Beyond Amethyst and Social Norms: Rethinking the Approach to Alcohol Use by College Students

1. 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 eehlinger@bhs.umn.edu

2. 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.

3. 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.

4. Alcohol Tolerant Attitudes Percentage of adults drinking 5 or more drinks on an occasion one of more times in last month CDC: BRFSS, 2004

5. Franz Kafka died on June 3, 1924 • “In the fight between you and the world, back the world.”

6. 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.

7. 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.

8. 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

9. 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

10. 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 alcohol-related property damage • College Drinking: Changing the Culture - NIAAA http://collegedrinkingprevention.gov/StatsSummaries/snapshot.aspx

11. 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 alcohol-related 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

12. 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.”

13. 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

14. 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 alcohol-dependent 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).

15. 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.

16. 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

17. 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

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

19. 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.

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

21. 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

22. Are these interventions working?(5+ drinks in one session past 2 weeks)19-20 Year Olds Source: Monitoring the Future, 1975-2006, NIH

23. Number of Deaths Attributable to the Harmful Effects of Excessive Alcohol Use Among 18-20 and 21-24 Year Olds: Alcohol Poisoning 2001-2006 Sources: CDC; Alcohol-Related Disease Impact (ARDI) Software; Alcohol Attributable Deaths (AAD)

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

25. 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.”

26. 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.”

27. 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

28. 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

29. Amethyst InitiativeA 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.

30. Jefferson Davis President of the Confederacy • Born on June 3, 1808 • “Never be haughty to the humble or humble to the haughty.”

31. 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?

32. 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.“

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

34. 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.

35. 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.

36. 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

37. Global Burden of AlcoholWHO 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%

38. 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

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

40. 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

41. 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 DrugUse and Health was conducted for 10,953 respondents aged 50years 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.

42. Burden of Alcohol-related Problems • Excessive alcohol use is the 3rd leading lifestyle-related 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%).

43. 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%.

44. 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

45. 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

46. Concentrate on Policy Changes • Increase the price of alcohol

47. Declining Price of Alcohol

48. Years since last alcohol tax increase • References: Marin Institute • Year of last increase, as of 2009. • 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

49. Erosion of beer tax due to inflation • References: Marin Institute • Year of last increase, as of 2009. • Excise tax rates were deflated using annual CPI data through 2008, the most recent year for which annual inflation data were available. • U.S. Bureau of Statistics CPI, U.S. city average, all items, Base Period: 1982-84=100. • 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

50. 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.