Prevention trial in the Cherokee Nation: design of a randomized community trial.

Despite advances in prevention science and practice in recent decades, the U.S. continues to struggle with significant alcohol-related risks and consequences among youth, especially among vulnerable rural and Native American youth. The Prevention Trial in the Cherokee Nation is a partnership between prevention scientists and Cherokee Nation Behavioral Health to create, implement, and evaluate a new, integrated community-level intervention designed to prevent underage drinking and associated negative consequences among Native American and other youth living in rural high-risk underserved communities. The intervention builds directly on results of multiple previous trials of two conceptually distinct approaches. The first is an updated version of CMCA, an established community environmental change intervention, and the second is CONNECT, our newly developed population-wide intervention based on screening, brief intervention, and referral to treatment (SBIRT) research. CMCA direct-action community organizing is used to engage local citizens to address community norms and practices related to alcohol use and commercial and social access to alcohol among adolescents. The new CONNECT intervention expands traditional SBIRT to be implemented universally within schools. Six key research design elements optimize causal inference and experimental evaluation of intervention effects, including a controlled interrupted time-series design, purposive selection of towns, random assignment to study condition, nested cohorts as well as repeated cross-sectional observations, a factorial design crossing two conceptually distinct interventions, and multiple comparison groups. The purpose of this paper is to describe the strong partnership between prevention scientists and behavioral health leaders within the Cherokee Nation, and the intervention and research design of this new community trial.

Beyond the clinic: improving child health through evidence-based community development.

BACKGROUND: Promoting child wellbeing necessarily goes beyond the clinic as risks to child health and development are embedded in the social and physical environmental conditions in which children live. Pediatricians play a vital role in promoting the health of children in the communities they serve and can maximize their impact by advocating for and supporting efficacious, evidence-based strategies in their communities. METHODS: To provide a succinct guide for community pediatric efforts to advance the wellbeing of all children and particularly disadvantaged children in a community, we conducted a theory-driven and structured narrative review to synthesize published systematic and meta-analytic reviews of policy-relevant, local-level strategies addressing potent and malleable influences on child health and development. An exhaustive list of policy-relevant, local-level strategies for improving child health was used to conduct a comprehensive search of recent (1990-2012), English language peer-reviewed published meta-analyses and systematic reviews in the 10 core databases of scientific literature. Our review of the literature encompassed six key conceptual domains of intervention foci, including distal influences of child health (i.e., income and resources, social cohesion, and physical environment) and proximal influences (i.e., family, school and peer). We examined intervention effects on four key domains of child health and development: cognitive development, social and emotional competence, psychological and behavioral wellbeing, and physical health. RESULTS: Published reviews were identified for 98 distinct policy-relevant community interventions, evaluated across 288 outcomes. We classified 46 strategies as meeting scientific criteria for efficacy by having consistent, positive outcomes from high-quality trials (e.g., tenant-based rental assistance, neighborhood watch programs, urban design and land use policies, access to quality childcare services, class size reductions, after-school programs that promote personal/social skills). Another 21 strategies were classified as having consistent evidence of positive outcomes from high-quality observational studies only, while 28 strategies had insufficient evidence available to assess their effectiveness based on published reviews. We did not limit the review to studies conducted in the United States, but the vast majority of them were U.S.-based, and the results therefore are most applicable to the U.S. context. CONCLUSIONS: Based on our synthesis of published literature on community development strategies, we provide an illustration combining a comprehensive set of evidence-based strategies to promote child health and development across a wide-range of child health outcomes.

Perceived racial/ethnic discrimination, problem behaviors, and mental health among minority urban youth.

OBJECTIVES: We examined perceived frequency and intensity of racial/ethnic discrimination and associations with high-risk behaviors/conditions among adolescents. DESIGN: With surveys from 2490 racial/ethnic minority adolescents primarily with low socioeconomic status, we used regression analysis to examine associations between racial/ethnic discrimination and behavioral health outcomes (alcohol use, marijuana use, physical aggression, delinquency, victimization, depression, suicidal ideation, and sexual behaviors). RESULTS: Most adolescents (73%) experienced racial/ethnic discrimination and 42% of experiences were 'somewhat-' or 'very disturbing.' Adolescents reporting frequent and disturbing racial/ethnic discrimination were at increased risk of all measured behaviors, except alcohol and marijuana use. Adolescents who experienced any racial/ethnic discrimination were at increased risk for victimization and depression. Regardless of intensity, adolescents who experienced racial/ethnic discrimination at least occasionally were more likely to report greater physical aggression, delinquency, suicidal ideation, younger age at first oral sex, unprotected sex during last intercourse, and more lifetime sexual partners. CONCLUSION: Most adolescents had experienced racial/ethnic discrimination due to their race/ethnicity. Even occasional experiences of racial/ethnic discrimination likely contribute to maladaptive behavioral and mental health outcomes among adolescents. Prevention and coping strategies are important targets for intervention.

Racial/ethnic differences in the etiology of alcohol use among urban adolescents.

OBJECTIVE: We examined relations between neighborhood context, home and family management practices, deviant peer affiliations, beliefs favorable to use, and alcohol use among urban African American and Hispanic adolescents. METHOD: The sample comprised 4,027 African American and Hispanic adolescents who were 50% boys and 75% low income. Participants completed surveys in 2002-2005 and 2008-2009. Structural equation modeling assessed direct and indirect relations between neighborhood context in 6th grade, home and family management practices in 7th grade, deviant peer affiliations and beliefs favorable to use in 8th grade, and alcohol use in 12th grade. RESULTS: There was significant variation in structural models across race/ethnicity but not gender. Differences included the influence of neighborhood and school strength and, where similarities existed, differences in effect magnitude. Similarities included significant correlations among measurement components; the indirect influence of alcohol advertisement exposure, gender, area deprivation, and home alcohol access on alcohol use; direct influence of deviant peer affiliations and beliefs favorable to use on alcohol use; and indirect effects highlighting the importance of preventing home alcohol access, deviant peer affiliations, and beliefs favorable to use and promoting protective family management practices. CONCLUSIONS: Neighborhood and school strength may be particularly important in preventing alcohol use among African Americans, whereas preventing early onset of alcohol use among Hispanics remains important. Preventive efforts may wish to focus on neighborhood deprivation, exposure to alcohol advertisements, and home risks and protective factors because they have direct and indirect effects on intrapersonal factors and alcohol use.

Preventing the link between SES and high-risk behaviors: "value-added" education, drug use and delinquency in high-risk, urban schools.

We examined whether schools achieving better than expected educational outcomes for their students influence the risk of drug use and delinquency among urban, racial/ethnic minority youth. Adolescents (n = 2,621), who were primarily African American and Hispanic and enrolled in Chicago public schools (n = 61), completed surveys in 6th (aged 12) and 8th (aged 14) grades. Value-added education was derived from standardized residuals of regression equations predicting school-level academic achievement and attendance from students' sociodemographic profiles and defined as having higher academic achievement and attendance than that expected given the sociodemographic profile of the schools' student composition. Multilevel logistic regression estimated the effects of value-added education on students' drug use and delinquency. After considering initial risk behavior, value-added education was associated with lower incidence of alcohol, cigarette and marijuana use; stealing; and participating in a group-against-group fight. Significant beneficial effects of value-added education remained for cigarette and marijuana use, stealing and participating in a group-against-group fight after adjustment for individual- and school-level covariates. Alcohol use (past month and heavy episodic) showed marginally significant trends in the hypothesized direction after these adjustments. Inner-city schools may break the links between social disadvantage, drug use and delinquency. Identifying the processes related to value-added education in order to improve school environments is warranted given the high costs associated with individual-level interventions.

Contemporary options for longitudinal follow-up: lessons learned from a cohort of urban adolescents.

This study reports efforts to locate and survey participants in Project Northland Chicago (PNC), a longitudinal, group-randomized trial of an alcohol preventive intervention for racial/ethnic minority, urban, early-adolescents, 3-4 years following the end of the intervention. Data were collected annually among students from 6th-8th grade and then at age 17-18. Tracking procedures were used to maintain contact with participants and data collection consisted of three phases: (1) Internet- and mail-based surveys; (2) in-school survey administration; and (3) courier service delivery. Contact was lost with 11% of this urban cohort from the end of the PNC intervention activities through these longterm follow-up efforts, as indicated by returned locating postcards. Fifty-three percent of the cohort responded to the survey, the majority completing in Phase 1 of our data collection. Additional school-based and courier-delivery efforts increased our response rate by 11.5%. Costs per completed survey were $118 in Phase 1, $166 in Phase 2, and $440 in Phase 3. This study illustrates that it is possible to track and follow-up a high-risk cohort as they progress through adolescence, even with minimal efforts in intervening years. Lessons learned from this study may inform future efforts to track and collect longitudinal data among high-risk populations.

Riskier sexual partners contribute to the increased rate of sexually transmitted diseases among youth with substance use disorders.

BACKGROUND: Youth with alcohol or marijuana dependence or disorders (substance use disorders [SUDs]) are at increased risk of acquiring sexually transmitted diseases (STDs). Sexual partner characteristics may explain the relationship between SUD and STD. METHODS: Clinical criteria for SUD, clinical STD diagnosis, and sexual partner characteristics were assessed among 15- to 24-year-old STD clinic attendees between 1999 and 2002 (n = 412). We used exact logistic regression and path analysis to examine the mediation effect of sexual partner characteristics (age discordance, incarceration, STD diagnosis, other partners, perceived alcohol problem, perceived marijuana problem, and a calculated composite measure) on the relationship between SUD and STD, adjusting for important demographics and condom use. RESULTS: We found evidence of mediation by partner characteristics on the relationship between SUD and STD. For the logistic regression analysis, adding the partner characteristic composite reduced the strength of the association between SUD and STD from a statistically significant odds ratio of 1.7 (95% confidence interval = 1.0-2.7) to a statistically nonsignificant odds ratio of 1.5 (95% confidence interval = 0.9-2.5). In the path analysis, adding the partner characteristic composite reduced the significant direct effect of SUD on STD (ß = 0.5, P = 0.04) to statistically nonsignificant effect (ß = 0.1, P = 0.2). We estimated that 31% of the total effect of SUD on STD was attributable to the indirect path through the composite partner characteristic measure. CONCLUSIONS: Even when controlling for demographics and condom use, partner characteristics partially explained the association between SUD and STD.

Trajectories of Physical Aggression Among Hispanic Urban Adolescents and Young Adults: An Application of Latent Trajectory Modeling from Ages 12 to 18.

This study sought to identify trajectories of physical aggression among urban Hispanic youth, and to examine the effects of risk and protective factors at age 11 on trajectories of physical aggression over time (ages 12-18). Relying on data from 731 urban Hispanic adolescents from Project Northland Chicago (PNC), latent trajectory modeling was used to determine the number of trajectories, and multinomial logistic regression was used to identify the predictors associated with trajectory membership. The results suggested five trajectories of physical aggression (non-aggressive, low stable, escalators, early-rapid desistors, and high aggression/moderate desistors). After adjusting for several risk and protective factors, language preference (e.g. speaking Spanish at home) was identified as a protective factor, while indirect exposure to alcohol, sadness/depression, fewer negative alcohol-related attitudes, and threatening to fight were associated with increased risk for physical aggression. Study implications indicate that early, multilevel prevention efforts are necessary to deter the initiation and promote the desistance of physical aggression over time among urban Hispanic adolescents.

Effects of alcohol tax and price policies on morbidity and mortality: a systematic review.

OBJECTIVES: We systematically reviewed the effects of alcohol taxes and prices on alcohol-related morbidity and mortality to assess their public health impact. METHODS: We searched 12 databases, along with articles' reference lists, for studies providing estimates of the relationship between alcohol taxes and prices and measures of risky behavior or morbidity and mortality, then coded for effect sizes and numerous population and study characteristics. We combined independent estimates in random-effects models to obtain aggregate effect estimates. RESULTS: We identified 50 articles, containing 340 estimates. Meta-estimates were r = -0.347 for alcohol-related disease and injury outcomes, -0.022 for violence, -0.048 for suicide, -0.112 for traffic crash outcomes, -0.055 for sexually transmitted diseases, -0.022 for other drug use, and -0.014 for crime and other misbehavior measures. All except suicide were statistically significant. CONCLUSIONS: Public policies affecting the price of alcoholic beverages have significant effects on alcohol-related disease and injury rates. Our results suggest that doubling the alcohol tax would reduce alcohol-related mortality by an average of 35%, traffic crash deaths by 11%, sexually transmitted disease by 6%, violence by 2%, and crime by 1.4%.

Trajectories or parental monitoring and communication and effects on drug use among urban young adolescents.

PURPOSE: Identify the number and characteristics of heterogeneous trajectories of parental monitoring and communication among a sample of urban, racial/ethnic minority youth and examine the effects of these patterns on alcohol, cigarette and marijuana use. METHODS: The study sample (n=2,621) was predominantly African American or Hispanic (38% and 32%, respectively) and low-income (67% received free, or reduced price, lunch). They completed classroom-based surveys when in 6th-8th grades. Multilevel general growth mixture modeling was used to identify the heterogeneous trajectories of parental monitoring and communication and estimate the effects of these distinct patterns on drug use in 8th grade. RESULTS: Four trajectories of parental monitoring and communication were identified: (1) High (76.4%), (2) Medium (9.1%), (3) Decreasing (6.0%) and (4) Inconsistent (8.5%). Relative to those with high monitoring/communication, youth in the decreasing and inconsistent trajectories were at significantly greater risk for past year and past month alcohol and marijuana use and having ever smoked a cigarette. After controlling for family composition, only youth in the decreasing trajectory were significantly more likely to report substance use in 8th grade. CONCLUSIONS: Findings support the role of parents in preventing drug use during early adolescence and suggest that efforts to improve the level and consistency of parental monitoring and communication may be a fruitful target for prevention. Many youth initiate use of alcohol, tobacco or marijuana in this critical developmental period and considered with the health and social consequences of use, engaging parents in preventing drug use should remain a priority for prevention.

Effects of alcohol use initiation patterns on high-risk behaviors among urban, low-income, young adolescents.

This study examined associations between patterns of alcohol use initiation and progression from age 12 to 14 years and recent cigarette and marijuana use, and violent and delinquent behavior at age 14. The study sample (n = 2,193) was predominantly African American or Hispanic (43% and 37%, respectively) and low-income (68% receiving free, or reduced price, lunch). They completed classroom-based surveys when in 6th-8th grades. Multilevel latent class analyses were used to identify the heterogeneous alcohol use trajectories. Linear and logistic mixed-effects regression was then used to examine the association between these patterns and high-risk behaviors in 8th grade. Five alcohol use trajectories were identified: (1) No Use (63.3%), (2) Onset of Consistently Infrequent Use at Age <12 (13.3%), (3) Onset of Monthly Use at Age 14 (9.9%), (4) Onset of Monthly Use at Age 13 to Heavy Use at Age 14 (6.6%), and (5) Onset of Consistently Heavy Use at Age 12 (6.9%). Relative to non-users, membership in any of the alcohol use trajectory classes was significantly associated with greater past month cigarette and marijuana use, as well as violent behaviors in 8th grade. Higher levels of delinquent behaviors were significantly associated with membership in all but one of the alcohol use trajectory classes relative to the "no use" class. Results suggest that any use of alcohol in early adolescence is associated with other high-risk behaviors and support the critical need for efforts to prevent early initiation and progression of alcohol use among youth as a key component to prevent future high-risk behaviors.

Effects of beverage-specific alcohol consumption on drinking behaviors among urban youth.

Alcoholic beverage consumption among high school students has shifted from beer to liquor. The current longitudinal study examined the effects of beverage-specific alcohol use on drinking behaviors among urban youth. Data included 731 adolescents who participated in Project Northland Chicago and reported consuming alcohol in 7th grade. Logistic regression tested the effects of beverage-specific use on consequences (e.g., alcohol use in the past month, week, heavy drinking, and ever drunkenness). Compared to wine users, adolescents who reported drinking hard liquor during their last drinking occasion had increased odds of alcohol use during the past month (OR = 1.44; 95% CI = 1.01-2.05), past week (OR = 3.37; 95% CI = 1.39-8.18), and ever drunkenness (OR = 1.56; 95% CI = 1.07-2.29). Use of hard liquor was associated with increased risk of alcohol-related consequences. Early selection of certain alcoholic beverages (e.g., hard liquor) may result in negative health outcomes and problematic alcohol use over time.

Assessing the victim-offender overlap among Puerto Rican youth.

PURPOSE: Knowledge about offenders and knowledge about victims has traditionally been undertaken without formal consideration of the overlap among the two. A small but growing research agenda has examined the extent of this overlap. At the same time, there has been a minimal amount of research regarding offending and victimization among minority youth, and this is most apparent with respect to Hispanics, who have been increasing in population in the United States. MATERIALS & METHODS: This study explores the joint, longitudinal overlap between offending and victimization among a sample of Puerto Rican youth from the Bronx, New York. RESULTS: Results indicate: (1) an overlap between offending and victimization that persists over time, (2) a considerable overlap in the number, type, direction, and magnitude of the effect of individual, familial, peer, and contextual factors on both offending and victimization, (3) some of the factors related to offending were only relevant at baseline and not for the growth in offending but that several factors were associated with the growth in victimization, and (4) various risk factors could not explain much of the overlap between offending and victimization. CONCLUSIONS: Theoretical, policy, and future research directions are addressed.

Relationships between drinking onset, alcohol use intensity, and nighttime risk behaviors in a college bar district.

OBJECTIVE: To identify antecedents of risk behavior events in college bar patrons. METHODS: In this nighttime field study, self-report data and alcohol intoxication readings were collected from patrons immediately upon exiting bars (n = 618). RESULTS: Multilevel structural equation modeling revealed positive associations between age of drinking onset and both alcohol use intensity in the past year and recent bar-going frequency. In turn, alcohol use intensity in the past year was positively associated with bar-going frequency and intoxication at bar exit. An association between drinking onset and bar-going frequency was mediated by alcohol use intensity in the past year. CONCLUSIONS: Discernable paths from age of drinking onset to monthly bar-going frequency and intoxication level after leaving a bar can be identified. The results highlight the critical role of drinking onset in development of college student alcohol abuse. Research is needed to determine whether college bars are environmental pathogens mediating between genetic risk factors and patron risk behavior.

Early adolescent, multi-ethnic, urban youth's exposure to patterns of alcohol-related neighborhood characteristics.

This study identified heterogeneous classes of alcohol-related neighborhood characteristics to which multi-ethnic, early adolescents in urban communities are exposed. The sample comprised 4,215 youth from 42 community areas in Chicago, Illinois who completed surveys at the beginning of 6th grade (2002). Neighborhood measures included: (1) mean number of alcohol outlets per 1,000 population per community area; (2) alcohol purchase attempt rate by pseudo-underage youth; (3) average number of alcohol advertisements within 1,500 feet of each school per community; and (4) a Census 2000-based deprivation index. Parents and community leaders provided data on perceived neighborhood problems and parental prevention actions, and neighborhood strength and preventive action by communities, law enforcement, and community organizations, respectively. Multilevel latent class analysis identified the number and characteristics of heterogeneous latent neighborhood classes in which these youth are exposed. Five classes best described the heterogeneity among the sample: (1) Low social capital/low exposure/high access to alcohol (19.8%), (2) Low social capital/low exposure/low access to alcohol (24.5%), (3) Moderate social capital/low exposure/high access to alcohol (30.0%), (4) Moderate social capital/moderate exposure/low access to alcohol (20.1%), and (5) High social capital/moderate exposure/high access to alcohol (5.6%). The racial/ethnic distribution among the classes varied considerably. Results suggest there is substantive heterogeneity among this seemingly homogeneous urban population. Further, they highlight the socioeconomic disadvantage of these inner-city communities and the resource disparity across the racial/ethnic groups. Understanding the nuances among communities may lend to development of more efficacious preventive interventions and policy initiatives, inform theory, and help prioritize limited resources.

Relationship between neighborhood context, family management practices and alcohol use among urban, multi-ethnic, young adolescents.

We examined relationships between alcohol-related neighborhood context, protective home and family management practices, and alcohol use among urban, racial/ethnic minority, adolescents. The sample comprised 5,655 youth who were primarily low SES (72%), African American (43%) and Hispanic (29%). Participants completed surveys in 2002-2005 (ages 11-14 years). Items assessed alcohol use, accessibility of alcohol at home and parental family management practices. Neighborhood context measures included: (1) alcohol outlet density; (2) commercial alcohol accessibility; (3) alcohol advertisement exposure; and (4) perceived neighborhood strength, reported by parents and community leaders. Structural equation modeling was used to assess direct and indirect relationships between alcohol-related neighborhood context at baseline, home alcohol access and family management practices in seventh grade, and alcohol use in eighth grade. Neighborhood strength was negatively associated with alcohol use (beta = -0.078, p < or = 0.05) and exposure to alcohol advertisements was positively associated with alcohol use (beta = 0.043, p < or = 0.05). Neighborhood strength and commercial alcohol access were associated with home alcohol access (beta = 0.050, p

Effects of legal BAC limits on fatal crash involvement: analyses of 28 states from 1976 through 2002.

PROBLEM: Hundreds of laws have been implemented in the United States over the past few decades designed to reduce alcohol-impaired driving and the crashes that often result. One approach has been to lower the legally allowable alcohol concentration for drivers. We examined the effects of changes in legal BAC limit in 28 U.S. states from January, 1976 to December, 2002. METHOD: An interrupted time-series quasi-experimental design was used, incorporating non-alcohol-related crashes as comparisons. Four outcome measures of alcohol-related crash involvement were examined: single-vehicle nighttime, BAC=0.01-0.07, BAC=0.08-0.14, and BAC>/=0.15. Missing BAC test result data were handled by using multiple imputations. Analyses involved estimation of state-specific ARIMA models, controlling for other factors affecting overall crash rates and other major DUI policy changes. Inverse variance weighting methods were used to pool results across states for the most precise underlying estimate of effect of legal BAC limits. RESULTS: Considerable state by state variability in estimated effects was observed, but results from the pooled analyses were clear and consistent. Changes in legal BAC limits significantly affected alcohol-related fatal crash involvement for both the SVN and BAC test result measures, and the laws affected drivers at all drinking levels. SUMMARY: An estimated 360 deaths are prevented each year in the United States as a result of the move from a 0.10 to 0.08 legal limit in recent years, and an additional 538 lives could be saved each year if the United States reduced the limit to 0.05, consistent with limits in most countries worldwide. IMPACT ON INDUSTRY: Given the significant effects of lower legal BAC limits on fatal crash involvement, businesses should support implementation of laws that further reduce the legal BAC limit for all drivers. Furthermore, all companies should set higher standards for employees, such as a zero allowable BAC limit for driving during work time.

Effects of home access and availability of alcohol on young adolescents' alcohol use.

AIMS: The purpose of the present study was to examine the effects of parental provision of alcohol and home alcohol accessibility on the trajectories of young adolescent alcohol use and intentions. DESIGN: Data were part of a longitudinal study of alcohol use among multi-ethnic urban young adolescents who were assigned randomly to the control group of a prevention trial. SETTING: Data were collected from a cohort of youth, and their parents, who attended public schools in Chicago, Illinois (2002-2005). PARTICIPANTS: The sample comprised the 1388 students, and their parents, who had been assigned randomly to the control group and were present and completed surveys at baseline, in the beginning of 6th grade (age 12). The sample was primarily low-income, and African American and Hispanic. MEASUREMENTS: Students completed self-report questionnaires when in the 6th, 7th and 8th grades (age 12-14 years; response rates 91-96%). Parents of the 6th grade students also completed questionnaires (70% response rate). FINDINGS: Student report, at age 12, of parental provision of alcohol and home alcohol availability, and parental report of providing alcohol to their child and the accessibility of alcohol in the home, were associated with significant increases in the trajectories of young adolescent alcohol use and intentions from ages 12-14 years. Student report of receiving alcohol from their parent or taking it from home during their last drinking occasion were the most robust predictors of increases in alcohol use and intentions over time. CONCLUSIONS: Results indicate that it is risky for parents to allow children to drink during early adolescence. When these findings are considered together with the risks associated with early onset of alcohol use, it is clear that parents can play an important role in prevention.

General deterrence effects of U.S. statutory DUI fine and jail penalties: long-term follow-up in 32 states.

INTRODUCTION: We examined effects of state statutory changes in DUI fine or jail penalties for firsttime offenders from 1976 to 2002. METHODS: A quasi-experimental time-series design was used (n=324 monthly observations). Four outcome measures of drivers involved in alcohol-related fatal crashes are: single-vehicle nighttime, low BAC (0.01-0.07g/dl), medium BAC (0.08-0.14g/dl), high BAC (>/=0.15g/dl). All analyses of BAC outcomes included multiple imputation procedures for cases with missing data. Comparison series of non-alcohol-related crashes were included to efficiently control for effects of other factors. Statistical models include state-specific Box-Jenkins ARIMA models, and pooled general linear mixed models. RESULTS: Twenty-six states implemented mandatory minimum fine policies and 18 states implemented mandatory minimum jail penalties. Estimated effects varied widely from state to state. Using variance weighted meta-analysis methods to aggregate results across states, mandatory fine policies are associated with an average reduction in fatal crash involvement by drivers with BAC>/=0.08g/dl of 8% (averaging 13 per state per year). Mandatory minimum jail policies are associated with a decline in single-vehicle nighttime fatal crash involvement of 6% (averaging 5 per state per year), and a decline in low-BAC cases of 9% (averaging 3 per state per year). No significant effects were observed for the other outcome measures. CONCLUSIONS: The overall pattern of results suggests a possible effect of mandatory fine policies in some states, but little effect of mandatory jail policies.