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Beyond Amethyst and Social Norms: Rethinking the Approach to Alcohol Use by College Students Edward P. Ehlinger, MD, MSPH Director and Chief Health Officer Boynton Health Service June 3, 2010 [email protected]

On June 3, 1800 • President John Adams left Philadelphia and took up residence in Washington, D.C. • His residence was Union Tavern in Georgetown because the White House wasn’t completed.

Dealing with alcohol is my least favorite part of college health • There is lack of consensus that alcohol use by college students is a big problem • We have not been successful in reducing the toll that alcohol takes on college students. • Our society doesn’t want to really address the problems caused by alcohol.

Alcohol Tolerant Attitudes Percentage of adults drinking 5 or more drinks on an occasion one of more times in last month

CDC: BRFSS, 2004

Franz Kafka died on June 3, 1924

• “In the fight

between you and the world, back the world.”

But, we can’t ignore the problems that alcohol causes college students – The data show that alcohol is taking a toll on students – People expect us to address it – There are some things that we can do that are effective – at least on an individual level, if not on a population level – College health has more power and influence than we realize – we can make a difference if we focus on the right things.

• On June 3, 1888 the poem “Casey at the Bat,” by Ernest Lawrence Thayer, was published by the San Francisco Examiner. • I hope I don’t strike out in my attempt to outline a slightly different approach to alcohol. • Oh, somewhere in this favored land the sun is shining bright; The band is playing somewhere, and somewhere hearts are light,

And somewhere men are laughing, and somewhere children shout; But there is no joy in Philadelphia, Ed Ehlinger has struck out.

June 3 is the Feast of Bellona • Bellona was an Ancient Roman war goddess. She is believed to be one of the numinous gods (present in places and objects). She is thought by many to have been the Romans' original war deity, predating the identification of Mars. She is also the mother of Romulus and Remus, The legendary founders of Rome.

Bellona by Rodin Philadelphia Museum of Art

We are in a war with alcohol • Death: 1,700 college students between the ages of 18 and 24 die each year from alcohol-related unintentional injuries, including motor vehicle crashes • From 1998 to 2001, alcohol-related unintentional injury deaths per 100,000 college students increased by 6%. • Injury: 599,000 students between the ages of 18 and 24 are unintentionally injured under the influence of alcohol • Assault: More than 696,000 students between the ages of 18 and 24 are assaulted by another student who has been drinking • Sexual Abuse: More than 97,000 students between the ages of 18 and 24 are victims of alcohol-related sexual assault or date rape •

College Drinking: Changing the Culture - NIAAA http://collegedrinkingprevention.gov/StatsSummaries/snapshot.aspx

We are in a war with alcohol • Health Problems/Suicide Attempts: More than 150,000 students develop an alcohol-related health problem and between 1.2 and 1.5 percent of students indicate that they tried to commit suicide within the past year due to drinking or drug use • Drunk Driving: 2.1 million students between the ages of 18 and 24 drove under the influence of alcohol last year • The proportion of 18- to 24-year-old college students who reported driving under the influence of alcohol increased by 20% • Vandalism: About 11 percent of college student drinkers report that they have damaged property while under the influence of alcohol • Property Damage: More than 25 percent of administrators from schools with relatively low drinking levels and over 50 percent from schools with high drinking levels say their campuses have a "moderate" or "major" problem with alcoholrelated property damage •

College Drinking: Changing the Culture - NIAAA http://collegedrinkingprevention.gov/StatsSummaries/snapshot.aspx

We are in a war with alcohol • Police Involvement: About 5 percent of 4-year college students are involved with the police or campus security as a result of their drinking and an estimated 110,000 students between the ages of 18 and 24 are arrested for an alcoholrelated violation such as public drunkenness or driving under the influence • Alcohol Abuse and Dependence: 31 percent of college students met criteria for a diagnosis of alcohol abuse and 6 percent for a diagnosis of alcohol dependence in the past 12 months, according to questionnaire-based self-reports about their drinking • Unsafe Sex: 400,000 students between the ages of 18 and 24 had unprotected sex and more than 100,000 students between the ages of 18 and 24 report having been too intoxicated to know if they consented to having sex • Academic Problems: About 25 percent of college students report academic consequences of their drinking including missing class, falling behind, doing poorly on exams or papers, and receiving lower grades overall • College Drinking: Changing the Culture - NIAAA http://collegedrinkingprevention.gov/StatsSummaries/snapshot.aspx

A Matter of Degree Initiative to Reduce Binge Drinking at Colleges and Universities - RWJF “Nationwide Strategy to Combat Underage Drinking Requires Shared Responsibility”

Reducing Underage Drinking: A Collective Responsibility (2004) Institute of Medicine

“The consequences of drinking on campus are too damaging to ignore.”

NIAAA - College Drinking Prevention 4 Tiers of Effectiveness • Tier 1: Evidence of Effectiveness Among College Students • Tier 2: Evidence of Success With General Populations That Could Be Applied to College Environments • Tier 3: Evidence of Logical and Theoretical Promise, But Require More Comprehensive Evaluation • Tier 4: Evidence of Ineffectiveness

NIAAA 3-In-1 Framework of Prevention • The research strongly supports the use of comprehensive, integrated programs with multiple complementary components that target: – (1) individuals, including at-risk or alcoholdependent drinkers, – (2) the student population as a whole, and – (3) the college and the surrounding community (Hingson and Howland, 2002; DeJong et al., 1998; Institute of Medicine, 1989).

A Matter of Degree • A 1996 Robert Wood Johnson Foundation initiative: • A National Effort to Reduce High-Risk Drinking Among College Students • $8.6 million program administered by the American Medical Association with evaluation by the Harvard School of Public Health. • Ten university-community coalitions led a national effort to reduce high-risk drinking among college students.

AMOD Schools • • • • • • • • • •

University of Wisconsin University of Vermont University of Nebraska-Lincoln University of Iowa University of Delaware University of Colorado Louisiana State University Lehigh University Georgia Institute of Technology Florida State University

A Matter of Degree • Used Tier I and 2 strategies. They also utilized promising strategies needing evaluation in college environments, which are characterized by NIAAA as Tier 3. Including: – Campus policies to reduce high-risk use, such as holding Friday classes, banning kegs, establishing alcohol-free dorms and activities – Increase enforcement at campus-based events – Publicity about enforcement and elimination of “mixed” messages – Consistent disciplinary actions for violations – Marketing campaigns to correct misperceptions – Safe-rides programs – Regulate happy hours and sales or restrict alcohol promotions – Enhance awareness of personal liability – Inform parents and new students about policies and penalties

And many other efforts • On-line courses • E-Chug • Social norms campaigns

• The National Social Norms Institute opened its doors in 2006 at the University of Virginia

to foster research, evaluation, and dissemination of information on the social

norms approach to the problems caused by alcohol and other issues.

After all of this and more, what have been the results?

Have these interventions worked? Percent of College Students Who Report Being Drunk in the Past 30 Days

Source: Monitoring the Future, College Students and Adults, 1975-2006, NIH

Are these interventions working? (5+ drinks in one session past 2 weeks) 19-20 Year Olds

Source: Monitoring the Future, 1975-2006, NIH

Number of Deaths Attributable to the Harmful Effects of Excessive Alcohol Use Among 18-20 and 21-24 Year Olds: Alcohol Poisoning 2001-2006

Alcohol Attributable Deaths (Alcohol Poisoning)

Sources: CDC; Alcohol-Related Disease Impact (ARDI) Software; Alcohol Attributable Deaths (AAD)

28

30

24

24

21

12 10

21 - 24 Year Olds

19

20

9

10

25

11

10

10 18 - 20 Year Olds

0 2006

2005

2004

2003

2002

2001

Number of Deaths Attributable to the Harmful Effects of Excessive Alcohol Use Among 18-20 and 21-24 Year Olds: Non-Highway Injury Deaths 2001-2006

Alcohol Attributable Deaths (Non-Highway)

Sources: CDC; Alcohol-Related Disease Impact (ARDI) Software; Alcohol Attributable Deaths (AAD)

300

267

269

255

258

255

260 21 - 24 Year Olds

200

150

151

142

143

141

143 18 - 20 Year Olds

100

0 2006

2005

2004

2003

2002

2001

A Matter of Degree - Evaluation • “While there was no change in the ten AMOD schools in study measures, significant although small improvements in alcohol consumption and related harms at colleges were observed among students at the five AMOD sites that most closely implemented the environmental model. Fidelity to a program model conceptualized around changing alcohol-related policies, marketing, and promotions may reduce college student alcohol consumption and related harms.”

Evaluation of Social Norms Programs • “In a national study, Wechsler and associates (2003) assessed changes in students’ misperceptions about peer alcohol use and actual rates of alcohol use at 37 colleges that had reported implementing social norms campaigns between 1997 and 2001 as compared to 61 campuses that had not implemented this approach. They observed no decreases in drinking rates on campuses that had implemented a social norms campaign but saw increases in two of the five drinking measures on these campuses. No changes in drinking rates were observed in the comparison colleges.”

Evaluation of Social Norms Programs • “Given the potential risk of increases in student alcohol use, campus-wide social norms campaigns should be implemented with caution. Any further studies of social norms campaigns should include multiple campuses and randomized study designs and quality of campaign implementation should be assessed.” • De-emphasizing the Role of Alcohol and Creating Positive Expectations on Campus Traci Toomey

Franz Kafka died on June 3, 1924 • “Believing in progress does not mean believing that any progress has yet been made.”

• “Kafkaesque” – Lack of evidence is treated as a pesky inconvenience

– Situations that are incomprehensibly complex, bizarre, or illogical

Amethyst Initiative A response to lack of progress • We call upon our elected officials: – To support an informed and dispassionate public debate over the effects of the 21 year-old drinking age. – To consider whether the 10% highway fund “incentive” encourages or inhibits that debate. – To invite new ideas about the best ways to prepare young adults to make responsible decisions about alcohol. – We pledge ourselves and our institutions to playing a vigorous, constructive role as these critical discussions unfold.

Jefferson Davis President of the Confederacy

• Born on June 3, 1808

• “Never be haughty to the humble or humble

to the haughty.”

Why aren’t things working? • Focus has been on: – Underage drinking – College student drinking – Binge drinking – Raucous behavior – Negative consequences • Is there consensus on these indicators?

Albert Einstein • “Insanity: doing the same thing over and over again and expecting different results.” • "Problems cannot be solved by the same level of thinking that created them.“

The Problem of Alcohol • Is not an underage problem • Is not a college/university problem • Is a community problem

• Is a societal problem

We need to change our focus • The focus on colleges/universities takes the focus off of the real problem. –The role of alcohol in our society –Now we are blaming the victims of our societal values. • By focusing on underage drinking and college drinking, we are playing into the hands of the alcohol industry.

Changing focus • From a college issue that needs community involvement • To a community/societal issue in which colleges/universities are a part of the community.

How to change the focus • Start with data • What is the impact of alcohol on our communities/society? – Not just impact on youth and young adults

Global Burden of Alcohol WHO has initiated a global program on alcohol

• Alcohol caused in 2004, – 3.8% of all global deaths – 4.6% of global disability-adjusted life-years. – Huge economic costs due to alcohol • Productivity losses -72.1% of the overall cost due to alcohol • Health costs - 12.8% • Direct law enforcement costs - 3.5% • Other direct costs - 11.6%

Harm Caused by Alcohol • • • • • • •

Reduced job performance and absenteeism Family deprivation Interpersonal violence Suicide and homicide Crime Fatalities caused by DUI Sexually transmitted diseases and HIV

Effects of Alcohol • Potent teratogen • Low birthweight infants • Cognitive deficiencies and fetal alcohol spectrum disorders • Neurotoxic to brain development, leading to structural hippocampal changes in adolescence and to reduced brain volume in middle age

• Dependence-producing drug • Immunosuppressant, increasing the risk of communicable diseases including tuberculosis • Classified as carcinogenic by the International Agency for Research on Cancer • A biform relation with coronary heart disease

Social Harms of Alcohol • Social Harms are under-represented in most cost estimates and economic models. Harms included in the global burden of disease (GBD) estimates are confined to physical and mental conditions. • Inferior job performance may affect a workplace’s productivity • Boisterous drunken crowds may make an area a “no-go area” for some citizens on a weekend night • The costs of “social harms” typically outweigh the health costs

The Epidemiology of At-Risk and Binge Drinking Among Middle-Aged and Elderly Community Adults: National Survey on Drug Use and Health

• Secondary analysis of the 2005 and 2006 National Survey on Drug Use and Health was conducted

for 10,953 respondents aged 50 years and older. – 50–64: 22.8% binge drinking

– ≥65:

14.5% binge drinking

• Am J Psychiatry August 17, 2009 Dan G. Blazer, Ph.D., and Li-Tzy Wu, Sc.D.

Burden of Alcohol-related Problems • Excessive alcohol use is the 3rd leading lifestylerelated cause of death for people in the United States each year. • In 2001, excessive alcohol use was responsible for approximately 75,000 preventable deaths and 2.3 million YPLLs in the United States. – The majority of these deaths involved males (72%), and the majority of the deaths among males involved those aged >35 years (75%).

Cost of Alcohol in the US • The costs of alcohol abuse and alcoholism were estimated to be $184.6 billion in 1998. – $18.9 billion in medical expenditures to treat the medical consequences of alcohol abuse and alcoholism, – $134.2 billion due to lost earnings, – $31.6 billion for other impacts to society (such as specialty alcohol services such as alcohol abuse treatment, crime costs and social welfare administration).

• Compared to 1992, this was a 25% increase, or an average annual increase of 3.8%.

The Human and Economic Cost of Alcohol Use in Minnesota in 2001 • Economic costs amounted to an estimated $4.5 billion, over $900 for every person. • Costs are about 19 times greater than the $234 million in tax revenues collected from alcohol sales in 2001

• Cost of Alcohol-related Crashes, Fatalities and Injuries By State and County, 2007 was estimated at $314,125,400

Role of Colleges in Changing Focus • College presidents have a broader community role – They can influence state and national policy makers

• Work with local and state health departments • Work with medical and nursing societies • Work with business groups

• Work with Substance Abuse & Mental Health Services Administration (SAMSHA) and other organizations who fund alcohol-related projects

Concentrate on Policy Changes • Increase the price of alcohol

Declining Price of Alcohol

Years since last alcohol tax increase Increase = Past Year (2009) Increase = 10 Years or Less Increase = 10 to 20 Years Increase = 20 to 30 Years Increase = 30 to 40 Years Increase = 40 to 50 Years Increase = 50 Years or More

References: Marin Institute 1.Year of last increase, as of 2009. 2.Beer tax rate and year changed data from the Brewer's Almanac and Adams Beer Handbook. http://www.marininstitute.org/site/campaigns/charge-for-harm/450-neglected-and-outdated-state-beer-taxes.html

Erosion of beer tax due to inflation

Beer Tax Erosion = More Than 75% Beer Tax Erosion = 50% to 75% Beer Tax Erosion = 25% to 50% Beer Tax Erosion = Less Than 25% No Beer Tax Erosion

References: Marin Institute 1.Year of last increase, as of 2009. 2.Excise tax rates were deflated using annual CPI data through 2008, the most recent year for which annual inflation data were available. 3.U.S. Bureau of Statistics CPI, U.S. city average, all items, Base Period: 1982-84=100. 4.State beer excise tax rates and historical changes were obtained from the Brewer's Almanac and Adams Beer Handbook. http://www.marininstitute.org/site/campaigns/charge-for-harm/450-neglected-and-outdated-state-beer-taxes.html

Increase the Price of Alcohol • Beverage alcohol prices and taxes are related inversely to drinking. – Effects are large compared to other prevention policies and programs.

– Public policies that raise prices of alcohol are an effective means to reduce drinking.

• Price affects drinking of all types of beverages, and across the population of drinkers from light drinkers to heavy drinkers.

Increase the Price of Alcohol • Policies that increase alcohol prices: – Delay the start of drinking – Slow young people's progression towards drinking

large amounts – Reduce young people's heavy drinking – Reduce the volume of alcohol consumed per occasion.

Higher alcohol prices or taxes lead to: • Fewer motor vehicle crashes and fatalities • Less alcohol-impaired driving • Less mortality from liver cirrhosis • Less all-cause mortality • Reduced levels of violence

Concentrate on Policy Changes • Increase the price of alcohol • Lower BAC for driving and implement other strategies to lower drinking and driving.

Strategies related to driving • Setting a low concentrations of alcohol in the blood, including a zero level, for young or novice drivers reduces drunk-driving casualties. • Administrative suspension of the driver's license for a driver caught over the limit has positive impacts • Intensive random breath-testing at which all vehicles are stopped and drivers suspected of drink-driving are breath tested reduces alcoholrelated injuries and fatalities.

Strategies related to driving • Mandatory treatment for DUI cases • Use of an ignition interlock (a mechanical device that does not allow a car to be driven by a driver who is over the limit) for repeat drink drivers • No beneficial effect of designated driver programs

Concentrate on Policy Changes • Increase the price of alcohol • Lower BAC for driving and implement other strategies to lower drinking and driving. • Ban advertising of alcohol

Alcohol advertising • Alcohol advertisers spent $2 billion on alcohol advertising in measured media (television, radio, print, outdoor, major newspapers and Sunday supplements) in 2005.

Alcohol Advertising • Between 2001 and 2005, youth exposure to alcohol advertising on television in the U.S. increased by 41%.

• In a sample of radio advertising for the 25 leading alcohol brands in the summer of 2004, more than two-thirds of youth exposure to alcohol advertising came from ads placed on youthoriented programming, defined as programming with youth audiences larger than the population of youth ages 12 to 20 in the local market.

Alcohol Advertising • A study of alcohol advertising in magazines from 1997 to 2001 found that the number of beer and distilled spirits ads tended to increase with a magazine's youth readership. For every 1 million underage readers ages 1219 in a magazine, researchers found 1.6 times more beer advertisements and 1.3 times more distilled spirits advertisements.

Concentrate on Policy Changes • Increase the price of alcohol • Lower BAC for driving and implement other strategies to lower drinking and driving. • Ban advertising of alcohol • Decouple alcohol and sports

Alcohol and Sports • Alcohol producers spent $991 million on television advertising in 2002—60 percent of it on sports programming. • 2008 NCAA Men's Basketball Tournament, the beer category, which includes the AnheuserBusch and Miller brands, accounted for $42.8 million in revenue for CBS

Alcohol and Sports • “People who like sports are beer drinkers, and people who are beer drinkers like sports.” – Anheuser-Busch CEO Patrick Stokes – Anheuser-Busch’s Budweiser and Bud Light (in 2003) spent 82 percent and 77.2 percent, respectively, of their total television advertising dollars on sports television.

Concentrate on Policy Changes • Increase the price of alcohol • Lower BAC for driving and implement other strategies to lower drinking and driving. • Ban advertising of alcohol • Decouple alcohol and sports • Eliminate alcohol sponsorship of public events

Alcohol Industry Sponsorship • The alcohol industry spends almost $6 billion a year in the United States on advertising and promotion. About 75 percent of those dollars go towards promotional efforts, including sponsorship of community events and programs.

• The National Social Norms Institute is made possible through a generous gift from the Anheuser Busch companies and its charitable foundation.

Concentrate on Policy Changes • Increase the price of alcohol • Lower BAC for driving and implement other strategies to lower drinking and driving. • Ban advertising of alcohol • Decouple alcohol and sports • Eliminate alcohol sponsorship of public events

Stepwise approach to the choice of alcohol-control policies

Core

• Affordability – Excise tax graded by volume of ethanol – Inflation-adjusted taxes • Availability – Regulation of all production and sale – Licensing of places for sale and consumption – Licensing of days and hours of sale • Drinking-driving – Blood limit of alcohol concentration established in law – Sobriety check points

• Regulation of marketing – Regulation of all marketing, including sponsorship – Content restricted with no lifestyle advertisements – Bans on sponsorship – Placement restricted by volume and media (eg, no electronic media) • Treatment – Brief intervention

Stepwise approach to the choice of alcohol-control policies Expanded • Availability – Bans on sales and drinking in public places – Enforced laws on service (to intoxication and to minors) – Different availability based on volume of alcohol

• Regulation of marketing – No pricing promotions or discounts – No promotions using competitions or gifts

• Drinking-driving – Random breath testing – Administrative license suspension

Optimum •

Affordability –



Availability –



– –

Restrictions on packaging and product design Ban advertising of corporate philanthropy Ban on all forms of product marketing

Drinking-driving – –



Mass media campaigns supporting availability policy

Regulation of marketing –



Minimum price

Mass media campaigns supporting policy—eg, drink-driving Mandatory treatment for repeat drinking drivers

Treatment – – –

Detoxification Cognitive-behavioral therapies Pharmacological treatments

Concentrate on Policy Changes • Increase the price of alcohol • Lower BAC for driving and implement other strategies to lower drinking and driving. • Ban advertising of alcohol • Decouple alcohol and sports • Eliminate alcohol sponsorship of public events

• These are effective strategies but they can’t be done by colleges alone. Colleges should be part of a local/state/national effort to implement these polices.

A Matter of Degree from NIAAA Tier 1, 2, & 3 Strategies

• The underlying principles guiding the AMOD projects were: – Alcohol problems and solutions are shared by campus and community – Campus and community interact within a shared environment. Universities are part of a larger community. – Identification, discussion and solutions for problems must therefore be collaborative involving city and campus governance, concerned citizens, law enforcement, and business. – As campuses take measures to change their environments, communities could also play a lead role.

• The point of focus should be reversed

A Matter of Degree from NIAAA Tier 1, 2, & 3 Strategies

• The underlying principles guiding the AMOD projects were: – Alcohol problems and solutions are shared by campus and community – Campus and community interact within a shared environment. Universities are part of a larger community. – Identification, discussion and solutions for problems must therefore be collaborative involving city and campus governance, concerned citizens, law enforcement, and business. – As communities take measures to change their environments, campuses could also play a lead role.

• The point of focus should be reversed

But, we can’t ignore the problems that alcohol causes college students on our campuses

– The data show that alcohol is taking a toll on students – People expect us to address it – There are some things that we can do that are effective – at least on an individual level, if not on a population level – College health has more power and influence than we realize – we can make a difference if we focus on the right things. – So what should we do on our campuses?

College Drinking Prevention NIAAA 4 Tiers of Effectiveness • Tier 1: Evidence of Effectiveness Among College Students – Strategy: Combining cognitive-behavioral skills with norms clarification and motivational enhancement interventions. – Strategy: Offering brief motivational enhancement interventions. – Strategy: Challenging alcohol expectancies.

• We should implement these strategies as part of our clinical role.

Franz Kafka died on June 3, 1924 • “My peers, lately, have found companionship through means of intoxication - it makes them sociable. I, however, cannot force myself to use drugs to cheat on my loneliness - it is all that I have - and when the drugs and alcohol dissipate, will be all that my peers have as well.”

What should we be doing on our campuses in our role as a public health agency? • Focus has been on: – Underage drinking – College student drinking – Binge drinking – Raucous behavior – Negative consequences • Is there consensus on these indicators?

Is there consensus on these indicators? • No one should die from alcohol poisoning. • No one should die from an alcohol-related

injury. • No one should be sexually assaulted because

of alcohol.

Eliminating those consequences should be our “Stake in the Ground?”

How should we proceed? • Get better data • Intensive case by case epidemiological investigation of every major alcohol event – ER visit – Detox visit – Death – Sexual assault

Campaign to • Call 911 if someone is passed out and unresponsive.

If a person passed out from alcohol/drug use and you could not wake the person up, how likely is it that you would call 911?

Response to Question Very Likely

Somewhat Likely Somewhat Unlikely Very Unlikely

Did not use alcohol in last 30 days 65.3

Used alcohol in last 30 days

23.2

29.0

8.4

14.5

3.0

5.8

50.7

U of MN – TC CORE Survey 2005

Campaign to • Call 911 if someone is passed out and unresponsive.

• Call 911 if someone is going to drive a car who is intoxicated • Make prevention of sexual assault a community responsibility

What should we do? • Implementation of “Best Practices” for individuals • Shift focus to community of which colleges are a part • Provide leadership • Commit resources and energy • Work on changing societal expectations • Enhance our alcohol epidemiology • Implement policy changes • Foster multi-institutional/system collaboration

Put our Stake in the Ground that no student will die or be sexually assaulted because of alcohol!

Change the conversation about alcohol. College health has more power and influence than we realize.

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