Just How Dangerous Are Alcohol/Energy Drink Combinations?

Recently, there has been a great deal of scare stories regarding the supposed dangers of alcohol mixed with energy drinks (AMEDs for short).  In 2010 this led to the banning of premixed canned AMEDs such as the notorious Four Loko, which still is on the market but without the caffeine and taurine.  Of course, drinkers (and bartenders) are free (for now at least) to mix energy drinks with alcohol after obtaining them separately.  But are such fears (and laws based on them) actually warranted, or are they exaggerated?

A recent review of the scientific literature on the topic of AMEDs suggests that the dangers have been greatly exaggerated.  After surveying numerous studies of the effects of combining the two beverages, the authors concluded that there was, contrary to popular opinion:

• virtually no hard evidence that adding energy drinks to the mix significantly alters the behavioral effects of alcohol
• no reliable evidence that energy drinks significantly affect the perceived level of intoxication by drinkers
• zero evidence that mixing energy drinks with alcohol increases the odds of alcohol or drug abuse or dependence, and
• no significant adverse health effects for healthy individuals from combining energy drinks and alcohol in moderation.

Of course, it should go without saying that both alcohol and energy drinks, alone or in combination, can indeed be harmful when consumed to excess.  Also, one should always remember that caffeine (in energy drinks or otherwise) does not make a drunk person less impaired or more able to drive.  The best take-home message from all this is that moderation is the key.

In the case of Four Loko and similar drinks, it appears that the real issue was not that it contained alcohol and caffeine in combination, but rather that it contained such large amounts of each per can.  One 23-ounce can apparently contained the equivalent of 5 shots of vodka and 3 cans of Red Bull, and typically cost less than $3.00.  Such cheap and highly potent concoctions don't exactly promote moderation.  But unfortunately that fact was lost in all the hysteria over alcohol and energy drinks.

Hand Sanitizer Hype

Anyone who has looked at the news in the past two weeks is probably familiar with the latest moral panic:  teenagers drinking hand sanitizer to get drunk.   Apparently, most hand sanitizers (which unlike beer don't have an age limit) contail large amounts of ethanol (i.e. drinking alcohol), up to 60-70% in fact--making it nearly as strong as 151.  So strong, in fact, that some teens ended up in the emergency room with alcohol poisoning as a result.  (WARNING:  DO NOT TRY THIS AT HOME!)  And the media are clearly eating it up.

But is there really any reason to panic?  Probably not.  For one thing, overall teenage drinking is actually at a record low according to the Monitoring the Future survey and other surveys.  Secondly, alcohol "surrogates" are nothing new--vanilla extract, mouthwash, and cough medicine all typically contain alcohol and have no age limit to purchase them despite the fact that they are (ironically) more harmful than normal alcoholic beverages.  There have always been at least some people consuming them, and there is zero hard evidence that surrogates in general are any more popular among young people today than they were a generation ago.  In fact, very few teens actually end up resorting to drinking sanitizer or any other surrogate alcohol, and so far the number reportedly ending up in the ER from sanitizer remains in the single digits.  But just like moral panics and media hype about glue-sniffing in the 1960s actually made the practice more popular among teenagers, there is the same potential for hand sanitizer to follow such a trend if the media keeps at it long enough.

One thing is clear, however.   The idea that the drinking age should be 21 (as opposed to 18) to keep booze away from high-schoolers now appears to be even more of a canard in light of the fact that kids of any age can just drink sanitizer (and other more harmful surrogates) to catch a cheap buzz when all else fails.  It appears that this "trickle-down" theory is just as bogus as the other one.

If all this sounds similar to what happened during Prohibition, you would be correct.  "Paint remover" (industrial denatured alcohol) and various patent medicines like "ginger jake" were among the surrogates used by drinkers in the 1920s, with disastrous consequences.   Sadly, as many as 10,000 people died as a result, and their blood lies on the hands of the feds who mandated the deliberate poisoning of alcohol surrogates while simultaneously denying legal, quality-controlled alcoholic beverages to the people for thirteen years in a row.  The results were all too painfully predictable.  And unfortunately, those who fail to learn from history are doomed to repeat it.

When Alcohol Retreats, Cannabis Advances (And Vice-Versa)

A number of studies suggest that alcohol and cannabis (marijuana) are economic substitutes, meaning that when one increases, the other tends to (albeit unequally) decrease.  The past five years are one example of such opposing trends.  Thus, one apparent unintended consequence of raising the drinking age to 21 was a modest increase in cannabis use among 18-20 year olds and high school seniors.

The most recent study by Crost and Guerrero (2011) found that, using a regression discontinuity approach, upon turning 21 young adults tend to increase their drinking and decrease their cannabis use, both in terms of probability and frequency.  The authors estimate from this pattern that the 21 drinking age law decreases past-month alcohol use by 16% while increasing past-month cannabis use by 10% among 18-20 year olds.  The apparently larger effect size for alcohol may reflect greater reporting bias of drinking (which is illegal before 21 but legal afterward) relative to cannabis use (which is illegal for all ages), so the real effect on alcohol may be considerably smaller.  This study dovetails nicely with an older study by DiNardo and Lemieux (2001), which found that raising the drinking age to 21 in the 1980s led to a decrease in self-reported alcohol use accompanied by an increase in self-reported cannabis use by high school seniors, though both effects were fairly small.  It also dovetails somewhat with the webmaster's own (albeit unscientific) observations of his peers' behavior in high school and especially college.

Further evidence for substitution effects can be found in another recent study by Anderson and Rees (2011).  This study found that legalization of medical cannabis was associated with a modest increase in self-reported cannabis use among young adults aged 18-25 (but not among people under 18) and a modest decrease in alcohol sales and consumption.  Even more notably, legalization of medical cannabis was associated with a 9% decrease in traffic fatailites, which was most likely a result of reduced alcohol consumption.  Also, the same DiNardo and Lemieux study mentioned before found that state-level decriminalization of cannabis was associated with a decrease in drinking among high school seniors, even though there was no corresponding increase in cannabis use (actually, both went down).  Interestingly, in contrast to the effects of the drinking age, higher beer taxes were found to reduce both alcohol and cannabis use.

So is this apparent substitution effect of the 21 drinking age a good thing or a bad thing?  While it is true that unadulterated cannabis is generally safer than alcohol by just about any objective measure of harmfulness, neither substance is absolutely safe for everyone, and most of the pro-21 crowd would probably not be very thrilled about an increase in cannabis use.    Furthermore, reporting bias may very well overstate the effects of the drinking age on alcohol (but not cannabis) use, and thus the net effect is uncertain.  Even though probability and frequency of drinking may be reduced somewhat by a 21 drinking age, the intensity of the clandestine drinking that remains may very well increase to more dangerous levels for a variety of reasons.  More ominously, though there have been no direct studies to our knowledge of the effects of the drinking age on hardcore drug (cocaine, heroin, methamphetamine, etc.) or prescription drug abuse among teens and young adults, it is nonetheless plausible that there may be some substitution of those more dangerous substances for alcohol as well.  After all, the crack epidemic of the late 1980s and early 1990s roughly coincided with the drinking age being raised to 21, and the more recent increase in prescription drug abuse coincided with increasingly tougher enforcement of the 21 drinking age.  And while the gateway drug theory is largely a bogus concept, as long as cannabis remains illegal, users will continue to expose themselves to dealers who may also be peddling more dangerous wares.

While Twenty-One Debunked does not take an explicit position on whether cannabis should be legalized, it should be noted that our parent organization, the True Spirit of America Party (TSAP), fully supports cannabis legalization for all adults 18 and over.  And Twenty-One Debunked believes that, if and when cannabis does become legal, the age limit should be 18 rather than 21, for many of the same reasons that we believe that the drinking age should be lowered to 18.

The Invisible Knapsack

Two decades ago, Wellesley College professor Peggy McIntosh coined the term "invisible knapsack" to refer to the subtle and not-so-subtle advantages that come with white privilege and male privilege resulting from inequality.  She describes such privilege as being "like an invisible weightless knapsack of special provisions, maps, passports, codebooks, visas, clothes, tools and blank checks".  The idea is that while we are generally taught that racism and sexism put some people (i.e. women and people of color) at a disadvantage, we are often taught to remain blissfully unaware of its corollary advantages that accrue to white males.  Hence, the "invisible knapsack" of privilege.

We at Twenty-One Debunked couldn't help but notice just how much this metaphor also relates to America's 21 drinking age and the "over-21 privilege" that results.  Being well over 21 myself, as the webmaster and founder of Twenty-One Debunked I have put together a list of advantages in the invisible knapsack of over-21 privilege that people like myself carry every day.  As a person over 21, as long as I have an ID to prove it:

1. I can buy alcoholic beverages at any store that sells them, in any quantity I wish.
2. I can enter pretty much any bar or nightclub of my choosing without fearing that people of my age group cannot get in or will be mistreated in the places I have chosen.
3. If I do not want to associate with people under 21, I may frequent numerous establishments that ban younger people from entering.
4. I am never asked to speak for all of the people in my age group, nor do I have to worry about my individual behavior reflecting on my entire age group.
5. I can legally host a drinking party with my friends, as long as all the guests are over 21.
6. I can join my co-workers for happy hour after work, and even talk about it at work, without any sort of shame.
7. When I go out with people under 21, it is generally understood that one (or more) of them will be the designated driver instead of me.
8. Generally speaking, I can drink alcoholic beverages fairly openly without having to worry about getting arrested, fined, jailed, expelled, having my driver's license revoked, or being publicly humiliated.
9. As long as I am not driving, I can legally get as drunk as I please in many states. 
10. Even in states where public drunkenness is technically illegal, the cops are unlikely to arrest me unless my behavior is really out of control.
11. If I get in alcohol-related trouble on campus, I will likely face lesser penalties, and I will not have to worry about my parents being notified without my consent.
12. If I think one of my peers may have alcohol poisoning, there would be no reason for me to hesitate to call 911 for fear of the law (and vice-versa).
13. I can have a drink or two (or maybe even three!) before driving without having to worry about being over the legal limit for DUI.
14. Even if I drive while over the limit, I can be assured that drunk drivers in my age group will NOT be the highest law enforcement priority.
15. If I choose to drive drunk, I can know that I am statistically more likely to kill someone under 21 than the other way around.
16. Even if I had several convictions for DUI or drunken violence, I can rest assured that I will still be allowed to buy and consume alcohol.
17. I enjoy less scrutiny over my own behavior, because I live in a society in which young people are scapegoated for adult problems.
18. I do not have to worry about being a good role model when it comes to drinking, since people under 21 can be punished (often severely) for emulating me.
19. Finally, I have a much better chance of being taken seriously on the issue of lowering the drinking age, without being accused of selfishness or immaturity.

And the list goes on.  As we see, the 21 drinking age is not just about disadvantaging people under 21, but giving unearned advantages to people over 21 as well.  And while some of these advantages are positive rights that should be extended to everyone (or at least all adults over 18), others are not "rights" at all, but wrongs that are an unfortunate byproduct of setting arbitrary age limits and of adultism in general.  Still others could be considered either rights or wrongs depending on the context.  And let's not forget the luxury of being able to ignore the issue entirely.

So, are the advantages found in this invisible knapsack really worth it?  Many people over 21 would say yes, but upon closer examination these advantages actually come at a hefty price, even for people over 21.  Just think about social host liability laws, other annoying ancillary laws, millions of tax dollars wasted on enforcement, loss of social cohesion, and precedent that can be used to make our supposedly free country even more of a police state.  In fact, the only people over 21 who, on balance, really benefit from the status quo are the ones who least deserve to benefit--those who drive drunk or otherwise behave irresponsibly when it comes to alcohol, as well as those parents who would rather stick their heads in the sand than teach their kids how to drink responsibly.

Do you hear that?  That's (hopefully) the sound of the pro-21 crowd throwing up all of the proverbial Kool-Aid they drank long ago.

2022 UPDATE:  Ten years after writing this, we felt the need to update this list to also include tobacco and cannabis well.  The smoking age for the former was raised to 21 in recent years, and all the states that legalized cannabis set the age limit at 21 as well.

Do Movies Drive Adolescents to Drink?

Just in time for the new movie Project X, a new study comes out that suggests that movies with scenes of alcohol consumption apparently leads to more "binge" drinking among teenagers.  The cross-sectional study, conducted in six European nations (Germany, Iceland, Italy, Netherlands, Poland, and Scotland) did in fact find a statistically significant correlation in five of the six countries, and the mainstream media are really eating it up.

However, correlation is not the same as causation.  Famous 18th century philosopher David Hume's criteria for causation requires three criteria:  1) association (correlation), 2) temporal precedence (which came first), and 3) isolation (from all potentially confounding variables).  While the first one was found, the second was not (a cross-sectional study can never determine temporality), and while the third one was attempted, it is very difficult to do in practice, especially with a single study.   So, even the authors concede that the study does not in itself prove causation due to the lack of data on temporal precedence, which really is the sine qua non of causation.  And while criterion #3 (isolation) is arguably a very stringent standard to apply, this study doesn't even meet many of the Bradford-Hill criteria favored by epidemologists.   So we have good reason to be skeptical of this study.

Due to the lack of data on temporality, reverse causation remains a plausible explanation (i.e. “binge” drinkers are more likely to prefer to watch movies about drinking and partying like Animal House, Van Wilder, Superbad, and the new Project X rather than the other way around). And there is always the possibility of residual confounding.  Interestingly, the study only looked at whether participants ever consumed 5 or more drinks in an evening, not whether they currently do or how often.  Also, one of the countries (Iceland) saw no significant association (in fact, it had the "wrong" sign) after adjustment for confounders.  But we at Twenty-One Debunked must point out even if the relationship is truly causal, it does not follow that censorship is the answer.   Better education about both alcohol AND media literacy seems to be a better solution for a country that is supposed to be a free society.

In the USA and Canada (neither were included in the study), we know that self-reported teen drinking and “binge” drinking (except perhaps for American college students) has significantly declined in the past decade or so in spite of the apparent increase in these types of movies.  In fact, high school drinking is at a record low in both countries as of 2011.  In a similar vein, teen pregnancy rates in the USA, though still the highest in the industrialized world, are also at a record low despite the fact that TV and movies today are by far the raunchiest in history.

Perhaps we should listen to the wisdom of sociologist Mike Males.

A Critique of Barnum et al. (2012)

A new study by Barnum et al. (2012) on drinking age law enforcement was recently published online this month.  In this first-of-its-kind study, using data from 1975-2006 they find that birth cohorts exposed to tougher enforcement of PAULA (possession of alcohol under the legal age) laws (as measured by underage drinking arrest rates) from ages 15-20 had modestly lower arrest rates for assault and vandalism between the ages of 15-24.  This remained true even when age effects, period effects, relative cohort size, and percentage of nonmarital births were controlled for.   But was it really a causal relationship?

While the authors appear to be convinced that this relationship is causal, we at Twenty-One Debunked note that there are plenty of reasons that this relationship could easily be spurious.  For example:

• Several other potentially important variables were not controlled for, including ones that may not have been captured by age and period effects.
• State-to-state variation was not explored at all.
• Arrest rates may have given biased estimates due to underreporting and changes in reporting rates and police practices over time, which can yield specious inferences.
• The strengths of the underage drinking laws themselves were not explored, only the enforcement of such laws as measured by arrest rates.
• Cohorts exposed to drinking ages of 18, 19, 20, and 21 were all lumped together, with no attempt to distinguish between them.
• No other crimes were explored besides assault and vandalism, and no distinction was made between types of assault (i.e. simple vs. aggravated).
• Allocating more resources towards arresting underage drinkers (and those who commit other victimless crimes) takes away from resources used to fight real crime, including assault and vandalism.  So, an increase in the former could lead to a spurious decrease in arrests for the latter in the absence of any real change in the latter.

Even if we accept the authors' conlcusions at face value, arresting underage drinkers does not appear to be a particularly cost-effective crime reduction strategy from a public safety standpoint.  The study reported that for every full unit increase in underage drinking arrests, there was only a 0.125 unit decrease in assault arrests and a 0.134 unit decrease in vandalism arrests.  Other sources note that on average, for every 1000 or so incidents of underage drinking, only one PAULA arrest occurs, making it a highly inefficent use of resources.  Law enforcement resources would thus be better spent actually targeting real crimes rather than victimless ones like underage drinking.

The example of San Francisco is highly instructive in this regard.  In 1990-1992, they were a crack-infested, gang-ridden hellhole.  By 2000, violent crime had plummeted by half (and even more so for juveniles), and by 2009 they became one of the safest big cities in America.  And how did they manage to do this?  Did they employ a "broken-windows," zero-tolerance approach to the most minor offenses, especially by young people?  Hardly!  In fact, beginning in 1992 (the city's peak year for violent crime), they stopped enforcing their youth curfew law (which was completely abolished in 1995), and since then they have actually cut back on arresting young people for "status" offenses (such as underage drinking) and cannabis possession, making such offenses the lowest priorities.  In other words, "don't sweat the small stuff."   Meanwhile, the police freed up more resources to tackle serious crime, and managed to build better relations with the community.  While the exact reasons for the drop in crime are not entirely clear, and several other cities nationwide saw similar improvements, it certainly casts doubt on the authors' thesis that cracking down on underage drinking reduces crime.

Interestingly, 'Frisco teens also show significantly lower rates of violence, "binge" drinking, driving after drinking, drinking in general, cannabis use, huffing, and crack/cocaine use compared with the national average according to the Youth Risk Behavior Survey.   Furthermore, the rates in San Francisco are comparable to or lower than those in NYC (and dropped at a similar or faster rate) despite the latter city's notoriously heavy-handed police tactics under Mayors Giuliani and Bloomberg.

Who Says Alcohol Education Doesn't Work?

Whenever the issue of lowering the drinking age comes up, proponents often feel compelled to fill the "void" by offering other policy solutions.   Aside from getting tougher on drunk driving (and drunk violence), the most common alternative touted is increased alcohol education.  Predictably, the opponents respond with claims that "education doesn't work" to actually change behavior or reduce alcohol-related harm.  And because it is nearly impossible to prove a negative, when pressed repeatedly they offer the caveat that there is simply "not enough evidence" either way to draw a firm conclusion about their effectiveness. 

Fortunately, nothing can be further from the truth.  The main reason why many alcohol "education" programs (especially school-based ones such as DARE) have tended to show little to no success is that they tend to be little more than a temperance lecture.   They typically fail to distinguish between use and abuse, and are often based on faulty assumptions.  In fact, many such programs are just plain disingenuous and often resort to exaggerated scare tactics.  Also, nearly every study of alcohol education programs looks only at short-term effects, and the absence of short-term effects does not imply the absence of longer-term benefits.  Some programs just need to be given more time to have their desired effects.

On the contrary, there ARE effective programs out there, ones that have been proven repeatedly to reduce dangerous drinking behaviors in both high school and college.  Some of them have even won awards for their effectiveness.  Examples of which include:

1)  The Hobart and William Smith Colleges' Alcohol Education Project, whose foundation is social norms marketing.  Devised by H. Wesley Perkins, it has been proven to reduce risky drinking behavior among college students in general, especially high-risk groups such as student athletes.   Immediate and persistent reductions in heavy drinking and its consequences were noted following implementation of this program.

2)  Web-based programs such as AlcoholEdu by Outside the Classroom.   Both the high school and college versions of the program have shown measurable benefits in reducing risky drinking behavior as well as changing students' attitudes about alcohol.  The user-friendly programs only take at most a few hours (typically two hours) to complete, and show immediate and often persistent effects despite the very short length of the programs. 

So why doesn't every high school and college utilize programs such as these?  One reason could be that some neoprohibitionists continue to denounce them as ineffective, though such claims are dubious at best.  Another reason is resistance to change, which can be observed in several other aspects of life as well.  But whatever the reason, it is simply false to claim that "education doesn't work".  Because it does--as long as it is conducted properly.  And our children--that is, our future--deserve nothing less.

On the other side of the pond, British social anthropologist Kate Fox has an even more controversial view of why many traditional alcohol education programs have had such meager success.  That is, exaggerating the "disinhibitory" effects of alcohol may actually promote alcohol-related misbehavior, and make alcohol seem more exciting and interesting to young people than it actually is.  Perhaps she is right.

The Twenty-One Debunked Creed

It has recently occured to us that, despite the fact that Twenty-One Debunked has existed for nearly two years, we have had yet to post an explicit and concise statement of what it is we actually believe aside from our relatively vague-sounding call to lower the drinking age to 18.  Ergo, here it is, the Twenty-One Debunked Creed:

We believe that 18-20 year olds are adults, not children, and should have the same rights and responsibilities that people over 21 currently enjoy, whether it involves alcohol or otherwise.

We believe that all adults over 18 are sovereign in body and mind, and that the onus is on the state to show that this is not true for a particular individual.  We believe it is wrong to punish all for the actions of the few.

We believe that consumption of alcoholic beverages by consenting adults age 18-20, in and of itself, is a victimless crime and is not sufficiently different from the same by adults over 21 to justify its prohibition.

We are 100% against driving under the influence of alcohol at ANY age, or any other acts that actually harm others (or create a definite and significant risk of harm to others), and believe there is absolutely no excuse for doing so.  We support tougher penalties and enforcement for those who drive or operate machinery while impaired, as well as those who commit acts of violence or other crimes while under the influence.  Alcohol-related misbehavior is a conscious choice and should be treated as such.

As much as we are fighting for the right to drink, we will fight twice as hard for the right NOT to drink, as well as the right to not be harmed by irresponsible drinkers of ANY age.

We believe that the United States of America was intended to be a free country, and those who can't handle living in a free society should take advantage of the best freedom we have to offer--the freedom to leave.

And that's the basic creed, in a nutshell.   It has much in common with the philosopher John Stuart Mill's essay On Liberty.  That is:

The only part of the conduct of any one, for which he is amenable to society, is that which concerns others. In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign.

But what about the children, you ask?   Again, we defer to Mill's wisdom:

It is, perhaps, hardly necessary to say that this doctrine is meant to apply only to human beings in the maturity of their faculties. We are not speaking of children, or of young persons below the age which the law may fix as that of manhood or womanhood. Those who are still in a state to require being taken care of by others, must be protected against their own actions as well as against external injury.

And generally speaking, the age of majority (adulthood) is currently 18 in the USA.  While we do not take a position on whether the drinking age should at some point in the future be made even lower than 18 (e.g. 16 like in some European nations), we currently do not believe that it is a worthwhile goal at the present time.   If and when the drinking age is lowered to 18, we support all reasonable efforts to enforce the new drinking age, but even so we do not support the use of harsh criminal penalties on the underage drinkers themselves.   Nor do we support any sort of social host laws that punish those who simply allow underage drinking on their private property without physically furnishing the alcohol.  Also, we believe that parents should be allowed to give alcohol to their own under-18 children (within reason).

What about those compromises we have mentioned or alluded to in other posts about zero tolerance laws and other alcohol restrictions on 18-20 year olds?  Actually, those are primarily based on pragmatism more than anything else.  For zero-tolerance DUI laws, we support keeping the status quo (age limit of 21) for now as any attempt to lower the drinking age would be certain to fail if that was changed as well.  However, we support reducing the penalties for very low BAC drivers (i.e. below 0.05) while at the same time dramatically raising them on higher BAC drivers of any age (see previous post).  The fact that driving after one drink is punished the same as ten drinks for drivers under 21 in some states is just plain ludicrous.   And while Twenty-One Debunked ideally wants the drinking age lowered to 18 across the board, we feel that another reasonable compromise would be to keep the purchase age at 20 or 21 for kegs, cases, or any other large bulk quantities of alcohol while otherwise lowering it to 18.   That should alleviate any hyped-up fears of increased high-school keggers, while still allowing 18-20 year olds to buy their own six-packs and go to bars.  But we will not make any other compromises, period.  And unlike Choose Responsibility, we do NOT support the idea of requiring a drinking license for 18-20 year olds.  If you're old enough to go to war, you're old enough to go to the bar.  'Nuff said.

A New List of 39 Recommendations (Updated)

In 1982, President Reagan appointed a special commission to study the problem of drunk driving in America. They came up with 39 recommendations, #8 of which was to raise the drinking age to 21 in all 50 states. Of all the recommendations, that was the one that got the most attention, often at the expense of the others. Most of the other 38 were just simple common sense measures, and many of these were implemented to some extent in both the United States and Canada. Interestingly, the decline in alcohol-related traffic fatalities since 1982 occurred at about the same rate in both countries, with no evidence of divergence in the expected direction despite the fact that Canada did not raise the drinking age to 21. In fact, the decline was slightly faster in Canada (ditto for the UK and Australia as well, who remained at 18).  And fatalities declined in all age groups, not just those under 21.  While the problem of drunk driving has been greatly reduced in both the US and Canada, it remains persistent.  We still hear all too often about innocent people killed by drunk drivers who already have multiple DUIs on their record, in addition to countless others who simply weren't caught until it was too late.

More than a quarter-century later, a new set of 39 recommendations is long overdue. We know a lot more about the problem now than we did in 1982, and have a better sense of what works in the long run and what does not. The nature of the problem has also changed, with most of the deaths caused by so-called "hardcore" DUI offenders who drive drunk repeatedly.  By the time someone finally gets caught even once, they had already driven drunk an average of 88 times--often hundreds of times.  And it's an open secret that the vast majority (nearly 9 out of 10) of them are over 21, with 21-24 year olds being the worst offenders of all.  Thus a multifaceted and wholehearted approach is essential. But what is currently being done is both over-inclusive and under-inclusive, and progress has stalled until very recently.  And as long as we keep following outdated methods, we will surely fail to see any further progress in the future.  The updated list, devised by Twenty-One Debunked, is as follows, with those in red being the highest priorities:

1. Lower the drinking age to 18, ideally in all 50 states and DC. The more states, the better.
2. Raise and equalize all of the federal alcohol taxes to the 1991 real value of the liquor tax. That would be $21.33/proof-gallon for all beverages, proportional to alcohol content.   Use the bulk of the revenue for education, treatment, and DUI enforcement.
3. Lower the blood alcohol limit to 0.05 BAC for administrative penalties, while keep the BAC limit 0.08 for criminal penalties, as some Canadian provinces have done.   Maintain a Zero Tolerance law (0.02 BAC) for drivers under 21 and/or all drivers with less than 3-5 years of licensed driving. 
4. Increase the number of roving patrols and sobriety checkpoints for DUI enforcement, and their publicity.  Checkpoints should be considered a supplement to patrols, not a substitute.
5. Increase alcohol education programs, but make them more honest and comprehensive. An excellent model is AlcoholEdu, by Outside the Classroom. This can also be combined with social norms marketing campaigns.
6. Toughen the penalties for driving under the influence, with graduated penalties based on BAC.  See the chart below. 
7. Make fines for DUI proportional to the relative risk at a particular BAC. For example, 0.15 would be 50-100 times higher than 0.05. 
8. Restrict alcohol advertising to no more than what is currently allowed for tobacco. That means no TV, radio, or billboards.
9. Increase alcohol treatment. Require all DUI offenders to undergo an alcohol assesment to determine if they have an alcohol use disorder. If so, force them into treatment via DUI court and monitor them electronically with a SCRAM bracelet, in addition to other penalties.
10. Use fines and fees from offenders to pay for enforcement of DUI laws, to make the program completely self-sustaining.
11. For the eight states that currently lack it, institute administrative license suspension/revocation. The administrative penalty for refusing a breathalyzer or any other test should be greater than or equal to that for failing it.
12. Have mandatory jail time for all DUI offenses of 0.08 or greater, including first offenses. Make driving with 0.15 BAC or higher a felony on the first offense, and 0.08 or higher a felony on the second offense, punishable by up to 5 years in prison.
13. Those who kill or seriously injure someone else in an alcohol-related, at-fault crash should get a mandatory minimum of 10 years in prison, permanent license revocation, and forfeiture of any and all vehicles owned by that person upon conviction.
14. Do not allow plea bargains for any DUI offense.
15. For anyone convicted of drunk driving, drunk violence, or repeated drunk and disorderly conduct, blacklist them from buying alcohol or even entering a bar for at least a year or until age 21, whichever is longer.  Do the same for anyone furnishing alcohol to anyone under 18 that is not one's own child.
16. De-register any car owned (or registered) by a DUI offender, boot it, and confiscate the plates upon arrest.  Or better yet, impound the vehicle at the offender's expense.  When (if) they get their license back, or get a conditional license, give them special "scarlet letter" DUI plates. 
17. Require ignition interlocks for all conditional licenses, and for any DUI offender that gets their license back, forever.
18. Make ignition interlocks standard on all newly manufactured vehicles sold in the USA, with use and maintenance of these devices voluntary for non-offenders.
19. Abolish the "assigned risk" pools for auto insurance, or at least forbid any DUI offenders from joining them.
20. Repeal all "alcohol exclusion" laws for insurance, which have been shown to do more harm than good.
21. Make it a federal crime to drive drunk across state lines.  Punishable by a mandatory 5 years hard labor in federal prison.
22. Eliminate any rules of evidence that prohibit admission of chemical test refusals--it should be used against a DUI defendant in court.
23. Make the road test tougher--an hour long like it is in the UK.
24. Make licenses easier to lose for moving violations, especially during the first two years.
25. Bring back free driver's ed classes for all high school and college students.
26. Require all drivers involved in fatal accidents to be tested for alcohol and drugs.
27. Lift state-mandated smoking bans in bars, which have been shown to increase DUI fatalities.
28. Extend bar hours to 3 am or later, but have a one-way door policy after 1 or 2 to reduce late night bar-hopping. Or let the locals decide rather than the state.
29. Raise the gas tax by a penny each week until it is $1.00 higher than it currently is.  Call it "a penny for progress."
30. Improve public transportation, especially very late at night. Use the alcohol and gas taxes to pay for it.
31. Lift any cap on the number of taxicabs wherever it exists, or better yet, subsidize taxi service to reduce the costs.
32. Encourage the hospitality industry to set up "safe rider" programs, particularly in rural areas.
33. Limit or reduce alcohol outlet density in cities and other high-density areas, but increase it in rural areas. More rural bars within walking distance = less drunk driving deaths.
34. Dry counties and towns should go wet, especially if their neighbors are wet.
35. Abolish all social host laws, both civil and criminal. Furnishing alcohol to minors should not include merely providing a safer location to drink.
36. Put a price floor on alcoholic beverages, especially for off-premises sales.
37. Kegs and cases of beer should be sold only in beer distributors, which should close at 10 pm. A purchase age limit higher than 18 may be desirable for such bulk quantities, which are very unlikely to be for personal use. Ditto for very large quantities (i.e. multiple liters) of hard liquor.
38. Increase media campaigns against drunk driving, similar to the Australian model.
39. Last but not least, park a police car in front of every bar possible to watch for drunks getting into their cars about to drive.  Then nail them.  It would be like shooting fish in a barrel.

Recomendation #1 implies that, at the very least, we should repeal the federal highway funding penalty for doing so, and let the states use their Constitutional rights to decide for themselves. Recommendations #3, #4, and especially #21 should take care of any potential adverse effects of unequal drinking ages across states or internationally, as well as dry counties that refuse to go wet.

To avoid collateral damage, recommendation #2 should not apply to microbrewers. Their beer is already relatively expensive anyway, and those who abuse alcohol tend to go for the mass-produced, cheap stuff.

If all 39 of these recommendations were followed, the alcohol-related fatality rates should be cut by at least half in the first year alone. If only the ones in red were followed, or even just the first six, there would still be a dramatic drop in fatalities in both the short and long term. Some of them, such as #1, are a bit counterintuitive (the whole purpose of this blog explains in detail why #1 is actually a good thing rather than something to fear).

When we say graduated penalties, the table below is a good guide to what they should be:

BAC Threshold	First offense	Subsequent offenses within 10 years
0.02-0.08 (under 21 or novice, administrative only)	$250 fine ($500 if over 0.05) 30 day suspension (90 day if over 0.05) 3 day impoundment	$500 fine 6 month suspension (2nd), 1 year revocation or until 21 (3rd or 2nd over 0.05) 7 day impoundment Ignition interlock 1 year or until 21
0.05-0.08 (administrative only)	$500 fine 3 day suspension 3 day impoundment	$750 fine (2nd), $1000 (3rd) 30 day suspension (2nd), 1 year revocation (3rd) 7 day impoundment (2nd), 30 day impoundment (3rd) Ignition interlock 1+ year
0.08-0.10 (criminal)	$1000 fine Minimum 1 year revocation (or until 21, whatever is longer) Mandatory 30 days in jail, up to 6 months Ignition interlock 5+ years after re-license	$2500 fine License revoked for at least 10 years (forever for 3rd offense) Mandatory 1+ year in jail (possible felony) Possible vehicle forfeiture upon conviction
0.10-0.15 (criminal)	$5000 fine Minimum 5 year revocation Mandatory 6 months jail, up to 1 year Ignition interlock forever	$7500 fine License revoked forever Mandatory 5 years prison (felony) Vehicle forfeiture upon conviction
0.15+ (felony)	$10,000 fine Minimum 10 year revocation Mandatory 1 year in prison, up to 5 years Ignition interlock forever	$20,000 fine License revoked forever Mandatory 5+ years prison (felony) Vehicle forfeiture upon conviction

In addition to (and independently of) criminal penalties, those who blow above 0.08 or refuse the test should be given the following immediate adminstrative penalties upon arrest:

Test failure, first offense:  90 day suspension, 7 day impoundment
Test failure, second offense in 5 years: 1 year suspension, 30 day impoundment
Test refusal, any offense:  1 year suspension, 30 day impoundment 

Conditional licenses should only be given for grave reasons, be highly restricted, and require ignition interlocks.

All offenses would require completion of an alcohol education program and alcohol abuse screening, paid for by the offender. 

Driving with a  BAC above 0.08 with kids under 16 in the car should be an automatic felony, and treated like 0.15+.

In other words, though we've clearly wrestled the problem to the ground, we have unfortunately allowed ourselves to become complacent and distracted.  It's time to finish the job.

Common Sense in Alberta, Canada

The Canadian province of Alberta (just north of Montana) has had a legal drinking age of 18 since 1970, when it was first lowered from 21 along with the age of majority.  Recently, a few police chiefs have been talking about wanting to raise the drinking age to 19, which it currently is in most other provinces except for Manitoba and Quebec.  They claim it would reduce binge drinking, drunk driving, and other alcohol-related problems among young people.  However, the current Tory government of the province doesn't buy that line of reasoning, and states that they have no intention to raise the drinking age.   Premier Alison Redford says that the move is "off the table", and we at Twenty-One Debunked couldn't agree more.

Instead, the provincial government is moving forward with plans to toughen up their DUI laws and make them similar to the successful model found in their neighboring province, British Columbia.  A previous post discusses the BC success story in more detail.