Policy Approaches to Reduce Binge Drinking and Impaired

Driving

Toben F Nelson, ScDDivision of Epidemiology and Community HealthUniversity of Minnesota

Learning Objectives:• Describe the problem of underage

drinking within a public health perspective• Describe the value of adopting a public

health perspective to combat underage drinking

• Identify the ways that a public health perspective is unique

• Identify a menu of public health / policy options to reduce underage drinking

Alcohol Misuse

Injuries

Liver disease

Violence, Sexual Assault

Unintended Pregnancies

Cardiovascular disease

Alcohol Use Disorders

RISK FACTOR OUTCOME

Child Neglect

GI cancers, GI disorders

Crime, legal costs

Lost productivity, absenteeism

PERSON

CONSUMPTION

CONSEQUENCE(S)

Consequences of Alcohol

Probabilistic relationship

By drinking event

By drinker

PREVENTION

HARM REDUCTION

Underage drinking is part of a larger societal problem

with alcohol• 3rd leading cause of preventable death

in the US– 4,500 under 21– 79,000 adults

• Youth tend to drink like the adults around them

• The causes are the same• The solutions the same too…

Binge Drinking amongCurrent Drinkers

0

10

20

30

40

50

60

70

18-20 21-25 26-34 35-54 55+

Age Group (years)

Bin

ge

Pre

vale

nce

(%

)

Male Female

Naimi et al., JAMA, (2003)

Percentage of High School Students Who Reported Binge Drinking

* Had five or more drinks of alcohol in a row within a couple of hours on at least 1 day during the 30 days before the survey.

11.5% - 21.8%

21.9% - 23.9%

24.0% - 25.1%

25.2% - 30.7%

No Data

State Youth Risk Behavior Surveys, 2009

Minnesota has a problem

Underage>60 alcohol-attributable deaths annually

• Mostly acute conditions– Motor vehicle crash – Homicide / Suicide

General population>1,100 alcohol-attributable deaths annually

• Both acute and chronic conditions– Abuse/Dependence– Liver disease

Source: Alcohol-Related Disease Impact (ARDI) CDC

Ronald Reagan signs national minimum legal drinking age bill,

July 1984“…raising that drinking age is not a fad or an experiment. It's a proven success. Nearly every State that has raised the drinking age to 21 has produced a significant drop in the teenage driving fatalities.”

-President Ronald Reagan

Policy Success

Effects of Minimum DrinkingAge Laws

Review of 241 published analyses 1960-2000

135 were of high quality• Outcomes

– Alcohol consumption (n=33)– Traffic crashes (n=79)– Other (n=23)

Wagenaar & Toomey, 2002

Effects of Minimum DrinkingAge Laws

Alcohol consumption (n=33)• Higher MDLA – Lower Consumption (n=11; 33%)• Higher MDLA – Higher Consumption (n=1; 3%)

Traffic crashes (n=79)• Higher MDLA – Fewer Traffic Crashes (n=46; 58%) • Higher MDLA – More Traffic Crashes (n=0; 0%)

Other (n=23)• Higher MDLA – Fewer Alcohol-related problems (n=8; 35%)• Higher MDLA – More Alcohol-related problems (n=0; 0%)

Wagenaar & Toomey, 2002

Annual lives saved by 21 MLDA• Based on an average decline in deaths of

13% when individual states raised the MLDA• 890 lives saved in 2006• Total lives saved - more than 25,000

Source: The Monitoring the Future Study, the University of Michigan

Underage Drinking in the U.S.

• 10.8 million youth ages 12-20 years in the U.S. reported past-month drinking in 2004, and 7.4 million reported past-month binge drinking.

• 5,400 children under 16 years start drinking every day in the U.S.

• On average, 12-17 year olds report they began drinking at age 14 years.

Source: Substance Abuse Mental Health Services Administration, National Survey on Drug Use and Health, 2005

Deaths and YPLL among Youth <21 due to Exposure to

Excessive Drinking• 4,500 alcohol-attributable deaths • 274,000 YPLL (60 yrs lost/death)• >95% of deaths and YPLL involved binge

drinking.• 1 of 4 deaths among males and 1 of 6 deaths

among females age 15 to 20 years.• Three-fourths of the deaths involved young

men.

CDC: ARDI Web Site (www.cdc.gov/alcohol), 2007

Onset of drinking

Early start (before age

15) associated with:– Alcohol use – Other substance use– Alcohol-related health and social

consequences– Abuse, Dependence, Alcoholism

…in adulthood

Grant J Stud Alcohol (1997)

Long‐Term Effects of Minimum Drinking Age Laws on Past‐Year Alcohol and Drug Use Disorders

Alcoholism: Clinical and Experimental ResearchVolume 33, Issue 12, pages 2180-2190, 23 SEP 2009 DOI: 10.1111/j.1530-0277.2009.01056.xhttp://onlinelibrary.wiley.com/doi/10.1111/j.1530-0277.2009.01056.x/full#f2

Surgeon General’s Recommendations

• Enforce all policies and laws against underage drinking and publicize these efforts

• Gain public support for enforcing underage drinking laws

Source: Office of the US Surgeon General (2007)

Some Distinctions between Public Health and Medicine

Public Health Medicine

Focus Populations Individuals

Ethic Public Service Personal Service

Emphasis Prevention, Community Health Promotion

Diagnosis & Treatment, Patient Care

Interventions Environment, Behavior, Medical Care

Medical Care

H Fineberg, Harvard School of Public Health, 1990 http://www.hsph.harvard.edu/about.html

The Strategy of Prevention

An example

The Prevention Paradox

• Greatest risk health harms among extreme drinkers.

• HOWEVER, few extreme - many “moderate” drinkers.

• “Moderate” drinking also carries risks• Vast majority of health harms in a community

arise from moderate or low consumption. • Greatest health gains from incrementally

moving majority.

Rose (1985); Rose (1992)

0

5

10

15

20

25

0 1 2 3 4 5 6 7 8 9 ormore

Usual Number of Drinks

Po

pu

lati

on

Per

cen

t

0.00

0.10

0.20

0.30

0.40

0.50

0.60

Ris

k o

f B

ein

g H

urt

or

Inju

redPopulation Percent Risk ofHarm

Risk of injury, by usual number of drinks (past 30 days)

Weitzman & Nelson (2004)

Evidence for findings regardless of:• consumption measure

– Usual drinks– Drinking frequency– Frequency of drunkenness

• Negative social/health consequence– 14 different outcomes– Only the risk trajectory varied

The Prevention Paradox

Weitzman & Nelson (2004); Wechsler & Nelson (2006)

The Prevention Paradox

“A prevention measure that brings large benefits to the community affords little to each participating individual”

Geoffrey Rose , 1998

High-risk & Population Approaches

• High-risk: change extreme, high-risk individuals, treatment

• Population: change majority, the conditions that shape everyone’s behavior.

High-Risk Approach

Advantages• Intervention

tailored/targeted to the individual

• Clear benefits (when achieved) to the individual

• Intuitive

Disadvantages• Difficult & costly to ID “at-

risk”

• Effects palliative, temporary

• Low odds success

• Modest benefit to the population

Population Approach

Advantages• Large population benefits

• Broad target audience

• Longer lasting effects

Disadvantages• May limit personal

freedoms

• Resistance from invested parties

• Counter-intuitive

High-Risk & Population Approaches Not

Mutually Exclusive

You Can Do Both

Social Ecology of Drinking

What are some mutable factors that can shift the population

distribution?

Underage drinking

Adult drinking

EnvironmentalConditions

Integrated theory of drinking behavior

Public Policy & Institutional

Policies/Structures

Legal Availability

Formal Social Controls

Economic Availability

Physical Availability

Individual Risk Factors

Drinking Behavior

Alcohol-related Problems

Adapted from Wagenaar & Perry, 1994

Problems that stem from alcohol use are primarily a function of

availability

Public Health Triad

AgentHost

Environment

Knowledge

Attitudes

Intentions

Skills

Pricing

Composition

Labeling

Packaging

Person Drug

Advertising/Promotion

Physical Context

Availability

SocioculturalContext

Institutions

Legal Sanctions

KeyInfluencers

Drug-Related Problems

Environment

Torjman (1986)

Intervening to Reduce Alcohol-related Motor Vehicle Crashes

Alcohol-

Related

MV

Death

DWI

Arrest/

Conviction

Alcohol-

Related

MV

Injury

Alcohol-

Related

MV

Crash

Alcohol-

Impaired

Driving

Binge

Drinking

Any

Drinking

Regulating price

Regulating access

Altering the drinking context

Advertising content control

Education and persuasion

Drinking driver countermeasures

Treatment and early intervention

Assessing the State Alcohol Policy

Environment in the United States

Percentage of High School Students Who Reported Binge Drinking

* Had five or more drinks of alcohol in a row within a couple of hours on at least 1 day during the 30 days before the survey.

11.5% - 21.8%

21.9% - 23.9%

24.0% - 25.1%

25.2% - 30.7%

No Data

State Youth Risk Behavior Surveys, 2009

Policy Environment

Youth Alcohol Pattern

- 5+ (binge) drinking- Freq. 5+ drinking- Current drinking- Freq. current drinking- Drinking/Driving

Youth-Specific Policies

Adult Alcohol Pattern- 5+ (binge) drinking- Freq. 5+ drinking- Heavy drinking- Total drinks- Current drinking

Adult-Oriented (i.e., population-based)

Policies

http://www.epi.umn.edu/alcohol