Prevention of Prevention of Underage Drinking Underage Drinking Problems Problems Ralph Hingson, ScD Ralph Hingson, ScD Director, Division of Epidemiology and Prevention Director, Division of Epidemiology and Prevention Research Research National Institute on Alcohol Abuse and Alcoholism National Institute on Alcohol Abuse and Alcoholism Preventing Underage Alcohol Use: A National Meeting of the States Sponsored by the Interagency Coordinating Committee for the Prevention of Underage Drinking October 31, 2005
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Prevention of Underage Drinking Problems Prevention of Underage Drinking Problems Ralph Hingson, ScD Director, Division of Epidemiology and Prevention.
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Prevention of Underage Prevention of Underage Drinking ProblemsDrinking Problems
Ralph Hingson, ScDRalph Hingson, ScDDirector, Division of Epidemiology and Prevention ResearchDirector, Division of Epidemiology and Prevention Research
National Institute on Alcohol Abuse and AlcoholismNational Institute on Alcohol Abuse and Alcoholism
Preventing Underage Alcohol Use: A National Meeting of the States
Sponsored by the Interagency Coordinating
Committee for the Prevention of Underage Drinking
October 31, 2005
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Dr. Margaret Jonathan Travis
Moore Levy Stedman
Magnitude of Alcohol Problems on U.S. College Campuses
Hingson et al. (2002) J. Studies on Alcohol
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InterventionsInterventions
Individually orientedIndividually oriented FamilyFamily SchoolSchool EnvironmentalEnvironmental Comprehensive Community Comprehensive Community
InterventionsInterventions
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Brief Motivational Alcohol Brief Motivational Alcohol Intervention in a Trauma CenterIntervention in a Trauma Center
46% of injured trauma center patients 46% of injured trauma center patients age 18 and older screened positive for age 18 and older screened positive for alcohol problems.alcohol problems.
Half (N=336) randomly allocated to Half (N=336) randomly allocated to receive 30 minute brief intervention to receive 30 minute brief intervention to reduce risky drinking and offers links to reduce risky drinking and offers links to alcohol treatmentalcohol treatment
Source: Gentilello Source: Gentilello Annals of SurgeryAnnals of Surgery, 1999, 1999
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Brief Motivational Alcohol Brief Motivational Alcohol Intervention in a Trauma CenterIntervention in a Trauma Center
Results:Results: Reduced alcohol consumption by an average Reduced alcohol consumption by an average
21 drinks per week at 1 year follow up21 drinks per week at 1 year follow up 47% reduction in new injuries requiring 47% reduction in new injuries requiring
treatment in EDtreatment in ED 48% reduction in hospital admissions for 48% reduction in hospital admissions for
injury over 3 yearsinjury over 3 years 23% fewer drunk driving arrests23% fewer drunk driving arrests
Source: Gentilello Source: Gentilello Annals of SurgeryAnnals of Surgery, 1999, 1999
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Brief Alcohol Intervention Brief Alcohol Intervention for Older Adolescents for Older Adolescents
94 ED patients, mean age 18.4, injured after drinking94 ED patients, mean age 18.4, injured after drinking Half randomly allocated to a 35-40 minute motivational Half randomly allocated to a 35-40 minute motivational
intervention to reduce drinking and related risky intervention to reduce drinking and related risky behaviors such as DWIbehaviors such as DWI
Results at six months:Results at six months: Brief intervention group had Brief intervention group had
– ¼ drinking and driving occasions¼ drinking and driving occasions
– Fewer moving violations 3% vs. 23%Fewer moving violations 3% vs. 23%
– ¼ alcohol related injuries¼ alcohol related injuries
Source: Monti et al. Source: Monti et al. J. Consulting and Clinical Psychology J. Consulting and Clinical Psychology (1999)(1999)
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Fifteen Studies Provide Strong Fifteen Studies Provide Strong Support for the Efficacy of This Support for the Efficacy of This
Approach Among College StudentsApproach Among College Students
Barnett et al. 2004Barnett et al. 2004 Borsari and Carey Borsari and Carey (in press)(in press)
Labrie 2002Labrie 2002 Gregory 2001Gregory 2001 LaChance 2004LaChance 2004 Murphy et al. 2001Murphy et al. 2001 Murphy et al. 2004Murphy et al. 2004
Source: Larimer and Cronce (2002, 2005 In Review)
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Fewer thanFewer than– ½ of pediatricians screen all adolescents for ½ of pediatricians screen all adolescents for
use of alcohol and drugsuse of alcohol and drugs– ¼ screen for drinking and driving.¼ screen for drinking and driving.
Pediatric Medical Care Providers considerably Pediatric Medical Care Providers considerably underdiagnose alcohol use, abuse, and underdiagnose alcohol use, abuse, and dependence among patients ages 14-18.dependence among patients ages 14-18.
1.5 million 12-17 year olds need alcohol 1.5 million 12-17 year olds need alcohol treatmenttreatment
Only 216,000 14% received treatmentOnly 216,000 14% received treatmentSources: American Academy of Pediatrics, 1997; Wilson, Sheritt, Gates, Knight Wilson, Sheritt, Gates, Knight Pediatrics,Pediatrics, 2004; National Household Survey on Drug Use and Health, 2003 2004; National Household Survey on Drug Use and Health, 2003
Implementation Gap
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Insurers’ Liability for Losses Insurers’ Liability for Losses Due to IntoxicationDue to Intoxication
As of January 1, 2004As of January 1, 2004
28 States and DC allow with holding of medical reimbursement if injured under the influence
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Family InterventionsFamily Interventions Iowa Strengthening Families Program Iowa Strengthening Families Program
Goals:Goals: Improve parent/child relationsImprove parent/child relations Strengthen family communication skills Strengthen family communication skills Increase child coping skillsIncrease child coping skills
Implementation:Implementation: 7 sessions at school7 sessions at school 13 hours total13 hours total Parent and child separately and togetherParent and child separately and together
Lifetime Drunkenness Through 6 Years Past Baseline:
Logistic Growth Curve
A randomized controlled trial with families of 6th graders: Iowa Strengthening Families Program (ISFP) (206 families)Iowa Strengthening Families Program (ISFP) (206 families) Preparing for Drug Free Years Program (PDFYP) (221 families) Control (221 families)
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School Based ProgramsSchool Based Programs Programs that rely primarily on increasing knowledge Programs that rely primarily on increasing knowledge
about consequences of drinking about consequences of drinking are not effective.are not effective.
Effective Programs :Effective Programs :– Are based on social influence modelsAre based on social influence models– Include norm settingInclude norm setting– Address social pressures to drink and teach resistance skillsAddress social pressures to drink and teach resistance skills– Include developmentally appropriate informationInclude developmentally appropriate information– Include peer-led componentsInclude peer-led components– Provide teacher trainingProvide teacher training– Are interactiveAre interactive
School only program effects are generally smallSchool only program effects are generally small
Less effective with students who initiate drinking prior to Less effective with students who initiate drinking prior to grades 5 or 6grades 5 or 6
Source: NIAAA, Alcohol and Development in Youth: A Multidisciplinary OverviewSource: NIAAA, Alcohol and Development in Youth: A Multidisciplinary Overview
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School Based Life Skills ProgramSchool Based Life Skills Program Junior High- 30 sessions, most in Year 1Junior High- 30 sessions, most in Year 1
Curricula:Curricula:Drug InformationDrug InformationAlcohol/Drug Resistance SkillsAlcohol/Drug Resistance SkillsSelf Management SkillsSelf Management SkillsGeneral Social SkillsGeneral Social Skills
Results:Results:Beneficial EffectsBeneficial EffectsAlcohol & Tobacco UseAlcohol & Tobacco Use
Through High School, Not AfterThrough High School, Not AfterSources: Botvin et al. Sources: Botvin et al. J. Consulting and Clinical PsychologyJ. Consulting and Clinical Psychology (1990); (1990); JAMA JAMA
Combined Family Interventions& School Based Life skills Program
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 cFamily and school interventions combinedombined are more effective than are more effective than school interventions onlyschool interventions only
Source: Spoth, et al Psychology of Addictive Behaviors (In Press)
Randomized controlled trial of 7th graders from 36 rural schools:
ISFP ISFP Plus Life Skills Training (n=549) Life Skills Training Only (n=517) Control (n=453)
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Environmental ApproachesEnvironmental Approaches
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Drinking Trends AmongDrinking Trends AmongHigh School Seniors, 1975-2003High School Seniors, 1975-2003
0102030405060708090
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Source: Monitoring the Future, 2004
Federal 21 drinking age
Drinking age 21 in all States
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Trends in Alcohol Related and Non Alcohol Related Traffic Fatalities persons 16-20 U.S. - 1982-2004
Legal Drinking Age ChangesLegal Drinking Age Changes
CDC reviewed 49 studies published in CDC reviewed 49 studies published in scientific journalsscientific journals
Alcohol-Related Traffic Crashes:Alcohol-Related Traffic Crashes:- - IncreasedIncreased 10% when the drinking age was 10% when the drinking age was
loweredlowered
- - DecreasedDecreased 16% when the drinking age was 16% when the drinking age was raisedraised
Source: Shults et al., American Journal of Preventive Medicine, 2001
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Cumulative Estimated Number of Lives Cumulative Estimated Number of Lives Saved by the Minimum Drinking Age Laws Saved by the Minimum Drinking Age Laws
Source: National Highway Traffic Safety Administration
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10 Reasons for 10 Reasons for Legal Drinking Age of 21Legal Drinking Age of 21
Alcohol-related traffic Alcohol-related traffic fatalities and injuriesfatalities and injuries
Other unintentional Other unintentional injuries (falls, injuries (falls, drownings, burns)drownings, burns)
Homicide and assaultHomicide and assault Sexual assaultSexual assault
SuicideSuicide STDs, HIV/AIDSSTDs, HIV/AIDS Unplanned pregnancyUnplanned pregnancy Alcohol dependenceAlcohol dependence Teen drug useTeen drug use Poor academic Poor academic
performanceperformance
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Source: Grant and Dawson J. Substance Abuse (1997)
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PurposePurpose
To assess whether an earlier drinking onset To assess whether an earlier drinking onset is related to:is related to:
Unintentional injuries under the influence Unintentional injuries under the influence of alcoholof alcohol
Motor vehicle crashes because of drinkingMotor vehicle crashes because of drinking Physical fights after drinkingPhysical fights after drinking
- ever in the respondent’s life- ever in the respondent’s life
- during the year prior to the survey - during the year prior to the survey
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Micheal Timothy Wilder
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Ever in a Physical Fight While or After Drinking Ever in a Physical Fight While or After Drinking According to Age of Drinking Onset, National According to Age of Drinking Onset, National
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<.001Age Started
Drinking
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Why Are These Findings Why Are These Findings Important?Important?
Injuries are the leading cause of Injuries are the leading cause of death among youth 1-44death among youth 1-44
Successful Comprehensive Successful Comprehensive Community InterventionsCommunity Interventions
Project Northland Perry (1996)Project Northland Perry (1996) Communities Mobilizing for Change Communities Mobilizing for Change
Wagenaar (2002)Wagenaar (2002) Community Trials Holder (2000)Community Trials Holder (2000) A Matter of Degree Weitzman (2004) A Matter of Degree Weitzman (2004) Fighting Back Hingson (2005)Fighting Back Hingson (2005) Saving Lives Program Hingson (1996)Saving Lives Program Hingson (1996) Clapp et al. (2005)Clapp et al. (2005)
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Project Northland
Intervention to prevent or reduce alcohol use Intervention to prevent or reduce alcohol use among 6, 7, and 8among 6, 7, and 8thth grade students grade students– School Education Programs (general program School Education Programs (general program
each grade)each grade)– Parent InvolvementParent Involvement– Peer ParticipationPeer Participation– Community task forces to engage citizensCommunity task forces to engage citizens
Compliance ChecksCompliance Checks Server TrainingServer Training Ordinances Ordinances
Source: Perry C. et al. American Journal of Public Health, 1996;Perry C. et al. Health Education Research, 2002.
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Project Northland
Results:Results:
3 Years Later3 Years Later– Drinking 50% lower among baseline non-drinkers Drinking 50% lower among baseline non-drinkers
(5% vs 10%)(5% vs 10%)– Lower rates of cigarette and marijuana useLower rates of cigarette and marijuana use– Monthly and weekly drinking 20-30% lower Monthly and weekly drinking 20-30% lower
among entire sampleamong entire sample
Grades 11 & 12Grades 11 & 12– Fewer Northland students drink 5+Fewer Northland students drink 5+– 80% reduction in youth ability to purchase 80% reduction in youth ability to purchase
alcohol (Off Sale)alcohol (Off Sale)
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Communities Mobilizing for Change Interventions to Reduce AvailabilityInterventions to Reduce Availability::
– Merchants record underage buy attemptsMerchants record underage buy attempts– Beer kegs prohibited at University Beer kegs prohibited at University
HomecomingHomecoming– Policies to discourage motels from permitting Policies to discourage motels from permitting
underage drinking partiesunderage drinking parties– Security at high school dancesSecurity at high school dances– Model local ordinances to restrict underage Model local ordinances to restrict underage
access to alcohol access to alcohol – Compliance checksCompliance checks
Source: Wagenaar et al., J. Studies on Alcohol, 2000
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Communities Mobilizing for Change
Results::
-17% increase in outlets checking age ID-17% increase in outlets checking age ID
-24% decline in bar and restaurant sales-24% decline in bar and restaurant sales
-25% decrease in the proportion of 18-20 year olds-25% decrease in the proportion of 18-20 year olds
-17% decline in the proportion of older teens -17% decline in the proportion of older teens
providing alcohol to younger teensproviding alcohol to younger teens
-7% decrease in the percent under 21 who drank-7% decrease in the percent under 21 who drank
-14% decline in alcohol traffic injuries, drivers 18-20-14% decline in alcohol traffic injuries, drivers 18-20
Source: Wagenaar et al., J. Studies on Alcohol, 2000
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Community TrialsIntervention:
Reduce youth alcohol availability Drinking and driving enforcement Alcohol outlet density reduction Community mobilization & media Advocacy Responsible alcohol service
Results:Results:– Self reported DWI cut in halfSelf reported DWI cut in half– 10%-11% decrease in single vehicle night crashes10%-11% decrease in single vehicle night crashes– 43% decrease in emergency department alcohol 43% decrease in emergency department alcohol
related assault admissionsrelated assault admissions
“Mountain of Beer”
Source: Holder et al., JAMA (2000)
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A Matter of Degree Intervention Components:Intervention Components:
– College/ Community PartnershipsCollege/ Community Partnerships
– Environmental strategies to reduce Environmental strategies to reduce drinking problems:drinking problems:– Keg registrationKeg registration– Mandatory responsible beverage serviceMandatory responsible beverage service– Police wild party enforcementPolice wild party enforcement– Substance free residence hallsSubstance free residence halls– Advertising bansAdvertising bans
Source: Weitzman et al. American Journal of Preventive Medicine. 2004
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A Matter of Degree
Results:Results: Achieved reductions among college Achieved reductions among college
students instudents in– Binge drinkingBinge drinking– Driving after drinkingDriving after drinking– Alcohol related injuriesAlcohol related injuries– Being assaulted by other drinking college Being assaulted by other drinking college
studentsstudents
Source: Weitzman et al. American Journal of Preventive Medicine 2004
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Fighting Back ProgramFighting Back Program
First Community Program to combine:First Community Program to combine:
Environmental interventions to limit Environmental interventions to limit alcohol availabilityalcohol availability
Efforts to increase substance abuse Efforts to increase substance abuse treatmenttreatment
Source: Hingson et al. Injury Prevention (2005)
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Fighting Back Program Fighting Back Program Selected InterventionsSelected Interventions
Limit Alcohol AvailabilityLimit Alcohol Availability Youth access compliance check surveysYouth access compliance check surveys Responsible beverage service trainingResponsible beverage service training Monitoring and closing problem liquor outletsMonitoring and closing problem liquor outlets Bill board restrictionsBill board restrictions
Expand TreatmentExpand Treatment Sales tax increase for expanded treatmentSales tax increase for expanded treatment New treatment programs- courts, jails, health care New treatment programs- courts, jails, health care
agencies, public housingagencies, public housing Emergency department screening/brief interventionsEmergency department screening/brief interventions New inpatient, outpatient and recovery programsNew inpatient, outpatient and recovery programsSource: Hingson et al. 2005
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Fighting Back - ResultsGreater Relative Reduction in Alcohol-Related Fatal
Crashes VS Fatal Crashes with Zero BAC
Communities: Kansas City, MO, Milwaukee, WI, San Antonio, TX, Santa Barbara, CA, and Vallejo, CA
Courtney Birch
Pooled Pooled EffectsEffects
BAC .01%+ BAC .01%+
vs Zero BAC vs Zero BAC
DriversDrivers All AgesAll Ages 16-2016-20
5 FB sites 5 FB sites vs controlsvs controls
22%22%
P=.01P=.01
26%26%
P=.08P=.08
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ConclusionsConclusionsResearch indicates reductions in Underage Research indicates reductions in Underage Drinking and Related Problems can be Drinking and Related Problems can be achieved with Interventions that focus onachieved with Interventions that focus on
Interventions targeting multiple levels are Interventions targeting multiple levels are more effectivemore effective
Comprehensive community interventions Comprehensive community interventions address underage drinking at multiple levelsaddress underage drinking at multiple levels
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ConclusionsConclusions
Community Level Interventions can includeCommunity Level Interventions can include
- Coordination of multiple city departments- Coordination of multiple city departments- Clear measurable objectives and strategic - Clear measurable objectives and strategic
plansplans- Combine education and enforcementCombine education and enforcement- Treatment programsTreatment programs- Use of data to plan and evaluate- Use of data to plan and evaluate- Involvement of private citizensInvolvement of private citizens- Youth involvement (be inclusive)Youth involvement (be inclusive)
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AcknowledgementsAcknowledgements
NIAAA staff who assisted with this presentationNIAAA staff who assisted with this presentation
Panel DiscussionPanel DiscussionModeratorModeratorFaye Calhoun, Sc.D.Faye Calhoun, Sc.D.Deputy DirectorDeputy DirectorNational Institute on Alcohol Abuse and AlcoholismNational Institute on Alcohol Abuse and Alcoholism
PanelistsPanelistsHarold Holder, Ph.DHarold Holder, Ph.DSenior Research ScientistSenior Research ScientistPrevention Research CenterPrevention Research Center
John Knight, MDJohn Knight, MDAssociate Professor of Pediatrics, Harvard Medical SchoolAssociate Professor of Pediatrics, Harvard Medical SchoolDirector, Center for Adolescent Substance Abuse Research, Children's Director, Center for Adolescent Substance Abuse Research, Children's
Hospital, Boston Hospital, Boston
Kelli A. Komro, MPH, Ph.D.Kelli A. Komro, MPH, Ph.D.Associate Professor, Department of Epidemiology and Health Policy ResearchAssociate Professor, Department of Epidemiology and Health Policy ResearchInstitute for Child Health Policy, University of FloridaInstitute for Child Health Policy, University of Florida