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Reducing Underage Drinking: A Collective Responsibility 7 Supply Side Approaches to Reducing Underage Drinking: An Assessment of the Scientific Evidence Harold D. Holder The consumption of alcoholic beverages by youth is an issue of importance to public health and safety in most countries, especially in the United States. The extent to which the supply of alcoholic beverages, including its production, distribution, and retail sale, influence consumption and cause harm is especially relevant to public policy concerning preventing underage drinking, especially heavy drinking. At the simplest level, supply responds to demand. Whenever there is a public desire for alcohol, a supply will be created (even if it is illicit). Yet the supply and demand relationship is hardly one-directional. This is especially true if the supply of alcohol is legal and public, for there is also a clear potential for supply to influence demand, especially among youth who can view drinking as an “adult” activity. Therefore, the supply of alcohol and retail sales are especially relevant to policy concerns about youth drinking. Youth are attracted to lower cost and illegal supply of alcohol because purchase of alcohol in legal retail outlets is forbidden. As a result, this chapter is directed to research concerning the supply side of alcohol and its interaction with alcohol consumption and eventually with alcohol problems. ALCOHOL SUPPLY AND ACCESS BY YOUTH Even with the highest minimum alcohol purchase age in the world, American youth enjoy many opportunities to obtain alcohol. There is clear evidence that youth perceive alcohol to be available to them, whether
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Reducing Underage Drinking: A Collective Responsibility through retail or social outlets. Youth continue to experience ready access to alcohol, and 94 percent of twelfth graders reported in 2001 that it is “fairly” or “very” easy to get (University of Michigan, 2001). In a national study of adolescents in grades seven through twelve, Swahn, Hammig, and Ikeda (2002) found that youth report relatively easy access to both alcohol and guns in their home. In fact, gun versus alcohol availability was relatively similar (29 percent versus 24 percent). Purchase surveys reveal that anywhere from 30 percent to 70 percent of outlets may sell to underage buyers, depending on their geographical location (e.g., Forster et al., 1994; Forster, Murray, Wolfson, and Wagenaar, 1995; Preusser and Williams, 1992; Grube, 1997). Even at the lowest end of this range (30 percent), seven tries at different outlets will yield a 92 percent successful purchase rate. Given the likelihood that social networks of youth will share information about outlets at which alcohol has been purchased successfully, the estimated maximum of six unsuccessful tries prior to almost certain purchase is conservative. Focus groups have also indicated that underage youth typically procure alcohol from commercial sources and adults or at parties where parents and other adults are not present (Jones-Webb et al., 1997; Wagenaar et al., 1993). Wagenaar et al. (1996) have reported that 46 percent of ninth graders, 60 percent of twelve graders, and 68 percent of youth aged 18 to 20 obtained alcohol from an adult on their most recent drinking occasion. Commercial outlets were the second most prevalent alcohol source for youth aged 18 to 20. The source of alcohol varies by age group, as shown in Table 7-1 (Wagenaar et al., 1996). Students in ninth grade rely on home sources of alcohol much more than the older students. The reliance on home supply declines significantly by the end of high school. Of particular note is that social sources, that is, other persons either underage themselves or persons of legal age, were the predominate sources of alcohol for all age groups. A similar finding from other studies suggests that younger adolescents’ primary sources of alcohol are older siblings, friends and acquaintances, and adults (through third-party transactions) as well as parties (Harrison, TABLE 7-1 Source of Alcohol by Age Group (all numbers in percentages for current drinkers over the past 30 days) Source of Alcohol 9th Grade Students 12th Grade Students Youth Ages 18-20 Commercial alcohol outlet 3 9 14 Home 27 6 11 Another person under age 21 29 29 10 Another person age 21 or older 46 60 68 SOURCE: Wagenaar et al. (1996).
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Reducing Underage Drinking: A Collective Responsibility Fulkerson, and Park, 2000; Jones-Webb et al., 1997; Schwartz, Farrow, Banks, and Giesel, 1998; Wagenaar et al., 1993). In addition, the national surveys of college student drinking find that a large percentage of college youth report they do not have to pay anything for alcohol, presumably because they are at a party where someone else is supplying the alcohol (Wechsler, Kuo, Lee, and Dowdall, 2000). The importance of alcohol supply to youth has been studied by examining the effects of alcohol advertising on youth decisions about drinking (Atkin, Eadie, Leather, McNeill, and Scott, 1988; Austin and Nach-Ferguson, 1995; Grube and Wallack, 1994). There is evidence of the effects of alcohol promotion on youth. In addition, such issues as legal age for purchase of alcohol and the enforcement of underage sales of alcohol have been shown to affect youth access to retail supply (Grube, 1997; Wagenaar and Toomey, 2002). In addition, alcohol prices have an important effect on youth drinking (see Cook and Moore, 2001). STANDARDS OF EVIDENCE FOR PREVENTION STRATEGIES Solid empirical evidence should form the basis for the decisions that communities, agencies, and individuals make about how to reduce availability of alcohol to youth. At a minimum, this evidence should (1) provide substantial indication of effectiveness in reducing access and ideally youth drinking, and (2) should be based on methodologically strong research. In other words, good ideas are not sufficient, regardless of their logical, intuitive, or popular appeal. First, the evaluation of the prevention strategy must show that it affects reliable and valid measures of youth drinking or risk factors clearly shown to increase risk of drinking. Second, this effect must be demonstrated using designs that allow the research to rule out competing explanations and the utilization of appropriate statistical analyses in comparison to an appropriate comparison or control group or condition. Third, an appropriate research design should be used. Evaluating investigator-designed prevention programs can utilize randomized controlled trials, which can be used to rule out competing hypotheses. With many policy interventions, however, it is impractical, inappropriate, or not possible to undertake random assignment. With interventions such as alcohol taxation and drunk driving laws, the political process, not random assignment, determines whether individuals in a certain jurisdiction on a given date are subject to high or low taxes, tough or lenient drunk driving laws, and so on. Such studies have been called quasi-experimental designs (Cook and Campbell, 1979) to describe designs that do not employ random assignment to experimental or control conditions. Scientists also use the term natural experiments or “experiments without random assignment.” Alternative designs should be em-
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Reducing Underage Drinking: A Collective Responsibility ployed that provide the strongest evidence for the specific prevention situation. Fourth, the characteristics of the population addressed should be clearly specified, as should the intervention. Fifth, prevention effects should be replicated by independent investigators. For this chapter there was no requirement that policy interventions be evaluated with randomized control designs. Youth drinking is a primary dependent variable, which could be considered the target for supply side prevention strategies. However, such a variable is often unavailable for evaluating supply side strategies, and other indicators or surrogates are employed. One dependent variable often used is alcohol-involved traffic crashes for underage persons—persons who are under 21 years old, but licensed to drive. This dependent variable has at least two desired features; (1) longitudinal data are available for traffic crashes in all states, so complex outcome analyses can be undertaken, and (2) traffic crashes are frequently an alcohol-involved harm for youth. Other indicators, including self-reported drinking over the past 30 days (a reasonable indicator of frequency of drinking) and heavy drinking events or frequency (often 5 drinks or more per drinking occasion for males and 4 drinks or more for females), are also used when survey data are available. Recently, alcohol-involved injuries and violence involving youth and young adults (either as victims or perpetrators) also have been used. STRATEGIES TO AFFECT THE SUPPLY OF ALCOHOL TO YOUTH Most policy measures aimed at young people target the availability of alcohol by increasing personal cost or risk. Other alcohol policies that do not specifically target youth can also have a substantial impact on drinking by young people, and such policies can communicate norms to young people regarding the unacceptability of their drinking and to adults about the unacceptability of providing alcohol to underage persons (see Laixuthai and Chaloupka, 1993). Minimum drinking or purchase age limits, for example, are intended specifically to decrease or prevent drinking by young people without regard to the situation in which the drinking takes place. Policies targeting drinking occasions attempt to prevent drinking in conjunction with risky activities or situations without necessarily reducing overall drinking in the population or among specific groups. Random breath testing, for example, is designed to reduce drinking and driving, but does not target specific groups nor is it intended to reduce overall alcohol consumption in the population. See the summary of research by Grube and Nygaard (2001), of which this chapter makes extensive use, as well as Komro and Toomey (2002). In general, one can organize into two groups alternative strategies that are designed to directly or indirectly alter the availability of alcohol to
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Reducing Underage Drinking: A Collective Responsibility youth: those that affect economic availability and those that affect physical availability. The former includes both the actual retail price of alcohol (or full price) as paid by the consumer and what might be called “acquisition or opportunity costs,” that is, the cost of locating alcohol, including finding transportation. This is covered in Chapter 9 of this volume. The latter is a much larger domain of prevention; it includes efforts to reduce retail availability of alcohol, but also social availability. The Physical Availability of Alcohol This section summarizes the alternative strategies for reducing the physical availability of alcohol to youth. The subsections are organized under strategies with similar characteristics: restricting retail access, reducing convenience, reducing social and third-party access, and increasing sanctions. Restricting Retail Access by Youth and Its Enforcement This subsection discusses strategies that are specifically directed at reducing the retail access of alcohol to youth, including specifying a legal age of purchase, limiting the age of alcohol sellers, responsible beverage service, controls on age of alcohol seller, reducing use of false identification, enforcement against sales of alcohol to youth, and restrictions on alcohol advertising. Underage drinking and purchase laws. The goal of a higher minimum legal drinking age is to reduce alcohol consumption among those under 21 years of age. In the 1980s, all U.S. states were required to adopt a uniform minimum age of 21 for all beverages. The U.S. General Accounting Office (GAO) (1987) reviewed 32 published research studies both before and after the law changed. GAO concluded that there was solid scientific evidence that increasing the minimum age for purchasing alcohol reduced the number of alcohol-involved traffic crashes for those below the age of 21. These and more recent studies uniformly show that increasing the minimum drinking age significantly decreases self-reported drinking by young people, the number of fatal traffic crashes, and the number of arrests for driving under the influence of alcohol (DUI). Yu, Varone, and Shacket (1997) found a 70 percent decrease in self-reported alcohol purchase by 19- to 20-year-olds after the implementation of a minimum drinking age of 21 in New York state. O’Malley and Wagenaar (1991) found that the minimum age affected self-reported alcohol use among young people and reduced traffic crashes. The effect on car crashes continued well after young people reached the legal drinking age. Klepp, Schmidt, and Murray (1996) found that implementation of the uniform
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Reducing Underage Drinking: A Collective Responsibility minimum legal drinking age of 21 in the United States reduced the overall prevalence of drinking and driving. Saffer and Grossman (1987a, 1987b), Wagenaar (1981, 1986), and Wagenaar and Maybee (1986) indicate that raising the minimum legal drinking age from 18 to 21 decreased single vehicle nighttime crashes involving young drivers from 11 percent to 16 percent at all levels of crash severity. Voas, Tippetts, and Fell (1999), using data from all 50 states and the District of Columbia for 1982 through 1997, concluded that the enactment of the uniform minimum drinking age law was responsible for a 19 percent net decrease in fatal crashes involving young drinking drivers after controlling for driving exposure, beer consumption, enactment of zero-tolerance laws, and other relevant changes in the laws during that time period. In the most comprehensive review to date, Wagenaar and Toomey (2002) analyzed all identified published studies on the drinking age from 1960 to 1999, a total of 132 documents. They coded eight key variables for each study. The variables included the jurisdiction (i.e., state or province) studied, specific outcome measures analyzed (e.g., self-reported drinking, car crash fatalities), and whether the study was specific to college student populations. In addition, each study was rated on three indicators of methodological quality. In 48 of the studies they reviewed, the effects of changes in the drinking age on alcohol consumption were examined, using a total of 78 alcohol consumption measures (e.g., sales figures, self-reported drinking). Of the 78 measures, 45 percent showed that a higher legal drinking age was associated with reduced alcohol consumption among youth, while 5 percent found that a higher drinking age was associated with greater adolescent consumption. Wagenaar and Toomey (2002) found 57 published studies that assessed the effects of changes in the legal minimum drinking age on indicators of drunk-driving and traffic crashes. A total of 102 crash outcome measures were analyzed (e.g., fatal crashes, drunk-driving crashes, self-reported driving-after-drinking). Of the 102 analyses, more than 50 percent found that raising the drinking age reduced crashes, and lowering it raised the crash rate. Only 2 found a positive relationship between the legal drinking age and traffic crashes. Of the 95 analyses, including comparison groups, 50 (53 percent) found a statistically significant effect of changing the drinking age on car crashes. Most of these analyses (92 percent) employed probability samples or a complete census of the relevant population. Wagenaar and Toomey (2002) analyzed 24 published studies that assessed the effects of changes in the legal minimum drinking age on indicators of other health and social problem outcomes, such as suicide, homicide, or vandalism. Sixteen percent of these studies showed lower problem levels among adolescents when the drinking age was higher. When they analyzed the 23 studies of higher methodological quality, they found that
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Reducing Underage Drinking: A Collective Responsibility 35 percent showed that a higher minimum drinking age was associated with lower rates of other problems. Their analysis of the evidence led them to conclude that—compared to a wide range of other programs and efforts to reduce drinking among high school students, college students, and other teenagers—increasing the legal age for purchase and consumption of alcohol to 21 appears to have been the most effective strategy. In agreement with that, the National Highway Traffic Safety Administration (NHTSA, 1998) estimated that a drinking age of 21 reduced traffic fatalities by 846 deaths in 1997 and prevented a total of 17,359 deaths since 1975. It is clear, however, that the benefits of a higher drinking age are realized only if the law is enforced. Despite higher minimum drinking age laws, young people can and do purchase alcohol (e.g., Forster et al., 1994; Forster et al., 1995; Preusser and Williams, 1992; Grube, 1997). Such sales result from low and inconsistent levels of enforcement, especially when there is little community support for underage alcohol sales enforcement (Wagenaar and Wolfson, 1994, 1995). Even moderate increases in enforcement can reduce sales of alcohol to minors by as much as 35 percent to 40 percent, especially when combined with media and other community and policy activities (Grube, 1997; Wagenaar et al., 2000a,b). Responsible beverage serving practices. Efforts to promote responsible beverage service or sales (RBS) involve the creation of clear policies (e.g., requiring clerks or servers to check identification for all customers appearing to be under the age of 30) and training in their implementation (e.g., teaching clerks and servers to recognize altered or false identification). RBS can be implemented at both on-license establishments, which can sell alcohol for consumption on premise (e.g., bars, pubs, and restaurants) (Saltz and Stanghetta, 1997), and off-license establishments, which can only sell alcohol for consumption elsewhere (e.g., liquor stores and grocery stores) (Grube, 1997). Saltz and Hennessy (1990a, 1990b) and Saltz (1988) demonstrated that server training is most effective when coupled with a change in actual serving policy and practices of a bar or restaurant. RBS has been found to reduce the number of intoxicated patrons leaving a bar (e.g., Dresser and Gliksman, 1998; Gliksman et al., 1993; Saltz, 1987, 1989) and the number car crashes (e.g., Holder and Wagenaar, 1994). Whether RBS interventions can reduce minors’ use of alcohol is less clear. Establishments with firm and clear policies (e.g., checking ID for all patrons who appear under the age of 30) and a system for monitoring staff compliance are less likely to sell alcohol to minors (Wolfson et al., 1996a; Wolfson et al., 1996b). However, Grube (1997) found that voluntary clerk and manager training at off-license establishments had a negligible effect on sales to minors above and beyond the effects of increased enforcement. Similarly, a
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Reducing Underage Drinking: A Collective Responsibility study in Australia found that, even after training, age was rarely checked in bars, although decreases in the number of intoxicated patrons were observed (Lang, Stockwell, Rydon, and Beel, 1996, 1998). In one study, RBS training was associated with an increase in self-reported checking of identification by servers (Buka and Birdthistle, 1999). Overall, establishing definite alcohol serving policies in each licensed establishment has the potential to reduce sales of alcohol to youth and overall problematic consumption of alcohol. Controls on who is selling alcohol. Alcohol control agencies typically spend a considerable part of their time checking the credentials of those seeking licenses to sell alcoholic beverages. Typically, they attempt to keep those with criminal records or associations out of the trade. The minimum age of alcohol sellers that is set in some countries could affect the extent to which underage sales might occur, with younger persons finding themselves less able to distinguish underage from of-age buyers and being more willing to sell to underage buyers. Treno, Gruenewald, Alaniz, Freisthler, and Remer (2000) report that among a community-based sample of alcohol establishments, off-premise sales were more likely from younger than older sales-people. In places where a minimum legal drinking age exists, there is likely to be some sort of informal market to serve underage drinkers. However, no evaluations have been done of minimum age-of-seller restrictions. Use of false ID to obtain alcohol. Underage persons can obtain alcohol from retail sources using false age identification cards. For example, a survey was conducted among high school juniors and seniors and college students under age 21 in New York and Pennsylvania. New York has generally weak laws on purchase of alcohol by persons under legal age, while Pennsylvania has generally strong laws and state-controlled liquor stores. In comparison with high school respondents in Pennsylvania, more high school students in New York reported that they drank, drank more often, and obtained alcohol from underage friends. More attempts to purchase alcohol at bars, liquor stores, and other outlets were reported by New York high school and college students. Preusser, Ferguson, Williams, and Farmer (1995) found that nearly 60 percent of New York college student respondents reported using false, borrowed, altered, or counterfeit identification to purchase alcohol, compared with 37 percent in Pennsylvania. They also found that nearly 30 percent of New York high school students reported the use of false identification, compared with 14 percent in Pennsylvania. Schwartz et al. (1998) found that 15 percent of high school students, 14 percent of college freshmen, and 24 percent of youth reporting also using illegal drugs said they were able to purchase beer by the case with borrowed, altered, or fake ID. Suggestions to reduce the effective use of
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Reducing Underage Drinking: A Collective Responsibility illegal identification include universal ID checking of all alcohol customers, use of two-view or hologram photos on a driver’s license, and requiring two or more different ID cards at the point of purchase. Increased enforcement against stores that fail to identify underage customers is another strategy to reduce sales to youth. Administrative regulations concerning alcohol sales to youth. The enforcement of laws against sales of alcohol to youth varies considerably across states. States that take youth drinking less seriously have much lower arrest rates for violations of sales to youth laws, while states that apparently take sales of alcohol to youth seriously have much higher arrest rates for law violations (Wagenaar and Wolfson, 1994). Wagenaar and Wolfson (1994) found that states that had more arrests for minor crimes tended to have fewer arrests for underage drinking. They concluded that where penalties were lenient, the threats were inadequate to deter providers of alcohol from selling or providing alcohol to underage persons. As a result, they concluded that the enforcement and penalties against providing alcohol to youth were inadequate to serve as an effective deterrent. Because few commercial establishments were cited for serving/selling alcohol to youth, there was no real practical level of deterrence for retail establishments (Wagenaar and Wolfson, 1994). Compliance checks are efforts to test if underage persons can purchase alcohol from licensed alcohol outlets. While police sting operations often utilize an actual underage person and cite or arrest a clerk or store manager when the underage person is successful in purchasing, most research-based compliance checks utilize underage persons whom a committee of local citizens have judged to look underage and therefore should naturally have their identification checked when attempting to purchase alcohol (Grube, 1997; Holder et al., 2000). Because retailer awareness of enforcement activities is important to the success of compliance check programs, media advocacy efforts are important and should be used to inform the public and retailers about the ongoing intervention. The effects of compliance checks within a community context are described later in this chapter. A recent study in Louisiana (Scribner and Cohen, 2001) used a repeated intervention design of a random sample of off-sale alcohol outlets in New Orleans. The intervention was a compliance check carried out by the Louisiana Department of Beverage Control (ABC) and involved the use of “underage-looking youth” who ranged from ages 17 to 22 to attempt to purchase alcohol in licensed outlets. If an alcohol sale was made without requiring age identification, then the outlet was considered noncompliant. This enforcement strategy was linked with increased local news coverage to increase both public and off-premise outlet owner/manager awareness of the compliance checks. At baseline before intervention, 11.2 percent of
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Reducing Underage Drinking: A Collective Responsibility outlets were compliant. Two months after the intervention, the level of compliance had increased to 39.9 percent. Eight months after the intervention, there was a residual level of compliance even without any further media coverage. Restrictions on alcohol advertising to youth. Policies that restrict advertising to young people are strategies designed to limit the supply side of alcohol to youth. Such restrictions could conceivably affect consumption (see Grube and Nygaard, 2001). Survey studies consistently find small, but significant, relationships between awareness of and liking of alcohol advertising and adolescents’ drinking beliefs and behaviors (e.g., Casswell and Zhang, 1998; Connolly, Casswell, Zhang, and Silva, 1994; Grube, Madden, and Friese, 1996; Grube and Wallack, 1994; Wyllie, Zhang, and Casswell, 1998). Although a few econometric studies have shown positive relationships between advertising expenditures and overall consumption or alcohol-related mortality (e.g., Saffer, 1997), others are negative or mixed in their findings (Duffy, 1995; Nelson and Moran, 1995). Apparently no studies have investigated the specific effects of advertising restrictions on youth drinking or associated problems. Reducing the Convenience of Retail Alcohol Such strategies are not targeted specifically at young or underage drinkers, but they have the potential to limit the overall availability of alcohol to all drinkers, including youth. These strategies typically increase the opportunity cost to the drinker, that is, the cost in time and money to actually obtain alcohol from retail sources. Density of alcohol outlets. The number and concentration of alcohol retail outlets affect the convenience of youth obtaining alcohol, and the distance between outlets increases the cost to obtain alcohol. Restricting alcohol availability through law has been a key policy in Canada, the United States, and many other parts of the world (Kortteinen, 1989; Room, 1987). Gruenewald, Ponicki, and Holder (1993) conducted a time series cross-sectional analysis of alcohol consumption and density of alcohol outlets over all 50 U.S. states. The results indicated that a 10 percent reduction in the density of alcohol outlets would reduce consumption of spirits from 1 percent to 3 percent and consumption of wine by 4 percent. However, Gruenewald, Millar, Ponicki, and Brinkley (2000) did not find a significant relationship between consumption and the density of outlets in neighborhoods. One recent study has investigated the relationship of density of alcohol outlets with underage drinking and driving behavior as reported on two telephone surveys in California (Treno, Grube, and Martin, in press).
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Reducing Underage Drinking: A Collective Responsibility The study found that although outlet density did not directly affect either youth driving after drinking or riding with drinking drivers, density did interact with the driver licensing status of the youth on both behaviors. Thus higher density was positively related to drinking and driving among licensed youth drivers and negatively related to riding with drinking drivers among youth who did not have driver licenses. This is the first solid evidence of a relationship between alcohol outlet densities and drinking-related risky behavior by youth. Licensing of alcohol outlets can restrict the number or density of outlets in a given area as well as the hours of sale, the types of beverages, and the size of beverage containers. Several U.S. studies have investigated the effects of privatization of wine sales and the elimination of a state monopoly on retail sales of distilled spirits (e.g., Wagenaar and Holder, 1995; Holder and Wagenaar, 1990). These studies found an increase in overall consumption, but did not analyze consumption by young people. Valli (1998) reported that when medium strength beer was made available in grocery stores in a township in Finland, drinking among 13- to 17-year-olds increased. Minors could purchase alcohol more easily than when sales had been restricted to state stores. Days and hours of sale. Reducing the days and times of alcohol sales restricts the opportunities for alcohol purchasing and can reduce heavy consumption. It is a common strategy for reducing drinking-related problems, although the trend in recent years has been to liberalize such restrictions in many countries (e.g., Drummond, 2000). Smith (1988) found that the introduction of Sunday alcohol sales in Brisbane, Australia, was related to increased traffic crashes. However, these results are not unequivocal, as these effects could be contaminated by other trend effects on Sunday sales and nonequivalent distribution of crashes over days of the week (see Gruenewald, 1991). Reducing the hours of sale is associated with decreases in drinking and drinking problems (e.g., Gray, Saggers, Atkinson, Sputore, and Bourbon, 2000) with reductions in hospital admissions, and with arrests for alcohol-related causes. In one of the few studies focusing on youth, it was found that temporary bans on the sales of alcohol from midnight Friday through 10 a.m. Monday because of federal elections reduced cross-border drinking in Mexico by young Americans (Baker, Johnson, Voas, and Lange, 2000). In particular, the early closing on Friday night was associated with a 35 percent reduction in the number of pedestrians crossing the border and a reduction in the number of these with blood alcohol levels of 0.08 percent or higher. In sum, it appears that changes in licensing provisions that substantially reduce hours of service can have a significant impact on drinking and drinking-related problems overall. The evidence that
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Reducing Underage Drinking: A Collective Responsibility quantitative process data were collected to capture how the intervention moved ahead and the obstacles staff and communities faced in reaching their objectives. Merchant survey data revealed that they increased checking for age identification, reduced their likelihood of sales to minors, and reported more care in controlling sales to youth (Wagenaar et al., 1996). The study using purchasers who looked young confirmed that alcohol merchants increased age-identification checks and reduced their propensity to sell to minors. The telephone survey of 18- to 20-year-olds indicated that they were less likely to consume alcohol themselves and less likely to provide it to other underage persons (Wagenaar et al., 2000a,b). Finally, the project found a statistically significant net decline (intervention compared to control communities) in drinking and driving arrests among 18- to 20-year olds and disorderly conduct violations among 15- to 17-year-olds (Wagenaar et al., 2000a,b). The interventions (Wagenaar et al., 2000a,b) reduced both drinking (7 percent reduction in 30-day prevalence and 4 percent decrease in drinking occasions) and drinking-related behaviors among 18- to 20-year-olds, and decreased alcohol sales to minors. However, no overall effect was found for drinking by high school-aged youth. A purchase attempt survey revealed that the interventions led to a 10 percent net increase in checking for age identification, and a 10 percent net reduction in merchants’ alcohol sales to minors (Wagenaar et al., 2000a,b). The Community Trials Project The Community Trials Project (Holder et al., 1997) tested a five-component community intervention to reduce alcohol-related harm among people of all ages. Three experimental and three matched comparison communities were selected, each with a population of approximately 100,000. Each community was racially diverse, with 40 percent or more minority group members. The Community Trials Project fielded five intervention components: (1) a “Media and Mobilization” component to develop community organization and support for the goals and strategies of the project and to utilize local news to increase public support of environmental strategies; (2) a “Responsible Beverage Service” component to reduce service to intoxicated patrons at bars and restaurants; (3) a “Sales to Youth” component to reduce underage access; (4) a “Drinking and Driving” component to increase local enforcement of driving while intoxicated laws; and (5) an “Access” component to reduce the availability of alcohol. Comparing experimental and control communities, it was found that the intervention produced significant reductions in nighttime injury crashes (10 percent lower in experimental than in comparison communities) and in crashes in
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Reducing Underage Drinking: A Collective Responsibility which the driver was found by police to “have been drinking” (6 percent). Assault injuries observed in emergency departments declined by 43 percent in the intervention communities vs. the comparison communities, and all hospitalized assault injuries declined by 2 percent. There was a 49 percent decline in reports of driving after “having had too much to drink” and 51 percent in self-reports of driving when “over the legal limit.” Surprisingly, although the drinking population increased slightly in the experimental sites over the course of the study, there was a significant reduction in problematic alcohol use: Average drinks per occasion declined by 6 percent and the variance in drinking patterns (an indirect measure of heavy drinking) declined by 21 percent (Holder et al., 2000). Of particular interest is that the Sales to Youth component produced a significant reduction in alcohol sales to minors. Overall, off-premise outlets in experimental communities were half as likely to sell alcohol to minors as in the comparison sites. This was the joint result of special training of clerks and managers to conduct age identification checks, the development of effective off-premise outlet policies, and, especially, the threat of enforcement of lawsuits against sales to minors (Grube, 1997). Community Interventions Overall These two community studies support the positive effects of compliance checks of alcohol merchants as well as the utilization of multiple strategies in concert. Other studies have also demonstrated that such comprehensive strategies can make substantial contributions to declines in alcohol sales to minors in a relatively short period of time. For example, a program in Denver yielded reductions in sales to underage police cadets of more than 50 percent over 10 months (Preusser, Williams, and Weinstein, 1994); similar reductions are reported by Lewis et al. (1996). Levels of enforcement can be enhanced significantly with only modest increases in community support, and even moderate increases in enforcement can reduce outlet sales of alcohol to minors, especially when combined with media and other community and policy activities (Grube, 1997; Lewis et al., 1996; Wagenaar et al., 2000a,b). Available research has confirmed that no local policy to reduce youth drinking can be fully effective unless it is enforced adequately, and there is public awareness of both the policy and its enforcement efforts on the part of the intended targets. Media advocacy constitutes the purposeful use of local news (i.e., newspapers, radio, and TV) in support of local policy. It has been shown to be a low-cost, yet effective strategy to increase public awareness and public support of alcohol availability strategies (Stewart and Casswell, 1993; Treno and Holder, 1997; Treno et al., 1996; Holder and
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Reducing Underage Drinking: A Collective Responsibility Treno, 1997). Media advocacy will be used to increase perception of risk of citation of retail sellers, underage buyers, parents, and other adults for selling and/or providing alcohol to underage persons; increase citizens’ awareness and acceptance of enforcement; enhance communities’ perceptions of ownership of intervention strategies; and support efforts to increase the perceived risk of providing alcohol to minors at parties. The project coordinator in each intervention community will arrange for newspaper articles that describe the intervention activities and report the number of off-sale outlets that were cited for sales to minors. Television news coverage will include hidden cameras that record decoy operations where alcohol is purchased by underage decoys, as well as more general stories (Grube, 1997). Based on the Community Trials Project (Holder et al., 2000), media advocacy will increase local media news coverage of the problem of underage drinking and the enforcement strategies being undertaken. In practice, local news media monitor each other’s news and, as a result, a story in one source often is repeated in another source. This increase in news coverage leads to community awareness (Holder and Treno, 1997). Thus it operates as an essential adjunct of the environmental strategies implemented, although it is not an end in itself. CONCLUSION Based on the available scientific evidence from more than one controlled study, the most effective public policies to reduce the retail and social alcohol availability to youth and associated problems appear to be (1) the minimum drinking age and its enforcement, (2) zero tolerance or graduated licensing, and (3) enforcement of sales of alcohol to underage persons, especially using compliance checks of retail sales of alcohol to underage persons. The effects of reducing alcohol outlet density on youth drinking need further study. There is one positive, significant finding of a relationship between outlet density and youth DUI. The potential of tort liability to reduce traffic crashes for persons under 21 is based on one national study. Random breath testing and sobriety checkpoints appear promising for reducing drinking and driving based on studies with the general population, although there is little available evidence for their effectiveness, specifically with young people and the potential to impact both social and retail supply. Relatively large changes in the conditions of sale, such as increasing the form of alcohol availability or changing the days and hours of alcohol sale, could possibly alter youth access to alcohol. Similarly, the introduction or legalization of specific beverage types appears to change beverage preferences and possibly increase consumption.
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Reducing Underage Drinking: A Collective Responsibility What is unknown at this point in time is the effectiveness of strategies to reduce the social availability of alcohol to youth. Approaches such as shoulder taps, party patrols, or keg registration need controlled testing and evaluation, although on the surface such strategies have the potential to be effective. Although strategies with a similar theoretical basis have been shown to be effective, we do not have evidence from controlled trials. The bottom line is that no strategy to affect the supply side of alcohol for youth will be consistently effective unless applied in practice and enforced. This enforcement is largely dependent on the will and desire of states and communities to support such application and enforcement. Without consistent enforcement, little of the potential of these strategies can be achieved in practice. REFERENCES Atken, P.P., Eadie, D.R., Leathar, D.S., McNeill, R.E., and Scott, A.C. (1988). Television advertisements for alcoholic drinks do reinforce under-age drinking. British Journal of Addiction, 83, 1399-1419. Austin, E.W., and Nach-Ferguson, B. (1995). Sources and influences of youth and school-age children’s general and brand-specific knowledge about alcohol. Health Communication, 9, 323-349. Baker, T.K., Johnson, M.B., Voas, R.B., and Lange, J.E. (2000). Reduce youthful binge drinking: Call an election in Mexico. Journal of Safety Research, 31(2), 61-69. Balmforth, D. (1999). National survey of drinking and driving, attitudes and behavior: 1997. (DOT HS No. 808 844). Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration. Blomberg, R.D. (1992). Lower BAC limits for youth: Evaluation of the Maryland .02 Law (DOT HS No. 807 860). Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration. Boase, P., and Tasca, L. (1998). Graduated licensing system evaluation: Interim report ’98. Toronto: Ministry of Transportation of Ontario. Buka, S.L., and Birdthistle, I.J. (1999). Long-term effects of a community-wide alcohol server training intervention. Journal of Studies on Alcohol, 60, 27-36. Cameron, M., Cavallo, A., and Sullivan, G. (1992). Evaluation of the random breath testing initiative in Victoria 1989-1991. Multivariate time series approach. (Report No. 38). Victoria, Australia: Monash University Accident Research Centre. Cameron, M., Diamantopoulou, K., Mullan, N., Dyte, D., and Gantzer, S. (1997). Evaluation of the country random breath testing and publicity program in Victoria, 1993-1994. (Report No. 126). Victoria, Australia: Monash University Accident Research Centre. Casswell, S., and Zang, J.F. (1998). Impact of liking for advertising and brand allegiance on drinking and alcohol-related aggression: A longitudinal study. Addiction, 93(8), 1209-1217. Cohen, F., and Rogers, D. (1997). Effects of alcohol policy change. Journal of Alcohol and Drug Education, 42, 69-82. Communities Mobilize to Rescue the Parks. (1991, Winter). Prevention File, 6(1), 7-8. Connolly, G.M., Casswell, S., Zhang, J.F., and Silva, P.A. (1994). Alcohol in the mass media and drinking by adolescents: A longitudinal study. Addiction, 89(10):1255-1263.
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Representative terms from entire chapter: