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One too many: alcohol and risk of injury
  1. Frederick P Rivara, Chair, ISCAIP
  1. Harborview Injury Prevention and Research Center, Box 359960, 325 Ninth Ave, Seattle, WA 98104, USA (Tel: +1 206 521 1530, fax: +1 206 521 1562, e-mail: fpr{at}

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    Working in a trauma center in Seattle, I am often confronted by the problem of alcohol and its role in injury. As many as 45% of our adult trauma patients are intoxicated at the time of their injury, and at least one half of these have chronic alcohol abuse or dependency.1 Attention to the impact of alcohol on injuries to children and adolescents has to date been very limited. I believe it is a problem that our Society and this Journal should not ignore.

    Children and adolescents are placed at risk of injuries in a number of ways. First, adults with problem drinking place children in their care at increased risk of injury. Bijur and her colleagues, using data from the US National Health Interview Survey, found that children of mothers classified as problem drinkers had more than twice the risk of injury than children of mothers who were non-drinkers.2 This risk of injury was increased to nearly threefold when mothers with problem drinking were married to men who were moderate or heavy drinkers. Children under the age of 5 are the group at greatest risk of death in house fires; this risk is doubled when the adults in the household are impaired by alcohol at the time of the fire.3 The Centers for Disease Control has recently demonstrated that one quarter of children who die in motor vehicle crashes in the US are due to cars driven by an intoxicated driver.4

    Alcohol also plays a part in the injuries of adolescents. The proportion of adolescents who are found to be intoxicated at the time of injury has been reported in various studies to be one fifth of motor vehicle drivers,5 one fifth to one third of self inflicted injuries,6, 7 one half of assaults,7 and 70% of those with gunshot wounds.8 A recent Canadian study in this journal reported that alcohol intoxication increased the risk of fatal injury fivefold among teen drivers involved in motor vehicle crashes.9 The risk taking behavior evident by drinking and driving not surprisingly extends to seat belt use; Spain and colleagues found that only 7% of intoxicated adolescents involved in motor vehicle crashes were restrained.5

    The problem of alcohol and trauma, in my view, has not generated the type of response it deserves. During the 1970s and 1980s, much of the focus of injury control was on “passive prevention”, with an emphasis on changing the environment and product to decrease the risk of injury. Problem drinking is clearly a behavioral issue, which requires much more complicated solutions. What should be our response, as professionals responsible for the prevention of injuries to children and adolescents? Here are some suggestions.

    • Better understand the magnitude of the problem—Only a few studies have examined the extent to which children have been the innocent victims of problem drinking by caretaking adults.2, 3 Further studies should be undertaken to understand the frequency and epidemiology of the problem. In many countries, routine blood alcohol testing of injury patients is not done, because “alcohol is not a problem”. It is hard to know whether it is a problem without routine testing of all adolescents and adults.

    • Identify alcohol problems—Many screening instruments are available to identify adults who are at risk of alcohol abuse and dependency.10 These should be applied in a far more routine fashion when alcohol problems may exist. Unfortunately most of these have only been developed for adults; appropriate screening tools for adolescents are needed.

    • Brief interventions for problem drinkers—The World Health Organization strongly supports the use of brief interventions for problem drinkers.11 These 15–30 minute interventions have been shown to be remarkably successful in reducing alcohol consumption by problem drinkers.12 They should be viewed as injury prevention tools; a recent randomized controlled trial conducted at our trauma center indicates that brief interventions can decrease repeat episodes of trauma by 50%.

    • Advocate for effective legislative strategies—There are a number of studies that clearly are effective in decreasing the risk of drunk-driving. These include random breath tests, whereby police stop motorists at checkpoints and administer breath alcohol tests; administrative revocation of licenses, which insures swift and immediate punishment; lower blood alcohol concentration limits for teens; and raised drinking ages (now 21 across the US). In our communities, we should act as advocates for the implementation of these effective laws.

    Some readers may feel that this editorial is not appropriate for Injury Prevention. If we are truly dedicated to decreasing morbidity and mortality from injuries to children and adolescents, I believe we cannot fail to study, understand, and intervene on one of the most important direct causes of injuries to individuals in this age group in most parts of the world.