Underage Drinking Causal Model Documentation

Prevention of Underage Drinking:

Logic Model Documentation

Pacific Institute for Research and Evaluation (PIRE)

11720 Beltsville Drive, Suite 900
Calverton, MD 20705
Tel: (301) 755-2700
Fax: (301) 755-2799

February 8, 2008

Contributing authors (in alphabetical order):

Johanna D. Birckmayer, Ph.D., M.P.H., Renée I. Boothroyd, Ph.D., M.P.H.,
Deborah A. Fisher, Ph.D., Joel W. Grube, Ph.D., Harold D. Holder, Ph.D.

The Logic Models here are a work in progress; no Logic Model is ever complete or final. The
goal of this Logic Model is to document the best available research evidence as well as identify
gaps or areas in our understanding which need further study or replication in future research.
These documents are presented freely for the use of prevention researchers and prevention
practitioners, and can be downloaded and reprinted as desired.

PIRE respectively requests that any uses or distributions of these documents in part or in whole
give credit to the Pacific Institute for Research and Evaluation, Calverton, MD.

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 Table of Contents

I. Definition.....................................................................................................................................1
Measurement of the Problem........................................................................................................1
II. Logic Model of Underage Drinking Prevention...........................................................................3
III. Documentation of Intermediate Variables, Relationships, and Prevention Strategies...................5
Drinking Beliefs...........................................................................................................................6
Family Influence.........................................................................................................................13
School Influence.........................................................................................................................16
Peer Influence.............................................................................................................................20
Drinking Context........................................................................................................................22
Retail Availability of Alcohol to Youth......................................................................................25
Social Availability of Alcohol to Youth.....................................................................................34
Price............................................................................................................................................40
Visible Enforcement...................................................................................................................43
Underage Drinking Laws............................................................................................................52
Community Norms about Youth Drinking.................................................................................57
Alcohol Promotion.....................................................................................................................60
IV. References..................................................................................................................................70

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I. Definition

Underage Drinking refers to any use of alcohol by persons under the legal drinking age of 21.
Consumption and/or purchase of alcohol by persons under the age of 21 is illegal in all 50 states
and the District of Columbia. According to the NIAAA Alcohol Policy Information System
(APIS) while all 50 States and DC prohibit underage possession, only 30 prohibit consumption
and 47 prohibit purchase.

Justification: Alcohol led to 3,170 deaths and 2.6 million other harmful events among underage
drinkers in the US in 2001. Underage drinking is associated with a host of problems, including
traffic crashes and fatalities, unwanted and risky sex, pregnancy, and intentional injury. It is
estimated that underage drinking costs America as much as $61.5 billion each year. Studies have
shown that youth who begin drinking at an early age are at a 3-5 fold increased risk of problem
drinking later in life.

Measurement of the Problem

Recommended Indicator/Measure 1: Current use of alcohol by persons under the age of 21 years

Definition: Percent of persons aged 12 and older reporting any use of alcohol within the past 30
days and past year.

Data Source: National Survey on Drug Use and Health (NSDUH), Substance Abuse and
Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human
Services (DHHS).

Frequency: Annual and past 30-day use

Geographic Levels: National and State

Demographic Categories: Age, gender, ethnicity, socio-economic status

Strengths: NSDUH is the only national source that currently provides prevalence of use
estimates for both adolescents and adults for every state.

Limitations: State-level estimates for most states are based on relatively small samples. Although
augmented by model-based estimation procedures, estimates for specific age groups have
relatively low precision (i.e., large confidence intervals). The estimates are provided directly by
SAMHSA and raw data that could be used for alternative calculations (e.g., demographic
subgroups) are not available. The estimates are subject to bias due to self-report and non-
response (refusal/no answer).

Recommended Indicator/Measure 2: Current use of alcohol by high school students

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Definition: Percent of students in grades 9 through 12 reporting any use of alcohol within the
past 30 days
Data Source: Youth Risk Behavior Surveillance System (YRBSS), Centers for Disease Control
and Prevention (CDC)

Frequency: Biennial

Geographic Levels: National and State

Demographic Categories: Grade Level, age, Gender, Race/Ethnicity

Strengths: YRBSS estimates are typically based on larger samples than the National Survey on
Drug Use and Health, and can be further broken down by grade level, gender, and race/ethnicity.
Some states also collect YRBSS data for individual communities or school districts, which can
be compared with their state-level data.

Limitations: As of 2003, weighted representative samples were available for only 32 states. Not
all states participate, and some participating states do not provide representative samples.
YRBSS is a school-based survey, so students who have dropped out of school are not
represented. It is also subject to bias due to self-report, non-coverage (refusal by selected schools
to participate), and non-response (refusal/no answer). Estimates for some subgroups may have
relatively low precision (i.e., large confidence intervals).

Recommended Indicator/Measure 3: Current use of alcohol by persons under the age of 21.

Definition: Percent of persons under the age of 21 who used alcohol in the past year and in the
past 30 days.

Data Source: Behavioral Risk Factor Surveillance System (BRFSS), Centers for Disease
Control and Prevention (CDC)

Frequency: Annual

Geographic Levels: National and State

Demographic Categories: Age, Gender, and Race/Ethnicity

Strengths: BRFSS provides prevalence estimates of adult use for every state. State-level
estimates are typically based on larger samples than the National Survey on Drug Use and Health
and may be further broken down by age, gender, and race/ethnicity.

Limitations: BRFSS is a telephone survey subject to potential bias due to self-report, non-
coverage (households without phones), and non-response (refusal/no answer). Estimates for
subgroups may have relatively low precision (i.e., large confidence intervals).

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II. Logic Model of Underage Drinking Prevention

A Logic Model is a combination of (a) a causal model which shows the key intermediate
variables in a system of relationships to explain a specific outcome (in this case, underage
drinking) and (b) the relationship of variables to the outcome or to other variables which have
been actually affected via purposeful prevention interventions. This logic model is a public
health approach, concerned primarily with underage drinking and associated alcohol-related
problems. As such, this model emphasizes variables, relationships, and prevention effects at the
population level or the community-wide level.

(a) Causal Relationships: Figure 1 is first a general causal model for underage drinking based
upon existing research and/or theory. The figure shows key intermediate variables which
research has identified as being empirically associated with underage drinking and alcohol-
related problems as well as to other intermediate variables in the model. Most of these variables
have sufficient strength of association with either underage drinking, alcohol-related problems,
or other key variables to be included as shown in the documentation which follows. All such
intermediate variables are shown with a least one solid line. A few of the variables have a
theoretical rationale for inclusion but currently no empirical research to confirm and are shown
with dotted lines.

(b) Prevention Effects: As a Logic Model of Underage Drinking Prevention, Figure 1 also shows
the relative strength of evidence of tested prevention strategies in reducing underage drinking
and/or alcohol-related harms at the population level or other key intermediate variables which
have demonstrated effect on population level outcomes. These are indicated by solid lines. If the
outcomes or effects from specific prevention strategies or programs are limited to the specific
group served or involved in the program, then this is considered less significant in the Logic
Model than achieving a population level outcome. If there is no evidence of effect on either
population level underage drinking, alcohol-related problems or other key intermediate variables
nor on target group variables, then this is indicated by a thin line.

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Figure 1-- 9-6-2007

Underage Drinking Causal Model

Visible Retail Availability

Enforcement of Alcohol to
Youth Price

Alcohol-Related
Problems

Underage Social
Drinking Laws Availability of
Alcohol to
Youth
Underage
Drinking
Drinking Beliefs

Community Family, School,

Norms and Peer
About Influence
Youth
Drinking

Drinking Context

Alcohol Promotion

Figure 1-- Legend: Strength of (a) Evidence of relationship to underage drinking and (b)
Evidence of Population-Level Effect on Underage Drinking, Alcohol-related Problems or Other
Key Intermediate Variables Resulting from Prevention Interventions

Strong evidence of relationship and strong evidence (i.e., 3 or more studies)

of population level prevention effects and/or strong effect on other
intermediate variables which have population level prevention effects.

Strong evidence of relationship and moderate evidence (i.e., 1-2 studies) of

population level prevention effects or moderate evidence of effect on key
intermediate variables which have population level effects

Strong evidence of relationship but only limited or no evidence of population

level prevention effects but some evidence of target group effects.

Theoretical, but no empirical evidence of relationship and therefore no evidence of

population level or target group prevention effects.

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III. Documentation of Intermediate Variables, Relationships, and
Prevention Strategies

Section III provides documentation for each of the elements (problems, intermediate variables,
relationships, and strategies) for the causal model presented in Section II. For each intermediate
variable, the following subsections headings (in bold) will be used:

Conceptual Definition—This is the definition of each intermediate variable as a hypothetical or

theoretical construct. The conceptual definition provides a rationale as to why this intermediate
variable is included in this causal model.

Measurement—This section provides operational definitions for the intermediate variable, that
is alternative methods, techniques, tools, approaches, etc. to measure this variable and to develop
valid and reliable indicators. Data sources may be surveys, archival data, or other sources.

Relationship of the Intermediate Variable to the Problem—This subsection is a Summary of

the Research evidence of the relationship of the intermediate variable to the specific ATOD
problem being addressed by the logic model. Emphasis will be given to published research in
scientific journals. In some cases, no direct empirical evidence may exist for the intermediate-
variable-to-ATOD-Problem relationship. In such a situation, the relationship can be presented in
theoretical terms, i.e., reasoned argument, based upon other research evidence which can be
generalized to this case or situation.

Relationship of the Intermediate Variable to Other Variables—This subsection is a

Summary of the Research evidence of the relationship of the intermediate variable being
documented to important outcomes as shown in the logic model. In this summary, each
relationship discussed will focus on the assumed relationship of interest for prevention, for
example, Price  Drinking but not Drinking (as demand)Price. Reciprocal relationships,
however, will be discussed in the documentation of that other variable. For example, drinking
(demand for alcohol) and its influence on price will be discussed under Drinking.

Strategies—This subsection will present the research evidence concerning strategies,

interventions, policies, programs, etc. which have been shown capable of affecting this
intermediate variable. Evidence that purposeful changes in the intermediate variable can affect
the ATOD problem and evidence of effects on other intermediate variables will also be
summarized or cited. Limitations of the research evidence about effects will also be noted, for
example, if important concerns exist about generalizability to other situations, populations, or
settings or selection biases exist for the population in which the effects were observed. When no
research evidence exists of an effect from prevention strategies, this will be noted. In many
cases, the research evidence which demonstrates a causal or mediating influence of one
intermediate variable to the ATOD problem or to other variables in the causal model will come
from purposeful prevention efforts and will already be noted in previous subsections.

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Drinking Beliefs

Conceptual Definition

Drinking Beliefs included in the model refer to five of the most proximal correlates of underage
drinking behavior: alcohol attitudes, alcohol expectancies, normative beliefs, subjective
availability, and resistance/refusal efficacy beliefs. Inclusion of these variables is grounded in
such theoretical approaches as cognitive social learning theory (e.g., Bandura, 1977, 1986,
1997), problem behavior theory (e.g., Jessor, Donovan, & Costa, 1991), the DOMAIN model of
drug use (e.g., Newcomb & Bentler, 1988), and current reformulations of the Theory of Planned
Behavior (Ajzen, 1989, 2001; Fishbein et al., 2002, Fishbein, Hennessy, Yzer, & Douglas,
2003).

Alcohol attitudes refer to overall affective evaluations of drinking (e.g., wrong-not wrong; good-
bad; pleasant-unpleasant) by an individual. Alcohol attitudes are hypothesized to mediate the
effects of alcohol expectancies and normative beliefs on drinking behaviors.

Alcohol expectancies refer to perceptions of perceived risk and the perceived personal likelihood
of positive and negative consequences of drinking and heavy drinking. Thus they are the
cognitive representations of anticipated rewards and costs associated with drinking behaviors.

Alcohol normative beliefs refer to perceptions of the approval or disapproval of drinking by

significant others (prescriptive norms) and the extent to which these others drink themselves
(descriptive norms).

Subjective alcohol availability refers to the perceived ease or difficulty of obtaining alcohol
overall and from specific social and commercial sources and to the frequency of use of these
sources.

Refusal/resistance efficacy beliefs refer to perceptions of one’s own ability to resist peer pressure
to drink and offers to drink. These beliefs also include perceptions of how easy or difficult it
would be to avoid situations in which youth drinking occurs.

Measurement

The five elements are summarized below:

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 Drinking Beliefs Measures
Alcohol attitudes Personal evaluations of alcohol use and heavy drinking. Source: Student
Survey.
Perceived likelihood of positive and negative personal consequences of
Alcohol expectancies drinking. Perceived risks and benefits of alcohol use and heavy drinking.
Source: Student Survey.
Perceived level of alcohol use by same-age peers, friends and parents;
Normative beliefs perceived level of approval/disapproval of alcohol use by same-age peers,
friends and parents. Source: Student Survey.

Subjective alcohol How easy or difficult it would be to get alcohol from various social and
availability commercial sources (e.g., grocery store, friends, strangers). Source:
Student Survey.

Refusal/resistance Perceived ability to resist peer pressures or peer offers to drink. Ability to
efficacy beliefs avoid situations in which alcohol is consumed. Source: Student Survey.

Youth Surveys--Drinking Beliefs: Attitudes Toward Alcohol Use. Typical alcohol attitude items
ask young people how wrong they think it is for someone their age to drink beer, wine, or hard
liquor or how “good” or “bad” drinking is. Such items show excellent convergent validity and
are highly predictive of drinking, heavy drinking, and drinking intentions among youth (e.g.,
Grube & Morgan, 1990a; Hampson, Andrews, Barckley, & Severson, 2006, Trafimow, Brown,
Grace, Thompson, & Sheeran, 2002).

Youth Surveys--Alcohol Expectancies. Alcohol expectancies are measured with items focusing
on perceived personal consequences of drinking. Specifically, respondents are asked how likely
or unlikely they think it is that a series of consequences would happen to them personally if they
were to have 3 or more drinks. Examples of such expectancy items can be found in the
PIRE/OJJDP Youth Survey (AE-1a-q). The items focus on both negative expectancies (e.g., get
into trouble with parents), and positive expectancies (e.g., have fun, make me feel relaxed, make
me feel more outgoing or friendly). These items are presented on 4-point scales (very likely--not
at all likely). They form two primary scales (positive expectancies and negative expectancies)
that are modestly correlated (r  -.19) and independently predict drinking and changes in
drinking over time. In previous studies (e.g., Grube, Chen, Madden, & Morgan, 1995; Chen,
Grube, & Madden, 1994) these scales have shown good internal reliability (s .79-.83). More
general items relating to perceived risk ask how much respondents think people risk harming
themselves (physically or in other ways) if they drink alcoholic beverages.

Youth Surveys-- Normative Beliefs. Survey items can include measures of descriptive norms
(i.e., perceived levels of alcohol use by others) and prescriptive norms (i.e., perceived level of
approval or disapproval of alcohol use by others). Item D1j in the Oregon Healthy Teens (OHT)
survey asks students to indicate how many of their four best friends have tried beer, wine, or
liquor when their parents didn’t know about it in the past year. Five possible responses range
from “none” to “4.” Item D2a asks students if any of their siblings have ever drunk beer, wine, or
hard liquor (yes/no). These items can be supplemented with several items adapted from the
PIRE/OJJDP Youth Survey (CN-1a,b,f), which ask how often they think their parents, friends,
and same-age peers have had at least one whole alcoholic beverage in the past 12 months.

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Prescriptive Norms. Item C4a in the OHT asks students how wrong their parents feel it would be
for them to drink beer, wine, or liquor regularly with four possible responses ranging from “very
wrong” to “not wrong at all.” This item can be supplemented with several items adapted from the
PIRE/OJJDP Youth Survey (CN-2d,e,f), which ask respondents how much they think other
people (best friend, other good friends, other people your age you know) would disapprove or
approve if they have three or four whole drinks. Analyses of PIRE/OJJDP Youth Survey data
with several large samples of adolescents indicate that these multi-item scale measures of
descriptive and prescriptive norms are internally reliable (α ≥ .70) and moderately to strongly
associated with past-30-day alcohol use and heavy drinking measures (Grube, Keefe, & Stewart,
1999).

Youth Surveys-- Subjective Alcohol Availability refers to an overall perception of how easy or
difficult alcohol is to obtain through retail and social sources. Oregon Healthy Teens (OHT)
survey items E10a-h ask students to indicate how easy or difficult they think it would be to get
alcohol (beer, wine, or hard liquor) from various sources, including grocery stores, convenience
stores, friends 21 or older, friends under 21, a parent, a brother or sister, through the internet, or
from home without permission. Four possible responses to each item range from “very easy” to
“very hard.” The internal consistency of this 8-item scale is good (α = .80) and it is significantly
associated with past-30-day alcohol use (r = .41) and heavy drinking (r = .40). An additional
item from the PIRE/OJJDP Youth Survey (AV-3) regarding how easy or difficult it would be to
get alcohol from a stranger over the age of 21 can be added to these items. Although they are
correlated, two scales are derived from these items representing ease of using social and retail
sources of alcohol, respectively. Overall subjective alcohol availability can be measured with a
set of items asking how easy or difficult it would be to get (a) coolers or fruit-flavored alcoholic
beverages (alcopops), (b) beer, (c) wine, and (d) liquor. These items can be summed into an
overall measure. Recent studies indicate that subjective availability is related to drinking
behaviors among youth and, moreover, is itself affected by actual availability at the community-
level (Dent, Grube, & Biglan, 2005; Paschall, Grube, Black, & Ringwalt, 2007b).

Youth Surveys--Refusal/resistance efficacy beliefs refer to perceptions of one’s own ability to

resist drinking, refuse drink offers, and resist direct pressure to drink. The Drinking Refusal Self-
Efficacy Questionnaire (Lee & Oei, 1993; Oei, Hasking, & Young, 2005; Young, Hasking, Oei,
& Loveday, 2007) measures these beliefs. The Drinking Refusal Self-Efficacy Questionnaire--
Revised Adolescent Version (DRSEQ-RA) also designed to assess an individual's belief in their
ability to resist drinking alcohol consists of three factors reflecting social pressure refusal self-
efficacy, opportunistic refusal self-efficacy and emotional relief refusal self-efficacy. The three
factor structure has been confirmed using confirmatory factor analysis. All three factors are
negatively correlated with both frequency and volume of alcohol consumption with drinkers
reporting lower drinking refusal self-efficacy than non-drinkers.

Relationship of the Intermediate Variable to the Problem

Alcohol attitudes on underage drinking—Both longitudinal and cross-sectional research shows

that attitudes predict drinking such that drinking increases as attitudes become more favorable
(e.g., Grube & Morgan, 1990a, 1990b, 1994; Hampson et al., 2006; Trafimow et al., 2002).

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Alcohol Expectancies—More favorable expectancies (lower negative and higher positive) are
hypothesized to increase drinking. Research has consistently shown that alcohol expectancies are
related to drinking in the anticipated ways in both cross-sectional and longitudinal analyses and
may mediate more distal risk factors (e.g., Chen et al., 1994; Darkes, Greenbaum, & Goldman,
2004; Grube & Agostinelli, 1999; Grube, Ames, & Delaney, 1994; Grube et al., 1995;
Henderson, Goldman, Coovert, & Carnevalla, 1994).
Normative beliefs—Previous research has demonstrated that normative beliefs, and especially
perceptions of friends’ drinking, are strong predictors of alcohol consumption and of changes in
alcohol consumption over time (Ames & Grube, 1999; Grube & Morgan, 1990a; 1990b; Grube,
Morgan, & McGree, 1986; Morgan & Grube, 1991). Youth with normative beliefs that are
supportive of drinking may place fewer limits on their drinking behavior and take greater risks
when drinking than those with more conservative drinking beliefs. Peers may also place direct
pressure on some youth to drink or drink heavily or may be sources for alcohol, providing
opportunities to drink. Additionally, peers may also reinforce expectations that alcohol makes
one attractive, powerful, and mature.
Subjective Alcohol Availability—Studies considering subjective availability show that as
perceived ease of obtaining alcohol increases, quantity and frequency of drinking also increase
among adolescents (e.g., Abbey, Scott, & Smith, 1993; Ames & Grube, 1999; Morgan & Grube,
1994). Thus, 95% of 12th graders, 85% of 10th graders, and 68% of 8th graders who participated
in the 2002 Monitoring the Future (MTF) survey reported that it is “fairly easy” or “very easy” to
get alcohol (Johnston, O'Malley, & Bachman, 2002). Research indicates that measures of alcohol
availability are moderately correlated with alcohol consumption (Grube & Morgan, 1990a;
Maddahian, Newcomb, & Bentler, 1986; Morgan & Grube, 1994; O'Malley & Wagenaar, 1991).
Resistance/refusal efficacy beliefs. Research indicates that resistance/refusal efficacy beliefs are
negatively correlated with frequency and quantity of alcohol consumption and with risky
drinking (Lee & Oei, 1993; Oei et al., 2005; Young et al., 2007). Moreover, these efficacy
beliefs may contribute to drinking independently of expectancies and other beliefs. Thus,
drinking refusal self-efficacy may have broader application in understanding drinking behaviors
among youth.
Relationship of the Intermediate Variable to Other Variables
Drinking Beliefs (Subjective Availability) to Retail Availability and Social Availability. Perceived
alcohol availability has been especially associated with alcohol consumption for males.
Subjective alcohol availability may influence consumption in two ways. First, actual availability
of alcohol provides greater opportunities for adolescents to drink. When alcohol is readily
available, adolescents simply consume more of it. Second, actual alcohol availability may
influence adolescent drinking by both shaping perceptions of availability (subjective availability)
and shaping adolescent normative expectations about appropriate drinking behavior and
expectations about consequences. In other words, as a result of ease with which alcohol can be
obtained, some youth may believe that drinking is expected and subsequently drink more
heavily. It is important to keep in mind, however, that subjective availability is a perception and
thus may not be entirely congruent with actual physical availability. Perceived ease of obtaining
alcohol may influence drinking and, in turn, may itself be influenced by drinking through self-
serving biases or through increased knowledge of sources of alcohol resulting from drinking
experiences.

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Strategies

School Educational Approaches Alone. Traditionally, alcohol prevention for adolescents has
focused on changing drinking beliefs through school-based education. Although some
educational programs have been found to be moderately effective in reducing youth drinking or
delaying onset of drinking (Donaldson, Piccinin, Graham, & Hansen, 1995; Griffin, Botvin, &
Nichols, 2004; Hecht, Graham, & Elek, 2006; Shope, Copeland, Kamp, & Lang, 1999; Taylor,
Graham, Cumsille, & Hansen, 2000), others have been found to be less effective, effect sizes are
small, and demonstrated long-term effects are rare (Bell, Ellickson, & Harrison, 1993; Ennett et
al., 1994a; Ennett, Tobler, Ringwalt, & Flewelling, 1994b). Methodological issues have also
limited much of the available research (Gandhi, Murphy-Graham, Petrosino, Chrismer, & Weiss,
2007; Gorman, 1998). Meta analyses suggest that interactive and peer-lead delivery methods,
social influence and life skills models, and programs that focus on norms, commitment not to
use, and intentions not to use may be most effective (Cuijpers, 2002). Findings across programs
and studies, however, are inconsistent, making conclusions difficult (Skara & Sussman, 2003).
School-based education cannot provide a complete answer to the problem of drinking by young
people. In part, this limitation arises because young people are immersed in a broader social
context in which alcohol is readily available and glamorized (Mauss, Hopkins, Weisheit, &
Kearney, 1988).

School Educational Approaches with Community Elements. Adding community elements to

school education may increase the effectiveness of school-based programs (Cuijpers, 2002).
Project Northland (Perry et al., 1996), a school educational program which included components
targeting sixth graders with family take-home assignments, has led to substantial reductions (19-
46%) in alcohol use among younger adolescents in rural Minnesota. More recently, the
effectiveness of a cross-cultural adaptation of the home-based component of Project Northland,
the Slick Tracey Home Team Program, was examined in a randomized controlled trial among
sixth grade school students in Chicago (Komro et al., 2006). Despite high participation rates
across the sample of diverse, inner city, low-income youth, results were mixed. The program
produced significant between-group effects on only two of the six belief and behavioral factors
associated with the onset of alcohol use. In its second phase Project Northland included
environmental strategies such as stimulating local policies requiring responsible beverage service
(RBS) for on- and off-premise alcohol establishments, and implementing a gold-card system
with local merchants to give discounts to students who pledged to remain alcohol- and drug-free
(Veblen-Mortenson et al., 1999). Project Northland's effects cannot be attributed with confidence
to the environmental strategies implemented. Because few high school students obtain alcohol in
licensed on-premise outlets, this strategy has limited potential as a significant barrier against
drinking by middle school students. Furthermore, no information was reported about level of
actual RBS implementation or level of enforcement (Veblen-Mortenson et al., 1999) andProject
Northland also reported nothing concerning police enforcement of sales to underage persons,
which has been shown to be essential in reducing alcohol access (Grube, 1997a, 1997b).
Social Norms Education or Marketing: In addition to school-based education, media and public
educational approaches are also used in an attempt to modify alcohol norms beliefs. There is
some evidence that media interventions, especially social norms marketing or campaigns, can
affect drinking beliefs and behaviors among young people (DeJong et al., 2006).

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Other studies are less optimistic. Social Norms approaches have been popular in college and
university alcohol prevention; however, the evidence of both (a) effectiveness of these
approaches in reducing positive norms about drinking and (b) reducing drinking, especially
heavy drinking among underage students as a direct result of changed norms about drinking, is
limited. Campo, et al, (Campo et al., 2003) studied the effects of misperceptions of friends' and
typical college students' drinking on college student drinking and found that drinking is related to
perceptions of friends' drinking as suggested by the theory of planned behavior, which
emphasizes subjective as opposed to social norms as promoted in Social Norms Marketing. In a
study of a social norms program on a large university campus, Polonec, Major, and Atwood
(2006) found that the overwhelming majority of students (72.6%) did not believe the norms
message that most students on campus had “0 to 4” drinks when they partied. Additionally, when
students’ perceptions of their friends’ drinking behavior was held constant, the correlation
between their own drinking and that of “most other” students dropped from a significant 0.37 to
a nonsignificant 0.09., again suggesting that group or social network norms are more influential
on students’ own drinking behavior than are estimates of the campus drinking norm. Weschler et
al. (2003) in a national study of college students and the utilization of social norm prevention
programs did not find a positive effect of this strategy on college students.

Campo and Cameron (2006) analyzed college students' processing of alcohol social norms
messages, related effects on normative judgments, attitudes toward their own behaviors, and
perception of undergraduate attitudes using expectancy violation theories and social norms
marketing. After social norms message exposure, the majority moved their normative judgments
toward the norms messages. However, those most likely to develop unhealthier attitudes drank
more than those who developed healthier attitudes, consistent with psychological reactance to the
messages. The authors concluded that the effects of social norms campaigns on those at greatest
risk for increased alcohol consumption could lead to increased risk for such participants and that
social norms programs should be utilized cautiously. In a second paper, Cameron and Campo
(2006) sociodemographics, normative perceptions, and individual attitudes on consumption of
alcohol and tobacco use as well as exercise. They found that for all three behaviors, the variable
accounting for the greatest variance was whether or not the individual liked participating in that
particular behavior. The authors concluded that predicted (or desired) attitudinal and behavioral
effects from social norms approaches may not be found when applied across diverse health
behaviors.

The theory of normative social behavior (TNSB; Rimal & Real, 2005) posits that the
associations between norms and behavior should take into account important moderating
influences such as group identity and outcome expectancies. For example, in a recent cross-
sectional survey of college students, Real and Rimal (2007) found that peer communication
about alcohol (i.e., frequency of alcohol discussions over the past 2 weeks and “normally”)
moderated the relationship between descriptive norms and alcohol consumption. That is, the
relationship between descriptive norms and drinking was stronger among those who engaged in
extensive peer discussion as compared to those who did not. Such a moderating effect, however,
was not found for intentions to drink.

Counter-advertising commonly is used to balance the effects that alcohol advertising may have
on alcohol consumption and alcohol-related problems. Such measures can take the form of print

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or broadcast advertisements (e.g., public service announcements [PSAs]) as well as product
warning labels. See discussion of strategies under Promotion and Advertising.
Summary
Alcohol attitudes, expectancies, normative beliefs, and subjective availability have all been
associated with drinking by youth and with changes in drinking by youth over time. Many social-
psychological models of drinking assume that other environmental and personal influences on
drinking are mediated through these beliefs. Interventions can target these beliefs directly (e.g.,
normative education, media) or indirectly by addressing the environmental factors (e.g., physical
availability, enforcement of minor in possession laws) that underlie them. More comprehensive
approaches to prevention have considerable promise for addressing the problems associated with
adolescent drinking by changing the larger community environment in which youth live. In
particular, such strategies can be used to reduce alcohol retail and social availability, drinking by
increasing the personal costs associated with it, and communicate norms to young people about
the unacceptability of their drinking and to adults about the unacceptability of providing alcohol
to them.

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Family Influence

Conceptual Definition

Youth acquire knowledge, attitudes, and values about a variety of issues, including substance
use, through a gradual and intricate process of assimilating information from numerous social
sources. Primary among these sources is the family context in which a young person develops. A
variety of family factors have been identified as influencing young people’s behavior, including
parents’ norms for appropriate behavior and their family management practices (such as
supervision/monitoring, family rules, and discipline).

Measurement

Park et al. (2000) provide measures for various parenting constructs/family influences including
parents’ norms, family management, and family conflict.

Parents’ norms—sixteen parents items and one child self-report item were combined for a
measure of parents’ norms against substance use (e.g., How wrong would it be for children who
are the same age as your child to drink alcohol?). The child item correlated .20, on average, with
the parent items. (Average alpha reliability over the four data collection points was .68.)

Family management—eighteen parent and three child self-report items were combined for a
measure of proactive family management. Items assessed parents’ vigilance in the monitoring of
their child (e.g., In the course of a day, how often do you know where this child is?), parents’
consistent discipline practices (e.g., How often do you discipline this child for something at one
time, and then at other times not discipline him or her for the same thing?), and establishment of
clear family rules (e.g., The rules in my family are clear) (average alpha = .71).

Relationship of the Intermediate Variable to the Problem

Many studies examining environmental factors related to youth drinking have focused on peer
and parental influence (Baumrind, 1985, 1991; Brook, Brook, Gordon, Whiteman, & Cohen,
1990; Chassin, Pillow, Curran, Molina, & Barrera, 1993; Downs, 1987; Dishion & Loeber,
1985). These studies have shown that parents and peers influence youth drinking even after
controlling for numerous individual-level characteristics.
Studies of family-focused interventions designed to improve parenting practices (e.g.,
communicate clear norms against substance use, proactively manage families, reduce family
conflict, etc.) have shown positive outcomes in terms of substance use and specifically youth
alcohol consumption which suggests that family process factors have relevance to youth
drinking. Compared to control group participants, youth in family intervention groups have
reported lower levels of initiation of substance use both in middle school and high school
(Bauman et al., 2002; Dishion, Kavanagh, Schneiger, Nelson, & Kaufman, 2002; Park et al.,
2000; Spoth, Lopez Reyes, Redmond, & Shin, 1999a; Spoth, Redmond, & Lepper, 1999b; Spoth,

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Redmond, & Shin, 2001; Spoth, Redmond, Trudeau, & Shin, 2002). Research on specific
interventions is discussed below in the strategies section.
Parental monitoring and supervision are critical for drug abuse prevention. These skills can be
enhanced with training on rule-setting; techniques for monitoring activities; praise for
appropriate behavior; and moderate, consistent discipline that enforces defined family rules
(Kosterman, Hawkins, Haggerty, Spoth, & Redmond, 2001). Drug education and information
for parents or caregivers reinforces what children are learning about the harmful effects of
drugs and opens opportunities for family discussions about the abuse of legal and illegal
substances (Bauman et al., 2001). Brief, family-focused interventions for the general
population can positively change specific parenting behavior that can reduce later risks of
drug abuse (Spoth et al., 2002). Family-based prevention programs should enhance family
bonding and relationships and include parenting skills; practice in developing, discussing, and
enforcing family policies on substance abuse; and training in drug education and information
(Ashery, Robertson, & Kumpfer, 1998).

Relationship of the Intermediate Variable to Other Variables

Family influence to drinking beliefs--Families are a central socializing context where children
may learn about alcohol and develop drinking behaviors, alcohol expectancies, and other
drinking beliefs such that changes in family processes (e.g., applying clear family rules about
drinking) can decrease drinking in adolescence and may delay initiation of drinking (Guo,
Hawkins, Hill, & Abbott, 2001; van der Vorst, Engels, Meeus, Dekovic, & Van Leeuwe, 2005;
van der Vorst, Engels, Meeus, & Dekovic, 2006a; van der Vorst, Engels, Meeus, & Dekovic,
2006b; Jackson, Henriksen, & Dickinson, 1999). On the other hand, findings regarding
frequency of communication more generally about alcohol issues are mixed. In some cases such
communication has been found to be positively associated with alcohol consumption of
adolescents, possibly because it is reactive (van der Vorst et al., 2006a). In other cases no
relation has been found (Jackson et al., 1999). The likelihood of alcohol use is significantly
greater among children who perceive no parental monitoring of alcohol use or have been allowed
by parents to have a drink with alcohol at home which suggests a parental influence on youthful
drinking beliefs (Jackson et al., 1999). Good attachment or bonding between parents and their
children does not appear to prevent adolescents from drinking once other factors are taken into
account (van der Vorst et al., 2006b).
Family influence on Context--It is reasonable to believe that there exists some influence of
parents on the context of drinking by adolescents, e.g., with parents or especially at home
supervised by parents. Parents who sponsor and organize drinking parities for underage persons
are communicating that underage drinking is accepted if it is undertaken with the context of the
home or an adult supervised setting. However, research on this specific relationship (in contrast
to actual drinking influence and the beliefs of adolescents) has not been reported.
Strategies
Family Education Programs. Family programs are designed to affect the specific families and
thus children who participate in the program. They are not designed to change the behavior of
children from families not enrolled in the training programs. Family programs attempt to help
parents improve their skills to explicitly establish family norms for behavior; manage their
families with clear communication, monitor and enforce family norms, and manage and reduce

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family conflict. Several family-based programs have been effective in delaying initiation to
alcohol use and reducing quantity-frequency of drinking among youth, including the Adolescent
Transition Program (Dishion et al., 2002), Strengthening Families Program (Spoth et al., 1999a,
1999b, 2001; Spoth & Redmond, 2002), and Preparing for the Drug Free Years (Park et al.,
2000). A trial of the Preparing for the Drug Free Years, for example, showed that the program
significantly reduced the growth of alcohol use and improved parent norms regarding adolescent
alcohol use over time. At a 3½-year follow-up, 65% in the control group versus 52% in the
Preparing for the Drug Free Years group reported that they had initiated alcohol use, 42% versus
32% reported having been drunk, and 40% versus 24% said they had used alcohol in the past
month. Similarly, analyses of initiation indices suggest a pattern of increasing differences
between the intervention and control groups in the Strengthening Families program through the
10th-grade follow up assessment. Specifically, there was a significantly lower rate of increase in
alcohol initiation through the 10th-grade follow-up assessment for students in the program,
relative to those in the control group (Spoth et al., 2001). These findings are consistent with the
results of analyses of earlier waves of data (Spoth et al., 1999a; 1999b). Such programs may also
reinforce and increase the effectiveness of other interventions. Data from a randomized trial on
the Strengthening Families Program, for example, indicate that adolescents receiving the
Strengthening Families Program + Life Skills Training intervention reported lower initiation of
alcohol use than adolescents in either the control and Life Skills Training -only groups (Spoth et
al., 2002). At the follow-up 2.5 years after baseline (Spoth, Randall, Shin, & Redmond, 2005),
growth of substance initiation was significantly slower for the SFP + LST group compared to the
LST-only and control groups; however, the difference in adjusted mean scores was only
marginally significant for SPF + LST versus control groups. In terms of weekly drunkenness,
observed rates of growth of weekly drunkenness for both intervention conditions were found to
be lower than that of the control condition, but only marginally; adjusted mean scores for the
SFP + LST group were found to be significantly lower from the control group. No differences
between the three groups were found for regular alcohol use in either growth analyses or point-
in-time analyses. The practical question for such intensive family training is whether (a) the level
of youth reported reduction in “any drinking” and “binge or high volume drinking” is practically
significant to justify an investment in the program and (b) whether the effects achieved are
generalizable to the larger community population of youth or only limited to the participating
families? Spoth and Redmond (2002) have noted that there has been limited investigation of
family participation in preventive interventions from general populations. They point out that
families in eligible general populations can differ to a significant degree in intervention
preferences and beliefs that influence their motivation to engage in interventions or in
intervention evaluations. Further they point out that stable family member characteristics, such as
internalizing/externalizing problems, have not been predictive of family participation or
engagement. While educational level has been predictive of engagement, the differences between
participants and nonparticipations have “tended to be small” according to Spoth and Redmond
(Spoth & Redmond, 2002). The generalizability of parental training effects into general
populations which account for the self-selection bias of participating families has not been
reported in published research.

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School Influence

Conceptual Definition

The influence of school can encompass both the physical and social environment of the
institution. The formal school environment is largely governed by adult teachers and
administrations. One of the expressions of this formal environment is school policy concerning
drinking/intoxication at school or possession of alcohol on school grounds or at school functions.

Measurement

Perceived attachment or bonding to school has been a primary variable used to describe potential
for school influence. It has been measured with survey items that ask about liking of school,
importance of doing well in school, participation in school activities, aspirations, and grades.
Typical items are available in the Guide to Conducting Youth Surveys (Office of Juvenile Justice
and Delinquency Prevention, 1999). Scales based on these items have good internal consistency and
are known to correlate moderately and negatively with adolescent drinking, smoking, and drug use.
Perceptions of the school context, norms, and atmosphere can also be measured through survey
items aggregated to the school-level. Rules and policies can be measured directly through
content analyses or surveys of principals and school administrators.

Relationship of the Intermediate Variable to the Problem

Many studies have shown that school bonding is related to alcohol use. Generally, closer
bonding to school and greater connectedness to school are associated with lower levels of
alcohol use at the individual level (e.g., Bond et al., 2007; Catalano, Haggerty, Oesterle,
Fleming, & Hawkins, 2004; Hawkins et al., 1997; Henry, Swaim, & Slater, 2005). A recent
study showed that regardless of a student's own level of school attachment, students who attend
schools where the pupils overall tend to be well attached to school are less likely to use alcohol
(Henry & Slater, 2007). In addition, they also have lower intentions to use alcohol, perceive that
fewer of their peers at school use alcohol, and more strongly hold aspirations that are
inconsistent with alcohol use. It should be noted that all of this research addressed school
influence based upon individual self-report, not population level effects.
Relationship of the Intermediate Variable to Other Variables
School Influence to Drinking Beliefs--Students who are poorly bonded to school are less likely to
believe that substance impedes future goals (Henry et al., 2005). However, early alcohol
initiation is related to a higher level of alcohol misuse at age 17-18 and may mediate the effects
of school bonding (Hawkins et al., 1997). School bonding or connectedness reported by students
has been shown to be related to positive classroom management, tolerant disciplinary policies,
and small school size (McNeely, Nonnemaker, & Blum, 2002).

School Influence to Drinking Context—The drawing, Figure 1, contains a line which suggests a
potential influence by the school on drinking context. However, that relationship has not been
confirmed via empirical research. The solid line in the drawing reflects the documented
relationship of school bonding to individual self reported drinking but not to drinking context per
se.

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Strategies

School Policies and Violations-- School policies are formal regulations which provide for
sanctions against youth for the possession of alcohol on school property. The penalties are
usually a part of school policies which ban or provide restrictions for possession or provision of
alcohol on school property. Many schools are adopting zero-tolerance policies. These policies
mandate predetermined consequences or punishments for specific serious student infractions. A
large majority (87 percent) of public schools report having zero-tolerance policies for alcohol
violations (Heaviside, Rowand, Williams, & Farris, 1998, March). Such policies are popular
among schools such that nearly half of elementary, middle/junior high, and senior high schools
in the U.S. have explicit policies prohibiting alcohol use on campus and at school functions and,
in some cases, any possession of alcohol by students (Modzeleski, Small, & Kann, 1999). When
alcohol policies are violated, a common response is suspension or expulsion, a response that may
be dictated by state law (see, e.g., HAW. REV. STAT. § 302A-1134.6 [2002]). Gottfredson and
colleagues (2000) conducted a national survey of school principals, which among other things
asked about principals’ responses to undesirable behavior. Gary Gottfredson, (Gottfredson
Associates, Inc., personal communication, October 9, 2002) calculated the rates of suspension
and expulsion exclusively for alcohol infractions and found some consistency across grade
levels. According to elementary school principals surveyed, for alcohol policy violations, 65.4
percent of the principals reported that their students are automatically suspended or expelled,
while 24.2 percent of the principals said their students receive a hearing, but this hearing usually
results in suspension or expulsion. For middle schools, 74 percent of the principals said that
when alcohol policy violations occur, students violating the policies are automatically suspended
or expelled, and another 23 percent of the principals said their students are usually suspended or
expelled after a hearing. Finally, for high school, 67.5 percent of the principals surveyed said
students violating alcohol policies are automatically suspended or expelled, and another 24
percent are usually suspended or expelled after a hearing for an alcohol policy violation. Thus,
suspension or expulsion is the dominant response to alcohol violations regardless of grade level.

Other studies that have not focused exclusively on alcohol use report similar findings. Heaviside
et al. (Heaviside et al., 1998, March) asked principals to report the number of expulsions,
transfers to alternative schools, and out-of-school suspensions lasting five or more days for
possession, distribution, or use of alcohol, drugs, and tobacco. They found that 27 percent of all
school principals surveyed reported taking a total of about 170,000 disciplinary actions for these
offenses, and of these actions, 62 percent of the disciplinary actions were out-of-school
suspensions lasting five days or longer, 20 percent were transfers to alternative schools or
programs, and 18 percent were expulsions. Clearly, suspension was the most common response
to substance-related problems in schools. Other responses to violations of school alcohol policy
include involving law enforcement in some way. For example, in some states, school officials
either may or must inform local law enforcement of such violations. Studies have not been
conducted of the effectiveness of this approach.

Alcohol Policies at Universities--Universities have similar policies prohibiting alcohol in school

facilities, prohibiting use by underage students, or restricting alcohol advertising on campus
(Wechsler, Kuo, Lee, & Dowdall, 2000). Grimes and Swisher (1989) found that students report
such policies are barriers to drinking, but there are few controlled evaluations of such policies.

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Odo, McQuiller, and Stretsky (1999) in a study of newly enacted policy that prohibited alcohol
in all university affiliated living residences (i.e., dorms, fraternities, sororities) found that such
policies were associated with reduced prevalence of drinking in the affected residences, but not
with the frequency of heavy drinking. A case study of a campus prohibition on underage
drinking or possession of alcohol, public consumption, and use of kegs reported positive
findings; however, because it lacked a control or comparison condition, it is not possible to
accept the findings unconditionally (Cohen & Rogers, 1997). These studies provide promising
but incomplete evidence of the potential for such administrative policies to reduce underage
drinking.

In sum, the vast majority of elementary and secondary schools have alcohol-related policies and
the majority of schools have adopted zero tolerance policies. When alcohol violations are
detected, suspension and expulsion are the typical responses. However, it is presently unknown
what effect, if any, school sanctions have on the prevalence of underage drinking either at the
individual or school population levels, whether schools are an appropriate venue for addressing
this behavior, or, when compared to other possible venues, whether schools are better, worse, or
equally effective in deterring or modifying this behavior.

Although the research on the topic is limited, there are some inferences that can be drawn about
efforts to deter underage drinking. For example, all states and a number of municipalities have
some type of prohibition against youth drinking, although these prohibitions vary from state to
state. The nature and severity of the sanctions associated with violations of these prohibitions
vary considerably across jurisdictions. It is also apparent that for a variety of reasons,
enforcement of these laws is relatively sporadic and inconsistent. In addition, although all
schools in this country have an alcohol policy, these policies also vary considerably.

A number of sanctions are being applied by a range of agents in conjunction with underage
alcohol offenses. Fines and community service are common sanctions imposed by the legal
system for underage drinking violations. Diversion programs continue to grow in popularity.
Schools are likely to respond to alcohol policy violations with suspension or expulsion.
Unfortunately, little is known about the effectiveness of these responses, and their imposition
appears to be rarely guided by supporting empirical evidence regarding their effectiveness.

There does seem to be a general consensus that if sanctions are used, they should be just one part
of a constellation of responses to underage drinking violations. Researchers and advocates are
calling for comprehensive approaches to underage drinking that involve the youth, their families,
and their communities. Teen courts, for example, have adopted this position. Evaluation of the
effectiveness of teen courts specifically in conjunction with alcohol-related offenses is needed to
test this hypothesis. The suggestion also has been made that sanctions should be aimed at helping
youth rather than simply punishing them for alcohol violations.

In addition, it is important to recognize that sanctions will not be equally effective for all youth.
Sanctions are often used as a blunt instrument of the courts, virtually ignoring developmental
differences among adolescents. However, a sanction (e.g., a fine of $100) that is perceived as
particularly onerous by one youth and thus serves as an effective deterrent may be seen as trivial
or as an inconvenience by another youth. In general, studies generally have failed to consider the

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developmental level, gender, ethnicity, and geographic location of the youth, all of which may be
important considerations (PIRE, 1999; U.S. Department of Health and Human Services, 2001).
In summary, there is no evaluation of the effects of these policies or suspension on population
level underage drinking or associated problems.

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Peer Influence

Conceptual Definition

Peer influence can be conceptualized as including modeling of drinking behaviors, direct peer
pressure to drink, and providing opportunities to drink and obtain alcohol. Generally a distinction
can be made between descriptive norms (how many peers drink) and prescriptive norms (how
approving of drinking peers are).

Measurement

Measures of peer drinking and approval of drinking can be obtained through surveys. These
measures can be either aggregated at the level of school or community or considered at the
individual level.

Relationship of the Intermediate Variable to the Problem

Many studies have addressed the relations between perceived peer drinking and approval of
drinking and alcohol consumption (Baumrind, 1985, 1991; Brook et al., 1990; Chassin et al.,
1993; Downs, 1987; Dishion & Loeber, 1985). These studies routinely have shown that young
people who report (perceive) more peer drinking and peer approval of drinking are more likely to
drink and drink heavy and frequently, even after controlling for numerous individual-level
characteristics. Many fewer studies have investigated the relations between actual peer behavior
and beliefs and drinking among young people. As has been noted, youth may over-estimate
drinking and approval of drinking among peers and this may, in itself, be a risk factor.

Relationship of the Intermediate Variable to Other Variables

Peer Influence to Drinking Beliefs--It is assumed that actual levels of peer drinking and approval
of drinking are related to normative beliefs and alcohol expectancies in predictable ways: greater
peer drinking and approval are hypothesized to be related to more favorable beliefs about
drinking. In addition, it can be postulated that peers influence the drinking context by
establishing the acceptability of drinking at the moment and within specific settings, e.g., in cars,
at parties, or in recreational areas. See Clapp, Shillington & Segars (2000).

Peer Influence to Drinking Context.—It is reasonable to postulate this relationship since

adolescent drinkers who are influenced by peers to drink are also likely influenced by the context
or setting in which drinking occurs. When peer groups involve drinking, this is often related to
the setting such as in isolated areas away from adult supervision or within the privacy of a home
without adult supervision or with parent permission. While the research on these relationships is
limited, the influence of context on underage drinking suggests (See Drinking Context) suggests
that such settings are influenced by peers. See Clapp, Shillington, and Segars (2000). It is this
research which supports the thin solid line connecting Family, Peer, and School Influence to
Drinking Context.

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Strategies

Most commonly, peer influences are addressed through programs that focus specifically on
resistance skills or more generally on life skills. Life Skills Training or LST (Botvin & Griffin,
2002; Botvin, 2000) is typical of such interventions. LST is a universal preventive intervention
program based on social/cognitive learning theory (Bandura, 1977, 1986, 1997) and problem
behavior theory (Jessor & Jessor, 1977). The primary goals of LST are to promote skill
development (such as social resistance, self-management, and general social skills) and to
provide a knowledge base concerning substance use. These skills moderate or reduce
susceptibility to social influences (Epstein & Botvin, 2002; Epstein, Zhou, Bang, & Botvin,
2007). Skill development is accomplished through five curriculum components: a cognitive
component, designed to present information concerning the consequences, prevalence rates, and
social acceptability of substance use; a self-improvement component related to self-image
improvement; a decision-making component containing decision-making strategies; a coping
with anxiety component designed to recognize anxiety-inducing situations and to rehearse
strategies to cope with anxiety; and a social skills training component including communication,
overcoming shyness, boy–girl relationships, assertive skills, and substance use resistance skills
(Botvin, 2000; Botvin & Griffin, 2002; Botvin & Kantor, 2000). The LST intervention has
shown positive effects among urban and minority populations (Botvin, Griffin, Diaz, & Ifill-
Williams, 2001) and in a rural Midwestern population (Spoth et al., 2002). There were strong
positive correlations between initial levels of expectancies and refusal intentions; there also were
strong negative correlations between initial levels of expectancies and refusal intentions and
substance initiation. Other studies have shown significant reductions in both drug and polydrug
use for groups that received the LST program relative to controls, with up to 44% fewer drug
users and 66% fewer polydrug (tobacco, alcohol, and marijuana) users in those groups (Botvin,
Baker, Dusenbury, Botvin, & Diaz, 1995).. Another study examined the effectiveness of the LST
prevention program in reducing heavy episodic drinking in a sample of minority, inner-city,
middle-school students (Botvin et al., 2001). Rates of binge drinking were compared among
youth who received the program beginning in the 7th grade and a control group that did not. The
prevention program reduced the prevalence of binge drinking by as much as 50% at the 1-year
and 2-year follow-up assessments. There were also significant positive effects on drinking
knowledge, pro-drinking attitudes, and peer drinking norms.

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Drinking Context
Conceptual Definition

Although there is no standard definition for drinking context, it can be conceptualized as where
one drinks, with whom one is drinking, and when one drinks. Others have suggested adding,
‘‘why one drinks’’ to this definition. When consumption is high, contextual risk or protective
factors might be even more important. The identification of such characteristics has the potential
for developing prevention policies and programs.

Measurement

Clapp, Shillington, and Segars (2000) have measured contextual factors associated with binge
drinking events over the past 14 days by asking college-age respondents a series of detailed
questions concerning the last heavy drinking event they engaged in within the past 2 weeks.
Questions included in this series focused on (a) the total number of drinks consumed during the
occasion, (b) the day of the week of the occasion and the starting and ending time for the event
(duration of event). (c) the social purpose of the event (party, date/socializing), (d) the number of
the people at the event, (e) the composition of the drinking group (partner, roommates, college
friends, non-college friends, family members, and coworkers), (f) the location of the event
(bar/restaurant, private home), (g) risk factors associated with the event (played drinking games,
illicit drugs available, alcohol served to all, several people intoxicated), and (h) factors associated
with the event (food served, nonalcoholic beverages available, bartender served drinks). Other
recent studies on drinking context (e.g., Walker, Waiters, Grube, & Chen, 2005) simply ask
location of drinking.

Relationship of the Intermediate Variable to the Problem

The context of drinking has been demonstrated to be related to drinking and especially heavy
consumption. Kraft (1982) examined alcohol consumption patterns, related problems, and
contexts of drinking at one east coast university in the late 1970s. He reported that respondents
tended to drink with friends, on weekends, and at parties most frequently. The heaviest drinkers
often patronized bars as well. With the increase in frequency of attendance at parties or bars,
there was also an increase in the frequency of self-reported problem behaviors, such as driving
drunk, academic problems, belligerence, job-related problems, vandalism, and trouble with
authorities. Kraft (1982) reported that female college students drank more often at parties and in
bars than in any other contexts.

Clapp, Shillington, and Segars (2000) found that parties and dates/socializing were the most
common occasions associated with last heavy drinking event. These events were almost evenly
split between public (42.2% bars and restaurants) and private (43.1% homes) contexts. In their
most recent binge drinking event, students most often drank with friends (either from school or
not) and their partner/spouse. Most events had food and nonalcoholic beverages available, and
over a quarter of the events had illicit drugs available. Slightly less than half (47.3%) of the
events resulted in some self-reported problem to the drinker. Overall, public and private contexts
seemed to be equally ‘‘wet,’’ with females drinking slightly more in public settings than they do

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in private settings. In public settings, having food present, college friends present or a bartender
serve all alcohol strongly protected against alcohol-related problems.

A more recent study of underage drinking and driving showed that white males, older
adolescents, those who had a driver license, and those who drove more often were more likely to
report drinking alcohol in the past year (Walker, Treno, Grube, & Light, 2003). Heavy episodic
drinking and drinking in cars increased both drinking and driving (DUI) and riding with drinking
drivers (RWDD) among underage adolescents. Drinking in restaurants also increased DUI. The
effects of overall alcohol consumption on DUI were entirely mediated through heavy episodic
drinking and drinking in restaurants and cars. Alcohol consumption had both direct and indirect
effects on RWDD. With the exception of being Latino and frequency of driving, the effects of
the background variables on RWDD were all entirely mediated through alcohol consumption.
Heavy drinking and drinking in specific locations thus appeared to be important unique
predictors of both DUI and RWDD. The authors suggested that prevention programs and policies
aimed at underage drinking should focus on developing more effective responsible beverage
service programs, increasing compliance with laws limiting alcohol sales to youth, and enforcing
graduated driver licensing and zero tolerance laws.

Drinking behavior and drinking consequences may vary by location several reasons. First,
different policies or controls may exist at different locations, thus regulating the availability and
distribution of alcohol. Second, the likelihood of friends and servers intervening may vary in
different locations such as private homes, bars, restaurants, and parks. Collins and Frey (1992)
found that college freshmen were more likely to report stopping a friend from driving after
drinking in public places such as a bar or party than at work or at a private residence.

Relationship of the Intermediate Variable to Other Variables (none specified in model)

Strategies

There are a number of strategies that target the drinking context for alcohol.

Social Availability and Context—Since youth who drive, often supply alcohol to others in the
context of motor vehicles, therefore regular and highly visible enforcement of drinking and
driving can affect social supply such as the provision of alcohol to youth at parties. Therefore
relevant strategies can be reviewed in the Social Availability section.

Retail Availability-- Alcohol retail outlets such as bars, restaurants, and pubs can be affected
(sometimes threatened) by highly visible enforcement of their alcohol service practices. See
strategies in the Retail Enforcement section.

Drinking and Driving Enforcement--Extensive and visible drink drive enforcement such as
Random Breath Testing can alter the drinking context, e.g., for over serving customers as well as
decisions by youth to drink in conjunction with drinking.. See strategies in Retail Availability
section.

Zero Tolerance Laws—These laws concerning lower BAC limits for youth drivers or even
possession of alcohol in a motor vehicle whether one is the driver or not, when enforced, can

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result in loss of driving license (a personally prized possession) for both drinking and drinking
and driving. Such a threat of the loss of one’s drivers license for possession of alcohol or even
for drinking can alter youth motivation to seek alcohol and reduce alternative forms of alcohol
supply. See Zero Tolerance Policies in Retail Availability section.

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Retail Availability of Alcohol to Youth

Conceptual Definition

Retail availability refers to the ease of physical access to alcohol through commercial sources.
This availability includes on-premise outlets, such as bars or restaurants, as well as off-premise
outlets such as grocery stores, liquor stores, or other retail outlets licensed to sell alcohol within
their community. In general, when retail alcohol is cheap, convenient, and easily accessible,
people drink more and the rates of alcohol problems are higher. Conversely, when alcohol is
more expensive (e.g., through taxes), less convenient (e.g., fewer retail outlets), and less
accessible (e.g., restrictions on drinking age), people generally drink less and problem rates are
lower. Availability in this document refers to overall level of access by underage persons to
alcohol. Availability can refer to the presence and density of alcohol outlets and the frequency of
use of specific commercial sources of alcohol (e.g., markets, liquor stores) by young people.

Measurement

Retail availability—This variable can be measured in a number of ways which reflect the
accessibility of alcohol to the general drinking population as well as specific level of access for
underage persons, e.g., levels of compliance with state sales laws by alcohol merchants. Retail
availability of alcohol can be measured by (a) Retailer Compliance with Licensing Laws, (b)
Retail Sales Availability, (c) Hours and Days of Sale, and (d) Alcohol Outlet Density (distance to
a retail outlet).

Retailer Compliance with Licensing Laws -- Compliance Checks—This variable is measured as

the percentage of times an underage person or a youthful looking person who would appear to be
under 21 years old is able to purchase alcohol without having to show age identification.
Compliance Checks are a direct documentation of the level of retail availability of alcohol to
underage youth. While not intended for enforcement, compliance checks are efforts to test if
underage persons can purchase alcohol from licensed alcohol outlets. While police compliance
checks use an actual underage person and cite or arrest a clerk or store manager when a purchase
is consummated, most research-based compliance surveys utilize persons over 21 years of age
who have been judged to appear underage (Grube, 1997b; OJJDP, 1999). Alcohol sales
compliance rates (%) in any community, based on alcohol purchase surveys or compliance
checks conducted, can be a direct measure of retail availability to underage persons.

Retail Sales Availability--Sources of Alcohol. The actual sources of alcohol as self reported by
adolescents provides a means to measure retail sales availability. Frequency of getting alcohol
from various sources in the past 30 days (e.g., grocery store, friend, stranger). Source: Student
Survey. OHT items E8a-k ask students how many times during the past 30 days they obtained
alcohol (beer, wine, or hard liquor) from various sources, including grocery stores, convenience
stores, drug stores, gas stations, friends 21 or older, friends under 21, a parent, a brother or sister,
through the internet, from home without permission, or by using a fake ID. Eight possible
responses range from “none” to “15 or more times.” Item E9 asks students how often in the past
30 days any store or gas station refused to sell them alcohol, with eight possible responses

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including “I did not try to buy alcohol,” and then ranging from “none” to “6 or more times” (rs
> .12). These items will be supplemented with items adapted from the PIRE/OJJDP Youth
Survey (SP-2a-i) regarding places/settings where students may have consumed alcohol in the
past 30 days, including parties.

Hours and Days of Sale. This variable is typically measured via specific hours of alcohol sales
by type of outlet (off premise or on premise) each day or the specific days of sale (independent
of the specific day of the week or the total hours of sale each week, i.e., the total hours of sales
across all seven days in the week.

Outlet density. Outlet density is another potential measure of alcohol availability. Density is
measured as the number of alcohol outlets per capita population or per roadway mile. Measures
of outlet density represent the physical availability of alcohol by outlet type which can be
measured over a metric scale representing use of space, i.e., the number of bars, restaurants,
grocery stores, and liquor stores per kilometer of a defined area. Measurements in terms of
outlets per geographical unit better reflect a consumer’s ease or difficulty in obtaining alcohol.
Analyses of fixed geographical units are interrelated, possess a good bit of spatial
interdependence, and thus require specialized statistical analyses. See Gruenewald and Ponicki
(1995a; 1995b); Gruenewald et al. (1996); and Gruenewald, Ponicki, and Mitchell (1995).

Relationship of the Intermediate Variable to the Problem

While the evidence from studies of overall consumption and alcohol-related problems provides
convincing evidence of a relationship to level of retail availability, there are fewer studies which
have specifically investigated changes in retail availability on the drinking of underage persons.
In the studies that have focused on youth, aspects of retail availability such as privatization,
hours and days of alcohol sales, and outlet density have been associated with changes in alcohol
sales to underage youth, shifts in beverage choice to more readily accessible alcoholic beverage
types, and drinking behavior (Kelley Baker, Johnson, Voas, & Lange, 2000; Todd, Gruenewald,
Grube, Remer, & Banerjee, 2006; Valli, 1998). Among college students—many of whom are
under the legal drinking age—outlet density surrounding college campuses has been found to
correlate not only with heavy drinking and frequent drinking, but also with drinking-related
problems (Weitzman, Folkman, Folkman, & Wechsler, 2003). Treno, Grube, and Martin (2003)
similarly found evidence that outlet density was positively associated with frequency of underage
drinking and driving and riding with drinking drivers. A recent study found that perceived
compliance and enforcement of underage drinking laws at the community-level was inversely
related to individual heavy drinking, drinking at school, and drinking and driving and to use of
commercial sources for alcohol by adolescents (Dent et al., 2005). Similarly, compliance rates as
determined by alcohol purchase surveys have been found to be inversely related to frequency of
use of commercial sources for alcohol by minors (Paschall et al., 2007a). In another study,
random alcohol purchase surveys (N = 385) were conducted in 45 Oregon communities in 2005.
Youthful buyers were able to purchase alcohol at 34% of the outlets approached. Purchase rates
were highest at convenience (38%) and grocery (36%) stores but were relatively low (14%) at
other types of outlets (e.g., liquor and drug stores). Alcohol purchases were less likely at stores
that were participating in the Oregon Liquor Control Commission's Responsible Vendor Program
(RVP), when salesclerks asked the decoys for their IDs, and at stores with a posted underage

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alcohol sale warning sign. Alcohol purchases were also inversely related to the number of
salesclerks present in a store, but were not related to salesclerks' age and gender. Findings of this
study suggest that more frequent compliance checks by law enforcement agents should target
convenience and grocery stores, and owners of off-premise outlets should develop policies and
require training of all salesclerks to ensure reliable checks of young-looking patron IDs, and
should post underage alcohol sales warning signs in clear view of patrons. In a recent study of
college students, individual binge drinking was independently associated with community
patterns of alcohol availability, policy enforcement, and control (Weitzman, Chen, &
Subramanian, 2005). Specifically, students exposed to high levels of alcohol availability were at
higher risk binge drinking than youth where availability was low. Conversely, students exposed
to strongly enforced alcohol policy environments were less likely to binge than youth in areas
with less strongly enforced policies. Similarly, students who attend colleges in states that have
more restrictions on underage drinking, high volume consumption, and sales of alcoholic
beverages, and devote more resources to enforcing drunk driving laws, report less drinking and
driving (Wechsler et al., 2003).

Paschall et al. (2007b) examined whether compliance with underage sales laws by licensed retail
establishments is related to underage use of commercial and social alcohol sources, perceived
ease of obtaining alcohol, and alcohol use. They found that the alcohol sales rate was positively
related to students' use of commercial alcohol sources and perceived alcohol availability, but was
not directly associated with use of social alcohol sources and drinking behaviors. Additional
analyses indicated stronger associations between drinking behaviors and use of social alcohol
sources relative to other predictors. These analyses also provided support for an indirect
association between the alcohol sales rate and alcohol use behaviors. Paschall et al. (2007b)
concluded that compliance with underage alcohol sales laws by licensed retail establishments
may affect underage alcohol use indirectly, through its effect on underage use of commercial
alcohol sources and perceived ease of obtaining alcohol. However, use of social alcohol sources
is more strongly related to underage drinking than use of commercial alcohol sources and
perceived ease of obtaining alcohol.

Relationship of the Intermediate Variable to Other Variables (None specified in model)

It is assumed that level of retail availability of alcohol to underage persons affects their use of
alcohol sources and thus subjective (self assessed) alcohol availability. Enforcement of minor in
possession laws (MIP) can influence alcohol-related expectancies regarding the likelihood of
being apprehended attempting to purchase alcohol. However, while possible there is no empirical
evidence to support this relationship in the model.

Strategies

Strategies designed to affect access to alcohol from retail sources are not always targeted
specifically at young or underage drinkers but have the potential to limit the retail availability of
alcohol to all drinkers including youth. These strategies typically increase the opportunity cost to
the drinker, e.g., the cost in time and money to actually obtain alcohol from retail sources.

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Retail Monopoly of Alcohol Sales --Studies examining policy movements from state
monopolization of alcohol sales to privatization generally find an increase in overall
consumption following privatization (Holder & Wagenaar, 1990; Wagenaar & Holder, 1995),
but rarely report on consumption by young people. In one of the few studies focusing on youth,
Valli (1998) describes the effects on drinking among 13- to 17-year-olds in a Finnish township,
when medium strength beer was made available in grocery stores as opposed to being available
only in state monopoly stores. The results show that age limits were observed less strictly and
that the beverage of choice among girls changed from wine to medium strength beer. Minors
could purchase alcohol more easily than when sales had been restricted to state stores and
drinking among 13 to 17-year-olds increased. Alternatively, elimination of a private profit
interest typically facilitates the enforcement of rules against selling to minors or the already
intoxicated (Her, Giesbrecht, Room, & Rehm, 1999). A recent study Miller Snowden,
Birckmayer, and Hendrie (2006) found that underage drinking rates including heavy drinking as
well as youth-involved traffic crashes were lower in states which had retail sale monopolies
controlling for other factors.

Outlet Density Restrictions--Studies find significant relations between outlet densities and
alcohol consumption, violence, drinking and driving, and car crashes (e.g., Gruenewald,
Johnson, & Treno, 2002). In a study focusing on youth (Treno et al., 2003) found that on- and
off-license outlet density was positively related to frequency of driving after drinking and riding
with drinking divers among 16 to 20-year-old youth. Outlet density surrounding college
campuses has also been found to correlate with heavy drinking, frequent drinking, and drinking-
related problems among students (Weitzman et al., 2003). Such studies of outlet density are
cross-sectional, however, and the causal nature of the relations between outlet density and
alcohol consumption and problems among youth is an open question.

In a longitudinal study, Todd, Grube, and Gruenewald (2005, June) examined the effects of
neighborhood characteristics (socioeconomic status, alcohol outlet density) on availability of
alcohol and drinking among adolescents. Average household (HH) income was positively related
to ease of obtaining alcohol from parents and negatively related to ease of purchase without ID.
Density of alcohol-licensed restaurants was positively related to ease of obtaining alcohol from
someone over 21 and ease of purchase without ID. Past year drinking status at Wave 2 was
positively related to density of alcohol-licensed restaurants but negatively related to density of
off-premise alcohol outlets (e.g., liquor stores). Similarly, among Wave 1 never drinkers who
participated in Wave 2, preliminary longitudinal analyses indicate that change in lifetime
drinking status (from never drinker to ever drinker) was positively related to household income
and density of alcohol-licensed restaurants but negatively related to density of off-premise
alcohol outlets. Counter to expectations, preliminary findings indicate that underage alcohol use
and growth in use appears to be negatively related to density of off-premise alcohol outlets.

Paschall et al. (2007a) examined characteristics of off-premise alcohol outlets that may affect
alcohol sales to youth. Random alcohol purchase surveys were conducted in 45 Oregon
communities using underage-looking decoys who were 21 years old but did not carry IDs. These
decoys were able to purchase alcohol at 34% of the outlets. Purchase rates were highest at
convenience (38%) and grocery (36%) stores but were relatively low (14%) at other types of
outlets (e.g., liquor and drug stores). Alcohol purchases were also inversely related to the number

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of salesclerks present in a store, but were not related to salesclerks’ age and gender. Paschall et
al. (2007a) concluded that more frequent compliance checks by law enforcement agents should
target convenience and grocery stores, and owners of off-premise outlets should require training
of all salesclerks to ensure reliable checks of young-looking patron IDs, and should post
underage alcohol sales warning signs in clear view of patrons.

Restrictions on Hours and Days of Alcohol Sales--Quite a large number of studies have indicated
that changing either hours or days of alcohol sale can affect alcohol-related crashes and other
violent events related to alcohol take place (e.g., Smith, 1988; Ligon & Thyer, 1993). A number
of studies have investigated the effects of changing hours of sale on alcohol consumption and
problems. In general, greater restrictions have been associated with decreases in drinking and
drinking problems. Smith (1988), for example, found that the introduction of Sunday alcohol
sales in the city of Brisbane, Australia, was related to casualty and reported property damage
traffic crashes. However, these results are not unequivocal, as these effects could be
contaminated by other trend effects on Sunday sales and non-equivalent distribution of crashes
over days of the week (see Gruenewald, 1991). A recent study (Duailibi et al., 2007, in press)
investigated the effects of limiting the hours of sale of alcoholic drinks on violence against
women and homicides in the Brazilian city of Diadema. The study found that a policy
prohibiting on-premises alcohol sales after 11 pm led to a decrease of almost 9 murders a month.
Assaults against women also decreased but this impact was not significant in models that
controlled for underlying trends.

In one of the few studies focusing on youth, Kelley-Baker, Johnson, Voas, and Lange (2000)
found that temporary bans on the sales of alcohol from midnight Friday through 10:00 AM
Monday because of federal elections reduced cross-border drinking in Mexico by young
Americans. In particular, early closings on Friday night were associated with a 35% reduction in
the number of pedestrians crossing the border with blood alcohol concentrations (BAC) of 0.08
percent or higher, based upon breathalyzer testing at the border. 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 such changes affect young
people is more limited as most evaluations have focused on the total drinking population.

Responsible Beverage Service (RBS)--The focus of RBS programs is to prevent alcohol service
to minors and intoxicated patrons and to intervene so that intoxicated patrons do not drive.
Efforts to promote RBS consist of the implementation of a combination of outlet policies (e.g.,
requiring clerks or servers to check identification for all customers appearing to be under the age
of 30, cutting off service to intoxicated patrons, limiting sales of pitchers of alcohol, promoting
alcohol-free drinks and food, and eliminating last call announcements) and training in their
implementation (e.g., teaching clerks and servers to recognize altered or false identification,
training servers to recognize intoxicated patrons and deny service). RBS can be implemented at
both on-license and off-license establishments. Such programs have been shown to be effective
in some circumstances. Thus, RBS has been found to reduce the number of intoxicated patrons
leaving a bar, car crashes, sales to intoxicated patrons, sales to minors, and incidents of violence
surrounding outlets (e.g., Wallin, Norstrom, & Andreasson, 2003). Voluntary programs appear to
be less effective than mandatory programs or programs using incentives such as reduced liability.
How RBS is implemented and what elements are included in a particular program may be an

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important determinant of its effectiveness. Policy development and implementation within
outlets may be more important than server training in determining RBS effectiveness.

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; 1996b). However, voluntary clerk and manager training in off license establishments
appears to have a negligible effect on sales to minors above and beyond the effects of increased
enforcement (Grube, 1997b; Wagenaar, Harwood, Silianoff, & Toomey, 2005a). Similarly, a
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, & Beel,
1996, 1998). In one study, RBS training was associated with an increase in self-reported
checking of identification by servers (Buka & Birdthistle, 1999). Overall, however, 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.

Compliance of Off-Premise Outlets—Off-premise outlets are important sources of alcohol for

underage persons (Harrison, Fulkerson, & Park, 2000; Preusser, Ferguson, Williams, & Farmer,
1995; Schwartz, Farrow, Banks, & Giesel, 1998; Wagenaar et al., 1996). Such outlets are not
often operating with written sales polices and, in some cases, these outlets actually benefit
economically from sales of alcohol to youth. Purchase surveys show that anywhere from 30% to
90% of outlets sell to underage buyers, depending upon geographical location (e.g., Forster et al.,
1994; Forster, Murray, Wolfson, & Wagenaar, 1995; Preusser & Williams, 1992; Grube, 1997b).
Voluntary clerk and manager training in off license establishments appears to have a negligible
effect on sales to minors without visible and consistent enforcement. Wagenaar et al. (Wagenaar,
Harwood, Toomey, Denk, & Zander, 2000a; Wagenaar & Wolfson, 1994) evaluated a
community organizing intervention (Communities Mobilizing for Change on Alcohol --CMCA)
that was designed to bring about change in policies regarding access to alcohol by those under
21. Through numerous contacts with groups and organizations that might affect policies,
practices, and norms for minors’ access to alcohol, a strategy team was created in each
community to lead efforts to bring about change (Wagenaar, Gehan, Jones-Webb, Toomey, &
Forster, 1999). Through media advocacy they increased coverage of alcohol issues in the
community. The strategy teams implemented quite a variety of activities to reduce access. They
included steps to get alcohol merchants not to sell to young people, increased enforcement of
laws regarding underage sales, changes in community events to make alcohol less readily
available to young people, the prevention of underage drinking parties at hotels, information
provided to parents, and alternative sentencing for youth who violated drinking laws. The
specific activities varied across communities. CMCA was evaluated in a randomized trial in
which 15 Minnesota and Wisconsin communities were randomly assigned to receive or not
receive the program. The CMCA communities had lower levels of sales of alcohol to minors in
their retail outlets (effect size = 1.18, p < .05) and had marginally lower sales to minors at bars
and restaurants (effect size = 0.32, p < .08). Phone surveys of 18 to 20 year olds indicated that
they were less likely to try to buy alcohol (p = .06) and that they were less likely to provide
alcohol to others (p = .01). The proportion of 18 to 20 year olds who reported drinking in the past
30 days lower in intervention communities (p = .07). However, the prevalence of heavy drinking
in this age group was not affected. And, there were no significant effects on the drinking

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behavior of 12th graders (who were surveyed in school). Arrests of 18 to 20 year olds for driving
under the influence of alcohol declined significantly more in CMCA communities than in control
communities (Wagenaar, Murray, & Toomey, 2000b). The difference for 15 to 17 year olds
approached significance.

The Community Trials Project (Holder & Treno, 1997) tested a five-component community
intervention to reduce alcohol-related harm among people of all ages. It sought to reduce the
primary sources of acute injury and harm related to alcohol: drunken-driving injuries and
fatalities, injuries and deaths related to violence, and drownings, burns and falls. The effects of
the program were evaluated by comparing three communities that received the intervention with
matched comparisons communities. Communities were selected that had a population over
100,000 and were not bedroom communities. Their alcohol problem indicators were about equal
to the state average. Each community was racially diverse, with 40% or more minority group
members. The Community Trials 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. Each of these
interventions was shown to affect its target in the communities in which it was implemented.

Of particular interest is the Underage Drinking Component (Grube, 1997b), which comprised
three intervention strategies: enforcement of underage sales laws, off-premise retail clerk training
and policy development for off-premise establishments, and media advocacy. Increased underage
sales enforcement activities were implemented by the local police in each community. This
research demonstrated that police are willing to undertake a range of enforcement activities,
including compliance checks, when given modest encouragement from the community (Grube,
1997b; Holder et al., 2000). In particular, the project was able to increase the number of outlets
visited in compliance checks in three experimental communities from fewer than 10 to over 60
per quarter. The evaluation of the effects of these activities using decoy buyers showed that
randomly selected outlets in the experimental sites were about equally as likely as those in
comparison sites to sell alcohol to an apparent minor on pretest. On posttest, experimental
community outlets were about half as likely to sell alcohol to an apparent minor as those in
comparison sites. Thus, not only was it possible to enlist local law enforcement to increase
enforcement of underage sales laws, but these increased enforcement activities led to significant
declines in 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, 1997b).

Treno, Gruenewald, Lee, and Remer (2007) reported the results of the Sacramento
Neighborhood Alcohol Prevention Project (SNAPP). SNAPP set as its goal the reduction of
alcohol access, drinking, and related problems in two low-income, predominantly ethnic
minority neighborhoods, focusing on individuals between the ages 15 and 29, an age group

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identified with high rates of alcohol-involved problems. Two neighborhoods in Sacramento were
selected to be the intervention sites because they were economically and ethnically diverse and
had high rates of crime and other drinking-related problems. The quasi-experimental design of
the study took a “phased” approach to program implementation and statistical examination of
outcome data. Outcome-related data were collected in the intervention sites as well as in the
Sacramento community at large. Five project interventions included a mobilization component to
support the overall project, a community awareness component, a responsible beverage-service
component, an underage-access law enforcement component, and an intoxicated-patron law
enforcement component. Archival data were collected to measure and evaluate study outcomes
and to provide background and demographic information for the study. Overall, they found
significant (p < .05) reductions in assaults as reported by police, aggregate emergency medical
services (EMS) outcomes, EMS assaults, and EMS motor vehicle accidents. Results from the
Sacramento Neighborhood Alcohol Prevention Project demonstrate the potential effectiveness of
neighborhood-based interventions in the reduction of alcohol-related problems such as assaults,
motor vehicle crashes, and sale of alcohol to minors.

Lower Levels of Alcohol in Beverages--Noval and Nilsson (1984) found that total alcohol
consumption in Sweden was substantially higher when medium-strength beer could be purchased
in grocery stores between 1965 and 1977, rather than only in state monopoly stores. Few studies
of the specific effects of reduced-alcohol beverages on young people have been conducted.
Geller, Kalsher, and Clark (1991) found that students attending a fraternity party where only
low-alcohol content drinks were served consumed the same number of drinks but had a lower
blood alcohol concentration (BAC) than did students at parties where regular alcohol content
beer and mixed drinks were served. The findings demonstrate the potential interaction between
retail availability (low absolute alcohol drinks) with social availability (social events).

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, there is a concern to keep those with criminal records or associations out of the trade.
The minimum age of alcohol sellers which is set in some countries could affect the extent to
which underage sales might occur; i.e., 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, June 24-29) 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 there is a minimum legal drinking age, there is
likely to be some sort of informal market to serve underage drinkers. There have, however, been
no evaluations of minimum age-of-seller restrictions.

Use of False ID to Obtain Alcohol--Underage persons can obtain alcohol from retail sources
using false or fake 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

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and college students. Preusser et al. (1995) found nearly 60% 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% of New
York high school students reported the use of false identification to purchase alcohol compared
with 14 percent in Pennsylvania. Schwartz et al. (1998) found that fifteen 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. A
number of suggestions concerning means to reduce the effective use of illegal identification in
alcohol sales to minors include universal checking of ID for all alcohol customers, use of two
view or hologram photos on a drivers' license, and requiring two or more different ID cards at
the point of purchase, and as described below increased enforcement against stores that fail to
identify underage customers.

Summary: Certainly, greater minimum legal drinking ages reduce alcohol sales, use, and
problems among young people. 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. 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. The U.S. National Highway Traffic Safety
Administration (NHTSA) 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 (NHTSA, 1997). Grube and
Nygaard (2001; 2005) concluded that for young people policy strategies can be used to reduce
alcohol availability, deter drinking by increasing the personal costs associated with it, and
communicate norms to young people about the unacceptability of their drinking and to adults
about the unacceptability of providing alcohol to them. Less strength of evidence is available
concerning reductions in numbers of outlets or outlet densities, and reductions in hours or days
of sale which do have the potential to reduce levels of alcohol consumption and alcohol-related
problems. Based on the available scientific evidence from more than one controlled study,
currently the most effective public policies to reduce the retail and social alcohol availability to
youth and associated problems appear to be (a) the minimum drinking age and its enforcement,
(b) zero tolerance or graduated licensing, and (c) enforcement of sales of alcohol to underage
persons, especially using compliance checks about retail sales of alcohol to underage persons.

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Social Availability of Alcohol to Youth
Conceptual Definition

Social availability is the access to alcohol through “social sources” including receiving, stealing,
or buying substances from friends, relatives, and strangers. Adolescents, and especially younger
adolescents, often obtain alcohol from a variety of non-commercial sources. A substantial
portion of alcohol obtained by underage persons is from social sources (friends, parties, homes,
etc.) and other persons who purchase alcohol and provide it to underage persons (both persons
themselves under the legal purchase age and persons who themselves are of legal age).

Measurement

Sources of alcohol-- Frequency of getting alcohol from various sources in the past 30 days (e.g.,
grocery store, friend, stranger). Source: Student Survey.
For example, the Oregon Healthy Teens (OHT) survey items E8a-k ask students how many times
during the past 30 days they obtained alcohol (beer, wine, or hard liquor) from various sources,
including grocery stores, convenience stores, drug stores, gas stations, friends 21 or older, friends
under 21, a parent, a brother or sister, through the internet, from home without permission, or by
using a fake ID. Eight possible responses range from “none” to “15 or more times.” Item E9 asks
students how often in the past 30 days any store or gas station refused to sell them alcohol, with
eight possible responses including “I did not try to buy alcohol,” and then ranging from “none”
to “6 or more times” (rs > .12). These items will can be supplemented with items adapted from
the PIRE/OJJDP Youth Survey (SP-2a-i) regarding places/settings where students may have
consumed alcohol in the past 30 days, including parties.

Relationship of the Intermediate Variable to the Problem

Parties, friends, and adult purchasers are the most common sources of alcohol among adolescents
(Harrison et al., 2000; Preusser et al., 1995; Schwartz et al., 1998; Wagenaar et al., 1996). Young
people secure alcohol from a variety of commercial and social sources. Research indicates that
parties, friends, and adult purchasers are the most common sources of alcohol among adolescents
(Harrison et al., 2000; Preusser et al., 1995; Schwartz et al., 1998. Wagenaar et al. (1996) found
that parties, where older adolescents or young adults introduce their younger peers to drinking,
constitute the major source of alcohol for high school students. In this same study, commercial
outlets were the second most important source of alcohol. Purchase surveys reveal that anywhere
from 30% to 90% of outlets will sell alcohol to underage buyers, depending upon their
geographical location (e.g., Forster et al., 1994; 1995; Preusser & Williams, 1992; Grube,
1997b). Such results are also found in the ORI Oregon Healthy Teens survey which found that
commercial sources were used by 26% of 8th grade drinkers and 30% of 11th grader drinkers. In
the same study 70% of 8th grader drinkers and 73% of 11th grader drinkers reported using social
sources, predominately adult and underage friends. These sources include parents, parents of
friends, friends, acquaintances, co-workers, siblings, and even strangers.

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"Shoulder-tapping" occurs when an underage person approaches a stranger outside of an alcohol
establishment and asks this person to purchase alcohol for him or her. A recent study (Toomey,
Fabian, Erickson, & Lenk, 2007) found that 19 percent of young males over the age of 21 were
willing to purchase alcohol for youth who appeared to be underage when "shoulder-tapped"
outside of a convenience or liquor store. In contrast, only 8 percent of the general adult
population entering alcohol establishments were willing to purchase the alcohol. Researchers
conducted two waves of shoulder-tap requests outside of 219 randomly selected convenience or
liquor stores in both urban and suburban areas. Requesters were young adults (4 females, 1 male)
aged 21 years or older who appeared to be 18 to 20 years old. Requesters explained that they did
not have their identification with them, and asked the adults to purchase a six-pack of beer for
them. During wave one, requesters conducted 102 attempts, with the requester approaching the
first adult entering the store alone. During wave two, requesters conducted 102 attempts,
approaching the first male entering the store alone who appeared to be 21 to 30 years old. The
study also found that adults approached at a city convenience or liquor store rather than one
located in a suburb were nine times more likely to make the purchase.

A major opportunity that underage drinkers use to gain access to alcohol is at parties. In one
study, 32% of 6th graders, 56% of 9th graders, and 60% of 12th graders reported obtaining alcohol
at parties (Harrison et al., 2000). Underage drinking parties frequently involve large groups and
are commonly held in a home, an outdoor area, or other location such as a hotel room. Further
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., 1997a; Wagenaar et al., 1993). Beer is the primary beverage of choice of the underage and a
major source of beer is a social events where beer is available via a beer key (social events where
beer is available via a beer keg (Erickson, Toomey, & Wagenaar, 2001). In this case there is an
enhanced effect of social context, party, and low cost per drink of alcohol.

Given the fact that young people use multiple sources for alcohol, social availability is a
significant means for underage youth to obtain access to alcohol beyond commercial access. This
includes social availability through friends, at parties, and from strangers (Holder, 1994).

Relationship of the Intermediate Variable to Other Variables (None specified in model)

Strategies

Curfews for Youth. Curfews establish a time when children and young people below certain ages
must be home. While this policy was not initially considered an alcohol-problem prevention
strategy, research has shown positive effects. The strategy is one of reducing the availability of
alcohol to youth through social sources as well as reducing the convenience of obtaining alcohol
at gatherings of youth. In those states that established such curfews, alcohol-involved traffic
crashes for young people below the curfew age have declined (Preusser, Williams, Zador, &
Blomberg, 1984; Williams, Lund, & Preusser, 1984).

Social Host Liability. Under social host liability, adults who provide alcohol to a minor or serve
intoxicated adults in social settings can be sued through civil action, for damages or injury
caused by that minor or intoxicated adult (Grube & Nygaard, 2005). There is very little research

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on the effectiveness of social host liability laws and what evidence exists is conflicting. In one
study in the US, social host liability laws were associated with decreases in alcohol-related
traffic fatalities among adults, but not among minors (Whetten-Goldstein, Sloan, Stout, & Liang,
2000). Social host statutes were not related to single vehicle nighttime crashes for either group.
In a second study, social host liability laws were associated with decreases in reported heavy
drinking and in decreases in drinking and driving by lighter drinkers (Stout, Sloan, Liang, &
Davies, 2000). They had no effect on drinking and driving by heavier drinkers. The conflicting
findings may reflect the lack of a comprehensive program that insures that social hosts are aware
of their potential liability. Although social host liability may send a powerful message, that
message must be effectively disseminated before it can have a deterrent effect.

Restricting Access to Alcohol at Social Events--This strategy involves restricting the flow of
alcohol at parties and other events on and off college campuses to reduce overall social
availability of alcohol. Policies for preventing underage access to alcohol at parties can also be
used to decrease the amount of drinking among older students. Overlapping community policies
include banning beer kegs and prohibiting home deliveries of large quantities of alcohol.
Overlapping policies for campus events include limiting the quantity of alcohol per person and
monitoring or serving alcohol rather than allowing self-service. At one fraternity party, Geller
and Kalsher (1990) found that attendees who obtained beer through self-service consumed more
beer than those who got alcohol from a bartender. Event and party planners could also be
required to serve food and offer a large selection of alcohol-free beverages. Another strategy is to
serve low-alcohol content beverages (see below)

Strategies for Reducing Social and Third Party Access to Alcohol—As described previously a
substantial portion of alcohol obtained by underage persons is from social sources (friends,
parties, homes, etc.) and other persons who purchase alcohol and provide it to underage persons
(both persons themselves under the legal purchase age and persons who themselves are of legal
age).The study by Toomey et al. (2007) concerning the willingness of males of legal purchase
age to obtain alcohol for underage persons confirms that efforts to limit alcohol access from
these sources most likely remains a significant challenge for youth drinking prevention

The Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice, has
created a guide for reducing alcohol access by youth (OJJDP, 1999). The highest priorities
recommended by OJJDP is a compendium of environmental strategies including "shoulder taps"
and Compliance Checks (described previously). Shoulder taps occur when an underage person
asks another person to purchase alcohol on their behalf. These are common means by which
adolescents obtain alcohol (e.g., Jones-Webb et al., 1997a, 1997b; Smart, Adlaf, & Walsh, 1996;
Wagenaar et al., 1993, 1996), in part because young people believe it to be less risky than
purchasing alcohol themselves. Underage persons themselves are breaking the law through this
purchase, even if they do not consume the alcohol. Adults of legal purchase age are also breaking
the law by purposefully purchasing alcohol for a young person. Shoulder tap interventions occur
when an underage person or a person who appears to be underage age, stand outside a licensed
alcohol outlet and approach an older person to request that he/she purchase alcohol for them. In
such cases, the potential buyer may be offered a small “fee” for making this purchase. If the
older person actually makes the alcohol purchase and gives it to the youth, then they can be
arrested or cited by the police. These “shoulder tap” interventions are a recommended strategy to
directly reduce third party alcohol transactions by enforcing laws prohibiting the provision of

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alcohol to minors (NHTSA, 1997; Stewart, 1999). The utilization of strategies addressing
shoulder taps is a potentially promising strategy to reduce third party sources of alcohol to
minors that has not been seriously tested in replicated controlled studies.

Party Patrols--Another major way that underage drinkers gain access to alcohol is at parties
(e.g., Wagenaar et al., 1993). Party patrols are a local enforcement strategy in which police arrive
at a social event in which alcohol is being served and check the age identifications of party
participants. Underage drinking parties frequently involve large groups and are commonly held
in a home, an outdoor area, or other public location such as a hotel room. Party patrols are a
recommended strategy to address underage drinking parties (Little & Bishop, 1998; Stewart,
1999). Parties are frequently cited as one of the settings at highest risk for youth alcohol
consumption and related problems, and have been linked to impaired driving, sexual assaults,
violence, property damage, and to the initiation of alcohol use of younger adolescents by older
adolescents (Mayer, Forster, Murray, & Wagenaar, 1998; Schwartz & Little, 1997; Wagenaar et
al., 1993). Decreased sales to older minors, in turn, are expected to reduce availability of alcohol
to younger adolescents.

Without these special patrols law enforcement agencies sometimes do not have enough
manpower to thoroughly investigate underage drinking parties. They cannot always trace who
provided the alcohol or other drugs to minors. One example of a specific utilization of strong
local enforcement of provision of alcohol to underage persons is in Omaha, Nebraska. Under
local ordinance, anyone who provides or procures alcohol for minors is committing a Class I
misdemeanor, punishable by up to one year in jail, up to a $1,000 fine, or both. PRIDE-Omaha,
Inc. is assisting law enforcement agencies in conducting the MIP Party Patrols. Funding for the
patrols is provided through special grants from the local drug prevention coalition.

Party patrols involve police entering locations where parties are in progress. The police can use
noise or nuisance ordinances as a basis for entering a party to observe if underage drinking is
taking place. In party patrol strategies, police are enlisted, as a part of their regular patrol duties,
to routinely: (a) enter premises where parties that may involve underage drinking are underway,
(b) respond to complaints from the public about noisy teenage parties where alcohol use is
suspected, and (c) check, as part of regular weekend patrols, open areas and other venues where
teen parties are known to occur. When underage drinking is discovered, the drinkers can be cited
as well as the person who supplied the alcohol. Even when it is not possible to cite the person
who supplied the alcohol, awareness of increased police activity in this regard can act as a
deterrent and can express community norms regarding the unacceptability of providing alcohol
to minors. As with other environmental interventions, public awareness and media attention is
important to increase the deterrence effect of this strategy. There is some evidence that this
technique is effective. Oregon implemented a weekend drunk driving and party patrol program
that has law enforcement officers working with schools to identify in advance the anticipated
location of teen parties, which the officers then patrol. An unpublished evaluation of this
program revealed that arrests of youth for possession of alcohol increased from 60 to 1,000
individuals in one year (with a corresponding decrease of 35 percent in underage drunk driving
accidents) (Little & Bishop, 1998; Radecki, 1995).

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Keg Registration-- Beer consumption as the primary beverage of choice of underage drinkers
was found to be a potential factor in underage drinking alcohol-related harm, especially traffic
fatalities (Cohen, Mason, & Scribner, 2001). Beer kegs are often a main source of alcohol at
teenage parties and may encourage drinking greater quantities of beer, increasing the risk of
driving under the influence of alcohol and other alcohol-related problems. When police arrive at
underage keg parties, people often scatter. Without keg tagging, there is no way to trace who
purchased the keg.

As a result beer key registration is one strategy directed at social events where beer can be
provided without restrictions. Keg registration laws require the purchaser of a keg of beer to
complete a form that links their name to a number on the keg. In this way, if a beer keg is present
in a drinking setting where young people are consuming alcohol, then the person who purchased
the keg can be identified and held responsible. For example, in Billings, Montana, a keg
registration ordinance was passed by the City Council in June, 2002. A year-long process to get
the ordinance passed was led by a group called Montanans United Saving Lives. The ordinance
requires permanent marking on each keg that identifies where and when it was purchased (Webb,
2002). A different form of keg registration was passed in Madison, Wisconsin, in December,
2001. The City Council passed an ordinance that requires keg delivery rentals to be made in
person at the store. The purchaser must show two forms of ID at the store and be present at the
delivery address to sign a receipt upon delivery. Records of all keg purchases are required to be
kept by the stores for two years. None of the liquor store owners expressed opposition to the new
regulations, stating that the new law does not interfere with regular business operations (Spaetti,
2001).

Specifically, public opinion surveys find that over 60% of the population support laws that
require beer keg registration, and as of January 1, 2007, 29 states had enacted keg registration
laws. In a different approach to regulating kegs, Utah bans kegs altogether. Some jurisdictions
collect information that may aid law enforcement efforts such as the location where the keg is to
be consumed and the tag number of the vehicle in which the keg is transported. Some
jurisdictions also require retailers to provide warning information at the time of purchase about
laws prohibiting service to minors and/or other laws related to the purchase or possession of the
keg.

Keg registration is seen primarily as a tool for prosecuting adults who supply alcohol to young
people at parties and even establishments which rent filler beer kegs to underage persons
(Hammond, 1991). Keg registration laws have become increasingly popular in local
communities in the U.S. Wagenaar, O’Malley, and LaFond (2001) examined existing beer keg
registration policies in all states to determine core conceptual dimensions of the laws, test
procedures to increase reliability of keg policy coding, and describe variations in existing
policies. They found no controlled studies of the effects of keg registration laws which might
include measurement of rates of keg sales, bottled beer sales, beer consumption, intoxication
among teens and teen parties, or frequency of disturbance calls to police, as well as more direct
measures of teen consumption of keg beer. Wagenaar et al (2005a) found that most state alcohol
control agency rvey respondents noted very low levels of enforcement of extant keg registration
laws and high levels of leniency in imposing penalties.

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Keg registration laws are associated with a significant decrease in traffic fatalities. Cohen et al.
(2001) found that the presence of a local keg registration law was associated with lower alcohol
fatality rates (r = -.288 p <0.004) as a part of a composite score for level of alcohol regulation.
There are no controlled longitudinal studies of the passage of a beer keg registration and its
specific effects on alcohol-involved traffic crashes by underage persons or other alcohol
problems.

Restrictions on Drinking Locations and Possession of Alcohol. Specifying locations where

drinking cannot occur is a policy that has been implemented with laws about public drinking
and/or public intoxication, as well as those prohibiting drinking in parks or recreational
locations, or at the workplace. These restrictions have real potential for affecting the drinking of
youth since youth often prefer recreational venues for drinking, e.g., public parks, beaches, lakes,
etc. and limiting drinking in such locations also holds the potential for reducing social access of
alcohol provided by others. Discussions of these types of interventions are contained in
Giesbrecht and Douglas (1990) and "Communities Mobilize to Rescue the Parks" (1991). These
policies have been employed in a number of forms throughout the world, but have not been
systematically evaluated for the specific effects on access to alcohol by underage persons.

Such approaches as shoulder taps, party patrols or keg registration need more extensive
controlled testing and evaluation, although on the surface such strategies have the potential to be
effective. While strategies with a similar theoretical basis have been shown to be effective, we do
not have evidence from controlled trials for alcohol. For example, there is consistent evidence
that the restrictions on handguns is a means to reduce violence including social violence (Kleck
& Patterson, 1993; Lester, 1993; Lester & Clarke, 1991; Leenaars, 2007). Examples of control
strategies affecting social availability include studies of heron (Stimson & Oppenheimer, 1984)
and tobacco (Harrison et al., 2000; Bauer, Johnson, Hopkins, & Brooks, 2000; Forster, Chen,
Blaine, Perry, & Toomey, 2003; Bauer et al., 2000). A general foundation for local control of
potential risks to public health and safety is provided by Ashe, Jernigan, Kline, and Galaz
(2003). 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 upon the will and desire of states and communities to support such application and
enforcement. Without consistent enforcement, little of the potential of the above strategies can be
achieved in practice.

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Price

Conceptual Definition
Price as used here simply refers to the retail price or direct monetary costs of a product. Price can
be contrasted with the full costs of a product, which also include opportunity costs (e.g., effort or
difficulty in finding a product) as well as monetary costs. Alcohol, as are most commodities, is
price sensitive. That is, as the price increases, the demand for the alcohol declines and vice versa.
Measurement

Price elasticity refers to the percent change in consumption expected for a unit change in price.
Although price is affected by other considerations as well, it most easily indexed to or measured
as level of taxation (Young & Bielinska-Kwapisz, 2003).

Relationship of the Intermediate Variable to the Problem

Most studies have focused on the relation between taxation or price and alcohol consumption and
related problems among youth (Grossman, Chaloupka, Saffer, & Laixuthai, 1994). It has been
estimated that increasing taxation on alcohol in the US to keep pace with inflation would lead to
a 19% reduction in heavy drinking by youth and a 6% reduction in high risk drinking (Laixuthai
& Chaloupka, 1993). Substantial reductions in drinking and driving and alcohol-related traffic
fatalities also have been associated with price or tax increases across all beverage (Saffer &
Grossman, 1987a). It has been specifically estimated that increasing the price of beer (typically
the preferred beverage of youth) to keep pace with inflation would reduce youth drinking by 9%
and heavy drinking by 20% (Laixuthai & Chaloupka, 1993). In contrast to these studies,
however, recent research has found no evidence for the effects of taxation and price on alcohol
consumption and alcohol-related traffic fatalities, either among youth or in the general
population (Dee, 1999; Young & Likens, 2000). Although taxation and price increases may be
effective prevention strategies in some cases, price elasticities are moderated by social,
environmental, and economic factors. As a result, the price sensitivity of alcohol may vary
considerably across time, states, and countries, depending on drinking patterns and attitudes and
on the presence of other alcohol policies. Increasing alcohol costs would reduce both violent and
nonviolent crime, including damaging property, getting into fights, being a perpetrator of sexual
assault, and abusing a child (Grossman & Markowitz, 2001; Markowitz, 2000; Markowitz &
Grossman, 2000). Markowitz and Grossman (1998) analyzed data on violence come from the
1976 Physical Violence in American Families survey in the United States and concluded that
increasing the tax on beer can reduce violence and that laws designed to make obtaining beer
more difficult also may be effective in reducing violence. Ohsfeldt and Morrisey (1997) found
that a $0.25 increase in beer taxes would reduce work-loss days from nonfatal injuries by 4.6
million, at an estimated savings in lost productivity by $491 million. Examining State data from
1971-1985, Chesson, Harrison, and Kassler (2000) reported that a $1.00 tax increase would
reduce gonorrhea rates by 2.1%. These findings provide indirect support that price level is a
factor in heavy or binge drinking and thus problem risks associated with alcohol.

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More recent studies suggest that the relations between taxes on alcohol and alcohol consumption
and problems may have weakened in recent years in the US, possibly because of the
implementation of the age 21 MLDA and other alcohol policies (Young & Likens, 2000). It
recently has been suggested that people respond primarily to changes in the full price of alcohol,
including opportunity costs (Trolldal & Ponicki, 2005). As a result, the demand for alcohol
should be less sensitive to changes in price where regulation is stricter. Consistent with this
hypothesis, it was found that demand for beer and spirits was less price sensitive in states with
monopolies on alcohol sales and distribution than in license states where alcohol sales are
privatized. Similarly, a study showed that raising either MLDA or beer taxes in isolation led to
fewer youth traffic fatalities (Ponicki, Gruenewald, & LaScala, 2007). A given change in price,
however, caused a larger proportional change in fatalities when the MLDA was low than when it
was high. Thus, a 10% increase in price was estimated to reduce traffic fatalities among youth by
3.1% if the legal drinking age were 18, but only by 1.9% if the legal drinking age were 21. It was
concluded that communities with relatively strong existing policies might expect smaller impacts
on alcohol-related problems to result from the implementation of new policies than suggested by
prior research, whereas communities with weak policies might expect larger benefits. In
addition, although tax increases may serve as a means to raise the cost of alcohol, consumers
may find means to circumvent such increases. They may switch to cheaper forms of alcohol or to
cheaper brands (Treno, Gruenewald, Wood, & Ponicki, 2006).

Relationship of the Intermediate Variable to Other Variables (none specified in model)

Little is known about how prices relate to variables in the logic model other than consumption
and problems. Conceptually, it is reasonable to assume that differences in price may relate to
subjective availability of alcohol, with lower prices being associated with greater perceived
availability. Price may also affect expectancies and normative beliefs. In particular, lower prices
may signal greater acceptance of drinking.

Strategies

Restrictions on discount pricing and promotions. Several types of policies affect price of alcohol.
One type of policy is restrictions on happy hours or price promotions (e.g., two drinks for the
price of one, women drink for free). Babor, Mendelson, Greenberg, and Kuehnle (1978) found
that happy hours were associated with higher consumption among both light and heavy drinkers.
Although not specific to college populations, the study has clear implications for college
students; many bars surrounding campuses attract students by promoting drink specials.
Restrictions on happy hours can be implemented by individual outlets, campuses (if a licensed
establishment is on campus), local communities (if communities are not preempted by state law)
and the state. In non-licensed settings on campus where alcohol is served, event planners may
want to limit the amount of free alcohol available.

Increasing excise taxes on alcohol is another type of policy that affects price. Using national
samples of youth, several studies indicate that raising alcohol excise taxes may have large effects
in reducing youth drinking. Higher beer taxes are associated with less frequent drinking among
16- to 21-year olds (Coate & Grossman, 1988; Grossman et al., 1994); effects of tax increases
are stronger among frequent and fairly frequent drinkers than among infrequent drinkers which
lends support to this strategy as a means to reduce higher risk drinking patterns among youth.

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Cook and Moore (1993) found that students who went to high school in states that had higher
taxes and higher MLDAs were more likely to graduate from college. Using a nationally
representative sample of college students, Chaloupka and Wechsler (1996) found that indexing
the federal beer tax to the rate of inflation since 1951 could lead to a 15% reduction in drinking
participation among underage women, and a 17% and 21% reduction in high-risk drinking
among underage women and women over 21, respectively.

Tax increases may influence not only consumption, but also other alcohol-related outcomes, and
youth again appear to be more price responsive than adults in terms of these outcomes. For
example, increased costs appear to reduce drinking and driving among youth more than among
adults (Chaloupka, Saffer, & Grossman, 1993). Kenkel (1993) estimated that a 10% increase in
alcohol price would result in 7% less drinking and driving among all men and over 8% among all
women. Price effects were even greater among young men and women, however (13% and 21%,
respectively). Dee (1999) and Dee and Evans (2001) reported that price increases would reduce
motor vehicle accident fatalities among 18-20 year olds.

Manning, Blumberg, and Moulton (1995) reported that moderate drinkers were most price
responsive, with a price elasticity of -1.19. They also found that both light and heavy drinkers
had elasticities nearly equal to zero. In contrast, Chaloupka, Grossman, Becker, and Murphy
(1992) found that a 10% increase in alcohol price would reduce cirrhosis mortality (i.e., reduce
consumption among heavy drinkers) by an estimated 8.3% to 12.8%. Cook and Tauchen (1982)
reported that a $1.00 increase in alcohol would reduce cirrhosis mortality by 5.4% to 10.8%.

Effects of tobacco and marijuana as complements to alcohol use—An important empirical

question is what the effects of higher prices for alcohol on other substances of abuse, e.g.,
tobacco or marijuana.. Several studies have found that alcohol and tobacco, or marijuana and
tobacco, are complements (i.e., use of one results in greater use of the other) (Chaloupka,
Grossman, Bickel, & Saffer, 1999; Farrelly, Bray, Zarkin, & Wendling, 2001; Jimenez &
Labeaga, 1994). In contrast, however, Goel and Morey (1995) reported that alcohol prices were
positively related to cigarette use, implying that cigarettes and liquor are substitutes such that as
alcohol price increases, then smoking increases.

Summary

The majority of alcohol price studies find that increases in alcoholic beverage prices are effective
in reducing alcohol use. Many of these studies clearly show that these reductions in use are not
limited to drinking by light or infrequent drinkers; significant reductions are also seen in heavy
and/or frequent drinking and its consequences. In addition, studies that look at drinking by youth
generally find even larger effects of taxes and prices than are found for the overall population,
suggesting that increases in prices are particularly effective in reducing youth drinking and its
consequences. Although a few studies produce contradictory findings, the overall weight of the
evidence supporting the effectiveness of alcohol price increases in reducing alcohol use, abuse,
and related problems is substantial. Alcohol taxes are thus an attractive instrument of alcohol
policy as they can be used to both generate direct revenue and to reduce alcohol-related harms.
The most important downside to raising alcohol taxes is the possibility of potential alternatives
or substitutions to taxed alcoholic beverages, particularly in terms of illegal smuggling or illegal

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in-country alcohol production. The net effects of taxation and price increases, however, are the
potential to reduce alcohol use and related problems among underage persons.

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Visible Enforcement

Conceptual Definition

Enforcement refers to enforcing policies to decrease retail and social availability as well as youth
use of alcohol through threat of sanctions. Official policies might call for arrest, prosecution, and
punishment to help reduce alcohol availability and alcohol-related violations. Punishment might
include fines to stores that sell alcohol to minors or stiff penalties for drinking and driving. The
distinguishing characteristic of the enforcement domain is the reliance on the formal criminal
justice system to implement penalties. “Informal enforcement” is also an important complement
to formal mechanisms. For example, “informal enforcement” might come in the form of
communities being unwilling to patronize stores that sell alcohol to minors.

Measurement

A number of alternative measurement possibilities exist:

Enforcement of youth access/alcohol sales laws—Compliance checks, sometimes called “decoy”

or “sting” programs, involve the use of underage buyers working as confederates of law
enforcement agents to test alcohol retailers’ practices concerning alcohol sales to minors.

Enforcement of laws prohibiting third-party provision of alcohol to minors—Shoulder tap

programs utilize underage adolescents who, working as confederates of local law enforcement,
invite adults outside retail outlets to buy alcohol for them, in return for a financial incentive or an
offer to share with them some of the alcohol purchased.

Party Patrols Results--Party patrols use law enforcement officers to (a) enforce laws prohibiting
adult provision of alcohol to minors and underage drinking at private parties and (b) disrupt one
of the highest risk settings for alcohol availability and misuse, i.e., private drinking parties by
conducting weekend patrols of areas known to be regular drinking locations. Party patrols
increase law enforcement’s responsiveness to reports of teenage drinking parties by community
members.

Youth Surveys: Perceived Enforcement of Underage Drinking Laws. In addition to actual

enforcement efforts, youths’ perceptions of the risks of detection and punishment for alcohol
violations may be measured. Assessments may be obtained of the perceived likelihood of (a)
police breaking up a party where youth are drinking, (b) getting caught by police at a party where
youth are drinking, (c) getting caught by police when trying to purchase alcohol, and (d) having
ID checked when trying to purchase alcohol. Source: Student Survey and the PIRE/OJJDP.

Students can be asked how likely or unlikely it is that (a) they will be asked for their ID if they
try to purchase alcohol, (b) they will be caught by police if they try to purchase alcohol, (c)
police will break up a party where youth are drinking, and (d) they will be caught by police if
they are at a party where youth are drinking. A similar item from the OHT asks students whether
a “kid their age” drinking in their neighborhood would get caught by the police (C16g).

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Relationship of the Intermediate Variable to the Problem

Visible enforcement against sales to underage persons has been shown to be associated with
reductions in such sales (See Grube [1997b] and Wagenaar, Toomey, and Erickson [2005b,
2005c].) Young drinkers may be particularly adept at identifying outlets that continue to sell to
minors despite enforcement efforts or may shift to alternative social sources for alcohol. Dent,
Grube, and Biglan (2005) found that stronger enforcement of minor in possession laws, as
indexed by the student’s average perceived level of enforcement in the community, was
significantly related to lower levels in the communities’ general frequency of use and binge
drinking but not levels of drinking in school or drinking and driving/riding with a drinking
driver. Community level enforcement of minor in possession laws was a deterrent for
individuals’ use of commercial sources to drink in school or to drink and drive. It also deterred
the use of friends under 21 for binge drinking, use in general, and the use of parent sources for
drinking and driving. On the other hand, communities with higher MIP enforcement also tended
to have more reliance on taking alcohol from home without permission for binge drinking, use in
general, and more frequent use of friends over 21 as a source while driving.

Support for the importance of reducing retail access to alcohol can be obtained from the
literature on tobacco control. Most notably, a recent randomized community trial suggests that
increasing retailer compliance with age identification for underage tobacco sales not only
reduced tobacco sales to minors and youth smoking, but also underage drinking (Biglan, Ary,
Smolkowski, Duncan, & Black, 2000). Enforcement of laws prohibiting sales to intoxicated
patrons can also be effective. Thus, McKnight and Streff (1994) found a rise in refusals of
service to “pseudo-patrons” simulating intoxication, and a decline in the percentage of drunk
drivers coming from bars and restaurants following increased enforcement of laws prohibiting
sales to intoxicated patrons.

The review of published research concerning minimum drinking age and youth consumption by
Wagenaar and Toomey (2002) found a significant inverse relationship between the legal age and
alcohol consumption. However, the limited degree to which age 21 policies have been
implemented is also shown in several enforcement studies. Such studies have consistently found
very low levels of enforcement of the age-21 policy. Enforcement actions against those selling or
providing alcohol to minors is particularly rare (Wagenaar & Wolfson, 1994). In general, studies
of the effects of increased enforcement show it to be a highly effective means to reduce alcohol
sales to minors. Increased enforcement — specifically compliance checks on retail alcohol
outlets — typically cuts rates of sales to minors by at least half (Preusser, Williams, &
Weinstein, 1994 Lewis et al., 1996; Grube, 1997b). The extent to which visible enforcement of
alcohol sales or service to underage persons translates into specific decreases in underage
drinking is not as well documented by research studies. However, if lower retail sales to youth
are associated with lower consumption, and higher enforcement is associated with lower youth
sales, then the association of level of enforcement to youth drinking can be inferred.

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Relationship of the Intermediate Variable to Other Variables

Enforcement to Retail Availability—Even with minimum drinking age limits, minors can often
purchase alcohol with little difficulty. Increasing enforcement against retailers who sell to
minors, however, can have an impact. Importantly research shows that even moderate increases
in enforcement can reduce sales of alcohol to minors by as much as 35% to 40%, especially
when combined with strategic media advocacy and other community and policy activities Grube
(1997b) found that enforcement of sales laws coupled with media coverage produced a net
reduction in sales to minors of 20 to 25%. In a study in New Orleans, enforcement of underage
sales laws increased compliance with alcohol sales laws from 11% to 39% (Scribner & Cohen,
2001). The greatest gains in compliance occurred among those retailers who had been cited
(51%), but substantial gains were also seen for those not cited (35%).

Enforcement to Social Availability—The relationship of enforcement of social availability of

alcohol to underage persons to underage drinking is not as well documented as retail availability.
Dent, Grube, and Biglan (2005) found that higher minor-in-possession (MIP) enforcement in the
community can increase the use of taking alcohol from home without permission for binge and
general drinking, perhaps because youth simply drink at home if they feel they would be caught
outside the home. The negative interaction between use of parent sources (with or without
permission) for drinking and driving does appear to be reduced in stricter MIP-enforced
communities below already infrequent overall levels, perhaps because of the wider message it
sends parents regarding the unacceptability of providing alcohol to their children, especially if
they are going to be driving or riding in vehicles. Cohen et al. (2001) concluded that beer
consumption as the primary beverage of choice of underage drinkers was found to be a potential
factor in traffic fatalities and that existence of a beer keg registration law as part of an overall
local approach to restricting alcohol availability was associated with reduced traffic fatalities.
See Social Availability.

Strategies

Enforcement of youth access/alcohol sales laws. Dent, Grube, and Biglan (2005) concluded that
communities with high levels of enforcement of minimum age of drinking tended to have lower
community levels of binge drinking and drinking in general. These effects are consistent with the
notion that perceived negative consequences (being caught by the police), if broad and severe
enough, could be a deterrent to behavior. Enforcement interacted with source usage. Use of
sources under the age of 21 for binge drinking and general alcohol use was curtailed in
communities with high enforcement, as could be expected when possession by those under 21 is
restricted. Use of commercial sources was also curtailed in communities with high enforcement
of minimum age laws for in-school drinking and drinking while driving.

Compliance Checks—Compliance checks are the systematic checking by law enforcement of

whether a licensed establishment actually sales alcohol to underage persons or “underage looking
persons”. Studies indicate regular compliance checks substantially reduce illegal alcohol sales
(Grube, 1997b; Preusser et al., 1994), a result well established in literature on tobacco sales to
teens (Difranza, Carlson, & Caisse, 1992; Hinds, 1992; Hoppock & Houston, 1990). Studies of
enforcement effects show that enforcement has reduced sales to youth (Preusser et al., 1994;

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Lewis et al., 1996; Scribner & Cohen, 2001). There is some evidence that enforcement primarily
affects the specific establishments targeted in compliance checks with limited diffusion and that
any effects on sales may decay relatively quickly (Wagenaar et al., 2005b, 2005c).

Nationally, however, weak enforcement appears to be more the norm, with the result being that
youth appear to have readily available access to alcohol (Jones-Webb et al., 1997b; Radecki &
Strohl, 1991; Wagenaar et al., 1993). Forster et al. (1995) reported the results of an enforcement
program conducted in 24 communities in Minnesota and Wisconsin. They found that buyers who
were 21 years of age but looked underage were successful in buying alcohol about 50% of the
time. Off-sale purchases were more successful if the clerks were male and the store was located
in a residential area or mall. On-sale buys were more successful if the server looked under age
30, if the firm was a restaurant/bar combination as opposed to bar alone, and if warning signs
were posted (likely because signs may have substituted for more substantive merchant
educational programs). Wagenaar and Wolfson (1994) found that, without adequate penalties,
attempts to reduce underage retail sales were likely to be ineffective. Wagenaar and Wolfson
(1994) reported that only 2 of every 1,000 occurrences of underage drinking resulted in arrest.

A recent study in Louisiana, (Cohen, Mason, & Scribner, 2002) 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 17 to 22 to attempt to purchase
alcohol in licensed outlets. At baseline on, 11.2% of outlets were compliant. Two months after
the intervention, the level of compliance had increased to 39.9%. At 8 months after the
intervention, there was a residual level of compliance even without any further media coverage.

Random Breath Testing. Random Breath Testing (RBT) involves extensive and continuous
random stops of drivers who are required to take a breath test to establish their blood alcohol
level. Tests of RBT in Australia (Homel, 1986, 1990), Canada (Mercer, 1985) and Great Britain
(Ross, 1988a , 1988b) indicate that they reduce car crashes. For example, in Australia, RBT
resulted in a 24% reduction in night-time crashes, especially in metropolitan areas (e.g.,
Cameron, Cavallo, & Sullivan, 1992; Cameron, Diamantopolou, Mullan, Dyte, & Gantzer, 1997;
Drummond, Sullivan, & Cavallo, 1992). Both enforcement and public awareness seem to be
needed for the success of these programs. Moore, Barker, Ryan, and McLean (1993) found that
males and those aged under 30 years perceived it was unlikely that they would be apprehended
for drinking and driving despite RBT programs. However, the perceived likelihood of
apprehension increased with exposure to RBT, notably when that exposure was recent. Ross
(1982) pointed out that the threat of enforcement, or public expectation that one may be stopped
and arrested, has had more influence than actual enforcement. However, increased public
expectations of arrest must be reinforced with actual increased enforcement to have sustained
effect (Hingson, Howland, & Levenson, 1988; Vingilis & Coultes, 1990; Zador, Lund, Fields, &
Weinberg, 1989).

Sobriety checkpoints., A limited version of RBT, sobriety checkpoints, are often implemented in
individual U.S. states under proscribed circumstances often involving pre-notification about
when and where they will be implemented. Even under these restricted circumstances there is
some evidence that they reduce drinking and driving and related traffic crashes. Evaluation of a
Tennessee checkpoint program (Lacey, Jones, & Smith, 1999), for example, showed a 20%

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decrease in alcohol-related fatal crashes and a 6% reduction in single vehicle nighttime crashes.
These effects were observable 21 months after implementation of the program. Similarly, an
evaluation of checkpoint programs in four California communities indicated that they decreased
alcohol-involved injury and fatal crashes by 9% to 40%, depending upon the community (Stuster
& Blowers, 1995). No significant changes were observed in non-alcohol involved crashes or in a
comparison community. Surprisingly, the degree of success of the programs was the same
regardless of low or high staffing levels or whether mobile units or stationary checkpoints were
used. Public awareness and publicity, however, were identified as important mediators of
effectiveness. No studies have evaluated the effects of these strategies on youth drinking and
driving but there is no reason to believe that this age group of drinking drivers would not be
affected by such policies.

Per se Laws. Per se laws specify the blood-alcohol level or concentration at which a driver is
considered legally impaired, (i.e., the level at which a driver can be arrested and charged with
drinking and driving). The per se level has been declining in Europe, Australia, New Zealand,
and North America. Reductions in the allowable levels of driver impairment have been
associated with reduced crash levels (Liben, Vingilis, & Blefgen, 1987; Ross, 1982; Zador et al.,
1989).

Administrative License Revocation. Laws permitting the withdrawal of driving privileges without
court action have been adopted by 38 states to prevent traffic crashes caused by unsafe driving
practices, including driving with a BAC over the legal limit (Hingson et al., 1996). These laws
were associated with a 5%-9% decline in nighttime fatal crashes in some studies (Hingson, 1993;
Zador et al., 1989). License revocation is one type of punishment that has been shown to be
effective in reducing repeated incidents of drinking and driving and as a major deterrent to
youthful drinkers who drive (Ross & Gilliland, 1991). This strategy, which has not been
specifically evaluated for effects on youth drinking and driving, is considered to be especially
relevant to youth since the possession of a driving permit is a high status and valuable possession
for young people.

Graduated Licenses. Graduated licensing places special limits on new or young drivers. For
example it restricts nighttime driving and/or prohibits driving with other adolescents. A
graduated licensing program in Connecticut led to a 14% net reduction in crash involvement
among the youngest drivers (Ulmer, Ferguson, Williams, & Preusser, 2000). Similarly, in New
Zealand, a 23% reduction in car crash injuries among novice drivers was found after
implementation of a graduated licensing system (Langley, Wagenaar, & Begg, 1996). In Ontario,
Canada, a 25% reduction in self-reported drinking and driving was found following the
introduction of graduated licensing (Mann et al., 1997). A 27% reduction in alcohol-related
crashes involving new drivers was also found in that province following implementation of the
program (Boase & Tasca, 1998). Among the youngest drivers (ages 16-19 years), the reduction
in alcohol-related crashes was somewhat smaller (19%), but still statistically significant.

Automobile Ignition Interlock Devices. Automobile ignition interlocks are devices that prevent
drivers from starting their cars if their blood alcohol level is above a preset limit. This device has
been discussed as a potential means to reduce all drinking and driving but has been used in the
United States primarily as a means to prevent a multiple drinking and driving offender from

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starting his/her auto after drinking (Voas, 1988). As the price of these devices comes down, it
could be possible to require them in cars that adolescents drive.

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 lowering the days and hours of alcohol sale could possibly increase or
decrease youth access to alcohol. Similarly, the introduction or legalization of specific beverage
types appears to change beverage preferences and possibly increase consumption.

Punishment and Sanctions Law enforcement officials generally believe that fines are not an
effective deterrent to underage drinking for several reasons. First, parents often pay these
nominal fines for the youth (Wolfson, Wagenaar, & Hornseth, 1995). Second, because the
majority of teens are employed, a $50 fine, for example, is a relatively small amount of money to
them (American Savings Education Council, 1999; Teenage Research Unlimited, 2001, January
25). Finally, many fines go uncollected and there is often no mechanism to collect on the debts.
Unfortunately, empirical evidence regarding the effectiveness of fines in deterring underage
drinking is lacking (Grube & Nygaard, 2005).

Community service is widely viewed as an effective sanction to impose on youth. Wolfson et al.
(1995) recommend community service placements in locations where the youth are most likely
to see the effects of alcohol abuse. Unfortunately, there is little direct evidence on the
effectiveness of community service as a deterrent to underage drinking (NHTSA & NIAAA,
1999, September). In addition, one concern with imposing community service is that many
communities lack the resources necessary to coordinate and supervise the community placements
(Canadian Cancer Society, 2001, September).

An increasingly common response by legislatures is to suspend or revoke an offender’s driver’s

license (NHTSA & NIAAA, 1999, September). Previously, license suspension and revocation
were pursued in the context of drunk driving. However, states have expanded the grounds for
which driver’s licenses may be suspended or revoked to encompass underage drinking offenses
that do not involve the operation of a motor vehicle (Alcohol Policy Information System (APIS),
2007). Law enforcement personnel strongly believe that the possibility of license revocation is an
effective deterrent because a driver’s license is important to most youth. There is some concern,
however, that because the threat of detection of driving without a license is so low, youth will
simply drive without a license (Canadian Cancer Society, 2001, September). However, this has
not been empirically demonstrated nor has the belief that license revocation is an effective
deterrent to underage drinking in general.

Another available sanction is required attendance at an educational program, typically an alcohol

education program (PIRE, 1999). These specialized classes are designed to deal with alcohol-
related issues and to inform youth of the consequences of their alcohol-related behavior (NHTSA
& NIAAA, 1999, September). The effect of such required education programs on the drinking
behavior of youth is unknown. It has been suggested, however, that imposing sanctions that are
readily, easily, and cheaply applied, such as education, are likely to be more effective than
responses such as incarceration (PIRE, 1989). However, it is doubtful whether education alone

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will be an effective deterrent given that education-based programs have been ineffective at
changing behavior in settings such as school-based substance abuse prevention programs (e.g.,
Gottfredson, 1997).

Some state laws require that law enforcement and schools collaborate in responding to underage
drinking cases (Pacific Institute for Research and Evaluation, 1989). For example, Iowa requires
law enforcement officers to notify the school of an alcohol possession violation (IOWA CODE
ANN. § 123.47B [2001]). A Montana law specifies that the teen court must notify the school
district when a minor is involved in teen court as a result of a substance violation (MONT.
CODE ANN. § 41-5-215 [2002]). The impact of this type of collaboration has not been
evaluated. However, it is arguable that such an approach provides greater monitoring of the
offender and therefore may help to change behavior.

Case dispositions may include commitment to a residential facility (e.g., training schools, camps,
ranches) for delinquents or status offenders (NHTSA & NIAAA, 1999, September; OJJDP,
2002). However, commitment to a residential facility is a less commonly used sanction (NHTSA
& NIAAA, 1999, September). For example, the OJJDP Statistical Briefing Book (OJJDP, 2002)
reports that 8 percent of adjudicated liquor law violation cases resulted in placing minors in a
residential facility. The deterrent effect of placing youth in a residential facility for underage
drinking is unknown.

Incarceration is the most severe form of sanction and appears to be used far less frequently for
underage drinking offenses than other sanctions. Unfortunately, as is true of underage drinking
sanctions in general, there are no data available on the impact of incarceration on underage
drinking, including whether youth are aware that this is a possible sanction and, if they are
aware, whether its availability deters this behavior. However, if incarceration is part of the
sanctioning response, less severe but certain punishment is likely to have greater long term
effects on young drivers (Yu, 2000).

As mentioned earlier, a number of sanctions are available to teen court juries. In addition to those
sanctions discussed above, other sanctions include future participation as a teen court juror, in-
house detention, writing a letter of apology or an extensive essay, and sanctions targeting the
parent(s) of the youth (e.g., parent required to spend one hour a day with the minor) (Johnson &
Rosman, 1997). Additional sanctions typically used by JDCs include imposition of or an increase
in curfew conditions, an increase in frequency of court contacts, intensive probation, a lecture
from the court, a loss of sobriety time, home detention, and a change of school placement
(National Council of Juvenile and Family Court Judges, 2001). Although teen court and JDC
programs have been subjected to some global evaluations, these various sanctions have not been
evaluated and therefore it is unknown what individual deterrent effect they have on underage
drinking.

Little has been written about the importance of monitoring compliance, but it appears to be
critical for enhancing the deterrent effects of sanctions. In juvenile court, compliance with
sanctions is usually monitored by the probation department. Probation (as a form of monitoring
compliance) places youth under informal or formal supervision. Also available to courts is
intensive probation, which may include biweekly visits, electronic monitoring, and unannounced

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visits. Judges have wide-ranging discretion in stipulating the probation conditions (NHTSA &
NIAAA, 1999, September). These conditions typically encompass many of the sanctions already
discussed. For example, judges may include as a condition of probation the payment of a fine,
obtaining an alcohol dependency assessment or periodic testing for alcohol use, attendance at an
education program, or community service. A number of conditions can be set simultaneously by
the court. Probation provides a mechanism for ensuring that these conditions are satisfied. It can
also provide a means to monitor the behavior of the youth, either by regular or sporadic
encounters with a probation officer, and to ensure a swift reengagement with the courts should
the youth reoffender violate probation.

The effectiveness of probation to deter underage drinking has not been studied (Grube &
Nygaard, 2005). Similarly, there have been no evaluations of intensive probation (NHTSA &
NIAAA, 1999, September). Obtaining sufficient resources to permit ongoing monitoring of
offenders by probation officers historically has been a challenge for the criminal justice system.
To the extent that more resources are available to monitor the ongoing behavior of an underage
drinker, this approach may have more promise in this context. Also, some youth may be more
accustomed to relatively close supervision and the monitoring of their behavior in general and
thus be less resistant and more responsive to periodic monitoring by probation officers.

Some communities have responded to underage drinking by making public the names of
individuals involved in underage drinking incidents (Wolfson et al., 1995). For example, the
Inspector General (1991) reported that Alabama issued press releases listing names of minors
arrested for alcohol violations. Similarly, Michigan published the results of vendor sting
operations (Inspector General, 1991). No evaluation of this approach has been conducted.

The National Highway Traffic Safety Administration (NHTSA, 1997) recommends parental
notification as a response to underage drinking. For example, law enforcement officials may be
required to notify a parent when a minor has been cited (i.e., no arrest occurs) for an alcohol-
related violation (e.g., MICH. COMP. LAWS ANN. § 436.1703(6) [2002]). This approach has
been recommended because it is believed to engage parents in addressing the problem, allows
parents to handle the problem at home, and enables them to use disciplinary means that they
have found effective and as they see fit, rather than interjecting the courts into an environment
with which they are not familiar. No evaluations of this approach have been conducted.
Moreover, evaluation of this approach probably would be difficult because the intervention takes
place in the home, where outsiders would not know exactly what transpired and where situations
would vary considerably from case to case.

One primary difference between JDCs and other types of courts is the emphasis of JDCs on
providing incentives for positive behavior change. Incentives include promotion to a subsequent
program phase, providing an award or a gift (e.g., a voucher to a local sporting event), issuing a
certificate or a token acknowledging the participant’s accomplishments, and receiving the
judge’s praise or the praise of other drug court participants. However, there have been no
empirical studies of the effect of these various incentives.

Bonnie (1979) recommends that prior to enacting a law, legislators need to determine the
purpose of the law and their desired goals, then craft laws that will enable them to meet those

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goals. The purpose of possession, consumption, purchase, and misrepresentation laws is to
protect, not punish, youth. Wolfson and Hourigan (1997) argue that it may not have been the
intent of legislatures to criminalize underage drinkers (and thereby to establish a permanent
criminal record for such youth), but this has been the result. Criminal penalties tend to
accomplish deterrence only when punishment is sufficiently swift, certain, and severe (Zimring
& Hawkins, 1973). Wolfson and Hourigan (1997) add that the assumption of legislators may
have been that the mere existence of underage drinking laws would deter underage drinking and
that enforcement and sanctions would not be necessary. However, there is little indication that
this has occurred. But for those youth who have been apprehended and successfully prosecuted,
the result may be the imposition of a criminal record with long-term implications.

Summary

Although the research is limited, there are some inferences that can be drawn about efforts to
deter underage drinking. For example, all states and a number of municipalities have some type
of prohibition against youth drinking, although these prohibitions vary from state to state.
The nature and severity of the sanctions associated with violations of these prohibitions vary
considerably across jurisdictions. It is also apparent that for a variety of reasons, enforcement of
these laws is relatively sporadic and inconsistent. In addition, although all schools in this country
have an alcohol policy, these policies also vary considerably.

A number of sanctions are being applied by a range of agents in conjunction with underage
alcohol offenses. Fines and community service are common sanctions imposed by the legal
system for underage drinking violations. Diversion programs continue to grow in popularity.
Schools are likely to respond to alcohol policy violations with suspension or expulsion.
Unfortunately, little is known about the effectiveness of these responses, and their imposition
appears to be rarely guided by supporting empirical evidence regarding their effectiveness.

There does seem to be a general consensus that if sanctions are used, they should be just one part
of a constellation of responses to underage drinking violations. Researchers and advocates are
calling for comprehensive approaches to underage drinking that involve the youth, their families,
and their communities. Teen courts, for example, have adopted this position.
Evaluation of the effectiveness of teen courts specifically in conjunction with alcohol-related
offenses is needed to test this hypothesis. The suggestion also has been made that sanctions
should be aimed at helping youth rather than simply punishing them for alcohol violations.
In addition, it is important to recognize that sanctions will not be equally effective for all youth.
Sanctions are often used as a blunt instrument of the courts, virtually ignoring developmental
differences among adolescents. However, a sanction (e.g., a fine of $100) that is perceived as
particularly onerous by one youth and thus serves as an effective deterrent may be seen as trivial
or as an inconvenience by another youth. In general, studies have failed to consider the
developmental level, gender, ethnicity, and geographic location of the youth, all of which may be
important considerations (PIRE, 1989; USDHHS, 2001).

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Underage Drinking Laws

Conceptual Definition

Underage drinking and minor in possession (MIP) laws are the formal rules, regulations, and
laws concerning purchase, possession, and use of alcohol by persons under a specifically defined
age, uniformly 21 in the United States. States differ on the specific provisions of their own
statue.

Measurement

All 50 states and the District of Columbia have a minimum legal drinking or purchase age of 21
and have zero tolerance laws for young drivers. Differences exist, however, in the details of the
state laws. Measurement can document differences in ether provision of a state law, e.g., whether
the law specifies 21 as a “drinking age” or as a “purchase age” or how law is implemented. The
Alcohol Policy Information System (APIS), for example, can be used to obtain detailed
descriptions of state level laws. Local differences in policy and implementation can be detailed
through surveys of local officials.

Relationship of the Intermediate Variable to the Problem

Underage Drinking. One goal of a higher minimum legal drinking age is to reduce alcohol
consumption and related harms among youth. In the 1980s, all U.S. states were required to adopt
a uniform 21 minimum age for all alcoholic beverages as a requirement for receiving federal
highway funds. The U.S. General Accounting Office (US GAO, 1987) reviewed 32 published
research studies both before and after the law changed. The GAO concluded that there was sound
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).

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 was examined, using a total of 78 alcohol
consumption measures (e.g., sales figures, self-reported drinking). Of the 78 measures 45%
showed that a higher legal drinking age was associated with reduced alcohol consumption among
youth, while five found that a higher drinking age was associated with greater adolescent
consumption.

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It is clear, however, that the benefits of a higher drinking age are only realized if the law is
enforced. Despite higher minimum drinking age laws, young people can and do purchase alcohol
(e.g., Forster et al., 1994, 1995; Paschall et al., 2007a; Preusser & Williams, 1992; Grube,
1997b). Studies show that anywhere from 30%-90% of outlets will sell to a minor, depending on
geographical location. Such sales result from low and inconsistent levels of enforcement,
especially when there is little community support for underage alcohol sales enforcement
(Wagenaar & Wolfson, 1994, 1995). Even moderate increases in enforcement can reduce sales of
alcohol to minors by as much as 35% to 40%, especially when combined with media and other
community and policy activities (Grube, 1997b; Wagenaar et al., 2000a).

There is growing evidence that alcohol availability is positively associated with drinking rates,
i.e., the easier alcohol is to obtain, the more alcohol is consumed (Edwards et al., 1994). The best
evidence of the effect of alcohol availability on aggregate measures of youth drinking comes
from studies of the minimum drinking age in the United States. Minimum drinking ages restrict
the legal availability of alcohol to youth. As many states increased their minimum drinking ages
to age 21 in the late 1970s and early 1980s, significant decreases in drinking rates and drinking
problems such as traffic crashes were observed among 18-20 year olds (O'Malley & Wagenaar,
1991; Wagenaar, 1993). Additional evidence come from recent studies showing compliance and
MIP enforcement at the community level are related to youth consumption, problem
consumption, and use of commercial sources for alcohol (Dent et al., 2005; Paschall et al.,
2007b).

Impaired driving and traffic crashes. O'Malley and Wagenaar (1991) found that the minimum
legal drinking age affected self-reported alcohol use among young people and reduced traffic
crashes. Indeed the effect on car crashes continued well after young people reached the legal
drinking age. Klepp, Schmid, and Murray (1996) found that implementation of the uniform
minimum legal drinking age of 21 in the U.S. 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 years
decreased single vehicle nighttime crashes involving young drivers from 11% to 16% at all
levels of crash severity. Voas, Tippetts, and Fell (1999), using data from all 50 states and the
District of Columbia for the years 1982 through 1997, concluded that the enactment of the
uniform age 21 minimum drinking age law was responsible for a 19% 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.

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, drink-driving crashes, self-reported
driving-after-drinking). Of the 102 analyses, over 50% found that raising the drinking age
reduced crashes and lowering it raised the crash rate. Only two found a positive relationship
between the legal drinking age and traffic crashes. Of the 95 analyses including comparison
groups, more than one half? (53%) found a statistically significant effect of changing the
drinking age on car crashes. It should be noted that most of these analyses (92%) employed
probability samples or a complete census of the relevant population. Overall, the National

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Highway Traffic Safety Administration estimates that a drinking age of 21 has prevented nearly
25,000 deaths since 1975 (National Center for Statistics and Analysis, 2007.

Other social/health problems. 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 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 35% showed that a
higher minimum drinking age was associated with lower rates of other problems. Additional
scientific evidence suggests that higher minimum purchase ages has also reduced non-traffic
injuries (Jones, Pieper, & Robertson, 1992; Birckmayer & Hemenway, 1999).

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. It is clear, however, that the benefits of a higher drinking
age are only realized if the law is enforced.

Relationship of the Intermediate Variable to Other Variables

Underage Drinking Laws to Retail Availability. Enactment and enforcement of MIP laws and
sales laws appears to decrease purchase. For example, Yu, Varone, and Shacket (1997) found a
70% decrease in self-reported alcohol purchase by 19- to 20-year-olds after the implementation
of a minimum drinking age of 21 years in New York state.

Underage Drinking Laws to Social Availability. There is much less research on the relationship
of underage drinking laws to social availability of alcohol to youth. The strength of the
relationship is clearly mediated by level of actual enforcement of this law in social situations. In
general, stricter enforcement of MIP laws and laws regarding provision to minors will decrease
social access to alcohol by making it more difficult for minors to obtain alcohol from friends,
strangers, and other adults. See Visible Enforcement to Social Availability.

Strategies

Legal (Tort) Liability Concerning Alcohol Sales and Service to Youth. Liability and
administrative regulations are strategies which have the power of court or legal regulation to hold
persons or establishments responsible for sale or service of alcohol to youth and the social
provision of alcohol (social hosts) to youth. Tort liability concerning drinking and alcohol
sale/service establishes civil penalties, usually some form of a fine or liability for civil suit, to
those who are found responsible for specific types of alcohol-involved harm, including providing
alcohol to minors. See discussion by Sloan, Stout, Whetten-Goldstein, and Liang (Sloan, Stout,
Whetten-Goldstein, & Liang, 2000). Most tort liability provisions and court actions have been
directed at licensed establishments for providing alcohol to an underage person. The rationale for
establishing third party liability, rather than first party offenders, e.g., drunks or minors, includes
a recognition that such parties may lack the ability to make appropriate compliance decisions
(Kraakman, 1998), there are fewer third parties to regulate, third parties can be efficient monitors

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of alcohol service practices, and commercial sellers are in a better financial position to render
compensation. In most states, there exists the requirement that the individual must be of a
specific age to be eligible to consume any alcohol which might be sold. Under these statutes,
statutory liability exists for a third party, not the minor, to underage legal action. Therefore, even
if a licensed establishment’s sale/service of alcohol to the minor may be an illegal sale, the minor
cannot establish the statutory cause of action (Mathew Bender and Co., 1998).

In a few jurisdictions, tort liability has been extended to social hosts with the rationale that social
hosts do possess an ability to monitor the serving of alcohol to minors and their guests’ drinking
before driving. In some states, such as California, there are strict limits on social host liability but
courts are increasingly finding ways around these limits. For example, in 1995 New Hampshire
recognized a common-law cause of action for social host liability and a North Carolina court in
1992 recognized a cause of action for a social host who serviced a visibly intoxicated guest. In a
1999 case in Georgia there was a suit against a 16-year-old boy and his parents who served
alcohol in their home to a 15-year-old girl. The parents were not held liable since they were not
home at the time and there was no evidence that they had previously provided beer to their son or
his friends. However, the boy was held liable, even though he himself was a minor, and it was of
no consequence that the girl willing drank the alcohol for under the Georgia legal code the from
legal licensed establishments are responsible for the consequences of their own drinking. State
legislatures and the courts under dram shop liability have established that providing alcohol to an
obviously intoxicated person or in amounts which obviously lead to impairment can be grounds
for a civil suit and possible damages. The use of dram shop liability has been advanced as a
potential tool to deter sellers and social hosts from irresponsible selling or provision of alcohol.
This is discussed in Mosher (1984) and Holder et al. (1993). Much of the research concerning the
effects of tort liability in general, and dram shop liability in particular, has focused on intoxicated
persons, who subsequently are involved in some type of traffic crash. However, since selling or
serving alcohol to persons under the legal drinking age can also be grounds for liability in many
states, this also becomes a part of the possible prevention strategies to reduce alcohol service and
sales to youth, especially when an intoxicated minor is involved in a traffic crash. In addition,
youth are more likely than older people to be driving while impaired by alcohol (Gruenewald et
al., 1996).

Tort liability has several features which support its place as a prevention strategy. The argument
for tort liability concerning youth drinking is that the threat of possible monetary damage for
inflicting harm on another while the youth is impaired by alcohol. If those who provide alcohol
to youth subsequently injure others are liable for damages, this can deter, so the argument goes,
those who would provide alcohol to youth.

Sloan et al. (2000) analyzed traffic fatalities across all states and examined the potential effect of
a number of factors on fatalities over time and across states. They examined in particular the
effect of tort liability on commercial servers for selling alcohol to underage drinkers. They found
that imposing such tort liability on commercial services resulted in reduced fatality rates for
those drivers under 21 years old (actually 15 to 20) controlling for other dependent variables.
This is a single cross sectional and time series study which demonstrates the potential of tort
liability about selling alcohol to persons under 21 years of age. Even though a single study, the
use of data from all 50 states across time increases the strength of the conclusion of the import of
the findings. The only issue for replication concerns the selection of other intervening and

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explanatory variables not included by these authors. This study did not include a variable for the
existence of social host liability.

Zero Tolerance Laws. Zero tolerance laws set lower BAC limits for underage drivers and/or
create a risk of loss of license when an underage youth has been found to be drinking, even if the
youth was not driving. Usually this limit is set at the minimum that can be reliably detected by
breath testing equipment (i.e., .01-.02 blood alcohol level). Zero tolerance laws also commonly
invoke other penalties such as automatic license revocation. An analysis of the effect of zero-
tolerance laws in the first 12 states enacting them found a 20% relative reduction in the
proportion of single vehicle nighttime (SVN) fatal crashes among drivers under 21, compared
with nearby states that did not pass zero-tolerance laws (Hingson, Heeren, & Winter, 1994;
Martin, Grube, Voas, Baker, & Hingson, 1996). Zwerling and Jones (1999) reviewed six studies
of the impact of zero tolerance. All studies showed that the policy reduced injuries and crashes
attributed to youthful drivers. In three of the studies, however, the reductions were not
statistically significant, possibly because of a lack of statistical power. More recent empirical
studies have provided additional evidence for the effectiveness of zero tolerance laws. Thus, a
study of all 50 states and the District of Columbia in the U.S. found a net decrease of 24% in the
number of young drivers with positive BACs as a result of the implementation of zero tolerance
laws (Voas et al., 1999). Similarly, a 19% reduction in self-reported driving after any drinking
and a 24% reduction in driving after five or more drinks was found using Monitoring the Future
survey data from 30 states (Wagenaar et al., 2001). Differences in enforcement of zero tolerance
laws have been identified as a key issue in understanding why some programs are less successful
than others (Ferguson, Fields, & Voas, 2000), as has lack of awareness on the part of young
people (Balmforth, 1998; Hingson et al., 1994). The use of media campaigns to increase young
peoples' awareness of reduced BAC limits and of enforcement efforts can significantly increase
the effectiveness of zero tolerance laws (Blomberg, 1992).

Effective enforcement and awareness of the laws among young people have been identified as
key factors in the success of zero tolerance laws (Ferguson et al., 2000; Voas, Lange, & Tippetts,
1998). Impediments to the enforcement of these laws include (a) requiring that zero tolerance
citations be supported by evidential BAC testing, (b) undue costs to police (e.g., paperwork,
time, court appearances), and (c) lack of behavioral cues for stopping young drivers at very low
BACs. It has been suggested that the most effective zero tolerance laws include passive breath
testing, are implemented in combination with DUI checkpoints or random breath testing, and
involve streamlined administrative procedures (Ferguson et al., 2000). Using media to increase
young peoples’ awareness of reduced BAC limits and of enforcement efforts may also increase
the effectiveness of zero tolerance laws.

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Community Norms about Youth Drinking

Conceptual Definition

Community Norms refer to level of local approval or disapproval of youth drinking by adults
other than their parents in the broader community. Community norms also refer to or be
influenced by perceptions of youth drinking by these others.

Norms and values can be defined as informal social rules or proscriptions defining acceptable
and unacceptable behavior within a social group, organization or larger community. Norms
reflect general attitudes about substance use and societal expectations regarding the levels and
types of consumption considered acceptable. What is considered acceptable behavior may vary
according to the location (e.g., by country or region within a particular country), occasion (e.g. at
a bar, a party or at home) and across demographic subgroups (e.g., by gender, race or ethnicity).

Measurement

Community norms can be measured by asking students about the level of alcohol use by adults
other than own parents in their neighborhood and the extent to which these adults would approve
or disapprove of drinking by young people. Specifically, C17b from the Oregon Healthy Teens
(OHT) survey asks students how wrong adults living in their neighborhood believe it would be
for “kids their age” to drink alcohol and CN-5 from the PIRE/OJJDP survey asks how wrong
they think these adults believe it is for young people to get drunk (very wrong—not at all
wrong). Item C15d from the OHT asks students how many adults (over 21) they have known
personally who in the past year have gotten drunk or high, with five possible responses ranging
from “none” to “5 or more.”

Community norms can be measured in a variety of ways:

--Youth perceived level of alcohol use by adults they know other than own parents
--Youth perceived approval/disapproval of teen alcohol use by adults they know;
--Youth perceptions of how wrong adults in neighborhood think it is for young people to drink,
and
--Youth perceptions of how wrong adults in neighborhood think it is for young people to get
drunk. Source: Student Survey.

Relationship of the Intermediate Variable to the Problem

In an early empirical study, Larson and Abu-Baban (1968) found that consumption increases or
decreases depending on the extent of norms proscribing drinking or consumption limits. In
general, where drinking is more accepted it is natural to assume that drinking (in general) will be
more widespread and average consumption is higher. The acceptability of drinking also has an
important influence on drinking pattern. For example, the more prominent drinking is in a
community, the lower the abstinence rates are likely to be. The percentage of population that
abstains is dependent in part on the relative importance of drinking in the community. While
underage drinking is certainly influenced by general community norms, there is limited research

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on the specific empirical relationship of overall community norms about drinking in general and
to the level of underage drinking. Thus it is reasonable to think about community norms in two
parts: (a) general acceptability of drinking and (b) the specific acceptability (or concern) about
underage or youth drinking. Most surveys of public opinion find high concern about underage
drinking and thus support for underage drinking laws (Wagenaar et al., 2000a). It is not clear
from empirical research exactly how community norms from the general population about
drinking specifically affect underage drinking. That is, are changes in the general acceptability of
drinking in a community also related to reduced acceptability of underage drinking?

It is the second aspect of community norms which may be of most import to underage drinking
and that is using community concern about underage drinking as a foundation for support of
strategies designed to reduce underage drinking. Such support has been frequently noted as a key
ingredient of effective community underage drinking prevention. See Wagenaar et al. (2000a)
and Holder and Treno (1997).

Relationship of the Intermediate Variable to Other Variables

Community Norms to Law Enforcement Community norms can either support or hinder
enforcement of underage drinking and possession laws (Little & Bishop, 1998). Parents can
plead with law enforcement officials, prosecutors, or judges to be lenient with their child to
avoid a permanent record, arguing, “We did this when we were young” (Wolfson et al., 1995).
Similarly, there can be considerable public indifference to underage drinking and related laws
(NHTSA & NIAAA, 1999, September). Generally, society may not concerned with youth
drinking at parties, as opposed to youth drinking and driving, presumably because the
consequences are perceived to be less serious (Little & Bishop, 1998). Yet in the past decade,
there has been much more attention to underage drinking laws and their enforcement, especially
at the local level. See Wagenaar et al (Wagenaar et al., 2000a). The theoretical foundation of this
relationship is that when norms are concerned about underage drinking there is greater support
for the enforcement of existing laws about youth possession, purchase, and drinking of alcohol.

Community Norms to Social Availability. It can be hypothesized that community norms that are
less supportive of underage drinking will be related to lower social availability of alcohol.

Community Norms to Drinking Beliefs & Expectancies It can be theoretically postulated that
community norms that are less accepting of underage drinking will be associated with less
support of drinking by youth and thus less supportive drinking beliefs by youth.

Community Norms to School Influence. It is postulated that community norms which are less
accepting of underage drinking will be related to stricter school policies and more consistent
enforcement of these school policies. However, there is little empirical evidence of this effect of
norms to social policies.

Strategies

Strategies directed at community norms and prevention of underage drinking have primarily
been directed at public support of actions to reduce access of alcohol to youth and thus

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reductions in underage drinking. There are no examples of strategies which have attempted to
change the general acceptability of drinking across all ages as a means to reduce underage
drinking specifically. Thus, it is proposed that community norms regarding underage drinking
will, in part, affect the extent to which underage drinking and possession laws and laws
regarding provision of alcohol to minors will be implemented and enforced. An evaluation of the
Reducing Underage Drinking through coalitions (RUD) project funded ten states for 8 years to
form coalitions designed to change the policy and normative environment regarding youth access
to alcohol (Wagenaar, Erickson, Harwood, & O'Malley, 2006). Measures included print news
media coverage, legislative bills enacted, youth drinking behavior, and youth alcohol-related
driving behaviors and traffic crash mortality. Significant differences in slopes between treatment
and comparison states were found for several outcome measures, particularly in the more-
proximal outcome domains. Across all outcome domains, the pattern of effects was in the
direction of positive effects of the RUD coalitions, although for most individual measures the
differences were not statistically significant.

Strategic use of media can play a key role in building community norms around alcohol issues.
Results from the Community Trials Project (Holder & Treno, 1997) indicate that: (a) training in
media advocacy can increase coverage of news events generated by local community members
including volunteers, (b) increased news coverage can be generated for both electronic
(television) and print media, (c) increased news coverage did focus public attention on specific
issues in support of prevention components, (d) while there are differential audiences/readers for
the print (newspaper) and electronic (TV) media, both audiences are affected, and (e) media
advocacy can be more effective than a paid public information campaign in increasing public
awareness of alcohol issues. Community participation and mobilization are important
complements to formal enforcement efforts because inadequate community support for such
interventions may serve to reduce resources dedicated to enforcement (Wagenaar & Wolfson,
1994, 1995). Lewis et al. (1996) found that enforcement implemented through a community
coalition could be just as effective in reducing youth access to alcohol as more traditional
enforcement mechanisms. In their study, liquor stores under citizens’ surveillance showed a
reduction in underage sales, from 83% to 33%, compared to a decrease from 45% to 36% in
control sites.

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Alcohol Promotion

Conceptual Definition

Retailers attempt to increase demand through the advertising and promotion of their products.
The purpose of advertising and promotion is to increase the attractiveness of drinking by creating
an image favorable to consumption of these substances. Advertising and promotion are designed
to recruit new users and to retain old users. The effects of alcohol advertising and promotion are
largely mediated through drinking beliefs, affecting attitudes and individuals’ decisions
regarding whether to drink, when to drink, and how much to drink. Promotion also influences the
cultural and social context of drinking, potentially altering the perceived legitimacy of social
drinking, including normalizing drinking and the integration of alcohol use into everyday life.

Measurement

General mass media advertising—this has been measured by (a) amount of dollars paid for
general alcohol advertising or (b) the amount of time or space purchased for alcohol
advertising. There appears to be no consistent measure of general advertising specifically
targeted to youth drinking.

Content Analyses of Advertising—This measurement involving coding the amount (time or

inches) of general advertising about alcohol and/or the coding of advertising which is judged
(by pre-established criteria) to appeal to youth drinkers. See Strickland, Finn, and Lambert
(1982), Finn and Strickland (1982), Austin and Hust (2005), and Grube and Waiters (2005)
for information about content coding of alcohol advertising.

Billboard Advertising—the number, placement and size of billboard advertising of alcohol

has been used in some communities as a measure of extent of local alcohol advertising. See
Pasch, Komro, Perry, Hearst, and Farbakhsh (2007) for information on approaches to
documenting the location and content of local billboards involving alcohol where all outdoor
advertisements within 1,500 feet of public schools were documented and coded for content
and theme.
Point-of-Purchase Advertising or Promotion—Where permitted by regulation, retailers and
producers/wholesales place advertising or promotional materials or signs. The
presence/absence or placement (at the point of service or sales or at the table in a bar or
restaurant) are alternative means to measure advertising which is closely associated with
actual sales or service of alcohol.

Relationship of the Intermediate Variable to the Problem

Each year, the alcohol industry in the United States spends more than a billion U.S. dollars on
"measured media" advertising, that is, television, radio, print, and outdoor ads. See
http://www.ftc.gov/reports/alcohol/appendixb.htm The available evidence indicates that more
than 300 wine brands, 350 beer brands, and 1,400 distilled spirits brands are marketed in the
U.S., but fewer than a quarter of them are advertised through measured media each year.

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Promotion of alcohol occurs in many alternative forms of promotion beyond purchased mass
media advertising space or time including sponsorship of cultural events, product placements in
movies and TV show, point of sale advertising, and price promotions, etc.In its special report to
the Federal Trade Commission one alcohol industry member estimated that during the course of
a year, its advertising for a single mid-sized brand would reach 88 percent of adults an average
frequency of 12 times -- more often in large markets.

While precise figures are not available, special reports to the United States Federal Trade
Commission suggest that total expenditures to promote alcohol may be three or more times its
expenditures shown in measured media advertising alone. Even for heavily advertised brands,
measured media advertising typically accounts for only one third to one half of total promotional
expenditures and obviously many alcoholic brands do not use measured media at all. A wide
array of alternative forms of alcohol promotion beyond purchased mass advertising used by the
industry include:

 sponsorship of cultural, musical, and sporting events;

 Internet advertising;
 point-of-sale materials, including window and interior displays at retail outlets, bars, and
restaurants;
 distribution of brand-logoed items such as t-shirts, hats, watches, and glassware;
 product placements in movies and TV shows;
 catalogs and other direct mail communications;
 price promotions such as sales, coupons, and rebates; and
 trade promotions directed at wholesalers and retailers.

Jernigen, Ostroff, and Ross (2005) combined occurrence and audience data to calculate youth
(aged 12–20 years) and adult (above the United States legal drinking age of 21 years) exposure
to alcohol advertising on television and radio, in magazines and on the Internet. Their research in
the United States shows that alcohol companies have placed significant amounts of advertising
where youth are more likely per capita to be exposed to it than adults. These data are updated in
Center for Alcohol Marketing and Youth (2007). This is reflected in the work of Hastings,
Anderson, Cooke, and Gordon (2005) who also reviewed the published research on advertising
and promotion of alcohol and concluded that most econometric studies provide little evidence of
an aggregate effect on consumption, and little or no information about the effect on the drinking
of youth and young people. Instead, Hastings et al. (2005) conclude that consumer studies which
examine the effect of advertising on subgroups of consumers overcome the deficiency of large
macro-studies and do suggest that there is a link between advertising and young people’s
drinking knowledge, attitudes and behavior.

Markowitz and Grossman (1998) concluded that restrictions on alcohol advertising and increases
in illegal drug prices have no effects on violence. Snyder, Milici, Slater, Sun, and Strizhakova
(2006) in a study to test whether alcohol advertising expenditures and the degree of exposure to
alcohol advertisements affect alcohol consumption by youth found that youth who saw more
alcohol advertisements on average drank more (each additional advertisement seen increased the
number of drinks consumed by 1% [event rate ratio, 1.01; 95% confidence interval, 1.01-1.02]).
The study also found that youth in markets with greater alcohol advertising expenditures drank

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more (each additional dollar spent per capita raised the number of drinks consumed by 3% [event
rate ratio, 1.03; 95% confidence interval, 1.01-1.05]).

Research suggests that there is high recall of alcohol advertising among youth (e.g., Lieberman
& Orlandi, 1987). This is not surprising because many advertisements are of high production
value and use a combination of fast action, popular music, provocative imagery and humor.
Nevertheless, the association between recall of number of advertisements seen on the one hand,
and drinking status or behaviors on the other, does not necessarily signify a causal connection.

A longitudinal study in New Zealand examined the association between recall of mass media
messages about alcohol at ages 13 and 15 and drinking at age 18 (Connolly, Casswell, Zhang, &
Silva, 1994). Among both males and females, consumption of wine and spirits at age 18 was not
predicted by recall of commercial advertisements. For males however, the number of
advertisements recalled at age 15 was significantly and positively associated with both average
and maximum amounts of beer consumed at age 18. For females, the number of advertisements
recalled at age 13 was significantly and negatively related to the frequency of beer consumption
at age 18. Further analysis indicated that liking advertising at age 18 predicted heavier drinking
and more alcohol-related problems at age 21 (Casswell & Zhang, 1998).

Kuo, Weschler, Greenberg, and Lee (2003) provided compelling evidence linking price and
promotions to problem drinking among college students. They analyzed the 2001 College
Alcohol Study, which surveyed over 10,000 college students, as well as 830 on-premise and
1,684 off-premise venues at 118 colleges. Results showed that low price and heavy advertising
and promotional activities were associated with increased heavy drinking among college students
and with total number of drinks consumed. Researchers have found that alcohol advertising is
disproportionately concentrated in low-income minority neighborhoods (Pasch et al., 2007) One
study found that minority neighborhoods in Chicago have on average seven times the number of
billboards advertising alcohol as do Caucasian neighborhoods (Hackbarth, Silvestri, & Casper,
1995). The researchers concluded that “Such concentration of alcohol advertising and
availability likely translates into increased problems associated with alcohol use in these
communities.” A similar observation is found in Alaniz (1998). Pasch et al. (2007) studied the
effects of alcohol advertising on billboards and window displays on pre-teens and early teens in
the vicinity of 63 Chicago schools. They found that children living in areas with large numbers
of alcohol ads on billboards, storefronts, bus stops and elsewhere are more likely to look
favorably on drinking and had higher expressed intentions to drink.
Other studies examined the extent of advertising, the times and type of television programming
that youth tend to watch and thus the implicit “targeting” of some advertising (Hill & Casswell,
2001). Measures to control advertising have been developed, at times as part of broader
campaigns focusing on promotion in general. These efforts include ensuring compliance with
reasonably stringent advertising codes of practice (e.g., California Wine Institute, 2005),
campaigning to remove specific advertising (e.g., Woodruff, 1996), and advocating restricted
hours for television ads or locations of billboards—e.g., away from schools. Other initiatives
involve working with scriptwriters to give a more balanced portrayal of drinking in the mass
media (Wallack, Dorfman, Jernigan, & Themba, 1993), seeking to curtail association between
child-oriented events and advertising (e.g., Halloween and beer paraphernalia), and enacting

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warning messages and counter-advertising campaigns (Giesbrecht, Johnson, Anglin, Kavanagh,
& Greenfield, 1998; Greenfield, Graves, & Kaskutas, 1999).

Point of Purchase Promotion to Underage Drinking. Although the exact relation is unknown,
greater promotion may decrease price by increasing competition. This especially appears to be
the case for local advertising. Price may then mediate the effects of promotion on consumption.
In a study of college communities, for example, it was found that alcohol specials, promotions,
and advertisements were prevalent in the alcohol outlets around the campuses. Low sale prices
and frequent promotions and advertisements were associated with higher binge drinking rates
(Kuo et al., 2003). Harwood et al. (2003) found that community, neighborhood and private
grocery store characteristics were related to beer price; however, only community and store
characteristics were predictive of beer promotions. They concluded that pricing and promotion
of beer varies systematically by some characteristics of communities, neighborhoods, and stores,
but not significantly by the number of young people populating a neighborhood.

Snyder et al. (2006) found that restrictions on point-of-purchase price advertising at liquor stores
reduced the probability of drinking and driving among all drinkers and with price advertising,
prices may be expected to fall, thereby leading to increases in over all consumption. They found
that drinkers who lived in states permitting grocery stores to sell beer and wine had a
significantly higher probability of drinking and driving and they concluded that that advertising
and availability of alcohol promote drinking.

Ellickson, Collins, Hambarsoomians, and McCaffrey (2005) examined the relationship between
exposure to different forms of alcohol advertising and subsequent drinking among US
adolescents. They found that for seventh-grade non-drinkers, exposure to in-store beer displays
predicted drinking onset by grade 9; for seventh-grade drinkers, exposure to magazines with
alcohol advertisements and to beer concession stands at sports or music events predicted
frequency of grade 9 drinking, These research findings are reflected in sales information that
74% of all beer sales in the U.S. are in retail establishments, led by convenience stores and gas
stations and that young adults (aged 21-27) are most likely to purchase beer in package and
convenience stores. (Miller Brewing Company, 1997), and that 75% of teens shop at
convenience or convenience/gas stores weekly (Point of Purchase Advertising Institute, 1992).

Bray, Loomis, and Engelen (2007) investigated the association between beer product
characteristics (type, package size, and brand name), market-area socioeconomic characteristics,
and promoted sales of beer in grocery stores. Using supermarket scanner data from 64 market
areas across the United States over 5 years they found that large-volume product containers, such
as 144-oz and 288-oz packages, are more likely to be promoted than smaller package sizes. The
researchers noted that marketing research has shown in-store merchandising and promotions to
substantially increase beer sales and that purchasing large package sizes may increase total
consumption.

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Relationship of the Intermediate Variable to Other Variables

Alcohol Promotion to Drinking Beliefs and Expectancies--Expectancies related to the effects of

alcohol and intentions to drink can also be influenced by advertising. For example, Lipsitz,
Brake, Vincent, and Winters (1993) found fifth and sixth grader students exposed to television
commercials had more positive expectations of the consequences of drinking. Among pre-
adolescents, Austin and Meili (1994) found that children’s intentions to drink were predicted by
their perception of alcohol-related behavior in the home environment, their interpretation of TV
messages, their desire to be like the television characters who drink, and their expectancies that
drinking brings rewards. Grube and Wallack (1994) reported that fifth and sixth graders’
awareness of beer advertising on television was related to more favorable beliefs about drinking,
greater knowledge of brands and slogans, and increased intention to drink as an adult.

Research examining the potential effects of exposure to drinking on television on young people’s
drinking beliefs and behaviors have concluded that the evidence for the effects of alcohol
advertising on drinking beliefs and behaviors is limited at best (e.g., Atkin, 1995; Calfee &
Scheraga, 1994; Fisher, 1993; Nelson & Young, 2001; Nelson, 1999). Generally speaking,
correlational studies have found small, but statistically significant, relations between television
viewing and alcohol-related beliefs and behaviors. Thus, Tucker (1985) found that high school
boys who were heavier television viewers drank more than lighter viewers. Similarly, Neuendorf
(1985) reported that television viewing was related to beliefs about drinking among 10- to 14-
year-old adolescents: Heavier viewers were more likely than lighter viewers to agree that people
who drink are happy and you have to drink to have fun at a sporting event. More recently, in a
prospective study of 1,533 ninth-grade students, it was found that television viewing was related
to initiation of drinking over an 18-month period (Robinson, Chen, & Killen, 1998). Snyder and
her colleagues (2006) found that youth in markets with greater alcohol advertising expenditures
drank more, with each additional dollar spent per capita raising the number of drinks consumed
by 3%. Coulson, Moran, and Nelson (2001) report a series of analyses using quarterly
advertising expenditures, taking into account the relative audience reach of different media types.
Some significant effects of alcohol advertising were found, although they were quite small. Thus,
spirits advertising had a positive effect on spirits consumption one quarter (3 months) later, and a
contemporaneous positive effect on wine consumption. Wine advertising, however, had a
negative effect on spirits consumption after one quarter and a positive contemporaneous effect
on wine consumption. It was concluded that the effects of alcohol advertising on overall
consumption were negligible.

Similar results have been reported for advertising expenditures on per capita alcohol
consumption in Ontario, Canada (Larivière, Larue, & Chalfant, 2000). Although the results were
unstable and varied considerably depending on model specification, they suggested that spirits
consumption was positively related to advertising expenditures, whereas beer and wine
consumption were negatively related to advertising expenditures. They concluded that
advertising effects were subtle, may vary by beverage, and probably affect brand or product
allocation, rather than overall consumption. Although significant positive relations were found
between TV viewing of alcohol advertising and self-reported involvement in risky behaviors for
specific genres (e.g., cartoons), the results were inconsistent across genres and no effect was

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found for overall TV viewing. These correlational studies suffer from potentially serious
conceptual and methodological problems.

In addition to the correlational studies, the influence of televised portrayals of drinking on young
people has been addressed in experimental studies (Kotch, Coulter, & Lipsitz, 1986; Rychtarik,
Fairbank, Allen, Foy, & Drabman, 1983). In both of these studies, children who were shown
videotaped segments from popular television series containing drinking scenes expressed more
favorable attitudes and beliefs about drinking than did children exposed to similar segments
without drinking. In one case (Kotch et al., 1986) significant effects were found for boys but not
girls, and then only for a few of the measures of alcohol beliefs that were obtained. Although
these studies are suggestive, they are problematic. The effects were small and selective, and the
experimental situation simply cannot provide a parallel to the real world where exposure occurs
more or less regularly over relatively long periods of time. In sum, the available evidence
regarding the influence of televised alcohol portrayals on young people is inconclusive, at best.

Studies on the effects on youth of exposure to depictions of drinking in films are rare. In one
study (Bahk, 2001), college students were exposed to one of two versions of A Star Is Born, one
of which depicted negative consequences of drinking for the lead character (e.g., performing
poorly at a concert, fighting, dying in a drinking-related crash) and the other with the negative
consequences edited out, leaving primarily positive consequences. The results indicated that
viewing the positive consequences version, relative to the negative consequences version, led to
more favorable attitudes toward drinking and to stronger intentions to drink. The effects were
strongest for attitudes toward drinking for tension reduction and amusement and intentions to
drink for stress management. In a similar study (Kulick & Rosenberg, 2001), college students
were exposed to a series of eight film clips with or without depictions of spirits consumption.
Results indicated that participants in the positive portrayal condition had significantly more
positive alcohol expectancies compared with controls, although they did not differ significantly
from those in the negative portrayals condition. Few studies have investigated the effects of film
portrayals of drinking on young adults, adolescents, and children. The findings from these
studies are mixed. Although evidence from one study shows that such portrayals can have small
effects on drinking attitudes and intentions, the results from the second study are ambiguous.
.
The results of earlier experimental studies have been mixed with some studies finding no effects
(e.g., Kohn, Smart, & Ogborne, 1984; Sobell et al., 1986) and other studies finding small or
short-term effects for some study participants (e.g., Kohn & Smart, 1987). Apparently only a
single recent study has been published that experimentally manipulated exposure to alcohol
advertising (Lipsitz et al., 1993). This study was intended to investigate the effects of television
beer advertising on alcohol expectancies among young people who were not yet regular drinkers.
Groups of fifth and eighth graders were exposed to videotapes containing five beer commercials,
the same five beer commercials plus two anti-drinking public service advertisements, or five soft
drink commercials. Results of a memory task indicated that the children paid attention to the
advertisements and remembered seeing the beer and soft drink commercials. Despite the
attention given to the advertisements, however, neither exposure to the beer advertisements alone
nor to the beer advertisements in combination with the anti-drinking PSAs affected scores on the
alcohol expectancy scales. The results of these experimental studies offer only very limited
evidence that alcohol advertising promotes more favorable drinking beliefs or increases

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consumption. Laboratory studies of alcohol advertising effects, however, can be criticized (See
Atkin, 1995; Grube, 1995, Grube, 2004; Lastovicka, 1995; Thorson, 1995). First, although
laboratory experimental studies can control for extraneous factors and allow for strong causal
inferences, they often lack realism. In the typical study, respondents will be exposed to alcohol
advertising in an artificial setting (e.g., schoolroom) that does not resemble the natural viewing
situation. As a result, it is difficult to draw conclusions about the “real-world” effects of alcohol
advertising on beliefs and behaviors based on these laboratory studies. Second, it has been noted
that advertisers target specific audiences with particular advertisements which can not
necessarily be replicated in experimental conditions (Thorson, 1995).

Alcohol Promotion to Community Norms about Youth Drinking. Alcohol promotion may
undermine existing community norms about alcohol or set new norms. However, there is little
direct empirical evidence of this relation.

Strategies

Advertising Restrictions. At the aggregate level, a central focus has been on trends in alcohol
advertising, per capita consumption and drinking problems. Only a few studies have considered
the effects of alcohol advertising restrictions on alcohol consumption or problems. Saffer (1991)
investigated the effects of restrictions on broadcast alcohol advertising on alcohol consumption
and alcohol problems (liver cirrhosis mortality, motor vehicle fatalities) in 17 European and
North American countries. He found that countries with partial restrictions on alcohol
advertising had lower alcohol consumption and fewer problems than countries with no
restrictions. Countries with complete bans had lower rates than countries with partial restrictions.
A reanalysis, however, suggested that there was reverse causation, with those countries
experiencing low rates of alcohol problems being more likely to adopt alcohol advertising bans
than were countries with high rates of alcohol problems (Young, 1993). A study of alcohol
advertising restrictions in 20 countries over 26 years found that moving from no restrictions to
partial restrictions or from partial restrictions to total bans reduced alcohol consumption between
5%-8% (Saffer & Dhaval, 2002). Other recent studies have found no effects of advertising bans
(Nelson & Young, 2001).

Saffer (2002) completed a review of published research literature on the potential effects of
alcohol advertising on consumption and in particular the effects on youth drinking. He concluded
that the results of the review suggest that alcohol advertising does increase consumption but that
an alcohol advertising ban alone is insufficient to limit all forms of promotion and that a
comprehensive ban would receive substantial public support. Saffer and Dhaval (2002)
concluded following an analysis of national alcohol consumption related to total advertising
expenditures that alcohol advertising bans decrease alcohol consumption. They found that one
more ban on beer and wine or on spirits advertising would reduce consumption by about 5% and
one more ban on all alcohol advertising in a media would reduce consumption y about 8%.
Nelson (2003) used a panel of 45 states for the period 1982–1997. This study analyzes the
importance of several restrictive alcohol regulations, including advertising bans for billboards,
bans of price advertising, state monopoly control of retail stores, and changes in the minimum
legal drinking age. In contrast to previous research, the study allows for substitution among
beverages as a response to a regulation that targets a specific beverage. Nelson (2003) concluded

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that “bans of advertising do not reduce total alcohol consumption, which partly reflects
substitution effects.” Recently, it has been estimated that a total ban on alcohol advertising in the
US would result in a 16.4% decrease in alcohol-related life-years lost, and a partial advertising
ban would result in a 4% reduction in alcohol-related life-years lost (Hollingworth et al., 2006).
Tremblay and Okuyama (2001) conducted an analysis of the potential effect of spirits advertising
on the demand for spirits as a result of spirits producers ending their voluntary ban on broadcast
advertising. The authors argued that previous conclusions of policy economists that removing
this voluntary ban had no effect on alcohol consumption was incorrect because it ignores the fact
that advertising restrictions may affect industry competition as well as market demand.

Some natural experiments on partial advertising bans have not provided a sound basis for
determining the unique potency of advertising (Montonen, 1996). Studies of partial advertising
bans in Canadian provinces (Ogborne & Smart, 1980; Smart & Cutler, 1976) failed to show clear
impacts perhaps because advertising from outside the province was not restricted. Other
international studies found that bans produced no drop in consumption and that stricter rules did
not produce lower rates of drinking (Simpson, Beirness, Mayhew, & Donelson, 1985). In
contrast, a major cross-national time-series study of advertising bans implemented in European
Community countries during the 1970s showed significant effects, including lower levels of
consumption and alcohol-related problems, as indicated by motor vehicle fatality rates (Edwards
et al., 1994; Saffer, 1991, 1995, 1998). Apparently no studies have investigated the specific
effects of advertising restrictions on drinking or drinking problems among young people. The
effects of advertising restrictions on young people’s drinking is best considered an open
question.

Warning Labels Warning labels on beverage containers constitute another strategy for targeting
risky drinking. The warning label legislation is among the few U.S. federal alcohol policies
motivated by public health concerns to be successfully enacted after 20 years of legislative
attempts (Kaskutas, 1995). It was enacted in 1988 (P.L. 100-690) and implemented in November
1989. The warning label mandated on all alcohol containers carried a “Government Warning”
tag line and alluded to the Surgeon General as the source of the determinations covered. The
warnings included: 1) birth defects risks during pregnancy; 2) impairment when driving; 3)
impairment when operating machinery; and 4) health problems. Some states also require posted
warnings of alcohol risks in establishments that serve or sell alcohol.

An early evaluation of warning labels on alcohol beverage containers in the US found that about
one fifth of respondents to a national survey remembered seeing the warnings six months after
their introduction (Kaskutas & Greenfield, 1992; Graves, 1993). A study of US adolescents
found that there were increases in awareness, exposure to, and memory of the labels after they
were implemented, but there were no changes in alcohol use or beliefs about the risks targeted by
the warning (MacKinnon, Pentz, & Stacy, 1993).

Self-reported precautionary behaviors have increased including personal caution regarding

drinking and driving and drinking during pregnancy (Kaskutas & Greenfield, 1992; Greenfield,
1997; Greenfield & Kaskutas, 1998; Greenfield et al., 1999). No direct impacts of warning labels
on alcohol-related problems have been reported. Much of the effect seen is consistent with the
intent of Congress to remind the public of certain risks associated with drinking (Greenfield et

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al., 1999). An experimental study of college students by Snyder and Blood (1992) involved
participants looking at different advertisements for alcoholic products, some with the U.S.
Surgeon General’s warning and some without. Results showed that the warnings did not increase
perceptions of alcohol risk and even made products more attractive to both drinkers and
nondrinkers. Conversely, the U.S. Warning Labels Study found that awareness—as indicated by
conversations about risks—was greater among the more frequent drinkers, including young
adults (Kaskutas & Greenfield, 1997; Greenfield & Kaskutas, 1998).

The effect of warning label exposure on conversations about risks of drinking during pregnancy
was seen also among women of childbearing age (Kaskutas, Greenfield, Lee, & Cote, 1998), and
not limited to those with high levels of health consciousness (Kaskutas & Greenfield, 1997).
Conversely, studies in prenatal clinics yielded little indication that the warning label had little
effect on drinking by inner city ethnic minority women (Hankin, Sloan, & Sokol, 1998) so
certain groups at particularly high risk may not be expected to be effectively reached. Greenfield
and Kaskutas (1998) noted that, while after four or more years, warning label exposure rates may
have leveled off, penetration of the warning label has been sufficient to reach numerous heavy
drinkers (Greenfield, 1997). The more drinkers handle (open) containers and, especially for men,
the more alcohol they purchased, the more likely the more they are to have seen and recalled the
label’s messages. Thus, warning labels assure that those most involved in drinking will have
exposure to health messages. Overall, there is only limited evidence that alcohol beverage
warning labels have any discernable effect on problem drinking among young people.

Mass Media Counter-Advertising Campaigns. This intervention involves disseminating

information about a product, its effects, or the industry that promotes it, in order to decrease its
appeal directly (Stewart, 1997). Counter-advertising can take the form of media literacy efforts
to raise public awareness of industry tactics, and a module in community or school prevention
programs (e.g., Greenfield & Zimmerman, 1993). There is evidence that synergies are achieved
by implementing multi-faceted strategies, such as health messages at the point of purchase signs
and public service announcements (PSAs) (Kaskutas & Graves, 1994; Kaskutas et al., 1998).

Billboard Bans of Alcohol Advertising— Billboard advertising, which can also include
freestanding signs and signs on buildings, vehicles and other public locations (such as bus
placards or subway ads) have been targeted by communities as a prevention strategy to reduce
alcohol promotion. Some communities have undertaken the strategy of restricting or limiting the
number and/or placement of billboards which contain alcohol advertising (Hackbarth et al.,
2001). Such strategies are based upon the potential influence of exposure to positive alcohol
messages on intention to drink and actual drinking by underage persons.

Milwaukee Fighting Back's Erase and Replace Campaign successfully reduced the number of
billboards and signs advertising alcohol in the community. The campaign pressured billboard
companies to abide by voluntary advertising guidelines by threatening to advocate for policies
that would ban all billboards in the area. Companies complied with voluntary guidelines by
agreeing to limit alcohol and tobacco advertising on billboards in Milwaukee County. The San
Antonio based Fighting Back "chapter" helped youth organize to replace billboards advertising
alcohol with billboards with positive messages. As part of this effort was a billboard "count" that

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compared the numbers of billboards in minority neighborhoods with Anglo communities. The
target of the effort were two the billboard advertising companies in the city. See Rabago (2000).

A complete handbook for local action on alcohol advertising is found at:

http://www.faceproject.org/Resources/CommunityActionKits.html See the University of
Minnasota School of Public Health suggested legal ordinance to limit billboards which advertise
alcohol: http://www.epi.umn.edu/alcohol/sample/billbrd.shtm. as well as the Health Policy
Guide: http://www.healthpolicyguide.org/doc.asp?id=126 and Coalitions against Alcohol and
Drug Abuse (CADCA) at: http://www.cspinet.org/booze/Alcohol_Advertising.pdf.

Nelson (2003) as a part of his study of the effect of several restrictive alcohol regulations,
included advertising bans for billboards and bans of price advertising. In contrast to previous
research, the study allows for substitution among beverages and concluded that “bans of
advertising do not reduce total alcohol consumption, which partly reflects substitution effects.”
Nelson did not address the effects of advertising bans on underage drinking. There are no studies
specifically of the effects of a local ban or restriction on billboard or public advertising of
alcohol and underage drinking initiation or drinking level.

Summary

Alcohol portrayals are relatively common on television, in film, and in music and music videos.
These portrayals are largely positive or neutral, often associating drinking with positive
consequences or desirable attributes. Negative consequences of drinking are rarely portrayed.
Only a few studies have investigated the effects of exposure to alcohol portrayals in popular
media. With some notable exceptions (e.g., Saffer, 1997), experimental and ecological studies
have produced little or no evidence that alcohol advertising affects drinking beliefs, behaviors, or
problems among young people. In contrast to experimental and ecological studies, however,
survey research studies on alcohol advertising and young people consistently indicate that there
are small, but significant, correlations between awareness of and affect toward alcohol
advertising and drinking beliefs and behaviors among young people. Children and adolescents
who are more aware of and favorably disposed to alcohol advertisements hold more favorable
beliefs about drinking, intend to drink more frequently as adults, and drink more frequently and
in larger quantities than do other young people. Taken as a whole, the survey studies provide
some evidence that alcohol advertising may influence drinking beliefs and behaviors among
some children and adolescents.

A growing body of research is confirming and extending these findings (cf. Martin et al., 2002).
This evidence, however, is far from conclusive. Because of the cross-sectional design of most of
the published studies, causal inferences are difficult. Alcohol advertising may predispose young
people to drink or the opposite may be true instead. That is, young people who are favorable
toward drinking may seek out information about alcohol and thus be more attentive to alcohol
advertisements. Although studies using longitudinal data and nonrecursive modeling techniques
suggest that responses to advertising affect many drinking behaviors, further research is needed.
Longitudinal studies that follow the samples of young people from childhood to late adolescence
and that adequately control for past drinking behaviors and predisposition would be particularly
useful.

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