33333direcWagennarr*Ed STATE PERFORMANCE & BEST PRACTICES FOR THE PREVENTION AND REDUCTION OF UNDERAGE DRINKING REPORT 2020 This State Performance & Best Practices for the Prevention and Reduction of Underage Drinking Report (SPBP) is required by the Sober Truth on Preventing (STOP) Underage Drinking Act (Pub. L. 109-422), which was enacted by Congress in 2006 and reauthorized in December 2016 as part of the 21st Century Cures Act (Pub. L. 114-255). The STOP Act directs the Secretary of the Department of Health and Human Services (HHS), working with the Interagency Coordinating Committee on the Prevention of Underage Drinking (ICCPUD), chaired by the Assistant Secretary for Mental Health and Substance Use, U.S. Department of Health and Human Services, to develop a set of performance measures for evaluating the states’ use of best practices in preventing underage drinking. To meet this requirement, the SPBP Report currently identifies 26 policies that are deemed known or potential best practices and provides a summary of the current status of adoption of these measures across the states. Further, it summarizes state and District of Columbia responses to an annual survey about underage drinking enforcement practices, prevention programs, and expenditures. Finally, it includes state and national data on alcohol-related outcomes for six performance measures. Time period covered by the 2020 SPBP: State legal data reflect the status of the law as of January 1, 2019. State survey data, collected in 2019, were drawn from the most recent 12- month period in which the states maintained the data. Data presented in the six performance measures were drawn from the Substance Abuse and Mental Health Administration’s National Survey on Drug Use and Health (NSDUH) estimates for 2017–18, and from 2018 data from the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System (FARS). Contents Introduction ................................................................................................................... 1 Chapter 1: Best Practices—State Prevention Policies ............................................... 7 Introduction ......................................................................................................................................8 Policies Addressing Underage Possession or Purchase of Alcohol ...............................................12 Policies Targeting Underage Drinking and Driving ......................................................................29 Policies Targeting Alcohol Availability ........................................................................................42 Policies Affecting Alcohol Pricing ..............................................................................................104 Chapter 2: The Importance of Enforcement in Preventing Underage Drinking ...................................................................................................................... 127 Introduction ..................................................................................................................................128 Chapter 3: Enforcement and Prevention Activities—2019 State Survey Results ............................................................................................................................. 135 Introduction ..................................................................................................................................136 Survey Instrument ........................................................................................................................138 Methods........................................................................................................................................139 Results ..........................................................................................................................................140 Comparison of Enforcement Data: 2011–19 ...............................................................................158 Concluding Observations .............................................................................................................164 Chapter 4: State Performance Measures ................................................................ 167 Introduction ..................................................................................................................................168 Measures ......................................................................................................................................169 Percentage of 12- to 20-Year-Olds Who Used Alcohol in the Last Month ............................169 Percentage of 12- to 20-Year-Olds Who Binge Drank (Four to Five Drinks at One Time) in the Last Month ...................................................................................................................170 Percentage of 12- to 17-Year-Olds Who Perceive Drinking Five-Plus Alcoholic Beverages Once or Twice a Week as Not a Great Risk .........................................................171 Percentage of 12- to 17-Year-Olds With DSM-IV Alcohol Use Disorder .............................172 Percentage of 12- to 17-Year-Olds Who Needed But Did Not Receive Treatment for Alcohol Use Disorder at a Specialty Facility in the Past Year ..............................................173 Percentage of Traffic Crash Deaths Involving a 15- to 20-Year-Old Driver With a BAC of 0.01 or Higher....................................................................................................................174 References ................................................................................................................. 175 __________________________________ 2020 State Performance & Best Practices for Preventing and Reducing Underage Drinking | i ___________________________________________________________________________________________________ Introduction Introduction The harmful consequences of underage drinking are widespread and affect individuals under age 21 as well as their families and their communities. The role of the states in preventing underage drinking is critical, particularly as regulators of the alcohol market. State legislatures adopt laws that regulate, directly or indirectly, underage alcohol use and availability in many ways, including the use of false identification, drivers licenses for young people, and adult responsibility for underage access. Enforcement of underage drinking laws and regulations takes place at the state and local level. State substance misuse agencies develop and support prevention, treatment, and recovery programs and activities in communities and schools. In many states and cities, public health agencies are involved in monitoring alcohol and drug use and are helping design and evaluate effective community-based prevention strategies as well. Congress recognized the essential function that states play in the national efforts to reduce underage drinking when it enacted the Sober Truth on Preventing Underage Drinking (STOP) Act (Pub. Law 109-422; reauthorized in 2016 as part of the 21st Century Cures Act [Pub. Law 114-255]). The Act’s preamble includes this statement of the sense of Congress: Alcohol is a unique product and should be regulated differently than other products by the States and Federal Government. States have primary authority to regulate alcohol distribution and sale, and the Federal Government should support and supplement these State efforts. States also have a responsibility to fight youth access to alcohol and reduce underage drinking. Continued State regulation and licensing of the manufacture, importation, sale, distribution, transportation, and storage of alcoholic beverages are … critical to … preventing illegal access to alcohol by persons under 21 years of age. The STOP Act states that a “multi-faceted Exhibit I.1: STOP Act Multi-Faceted Approach to the effort” and a “coordinated approach” to Prevention and Reduction of Underage Drinking addressing underage drinking are needed. The key activities included in this approach are prevention, intervention, treatment, enforcement, and research and are reliant on multiple entities for execution (Exhibit I.1). This document—State Performance & Best Practices for the Prevention and Reduction of Underage Drinking Report (SPBP Report)— is intended to provide guidance to decision-makers about how to identify and select the intervention(s) that will best serve their state or community, as required by the __________________________________ 2020 State Performance & Best Practices for Preventing and Reducing Underage Drinking | 1 ___________________________________________________________________________________________________ Introduction STOP Act.1 The report also provides measures of states’ use of best practices in preventing underage drinking, as required by the STOP Act. Chapter 1 of the document describes 26 state legal policies deemed known or potential best practices in preventing and reducing underage drinking and lists the current research supporting their level of effectiveness. In Chapter 2, the role of enforcement in successfully implementing these policies is discussed. Chapter 3 presents detailed summary data on the states’ enforcement and prevention activities, taken from an annual survey of the states. Finally, Chapter 4 provides charts showing state performance as measured by federal data for six key areas: (1) Underage past-month alcohol use, (2) past-month binge alcohol use, (3) perception of risk of excessive alcohol use, (4) prevalence of alcohol use disorder, (5) receipt of treatment for alcohol use disorder, and (6) traffic crash fatalities involving underage drivers with a blood alcohol content (BAC) greater than zero. The STOP Act The STOP Act directs the Secretary of the Department of Health and Human Services (HHS), working with the Interagency Coordinating Committee on the Prevention of Underage Drinking (ICCPUD), to develop a set of performance measures for evaluating the states’ use of best practices in preventing underage drinking (Section 2[c][2]). The Act requires the following categories to be considered in developing such measures: “(I) Whether or not the State has comprehensive anti-underage drinking laws such as for the illegal sale, purchase, attempt to purchase, consumption, or possession of alcohol; illegal use of fraudulent ID; illegal furnishing or obtaining of alcohol for an individual under 21 years; the degree of strictness of the penalties for such offenses; and the prevalence of the enforcement of each of these infractions. “(II) Whether or not the State has comprehensive liability statutes pertaining to underage access to alcohol such as dram shop, social host, and house party laws, and the prevalence of enforcement of each of these laws. “(III) Whether or not the State encourages and conducts comprehensive enforcement efforts to prevent underage access to alcohol at retail outlets, such as random compliance checks and shoulder tap programs, and the number of compliance checks within alcohol retail outlets measured against the number of total alcohol retail outlets in each State, and the result of such checks. “(IV) Whether or not the State encourages training on the proper selling and serving of alcohol for all sellers and servers of alcohol as a condition of employment. “(V) Whether or not the State has policies and regulations with regard to direct sales to consumers and home delivery of alcoholic beverages. “(VI) Whether or not the State has programs or laws to deter adults from purchasing alcohol for minors; and the number of adults targeted by these programs. “(VII) Whether or not the State has programs targeted to youths, parents, and caregivers to deter underage drinking; and the number of individuals served by these programs. “(VIII) Whether or not the State has enacted graduated drivers licenses and the extent of those provisions. 1 The material in this report is not intended as legal advice and is not a substitute for the services of a practicing attorney. Those in need of information about the application of law to their circumstances are encouraged to consult a qualified attorney. 2 | 2020 State Performance & Best Practices for Preventing and Reducing Underage Drinking __________________________________ ___________________________________________________________________________________________________ Introduction “(IX) The amount that the State invests, per youth capita, on the prevention of underage drinking, further broken down by the amount spent on-- “(aa) compliance check programs in retail outlets, including providing technology to prevent and detect the use of false identification by minors to make alcohol purchases; “(bb) checkpoints and saturation patrols that include the goal of reducing and deterring underage drinking; “(cc) community-based, school-based, and higher-education-based programs to prevent underage drinking; “(dd) underage drinking prevention programs that target youth within the juvenile justice and child welfare systems; and “(ee) other State efforts or programs as deemed appropriate.” To meet this requirement, the SPBP Report currently identifies 26 policies that are deemed known or potential best practices and provides a summary of the current status of adoption of these measures across the states. Further, it summarizes state and District of Columbia (hereinafter collectively referred to as “the states”) responses to an annual survey about underage drinking enforcement practices, prevention programs, and expenditures. The STOP Act also requires an annual report on each state’s performance in enacting, enforcing, and creating laws, regulations, and programs to prevent or reduce underage drinking.2 To meet this requirement, a report has been created for each of the states; the 2020 State Reports – Underage Drinking Prevention and Enforcement (2020 State Reports) are available at stopalcoholabuse.gov. The SPBP Report is intended to help put the 51 individual State Reports in a national context. Prevention and the Continuum of Care The STOP Act provides guidelines for evaluating states’ efforts to prevent and reduce underage drinking. Prevention exists as part of a continuum of care that also includes treatment and recovery support for those youth who meet the diagnostic criteria for having a serious alcohol use disorder. As formulated by the Institute of Medicine (IOM),3 the continuum of care model (IOM, 1994; National Research Council [NRC] & IOM, 2009; Substance Abuse and Mental Health Services Administration [SAMHSA], 2018) encompasses the following elements: • Promotional strategies to: (1) Create conditions supportive of behavioral health and (2) to reinforce the entire continuum of behavioral health services; • Prevention interventions to prevent or reduce the risk of developing a behavioral health problem; • Treatment services for those diagnosed with a substance use disorder or another disorder; and • Recovery services to support the ability of individuals in recovery to live productive lives and to continue abstaining from substance use. 2 The STOP Act also requires the Secretary of HHS and ICCPUD to produce an annual Report to Congress on the Prevention and Reduction of Underage Drinking (RTC), which provides national data on underage drinking and describes federal prevention activities. The current RTC is available at stopalcoholabuse.gov. 3 Now the National Academy of Medicine within the National Academies of Sciences, Engineering, and Medicine. __________________________________ 2020 State Performance & Best Practices for Preventing and Reducing Underage Drinking | 3 ___________________________________________________________________________________________________ Introduction Implicit in the description of a continuum is the understanding that some elements may overlap. For example, promotion and prevention strategies may share similar approaches (SAMHSA, 2018; NRC & IOM, 2009; National Academies of Sciences, 2019). Together, these elements must be seen as part of a comprehensive approach to the problem of underage alcohol consumption. Further, prevention of underage drinking should be understood as influencing the risk of excessive alcohol use (e.g., binge drinking) and the development of substance use disorders throughout the lifespan. Because early initiation of alcohol use is associated with the development of an alcohol use disorder later in life, and binge drinking by youth is strongly associated with binge drinking by adults, the use of effective prevention strategies for underage drinking can have a long-term effect on the entire continuum of care and help reduce the economic cost of excessive alcohol use and related harms in the United States, which was estimated to be $249 billion ($2.05 per drink) in 2010 (Hingson & Zha, 2009; Edwards et al., 2015; Flewelling et al., 2013; Sacks et al., 2015; Holder, 2002).4 It is also important to recognize that the drinking behavior of adults can have a substantial effect on the drinking behavior of youth (Nelson et al., 2009; 2005). Drinking by underage youth (e.g., high school students) is strongly correlated with drinking by adults living in the same state, and the drinking behavior of both youth and adults is strongly influenced by state alcohol control policies (Nelson et al., 2009; Xuan et al., 2015). At an individual level, a recent analysis of a longitudinal study noted that parental attitudes and monitoring of drinking behavior influenced emerging adults’ risky drinking behavior (e.g., driving while intoxicated, riding with an intoxicated driver, blackouts from binge drinking). The authors noted prevention programs that focus on binge drinking and bolster parental practices may reduce the likelihood of later major alcohol-related health-risk behaviors and their consequences (Vaca et al., 2020). These findings underscore both the influence of parental modeling and parental oversight, as well as the need to implement evidence-based alcohol policies that have been found to effectively reduce excessive drinking, including among adults and any underage drinking. Many of the most effective interventions for reducing youth drinking are universal interventions that also reduce the drinking behavior of adults (e.g., increasing alcohol taxes, regulating alcohol outlet density).5 Therefore, a comprehensive approach to preventing underage drinking that also emphasizes the prevention of excessive drinking (e.g., binge drinking) by adults is likely to have the greatest impact on reducing underage drinking and related harms (SAMHSA, 2019; The Guide to Community Preventive Services (The Community Guide; www.thecommunityguide.org/alcohol). Identifying and Implementing Statewide Policies Research indicates that effective prevention initiatives must be both multi-level (coordinating efforts among governments and agencies) and multi-faceted (employing both environmental and 4 It is estimated that reducing alcohol use among youth ages 12–17 alone could result in an overall savings of $52.9 billion. This estimate was derived from the product of: (1) The number of high-school–aged youth ages 12–17 years old in 2016 (25.01 million) and (2) the per-participant benefit (from implementing effective nationwide prevention programming for school-aged children and youth) minus cost associated with alcohol. The estimate was reduced by 25 percent to account for reduced intervention effectiveness as the implementation moves from demonstration to full implementation (Greenwood et al., 1996; Miller and Levy, 2000; Aos et al., 1999). Assumptions: Only savings from existing school-based programs are included in these estimates. Cost savings accrue over a multi-year period. Future costs were converted to present value using a 3 percent discount rate. Costs due to youth substance misuse decline at the same rate as the number of initiators. 5 Youth drinking refers to consumption of alcohol by those under the age of 21. 4 | 2020 State Performance & Best Practices for Preventing and Reducing Underage Drinking __________________________________ ___________________________________________________________________________________________________ Introduction individual-level approaches; Edwards, 2015; Flewelling et al., 2013; Holder, 2002). Prevention strategies must also be targeted strategically. The IOM describes three categories of prevention interventions: (1) Universal (aimed at all members of a given population), (2) selective (aimed at a sub-group determined to be at high risk for substance use), and (3) indicated (targeted to individuals who are already using substances but have not developed a substance use disorder; NRC & IOM, 2009). As noted in the 2016 Surgeon General’s Report, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, “…research has not yet been able to suggest an optimal mix” (HHS, 2016). As the Surgeon General’s Report states (HHS, 2016), the choices as to where to target a strategy are not always clear cut: Communities may think it is best to direct services only to those with the highest risk and lowest protection or to those already misusing substances. However, a relatively high percentage of substance misuse-related problems come from people at lower risk, because they are a much larger group within the total population than are people at high-risk. This follows what is known as the Prevention Paradox: “a large number of people at a small risk may give rise to more cases of disease than the small number who are at a high risk.” By this logic, providing prevention interventions to everyone (i.e., universal interventions) rather than only to those at highest risk is likely to have greater benefits. Given these complexities, communities and governments wishing to address underage drinking prevention are faced with multiple choices that must be appropriate to the specifics of their community and workable within the limits of their resources. Considerations must include whether specific interventions are culturally appropriate, especially when targeted toward diverse populations, or whether adaptations are necessary. Further, adaptations of an evidence-based intervention must be measured against preservation of the fidelity of the intervention (HHS, 2016). A strategy is only as effective as its implementation allows. Therefore, researchers stress that evaluation of the implementation process is a key component to putting any evidence-based strategies and programs into practice, and that both ensuring fidelity and adaptation (when appropriate) are critical to the ultimate effectiveness of the program (Fixsen et al., 2005; HHS, 2016). Implementation has been defined as a specified set of activities designed to put into practice an activity, policy, or program (Fixsen et al., 2005). It requires “deliberate and strategic efforts to facilitate collaboration, communication, and relationship-building among researchers, implementers, and policymakers” (Sturke et al., 2014). Similarly, sustainable implementation is supported by “a bi-directional model, where researchers work with, and learn from, people on the ground rather than coming to dictate what will be done” (Fogarty International Center, 2013). Researchers have suggested guidelines for promoting state and national policies to implement transformative human services practices and programs that are particularly relevant to the best practices discussed in Chapter 1 of this document: 1. Policymakers and planners need to build knowledge of implementation into policies and guidelines that impact human services. 2. Governments need to invest in the development and use of implementation strategies and methods that are grounded in research and elaborated through accumulated experience. 3. Funding strategies are critical to implementation of well-defined practices and programs (Fixsen et al., 2005). __________________________________ 2020 State Performance & Best Practices for Preventing and Reducing Underage Drinking | 5 ___________________________________________________________________________________________________ Introduction A significant component of successful policy implementation is the capacity to enforce the policies once they are in effect. Enforcement is the sum total of actions taken by public entities to increase compliance. Laws may or may not specify sanctions or enforcement practices. Enforcement and compliance of alcohol policies is discussed in greater detail in Chapter 2. Framework of State Performance and Best Practices Chapter 1 describes 26 state policies deemed to be known or potential best practices in preventing and reducing underage drinking. It also includes the status of adoption of these policies by the states. Most of these policies were included in original STOP Act legislation or were recommended by Congress during the 2009–10 appropriations process. Chapter 2 discusses the significance of enforcement in underage drinking prevention. As noted above, implementation of many policies, including prohibitions on underage possession, consumption, or purchase of alcohol is largely synonymous with enforcement. A significant component of the STOP Act’s mission is to collect data and report on each state’s performance in enforcing policies designed to prevent or reduce underage drinking. Chapter 3 provides an analysis of responses to the 2019 STOP Act State Survey, an annual survey on the states’ enforcement and prevention activities.6 This includes findings on the states’ environmental and individual-level strategies for addressing underage drinking. Chapter 4 provides data on how the states compare to national averages for six key performance measurements related to prevention and treatment of underage drinking. These measures have been identified by the ICCPUD as significant for purposes of evaluating progress in underage drinking prevention. It should be noted that the best practices described here are primarily environmental. That is, they seek to alter physical, economic, and social environments, which may be focused on entire populations or a sub-population. The main mechanisms for environmental change include state laws and local ordinances and their enforcement, institutional policies, and changing norms. In contrast, individual-level approaches include programs designed to impart knowledge, change attitudes and beliefs, or teach skills to youth and adults. Individual-level best practices for prevention, treatment, and recovery are discussed in the 2016 Surgeon General’s Report, as well as environmental-level best practices (HHS, 2016). The State Reports also describe many of the individual-level programs being used in each state. 6 Each state’s complete survey response is included in its State Report, described above. 6 | 2020 State Performance & Best Practices for Preventing and Reducing Underage Drinking __________________________________