Preventing and Reducing Underage Alcohol Use: Public Health and Medical Provider Perspectives

1. Preventing and Reducing Underage Alcohol Use: Public Health and Medical Provider Perspectives David E. Nelson, MD, MPH Senior Health Scientist, Alcohol Team Centers for Disease Control and Prevention (CDC)

2. Bob Brewer, MD, MSPH Tim Naimi, MD, MPH Jackie Miller, MD Richard Yoast, PhD Frank Chaloupka, PhD Acknowledgments

3. Outline • Health and other effects • Extent of alcohol/underage drinking problem • Public health (population-based) strategies • Clinical Strategies • Community examples • Useful information resources • Recommendation and conclusions

6. Alcohol Misuse: A Spectrum • High per-occasion consumption (5+ men, 4+ women) • CDC ‘binge’, NIAAA ‘risk’ (daily) • High average consumption (>2/d men, >1/d women) • CDC ‘heavy’, NIAAA ‘risk’ (weekly) • Alcohol abuse, alcohol dependence • Any drinking among certain groups • Any drinking under certain circumstances (e.g., pregnancy)

7. Public Health Impact of Underage Drinking • Alcohol is the most commonly abused drug by youth • 90% consumed as binge drinks (i.e., while drinking to get drunk) • Closely tied to leading health and social problems among youth (e.g., impaired driving, violence, & risky sexual behavior)

8. Long-Term Adult Alcohol-Related Risks October 22, 2004 • “Persons reporting first use of alcohol before age 15 were more than 5 times as likely to report past-year alcohol dependence or abuse than persons who first used alcohol at age 21 or older.” SOURCE: Substance Abuse and Mental Health Administration) Source: http://oas.samhsa.gov/2k4/ageDependence/ageDependence.htm

9. Injuries Liver disease Violence, Sexual Assault GI cancers, GI disorders Alcohol Misuse Unintended Pregnancies Cardiovascular disease Child Neglect Crime, legal costs Lost productivity, absenteeism Alcohol Use Disorders

10. Alcohol Misuse has Big Impacts • 75,000 deaths in U.S. annually • 3rd leading behavior-related cause of death • 30 years of potential life lost per alcohol-related death • Huge social morbidity, “second-hand” effects • $185 billion per year in costs

11. 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. • Results in 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

12. Extent of the Problem

13. Assorted Facts on 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

14. Trends in Current and Binge Drinking Among High School Students, YRBS, 1991-2003

15. Interpersonal Violence by Drinking Status Miller, Pediatrics, 2007

16. School Performance by Drinking Status Miller, Pediatrics, 2007

17. Sexual Activity by Binge Drinking Days Miller, Pediatrics, 2007

18. Underage Drinking and Adult Drinking • Youth drinking doesn’t occur in a vacuum: strongly related to adult drinking • Youth tend to model their behavior after adults • Adults often the source of the alcohol consumed by youth • Many alcohol control interventions (e.g., alcohol taxes, driving and drinking laws) affect youth and adults

19. College and Adult Binge Drinking • Adult binge drinking estimates in states are a strong predictor of binge drinking rates on college campuses • Binge drinking among college students were about one-third lower in 10 states with lowest adult binge drinking compared with the highest • States with lower binge drinking estimates tend to have more stringent alcohol control policies Nelson TF, Am J Public Health, 2005

20. Changes inBinge Drinking* among U.S. Adults, 1993-2001 Measure Prevalence Total Episodes Episodes per Person 1993 14.2% 1.2 billion 6.3 2001 14.3% 1.5 billion 7.4 Change + 1% + 29% + 17% *≥5 drinks on ≥1 occasion in the past 30 days Naimi, JAMA, 2003

21. Bottom Line Underage Drinking is…. • Common • Dangerous • Preventable

22. Public Health (Population) Strategies

23. Institute of Medicine (IOM): Mission and Substance of Public Health • Mission: “The fulfillment of society’s interest in assuring the conditions in which people can be healthy.” • Substance: “Organized community efforts aimed at the prevention of disease and promotion of health. It (public health) links many disciplines and rests upon the scientific core of epidemiology.” IOM, The Future of Public Health, 1988

24. Clinical and Public Health Practice

25. The Drinker’s Pyramid Babor & Higgins-Biddle, WHO, 2001

26. Reducing Harms:The Prevention Paradox • To maximally reduce harms, you cannot focus solely on the extreme end of a disease process • It’s too late to prevent – could we have reduced heart disease this much by just having cardiologists waiting in the catheter lab? • There tend to be relatively few people at the extreme, so in aggregate they do not account for most harms

27. Example: Alcohol Use and Motor Vehicles Alcohol- Related MV Death Alcohol- Related MV Injury Alcohol- Related MV Crash Binge Drinking Alcohol- Impaired Driving Any Drinking DWI Arrest/ Conviction Regulating access Regulating price Altering the drinking context Advertising content control Education and persuasion Drinking driver countermeasures Treatment and early intervention Source: NEW SLIDE

28. Research and evidence syntheses to assess effective approaches • World Health Organization (WHO) • United States Preventive Services Task Force (USPSTF) • Institute of Medicine (IOM) • Cochrane Collaborative Reviews • Task Force for Community Preventive Services (Community Guide)

29. Community Guide • Evidence-based • Systematic review of research studies by independent panel of experts • Criteria for quality, inclusion, and strength of studies • Recommendations re Intervention Effectiveness

30. Effective Strategies for Preventing Underage Drinking • Restrict alcohol availability (e.g., enforce minimum legal drinking age laws) • Restrict alcohol marketing to youth • Increase alcohol excise taxes • Implement alcohol-impaired driving countermeasures (e.g., 0.08 laws) The policy/social environment matters!

31. Example: Increasing Alcohol Taxes • 10% increase in tax could reduce binge episodes by 8% (Sloan, 1995) • Young people more influenced by tax increases • 51% of public strongly favor increase in alcohol taxes • 65% support using alcohol tax to reduce budget deficits

33. Societal/Cultural Environment … Marketing does matter … So do social attitudes

36. Clinical (Health Care) Strategies

37. IOM: Broadening the Base of Treatment, 1990

38. Screening and Brief Counseling Interventions (SBI) • Numerous research studies for adults • 20% reduction in total alcohol consumption • Similar or greater reductions in binge drinking, alcohol-related outcomes • Effects: 12-48 months • Additional long-term benefits unclear

39. Single Question Screen “When was the last time you had more than [X] drinks in one day?” X = 3 for women, 4 for men; positive screen if >X within 3 months of interview A positive screen results in further assessment (e.g., 10-question Alcohol Use Disorders Identification Test [AUDIT]) NIAAA Clinician’s Guide, 2005

40. SBI Uses Motivational Interviewing Techniques … A - Ask A - Assess A - Advise A - Assist/Agree A - Arrange

41. SBI (continued) • SBI for alcohol misuse among adults in primary care settings is a recommended clinical preventive service (USPSTF, 2004) • SBI is one of the most valuable clinical preventive services (Maciosek, 2006) • SBI is one of the least commonly performed of the recommended services (Coffield, 2001) • Insufficient evidence that SBI is effective for preventing or reducing alcohol misuse in adolescents

42. Public Health and Medical Care Provider Approaches: Complementary • Public health and medical care community are not competitors concerning underage drinking • Important roles for both population-based prevention and individual-based screening and treatment • But how to engage medical providers in community efforts?

43. Physicians can be engaged to participate and support community efforts • Recent national survey of direct care physicians on community participation, political involvement, collective advocacy • 72% rated preventing teen substance abuse “very important” • Pediatricians and family practitioners more likely to participate in community efforts • Major predictors of civic-mindedness: older age, women, underrepresented minority Source: Gruen, JAMA, 2006

44. Practical tips for finding local physicians to assist in community efforts • Consider selected physician specialties • Personal physician experience with issue • Directly approach physicians • Contact county medical society • Clearly define what physicians’ roles would be • Have realistic expectations as to what they can contribute (busy people…)

45. Community Examples

46. La Crosse, Wisconsin

48. In past 9 years, 8 college-aged men have died from alcohol-related drownings after drinking at La Crosse bars • 8th death, October 2, 2006: 21 year old male student-athlete’s body dragged from river, BAC 0.32% • Octoberfest ongoing … • Drinking buddy taken to detox unit that night Sources: Associated Press, 10/23/06; Chicago Tribune, 10/16/06

49. The Reaction • Fellow Student: “They need to do something more down by the river.” • Teammate: “At first you keep wondering why…After a while, you realize there are no answers.” • Reverend: “Most of us are lucky. We do foolish things. We take the risks. We escape tragedy.” • UW Official: “…just seems to be a standard part of La Crosse culture … At some point, we have to start working on personal responsibility.” • Mayor: “I’m not sure if there is anything we can do…It’s a behavior issue.”

50. The Environment • Wisconsin: highest adult binge drinking prevalence in the U.S. • 1 Town • 1 Brewery • 1 Octoberfest (“several days”) • 2 Rivers • 3 Colleges (63% of students binge drink) • ? Bars • ? Other alcohol outlets