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National Institute on Alcohol Abuse and Alcoholism |
No. 59 |
April 2003 |
Underage Drinking: A Major Public Health Challenge
By the time they reach the eighth grade, nearly 50 percent of adolescents
have had at least one drink, and over 20 percent report having been “drunk”
(1). Approximately 20 percent of 8th graders and almost 50 percent of
12th graders have consumed alcohol within the past 30 days (1). Among
12th graders, almost 30 percent report drinking on 3 or more occasions
per month (2). Approximately 30 percent of 12th graders engage in heavy
episodic drinking, now popularly termed “binge” drinking—that
is, having at least five or more drinks on one occasion within the past
2 weeks—and it is estimated that 20 percent do so on more than one
occasion (2).
Apart from being illegal, underage drinking poses a high risk to both
the individual and society (3). For example, the rate of alcohol–related
traffic crashes is greater for drivers ages 16 to 20 than for drivers
age 21 and older (4). Adolescents also are vulnerable to alcohol–induced
brain damage, which could contribute to poor performance at school or
work. In addition, youthful drinking is associated with an increased likelihood
of developing alcohol abuse or dependence later in life. Early intervention
is essential to prevent the development of serious alcohol problems among
youth between the ages of 12 and 20. This Alcohol Alert describes
some of the most harmful consequences of underage drinking as well as
prevention and treatment approaches that can be applied successfully to
meet the unique needs of this age group.
Injury and Social Consequences
Underage alcohol use is more likely to kill young people than all illegal
drugs combined (5,6). Some of the most serious and widespread alcohol–related
problems among adolescents are discussed below. For a more detailed discussion
of alcohol problems in the college–age population, see Alcohol
Alert No. 58 (7).
Drinking and Driving. Motor vehicle crashes are
the leading cause of death among youth ages 15 to 20 (8). Adolescents
already are at increased risk through their relative lack of driving experience
(9), and drivers younger than 21 are more susceptible than older drivers
to the alcohol–induced impairment of driving skills (4,9). The rate
of fatal crashes among alcohol–involved drivers between 16 and 20
years old is more than twice the rate for alcohol–involved drivers
21 and older (10).
Suicide. Alcohol use interacts with conditions such
as depression and stress to contribute to suicide, the third leading cause
of death among people between the ages of 14 and 25 (11,12). In one study,
37 percent of eighth grade females who drank heavily reported attempting
suicide, compared with 11 percent who did not drink (13).
Sexual Assault. Sexual assault, including rape, occurs
most commonly among women in late adolescence and early adulthood, usually
within the context of a date (14). In one survey, approximately 10 percent
of female high school students reported having been raped (5). Research
suggests that alcohol use by the offender, the victim, or both, increases
the likelihood of sexual assault by a male acquaintance (15).
High–Risk Sex. Research has associated adolescent
alcohol use with high–risk sex (for example, having multiple sexual
partners and failing to use condoms). The consequences of high–risk
sex also are common in this age group, particularly unwanted pregnancy
and sexually transmitted diseases, including HIV/AIDS (5). According to
a recent study, the link between high–risk sex and drinking is affected
by the quantity of alcohol consumed. The probability of sexual intercourse
is increased by drinking amounts of alcohol sufficient to impair judgment,
but decreased by drinking heavier amounts that result in feelings of nausea,
passing out, or mental confusion (16).
Alcohol’s Effects on the Brain
Adolescence is the transition between childhood and adulthood. During
this time, significant changes occur in the body, including rapid hormonal
alterations and the formation of new networks in the brain (17). Adolescence
is also a time of trying new experiences and activities that emphasize
socializing with peers, and conforming to peer–group standards (18,19).
These new activities may place young people at particular risk for initiating
and continuing alcohol consumption. Exposing the brain to alcohol during
this period may interrupt key processes of brain development, possibly
leading to mild cognitive impairment as well as to further escalation
of drinking. (For a review, see Reference 17.)
Subtle alcohol–induced adolescent learning impairments could affect
academic and occupational achievement (17). In one study, Brown and colleagues
(20) evaluated short–term memory skills in alcohol–dependent
and nondependent adolescents ages 15 to 16. The alcohol–dependent
youth had greater difficulty remembering words and simple geometric designs
after a 10–minute interval. In this and similar studies (21,22),
memory problems were most common among adolescents in treatment who had
experienced alcohol withdrawal symptoms (20). The emergence of withdrawal
symptoms generally indicates an established pattern of heavy drinking.
Their appearance at a young age underscores the need for early intervention
to prevent and treat underage drinking.
Although the prevalence of high–risk drinking declines after early
adulthood (23), alcohol–induced brain damage may persist. Memory
impairment has been found in adult rats exposed to alcohol during adolescence
(17). In addition, sophisticated imaging techniques revealed structural
differences in the brains of 17–year–old adolescents who displayed
alcohol–induced intellectual and behavioral impairment. Specifically,
the hippocampus—a part of the brain important for learning and memory—was
smaller in alcohol–dependent study participants than it was
in nondependent participants (24). Adolescents who began drinking at an
earlier age had proportionately smaller hippocampal volumes compared with
those who began later (24), suggesting that the differences in size were
alcohol induced.
The Link Between Early Alcohol Use and Alcohol Dependence
Early alcohol use may have long–lasting consequences. People who
begin drinking before age 15 are four times more likely to develop alcohol
dependence at some time in their lives compared with those who have their
first drink at age 20 or older (25). It is not clear whether starting
to drink at an early age actually causes alcoholism or whether it simply
indicates an existing vulnerability to alcohol use disorders (26). For
example, both early drinking and alcoholism have been linked to personality
characteristics such as strong tendencies to act impulsively and to seek
out new experiences and sensations (27). Some evidence indicates that
genetic factors may contribute to the relationship between early drinking
and subsequent alcoholism (28,29). Environmental factors may also be involved,
especially in alcoholic families, where children may start drinking earlier
because of easier access to alcohol in the home, family acceptance of
drinking, and lack of parental monitoring (27,26).
Prevention and Treatment
The immediate and long–term risks associated with adolescent alcohol
use underscore the need for effective prevention and treatment programs.
Research on the personal, social, and environmental factors that contribute
to the initiation and escalation of drinking is essential for the development
of such programs. It should be noted that preventing and identifying
alcohol use disorders in youth require different screening, assessment,
and treatment approaches than those used for adults (30,31). For example,
although relapse rates following alcoholism treatment are similar for
both adults and adolescents, social factors such as peer pressure play
a much larger role in relapse among adolescents (31).
Personal factors such as childhood behavior problems (32) or a family
history of alcohol use disorders (33) can help to identify high–risk
youth and may suggest direction for interventions. Evidence suggests that
the most reliable predictor of a youth’s drinking behavior is the
drinking behavior of his or her friends (32,34). Many research–based
interventions target the child’s relevant behavioral skills, such
as his or her ability to react appropriately to peer pressure to drink,
as well as his or her knowledge, attitudes, and intentions regarding alcohol
use (35). Positive beliefs about alcohol’s effects and the social
acceptability of drinking encourage the adolescent to begin and continue
drinking. However, youth often overestimate how much their peers drink
and how positive their peers’ attitudes are toward drinking. Consequently,
most prevention programs include social norms education, which uses survey
data to counter students’ misperceptions of their peers’ drinking
practices and attitudes about alcohol (36,35).
Family factors, such as parent–child relationships, discipline
methods, communication, monitoring and supervision, and parental involvement,
also exert a significant influence on youthful alcohol use (37,38). Accordingly,
family–based prevention programs for youth have been developed—for
example, Iowa’s Strengthening Families Program, which significantly
delayed initiation of alcohol use by improving parenting skills and family
bonding (37). The beneficial effects of this program on student alcohol
involvement were still evident 4 years after the intervention (39).
Some school–based programs are aimed at adolescents who have already
begun drinking. Preliminary research also has found promise in high school–based
motivational programs that encourage self–change in problem drinkers
(30).
Policy and Community Strategies
Another important factor in underage drinking is availability, that is,
the degree of effort required to obtain alcohol, as determined by geographic,
economic, and social factors (40,35). Consequently, interventions aimed
at the individual must be supplemented by policy changes to help reduce
youth access to alcohol and decrease the harmful consequences of established
drinking (35). For example, raising the minimum legal drinking age in
all States to 21 saved an estimated 20,000 lives between 1975 and 2000
(8). In addition, all States now have zero–tolerance laws, which
set the legal blood alcohol limit for drivers younger than age 21 at 0.00
or 0.02 percent (41). This policy has been associated with a 20–percent
decline in the proportion of single–vehicle, nighttime fatal crashes
among drivers younger than age 21 (42,43).
The drinking and driving laws described above were implemented in the
absence of an accompanying increase in existing law enforcement levels.
The effectiveness of such measures is enhanced by integrating them into
community–based strategies that involve the cooperation of local
government agencies, the law enforcement community, business leaders, and
grassroots organizations (35). Communities Mobilizing for Change on Alcohol
(CMCA) is an example of a community–wide program that focused on
policy changes to reduce youth access to commercial and social sources
of alcohol (44,35). Communities that adopted the program experienced significantly
fewer arrests for drinking and driving among youth ages 18 to 20 than
did neighboring communities (45).
Comprehensive Interventions. Project Northland
is an example of a successful comprehensive intervention that incorporated
family, school, and community components to prevent or reduce alcohol
use among adolescents. To determine the program’s effectiveness,
researchers began testing the students in grade six; and, after 3 years,
the prevalence of alcohol use by eighth graders was lower in intervention
communities than in comparison sites, and especially among students who
had not yet started drinking when the program began (46). During the next
2 years, interventions were only minimal, and the differences in the measures
of alcohol use between the two groups of students disappeared. However,
resumption of Project Northland activities in grades 11 and 12 had a significant
positive effect on the students’ tendency to avoid alcohol use and
binge drinking. Taken together, these results show the effectiveness of
continued, age–appropriate prevention activities for delaying or
reducing underage drinking (47).
Underage Drinking—A Commentary by NIAAA Director Ting–Kai
Li, M.D.
The immediate and long–term risks associated with adolescent alcohol
use underscore the need for effective prevention and treatment programs.
Research toward those ends is a top priority at NIAAA. Studies have revealed
genetic, biologic, developmental, and environmental influences on underage
drinking.
Scientists have found that variability is a crucial aspect of alcohol
problems across all age groups and thus is a key consideration in alcohol
research. For example, there is a three– to fourfold between–individual
variation in the rate of absorption, distribution, and elimination of
alcohol (pharmacokinetics) and a two– to threefold between–individual
variation in the sensitivity of the brain to the effects of a given concentration
of alcohol (pharmacodynamics). Understanding the underlying causes of
this variability, both genetic and nongenetic, should provide insights
into underage drinking and binge–drinking patterns.
Through prevention and intervention strategies directed at the individual,
family, school, and community, we aim to provide knowledge and change
belief systems and social norms to reinforce the message that underage
alcohol use is unacceptable. We also aim to enhance young peoples’
self–esteem, self–motivation, and identity formation to enable
them to take responsibility for their own health by making informed, deliberate,
and healthy choices regarding alcohol use.
Various intervention tools have brought about positive behavioral change
with regard to underage drinking. Further studies will follow cohorts
of young people from childhood through the college years, at different
locations and in different settings, to determine whether these interventions
are enduring and broadly applicable. Finding lasting solutions to such
an entrenched problem will not be easy, but we are confident that diligent
research efforts will meet this urgent challenge.
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All material contained in the Alcohol Alert is in the public
domain and may be used or reproduced without permission from NIAAA.
Citation of the source is appreciated.
Copies of the Alcohol Alert are available free of charge from
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National Institute on Alcohol Abuse and Alcoholism Publications Distribution
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P.O. Box 10686, Rockville, MD 208490686.
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