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"Addiction Policy Research Update" Newsletter - Summer 2008
This is the seventh volume of the quarterly news tips from the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation—a $66 million program that funds research into policies related to alcohol, tobacco and illegal drugs.

Please contact me at if you'd like to follow up on any of the news items below. —Prabhu Ponkshe

Research Update

Summer 2008

Minimum Drinking Age of 21 Saves Lives

Strong Sanctions on Fake IDs Limit Drunk Driving Deaths among Teens

One of the most comprehensive studies on the minimum drinking age shows that laws aimed at preventing consumption of alcohol by those under 21 have significantly reduced drinking-related fatal car crashes.

Specifically, the study published in the July 2008 issue of the journal Accident Analysis and Prevention found that laws making it illegal to possess or purchase alcohol by anyone under the age of 21 had led to an eleven percent drop in alcohol-related traffic deaths among youth; secondly, they found that states with strong laws against fake IDs reported seven percent fewer alcohol-related fatalities among drivers under the age of 21.

The study was funded by the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation.

The study, led by James C. Fell, M.S., of the Pacific Institute for Research and Evaluation (PIRE), accounted for a variety of factors, such as improved safety features in cars, better roadways and tougher adult drunk driving laws, that are supposed to have contributed to a reduction in fatalities involving underage drivers who have consumed alcohol. Fell’s research controlled for more variables than any other previous study on the topic, accounting for regional and economic differences, improvements in roadways and vehicles, and changes that lowered the illegal blood alcohol content for driving to .08. Yet, according to Fell, the eleven percent drop in youth fatalities is a “conservative” figure.

Fell notes that his research is more sophisticated and comprehensive than previous studies that have looked at the drinking age. “There has been evidence since the 1980s that an increase in the drinking age to 21 was having an impact on traffic deaths,” Fell said. “But this is the first time we’ve been able to tease out the real effect, free of the variables that had been used to question the validity of the evidence.”

In addition to providing comprehensive evidence of the life-saving impact of minimum drinking age laws, the authors of the new study found that tougher sanctions against fake identification cards may represent the second-best legislative tool that states have in combating drunk driving deaths among young people.

“States that merely confiscate a fake ID, or just give a slap on the wrist to the user, are passing up a significant opportunity to save lives,” said Fell. “We found a seven percent drop in youth alcohol-related fatalities in states that are willing to take strong actions, such as automatically suspending the driver’s license of a young person caught with a fake ID.“

Minimum legal drinking age of 21 (MLDA 21) laws have many components, which target outlets that sell alcohol to minors; adults who provide alcoholic beverages to minors; and minors who purchase or attempt to purchase, possess, or consume alcohol. In addition, there are companion laws that provide for lower blood alcohol content (BAC) limits for underage drivers and other legislation, such as laws that require registration of beer keg purchases and make hosts liable for the actions of underage drinking guests. The authors report great variability in how states use, adopt and implement legislation to reduce underage drinking. Such laws vary considerably from state to state, and no one state has adopted all the pieces of legislation aimed at preventing young people under the age of 21 from consuming alcohol.

The researchers looked at data from the Fatality Analysis Reporting system (FARS) (a database of all police- reported motor vehicle crashes resulting in at least one fatality) between 1982 and 1990 and then assessed the strength of each state’s legislation (using a scoring system) aimed at preventing underage drinking. Based on the FARS data for each state, the authors were able to determine the impact of the state’s individual laws on underage drinking and driving fatalities.


To reduce youth drinking and alcohol-related problems, the federal government passed legislation in 1984 that provided for a uniform minimum legal drinking age (MLDA) of 21 throughout the United States. Threatened by the loss of federal highway funds, by 1988, every state that had a lower MLDA had raised its minimum legal age for both the purchase and possession of alcohol to 21. All the states and the District of Columbia also have passed laws prohibiting the furnishing or selling of alcohol to those younger than age 21, many at the same time as they passed the two “core MLDA laws.”

Considerable evidence exists that such laws can influence underage alcohol related traffic fatalities. From 1988 to 1995, alcohol-related traffic fatalities for youth aged 15–20 declined from 4187 to 2212, a 47% decrease, with wide variability in these declines between states. But until now, Fell said, it had been difficult for researchers to pinpoint the precise effect of the change in the drinking age because of other confounding factors.

”Some have argued that the declining numbers are due to a general decrease in drunk driving, or because of the lowering of the BAC limit, or better cars and better roads. But we controlled for all of these to the extent possible in this study.”

According to MADD, in 2008 the following states have introduced legislation to lower the drinking age: Minnesota, Wisconsin, Louisiana, Kentucky (for military), South Carolina (for military), Vermont (to study lowering the MLDA), South Dakota (as a ballot initiative) and Missouri (as a ballot initiative).

Study Suggests Sports Stadiums Serve Alcohol to Minors and Intoxicated Fans

Research Goes Undercover; Reveals How Easy it is to Buy Booze in the Stands

In a novel study looking at the propensity of illegal alcohol sales at sports stadiums, researchers reported that nearly one in five people posing as underage drinkers, and three out of four seemingly intoxicated “fans” were able to buy alcohol at professional sporting events. They also found that location mattered: sales were more likely if the attempt took place in the stadium stands rather than at a concession booth.

“We saw that sporting events can be fertile ground for illegal alcohol sales, and that the seats provide an especially high risk environment at events that every year attract an average of 130 million people,” said lead author Traci Toomey, PhD, with the University of Minnesota School of Public Health. The study is published in the upcoming issue of the journal, Alcoholism: Clinical & Experimental Research and was funded by the Substance Abuse Prevention and Research Program (SAPRP) of the Robert Wood Johnson Foundation.

From September 2005 to November 2006, researchers conducted alcohol purchase attempts with pseudo-underage (i.e., persons age 21 or older who appear under 21) and pseudo-intoxicated (i.e., persons feigning intoxication) individuals to assess the likelihood of illegal sales of alcohol at stadiums that house professional hockey, basketball, baseball, and football teams. Purchase attempts were made at 16 sport stadiums in five different states.

For pseudo-underage purchase attempts, the researchers hired two men and five women who were 21 years or older, but were judged by a panel to look between 18 and 20 years old. For pseudo-intoxicated attempts, the researchers hired two male and two female actors (all over the age of 30) based on their ability to appear intoxicated. Their authenticity was assessed by a panel of eight to ten people who had worked in the hospitality industry. The actors – who had played similar roles for two prior studies – attempted to purchase alcohol while showing signs of obvious intoxication. In their interactions with sales staff, they dropped their money, repeated questions and slurred their words.

They found that the overall sales rates to the pseudo-underage and pseudo-intoxicated buyers were 18 percent and 74 percent, respectively. For both groups, the odds of being able to buy alcohol from the stands were three times as high as the odds of being able to purchase it from a concession booth.

“We know already that there’s a link between alcohol use and problem behaviors among fans,” Toomey said. “But there’s more that sports stadiums can do to prevent sales to people who are clearly drunk. If people are intoxicated, we don’t need them to consume more alcohol.”

Sales to “intoxicated” buyers were also more likely if the seller did not seem to notice the apparent intoxication, and servers in the stands were less likely to notice the intoxication level of the buyers than servers at the concession booths.

In the “underage” group, buyers were almost three times more likely to purchase alcohol if in the stands than at the concession booths. When in the stands, sales increased along with the distance of buyer from seller. Toomey called the results significant. “Combining thousands of fans with significant alcohol sales could be construed as a recipe for some serious problems, like increased instances of violence and drunk driving,” she said.

In the past few years, there have been several well-publicized alcohol-related problems at professional sporting events in the U.S. involving drunken behavior of fans and subsequent problems, either during or after stadium sporting events. Several of these incidents have resulted in lawsuits targeting the alcohol vendors for serving alcohol to fans who were obviously intoxicated, the authors write.

“Given the results of this study, stadium management and local and state elected officials may want to consider banning or restricting alcohol sales in the stands at sporting events, as some stadiums have already done,” Toomey said. “However, if such a policy is not politically feasible in a particular stadium, vendors in the stands may need to receive additional training regarding responsible service of alcohol—training that could include how to check age identification and more clearly recognize signs of obvious intoxication.” Toomey added, “In addition, law enforcement and community groups need to actively monitor and work with stadiums to promote responsible alcohol service at these events.”


Opioid Use Disorder In The United States

Insurance Status and Treatment Access

Opioids - chemical substances often prescribed for pain relief – can be highly addictive and prone to abuse. But until recently, little was known about those who had become dependent on opioids, including whether they were insured or how often they sought treatment .

Earlier this year, David Fiellin, MD, with the Yale University School of Medicine, and colleagues studied three years of national data on opioid use. They discovered that those dependent on, or abusing opioids, were younger and more likely to be unemployed, and were either uninsured or relied on Medicaid and other public funding mechanisms, compared to those without substance use disorders. They also found only 15 percent of those addicted to an opioid received formal treatment or counseling in the past year, leaving 85 percent without treatment.

“The take home message is that payment is a significant barrier to access to treatment, and that only a small minority of those patients who require treatment are receiving it,” Fiellin said,

He said that since most of those people who are dependent on pain-relief medications pay for the treatment with publicly financed programs, when new treatments are introduced, ”there needs to be an effort to insure that public funding policy accompanies the introduction of new treatments and new treatment paradigms.”

Researchers used data from 2002–2004 from the National Survey on Drug Use and Health (NSDUH) which has an annual sample size of approximately 70,000 respondents.

They found that those with opioid use disorder were more likely to be young, of Hispanic ethnicity, unemployed, and to either have Medicaid or no medical insurance. Among those with any disorder, 12- to 16-year olds were more likely to have opioid use disorder than a non-opioid substance use disorder, as were women and unemployed respondents.

“These findings highlight a population that appears to have significant barriers to care as do patients with other substance use disorders,” Fiellin said; “The results underscore the need to develop public funding options for treatment of opioid use disorder and for buprenorphine treatment in particular, as many patients will require public funding, especially in areas where methadone maintenance is either oversubscribed or unavailable.”

An estimated 4 million people are opiate-dependent in the U.S.; three million are addicted to prescription drugs and 1 million are addicted to heroin.

The study was funded by the Substance Abuse Policy Research Program of the Robert Wood Johnson Foundation and appears in the online edition of the journal Drug and Alcohol Dependence.

If you would like to speak with the researchers or obtain a copy of the article, please contact Carol Vieira at

Perceived Access to Cigarettes Predicts Youth Smoking

Kids who see cigarettes as easily accessible are more likely to end up as regular smokers, particularly if they have friends who smoke, according to a new report published in the current issue of Annals of Family Medicine. The study, funded by the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation, could be valuable to smoking intervention efforts by allowing health professionals to identify and target high-risk children.

“We found that if you get kids to answer just two simple questions – ‘would it be easy for you to get a cigarette?’ and ‘do you have friends who smoke?’ – you can identify those who are at high risk of becoming regular smokers,” said lead author, Chyke Doubeni, PhD, with the University of Massachusetts Medical School. “Saying yes to either should raise a red flag and prompt doctors and others to talk with parents and kids about how to avoid smoking.”

The researchers interviewed 1,195 sixth-graders in Massachusetts who had never before puffed on a cigarette or who smoked less than once a week. They followed them from January 2002 to February 2006.

Over the four years of the study, 177 students tried out smoking and 109 became regular smokers. All those who picked up the habit either agreed with the statement “it would be easy for me to get a cigarette” or acknowledged having a friend who smoked – or both. The researchers also found that perceptions of accessibility and prevalence of peer smokers both intensified as the kids got older. At the start of the study, 21 percent of the participating students perceived cigarettes as easily accessible and only 9 percent had friends that smoked. By the fourth year of the study period, 50 percent perceived easy access to cigarettes and 32 percent had friends who smoked. Also, the study found that as they get older, kids appear to become more aware of which stores sell cigarettes.

“The take home message is clear: knowing that it is easy to get cigarettes is like adding fuel to the fire when it comes to youth smoking,” Doubeni said. “And having a friend who smokes naturally makes cigarettes seem readily available. Ultimately, the kids who reported both peer smokers and easy access were the ones most likely to become regular smokers, compared to those who were exposed to none of those factors.”

“Either factor—easy access or peer smokers—should be seen as a warning sign, but when they all occur together, then you are really putting kids at risk,” Doubeni said. “We found that there is a synergy between having a friend that smoked and perceiving easy access; having a friend who smokes naturally makes cigarettes seem readily available. Ultimately, the kids who reported both peer smokers and easy access were the ones most likely to become regular smokers, compared to those who were exposed to only one of those factors.”

For children in low-income families eligible for Medicaid, the Early and Periodic Screening, Diagnosis and Treatment program already is supposed to screen for smoking risk factors, such as peer influences and tobacco use. The authors recommend that in general, family physicians and pediatricians inside and outside of Medicaid should make a point of specifically discussing with their patients perceptions regarding the availability of cigarettes and whether or not their friends smoke.

“Getting this kind of information can allow health care professionals to move more aggressively to warn children and their parents that they are dangerously close to engaging in a behavior that could severely damage their bodies and, over time, even kill them,” said Doubeni.

“It can serve as a wake-up call to intervene and help kids avoid succumbing to a habit that can be extremely hard to quit.”

The Substance Abuse Policy Research Program ( of the Robert Wood Johnson Foundation funds research into policies related to alcohol, tobacco and illegal drugs.

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 30 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. Helping Americans lead healthier lives and get the care they need—the Foundation expects to make a difference in our lifetime. For more information, visit

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