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Speech by J. Edward Hill M.D., Chairman-elect American Medical Association to The Leadership to Keep Children Alcohol Free Annual Conference

January 10, 2002

It is a special pleasure to join you today because we share a common concern for children and the influences shaping their young lives.

The Leadership to Keep Children Alcohol Free names the problem in clear and chilling simplicity -keeping children alcohol free. Not college students - although that is troubling. Not teens - although that also concerns me. Children are consuming alcohol, beginning on average, at age 12. And the consequences of childhood alcohol use will shape public and fiscal policy for years to come unless we alter this trend.

Alcohol use is one of seven completely preventable behaviors placing America's children at great health risk - tobacco use, teen pregnancy, sexually transmitted diseases, suicide, injuries from violence or unintentional acts and alcohol use are all preventable. Together these seven behaviors cost billions of dollars each year. Alcohol use alone costs the U.S. $22.5 billion each year, according to the Schneider Institute for Health Policy at Brandeis University.

The focus of this conference is underage drinking - which is becoming childhood drinking. Alcohol is placing its grip on our children at a very young age. As I mentioned earlier, the average age of first drink in America has dropped to age 12. In one study of young drinkers, 12.9% of the respondents reported drinking beer, 13.1% reported drinking wine and 11.4% reported drinking hard liquor or spirits between the ages of 12 and 13. 1.

Last year, the Journal of the American Medical Association published a study documenting that youth regularly consuming alcohol before age 14 were at least three times more likely to develop a diagnosable alcohol dependency than those who delayed alcohol consumption to age 21.

There is a clear link between delayed consumption of alcohol until adulthood and reduced levels of dependency. Children who begin drinking at age 13 have a 47.3% chance of becoming alcohol dependent. First time drinkers aged 16 have a 30.6% chance of alcohol dependency. Individuals who defer alcohol consumption until age 21 have only a 10% chance of alcohol dependency. Preventing childhood alcohol consumption can reduce the personal, societal and monetary costs of alcoholism. 2.

For nearly 50 years, the American Medical Association has taken a public stand on the health risks of dangerous alcohol consumption. In 1956, the American Medical Association affirmed that alcoholism is a disease, not a character flaw. Since then, the AMA has sharpened its focus addressing specific areas of risk. The AMA continues to differentiate between moderate adult consumption of a legal product and dangerous, health threatening or illegal consumption of alcohol. We successfully advocated eliminating alcohol from childhood medicines and for early education about fetal alcohol syndrome. In addition, we have taken a strong stand against alcohol advertising on television.

In 1989, the AMA affirmed a commitment to preventing substance abuse from becoming a chronic burden on our society. But the long-term burden of alcohol is still unclear. Medical research continues to reveal the full extent of alcohol's impact on young people.

The AMA should advocate for increasing the effectiveness of existing substance abuse treatment programs while leading a discussion of the less known, long-term medical effects of childhood alcohol use. Let me give you some examples:

We know the hippocampus is the part of the brain responsible for learning and memory. Research conducted by the University of Pittsburgh Medical Center demonstrated that the hippocampus of teens who abuse alcohol is 10% smaller than in teens who did not abuse alcohol. 3.

Another study shows that individuals, who used alcohol as adolescents, exhibit reduced ability to learn when compared to those exposed to alcohol as adults. Alcohol shrinks memory signals at a more rapid pace in children than adults and reduces memory acquisition. Adolescents who abuse alcohol may remember 10% less of what they initially learn when compared to non-drinking adolescents. 4.

And the medical risks go beyond brain injury. We have all heard about danger of untreated high blood pressure. A representative sample of current drinkers' aged 12-16 had higher levels of diastolic blood pressure than non-drinking counterparts. 5.

It is time to take a fresh look at the alcohol environment facing children.

In the past society has blamed children and later society blamed their parents for underage drinking. In fact, it seems as if we have blamed everyone but the alcohol industry. It's time to stop blaming and start changing the alcohol environment influencing our children.

Adults are often unaware of a child's alcohol environment - because it isn't directed at adults. Let me give you an example.
A few years back there was a billboard on Michigan Avenue near the AMA office. I thought it was a unattractive cartoon of some frogs that didn't seem to have anything to do with beer. Later I heard a colleague talk about his small children jumping on the furniture, pretending to be frogs while shouting Bud-Wei-Ser, and I understood. That billboard wasn't directed at me.

Your new video- "Drinking It All In" - is the first tool that recreates a child's alcohol environment for adults. You are to be congratulated for your vision and the Robert Wood Johnson Foundation deserves our gratitude for providing the resources to make your vision a reality. Seeing is believing and once "Drinking It All In" is viewed the enormity of the environmental challenge becomes clear.

Public policy is our tool for reshaping the alcohol environment. As individuals, your knowledge and personal involvement in public policy is a tremendous advantage in this effort. While each of us can take responsibility for ourselves, only public policy can change the community.

Politics, especially American politics, is local. Each community must respond to their specific situation -making changes within the local political - not partisan - framework. Tobacco control demonstrated the power of community-up organizing, a lesson the we can apply diligently to alcohol.

The AMA's Reducing Underage Drinking Through Coalitions project - also a Robert Wood Johnson funded effort, has focused on state and local changes in public policy and perception.

During the first phase of this program there has been action on: social liability the creation of alcohol free festivals or alcohol free zones elimination of alcohol advertising from public transportation state-wide beer keg registration the elimination of drive-up windows for alcohol purchase

to name just a few sponsored initiatives.

Limiting alcohol availability in college communities is the focus of the AMA's other alcohol program - A Matter of Degree. AMOD creates campus-community partnerships to break the "bar belts" surrounding many campuses.

For a moment, I would like to focus on one aspect of the alcohol environment that has been in the news over the past two weeks -alcohol advertising on television. TV viewing is invisible in our society and as familiar as the air we breathe.

Television is our constant companion - frequently a child's only companion. In 1999, The Kaiser Family Foundation published a study based on 3,000 interviews and completed questionnaires with children, aged 2- 18. That survey provides a revealing picture of the role TV plays in a child's life.

Children 8 years old and older watch on average nearly 20 hours of TV each week. At age 8 or older, parents are watching with their children only 5% of the time.

Over half, 58% of all children report that the TV set was "usually on" during meals.

One in three children between the ages of 2 and 7 have a TV in their room. At age 8, that jumps to 65% of children with personal TV sets.

Television is the backdrop of a child's life, accordingly solutions to reduce underage drinking must include television. While parents can - and many do - turn off the TV - the content of programs and advertisements is everyone's concern. Not just parents.

The AMA supports the elimination of all alcohol advertising on television.

We forcefully objected to NBC's recent decision to accept liquor ads. None of us believe that more alcohol advertising will lessen the problem of underage drinking. Advertising sells alcohol - if it didn't why did distillers demand "a level playing field" to match vintners and brewers dollar for dollar in airtime?

We should ban all alcohol advertising on TV because America's children need a level playing field. We may hear the same predictions of economic Armageddon we heard from the tobacco industry years ago when tobacco ads were banned. But it is step we must take.

Until that time - we must carefully evaluate what children see on TV. The inherent purpose of advertising is to motivate people to take a specific desired action. Part of motivation is the perceived relationship between the consumer and the product - my toothpaste, my soda, and my beer. Research shows that children develop brand identification at a very young age. Children hear and model seen behavior as early as 16 months.

A study of 9 -11 year olds conducted in 1996 found that the Budweiser Frogs had higher slogan recall than Tony the Tiger, Smokey the Bear, or the then popular Mighty Morphin Power Rangers.6.

Early brand identification and impressions are a critical part of a child's later behavior. Children begin to learn about alcohol and its effects long before they have their first drinking experience.

It is important to know that alcohol awareness directly translates into a child's intention to consume alcohol as an adult. The relationship between advertising, beliefs and childhood intentions is complex and very important. As early as 1994, studies found that alcohol advertising may predispose young people to drinking. 7.

Children are growing up assuming that they will consume alcohol. Survey research proves it. A random sample of 5th and 6th graders discovered that awareness of alcohol advertising was significantly related to knowledge of brands, slogans and to more positive beliefs about drinking. And children with more favorable attitudes towards drinking expected to drink more frequently as adults.

The same study did not find any association between the negative aspects of alcohol use reported by the children and advertising. The study concluded that children associate alcohol ads with romance, fun, relaxation and attractiveness.

In 1999, the Federal Trade Commission issued a report evaluating the alcohol industry's voluntary limitations on advertising. NBC's recent decision to air liquor advertising has rekindled interest in the FTC findings.

The report demystified ad placement statistics. The FTC report said, "Only 30% of the US population is under age 21 and only 10% is age 11 - 17. The 50% standardÉpermits placement of ads on programs where the underage audience far exceeds its representation in the population." Because audience age and composition figures are calculated nationally, some programs, in some markets, may have more child and teen viewers than adults.

It is foolish to pretend that at age 21 the scales suddenly fall from a young person's eyes and they begin to "see" alcohol advertising. Especially when we know they view ads created to appeal to teens.

Industry documents reviewed by the FTC for the 1999 report noted that as long as advertising appealed to those of legal drinking age in the same proportion as teens, it was acceptable by industry standards.

One focus group report, given to the FTC, actually contained criticism from group participants - the people the industry recruited to review their ads - for one version of an ad that the group believed was aimed at teens.

Another alcohol industry document given to the FTC discussed the importance of attracting "new" drinkers and stated that many individuals continue to consume the brands that initiated them to alcohol consumption. And that completes the circle taking us back to early identification of brands and brand name symbols at a very young age.

Further examination of alcohol advertising and TV program content is a subject ripe for collaboration between our two groups. The AMA Office of Alcohol is also working with the AMA Alliance, our spouses' organization, on this issue. In the past, The Alliance has focused on another area of preventable risk - injury with great success. Future networking between our three organizations provides a broad geographic springboard for a discussion of this issue.

Our different perspectives fuels the synergy between our groups. Physicians see the impact of alcohol one patient, one family at a time. You view underage drinking through the unique problems facing your state. Together, our groups cut across political, geographic, ethnic and economic boundaries. Our potential is immense.

So how can we, as a nation commit to providing children with decision-making skills and age appropriate information to make good decisions? And not just alcohol decisions. Comprehensive School Health Programs with a good curriculum addressing each of these behavioral risks would save more money than it costs, because each risk opens the door to a number of health problems. Dangerous behavior is like water, it seeks the path of least resistance and seeps into unexpected areas of people's lives. Comprehensive School Health Programs have the ability to give young people the opportunity to live healthy, fully productive lives. Looking at the whole child involves evaluating all the risks, as well as placing emphasis on a particular problem.

Suppose we added the goal of addressing all of the unhealthy preventable behaviors to the public dialog on underage childhood drinking as this dialog takes shape. Suppose this was the beginning of a long and difficult process.

Suppose the AMA, AMA Alliance and this Leadership group coordinated and focussed all efforts on the mandating and funding of Comprehensive School Health Programs in every school district in this nation - taught by certified health educators and trained school health nurses.

Suppose that our efforts - together - result in a 10 - 20 - 30 maybe 50% reduction is alcohol related accidents - violence and abuse - suicide - homicide etc. - saving literally billions of dollars in direct costs - not to mention indirect costs.

Changing communities and years of accepted - although unacceptable behavior - is difficult. Our colleagues in tobacco control provide a great many valuable lessons. The first lesson is simple - this is everyone's battle.

Another son of Mississippi - William Faulkner captured the potential of a great challenge. He said, "I believe that man will not merely endure, he will prevail. He is immortal, not because he alone among creatures has an inexhaustible voice, but because he has a soul, a spirit capable of compassion, sacrifice and endurance."

Soul, spirit, compassion and endurance. Good tools for the task ahead. I look forward to it.

1.Parents Resource Institute for Drug Education, 2000 - 2001 Survey
2. Grant, B. F., and Dawson, D.A. (for HHS) "Age Onset of Alcohol Use and its Association with DSM-IV Alcohol Use and Dependence," Journal of Substance Abuse, Vol. 9, pp. 103-110. 1997.
3. Swhwartzwelder, HS Wilson, WA and Tayyeb,MI, " Age dependent inhibition of long term potential by ethanol in immature versus mature hippocampus," Alcoholism: clinical Experimental Research, 20(8), 1996, pp. 1313-1323.
4. Brown, SA, Tapert S. F., Granholm, E. et al. 2000. Neurocognitive functioning of adolescents: Effects of protracted alcohol use. Alcoholism: Clinical and experimental research 24(2):164-171 Hanna, E.Z. et. al.
5.Drinking, smoking and blood pressure: Do their relationship among youth foreshadow what we know among adults? Paper presented at the American Public Health Association Annual Meeting, Chicago IL, November 1999.
6.Frogs Sell Beer, Gentile David, et. al., Paper presented at the Biennial conference of the Society for Research in Child Development (April, 2001) Minneapolis, Minnesota.
7.Television Beer Advertising and Drinking Knowledge, Beliefs, and Intentions Among Schoolchildren. Grube, Joel and Wallack, Lawrence, American Journal of Public Health, Vol 84, No. 2 p. 254.

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