Sobering Truths (Summer 2005 Trust magazine article)

Too many ads for alcoholic beverages find their way to underage youth. That's not surprising, given where they appear: in the magazines youngsters read and on the TV shows they watch, the Internet they're surfing and the radio they are tuned in to.

It would have been interesting to see the eyebrows rise, that day in the late 1990s, when the Federal Trade Commission asked the alcohol industry for evidence that it was complying with its own voluntary advertising codes on underage drinking.

The FTC was examining the ad practices of eight leading companies that account for some 80 percent of the alcohol advertising in regular media. Two companies' own data showed violations of the code. Two other companies had failed even to collect the age-demographic data needed to evaluate their compliance.

Yet even full compliance might not have earned the FTC's praise, since the standards allowed great latitude. In ad placement, for example, the codes at that time prohibited companies from advertising in media where 50 percent of the viewers or readers were less than 21 years of age. That criterion eliminated exactly one percent of all national television programs. Moreover, although some companies complied with the codes, alcohol ads had been placed on at least three of the 15 TV shows with the largest teen audiences. And the industry had placed its products in PG and PG-13 movies.

The FTC's investigation, undertaken at Congress's request, was the second report of its kind in the decade. In 1991, at the request of Surgeon General Antonia Novello, M.D., the Inspector General of the U.S. Department of Health and Human Services conducted a nationwide survey that suggested a link between irresponsible alcohol commercials and problem drinking among teenagers. The report found the industry guidelines vague, narrow, inconsistent, ineffective and “unenforceable.”

The FTC came to a similar conclusion and recommended strengthening the codes. While favoring continued selfregulation, the FTC urged the industry to create independent, external review boards to assure unbiased assessment and follow-up of complaints about the advertising. Such a mechanism, the FTC said, would help industry compliance and gain the public's confidence that the industry could police itself. And it called for the industry to institute “best practices,” that is, refuse to advertise in media with audiences of more than 25 or 30 percent of underage youth, as some companies were already doing.

Like the Novello study, the FTC's report went largely unheeded. (The exception was a change in the code of the Wine Institute, which in 2000 restricted its advertising to audiences that are only 30 percent, rather than 50 percent, under age. But the institute's members account for only 10 percent of all alcohol advertising expenditures, and wine is generally not the beverage of choice for underage drinkers.) Yet surveys showed a problem with underage drinking, and it continues:

• In 2003, 10.9 million of the 12-to-20 population—29 percent—took a drink in the previous month.
• Nearly 7.2 million reported binge drinking—five or more drinks at one sitting.
• In 2004, more than 6 percent of 8th graders, 18 percent of 10th graders and 32 percent of 12th graders were drunk in the past 30 days.
• The average age of first alcohol use for 12- to 17-year-olds has been dropping and now stands at 13 years old.

Drinking has consequences:

• Those who begin drinking before the age of 15 are four times more likely to develop alcohol dependence than those who wait until they are 21.
• Alcohol plays a substantial role in the three leading causes of death among youth: unintentional injuries, suicides and homicides.
• The estimated cost in crime, medical bills and deaths is $53 billion annually.

Some 92 percent of adults are concerned about children developing alcoholism or becoming dependent on alcohol—yet adults overall are sadly uninformed:

• 12 percent of parents of 13- and 14-year-olds think their child has consumed an alcoholic beverage. Yet 39 percent of 13- and 14-yearolds say they have had a drink. This amounts to a “perception gap” of 27 percent.
• The perception gap between 15- and 16-year-olds and their parents is even wider, at 29 percent: 31 percent of parents say their children have had a drink, but 60 percent of those teens report drinking.
• There is a similar disconnect about being drunk or at least tipsy: a 10- percent perception gap for the younger age group, and 25 percent for the older.

Some call this an epidemic of underage drinking—and epidemic is exactly the word used by, among others, the American Medical Association, Mothers Against Drunk Driving and the National Center on Addiction and Substance Abuse at Columbia University.

To be sure, underage drinking involves many facets other than advertising, including control of access, parental oversight, public-health education, personal choice, peer influence and the guidance of teachers and other mentors. “Yet when it came to advertising”— a billion-dollar expense item for the alcohol industry—“there was almost a total lack of knowledge,” says Jim O'Hara, executive director of the Center on Alcohol Marketing and Youth (CAMY).

He is referring to the period before 2002, when CAMY was launched. Based at Georgetown University's Health Policy Institute and supported by grants from The Pew Charitable Trusts and the Robert Wood Johnson Foundation, the project aims to reduce the exposure of underage youth to alcohol advertising and marketing. Its strategy involves research and analysis, communications, and outreach activities in coordination with organizations in selected states.

“By comparison,” O'Hara continues, “there was a wealth of data on tobacco advertising that we didn't have, and still don't fully have, on alcohol and underage drinking. It has always been a concern driven by anecdote and outrage rather than grounded in a systematic look at the issue. Even public health agencies had to throw up their hands and say ‘We don't know.'”

O'Hara knows his way around the public health sector. After a 17-year career as a reporter and editor for a newspaper in Tennessee, he went to Washington in the early 1990s, serving as associate commissioner for public affairs at the federal Food and Drug Administration. There, he developed and implemented strategic communications plans for initiatives on blood safety and food labeling and safety.

He moved to the Department of Health and Human Services, where, as deputy assistant secretary for health, he was responsible for the formulation of public health policy in food safety and other areas. He also served as a senior advisor to HHS Secretary Donna E. Shalala and U.S. Surgeon General David Satcher, M.D.

Immediately prior to his post at CAMY, he headed Health-Track, a Trusts-supported public education campaign at Georgetown University, with the ultimate goal of helping prevent chronic disease. Its strategy was to build support for a comprehensive national approach to tracking and monitoring the links between the environment and health.

That alcohol advertising could be addressed by a comparably data-driven approach came to the attention of Pauline M. Abernathy, assistant director of the Trusts' Health and Human Services program, when she heard David H. Jernigan, Ph.D., speak on alcohol advertising and underage drinking at a meeting of the American Public Health Association in 2000. Jernigan is an expert on the issue, having written his doctoral dissertation on alcohol advertising in developing countries and a “global status” report on alcohol and young people for the World Health Organization.

“It was striking that the public health community was relying on anecdotal information, despite the existence of the standard industry data bases,” Abernathy recalls. In a follow-up meeting, Jernigan told her about the FTC report, which had largely been ignored. “After reading the FTC report, the Trusts' HHS staff became convinced the public would be interested if the data were organized and made available in an understandable way,” she says. (Jernigan is now CAMY's research director.)

“We thought the issue seemed particularly appropriate for an investment by the Trusts,” says Maureen K. Byrnes, director of policy initiatives and the HHS program. “We look for issues where we can serve as is a catalyst for change. In this case, no one was tracking youth exposure to alcohol advertisements. We had a strong partner in the Robert Wood Johnson Foundation. And there were community coalitions and organizers interested in using CAMY's data to do something about the problem.”

CAMY brings to alcohol advertising the systematic examination that had not been done before. It tracks and monitors and then disseminates its findings. O'Hara: “If my old boss Dr. Satcher said it to me once, he said it a hundred times—‘Public health begins and ends with surveillance.'” In other words, the extent of a public health problem, the effectiveness of interventions and information that might lead to new hypotheses—all depend on credible, nonbiased facts and figures.

Without these, says O'Hara, “you end up having shouting matches, as opposed to serious policy debates about the best way to protect the public health” and—in the case of alcohol advertising—“the best way to balance the public health interest versus the industry's legitimate right to advertise to the legal market.”

Advertising placement can be dispassionately and objectively measured—unlike ad content. Content raises questions of appropriateness and good taste as well as free-speech issues, and it can be alarming, as when a survey in the 1990s showed that more 9- to 11-year-olds knew the mantra of the frogs Bud, Weis and Er than that of Kellogg's Tony the Tiger. Nonetheless, O'Hara notes, “The real issue is exposure—because if you reduce youth exposure, then conversations about content become moot.”

CAMY uses industry-standard data bases which companies use to determine where to place ads. They involve two types of data sets. One type answers questions about advertising occurrences: Where, when and how many ads ran, and at what cost? The other data set examines audience composition. These numbers tell the number of people who see, read or hear each ad, as well as their demographics.

For a brand or category of alcohol, they tell an ad's “frequency,” or the number of times individuals are exposed to an ad or campaign; and “reach,” that is, the percentage of a particular demographic group potentially exposed to the ad or campaign.

Multiplied together, frequency and reach yield an index called “gross rating points,” which reveals how much advertising a given audience is likely to have been exposed to on a per-capita basis. CAMY employs a media research firm, Virtual Media Resources, which uses standard industry software to produce the data for analysis.

Thus, CAMY will take an ad that may be nominally intended for an audience of 21- to 34-year-olds and ask how often it reaches, or “spills over” to, 12- to 20-year-olds. And how many of the ad's audience will be above 34 compared to those below 21.

Ads will always reach people other than the intended audience, O'Hara acknowledges, but he observes, “When you look at the data, it seems that some brands tend to spill young. Why does it spill down so often—so that, in some instances, the advertising reaches more 12s-to-20s, per capita, than 21s-to-34s?”

That's not a question for CAMY. “That's a question for the industry to answer. We just put it on the table,” he says, adding, “You do have a choice about where you place the ads, knowing what is likely to happen.”

The alcohol industry objects to the findings often by noting that more adults see the ads than do youth. O'Hara: “And I say, ‘Yes, and your point is . . . ?” His point is that adults will most certainly see more ads, since they outnumber youth by nearly 6 to 1: More than 200 million people are over 21 compared to approximately 35 million who are 12 to 20.

Some in the alcohol industry would prefer to base the analysis on “gross impressions,” another standard advertising measure that multiplies the audience by the number of ads. But for CAMY, this criterion does not differentiate among groups within the total population or reveal per-capita exposure.

The difference in the two methods was made clear in 2003, when CAMY released the report Radio Daze: Alcohol Ads Tune In Underage Youth. The Distilled Spirits Council of the United States countered by referring to gross impressions. O'Hara replied with a public letter that stated, in part: “Our analysis tells a parent that her child is hearing more alcohol ads than she is. Your mis-analysis—that all adults in the U.S. hear more ads than all the children—will be of little comfort to her.”

(You can become familiar with the per-capita calculation at CAMY's interactive Web site, http://camy.org, by clicking on “Take Action” and then on “Gauge Exposure.” Select an advertising medium, and then a type or brand of alcohol; for magazines, you will get figures showing the frequency, the percentage of reach and the gross rating points comparing illegal and legal drinkers. You can even insert the specific age of an underage youth and your own age to compare your exposure to the advertising against that of the youth. For television and radio, there is local media-market information.)

Since its launch in 2002, CAMY has issued 16 reports and 19 fact sheets. Some emphasize the medium: for instance, magazines, TV, radio or the Internet (its Web study also showed that surfers could be measured). Or specific audience groups, as African Americans, Hispanics or parents. Or themes like the comparison of the alcohol industry's “responsibility” advertising on TV with its product advertising or the status of state laws on alcohol advertising (with model policies). Or yearly overviews.

Last year, CAMY conducted the study “Sex Differences in Adolescent Exposure to Alcohol Advertising in Magazines,” which was published in the Archives of Pediatrics and Adolescent Medicine. The article shows that there is basic public-health research “that needs to be done and that can be done—and the peer-review, academicjournal community recognizes it,” says O'Hara.

The studies have been widely reported in the press—850 articles or editorial references last year alone. “Reporters know that this is a topic of concern, and we're giving them solid information that's newsworthy—and that they don't know,” says O'Hara. Ordinary citizens have reacted in the same way: “There is not a parent I have met in the past three years who, when I told them what I did, didn't go, ‘Oh thank heavens somebody's doing that.'”

Even some industry members have quoted CAMY's work “to try to get their own companies and others to do a better job in reducing underage exposure,” says O'Hara. “Now, they also argue with our numbers, and that's fine. I'm more than happy to have a vigorous conversation about it.”

Indeed, CAMY's efforts have gained the interest of more than 100 organizations, including the American Medical Association, the Center for Science in the Public Interest, Mothers Against Drunk Driving, the National Parent Teacher Association and the National Liquor Law Enforcement Association. Informed by the data, many of these groups have written letters, passed policy resolutions and other statements of support and publicized CAMY's findings.

“CAMY has brought believable research and well-documented data to the discussion,” says Hope Taft, first lady of Ohio and co-chair of Leadership to Keep Children Alcohol Free, a bipartisan coalition of governors' spouses. ”Without CAMY, it would be harder to motivate others to take an active role in preventing underage drinking.”

The Institute of Medicine of the National Academy of Sciences also drew significantly on CAMY for its 2003 report on underage drinking. The IOM was created by Congress to provide expert advice to the government, and when this group of preeminent scientists invited CAMY to present its data, “we jumped at the opportunity,” says O'Hara. “IOM reports can be hugely influential, even if it takes years to form a policy.”

CAMY recommended, among other things, that the threshold for placing ads be reduced to 15 percent (12- to 20-year-olds constitute approximately 15 percent of the U.S. population over the age of 12). The IOM called for an immediate reduction to 25 percent but followed CAMY in recommending that the industry move toward 15 percent, “which still allows the industry to reach its legal audience,” O'Hara notes.

CAMY's desire to involve public health agencies was reflected in the IOM's call for the Department of Health and Human Services to monitor youth exposure to alcohol advertising and report its findings to Congress and the public.

The report Reducing Underage Drinking: A Collective Responsibility, by the IOM and the National Research Council, was issued on September 9, 2003. The same day, the beer and distilled spirits industries announced that they would lower the threshold to 30 percent. “They were trying to deflect criticism, and I think people recognize that,” comments O'Hara, “but the reality is that it was also a step forward, and industry should be applauded for that.”

The IOM report and CAMY's data had a quick repercussion. Three weeks later, the U.S. Senate Subcommittee on Substance Abuse and Mental Health Services held a hearing on underage drinking. And a bipartisan group of members of Congress introduced the Sober Truth on Preventing Underage Drinking Act in 2004 and then reintroduced it in February of this year.

Meanwhile, CAMY is assessing the numbers for 2004, and the issue of underage drinking and the role of alcohol advertising are gaining new attention. Both the National Association of Attorneys General and the Conference of Western Attorneys General have created task forces on underage drinking, including examining alcohol advertising to youth.

At the state and local levels, organizations are disseminating the findings, often with specific policy goals. For example, Ohio Parents for Drug- Free Youth, founded by Hope Taft, has brought each of CAMY's reports to the attention of local media and presented the data to health boards and business groups. The state's Division of Liquor Control, informed by CAMY's findings, now prohibits alcohol billboards within 500 feet of schools and playgrounds— putting some teeth into the industry's same but voluntary restriction.

In Tennessee, CAMY delivered its findings at the annual meeting of the state PTA. “Some members got very engaged in the issue, asked for our PowerPoint presentation and went around the state making the presentation to other local PTAs,” says O'Hara, noting that the state group then passed a resolution on this issue.

In Philadelphia, the City Council asked CAMY to testify as an expert witness on barring alcohol advertising on city-owned or -controlled property— which included the local transportation system's bus shelters, which are used by the 27,000 Philadelphia children who ride public transportation to school. The ordinance passed and was signed into law.

“Without these strong local voices— and in other states, too, like Oregon, California, New Mexico, Nebraska, Texas, Maine and Connecticut—CAMY would not have had the policy impact it has had,” O'Hara says.

The National Liquor Law Enforcement Association objected to a beer company's ad depicting a young person hiding his beer from a police officer responding to a rowdy party. Legal drinkers don't have to hide their bottles, the association pointed out, so the people in the ad must be underage. CAMY disclosed that the ad had aired 119 times during The Simpsons, a TV program with a substantial underage youth audience share. The company withdrew the ad.

This incident stirred a revealing after-shock. The association was refused when it first asked the company to pull the ad, and then it asked the Beer Institute for help. According to The Boston Globe, the institute's general counsel said that code enforcement “is not our job. The code is not going to work if we become the judge.”

Those words appear on CAMY's Web site. “We use that quote to show the problems with self-regulation,” says O'Hara. “At the end of the day, nobody seems willing to enforce it.” At the same time, O'Hara is willing to credit the industry for taking some steps in this direction. CAMY issued a statement applauding the recent publication by the Distilled Spirits Council of the United States of its first-ever public report by its Code Review Board on complaints about violations of its code, and O'Hara appeared at the council's press conference to deliver the statement in person.

CAMY's data are often in the background. They are cited in litigation against the alcohol industry in cases of underage drinking, although CAMY is not involved in the lawsuits. “We're aware of them and try to follow them to see what happens regarding their impact on policy,” says O'Hara, “but we learn about them when we read about them in the newspaper, like other folks.”

CAMY's next goal is to see public health agencies institutionalize the monitoring and tracking “because this is an issue that will continue being addressed only if a spotlight continues to shine,” he says. “Before we had done this, no one really knew what the data were going to show and what was really happening—not even the industry itself, as the FTC showed in 1999. Now there's recognition that this kind of data, and other basic data on alcohol advertising and marketing, are important for parents and policymakers to have if we're going to have any chance of reducing underage drinking.”

Even so, he acknowledges, “Self regulation is the way it's going to be. But that means the industry must be responsible and hold itself accountable. And every time the industry shows that it won't be accountable, it's going to raise the eyebrows of policymakers.”

The Center on Alcohol Marketing and Youth can be reached at the Health Policy Institute of Georgetown University, Box 571444, 3300 Whitehaven Street, N.W., Suite 5000, Washington, DC 20057-1485. Its phone number remains 202.687.1019, and e-mail is [email protected]. Its Web site is http://camy.org.

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Modernizing Treatment for Alocoholism

Fourteen million Americans are a lot of people. They equal the population of New England and (minus California and Washington) almost equal that of all the Western states. As one of the United States, they would constitute the fifth most populous.

And 14 million is about the number of Americans with alcohol problems. Problem drinking is the third leading cause of preventable death in the United States, killing 85,000 Americans each year. Its annual price tag stands at some $184 billion, including the costs of treating the medical consequences, lost work productivity and motor vehicle accidents. And America's employers absorb most of those expenses—$134 billion annually.

Yet only 2.2 million of this group— a number equal to the 35th largest state—receive alcohol treatment services. Many individuals may deny they have a problem, or fear stigma. But even if they overcome personal barriers, they are likely to confront policies and practices in the health care system that limit access to the care they seek. These include high insurance deductibles and co-payments, administrative hurdles and defined courses of treatment, such as one-time, 28-day rehabilitation programs— which do not address the genetic underpinnings and chronic nature of alcohol problems.

Ensuring Solutions to Alcohol Problems, a Trusts-supported project of George Washington University, was established in 2002 to document the obstacles to alcohol treatment and highlight the need for better care. Its means are original, nonpartisan information and educational outreach for audiences of federal and state policymakers, governmental officials with key agencies, employers and concerned citizens. As the project's executive director, Eric Goplerud, Ph.D., says, Ensuring Solutions aims “to develop research-based tools to improve access to treatment for alcohol problems, and then to give them away.”

One such tool is the Alcohol Cost Calculator, which uses government data to compute the costs of untreated alcohol problems, so that businesses can reckon the impact on their bottom line. General Motors, the largest private purchaser of health care in the U.S., American Express, Marriott International and the U.S. Postal Service are among the organizations using the Calculator to help factor alcohol treatment into their health plans. And the “‘Calculator for Kids' brings the issue home and helps communities build a local case for treatment,” says Goplerud.

Working directly with large businesses and their associations, Ensuring Solutions analyzes health plans and recommends ways for employers to improve alcohol treatment benefits for their employees. It is also playing a key role in the national campaign “Making Recovery America's Business,” sponsored by the Hazelden Foundation, a leading treatment provider.

And even though its work is concentrated in the private sector, Ensuring Solutions has been invited to serve as a resource to policymakers at the federal, state and local levels. Its research and analysis makes the case for repeal of states' Alcohol Exclusion Law, which exempts insurance companies from covering medical costs if the injured party was under the influence of alcohol or drugs. In 1947, the National Association of Insurance Commissioners adopted the statute as part of a “model law,” but in 2001, with support from medical authorities, it revised its stance in light of advances in alcohol treatment and uses Ensuring Solutions' work that demonstrates the public health benefits of repealing the law.

Ensuring Solutions is carrying its outreach to regional business coalitions on health and working to expand the number of constituency groups educating policymakers about the barriers to alcohol treatment.

To access the Alcohol Cost Calculator, fact sheets and recommendations for action, visit www.ensuringsolutions.org. Ensuring Solutions is located at George Washington University, 2021 K Street NW, Suite 800, Washington, DC 20006.

Marshall Ledger is editor of Trust.