Preventing and reducing underage alcohol use public health and medical provider perspectives
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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). Bob Brewer, MD, MSPH Tim Naimi, MD, MPH Jackie Miller, MD Richard Yoast, PhD

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

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Preventing and reducing underage alcohol use public health and medical provider perspectives

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)


Bob Brewer, MD, MSPH

Tim Naimi, MD, MPH

Jackie Miller, MD

Richard Yoast, PhD

Frank Chaloupka, PhD




  • 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

Alcohol misuse a spectrum

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)

Public health impact of underage drinking

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)

Preventing and reducing underage alcohol use public health and medical provider perspectives

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)


Preventing and reducing underage alcohol use public health and medical provider perspectives


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

Alcohol misuse has big impacts

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

Deaths and ypll among youth 21 due to exposure to excessive drinking

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 (, 2007

Extent of the problem

Extent of the Problem

Assorted facts on underage drinking in the u s

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

Trends in current and binge drinking among high school students yrbs 1991 2003

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

Interpersonal violence by drinking status

Interpersonal Violence by Drinking Status

Miller, Pediatrics, 2007

School performance by drinking status

School Performance by Drinking Status

Miller, Pediatrics, 2007

Sexual activity by binge drinking days

Sexual Activity by Binge Drinking Days

Miller, Pediatrics, 2007

Underage drinking and adult drinking

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

College and adult binge drinking

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

Changes in binge drinking among u s adults 1993 2001

Changes inBinge Drinking* among U.S. Adults, 1993-2001



Total Episodes

Episodes per Person



1.2 billion




1.5 billion



+ 1%

+ 29%

+ 17%

*≥5 drinks on ≥1 occasion in the past 30 days

Naimi, JAMA, 2003

Bottom line

Bottom Line

Underage Drinking is….

  • Common

  • Dangerous

  • Preventable

Public health population strategies

Public Health (Population) Strategies

Institute of medicine iom mission and substance of public health

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

Clinical and public health practice

Clinical and Public Health Practice

Preventing and reducing underage alcohol use public health and medical provider perspectives

The Drinker’s Pyramid

Babor & Higgins-Biddle, WHO, 2001

Reducing harms the prevention paradox

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

Preventing and reducing underage alcohol use public health and medical provider perspectives

Example: Alcohol Use and Motor Vehicles























Regulating access

Regulating price

Altering the drinking context

Advertising content control

Education and persuasion

Drinking driver countermeasures

Treatment and early intervention


Research and evidence syntheses to assess effective approaches

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)

Community guide

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

Effective strategies for preventing underage drinking

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!

Example increasing alcohol taxes

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

Societal cultural environment

Societal/Cultural Environment

… Marketing does matter

… So do social attitudes

Clinical health care strategies

Clinical (Health Care) Strategies

Preventing and reducing underage alcohol use public health and medical provider perspectives

IOM: Broadening the Base of Treatment, 1990

Screening and brief counseling interventions sbi

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

Single question screen

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

Sbi uses motivational interviewing techniques

SBI Uses Motivational Interviewing Techniques …

A - Ask

A - Assess

A - Advise

A - Assist/Agree

A - Arrange

Sbi continued

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

Public health and medical care provider approaches complementary

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?

Physicians can be engaged to participate and support community efforts

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

Practical tips for finding local physicians to assist in community efforts

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…)

Community examples

Community Examples

La crosse wisconsin

La Crosse, Wisconsin

Preventing and reducing underage alcohol use public health and medical provider perspectives

  • 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

The reaction

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.”

The environment

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

The environment cont

The Environment (cont.)

  • Bar 1:

    • $1 shots

    • $5 all-you-can-drink special

    • Window sign: “You’re not drunk if you can lie on the floor without holding on”

  • Bar 2:

    • $ 1 beers

  • Bar 3:

    • $0.50 schnapps

    • $3 beer pitchers, 12 MN - 1:30 AM

Actual proposed solutions

Actual Proposed Solutions

  • Install motion-activated lights to alert intoxicated persons they are near the river

  • Build gates to the levee

  • Fence off the river

  • Have a “drunk bus”

  • Student patrols

  • Limit Octoberfest to one weekend

Concord new hampshire

Concord, New Hampshire

Enhanced enforcement of laws to prevent alcohol sales to underage youth in concord 1999 2004

Enhanced Enforcement of Laws To Prevent Alcohol Sales to Underage Youth in Concord, 1999–2004

Routine compliance checks in new hampshire

Routine Compliance Checks in New Hampshire

  • Enforcement of underage drinking laws

    • Liquor Commission

    • Local law enforcement

  • Underage buyer (17–19 years) attempts to purchase beer or wine

  • Summons to store owner and clerk

  • Discretionary fines and license suspension

Routine compliance checks in new hampshire1

Routine Compliance Checks in New Hampshire

  • Towns checked at invitation of local enforcement officials

  • All retail alcohol stores in selected town checked

  • 29% of retail stores checked per year

Enhanced enforcement program in concord

Enhanced Enforcement Program in Concord

  • Quarterly compliance checks

  • Set administrative penalties

  • Media coverage

Enhanced enforcement program in concord1

Enhanced Enforcement Program in Concord




City Council

Ad Hoc Underage

Access to Alcohol

Advisory Committee

Consistent enforcement of liquor laws

Strengthen sanctions for violations

Set administrative penalties

Set Administrative Penalties

Media coverage

Media Coverage

  • Press releases

    • Set penalties

    • Stores failing compliance checks

  • Local newspaper

    • Articles

    • Editorials

    • Letters to editor


Routine checks

Quarterly checks

Set penalties

Media coverage



Routine compliance checks


Aug 2000

Oct 1999

Mar 2000

Mar 2001

Aug 2001

Mar 2002

Aug 2002

Mar 2003

Aug 2003

Feb 2004

Failure rate for compliance checks before and during enhanced enforcement

Failure Rate for Compliance Checks Before and During Enhanced Enforcement




New Hampshire

(excluding Concord)

Binge drinking among high school students

Binge Drinking Among High School Students



  • 2003

  • Concord

  • 2003

  • New Hampshire

Examples of other community successes

Examples of other community successes

  • OR: successful effort to get Kohl’s department store to stop selling “drinking” games; eliminating Jack Daniels’ sponsored ads before movies in one community’s theater (Sherwood)

  • NE: Successful program to reduce drinking among U. of Nebraska students in Lincoln (e.g., increased enforcement)

Useful resources for scientific information federal agencies

Useful Resources for Scientific Information: Federal Agencies

  • Substance Abuse and Mental Health Services Administration (SAMHSA):

  • Centers for Disease Control and Prevention (CDC):

  • National Institute for Alcohol Abuse and Alcoholism (NIAAA):

  • National Highway Traffic Safety Administration (NHTSA):

Other useful resources ii

Other Useful Resources (II)

  • Guide for Community Preventive Services:

  • Council for State and Territorial Epidemiologists (CSTE):

  • American Medical Association (AMA):

Yet additional useful resources iii

Yet Additional Useful Resources (III)

  • Center on Alcohol Marketing and Youth (CAMY):

  • The Marin Institute:

  • Pacific Institute for Research and Evaluation (PIRE):

Cdc alcohol team

CDC Alcohol Team

  • Public health surveillance on alcohol use and alcohol-related conditions

  • Maintain Alcohol Related Disease Impact (ARDI) software: can use to estimate state and local mortality and YPLL

  • Applied research on health impacts and intervention effectiveness (e.g., Community Guide support)

  • Limited state capacity building & technical assistance

Recommendations and conclusions

Recommendations and Conclusions

Recommendations i

Recommendations (I)

  • Use evidence-based recommendations about what works to address underage drinking (most are public health/population-based): Good to have science on your “side”

  • Utilize surveillance and other data (e.g., from ARDI, BRFSS, YRBS) to raise or maintain awareness; use state and local data whenever possible

  • Build partnerships with state and local public health agencies, substance abuse agencies, health care providers, traffic safety, law enforcement, schools, etc.

Recommendations ii

Recommendations (II)

  • Use affected individuals and real-world stories whenever possible, especially with audiences that may not be sympathetic

  • Develop and maintain good relationships with local news media representatives: be a good resource and look for local relevance for national alcohol stories

  • Have courage: look at what tobacco prevention and control supporters have accomplished

  • Take a long-term perspective: try not to get discouraged with incremental progress

In conclusion

In Conclusion….

  • Alcohol: the “third rail” of health – so important but not well understood, fear of topic

  • Misuse must be understood as spectrum that requires a public health and clinical approach

  • Underage/Binge drinking is a huge public health problem in the U.S. (It’s Common)

  • It is strongly tied to many health & social problems. (It’sDangerous)

  • Effective prevention strategies are available but underused. (It’sPreventable)

Contact information

David E. Nelson, MD, MPH

Senior Scientific Advisor, Alcohol Team

National Center for Chronic Disease Prevention and Health Promotion/CDC


Contact Information

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