Policy Approaches to Reduce
Binge Drinking and Impaired
Driving
Toben F Nelson, ScD
Division of Epidemiology and
Community Health
University 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
RISK FACTOR
OUTCOME
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
Consequences of Alcohol
PREVENTION
HARM REDUCTION
PERSON
CONSUMPTION
Probabilistic relationship
By drinking event
By drinker
CONSEQUENCE(S)
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 among
Current Drinkers
Male
Female
Binge Prevalence (%)
70
60
50
40
30
20
10
0
18-20
21-25
26-34
Age Group (years)
35-54
55+
Naimi et al., JAMA, (2003)
Percentage of High School Students
Who Reported Binge Drinking
11.5% - 21.8%
21.9% - 23.9%
24.0% - 25.1%
25.2% - 30.7%
No Data
* 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.
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
Policy Success
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
Effects of Minimum Drinking
Age 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 Drinking
Age 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 pastmonth 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 Research
Volume 33, Issue 12, pages 2180-2190, 23 SEP 2009 DOI: 10.1111/j.1530-0277.2009.01056.x
http://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)
Risk of injury, by usual number of
drinks (past 30 days)
0.60
Population Percent
Population Percent
Risk ofHarm
0.50
20
0.40
15
0.30
10
0.20
5
0.10
0
Risk of Being Hurt or Injured
25
0.00
0
1
2
3
4
5
6
Usual Number of Drinks
7
8
9 or
more
Weitzman & Nelson (2004)
The Prevention Paradox
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
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
Disadvantages
• Intervention
tailored/targeted to the
individual
• Difficult & costly to ID “atrisk”
• Clear benefits (when
achieved) to the
individual
• Intuitive
• Effects palliative,
temporary
• Low odds success
• Modest benefit to the
population
Population Approach
Advantages
Disadvantages
• Large population benefits
• May limit personal
freedoms
• Broad target audience
• Longer lasting effects
• 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?
Environmental
Conditions
Adult
drinking
Underage
drinking
Integrated theory of drinking behavior
Legal Availability
Public Policy &
Institutional
Policies/Structures
Formal Social
Controls
Individual Risk Factors
Economic
Availability
Physical
Availability
Drinking
Behavior
Adapted from Wagenaar & Perry, 1994
Problems that stem from alcohol
use are primarily a function of
availability
Alcohol-related
Problems
Public Health Triad
Host
Agent
Environment
Knowledge
Pricing
Attitudes
Composition
Intentions
Labeling
Skills
Packaging
Person
Drug
Drug-Related
Problems
Advertising/
Promotion
Environment
Availability
Physical Context
Legal Sanctions
Institutions
Sociocultural
Context
Key
Influencers
Torjman (1986)
Intervening to Reduce Alcoholrelated Motor Vehicle Crashes
Any
Drinking
Binge
Drinking
AlcoholDWI
Impaired
Arrest/
Driving Conviction
AlcoholRelated
MV
Crash
AlcoholRelated
MV
Injury
Regulating access
Regulating price
Altering the drinking context
Advertising content control
Education and persuasion
Drinking driver countermeasures
Treatment and early intervention
AlcoholRelated
MV
Death
Assessing the State
Alcohol Policy
Environment in the
United States
Percentage of High School Students
Who Reported Binge Drinking
11.5% - 21.8%
21.9% - 23.9%
24.0% - 25.1%
25.2% - 30.7%
No Data
* 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.
State Youth Risk Behavior Surveys, 2009
Youth Alcohol Pattern
Youth-Specific
Policies
-5+ (binge) drinking
-Freq. 5+ drinking
-Current drinking
-Freq. current drinking
-Drinking/Driving
Policy Environment
Adult-Oriented (i.e.,
population-based)
Policies
Adult Alcohol Pattern
-5+ (binge) drinking
-Freq. 5+ drinking
-Heavy drinking
-Total drinks
-Current drinking
http://www.epi.umn.edu/alcohol