Toben F Nelson, ScD Division of Epidemiology and Community Health University of Minnesota

1. Understanding College Student Drinking and the Systems Used to Address It Toben F Nelson, ScD Division of Epidemiology and Community Health University of Minnesota

2. University of Minnesota – School of Public Health Division of Epidemiology and Community Health http://www.epi.umn.edu/alcohol

3. Harvard School of Public Health COLLEGE ALCOHOL STUDY http://www.hsph.harvard.edu/cas

4. Substance Abuse Policy Research Program

5. Objectives: • Describe the problem of college student drinking • Draw on relevant theory to frame the problem for intervention • Identify empirically-based approaches to effectively reduce student drinking • Describe existing college systems for addressing student drinking

6. College student heavy drinking is a serious problem Annual alcohol-related mortality and morbidity among U.S. college students • 1,825 deaths • 599,000 injuries • 696,000 assaults • 97,000 sexual assaults Hingson, Zha & Weitzman, 2009

7. RISK FACTOR OUTCOME Injuries Liver disease Violence, Sexual Assault GI cancers, GI disorders Alcohol Misuse Unintended Pregnancies Cardiovascular disease Child Neglect Crime, legal costs Lost productivity, absenteeism Alcohol Use Disorders

8. Consequences of Alcohol PREVENTION HARM REDUCTION PERSON CONSUMPTION Probabilistic relationship By drinking event By drinker CONSEQUENCE(S)

9. Individual-level Variation in Drinking High Risk Groups Males (Wechsler et al. 1995) Prior drinking history (Wechsler et al. 1995) Other substance users (Wechsler et al. 1995) Fraternity & Sorority members (Wechsler, Kuh & Davenport, 1996) Athletes (Nelson & Wechsler, 2001) Sports Fans (Nelson & Wechsler, 2003)

11. Toxic Alcohol Environments High binge colleges More likely to: focus on intercollegiate athletics and fraternity/ sorority life (settings for socializing and drinking) have a large number of alcohol outlets nearby have heavy marketing of alcohol have lax policy and enforcement College Local Community State Wechsler & Nelson, 2008

13. No real change in drinking behavior or related harms …despite considerable attention to the issue and investment in prevention efforts Grucza et al., 2009 Nelson et al., 2009 Johnston et al., 2008 Substance Abuse and Mental Health Services Administration, 2007 Wechsler et al., 2002

14. We can probably do better… By taking a wider view By paying attention to some useful theory By doing more science on what schools do and how they do it By moving beyond what has already been tried By resisting the temptation to do only what is easy

15. Some theories and perspectives that I have found useful… -Public Health Perspective -Integrated Theory of Drinking Behavior -Strategy of Preventive Medicine

16. Some Distinctions between Public Health and Medicine H Fineberg, Harvard School of Public Health, 1990 http://www.hsph.harvard.edu/about.html

17. Public Health Triad Host Agent Environment

18. Knowledge Pricing Attitudes Composition Intentions Labeling Skills Packaging Advertising/Promotion Legal Sanctions Availability Institutions Physical Context SocioculturalContext KeyInfluencers Drug-Related Problems Person Drug Environment Torjman (1986)

19. Legal Availability Formal Social Controls Public Policy & Individual Risk Factors Drinking Alcohol-related Problems Institutional Behavior Policies/Structures Economic Availability Physical Adapted from Wagenaar & Perry, 1994 Availability Integrated theory of drinking behavior Problems that stem from alcohol use are primarily a function of availability

20. Strategy of Preventive Medicine • High-risk: change extreme, high-risk individuals, treatment • Population: change majority, the conditions that shape everyone’s behavior. • Prevention Paradox Rose (1985)

21. The Prevention Paradox A person-centered (vs. event-centered) perspective Greatest risk of health harms among extreme drinkers. HOWEVER, few extreme - many “moderate” drinkers. “Moderate” drinkers are also at-risk Vast majority of health harms in a community arise from moderate or low consumers. Greatest health gains from incrementally moving majority. Rose (1985); Rose (1992)

22. Risk of injury, by usual number of drinks(past 30 days) Weitzman & Nelson (2004)

23. Evidence for findings regardless of: consumption measure Usual drinks Drinking frequency Frequency of drunkenness negative social/health consequence 14 different outcomes Only the risk trajectory varied The Prevention Paradox Weitzman & Nelson (2004); Wechsler & Nelson (2006)

24. Risk of injury, by usual number of drinks(past 30 days) Weitzman & Nelson (2004)

25. High Risk Approaches Systematically identify students at highest risk (screening) Science-based intervention Developmentally-appropriate treatment

26. High-Risk Approach Advantages Intervention tailored/targeted to the individual Clear benefits (when achieved) to the individual Intuitive Disadvantages Difficult & costly to ID “at-risk” Effects palliative, temporary Low odds success Modest benefit to the population

27. Population Approaches Create an environment that discourages: • all alcohol use among underage students • excessive alcohol use among students age 21 and older Prevention programs, policies, enforcement

28. Population Approach Advantages Large population benefits Broad target audience Longer lasting effects Disadvantages May limit personal freedoms Resistance from invested parties Counter-intuitive

29. The Prevention Paradox “A prevention measure that brings large benefits to the community affords little to each participating individual” Geoffrey Rose , 1998

30. High-Risk & Population Approaches Not Mutually Exclusive You Can Do Both

31. Social Ecology of Drinking How do we shape health promoting environments? What is the evidence?

32. Strong Evidence… increasing the minimum drinking age results in a decrease in traffic casualties. enforcement affects the rates of underage purchasing. increases in alcohol taxes result in a moderate decrease in alcohol consumption & alcohol-related problems server training and policy interventions curb illegal sales to intoxicated and underage individuals Medium Evidence… increase in the number of outlets per capita increases consumption and alcohol-related problems.

33. Institute of Medicine:Reducing Underage Drinking Recommendation: Strengthen Minimum Legal Drinking Age Laws & compliance check programs in retail outlets

34. Institute of Medicine:Reducing Underage Drinking Recommendation: Require all sellers and servers of alcohol to complete state-approved training as a condition of employment.

35. Institute of Medicine:Reducing Underage Drinking Recommendation: Establish and implement a system requiring registration of beer kegs that records information on the identity of purchasers.

36. Institute of Medicine:Reducing Underage Drinking Recommendation: Congress and state legislatures should raise excise taxes to reduce underage consumption and to raise additional revenues for this purpose. Top priority should be given to raising beer taxes, and excise tax rates for all alcoholic beverages should be indexed to the consumer price index so that they keep pace with inflation without the necessity of further legislative action.

37. Institute of Medicine:Reducing Underage Drinking Recommendation: The alcohol industry should refrain from marketing practices that have substantial underage appeal and take reasonable precautions to reduce youthful exposure to other alcohol advertising and marketing activity.

38. Surgeon General’s Recommendations • Enforce all policies and laws against underage drinking and publicize these efforts • Gain public support for enforcing underage drinking laws Source: Office of the US Surgeon General (2007)

39. Alcohol: No Ordinary Commodity • Increase alcohol excise taxes, price • Reduce access (hours of sale, density) • Implement server liability laws • Implement alcohol-impaired driving countermeasures Babor et al, Alcohol: No Ordinary Commodity

40. Recommendations for College Student Drinking • Individual interventions for those at-risk for alcohol problems • norms clarification • cognitive-behavioral skills training • motivational interviewing • Restricting alcohol outlets • Increasing alcohol prices and taxes • Responsible beverage service policies • Maintaining and enforcing • age-21 MLDA • Impaired driving laws • Compliance checks in bars Source: NIAAA College Drinking Task Force (2002)

41. Knowledge Pricing Attitudes Composition Intentions Labeling Skills Packaging Advertising/Promotion Legal Sanctions Availability Institutions Physical Context SocioculturalContext KeyInfluencers Drug-Related Problems Person Drug Environment Torjman (1986)

42. Currently no systematic assessment of college efforts to address student drinking

43. What are colleges doing? Can we characterize colleges by the types of efforts they use to address student drinking?

44. Assessing College Alcohol Systems Components of college alcohol system • Education • Screening • Intervention • Treatment • Prevention Programs • Prevention Policies • Enforcement Degree of implementation across campuses

45. Methodology • On-line surveys • Nationally representative sample • 3 leaders per campus • In-depth telephone interviews • 13 colleges • 8 leaders per campus

46. College Alcohol System Screening Treatment/ Intervention Policy Enforcement Education

47. Research Objective Assess the familiarity with and degree of implementation of NIAAA College Drinking Task Force recommendations on and around college campuses among administrators at a nationally representative sample of colleges in the United States.

49. Most college administrators surveyed are aware of NIAAA recommendations to reduce student drinking (78%) • However, nearly 1 in 4 (22%) were not • Nearly all use educational programs (98%) • Half of campuses have adopted empirically-supported intervention programs • However, only half have the capacity to meet student need • Services may be cost-prohibitive for colleges

50. Few colleges collaborate with local authorities to implement community-based strategies • Compliance checks to monitor illegal alcohol sales (33%) • Most operate without college involvement • Mandatory responsible beverage service training (15%) • Restricting alcohol outlet density (7%) • Increasing the price of alcohol (2%)