Prevention of Underage Prevention of Underage Drinking ProblemsDrinking Problems

Ralph Hingson, ScDRalph Hingson, ScDDirector, Division of Epidemiology and Prevention ResearchDirector, Division of Epidemiology and Prevention Research

National Institute on Alcohol Abuse and AlcoholismNational Institute on Alcohol Abuse and Alcoholism

Preventing Underage Alcohol Use: A National Meeting of the States

Sponsored by the Interagency Coordinating

Committee for the Prevention of Underage Drinking

October 31, 2005

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Dr. Margaret Jonathan Travis

Moore Levy Stedman

Magnitude of Alcohol Problems on U.S. College Campuses

Hingson et al. (2002) J. Studies on Alcohol

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InterventionsInterventions

Individually orientedIndividually oriented FamilyFamily SchoolSchool EnvironmentalEnvironmental Comprehensive Community Comprehensive Community

InterventionsInterventions

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Brief Motivational Alcohol Brief Motivational Alcohol Intervention in a Trauma CenterIntervention in a Trauma Center

46% of injured trauma center patients 46% of injured trauma center patients age 18 and older screened positive for age 18 and older screened positive for alcohol problems.alcohol problems.

Half (N=336) randomly allocated to Half (N=336) randomly allocated to receive 30 minute brief intervention to receive 30 minute brief intervention to reduce risky drinking and offers links to reduce risky drinking and offers links to alcohol treatmentalcohol treatment

Source: Gentilello Source: Gentilello Annals of SurgeryAnnals of Surgery, 1999, 1999

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Brief Motivational Alcohol Brief Motivational Alcohol Intervention in a Trauma CenterIntervention in a Trauma Center

Results:Results: Reduced alcohol consumption by an average Reduced alcohol consumption by an average

21 drinks per week at 1 year follow up21 drinks per week at 1 year follow up 47% reduction in new injuries requiring 47% reduction in new injuries requiring

treatment in EDtreatment in ED 48% reduction in hospital admissions for 48% reduction in hospital admissions for

injury over 3 yearsinjury over 3 years 23% fewer drunk driving arrests23% fewer drunk driving arrests

Source: Gentilello Source: Gentilello Annals of SurgeryAnnals of Surgery, 1999, 1999

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Brief Alcohol Intervention Brief Alcohol Intervention for Older Adolescents for Older Adolescents

94 ED patients, mean age 18.4, injured after drinking94 ED patients, mean age 18.4, injured after drinking Half randomly allocated to a 35-40 minute motivational Half randomly allocated to a 35-40 minute motivational

intervention to reduce drinking and related risky intervention to reduce drinking and related risky behaviors such as DWIbehaviors such as DWI

Results at six months:Results at six months: Brief intervention group had Brief intervention group had

– ¼ drinking and driving occasions¼ drinking and driving occasions

– Fewer moving violations 3% vs. 23%Fewer moving violations 3% vs. 23%

– ¼ alcohol related injuries¼ alcohol related injuries

Source: Monti et al. Source: Monti et al. J. Consulting and Clinical Psychology J. Consulting and Clinical Psychology (1999)(1999)

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Fifteen Studies Provide Strong Fifteen Studies Provide Strong Support for the Efficacy of This Support for the Efficacy of This

Approach Among College StudentsApproach Among College Students

Marlatt, 1998Marlatt, 1998 Anderson et. Al., 1998Anderson et. Al., 1998 Larimer, 2000Larimer, 2000 D’Amico & Fromme 2000D’Amico & Fromme 2000 Dimeff, 1997Dimeff, 1997 Aubrey, 1998Aubrey, 1998 Monti, 1999Monti, 1999 Baer, 2001Baer, 2001

Barnett et al. 2004Barnett et al. 2004 Borsari and Carey Borsari and Carey (in press)(in press)

Labrie 2002Labrie 2002 Gregory 2001Gregory 2001 LaChance 2004LaChance 2004 Murphy et al. 2001Murphy et al. 2001 Murphy et al. 2004Murphy et al. 2004

Source: Larimer and Cronce (2002, 2005 In Review)

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Fewer thanFewer than– ½ of pediatricians screen all adolescents for ½ of pediatricians screen all adolescents for

use of alcohol and drugsuse of alcohol and drugs– ¼ screen for drinking and driving.¼ screen for drinking and driving.

Pediatric Medical Care Providers considerably Pediatric Medical Care Providers considerably underdiagnose alcohol use, abuse, and underdiagnose alcohol use, abuse, and dependence among patients ages 14-18.dependence among patients ages 14-18.

1.5 million 12-17 year olds need alcohol 1.5 million 12-17 year olds need alcohol treatmenttreatment

Only 216,000 14% received treatmentOnly 216,000 14% received treatmentSources: American Academy of Pediatrics, 1997; Wilson, Sheritt, Gates, Knight Wilson, Sheritt, Gates, Knight Pediatrics,Pediatrics, 2004; National Household Survey on Drug Use and Health, 2003 2004; National Household Survey on Drug Use and Health, 2003

Implementation Gap

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Insurers’ Liability for Losses Insurers’ Liability for Losses Due to IntoxicationDue to Intoxication

As of January 1, 2004As of January 1, 2004

28 States and DC allow with holding of medical reimbursement if injured under the influence

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Family InterventionsFamily Interventions Iowa Strengthening Families Program Iowa Strengthening Families Program

Goals:Goals: Improve parent/child relationsImprove parent/child relations Strengthen family communication skills Strengthen family communication skills Increase child coping skillsIncrease child coping skills

Implementation:Implementation: 7 sessions at school7 sessions at school 13 hours total13 hours total Parent and child separately and togetherParent and child separately and together

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Family InterventionsFamily Interventions

Source: Spoth, Redmond, Shin J Consulting Clinical Psychology (2001, 2004)

Trajectory for ISFP Condition

Trajectory for Control Condition

0Months

6 18 30 48 72

Lifetime Drunkenness Through 6 Years Past Baseline:

Logistic Growth Curve

A randomized controlled trial with families of 6th graders: Iowa Strengthening Families Program (ISFP) (206 families)Iowa Strengthening Families Program (ISFP) (206 families) Preparing for Drug Free Years Program (PDFYP) (221 families) Control (221 families)

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School Based ProgramsSchool Based Programs Programs that rely primarily on increasing knowledge Programs that rely primarily on increasing knowledge

about consequences of drinking about consequences of drinking are not effective.are not effective.

Effective Programs :Effective Programs :– Are based on social influence modelsAre based on social influence models– Include norm settingInclude norm setting– Address social pressures to drink and teach resistance skillsAddress social pressures to drink and teach resistance skills– Include developmentally appropriate informationInclude developmentally appropriate information– Include peer-led componentsInclude peer-led components– Provide teacher trainingProvide teacher training– Are interactiveAre interactive

School only program effects are generally smallSchool only program effects are generally small

Less effective with students who initiate drinking prior to Less effective with students who initiate drinking prior to grades 5 or 6grades 5 or 6

Source: NIAAA, Alcohol and Development in Youth: A Multidisciplinary OverviewSource: NIAAA, Alcohol and Development in Youth: A Multidisciplinary Overview

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School Based Life Skills ProgramSchool Based Life Skills Program Junior High- 30 sessions, most in Year 1Junior High- 30 sessions, most in Year 1

Curricula:Curricula:Drug InformationDrug InformationAlcohol/Drug Resistance SkillsAlcohol/Drug Resistance SkillsSelf Management SkillsSelf Management SkillsGeneral Social SkillsGeneral Social Skills

Results:Results:Beneficial EffectsBeneficial EffectsAlcohol & Tobacco UseAlcohol & Tobacco Use

Through High School, Not AfterThrough High School, Not AfterSources: Botvin et al. Sources: Botvin et al. J. Consulting and Clinical PsychologyJ. Consulting and Clinical Psychology (1990); (1990); JAMA JAMA

(1995); (1995); Addictive BehaviorsAddictive Behaviors (2000) (2000)

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Combined Family Interventions& School Based Life skills Program

Results: 2 ½ Years Later Weekly drunkenness rate among intervention students 1/3 lower

–Strengthening Family plus Life Skills (p=.03)–Life Skills Training (p=.08)

Conclusion: Family and school interventions cFamily and school interventions combinedombined are more effective than are more effective than school interventions onlyschool interventions only

Source: Spoth, et al Psychology of Addictive Behaviors (In Press)

Randomized controlled trial of 7th graders from 36 rural schools:

ISFP ISFP Plus Life Skills Training (n=549) Life Skills Training Only (n=517) Control (n=453)

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Environmental ApproachesEnvironmental Approaches

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Drinking Trends AmongDrinking Trends AmongHigh School Seniors, 1975-2003High School Seniors, 1975-2003

0102030405060708090

100

Perc

en

t

Yearly

Monthly

5+ Drinks

Source: Monitoring the Future, 2004

Federal 21 drinking age

Drinking age 21 in all States

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Trends in Alcohol Related and Non Alcohol Related Traffic Fatalities persons 16-20 U.S. - 1982-2004

US MLDA Age 21 Law

MLDA 21 in All 50 States

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

5500

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

Num

ber

of F

atal

ities

3,781

2,738

2,115

5,244

↑38%

↓60%

Non Alcohol Related Fatalities

Alcohol Related Fatalities

Source: U.S. Fatality Analysis Reporting System

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Legal Drinking Age ChangesLegal Drinking Age Changes

CDC reviewed 49 studies published in CDC reviewed 49 studies published in scientific journalsscientific journals

Alcohol-Related Traffic Crashes:Alcohol-Related Traffic Crashes:- - IncreasedIncreased 10% when the drinking age was 10% when the drinking age was

loweredlowered

- - DecreasedDecreased 16% when the drinking age was 16% when the drinking age was raisedraised

Source: Shults et al., American Journal of Preventive Medicine, 2001

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Cumulative Estimated Number of Lives Cumulative Estimated Number of Lives Saved by the Minimum Drinking Age Laws Saved by the Minimum Drinking Age Laws

1975-20031975-2003

12,35713,15213,968

14,816 15,66716,513

17,35918,22019,121

20,04320,970

21,88722,798

0

5,000

10,000

15,000

20,000

25,000

1975-1991

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Source: National Highway Traffic Safety Administration

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10 Reasons for 10 Reasons for Legal Drinking Age of 21Legal Drinking Age of 21

Alcohol-related traffic Alcohol-related traffic fatalities and injuriesfatalities and injuries

Other unintentional Other unintentional injuries (falls, injuries (falls, drownings, burns)drownings, burns)

Homicide and assaultHomicide and assault Sexual assaultSexual assault

SuicideSuicide STDs, HIV/AIDSSTDs, HIV/AIDS Unplanned pregnancyUnplanned pregnancy Alcohol dependenceAlcohol dependence Teen drug useTeen drug use Poor academic Poor academic

performanceperformance

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Source: Grant and Dawson J. Substance Abuse (1997)

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PurposePurpose

To assess whether an earlier drinking onset To assess whether an earlier drinking onset is related to:is related to:

Unintentional injuries under the influence Unintentional injuries under the influence of alcoholof alcohol

Motor vehicle crashes because of drinkingMotor vehicle crashes because of drinking Physical fights after drinkingPhysical fights after drinking

- ever in the respondent’s life- ever in the respondent’s life

- during the year prior to the survey - during the year prior to the survey

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Micheal Timothy Wilder

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Ever in a Physical Fight While or After Drinking Ever in a Physical Fight While or After Drinking According to Age of Drinking Onset, National According to Age of Drinking Onset, National

Longitudinal Alcohol Epidemiologic SurveyLongitudinal Alcohol Epidemiologic Survey

4.10

3.203.50

2.90

2.30

1.50

2.00

1.50

1.00

0

1

2

3

4

5

6

<14 14 15 16 17 18 19 20 21+

Controlling for age, gender, black, non hispanic, Hispanic, other, education, marital status, current, past, never smoke current, past, never use drugs, family history of alcoholism, current, past, never alcohol dependent, frequency drank 5+ during respondent’s period of heaviest drinking

Odds Ratio and Confidence Intervals

P<.001Age Started

Drinking

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Why Are These Findings Why Are These Findings Important?Important?

Injuries are the leading cause of Injuries are the leading cause of death among youth 1-44death among youth 1-44

Unintentional injuries #1 1-44Unintentional injuries #1 1-44

Intentional injuries #2 8-34Intentional injuries #2 8-34

Source: Centers for Disease Control and Prevention

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Why Are These Findings Why Are These Findings Important?Important?

Source G. Smith et. al 1999

40% unintended injury deaths

39,00039,000

47% Homicides 8,000

29% Suicides 8,500

Alcohol is involved over 50,000 injury deaths annually*

* Over half under age 44

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BAC and ImpairmentBAC and Impairment

.10

.09

.08

.07

.06

.05

.04

.03

.02

.01 BAC

Concentrated Attention, Speed Control,Braking, Steering, Gear Changing, Lane Tracking, Judgement

Tracking, Divided Attention, Coordination,Comprehension, Eye Movement

Simple Reaction Time, Emergency ResponseChoice Reaction Time

Source: National Highway Traffic Safety Administration

Key driving functions are impaired at levels as low as .02-.04%.

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0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

0 .015-.049 .050-.079

Blood Alcohol Concentration (mg%)

Rel

ativ

e R

isk

of F

atal

Cra

sh

Relative Risk of Fatal CrashRelative Risk of Fatal CrashDrivers Age 16-19 and 20+ as a function of BACDrivers Age 16-19 and 20+ as a function of BAC

16-19 y.o.

20+ y.o.

Source: Simpson, H. 1989

The risk of fatal crash increases more with each drink among young drivers than drivers age 20 and older.

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Proportion of Teen Fatal Crashes Involving Single Vehicles at Night

Before and After Zero Tolerance Laws for Youth

31.3 31.7 31.6

25.1

0%

10%

20%

30%

40% Comparison

ZeroTolerance

SVNF 1439 1079 1150 717Fatal Crashes 4597 3400 3637 2851

1%

21%

Source: Hingson, Heeren, Winter, 1994

PercentComparison Zero Tolerance

Before After Before After

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States with Primary Safety Belt Laws

As of July 2004, 21 states, DC and Puerto Rico have primary safety belt laws. New Hampshire is the only state that has no adult safety belt law

Primary Law

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Younger heavier drinkers more affected than Younger heavier drinkers more affected than older heavier drinkersolder heavier drinkers

Kenkel, 1993Kenkel, 1993

Godfrey, 1997Godfrey, 1997

Chaloupka & Wechsler, 1996Chaloupka & Wechsler, 1996

Sutton & Godfrey, 1995Sutton & Godfrey, 1995

Higher prices reduce alcohol related problemsHigher prices reduce alcohol related problems

– Motor vehicle fatalities (Kenkel, 1993)Motor vehicle fatalities (Kenkel, 1993)– RobberiesRobberies– RapesRapes– Liver cirrhosis mortalityLiver cirrhosis mortality

See: Cook & Moore, 1993; Cook & Tauchen, 1982; Ruhm, 1996See: Cook & Moore, 1993; Cook & Tauchen, 1982; Ruhm, 1996

Increase Price of AlcoholIncrease Price of Alcohol

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Restricting Alcohol Licenses

Density of alcohol outlets is associated withDensity of alcohol outlets is associated with

- Higher alcohol consumption- Higher alcohol consumption

- Violence- Violence

- Other crime- Other crime

- Health problems- Health problems

Sources: Ornstein & Hanssens, 1985; Gliksman & Rush, 1986; Ornstein & Hanssens, 1985; Gliksman & Rush, 1986; Gruenewald et.al, 1993; Scribner et.al., 1995; Stitt and Gruenewald et.al, 1993; Scribner et.al., 1995; Stitt and

Giacopassi, 1992; Chaloupka & Wechsler, 1996 Giacopassi, 1992; Chaloupka & Wechsler, 1996

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Is Passing Laws Enough?Is Passing Laws Enough?

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Potential Process of Change Potential Process of Change After a Drinking Age IncreaseAfter a Drinking Age Increase

Legal Drinking Age Increase

Police and Enforcement

Court Enforcement

General Legal Deterrence

Public Education

Who

- Minors

- Alcohol Outlets

What

- Reasons for Law

- Enforcement

Changes in Public Perception about Alcohol

Reduction

In

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After

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Fatal and

Night

Fatal

Crash

Reductions

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Comprehensive Community Comprehensive Community InterventionsInterventions

Involve multiple departments of city Involve multiple departments of city government and private citizensgovernment and private citizens

Use multiple program strategiesUse multiple program strategies

– EducationEducation

– Media advocacyMedia advocacy

– Community organizing and mobilizationCommunity organizing and mobilization

– Environment policy changeEnvironment policy change

– Heightened enforcementHeightened enforcement

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Successful Comprehensive Successful Comprehensive Community InterventionsCommunity Interventions

Project Northland Perry (1996)Project Northland Perry (1996) Communities Mobilizing for Change Communities Mobilizing for Change

Wagenaar (2002)Wagenaar (2002) Community Trials Holder (2000)Community Trials Holder (2000) A Matter of Degree Weitzman (2004) A Matter of Degree Weitzman (2004) Fighting Back Hingson (2005)Fighting Back Hingson (2005) Saving Lives Program Hingson (1996)Saving Lives Program Hingson (1996) Clapp et al. (2005)Clapp et al. (2005)

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Project Northland

Intervention to prevent or reduce alcohol use Intervention to prevent or reduce alcohol use among 6, 7, and 8among 6, 7, and 8thth grade students grade students– School Education Programs (general program School Education Programs (general program

each grade)each grade)– Parent InvolvementParent Involvement– Peer ParticipationPeer Participation– Community task forces to engage citizensCommunity task forces to engage citizens

Compliance ChecksCompliance Checks Server TrainingServer Training Ordinances Ordinances

Source: Perry C. et al. American Journal of Public Health, 1996;Perry C. et al. Health Education Research, 2002.

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Project Northland

Results:Results:

3 Years Later3 Years Later– Drinking 50% lower among baseline non-drinkers Drinking 50% lower among baseline non-drinkers

(5% vs 10%)(5% vs 10%)– Lower rates of cigarette and marijuana useLower rates of cigarette and marijuana use– Monthly and weekly drinking 20-30% lower Monthly and weekly drinking 20-30% lower

among entire sampleamong entire sample

Grades 11 & 12Grades 11 & 12– Fewer Northland students drink 5+Fewer Northland students drink 5+– 80% reduction in youth ability to purchase 80% reduction in youth ability to purchase

alcohol (Off Sale)alcohol (Off Sale)

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Communities Mobilizing for Change Interventions to Reduce AvailabilityInterventions to Reduce Availability::

– Merchants record underage buy attemptsMerchants record underage buy attempts– Beer kegs prohibited at University Beer kegs prohibited at University

HomecomingHomecoming– Policies to discourage motels from permitting Policies to discourage motels from permitting

underage drinking partiesunderage drinking parties– Security at high school dancesSecurity at high school dances– Model local ordinances to restrict underage Model local ordinances to restrict underage

access to alcohol access to alcohol – Compliance checksCompliance checks

Source: Wagenaar et al., J. Studies on Alcohol, 2000

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Communities Mobilizing for Change

Results::

-17% increase in outlets checking age ID-17% increase in outlets checking age ID

-24% decline in bar and restaurant sales-24% decline in bar and restaurant sales

-25% decrease in the proportion of 18-20 year olds-25% decrease in the proportion of 18-20 year olds

attempting alcohol purchaseattempting alcohol purchase

-17% decline in the proportion of older teens -17% decline in the proportion of older teens

providing alcohol to younger teensproviding alcohol to younger teens

-7% decrease in the percent under 21 who drank-7% decrease in the percent under 21 who drank

-14% decline in alcohol traffic injuries, drivers 18-20-14% decline in alcohol traffic injuries, drivers 18-20

Source: Wagenaar et al., J. Studies on Alcohol, 2000

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Community TrialsIntervention:

Reduce youth alcohol availability Drinking and driving enforcement Alcohol outlet density reduction Community mobilization & media Advocacy Responsible alcohol service

Results:Results:– Self reported DWI cut in halfSelf reported DWI cut in half– 10%-11% decrease in single vehicle night crashes10%-11% decrease in single vehicle night crashes– 43% decrease in emergency department alcohol 43% decrease in emergency department alcohol

related assault admissionsrelated assault admissions

“Mountain of Beer”

Source: Holder et al., JAMA (2000)

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A Matter of Degree Intervention Components:Intervention Components:

– College/ Community PartnershipsCollege/ Community Partnerships

– Environmental strategies to reduce Environmental strategies to reduce drinking problems:drinking problems:– Keg registrationKeg registration– Mandatory responsible beverage serviceMandatory responsible beverage service– Police wild party enforcementPolice wild party enforcement– Substance free residence hallsSubstance free residence halls– Advertising bansAdvertising bans

Source: Weitzman et al. American Journal of Preventive Medicine. 2004

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A Matter of Degree

Results:Results: Achieved reductions among college Achieved reductions among college

students instudents in– Binge drinkingBinge drinking– Driving after drinkingDriving after drinking– Alcohol related injuriesAlcohol related injuries– Being assaulted by other drinking college Being assaulted by other drinking college

studentsstudents

Source: Weitzman et al. American Journal of Preventive Medicine 2004

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Fighting Back ProgramFighting Back Program

First Community Program to combine:First Community Program to combine:

Environmental interventions to limit Environmental interventions to limit alcohol availabilityalcohol availability

Efforts to increase substance abuse Efforts to increase substance abuse treatmenttreatment

Source: Hingson et al. Injury Prevention (2005)

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Fighting Back Program Fighting Back Program Selected InterventionsSelected Interventions

Limit Alcohol AvailabilityLimit Alcohol Availability Youth access compliance check surveysYouth access compliance check surveys Responsible beverage service trainingResponsible beverage service training Monitoring and closing problem liquor outletsMonitoring and closing problem liquor outlets Bill board restrictionsBill board restrictions

Expand TreatmentExpand Treatment Sales tax increase for expanded treatmentSales tax increase for expanded treatment New treatment programs- courts, jails, health care New treatment programs- courts, jails, health care

agencies, public housingagencies, public housing Emergency department screening/brief interventionsEmergency department screening/brief interventions New inpatient, outpatient and recovery programsNew inpatient, outpatient and recovery programsSource: Hingson et al. 2005

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Fighting Back - ResultsGreater Relative Reduction in Alcohol-Related Fatal

Crashes VS Fatal Crashes with Zero BAC

Communities: Kansas City, MO, Milwaukee, WI, San Antonio, TX, Santa Barbara, CA, and Vallejo, CA

Courtney Birch

Pooled Pooled EffectsEffects

BAC .01%+ BAC .01%+

vs Zero BAC vs Zero BAC

DriversDrivers All AgesAll Ages 16-2016-20

5 FB sites 5 FB sites vs controlsvs controls

22%22%

P=.01P=.01

26%26%

P=.08P=.08

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ConclusionsConclusionsResearch indicates reductions in Underage Research indicates reductions in Underage Drinking and Related Problems can be Drinking and Related Problems can be achieved with Interventions that focus onachieved with Interventions that focus on

- Individuals- Individuals

- Families- Families

- Schools- Schools- Environmental ChangesEnvironmental Changes

Interventions targeting multiple levels are Interventions targeting multiple levels are more effectivemore effective

Comprehensive community interventions Comprehensive community interventions address underage drinking at multiple levelsaddress underage drinking at multiple levels

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ConclusionsConclusions

Community Level Interventions can includeCommunity Level Interventions can include

- Coordination of multiple city departments- Coordination of multiple city departments- Clear measurable objectives and strategic - Clear measurable objectives and strategic

plansplans- Combine education and enforcementCombine education and enforcement- Treatment programsTreatment programs- Use of data to plan and evaluate- Use of data to plan and evaluate- Involvement of private citizensInvolvement of private citizens- Youth involvement (be inclusive)Youth involvement (be inclusive)

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AcknowledgementsAcknowledgements

NIAAA staff who assisted with this presentationNIAAA staff who assisted with this presentation

Rachel GoutosRachel Goutos Vivian Faden, Ph.D.Vivian Faden, Ph.D.

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Panel DiscussionPanel DiscussionModeratorModeratorFaye Calhoun, Sc.D.Faye Calhoun, Sc.D.Deputy DirectorDeputy DirectorNational Institute on Alcohol Abuse and AlcoholismNational Institute on Alcohol Abuse and Alcoholism

PanelistsPanelistsHarold Holder, Ph.DHarold Holder, Ph.DSenior Research ScientistSenior Research ScientistPrevention Research CenterPrevention Research Center

John Knight, MDJohn Knight, MDAssociate Professor of Pediatrics, Harvard Medical SchoolAssociate Professor of Pediatrics, Harvard Medical SchoolDirector, Center for Adolescent Substance Abuse Research, Children's Director, Center for Adolescent Substance Abuse Research, Children's

Hospital, Boston Hospital, Boston

Kelli A. Komro, MPH, Ph.D.Kelli A. Komro, MPH, Ph.D.Associate Professor, Department of Epidemiology and Health Policy ResearchAssociate Professor, Department of Epidemiology and Health Policy ResearchInstitute for Child Health Policy, University of FloridaInstitute for Child Health Policy, University of Florida