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Underage Drinking: Frequency, Consequences, andInterventionsRALPH W. HINGSON a , JEAN-PASCAL Assailly b & ALLAN F. WILLIAMS ca Boston University School of Public Health , Boston, Massachusetts, USAb National Institute for Transport and Safety Research (INRETS) , Arcueil, Francec Insurance Institute for Highway Safety , Arlington, Virginia, USAPublished online: 11 Aug 2010.

To cite this article: RALPH W. HINGSON , JEAN-PASCAL Assailly & ALLAN F. WILLIAMS (2004) Underage Drinking: Frequency,Consequences, and Interventions, Traffic Injury Prevention, 5:3, 228-236, DOI: 10.1080/15389580490465256

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Traffic Injury Prevention, 5:228–236, 2004Copyright C©© 2004 Taylor & Francis Inc.ISSN: 1538-9588 print / 1538-957X onlineDOI: 10.1080/15389580490465256

Underage Drink ing: Frequency, Consequences,and Intervent ions

RALPH W. HINGSONBoston University School of Public Health, Center to Prevent Alcohol Problems Among Young People, Boston,Massachusetts, USA

JEAN-PASCAL ASSAILLYNational Institute for Transport and Safety Research (INRETS), Arcueil, France

ALLAN F. WILLIAMSInsurance Institute for Highway Safety, Arlington, Virginia, USA

Objectives: To examine the frequency of underage drinking, driving after drinking and alcohol-related crashes, trends inthese behaviors, and promising interventions.Methods: We examined drinking and drinking- and-driving behaviors reported in the United States in the 2001 U.S. NationalHousehold Survey of Drug Abuse, the Centers for Disease Control and Prevention 2001 Youth Risk Behavior Survey, the1992 National Longitudinal Alcohol Epidemiologic Study, and the 1999 National Survey of Drinking and Driving conductedfor the National Highway Traffic Administration. We also examined the 1999 European School Survey Project on Alcoholand Other Drugs. Alcohol-related fatal crashes were examined from the U.S. Fatality Analysis Reporting System. Evaluationof interventions to reduce teenage drinking and driving after drinking were reviewed.Results: In the United States, 19% of youth ages 12–20 consumed five or more drinks on an occasion in the past 30 days.Although European nations have lower legal drinking ages (16–18) than in the United States (21), similar proportions engagein underage drinking. In two-thirds of European countries, a greater percentage of 15–16 year-olds drank five or more drinkson an occasion in the past month than in the United States. In both the United States and Europe, the earlier people begin todrink, the greater the likelihood of developing alcohol dependence and other alcohol-related problems, including alcohol-related crash involvement, during adolescence and adult years. During the past 20 years alcohol-related traffic deaths amongpeople younger than 21 have been cut in half in the United States, but progress has halted since 1995 and the problem is stilllarge. Interventions shown by research to reduce alcohol-related crashes among youth include raising the legal drinking ageto 21, zero tolerance laws, and some interventions that are family, school, or community based.Conclusions: Despite research showing that a variety of interventions can reduce underage drinking and alcohol-relatedcrash fatalities, the frequency of these behaviors remains high and the average age of drinking initiation is declining in theUnited States. Efforts are needed to enhance publicized enforcement of underage drinking laws. Comprehensive communityinterventions that include enforcement of these laws also are needed.

Keywords Underage Drinking; Alcohol-Related Traffic Crashes; Laws; Minimum Drinking Age; Education; CommunityPrograms; Enforcement

This article assesses the drinking behavior and drinking-and-driving behavior of underage youth in the United States.European data are included when available. Motor vehicle-related deaths associated with underage drinking, and trendsin alcohol-related deaths are indicated. Selective interventionsare presented that are specific to underage drinkers and showpromise in reducing underage drinking and/or driving after drink-ing or alcohol-related crashes. For the full range of interventions

Received 31 January 2004; accepted 28 March 2004.Address correspondence to Ralph W. Hingson, Boston University School of

Public Health, Social and Behavioral Sciences Department, 715 Albany Street,TW2, Boston, MA 02118, USA. E-mail: rhingson@bu.edu

applicable to underage drinking and its consequences, see thecomprehensive National Research Council report on this topic(NAS, 2003).

DRINKING BY UNDERAGE YOUTH

The minimum legal drinking age is 21 in all U.S. states,whereas in European countries it is 16–18. Underage drinkingis frequent in all countries for which data were available.

According to the 2002 National Household Survey on DrugAbuse in the United States, 29% of people ages 12–20 drankalcohol in the past 30 days. Nineteen percent consumed at leastfive or more drinks on an occasion in the past 30 days, and 6%

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consumed five or more drinks at least five or more times in thepast 30 days. People ages 18–20 were the most likely to drink.Just more than half of 18–20 year-olds drank in the past month,30% reported consuming five or more drinks at least once in thepast 30 days, and 13% reported consuming five or more drinkson at least five occasions in the past 30 days.

The Centers for Disease Control and Prevention’s NationalYouth Risk Behavior Surveillance System (YRBSS) examineda national random sample of high school students in the UnitedStates, nearly all of whom were ages 14–18 (Grunbaum et al.,2002). The survey showed that 78% drank alcohol at some pointin their lives, and 47% had drunk alcohol in the past 30 days.Thirty-four percent drank five or more drinks within a two-hour period at least once in the previous 30 days. Nearly 7%drank five or more drinks on at least six occasions in the past30 days.

The lower drinking ages in Europe do not result in less un-derage drinking. A recent survey of European youth age 15–16in 29 countries used identical questions as in the U.S. NationalMonitoring the Future Study of 10th graders. In all but one coun-try in Europe (Portugal) a greater percentage of 15–16 year-oldsdrank alcohol than U.S. respondents of the same age. In morethan two-thirds of the European countries a greater percentageof 15–16 year-olds drank five or more drinks on an occasion inthe past two weeks (NAS, 2003).

The major source of European data on this issue is theEuropean School Survey Project on Alcohol and Other Drugs(ESPAD), implemented in 30 European countries. This is a pop-ulation survey of psychoactive substance use (alcohol, tobacco,illicit drugs) among Europeans age 16, born in 1983 (Hibellet al., 1997, 2000).

ESPAD reveals differences among European countries. Forexample, occasional drinkers (drank at least 10 times in the pastyear) are more prevalent in Denmark (72% of 16 year-olds),the United Kingdom (56%), and Ireland (56%); they are lessprevalent in Hungary (20%) and France (27%). Regular drinkers(drank more than 10 times in the last month) are more prevalentin Denmark (18%), the United Kingdom (16%), Ireland (16%),and France (8%); they are less prevalent in Sweden (2%), Finland(1%), and Iceland (1%), reflecting the effects of strict policiesregarding alcohol in these countries. Binge drinking (more than5 drinks on an occasion and more than 3 times in the past month)is more prevalent in Ireland (31%), Poland (31%), and Denmark(30%); it is less prevalent in France (12%), Portugal (6%), andRomania (5%).

AGE OF FIRST DRINKING

According to the 2001 National Household Survey on DrugUse, the mean age of first alcohol use dropped in the UnitedStates from 17.4 in 1980 to 15.9 in 1999. YRBSS indicates 29%of high school students started to drink before age 13.

Scottish and French studies estimate around 12–13 as the ageof first alcohol use. ESPAD found that the average age for firstuse was 13.6 for French girls and 13.1 for French boys.

Studies in both the United States and Europe have indicatedthat early onset of alcohol use is a predictor of problems withalcohol later in life. The 1992 National Longitudinal AlcoholStudy (NLAES) survey interviewed 42,816 adults ages 18 andolder (response rate 90%). Included in the survey were questionsfrom the Alcohol Use Disorders and Associated Disabilities In-terview Schedule Grant and Hasin (1992) to determine whetherrespondents could be diagnosed with alcohol dependence or al-cohol abuse based on criteria from the Diagnostic and StatisticalManual, Fourth Edition (APA, 1994).

NLAES data showed that the younger respondents were whenthey first began to drink alcohol, the more likely they were todevelop alcohol dependence Grant (1998). Among both malesand females and people with and without a family history ofalcoholism, more than 40% of those who began drinking priorto age 14 developed alcohol dependence. They were at leastthree times more likely to develop alcohol dependence duringtheir lives than those who waited until age 21 or older to drinkGrant (1998).

French epidemiological studies Choquet et al. (2003) alsoidentify increased risks associated with starting to drink at ayounger age. Early use is associated with heavier drinking pat-terns or problem behaviors later in life. Early drunkenness also isa predictor of school drop out, delinquent behavior, anddepression.

Hingson et al. (2002) reported that persons who begin drink-ing at age 14 or younger relative to those who start at age 21or older are seven times more likely to be in a motor vehiclecrash because of their drinking alcohol both during adolescenceand adult years. While much of the increased risk of being in analcohol-related crash while an adult among those who starteddrinking at a young age results from their increased risk ofalcohol dependence, a significantly greater risk of alcohol re-lated crash involvement among non-alcohol–dependent adultswas identified even after controlling analytically for age, gen-der, race, ethnicity, years of drinking, family history, education,marital status, and other factors associated with starting to drinkat age 14 or younger Hingson et al. (2002).

DRIVING AFTER DRINKING AMONG PEOPLEYOUNGER THAN 21 IN THE UNITED STATES

The National Survey of Drinking and Driving conducted forthe National Highway Traffic Safety Administration (NHTSA)in 1999 estimated that in the United States, drivers ages 16–20drove 12 million times in the preceding year within two hours ofdrinking (NHTSA, 2000). When NHTSA calculated the aver-age blood alcohol concentration (BAC) of drivers on their mostrecent drinking-and-driving trips—based on weight, hours ofdrinking, gender, volume of consumption, length of drinkingepisode, and time since last drink—the average calculated BACfor 16–20-year-old drivers was 0.10%, more than three timesthe BAC of drivers of all ages who drove after drinking. Thus16–20 year-olds accounted for 12% of the 80 million trips drivenin the year by drivers with BACs of 0.10% or higher.

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MOTOR VEHICLE DEATHS ASSOCIATEDWITH UNDERAGE DRINKING

Young drivers drink and drive less than older drivers, but theircrash risk is higher when they do drink and drive, particularly atlow BACs (Mayhew et al., 1986; Voas et al., 1998; Zador et al.,2000). Compared with adults they are relatively inexperiencedat driving, at drinking, and in combining these two activities.Each percentage point increase in BAC increases the fatal crashrisks for drivers younger than 21 more than it does for olderdrivers. Epidemiologic research comparing drivers in single-vehicle fatal crashes with drivers operating motor vehicles atsimilar times on the same roadway who were not involved in fatalcrashes has revealed that each 0.02% increase in BAC nearlydoubles the risk of single-vehicle fatal crash involvement, andthe risk of death increases more with each drink more for youngerdrivers than it does for drivers older than 21 (Zador, 1991). Amore recent analysis found that in all age and gender groups,there was an 11-fold increased risk of single-vehicle fatal crashinvolvement at a BAC of 0.08% relative to zero. However, formale drivers 16 to 20, there was a 52-fold increased single-vehicle fatal crash risk Zador et al. (2000).

In 2002, 25% of fatally injured drivers younger than 21 hadBACs of 0.08 percent or greater. NHTSA (2003) also has es-timated that in 2002, 4% of drivers younger than 21 were inalcohol-related injury crashes and 3% were in alcohol-relatedproperty damage crashes.

TRENDS IN ALCOHOL-RELATED FATAL CRASHESIN THE UNITED STATES

Over the past two decades, alcohol-related traffic deaths havedeclined among all age groups, but the decline has been greatestamong those younger than 21. Overall there has been a 33% de-cline in alcohol-related traffic deaths nationwide, from 26,172in 1992 to 17,419 in 2002. During the same time non-alcohol-related traffic deaths increased 43%, from 17,772 to 25,396with more drivers and miles driven. Among 16–20-year-olds,alcohol-related traffic deaths declined 56%, from 5,244 in 1982to 2,329 in 2002.

Data from the Monitoring the Future annual national surveyof high school seniors reveal that from 1976 to 1982 self-reportedinvolvement in alcohol-related traffic crashes after drinking in-creased 25%, but from 1982 to 2001 they were cut in half. Ticketsfor DWI also increased among high school seniors from 1976to 1982 but have been more than cut in half from 1982 to 2001O’Malley and Johnston (2003). U.S. National Roadside Surveydata have shown that the percentage of drivers younger than 21with BACs of 0.10% or more dropped from 4.1% in 1973 to2.7% in 1986 and to 0.3% in 1996 (Voas et al., 1998).

Unfortunately since 1995 progress in reducing alcohol-related fatal crashes among 16–20 year-olds has stalled. Thepercent of fatally injured 16–20 year-olds with BACs of 0.08%or greater has been between 24% and 28% (25% in 2002) since1995.

INTERVENTIONS TO REDUCE UNDERAGE DRINKINGAND ALCOHOL-RELATED CRASHES

Research to date suggests that a variety of interventions caneither delay onset of drinking or reduce heavy problematic drink-ing, driving while intoxicated, and alcohol-related crash involve-ment among people younger than 21. These interventions may beaimed primarily at 16–20 year-olds or at younger individuals,beginning in elementary school. Three levels of interventionscan achieve such results:

• Interventions that target changes in individual knowledge, at-titudes, and beliefs about alcohol and alcohol-related problembehaviors.

• Interventions that reduce availability of alcohol in the envi-ronment of people younger than 21, and reduce driving afterdrinking.

• Comprehensive community interventions that organize mul-tiple departments of city government police, health, educa-tion, alcohol beverage control, etc. with private citizens andorganizations and that employ multiple types of education, en-forcement and clinical interventions (Hingson and Howland,2002).

Family InterventionsSpoth et al. (2001) tested the effects of two different interven-tions designed for families of young adolescents to see if theywould delay initiation and lower their amount of alcohol, to-bacco, and marijuana use. From 33 schools, 667 families of sixthgraders (51% of those eligible) were randomly assigned to eithera control group (N = 208), to the seven-session Iowa Strength-ening Families Program (ISFP) (N = 238), or to the Prepar-ing for Drug Free Years Program (PDFYP) (N = 221). PDFYPwas based on the Social Development Model of Catalano andHawkins (1996) and Hawkins and Weis (1985), which positsthat bonding to prosocial others is protective against adolescentsubstance abuse. The program stresses integration of childreninto family activities and rewarding behaviors that conform tofamily rules and expectations. Parents are trained to reward chil-dren for positive family involvement and interaction establish-ing child expectations, careful monitoring and appropriate dis-cipline, and managing family conflict. This program is deliveredin 5 two-hour sessions held on weekday evenings in schools ingroups of 10 families.

ISFP is based on the bio-psychosocial model Demarsh andKumpfer (1986). The program seeks to reduce poor disciplineskills and poor quality of parent-child relationships. It requiresseven sessions held on weekday evenings in school. Concurrentsessions for parents and children are followed by joint parent-child sessions.

Four years later those in ISFP compared with controls wereless likely to have drunk alcohol (50% vs. 68%), been drunk(36% vs. 44%), smoked cigarettes (44% vs. 50%), or used mar-ijuana (11% vs. 17%). Generally use levels of PDFYP werebetween ISFP and control group levels and did not significantly

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differ from controls. The results suggested the interventions hadtheir greatest effects on initiation and current use of alcohol,the substance of choice among U.S. adolescents. Whether theseinterventions will reduce drinking, driving after drinking, andalcohol-related crashes during later adolescence has yet to bedetermined.

School-Based ProgramsA recent review of school-based programs indicates several havebeen successful in reducing alcohol consumption among adoles-cents Komro and Toomey (2002). These include the Life SkillsTraining Program (Botvin et al., 1995), Project Smart (Hansen& Graham, 1991), and Project ALERT (Eckstein et al., 1993).

The Life Skills Program Botvin (1990, 1995) was the solecurriculum only prevention program that has reported long-termeffects of alcohol use. The program includes three years of pre-ventive curricula for junior high, 15 sessions in the first year,10 sessions in the second year, and 5 sessions in the third year.The curricula covers drug information, alchol/drug resistanceskills, self management skills, and general social skills. Long-term beneficial effects on alcohol and tobacco use have beenfound in experimental studies through high school but not in theyear immediately after high school Botvin (2000).

An analysis by Griffin et al. (2000) found that only a smallamount of the variance in alcohol use among youth as predictedby individual level variables targeted in school based curricula-only programs. They recommended that alcohol school-basedprograms be complemented by family, community, and policyinitiatives. Programs using this more comprehensive approachwill be described later in this article.

College Student InterventionsLarimer and Cronce (2002) reviewed individually orientedstrategies to reduce problematic alcohol consumption by coll-ege students from 1984 to 1999. Studies were included in thisreview if they had a control or comparison group and at leastone change in drinking or alcohol consequences outcome. A to-tal of 34 separate studies were identified. The reviewers foundlittle evidence for the effectiveness of informational-based andvalues-clarification programs. Several skills-based interventionsresulted in decreases in alcohol consumption including self-monitoring/self-assessment as well as expectancy-challengeprocedures involving alcohol/placebo administration. Brief mo-tivational interventions had demonstrated effectiveness in a va-riety of contexts including selected high-risk freshmen, highschool classrooms, fraternity organizations, outpatient counsel-ing centers, and emergency rooms. Mailed graphic feedbackin three studies resulted in reductions in alcohol consumptionequivalent or superior to skills-based interventions combinedwith feedback.

Of the studies examined, one by D’Amico and Fromme(2000) specifically examined driving after drinking and ridingwith drinking drivers. Three hundred high school students wererandomly assigned to a Risk Skills Training Group (N = 73) withpersonalized motivational feedback, a brief version of the DARE

program (N = 77), or a no treatment control. At post-treatmentassessment participants in the Risk Skills Training Group sig-nificantly reduced the frequency with which they drank heavily,drove after drinking, and rode with an intoxicated driver.

Minimum Legal Drinking Age of 21 in the United StatesThe greater decline in alcohol-related traffic deaths among 16–20 year-olds is attributable in part to the adoption of 21 as thelegal drinking age. In 1984 when 25 states had a legal drinkingage of 21, the U.S. Congress passed legislation that would with-hold highway construction funds from states that did not makeit illegal to sell alcohol to people younger than 21. By 1988 allstates had a legal drinking age of 21. A review of more than 49studies of changes in the legal drinking age revealed that in the1970s and 1980s, when many states lowered the drinking age,alcohol-related traffic crashes increased 10%. In contrast, whenstates increased the legal drinking age to 21, alcohol-relatedcrashes among people younger than 21 decreased an average of16% (Shults et al., 2001). Wagenaar and Toomey (2002) con-ducted an even more extensive review of more than 48 studiesof the effects of drinking age changes on driving and 57 studieson traffic crashes, concluding that of all programs those that in-crease the age of legal alcohol purchase and consumption havebeen the most successful to date. One national study of lawsraising the drinking age to 21 indicated that persons who grewup in states with a drinking age of 21 relative to those withlower legal drinking ages drank less not only when they wereyounger than 21 but also when they were ages 21–25 (O’Malley& Wagenaar, 1991). NHTSA estimates that a legal drinking ageof 21 saves 700–1,000 lives annually and that more than 21,000traffic deaths have been prevented by such laws since 1976.

Zero Tolerance Laws in the United StatesZero tolerance laws have also contributed to declines inalcohol-related traffic deaths among people younger than 21.These laws, which have been enacted in every state to supple-ment drinking age laws, provide penalties for people youngerthan 21 who drive after any drinking. A comparison of the firsteight states to adopt zero tolerance laws with nearby states with-out such laws revealed a 21% decline in the proportion of fatalcrashes among drivers younger than 21 that were of the typemost likely to involve alcohol (i.e., single-vehicle fatal crashesat night) (Hingson et al., 1994). This type of crash among adultsdeclined 3–4% in both zero tolerance and comparison states dur-ing the same time frame. Wagenaar et al. (2001) found that inthe first 30 states to adopt zero tolerance laws, relative to therest of the nation, there was a 19% decline in the proportion ofpeople younger than 21 who drove after any drinking and a 23%decline in the proportion who drove after five or more drinks.

Zero tolerance laws do not exist in Europe, except for a fewEast European countries. Under the probationary driving sys-tems in Germany or France, only 1 DWI can lead to licensesuspension, and the strict system in Sweden (legal BAC of0.02%) leaves little latitude in young people’s drinking and driv-ing. Increasingly, traffic safety experts suggest that a zero BAC

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would be the clearest preventive message for young as well asfor adult drivers.

Price of AlcoholThe National Academy of Sciences in its Report to Congress onpreventing underage drinking in 2003 reviewed the literature onprice of alcohol and alcohol-related problems and recommendedthat Congress and State legislators should raise excise taxes toreduce underage alcohol consumption and to raise additionalrevenues for this purpose.

The research literature on the effects of price on alcoholconsumption indicates that as price increases, consumption de-creases (Wagenaar & Toomey, 2002). In a separate review(Chaloupka, Grossman, & Saffer, 2002) reported that researchsince the early 1980s generally has concluded that increaseson the price of alcohol beverages lead to reductions in drink-ing, and heavy drinking as well as the consequences of alcoholuse and abuse. Among moderate drinkers, it has been estimatedthat a 1% price increase results in a 1.19% decrease in con-sumption Manning (1995). Younger, heavier drinkers tend tobe more affected than older, heavier drinkers (Kenkel, 1993;Godfrey, 1997; Chaloupka & Wechsler, 1996; Sutton & Godfrey,1995). Younger drinkers have less discretionary income and thatmay contribute to their heightened sensitivity to alcohol prices.Laixuthai and Chaloupka (1993), Grossman et al. (1987), andCoate and Grossman (1988) all found increasing price of alcoholreduces the percent of youths who drink infrequently and evengreater percentage declines in youths who drink frequently.

Higher alcohol prices have also been found to reduce alcohol-related problems such as motor vehicle fatalities (Kenkel, 1993),robberies, rapes, and liver cirrhosis deaths (Cook & Moore,1993; Cook & Tauchen, 1982; Ruhm, 1996) sexually transmit-ted diseases (Chasson et al., 2000) and child abuse (Markowitz& Grossman, 1998).

Research taking into account the addictive nature of alcoholshows that the long-term price elasticity is well above short termelasticity (Grossman et al., 1998).

Safer and Grossman (1987, 1988) concluded increases in beertaxes would reduce motor vehicle fatalitites. Chaloupka et al.(1993) concluded higher beer taxes are among the most effec-tive means of reducing drinking and driving in all segments ofthe population but they have their greatest impact on 18–20-year-olds. Kenkal (1993) reported a 10% increase in the price ofalcohol would reduce driving while intoxicated 7% among menand 8% among women, and among persons under 21 would pro-duce a 13% decrease among men 21% decrease among women.

Dee (1997) and Dee and Evans (2001) reported significanteffects of increase in beer taxes reducing motor vehicle fatalityrates.

If, as recommended by the National Academy Report (2003),revenues generated by alcohol tax increases to raise beverageprices are in turn earmarked for programs and enforcement ofpolicies known to reduce underage drinking that could be furtherreduce underage drinking problems beyond reductions associ-ated with alcohol price increases alone.

Alcohol Outlet DensityDull and Giacopassi (1988) in a study of 95 counties inTennessee found that after controlling for population size andurbanization and race, higher alcohol outlet density was associ-ated with increased motor vehicle fatality. Gruenwald and Pon-icki (1995) found a 10% increase in outlet density resulted in a4% increase in sales of spirits and a 3% increase in wine sales.Examining data from 38 states they found rates of single vehiclenight fatal crashes (those most likely to involve alcohol) wererelated to sales of spirits and wine and particularly beer. Mostrecently, Gruenwald et al. (2002) found that bar and restaurantoutlet density were related to greater drinking frequencies anddriving after drinking. The effects of outlet density specificallyon young drivers warrant research attention.

Law Enforcement IssuesMinimum purchase age and zero tolerance laws have effectivelyreduced alcohol-impaired driving problems for people youngerthan 21. However, even with these laws many youth continueto drink and to drive after drinking. Enforcement of these lawsgenerally has not been very vigorous (Jones & Lacey, 2001).Moreover, studies have found that young drivers are substan-tially underrepresented in the DWI arrest population relative totheir contributions to the alcohol crash problem (Preusser et al.,1992; Voas & Williams, 1986). One reason for this may be thatyounger drivers are more likely to drink at locations where DWIenforcement resources are less likely to be deployed. Youngdrivers with high BACs also are more likely to be missed bypolice at sobriety checkpoints (Wells et al., 1997).

Enhanced enforcement of alcohol purchase laws aimed atsellers and buyers can be effective (Preusser et al., 1994;Wagenaar et al., 2000) if resources are made available for thispurpose. Enforcement of zero tolerance laws is hindered in somestates because of the way the laws are written. For example, insome states the implied consent laws require either an arrest forDWI or probable cause for a DWI arrest before the evidentiarytest can be done to prove a zero tolerance violation (Fergusonet al., 2000). Thus in practice zero tolerance laws often are notenforced independently of DWI. In states such as New Mexico,where this situation exists, the majority of teenagers are unawarethat there is a zero tolerance law (Ferguson & Williams, 2002).

Comprehensive Community InterventionsSeveral carefully conducted school- and community-based ini-tiatives have had particular success in reducing drinking and/or related alcohol problems among young people. Theseprograms typically coordinate efforts of city officials from multi-ple departments of city government, school, health, police, alco-hol beverage control, and so on; concerned private citizens andtheir organizations; students; parents; and merchants who sellalcohol. Often multiple intervention strategies are incorporatedinto the programs, including school-based programs involvingstudents, peer leaders, and parents; media advocacy; communityorganizing and mobilization; environmental policy change to re-duce alcohol availability to youth; and heightened enforcement

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of laws regulating sales and distribution of alcohol and laws toreduce alcohol-related traffic injuries and deaths.

Mid-Western Prevention Project. This program attempted toprevent abuse of alcohol, tobacco, and illicit drugs, such as co-caine, among adolescents ages 10–14 in Kansas City, Missouri,and later in Indianapolis, Indiana. A quasi-experimental designin Kansas City and a randomized experimental design in Indi-anapolis were used to evaluate the program (Pentz et al., 1989).In Kansas City a 10-session youth training program on skills forresisting substance use included homework sessions involvingactive interviews and role plays with parents and family mem-bers about family rules regarding the use of these substances andsuccessful techniques to avoid their use and counteract mediaand community influences to use these substances. Approxi-mately 80% of students completed the exercises with parents oradult family members. Mass media coverage also was initiated aspart of the intervention. Topic areas included psychosocial con-sequences of the use of alcohol, tobacco, and other drugs; correc-tion of perceptions about the prevalence of peer drug use; recog-nition of adult media and community influences on substanceuse; peer and environmental pressure resistance; assertiveness inpracticing pressure resistance and problem solving for difficultsituations that involve potential substance use; and statements ofpublic commitments to avoid use of alcohol, tobacco, and otherdrugs. Modeling and role playing of resistance skills, feedbackwith peer reinforcement, peer leader facilitation, and discussionof homework results were part of the program.

Forty-two schools participated in the study. When students inthe 24 intervention schools were compared at one year follow-up with students in 18 delayed intervention schools, prevalenceof use of alcohol, cigarettes, and marijuana was lower in theintervention schools: 11% versus 16% (alcohol), 17% versus24% (cigarettes), and 7% verses 16% (marijuana).

Project investigators (Chou et al., 1998) also tracked 1,904students exposed to the program in Indianapolis. They werecompared with a sample of 1,508 students in the control group.Schools were randomly assigned to groups, and students werefollowed at 6 months, 1.5 years, 2.5 years, and 3.5 years af-ter baseline. After analytically controlling for ethnicity, gender,socioeconomic status, father’s occupation, and school type andgrade, the researchers found that among subjects using alcohol,tobacco, or other drugs at baseline, secondary prevention effectsreducing alcohol use were found at the 6 month and 1.5-year fol-low up, and for tobacco at 6 month follow up. The authors con-cluded the social influence based primary prevention programproduced benefits not only among students who are non-usersat baseline but also among students who were using substancesat baseline.

Project Northland. This program in Minnesota was designedto reduce alcohol use among young adolescents (Perry et al.,1996). Sixth, seventh, and eighth graders were exposed to threeyears of a behavior curriculum that educated them to commu-nicate with their parents about alcohol and to deal with peerinfluence and normative expectations about alcohol. Studentslearned skills to resist alcohol use and to bring about social, po-litical, and institutional change. A town meeting was conducted

by students making recommendations for community action foralcohol use prevention.

Community task forces included a cross section of commu-nity government officials, law enforcement personnel, schoolrepresentatives, health professionals, youth workers, parents,concerned citizens, and adolescents. Community task forcesstimulated passage of several local alcohol-related ordinancesto prevent sales to minors and intoxicated patrons. Businessesprovided discounts to students who pledged to refrain from al-cohol and drug use.

A higher percentage of students in the intervention groupwere alcohol users at baseline, prompting stratified follow-upanalyses of users and non-users at baseline. At follow-up, thepercentages who had used alcohol in the past week and pastmonth were significantly lower in the intervention group. Nosignificant follow-up differences between groups were found onmeasures of cigarette smoking or marijuana use.

DARE and DARE Plus. DARE Plus took the traditionalDARE program involving police education with seventh andeighth grade students about alcohol and drugs and enhanced itwith a peer-led parental involvement classroom program, youth-led extracurricular activities, community adult action teams, andpostcard mailings to parents. Evaluation of this program ran-domly allocated 24 middle and junior high schools to receiveDARE Plus, DARE, or a control intervention. More than 6,200students were enrolled, and 84% were followed for two years.

In schools receiving DARE Plus relative to control schools,boys showed less increase in the use of alcohol, other drugs,and tobacco. Girls showed less increase in drunkenness whenDARE Plus and DARE schools were compared. No significantdifferences between students’ behavior in DARE schools andcontrols schools were observed over time.

Communities Mobilizing for Change. In this program, 15communities were randomly allocated to intervention or com-parison groups (Wagenaar et al., 2000a). The intervention used acommunity organizing approach to reduce the accessibility of al-coholic beverages to people younger than the legal drinking age.

The intervention communities sought to reduce the numberof alcohol outlets selling to young people; availability of alcoholto youth from noncommercial sources such as parents, siblings,and older peers; and community tolerance of adults providingalcohol to underage youth. Action was encouraged through citycouncils, school and enforcement agencies, and private insti-tutions such as alcohol merchants, business associations, andthe media. Periodic compliance checks monitored the propor-tion of alcohol purchase attempts by people appearing to beunderage that resulted in sales and written feedback on theresults. Potential penalties for sales to minors were given tomerchants.

Relative to the comparison communities, the interventioncommunities achieved a 17% increase in outlets checking theage identification of youthful appearing alcohol purchasers, a24% decline in sales by bars and restaurants to potential un-derage purchasers, a 25% decrease in the proportion of 18–20-year-olds seeking to buy alcohol, a 17% decline in the propor-tion of older teens who provided alcohol to younger teens, and

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a 7% decrease in the percentage of respondents younger than21 who drank in the last 30 days. Further, drinking and drivingarrests declined significantly among 18–20-year-olds and disor-derly conduct violators among 15–17-year-olds (Wagenaar et al.,2000b).

Community Trials Program. This program was a five-yearinitiative designed to reduce alcohol-involved injuries and deathsin three experimental communities (Holder et al., 2000). Theprogram had five mutually reinforcing components.

The first tried to mobilize community support for public pol-icy interventions by increasing general awareness, knowledge,and concern about alcohol-related trauma. Initiatives jointlyplanned by project organizers and local residents wereimplemented.

Second, a Responsible Beverage Server component sought toreduce sales to intoxicated patrons and increase enforcement oflocal alcohol laws by working with restaurants, bar and hotel as-sociations, beverage wholesalers, the Alcohol Beverage ControlCommission, and local law enforcement.

Third, a DWI component sought to increase the number ofDWI arrests by a combination of special officer training, deploy-ment of passive alcohol sensors, and the use of DUI checkpoints.News coverage publicized these activities.

Fourth, the media brought attention to underage drinking.Sales clerks, owners, and managers were trained to prevent salesof alcohol to minors, and enforcement of underage drinkinglaws increased. Compliance checks detected sales of alcohol tounderage purchasers, and police gave citations to violators.

Fifth, local zoning powers regarding alcohol outlet densitywere used to reduce availability of alcohol.

Alcohol-related crash involvement, as measured by single-vehicle crashes at night, declined 10–11% more in program thanin comparison communities. Alcohol-related trauma visits toemergency departments declined 43% (Holder et al., 2000).

Massachusetts Saving Lives Program. This program was afive-year (1988–1993) comprehensive community interventiondesigned to reduce alcohol-impaired driving and related traf-fic deaths (Hingson et al., 1996). The program addressed allages, with special emphasis on underage youth. Six programcommunities were selected to receive financial support for theirinitiatives based on a competitive proposal process. These werecompared with five matched communities whose applicationsalso satisfied selection criteria but were not funded. The rest ofthe state of Massachusetts also served as a comparison. Outcomedata were collected for five years before and five years after theintervention.

In each program community, a full-time coordinator fromthe mayor or city manager’s office organized a task force ofconcerned private citizens and organizations and officials rep-resenting various city departments (e.g., school, health, police,and recreation). Each community received approximately $1 perresident per year in program funds. Half of the funds were spentto hire the coordinator, and the balance was used for increasedpolice enforcement and other program activities and educationalmaterials. Voluntary activity was also encouraged. Active taskforce membership ranged from 20 to more than 100 people in

each community. An average of 50 organizations participated ineach city.

Most of the initiatives were developed by the communities.The program sought to reduce drunk driving; behaviors dispro-portionately exhibited by drunk drivers; and related risks suchas speeding, running red lights, failure to yield to pedestrians incrosswalks, and failure to use safety belts. To reduce drunk driv-ing and speeding, communities introduced media campaigns,checkpoints, business information programs, speeding anddrunk driving awareness days, speed watch telephone hotlines,police training, education led by high school peers, StudentsAgainst Drunk Driving chapters, college prevention programs,alcohol-free prom nights, beer keg registration, and increasedliquor outlet surveillance by police to reduce underage alco-hol purchases. To increase pedestrian safety and safety belt use,program communities conducted media campaigns and policecheckpoints, posted crosswalk signs warning motorists of finesfor failure to yield to pedestrians, added crosswalk guards, andoffered preschool education programs and training for hospi-tal and prenatal staff. Coordinators engaged in numerous me-dia advocacy activities to explain trends in local traffic safetyproblems and strategies the communities were implementingto reduce traffic injuries and deaths. The proportion of driversyounger than 20 who reported driving after drinking in randomdigit dial telephone surveys declined from 19% during the fi-nal year of the program to 9% in subsequent years. There waslittle change in comparison areas. The proportion of vehiclesobserved speeding through use of radar was cut in half, whereasthere was little change in comparison cities. There was a 7%increase in safety belt use, a significantly greater increase thanshown in comparison area.

Fatal crashes declined from 178 during the five preprogramyears to 120 during the five program years. This was a 25%greater reduction than in the rest of Massachusetts. Fatal crashesinvolving alcohol declined 42%, and the number of fatally in-jured drivers with positive blood alcohol levels declined 47%relative to the rest of Massachusetts (90% of fatally injureddrivers in Massachusetts are tested annually for alcohol). Visi-ble injuries per 100 crashes declined 5% more in Saving LivesCities than in the rest of the state during the program period.The fatal crash declines were greater in program cities relativeto comparison areas, particularly among drivers ages 15–25.All six program cities had greater declines in fatal and alcohol-related fatal crashes than comparison cities or the rest of thestate.

FUTURE RESEARCH NEEDS

Several research questions need to be addressed to further ourunderstanding of the causes of underage drinking and how to im-plement more cost-effective measures to reduce underage drink-ing, driving after drinking, and alcohol-related traffic fatalities.

First, it is not known why the average age of first alcohol useis declining in the United States. It is possible that reductionsin the price of alcohol or changes in access or perceived accessto alcohol have contributed. Research is needed to understand

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better why early onset is related to later problems with alcoholand how to interrupt this progression.

Second, studies are needed to prospectively examine whetherinterventions such as (Spoth 2001; Perry et al., 1996, 2003),which delay onset of drinking, will in turn reduce drinking anddriving and alcohol-related crash involvement during later ado-lescence and adulthood.

Further, the recent focus on college drinking offers an oppor-tunity to enlist colleges and universities into community coali-tions to reduce alcohol related traffic deaths. Among collegestudents 18–24, the leading alcohol-related cause of death istraffic crashes accounting for 1100 deaths annually (Hingsonet al., 2002). Comprehensive community interventions that in-volve multiple departments of city government with private cit-izen groups and organizations can reduce alcohol related trafficcrashes (Holder et al., 2000) and deaths (Hingson et al., 1996).Whether their effects can be enhanced by involving colleges anduniversities warrants research attention.

Finally, evidence is quite clear that community interven-tions to reduce teenage access to alcohol (Holder et al., 2000;Wagenaar et al., 2000) and increase publicized enforcementof drinking and driving laws can reduce alcohol-related traf-fic crashes and fatalities among young people (Hingson et al.,1996; Holder et al., 2000). But these comprehensive commu-nity interventions have not been widely adopted. Strategies tofacilitate adoption need to be tested.

CONCLUSIONS

During the past two decades substantial progress has beenmade in reducing alcohol consumption and alcohol-related traf-fic deaths in the United States among people younger than 21.However, alcohol-related traffic deaths in this age group, whichwere declining from the early 1980s to the mid 1990s, havenot further declined since 1995. The average age of first alco-hol consumption is declining, and starting to drink at a youngerage is associated with development of alcohol dependence andinvolvement in alcohol-related crashes during adult years.

Progress in reducing alcohol-related traffic deaths in theUnited States resulted from raising the drinking age to 21 andenactment of zero tolerance laws, even though enforcement ofthese laws has not been extensive or consistent across states.While evidence is clear that these and other feasible measurescan reduce the problem, political will to increase efforts has beenlacking. There is urgent need for focused attention and actionon the problems resulting from underage drinking.

REFERENCES

American Psychiatric Association (APA). (1994) Diagnostics and Sta-tistical Manual of Mental Disorders, 4th Ed. (DSM-IV), APA,Washington, DC.

Botvin GJ, Baker E, Dusenberg L, et al. (1995) Long-term follow upresults of a randomized drug abuse prevention trial in a white middleclass population, J. of the American Medical Association, Vol. 273,No. 14, pp. 1106–1112.

Botvin GJ, Baker E, Dusenberg L, et al. (1990) Preventing adolescentdrug abuse through a multi-model cognitive–behavioral approach:Results of a 3 year study, J. of Consulting and Clinical Psychology,Vol. 58, No. 4, pp. 437–466.

Botvin GJ, Griffin KW, Diaz T, et al. (2000) Preventing illicit drug useon adolescents: Long term follow up data from a randomized controltrial of a school population, Addictive Behaviors, Vol. 25, No. 5,pp. 769–774.

Castle SP, Thompson JD, Spataro JA, et al. (1995) Early evaluation ofa statewide sobriety checkpoint program, Proc. of the 39th AnnualAAAM, pp. 65–78.

Catalano RF, Hawkins JD. (1996) The social development model: A the-ory of antisocial behavior. In Delinquency and Crime: Current The-ories, J.D. Hawkins, Ed. Cambridge University Press, Cambridge,England, pp. 149–197.

Chaloupka F, Grossman M, Saffer H. (2002) The effects of price onalcohol consumption on alcohol related problems, Alcohol Researchand Health, Vol. 26, No. 1, pp. 22—33.

Chesson H, Harrison P, Kassley WJ. (2000) Sex under the influence theeffects of alcohol policy on sexually transmitted disease, J. Law andEconomics, Vol. 43, No. 1, pp. 215–233.

Choquet M. (2003) Substance Use of School and College Students,INSERM Collective Expertise on Alcohol and Social Damage, In-stitute of Health and Medical Research (INSERM), Paris, France,pp. 33–54.

Chou CP, Montgomery S, Pentz MA, Rohrbach LA, Johnson CA, FlayBR, MacKinnon DP. (1998) Effects of a community-based preven-tion program on decreasing drug use in high-risk adolescents, Am. J.Public Health, Vol. 88, pp. 944–948.

Coate D, Grossman M. (1988) Effects of alcoholic beverage prices andlegal drinking ages on youth alcohol use, J. Law and Economics,Vol. 31, No. 1, pp. 145–171.

D’Amico E, Fromme K. (2000) Implementation of the risk skills train-ing program: A brief intervention targeting adolescent participa-tion in risk behaviors, Logistic Behavior Practice, Vol. 7, pp. 101–117.

DeMarsh J, Kumpfer KL. (1986) Family-oriented interventions for theprevention of chemical dependency in children and adolescents, Pre-vention, Vol. 18, pp. 117–151.

Ferguson SA, Fields M, Voas RB. (2000) Enforcement of zero tolerancelaws in the United States, Proc. 15th ICADTS, Swedish NationalRoad Administration, Borlange, Sweden, CD-ROM.

Ferguson SA, Williams AF. (2002) Awareness of zero tolerance lawsin three states, J. Safety Res., Vol. 33, pp. 293–299.

Grant BF. (1998) The impact of family history on the relationshipsbetween age of onset of alcohol use and dsm-iv alcohol dependence,Alcohol Health Res. World, Vol. 22, pp. 144–147.

Grant BF, Hasin DS. (1992) The alcohol use and associated disabil-ities interview schedule, National Institute on Alcohol Abuse andAlcoholism, Rockville, MD.

Griffin KW, Schier LM, Botvin GJ, Diaz T. (2000) Ethnic and genderdifferences in psycho social, risk, protection and adolescent alcoholuse, Prevention Science, Vol. 4, pp. 199–212.

Grossman M, Chaloupka FJ, Sirtalin I. (1998) An empirical analysisof alcohol addiction results from monitoring the future panels, Eco-nomic Inquiry, Vol. 36, No. 1, pp. 39–48.

Grossman M, Coate D, Anluck GM. (1997) Price sensitivity of alcoholbeverages in the United States in Control Issues in Alcohol AbusePrevention Strategies for States and Communities Greenwich, M.H.Moore, D.R. Gerstein, et al., (ed.). Conn JAI Press, pp. 167–198.

Dow

nloa

ded

by [

Am

s/G

iron

a*ba

rri L

ib]

at 0

0:24

08

Oct

ober

201

4

236 R. W. HINGSON ET AL.

Grunbaum JA, Kann L, Kinchen SA, Williams B, Ross JG, Lowry R,Kolbe L. (2002) Youth Risk behavior surveillance: United States,2001, MMWR Surveill. Summ., Vol. 51, No. 4, pp. 1–62.

Hawkins JD, Weis JG. (1985) The social development model: An in-tegrated approach to delinquency prevention, J. Prim. Prev., Vol. 7,pp. 73–97.

Hibell B, Andersson B, Ahlstrom S, Balakireva O, Bjarnasson T,Kokkevi A, Morgan M. (2000) The 1999 ESPAD Report: Alco-hol and Other Drug Use Among Students in 30 European Coun-tries, Swedish Council for Information on Alcohol and Other Drugs(CAN), Stockholm, Sweden, 362.

Hibell B, Andersson B, Bjarnasson T, Kokkevi A, Morgan M, NaruskA. (1997) The 1995 ESPAD Report: Alcohol and Other Drug UseAmong Students in 26 European Countries, Swedish Council for In-formation on Alcohol and Other Drugs (CAN), Stockholm, Sweden,p. 294.

Hingson R, Heeren T, Winter M. (1994) Lower legal blood alcohollimits for young drivers, Public Health Rep., Vol. 109, pp. 738–744.

Hingson R, Howland J. (2002) Comprehensive community interven-tions to promote health: Implications for college–age drinking prob-lems, J. Stud Alcohol, Suppl. Mar., Vol. 14, pp. 226–240.

Hingson R, McGovern T, Howland J, Hereen T, Winter M, Zakocs R.(1996) Reducing alcohol–impaired driving in Massachusetts: Thesaving lives program, Am. J. Public Health, Vol. 86, pp. 791–797.

Holder HD, Gruenewald PJ, Ponicki WR, Treno AJ, Grube, JW, SaltzRF, Voas RB, Reynolds R, Davis J, Sanchez L, Gaumont G, RoeperP. (2000) Effect of community–based interventions on high–riskdrinking and alcohol-related injuries, J. Am. Med. Assoc., Vol. 284,pp. 2341–2347.

Jones RK, Lacey JH. (2001) Alcohol and Highway Safety 2001, AReview of the State of Knowledge, National Highway Traffic SafetyAdministration, Washington, DC, Report no. DOT HS-809-383.

Lacey JH, Jones RK, Smith RG. (1999) Evaluation of Check-point Tennessee: Tennessee’s State Sobriety Checkpoint Program.Washington, District of Columbia: National Highway Traffic SafetyAdministration. DOT HS-808-841.

Laixuthai A, Chaloupka FJ. (1993) Youth alcohol use and public policy,Contemporary Policy Issues, Vol. 11, No. 4, pp. 70–81.

Larimer M, Cronce J. (2002) Identification, prevention and treatment:A review of individual–focused strategies to reduce problematic al-cohol consumption by college students, J. Stud Alcohol, Suppl. Mar.,No. 14, pp. 148–164.

Markowitz S, Grossman M. (1998) Alcohol regulation and domesticviolence towards children, Contemporary Economic Policy, Vol. 16,No. 3, pp. 309–320.

Markowitz S, Grossman M. (2000) The effects of beer taxes on physicalchild abuse, J. Health Economics, Vol. 19, No. 2, pp. 271–282.

Mayhew DR, Donelson AC, Beirness DJ, Simpson HM. (1986) Youthalcohol and relative risk of crash involvement, Accid. Anal. Prev.,Vol. 18, pp. 293–287.

National Academy of Sciences (NAS). (2003) In Reducing Under-age Drinking: A Collective Responsibility, (ed.), R.J. Bonnie, M.E.O’Connell, NAS, Washington, DC.

National Highway Traffic Safety Administration (NHTSA). (2000)Traffic Safety Facts 2000: Alcohol, NHTSA, Washington, DC, Re-port No. DOT HS-809-323.

National Highway Traffic Safety Administration (NHTSA). (2003)Traffic Safety Facts 2002: Alcohol, NHTSA, Washington, DC, Re-port no. DOT HS-809-606.

O’Malley P, Johnston L. (2003) Unsafe driving by high school seniors:National trends from 1976 to 2001 in tickets and accidents after use of

alcohol, marijuana and other illegal drugs, J. Stud. Alcohol, Vol. 64,pp. 305–312.

O’Malley P, Wagenaar A. (1991) Effects of minimum drinking age lawson alcohol use, related behavior and traffic crash involvement amongamerican youth, J. Stud. Alcohol, Vol. 52, pp. 478–491.

Pentz M, Dwyer J, MacKinnon D, Flay B, Hensen W, Wang E, JohnsonA. (1989) A multi-community trial for primary prevention of ado-lescent drug abuse, JAMA, Vol. 261, pp. 3259–3265.

Perry CL, Komro KA, Veblen-Mortenson S, Bosma LM, Farbakhsh K,Munson KA, Stigler MH, Lytle LA. (2003) A randomized controlledtrial of the middle and junior high school D.A.R.E. and D.A.R.E.plus programs, Arch. Pediatr. Adolesc. Med., Vol. 157, pp. 178–184.

Perry CL, Williams CL, Veblen-Mortenson S, Toomey TL, Komro KA,Anstine PS, McGovern PG, Finnegan JR, Forster JL, Wagenaar AC,Wolfson, M. (1996) Project Northland: Outcomes of a Community-wide Alcohol Use Prevention Program During Early Adolescence,Am. J. Public Health, Vol. 86, pp. 956–965.

Preusser DF, Ulmer RB, Preusser CW. (1992) Obstacles to Enforcementof Youthful (under 21) Impaired Driving, National Highway TrafficSafety Administration, Washington, DC, Report no. DOT HS-807-878.

Preusser DF, Williams AF, Weinstein HB. (1994) Policing underagealcohol sales, J. Safety Res, Vol. 25, pp. 127–133.

Shults RA, Elder RW, Sleet DA, Nichols JL, Alao MO, Carande-KulisVG, Zaza S, Sosin DM, Thompson RS, Task Force on CommunityPreventive Services. (2001) Reviews of evidence regarding interven-tions to reduce alcohol–impaired driving, Am. J. Prev. Med., Vol. 21,No. 4, pp. 66–88.

Spoth R, Redmond C, Shin C. (2001) Randomized trial of brief familyinterventions for general population adolescent substance use out-comes 4 years following baseline, J. Consult. Clin. Psychol., Vol. 69,pp. 627–642.

Voas RB, Wells JK, Lestina DC, Williams AF, Greene MA. (1998)Drinking and driving in the united states: The 1996 national roadsidesurvey, Accid Anal. Prev., Vol. 30, pp. 267–275.

Voas RB, Williams AF (1986) Age differences of arrested and crash-involved drinking drivers, J. Stud. Alcohol, Vol. 47, pp. 244–248.

Wagenaar AC, Murray DM, Gehan JP, et al. (2000) Communities mo-bilized for change on alcohol effects of a randomized trial on arrestsand traffic crashes addiction, Vol. 95, pp. 209–217b.

Wagenaar AC, Murray DM, Gehan JP, Wolfson M, Forster JL, ToomeyTL, Perry CL, Jones-Webb R. (2000) Communities mobilizing forchange on alcohol: Outcomes from a randomized community trial,J. Stud. Alcohol, Vol. 61, pp. 85–94.

Wagenaar AC, O’Malley PM, LaFond C. (2001) Lowered legal bloodalcohol limits for young drivers: Effects on drinking, driving anddriving after drinking behaviors in 30 states, Am. J. Public Health,Vol. 91, pp. 801–804.

Wagenaar AC, Toomey TL. (2002) Effects of minimum drinking agelaws: Review and analyses of the literature from 1960 to 2000,J. Stud. Alcohol, Suppl. Mar., Vol. 14, pp. 206–225.

Wells JK, Greene MA, Foss RD, Ferguson SA, Williams AF. (1997)Drinking drivers missed at sobriety checkpoints, J. Stud. Alcohol,Vol. 58, pp. 513–517.

Zador PL. (1991) Alcohol-related relative risk of fatal driver injuries inrelation to driver age and sex, J. Stud. Alcohol, Vol. 52, pp. 302–310.

Zador PL, Krawchuk SA, Voas RB. (2000) Alcohol-related relative riskof driver fatalities and driver involvement in fatal crashes in relationto driver age and gender: An update using 1996 data, J. Stud. Alcohol,Vol. 61, pp. 387–395.

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