy drinking.

Since 1982, Alcohol-related traffic deaths in youth ages 16-20 have declined 79 percent.

In fact, among 8th- to 12th-grade students, rates of current, binge, and heavy drinking have declined to record lows.

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Significant Progress Has Been MadeReductions in underage drinking, including rates of binge drinking, most significant among younger age groups:

Reductions in underage drinking have been most significant among younger groups.

Chart shows rates of binge drinking among 8th and 10th graders in the last 2 weeks, between 1991 and 2013.16

Significant Progress Has Been MadeRates of binge drinking among 12th-graders and college students also declined:

- Rates of binge drinking in the past 2 weeks among 12th-graders and college students have also declined during this same time period.

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Significant Progress Has Been MadeDrinking and Driving

Risky underage drinking and driving behaviors have declined since MLDA raised to 21.Minimum drinking age laws have prevented more than 30,000 alcohol-related traffic deaths since 1975.

- Risky underage drinking and driving behaviors have declined since the adoption of the minimum legal drinking age of 21.

- Analyses by the National Highway Traffic Safety Administration indicate that minimum drinking age laws have prevented more than 30,000 alcohol-related traffic deaths since 1975.

- According to the U.S. Department of Transportation, the greatest declines in alcohol-related traffic deaths since the early 1980s have been among those aged 1620 years, and declines in that age group have exceeded reductions in nonalcohol-related traffic deaths.18

Significant Progress Has Been MadeTrends in percentage of 12-graders reporting driving after alcohol use or riding after alcohol use by the driver:

This decline in risky underage drinking and driving behaviors continued over the last decade, as shown in this chart where it is shown that the percentage of 12th graders reporting drinking after alcohol use or riding with a driver who has used alcohol has been declining since 2001.19

Challenges Remain29% of drivers ages 15 to 20 who were killed in traffic crashes in 2013 had a measurable level of alcohol in their blood.Even 0.02% BAC increases fatal crash risk for underage drivers (legal limit is 0.08%)

Despite these encouraging data, challenges in addressing underage drinking remain. Rates of underage drinking and associated consequences are unacceptably high.

In 2013, of the 1,691 drivers aged 1520 years who were killed in motor vehicle traffic crashes, 492 (29%) had a blood alcohol concentration (BAC) of equal to or over 0.01.

Even the presence of 0.02% BAC increases fatal crash risk for underage drinkers.

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Challenges RemainSlower progress in the 18- to 20- year old age group

Past month alcohol use for 12- to 20-year olds:

Special attention is warranted for those aged 1820 years, as this group exhibits higher rates of alcohol-related risky behaviors and slower progress in reducing these behaviors than other age groups.

This chart shows the different rates of decline in past month alcohol use among different age groups, since 2004.21

Challenges RemainCollege drinking is a persistent problem.College student drinking and binging rates are higher than those of same-age peers.Underage college students drink about 48% of alcohol consumed at 4-year collegesConsequences of college underage drinking are serious:696,000 assaults due to drinking97,000 sexual assaults due to drinking25% of students report negative academic consequences due to drinking

Overall rates of college student drinking and binge drinking exceed those of same-age peers who do not attend college.

Underage college students drink about 48% of the alcohol consumed by students at 4-year colleges.

Consequences of underage drinking in college are widespread and serious. One study estimated that in a single year, more than 696,000 college students aged 1824 years were assaulted by another student who had been drinking and another 97,000 were the victims of alcohol-related sexual assaults.

About 25% of college students report negative academic consequences as a result of their drinking, including missing class, falling behind, doing poorly on exams or papers, and receiving lower grades overall.22

Challenges RemainMilitary Drinkers

18- to 20-year-olds in the military are less likely to binge than civilians, but are twice as likely to be heavy drinkers (i.e., more total drinks per week)

- Though 1820-year-olds in the military were less likely than their civilian counterparts to engage in binge drinking (21.5% vs 33.6%), they were twice as likely (5.9% vs 2.5%) to be heavy alcohol users (14 or more drinks per week for men and seven or more drinks per week for women).23

Challenges RemainOutlet Density

Increased alcohol outlet density near college campuses and military bases increases risk of heavy and frequent drinking among underage college students and military personnel

Increased alcohol outlet density (i.e., more alcohol outlets in a designated area) often occurs near college campuses and military bases. This exposes vulnerable populations to increased alcohol availability and is linked to excessive alcohol consumption and related harms.

Research has shown an association between retail outlet density near college and university campuses and military bases, and heavy and frequent drinking among college students and military personnel, including those who were underage.

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The National Response to Underage Drinking1984: Congress enacts National Minimum Drinking Age Act, resulting in national adoption of 21 as minimum legal drinking ageBy 1988: All states had adopted 21 as MLDA

Federal efforts to respond to this public health crisis have been growing since 1984, when the National Minimum Age Drinking Act was enacted.

By 1988, all states had adopted 21 as MLDA

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The National Response to Underage Drinking2001 - 2015Federal calls for coordinated approach to curbing underage drinking involving all levels of government, the alcohol industry and retailers, and community organizations and parents:2003: Reducing Underage Drinking: A Collective Responsibility (National Research Council and Institute of Medicine)2007: Surgeon General's Call to Action to Prevent and Reduce Underage Drinking

- The efforts have intensified since the early 2000s, as the federal government initiated a multipronged national effort to prevent underage drinking that involved federal, state, and local governments as well as community coalitions andorganizations and concerned individuals.

Two significant publications that spurred these efforts:

- 2003: Reducing Underage Drinking: A Collective Responsibility (from the National Research Council and the Institute of Medicine which called for a cooperative effort to curb underage drinking that involved all levels of government, the alcohol industry and retailers, and community organizations and parents; and

- 2007: Surgeon Generals Call to Action to Prevent and Reduce Underage Drinking, which called upon governments, the private sector, and individuals to coordinate efforts to reduce underage drinking.26

The National Response to Underage Drinking

2006: Congress enacts Sober Truth on Preventing (STOP) Underage Drinking Act, Public Law 109-422

In 2006, the Sober Truth on Preventing (STOP) Underage Drinking Act, Public Law 109-422, was enacted.

The three pillars of the STOP Act are:

Interagency Coordinating Committee on the Prevention of Underage Drinking and the production of the Annual Report to Congress;

The National Media Campaign;

Community-Based Initiatives

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Robert M. Vincent (RMV) - use this slide modify for slide 31-34 into one slideInteragency Coordinating Committee on the Prevention of Underage DrinkingA coordinated federal approach to preventing and reducing underage drinking.

Coordinates federal efforts aimed at preventing and reducing underage drinking; Works with governments and organizations at the state, territory, and local levels to reduce and prevent underage drinking and its consequences; andProduces the annual Report to Congress on the Prevention and Reduction of Underage Drinking.

SAMHSA is the lead agency.

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I. Interagency Coordinating Committee on the Prevention of Underage DrinkingSTOP Act directs that ICCPUD shall guide policy and program development across the Federal Government with respect to underage drinking.

Congress mandated the formation of the Interagency Coordinating Committee for the Prevention of Underage Drinking (ICCPUD), composed of representatives from 15 federal agencies.The STOP Act directs that ICCPUD shall guide policy and program development across the Federal Government with respect to underage drinking.

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Interagency Coordinating Committee on the Prevention of Underage Drinking

ICCPUD web portal ICCPUD agencies recent research and resources

www.StopAlcoholAbuse.gov

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Report to Congress on the Prevention and Reduction of Underage Drinking

Annual highlight of ICCPUD federal agency activities to reduce underage drinking;Includes best practices to address the problem of underage drinking; andSummarizes state underage drinking prevention activities.

The National Response to Underage Drinking

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Report on State Programs and Policies Underage drinking prevention programsEnforcement effortsExpenditures on underage drinking prevention

State ReportsState profiles and underage drinking facts

Report to Congress on the Prevention and Reduction of Underage DrinkingThe National Response to Underage Drinking

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The National Response to Underage DrinkingI. STOP Act mandates annual Report to Congress on the Prevention and Reduction of Underage Drinking.

The STOP Act requires the ICCPUD to submit an annual report to Congress on federal underage drinking prevention programs and policies along with data on the prevalence and patterns of underage drinking from federal research surveys and other sources, and

An annual report on state underage drinking prevention and enforcement activities.

Together, these are published as the annual Report to Congress on the Prevention and Reduction of Underage Drinking.33

The National Response to Underage DrinkingII. National Media CampaignGoal of SAMHSAs Center for Substance Abuse Prevention Talk. They Hear You. media campaign:Reduce underage drinking by providing parents and caregivers of children ages 9-15 with information and resources to discuss the issue of alcohol with their children

II. National Media Campaign:

Goal of SAMHSAs Center for Substance Abuse Prevention Talk. They Hear You. media campaign:Reduce underage drinking by providing parents and caregivers of children ages 9-15 with information and resources to discuss the issue of alcohol with their children.

2013: Talk. They Hear You. campaign officially launched with objectives of:

Increasing parents awareness of the prevalence and risk of underage drinking

Equipping parents with the knowledge, skills, and confidence to prevent underage drinking

- Increasing parents actions to prevent underage drinking

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Print PSAs

Scroll through each of the PSAs with enough time for the audience to view.

Remind the audience that the PSAs are on display around the room35

Video PSAs"Mom's Thoughts": 60 second

The National Response to Underage DrinkingIII. Community GrantsSTOP Act provides funding for annual grants to community coalitions working to prevent and reduce underage drinking.In 2012, a total of 81 new grants funded for upcoming 4 years.

- The STOP Act, administered by the Substance Abuse and Mental Health Services Administrations Center for Substance Abuse Prevention, provides funding for annual grants to community coalitions that work to prevent and reduce underagedrinking.

- In 2012, a total of 81 new grants were funded for the upcoming 4 years.37

A Comprehensive Approach to Underage Drinking

Identifying Effective Underage Drinking Prevention Policies is Key

The identification of effective prevention strategies is a key aspect of the national initiative to prevent underage drinking.38

A Comprehensive Approach to Underage DrinkingFEDERALLY SPONSORED RESEARCHCommunity Preventive Services Task Force (Guide to Community Preventive Services. Preventing excessive alcohol consumption, (http://www.thecommunityguide.org/alcohol/index.html)The Surgeon General (The Surgeon Generals Call to Action to Prevent and Reduce Underage Drinking, 2007)IOM (Reducing Underage Drinking: A Collective Responsibility, 2004)NIAAA (Planning Alcohol Interventions Using NIAAAs CollegeAIM Alcohol Intervention Matrix, 2015)

Four distinct federally sponsored or funded sources have synthesized the federally sponsored research on and developed recommendations regarding specific, evidence-based prevention research strategies:

Community Preventive Services Task Force (Guide to Community Preventive Services: Preventing Excessive Alcohol Consumption

The Surgeon General (The Surgeon Generals Call to Action to Prevent and Reduce Underage Drinking, 2007)

Institute of Medicine (Reducing Underage Drinking: A Collective Responsibility, 2004)

NIAAA (Planning Alcohol Interventions Using NIAAAs CollegeAIM Alcohol Intervention Matrix, 2015)39

A Comprehensive Approach to Underage Drinking40

RETAIL AVAILABILITYEnforcement of underage furnishing laws using compliance checks (sting operations)Dram shop liabilityMandatory/discretionary server-seller trainingFalse identification lawsBeer keg registration requirementsSOCIAL AVAILABILITYCriminal or civil liability for hosts of underage drinking partiesSocial host liability PRICINGIncreasing alcohol tax ratesRestrictions on drink specials such as happy hoursFederal efforts to support evidence-based prevention strategies:DRINKING AND DRIVINGGraduated drivers licensesYouth Blood Alcohol Concentration (BAC) Limits

Comprehensive Prevention Programming: A Multilevel ApproachEffective prevention initiatives require coordinated effort among:Federal, state and local policymakersLaw enforcementEducational institutionsHealthcare communityMass mediaConcerned citizens

- There now exists a body of evidence suggesting that effective prevention initiatives require a coordinated effort among a wide array of federal, state, and local organizations and agencies in multiple sectors including policymakers, lawenforcement, educational institutions, the healthcare community, the mass media, and concerned citizens.41

Comprehensive Prevention Programming: A Multilevel ApproachMultilevel approach must use many different strategies:EducationEnforcementPublic awareness/mediaEarly intervention and referral programs

- This multilevel approach must also be multifaceted, employing strategies such as education, enforcement, media, and early intervention in combination to maximize impact on underage drinking.

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Comprehensive Prevention Programming: A Multilevel ApproachEnforcement of Underage Drinking Laws Is CriticalResearch supports the effectiveness of enforcementEnforcement efforts must be maintained or effects will decay over timeMedia campaigns to increase public perception of risk or arrest or sanction can play an important roleResources devoted to enforcement are a determinant of its effectiveness.

Studies that have tested enforcement interventions in relation to outcomes (e.g., incidents of drinking and driving and underage drinking parties) make clear that enforcement can result in greater compliance and better public health outcomes.

Enforcement agencies have a number of strategies at their disposal, including those targeted at individuals (minors in possession arrests, operations to arrest adults who buy alcohol for minors, and underage drinking party patrol operations) and those targeted at retailers (compliance checks, fines, and other sanctions).

However, if enforcement efforts are not maintained, results may decay.

When community-based interventions to prevent underage drinking or other alcohol-related harms include a media campaign, this may increase public perception of the likelihood that the law will be enforced, and that violators will be sanctioned.

A key determinant of enforcement effectiveness is the resources devoted to enforcement actions. 43

ConclusionsMinimum legal drinking age of 21 and increased attention to underage drinking at all levels of society has contributed to meaningful progress in reducing underage drinking.Underage drinking rates are still alarmingly high, especially among 18- to 20-year-olds, and continued prevention efforts are needed.

Conclusions:

- Minimum legal drinking age of 21 and increased attention to underage drinking at all levels of society has contributed to meaningful progress in reducing underage drinking.

- Underage drinking rates are still alarmingly high, especially among 18- to 20-year-olds, and continued prevention efforts are needed.

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Questions for further researchWhat are the most effective combinations of policies and other strategies in reducing underage drinking?What is the minimum level of enhanced enforcement required to produce greater compliance with underage drinking laws?How efficacious is focusing prevention strategies on particular age groups among youth?

To enhance the progress made in reducing underage drinking, future research should address the following questions:

What are the most effective combinations of policies and other strategies in reducing underage drinking?

What is the minimum level of enhanced enforcement required to produce greater compliance with underage drinking laws?

- How efficacious is focusing prevention strategies on particular age groups among youth?

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Questions for further researchDo programs targeting both underage drinking and risky adult drinking have greater effects on underage drinking than just efforts to reduce underage drinking?By reducing underage drinking, will there be carryover benefits in adult life?How can reductions in underage drinking be sustained and increased in the most cost-effective way?

Continued: To enhance the progress made in reducing underage drinking, future research should address the following questions:

Do programs targeting both underage drinking and risky adult drinking have greater effects on underage drinking than just efforts to reduce underage drinking?

By reducing underage drinking, will there be carryover benefits in adult life?

- How can reductions in underage drinking be sustained and increased in the most cost-effective way?

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