why underage drinking is bad essay

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Page title The Consequences of Underage Drinking

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Children who drink alcohol are more likely to:

Frequent binge drinkers (nearly 1 million high school students nationwide) are more likely to engage in risky behaviors, including using other drugs such as marijuana and cocaine.

Get bad grades

Children who use alcohol have higher rates of academic problems and poor school performance compared with nondrinkers.

Suffer injury or death

In 2009, an estimated 1,844 homicides; 949,400 nonfatal violent crimes such as rape, robbery, and assault; and 1,811,300 property crimes, including burglary, larceny, and car theft were attributed to underage drinking.

Engage in risky sexual activity

Young people who use alcohol are more likely to be sexually active at earlier ages, to have sexual intercourse more often, and to have unprotected sex.

Make bad decisions

Drinking lowers inhibitions and increases the chances that children will engage in risky behavior or do something that they will regret when they are sober.

Have health problems

Young people who drink are more likely to have health issues such as depression and anxiety disorders.

Last Updated: 04/14/2022

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Short takes with niaaa: what are the dangers of underage drinking.

February 15, 2024

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The dangers of underage drinking

Why kids and teens drink, how to talk to your teen about alcohol, helping a teen who’s already drinking, binge drinking and alcohol poisoning, if you’re a teen with a problem, underage drinking and teen alcohol use.

It’s normal for parents to worry about their children using alcohol. But there are ways to help your teen cope with the pressures to drink and make better choices.

Reviewed by Jeff Sounalath, MS, LPC, LCDC, NCC , an Austin-based counselor at ADHD Advisor specializing in integrated behavioral healthcare, addictions, and multicultural counseling

If you’ve discovered your child or teen is drinking alcohol, it’s normal to feel upset, angry, and worried. Underage drinking can have serious implications that may not show up until later in your child’s life. Using alcohol at a young age can impact how a teen’s brain develops, disrupt their sleeping patterns, delay puberty, make it harder to concentrate at school, and even increase their risk for liver and heart disease, high blood pressure, and certain types of cancer.

On top of that, there are also emotional and behavioral consequences to underage drinking. Alcohol use can affect a teen’s mood and personality, trigger depression, anxiety, or suicidal thoughts/ideation, and lead to an increase in risky behavior such as driving while impaired, having unprotected sex, fighting, stealing, or skipping school.

Kids and teens are more likely to binge drink and are more vulnerable to developing a problem with alcohol than adults. Experts believe this may be because the pleasure center of a teen’s brain matures before their capacity to make sound decisions. In other words, they’re able to experience ”pleasurable” effects from alcohol (such as suppressing anxiety or improving mood) before they’re able to make the right choices about when and how much to drink. This can lead them to do things that are embarrassing, dangerous, or even life-threatening to themselves or others.

While parenting an adolescent is rarely easy, it’s important to remember that you can still have a major impact on the choices your child makes, especially during their preteen and early teen years. With these guidelines can help you identify the best ways to talk to your child about alcohol, address potential underlying problems that may be triggering their alcohol use, and help them to make smarter choices in the future.

The adolescent years can be a time of great upheaval. The physical and hormonal changes can create emotional ups and downs as kids struggle to assert their independence and establish their own identities. According to United States government statistics, by age 15, nearly 30% of kids have had at least one drink, and by age 18, that figure leaps to almost 60%. Similar patterns are reported in other countries.

While many teens will try alcohol at some point out of curiosity or as an act of rebellion or defiance , there is rarely just a single reason why some decide to drink. The more you understand about potential reasons for underage alcohol use, the easier it can be to talk to your child about the dangers and identify any red flags in their behavior.

Common reasons why teens drink include:

Peer pressure . This is among the most common reasons for underage drinking. As kids enter their teens, friends exert more and more influence over the choices they make. Desperate to fit in and be accepted, kids are much more likely to drink when their friends drink. One major sign of underage drinking that you as a parent can look for is a sudden change in peer group. It may be that their new friends are encouraging this negative behavior.

Environmental influences . Films and TV can make it seem that every “cool”, independent teenager drinks. Alcohol advertising also focuses on positive experiences with alcohol, selling their brands as desirable lifestyle choices. Social media, in particular, can make your child feel like they’re missing out by not drinking or cause them to feel inadequate about how they live their life. You can help by educating your child on how social media portrays a distorted, glamorized snapshot of only the positives in a person’s life, rather than a realistic view that includes their daily struggles, such as unhealthy alcohol use.

To cope with an underlying problem. The teen years are tough and kids may turn to alcohol in a misguided attempt to cope with problems such as stress, boredom, the pressure of schoolwork, not fitting in, problems at home, or mental health issues such as anxiety , childhood trauma, ADHD, or depression. Since alcohol is a depressant, using it to self-medicate can make problems even worse. If your child is regularly drinking on their own or drinking during the day it could be they’re struggling to cope with a serious underlying issue. You can help by fostering a relationship with your child where they feel that they can be open and honest with you, rather than being immediately disciplined.

To appear older, more independent . Teens often want to prove that they’re no longer kids. So, if drinking is exclusively for adults only, that’s what they’ll do. They may also copy your own drinking habits to establish their maturity. Remember that as a parent, your child is much more likely to mimic your actions than listen to your words. No matter how much you preach about the dangers of underage drinking, if you reach for a drink to unwind at the end of a stressful day, your teen may be tempted to follow your example. If you have concerns about your child’s alcohol use, you may want to reevaluate and make changes to your own drinking habits as well.

They lack parental boundaries . No matter how tall or mature your teen seems, they need boundaries, discipline, and structure as much as ever. While your rules won’t be the same or as rigid as when they were younger, having loose boundaries can be confusing and overwhelming for a teen. While you can expect a teen to test any boundaries, be clear on what is and isn’t acceptable behavior and what the consequences are for breaking your rules.

As most parents know all too well, talking to a teen is rarely easy. You can feel discouraged when your attempts to communicate are greeted by a sullen roll of the eyes, an incoherent grunt, or the slamming of a door. Or you may despair at the relentless anger or indifference your teen displays towards you. However, if you feel that your child will be exposed to underage drinking, finding a way to talk to them about alcohol can be crucial in either preventing them from starting or curbing any existing alcohol use.

Studies have shown that the earlier your child uses alcohol, the more problems they’re likely to experience later in life, so it’s never too early to start the conversation. It can even be easier to have these conversations early on in your child’s adolescent years, when they aren’t as rebellious and are less likely to be have already been exposed to underage drinking.

The following strategies can help you open the lines of communication with an adolescent without sparking more conflict:

Choose the right time . Trying to talk to a teen about drinking when they’re watching their favorite show, texting with their friends, or in the midst of a heated argument with you about something else isn’t going to be productive. Choose a time when your teen hasn’t been drinking and you’re both calm and focused—and turn off your phone to avoid distractions.

Find common ground . Attempting to dive straight in to a discussion about drinking may be a quick way to trigger an unpleasant fight. A better tactic is to find an area of common ground, such as sports or movies. Once you’re able to peacefully discuss a common interest, it may be easier to get your teen talking about the more sensitive issue of alcohol use.

Make it a conversation rather than a lecture . Allow your teen to talk and open up about their thoughts and opinions, and try to listen without being critical, disapproving, or judgmental. They want to feel heard and understood, so even when you don’t like or agree with what they’re saying, it’s important to withhold blame and criticism. This style of passive parenting, centered on support, non-judgement, and unconditional love, still allows you to appropriately discipline your child. But it can help your child feel that you are coming from a place of love and concern, rather than anger.

Discuss the benefits of not drinking . Teenagers often feel invincible—that nothing bad will ever happen to them—so preaching about the long-term health dangers of underage drinking may fail to discourage them from using alcohol. Instead, talk to your teen about the effects drinking can have on their appearance—bad breath, bad skin, and weight gain from all the empty calories and carbs. You can also talk about how drinking makes people do embarrassing things, like peeing themselves or throwing up.

Emphasize the message about drinking and driving . If your teen goes to a party and chooses to have a drink, it’s a mistake that can be rectified. If they drink and then drive or get into a vehicle driven by someone else who’s been drinking, that mistake could be a fatal one—for them or someone else. Ensure they always have access to an alternative means of getting home, whether that’s a taxi, a ride share service, or calling you, an older sibling, or another adult to pick them up.

Keep the conversation going . Talking to your teen about drinking is not a single task to tick off your to-do list, but rather an ongoing discussion. Things can change quickly in a teenager’s life, so keep making the time to talk about what’s going on with them, keep asking questions, and keep setting a good example for responsible alcohol use.

Plan ways to help your child handle peer pressure

As a teenager, your child is likely to be in social situations where they’re offered alcohol—at parties or in the homes of friends, for example. When all their peers are drinking, it can be hard for anyone to say “no.” While fitting in and being socially accepted are extremely important to teens, you can still help them find ways to decline alcohol without feeling left out.

Working on developing boundaries and the ability to say no in uncomfortable situations can help your child deal with peer pressure and resist the need to drink.

• Suggest reasons they can use to explain why they’re not drinking, such as “I don’t like drinking,” “I have homework to finish,” “I have to be up early for a game,” “My parents are picking me up,” or, “I’ll get grounded if I’m caught drinking again.”
• Teach them to only accept a beverage when they know exactly what’s in it.
• Make sure they have an exit strategy if they feel uncomfortable in a situation where people are drinking alcohol. That could involve a signal they make to a friend, a prepared excuse they have for leaving, or a text they send to you.
• Encourage them to have alternate plans, like going to the movies or watching a game, so they’re less tempted to spend all night in a drinking environment.

As disturbing as it can be to find out that your child or teen has been drinking, it’s important to remember that many teens try alcohol at some point, but that doesn’t mean they automatically have an abuse problem. Your goal should be to discourage further drinking and encourage better decision-making in the future.

It’s important to remain calm when confronting your teen, and only do so when everyone is sober. Explain your concerns and make it clear that your fears come from a place of love. Your child needs to feel you are supportive and that they can confide in you, since underage drinking is often triggered by other problem areas in their life.

Get to know your teen’s friends—and their parents . If their friends drink, your teen is more likely to as well, so it’s important you know where your teen goes and who they hang out with. By getting to know their friends, you can help to identify and discourage negative influences. And by working with their friends’ parents, you can share the responsibility of monitoring their behavior. Similarly, if your teen is spending too much time alone, that may be a red flag that they’re having trouble fitting in.

Monitor your teen’s activity . Keep any alcohol in your home locked away and routinely check potential hiding places your teen may have for alcohol, such as under the bed, between clothes in a drawer, or in a backpack. Explain to your teen that this lack of privacy is a consequence of having been caught using alcohol.

Talk to your teen about underlying issues . Kids face a huge amount of stress as they navigate the teenage years. Many turn to alcohol to relieve stress, cope with the pressures of school, to deal with major life changes, like a move or divorce, or to self-medicate a mental health issue such as anxiety or depression. Talk to your child about what’s going on in their life and any issues that may have prompted their alcohol use.

Lay down rules and consequences . Remind your teen that underage drinking is illegal and that they can be arrested for it. Your teen should also understand that drinking alcohol comes with specific consequences. Agree on rules and punishments ahead of time and stick to them—just don’t make hollow threats or set rules you cannot enforce. Make sure your spouse agrees with the rules and is also prepared to enforce them.

Encourage other interests and social activities . Some kids drink alone or with friends to alleviate boredom; others drink to gain confidence, especially in social situations . You can help by exposing your teen to healthy hobbies and activities, such as team sports, Scouts, and after-school clubs. Encouraging healthy interests and activities can help to boost their self-esteem and build resilience , qualities that make teens less likely to develop problems with alcohol.

[Read: Staying Social When You Quit Drinking]

Get outside help . You don’t have to tackle this problem alone. Teenagers often rebel against their parents but if they hear the same information from a different authority figure, they may be more inclined to listen. Try seeking help from a sports coach, family doctor, therapist , or counselor.

If your teen has an alcohol use disorder

You’ve found bottles of alcohol hidden in your child’s room and regularly smelled alcohol on their breath. You’ve noted the steep drop-off in their schoolwork, abrupt changes in their behavior, and the loss of interest in their former hobbies and interests. Spotting these signs may indicate your child is abusing alcohol.

Witnessing your child struggle with a drinking problem (also known as “alcohol use disorder”) can be as heartbreaking as it is frustrating. Your teen may be falling behind at school, disrupting family life, and even stealing money to finance their habit or getting into legal difficulties. But you’re not alone in your struggle. Drinking problems affect families all over the world from every different background.

While you can’t do the hard work of overcoming a drinking problem for your child, your patience, love, and support can play a crucial part in their long-term recovery. For more, see: Helping Someone with a Drinking Problem .

Speak to a Licensed Therapist

BetterHelp is an online therapy service that matches you to licensed, accredited therapists who can help with depression, anxiety, relationships, and more. Take the assessment and get matched with a therapist in as little as 48 hours.

Binge drinking is defined as drinking so much within a short space of time (about two hours) that blood alcohol levels reach the legal limit of intoxication. For kids and teens, that usually means having three or more drinks at one sitting. Young people who binge drink are more likely to miss classes at school, fall behind with their schoolwork, damage property, sustain an injury, or become victims of assault.

Because the adolescent years are a time of development, teens’ bodies are less able to process alcohol. That means they have a tendency to get drunk quicker and stay drunk longer than older drinkers.

Also, since underage drinkers haven’t yet learned their limits with alcohol, they’re at far greater risk of drinking more than their bodies can handle, resulting in an alcohol overdose or alcohol poisoning when they binge drink. Mixing drinks, doing shots, playing drinking games, and natural teenage impulsiveness can all contribute to binge drinking and increase a young person’s risk for alcohol poisoning.

[Read: Binge Drinking: Effects, Causes, and Help]

Alcohol poisoning can cause vomiting, confusion, impaired judgment, slow or irregular breathing, loss of consciousness, a drop in body temperature and blood sugar level, and even seizures or death.

What to do if your child develops alcohol poisoning

It can be extremely distressing as a parent to witness the after-effects of your teen’s binge drinking. If your teen is in an unconscious or semiconscious state, their breathing is very slow, their skin clammy, and there’s a powerful odor of alcohol, there’s a strong chance they may have alcohol poisoning.

• Don’t leave them alone to “sleep it off.”
• Turn your child onto their side to avoid them choking if they vomit.
• Call your country’s emergency services number (911 in the U.S.) and wait with them for medical help to arrive.

The teen years don’t last forever

When your teen abuses alcohol, it’s easy to judge yourself or negatively compare your family to others. But it’s worth remembering that the teen years don’t last forever. With your guidance and support, your child can learn to resist the allure of underage drinking and, if they later choose to do so, develop a healthy, responsible relationship with alcohol when they reach adulthood.

If you’re a child or teen and are worried about your own or a friend’s drinking, it’s important to reach out to an adult you trust. If you don’t feel you can talk to a parent, reach out to a family friend, older sibling, or school counselor, for example, or call one of the helplines listed below.

Acknowledging you have a problem with alcohol is not a sign of weakness or some kind of character defect. In fact, it takes tremendous strength and courage to admit your problem and decide to face up to it. The teenage years can often be challenging and stressful, and it’s not unusual for people to turn to alcohol as a way of coping with their issues. But whatever difficulties you’re facing at the moment, there is help available and there are healthier, more effective ways of resolving them. The first step is to reach out.

Call  SAMHSA’s National Helpline  at 1-800-662-4357.

Call Drinkline at 0300 123 1110, visit  Drinkaware .

Download  Finding Quality Addiction Care in Canada  for regional helplines.

Call the  Family Drug Helpline  at 1300 660 068.

More Information

• Kids and Alcohol - How to talk to your kids about alcohol, from preschoolers to teenagers. (KidsHealth)
• Alcohol Poisoning - How to recognize the signs and help someone. (Mayo Clinic)
• Talk. They Hear You - Articles, videos and other resources to help parents deal with underage drinking. (SAMHSA)
• Underage Drinking - Articles providing tips on preventing underage drinking, talking to your child, and recognizing problems. (Drinkaware)
• Soberful - Practical method for developing and maintaining an alcohol-free lifestyle from a  HelpGuide affiliate . (Sounds True)
• Substance-Related and Addictive Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders . American Psychiatric Association. Link
• “Underage Drinking-Why Do Adolescents Drink, What Are the Risks, and How Can Underage Drinking Be Prevented?” Accessed July 15, 2021. Link
• “Section 2 PE Tables – Results from the 2019 National Survey on Drug Use and Health: Detailed Tables, SAMHSA, CBHSQ.” Accessed July 15, 2021. Link
• Schilling, Elizabeth A., Robert H. Aseltine, Jaime L. Glanovsky, Amy James, and Douglas Jacobs. “Adolescent Alcohol Use, Suicidal Ideation, and Suicide Attempts.” The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine 44, no. 4 (April 2009): 335–41. Link
• Miller, Jacqueline W., Timothy S. Naimi, Robert D. Brewer, and Sherry Everett Jones. “Binge Drinking and Associated Health Risk Behaviors among High School Students.” Pediatrics 119, no. 1 (January 2007): 76–85. Link
• Lopez-Quintero, Catalina, José Pérez de los Cobos, Deborah S. Hasin, Mayumi Okuda, Shuai Wang, Bridget F. Grant, and Carlos Blanco. “Probability and Predictors of Transition from First Use to Dependence on Nicotine, Alcohol, Cannabis, and Cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).” Drug and Alcohol Dependence 115, no. 1–2 (May 1, 2011): 120–30. Link
• “Publications | National Institute on Alcohol Abuse and Alcoholism | Measuring the Burden — Alcohol’s Evolving Impact on Individuals, Families, and Society.” Accessed July 15, 2021. Link
• Windle, Michael. “Substance Use, Risky Behaviors, and Victimization among a US National Adolescent Sample.” Addiction 89, no. 2 (1994): 175–82. Link
• “Youth Drinking: Risk Factors and Consequences – Alcohol Alert No. 37-1997.” Accessed July 15, 2021. Link
• Chung, Tammy, and Kristina M. Jackson. “Adolescent Alcohol Use.” In The Oxford Handbook of Adolescent Substance Abuse, by Tammy Chung and Kristina M. Jackson, 130–68. edited by Robert A. Zucker and Sandra A. Brown. Oxford University Press, 2019. Link
• “Early Drinking Linked to Higher Lifetime Alcoholism Risk | National Institute on Alcohol Abuse and Alcoholism (NIAAA).” Accessed March 7, 2024. Link

More in Addiction

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Recognizing the signs and symptoms, and helping your child

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The health risks in young people and how to quit

The hidden risks of drinking

Binge Drinking

Help if you have trouble stopping drinking once you start

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Age 21 Minimum Legal Drinking Age

A minimum legal drinking age (mlda) of 21 saves lives and protects health.

Minimum Legal Drinking Age (MLDA) laws specify the legal age when an individual can purchase alcoholic beverages. The MLDA in the United States is 21 years.  However, prior to the enactment of the National Minimum Drinking Age Act of 1984, the legal age when alcohol could be purchased varied from state to state. 1

An age 21 MLDA is recommended by the:

• American Academy of Pediatrics 2 • Community Preventive Services Task Force 4 • Mothers Against Drunk Driving 5 • National Highway Traffic Safety Administration 1 • National Prevention Council 8 • National Academy of Sciences (National Research Council and Institute of Medicine) 9

The age 21 MLDA saves lives and improves health. 3

Fewer motor vehicle crashes

• States that increased the legal drinking age to 21 saw a 16% median decline in motor vehicle crashes. 6

Decreased drinking

• After all states adopted an age 21 MLDA, drinking during the previous month among persons aged 18 to 20 years declined from 59% in 1985 to 40% in 1991. 7
• Drinking among people aged 21 to 25 also declined significantly when states adopted the age 21 MLDA, from 70% in 1985 to 56% in 1991. 7

Other outcomes

• There is also evidence that the age 21 MLDA protects drinkers from alcohol and other drug dependence, adverse birth outcomes, and suicide and homicide. 4

Drinking by those under the age 21 is a public health problem.

• Excessive drinking contributes to about 4,000 deaths among people below the age of 21 in the U.S. each year. 10
• Underage drinking cost the U.S. economy $24 billion in 2010. 11

Drinking by those below the age of 21 is also strongly linked with 9,12,13 :

• Death from alcohol poisoning.
• Unintentional injuries, such as car crashes,  falls, burns, and drowning.
• Suicide and violence, such as fighting and sexual assault.
• Changes in brain development.
• School performance problems, such as higher absenteeism and poor or failing grades.
• Alcohol dependence later in life.
• Other risk behaviors such as smoking, drug misuse, and risky sexual behaviors.

Alcohol-impaired driving

Drinking by those below the age of 21 is strongly associated with alcohol-impaired driving. The 2021 Youth Risk Behavior Survey 14  found that among high school students, during the past 30 days

• 5% drove after drinking alcohol.
• 14% rode with a driver who had been drinking alcohol.

Rates of drinking and binge drinking among those under 21

The 2021 Youth Risk Behavior Surveillance System found that among high school students, 23% drank alcohol and 11% binge drank during the past 30 days. 14

In 2021, the Monitoring the Future Survey reported that 6% of 8th graders and 28% of 12th graders drank alcohol during the past 30 days, and 2% of 8th graders and 13% of 12th graders binge drank during the past 2 weeks. 15

In 2014, the New York City Department of Health and Mental Hygiene and the New York State Liquor Authority found that more than half (58%) of the licensed alcohol retailers in the City sold alcohol to underage decoys. 17

Enforcing the age 21 MLDA

Communities can enhance the effectiveness of age 21 MLDA laws by actively enforcing them.

• A Community Guide review found that enhanced enforcement of laws prohibiting alcohol sales to minors reduced the ability of youthful-looking decoys to purchase alcoholic beverages by a median of 42%. 16
• Alcohol sales to minors are still a common problem in communities.

More information on underage drinking

• National Highway Traffic Safety Administration.  Determine Why There Are Fewer Young Alcohol Impaired Drivers External . Washington, DC. 2001.
• Committee on Substance Abuse, Kokotailo PK.  Alcohol use by youth and adolescents: a pediatric concern External .  Pediatrics . 2010;125(5):1078-1087.
• DeJong W, Blanchette J.  Case closed: research evidence on the positive public health impact of the age 21 minimum legal drinking age in the United States External .  J Stud Alcohol Drugs . 2014;75 Suppl 17:108-115.
• Task Force on Community Preventive Services.  Recommendations to reduce injuries to motor vehicle occupants: increasing child safety seat use, increasing safety belt use, and reducing alcohol-impaired driving Cdc-pdf External  [PDF-78 KB].  Am J Prev Med . 2001;21(4 Suppl):16-22.
• Mothers Against Drunk Driving (MADD). Why 21? 2018;  https://www.madd.org/the-solution/teen-drinking-prevention/why-21/ External . Accessed May 3, 2018.
• Shults RA, Elder RW, Sleet DA, et al.  Reviews of evidence regarding interventions to reduce alcohol-impaired driving Cdc-pdf External  [PDF-2 MB].  Am J Prev Med . 2001;21(4 Suppl):66-88.
• Serdula MK, Brewer RD, Gillespie C, Denny CH, Mokdad A.  Trends in alcohol use and binge drinking, 1985-1999: results of a multi-state survey External .  Am J Prev Med . 2004;26(4):294-298
• National Prevention Council. National Prevention Strategy: Preventing Drug Abuse and Excessive Alcohol Use  [PDF-4.7MB]. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General; 2011.
• Bonnie RJ and O’Connell ME, editors. National Research Council and Institute of Medicine.  Reducing Underage Drinking: A Collective Responsibility External . Committee on Developing a Strategy to Reduce and Prevent Underage Drinking. Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press; 2004.
• Centers for Disease Control and Prevention (CDC). Alcohol-Related Disease Impact (ARDI) Application website . Accessed February 29, 2024.
• Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RD.  2010 national and state costs of excessive alcohol consumption External .  Am J Prev Med . 2015;49(5):e73-79.
• Miller JW, Naimi TS, Brewer RD, Jones SE.  Binge drinking and associated health risk behaviors among high school students External .  Pediatrics . 2007;119(1):76-85.
• Department of Health and Human Services. The Surgeon General’s call to action to prevent and reduce underage drinking External . Department of Health and Human Services, Office of the Surgeon General;2007.
• Centers for Disease Control and Prevention. 2021 Youth Risk Behavior Survey Data . Accessed on September 13, 2023.
• Johnston LD, Miech RA, O’Malley PM, Bachman JG, Schulenberg JE, Patrick ME. Monitoring the Future national survey results on drug use, 1975-2021: Overview, key findings on adolescent drug use external icon . Ann Arbor: Institute for Social Research, The University of Michigan; 2023.
• Elder R, Lawrence B, Janes G, et al.  Enhanced enforcement of laws prohibiting sale of alcohol to minors: systematic review of effectiveness for reducing sales and underage drinking External  [PDF-4MB].  Transportation Research E-Circular . 2007;E-C123:181-188.
• The New York City Department of Health and Mental Hygiene. Alcohol & Health website . Accessed October 18, 2016.

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• Published: 28 February 2023

Young people’s explanations for the decline in youth drinking in England

• Victoria Whitaker 1 ,
• Penny Curtis 2 ,
• Hannah Fairbrother 2 ,
• Melissa Oldham 3 &
• John Holmes 1  

BMC Public Health volume  23 , Article number:  402 ( 2023 ) Cite this article

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Youth alcohol consumption has fallen markedly over the last twenty years in England. This paper explores the drivers of the decline from the perspectives of young people.

The study used two methods in a convergent triangulation design. We undertook 38 individual or group qualitative interviews with 96 participants in various educational contexts in England. An online survey of 547 young people in England, was also conducted. Participants were aged between 12–19 years. For both data sources, participants were asked why they thought youth alcohol drinking might be in decline. Analysis of interview data was both deductive and inductive, guided by a thematic approach. Content analysis of survey responses further refined these themes and indicated their prevalence within a larger sample.

The research identified eight key themes that young people used to explain the decline in youth drinking: The potential for alcohol-related harm; Contemporary youth cultures and places of socialisation; The affordability of alcohol; Displacement of alcohol by other substances; Access and the regulatory environment; Disputing the decline; Future Orientations; and Parenting and the home environment. Heterogeneity in the experiences and perspectives of different groups of young people was evident, particularly in relation to age, gender, and socio-economic position.

Conclusions

Young people’s explanations for the decline in youth drinking in England aligned well with those generated by researchers and commentators in prior literature. Our findings suggest that changing practices of socialisation, decreased alcohol affordability and changed attitudes toward risk and self-governance may be key explanations.

Peer Review reports

Youth drinking is in decline in many high-income countries. This global trend manifests in terms of delayed age of initiation of drinking, and reductions in the volume and frequency of alcohol consumption [ 1 , 2 , 3 , 4 ]. While approximately synchronous national declines in youth drinking are evident in a number of high-income countries, there is substantial variation between countries in these declines [ 5 , 6 , 7 ]. Although youth alcohol consumption in England was high at the turn of the millennium, relative to international counterparts, England has nonetheless seen particularly sharp declines in youth alcohol drinking, especially amongst boys [ 4 ].

A number of potential drivers have been proposed for these changes. These include policy initiatives targeting underage purchasing [ 8 , 9 ], the role of migration from countries with abstemious attitudes to alcohol [ 9 , 10 , 11 ], economic factors that have made alcohol less affordable to young people [ 9 , 12 , 13 ], changes in prevailing social norms, particularly young people’s conscientiousness with regard to education [ 6 , 14 , 15 ], changes towards more authoritative and warm parenting relationships [ 16 , 17 , 18 , 19 , 20 , 21 ], drug substitution – in particular toward the use of cannabis [ 22 , 23 , 24 ], greater health consciousness amongst young people [ 9 , 25 , 26 ] and multiple mechanisms related to the proliferation of digital and internet-based technologies, including changes in the spatio-temporal structure of young people’s lives [ 9 , 27 ]. However, reviews have concluded that there remains insufficient evidence in favour of any of these explanations as a key driver of the decline in youth drinking [ 5 , 9 , 25 ]. Instead, researchers have increasingly sought more complex explanations that draw on the interaction of multiple factors or the extent of change is moderated by country-level characteristics [ 28 , 29 ], although these remain untested.

Qualitative studies echo many of these findings. For example, Torronen et al. [ 30 ] suggest, among other explanations, that drinking is no longer a key expression of normative masculinity, that social media deters drinking by facilitating surveillance of drunken behaviour while also provide socialising opportunities that do not involve drinking, and that a social trend towards healthiness has required a broad reorganisation of some young people’s habits and practices [ 31 , 32 , 33 ]. Despite some accounts suggesting that non-drinking is achievable due its normality within some age and peer groups [ 34 ], a separate literature also describes the complex strategies that many young people employ to achieve light drinking or abstinence. These include discrete management of consumption (e.g. pouring away half-finished drinks or pretending a non-alcoholic drink contains alcohol), claiming to be ‘taking a night off’ or actually having short- or long-term periods of abstinence while retaining the possibility of drinking in future [ 35 , 36 ]. Such strategies suggest that light- or non-drinking young people must still negotiate social tensions around alcohol consumption despite the decline in youth drinking, although successful negotiation of these tension may reinforce positive self-perceptions of autonomy, individuality and authenticity [ 37 ].

In this paper, we draw upon the social studies of childhood to inform a child-centred approach, and draw on two methods to explore young people’s own ideas about what might be driving the decline in youth alcohol consumption. This conceptual approach [ 38 ] is concerned with understanding “how children learn about the social world, the sense they make of it and the ways in which their experiential sense-making might shape the things they choose to do, the opinions they express and the perspectives on the world that they come to embrace and embody” ([ 38 ]:1). We take care to avoid the positioning of young people as somehow marginal to society and, instead, proceed from a standpoint that acknowledges that young people are active participants within society [ 39 ]. As social beings, young people learn about the world in which they live, and their place within it, through interactions with others. Our conceptual approach thus necessarily highlights the need to appreciate young people’s locatedness within networks of familial and extra-familial relationships of dependence, independence and interdependence [ 40 ].

Moreover, in grounding our research approach within the social studies of childhood, we also pay attention to the views of young people as individuals: “differentiated not only by gender, ethnicity, age or health status but also by the different and particular circumstances of their own biographies” ([ 38 ]:1). Reflecting this stance, we therefore present, in this paper, a child-centred account, articulated through the voices of individual young people and presented in verbatim quotes. This allows for an understanding of how young people themselves may be contributing to creating and sustaining the declines in alcohol consumption, rather than analysing these as phenomena happening to them and driven by forces external to them.

Data were generated in two phases between November 2018 and July 2019 within a convergent triangulation design [ 41 ]. This aimed to cross-validate young people’s perspectives on the decline in youth drinking using different data sources. In Phase 1, we undertook face-to-face discussions with young people in schools and other educational establishments. In Phase 2, we conducted an online survey to estimate the prevalence of different perspectives on the decline in youth drinking. As the survey used free-text responses, it also provided additional qualitative data to support the Phase 1 data. Triangulation took place during data analysis to align key themes across data sources, and then by comparing the prevalence of themes in the Phase 2 survey to their prominence and participants’ perceptions of their importance within the Phase 1 qualitative data.

Two age cohorts of young people were recruited: cohort 1 (C1) aged 12–15 and cohort 2 (C2) aged 16–19. These age cohorts were defined with reference to a larger project on the decline in youth drinking, of which this study is one component [ 42 ]. The data was collected in England, where the minimum legal purchase age for alcohol is 18. Although there is no prohibition on serving alcohol to anyone aged over five in a private home and over-16 s can consume alcohol (but not spirits) in a pub if it is served with a meal and they are accompanied by an adult, underage drinking is generally understood to mean drinking before age 18. We therefore treat such references in our data accordingly.

Phase one methods

Recruitment.

Ninety-six young people (Supplementary Table 1 ) were recruited from 5 socio-economically and geographically contrasting schools (two urban affluent, one urban deprived and two rural), two further education (FE) colleges and a university. All were within or close to a single city in the North of England.

Schools and FE colleges were identified by reference to the proportion of young people in each school in receipt of government financial support for school meals [ 43 ]. Rates of eligibility for free school meals are reported as percentage ranges to protect confidentiality (Table 1 ). Although free school meal data was absent for one of the FE colleges, it was chosen as a research site as it was situated in a highly deprived local authority area. The relative rurality of schools was determined through assessment of the distance between the school site and the city centre, and local area knowledge (these characteristics are not reported to protect the confidentiality of participating schools). University students were identified using an internal university email distribution list.

Recruitment was planned to take place in three schools (1 affluent, 1 deprived and 1 rural) As the first rural school admitted young people up to the age of 16 only, a second rural school, enrolling young people up to the age of 18, was also included. Following school-based recruitment and data collection, an under-representation of older, affluent school pupils was noted. Five additional C2 pupils from a second, urban affluent school were therefore recruited.

Information sheets were distributed prior to interviews, via email. For participants aged under 16, separate child and parent information sheets and parental consent forms were provided to schools, and distributed to both parents and young people.

All interviews were scheduled at the convenience of the educational institution and took place in either educational establishments or participants’ homes. On the day of the interview, the researcher recapped the information sheet and provided an opportunity to ask questions. All participants provided written consent and were advised that they could withdraw their consent to participate at any point. Written parental consent for young people aged under 16 was a prerequisite of participation. Participants were remunerated for their time with shopping vouchers and a small financial reward was offered to each participating school.

Data generation

Data were generated in 38 semi-structured, interviews. Participants had the option to participate individually or in friendship groups – according to their preferences. There was one individual interview with a university student and all other interviews were conducted in small friendship-groups, comprising between two and four young people. Friendship group interviews are argued to help young people to feel comfortable in sharing their views [ 44 ]. Interviews in schools ( n  = 31) and colleges ( n  = 4) were constrained by lesson duration and typically lasted between 40 and 60 min. The remaining interviews were not time-limited in this way and lasted up to an hour and a half. Interviews explored alcohol within the context of peer and family relationships, and in relation to other consumption and health practices. While interviews employed a range of creative, participatory methods (to be reported in a future publication), this paper reports young people’s spontaneous responses to the ‘mini-debate’ question, “why do you think young people today are drinking less alcohol?”.

Data analysis

Anonymisation of interviews took place at the point of transcription. Analysis was aided by the qualitative analysis software, NVivo 12. Given the congruence between the reasons for the decline that young people asserted in interviews and those discussed in the extant literature, debate data were deductively coded under the following headings: ‘Disputing the decline’, ‘Drug substitution’, ‘Digital technology’, Difficulty of access’, ‘Economic reasons’, ‘Parenting’, ‘Awareness of health risks’ and ‘Other’. Data recorded under each code was further sub-divided by educational context and age group. Members of the research team independently reviewed a sub-set of codes to facilitate an inductive, thematic analysis that facilitated the deduction of eight themes [ 45 ]. These initial eight themes were further refined via triangulation with the phase two data (see below). Final thematic headings are described at the start of the results section.

Phase two methods

Survey participants were recruited using targeted, paid-for advertisements on both Facebook and Instagram. This approach is responsive to the dynamic patterns of young people’s social media use [ 46 ]. The age range and geographical reach of the adverts aligned with Phase One of the methods to ensure a comparable sample. Participants provided consent before they were able to access the survey questions. Completion of the survey entered participants into a prize draw for a shopping voucher.

Participants completed an online survey, developed and administered using Qualtrics. The survey included two demographic questions (age and gender) followed by a free text question asking why the respondent thought youth drinking was in decline.

To reduce the likelihood that respondents would falsely specify their age in order to be eligible for the prize draw [ 47 ], we did not disclose the study’s age range to survey participants. Although we included all respondents in the prize draw, data from participants outside of the 12–19 age range were not included in our analyses. To minimise the time commitment required to complete the survey and promote engagement, we restricted the collection of demographic data to the factors noted (gender and age).

The online survey was completed over a period of two weeks, by 547 young people aged 12–19 years (Table 2 ).

Survey data were first stratified by age and gender before undertaking an initial reading of the free-text responses. Respondents typically provided a single sentence in response to the free-text question, but multiple reasons for the decline in youth drinking were often given.

The initial reading of the free-text responses suggested broad convergence with the eight themes identified in the interviews, but also enabled refinement of the initial themes as part of the triangulation process. For example, the concept of future orientations was developed to include notions of futurity related to work, not solely higher education. This refinement generated a common set of themes from phases one and two that structure our reporting of findings and comparison across data sources.

To assess the prevalence of each theme within the phase two dataset, we undertook a content analysis to code each of the survey responses to one of the eight themes and calculated the proportion of respondents citing each theme. Reflecting the multiple reasons that young people often gave in their free-text responses to the survey, individuals’ responses could be coded to multiple themes. Content analysis was undertaken by VW and PC, any coding disagreement was resolved by discussion. (Supplementary Table 2 ).

In the results below, we triangulate the phases one and two data by comparing the prevalence of themes in the survey with their prominence in the qualitative data and by using the free-text responses in the survey as qualitative data to provide support for or contrast with themes from the interviews. The information about the speaker provided after quotes is more detailed for phase one interviewees than phase two survey respondents, reflecting the data collected.

The research identified eight key themes that young people used to explain the decline in youth drinking: The research identified eight key themes that young people used to explain the decline in youth drinking: The potential for alcohol-related harm; Contemporary youth cultures and places of socialisation; The affordability of alcohol; Displacement of alcohol by other substances; Access and the regulatory environment; Disputing the decline; Future Orientations; and Parenting and the home environment.

The most commonly cited reasons for the decline in youth drinking identified by survey respondents fell under the themes ‘the potential for alcohol related harm’ (32%), contemporary youth cultures and places of socialisation (27%), and ‘affordability’ (22%). Young people were least likely to provide responses categorised as ‘parenting’ (6%), ‘future orientations’ (8%), or ‘disputing the decline’ (9%). There were some notable differences in responses between age cohorts, with largest disparities seen in relation to the themes of: affordability (C2 = 29%; C1 = 10%) and displacement of alcohol by other substances (C2 = 21%; C1 = 10%) (Supplementary Table 2 ; Fig.  1 ).

Percentage of respondents citing explanations for the decline in youth drinking by cohort and gender

In the following sections we use the interview data to discuss each theme, starting with those cited by most respondents in the survey, and then use the survey data to provide additional insight.

The potential for alcohol-related harm

Young people consistently noted a diversity of risks associated with the consumption of alcohol. There was broad understanding of the chronic health harms associated with alcohol consumption, including liver disease, cancer, mental ill-health, dependence and death, although cardiovascular risks were a notable omission from young people’s responses. However, concern for the shorter-term or social consequences of alcohol consumption were also prominent and included: public drunkenness, damage to personal relationships, accidents and drink-driving. Some girls also stressed the possibility of gendered risks: sexual violence for girls and physical violence for boys.

C2 participants additionally drew upon their experiential knowledge of alcohol consumption to emphasise the undesirable effects it could have, including vomiting, anti-social behaviour and hangovers, all of which were argued to be deterrents to drinking. Henry, for example, asked: ‘Who wants to really throw up and have a hangover? I mean it’s not really worth it in my opinion’ (male, C2, University Student).

Different patterns of drinking were, however, thought to be associated with different levels of risk of harm. Binge drinking, or daily drinking, were considered the antitheses of safe drinking. Nevertheless, alcohol consumption was generally described as purposeful and oriented towards intoxication to some degree; ‘I only want to drink if I know I’m going to feel the effects’ (Charlotte, female, C2, urban affluent). In this context, ‘properly-managed’ drunkenness was seen as a positive outcome of drinking, associated with a level of risk of harm that young people were prepared to accept.

Among survey respondents, the potential for alcohol related harm was the most frequently asserted contributory factor to the decline in youth alcohol consumption (32%). This remained true when sub-dividing responses by age and gender. In both datasets, discussion of risk and the associated patterns of self-governance were explicitly linked with the desire to avoid health-related harms, rather than a decision to promote healthy lifestyle choices.

Contemporary youth cultures and places of socialisation

Several aspects of contemporary youth culture were considered to be mediators of reductions in youth alcohol consumption by interview participants. In summary, these elements related to the timing and locations of young people’s alcohol consumption, and – as also suggested in the parenting theme below—a shift in the social cachet of alcohol for today’s young people relative to prior generations.

First, infrequent socialisation outside of the home during the school week and the importance of social media for everyday socialisation were highlighted. This was especially evident in the accounts of participants still in compulsory education and aged under 18. Moreover, there was also general agreement that young people benefited from the availability of diverse forms of distraction and entertainment – particularly, though not exclusively, associated with the use of social media—that both mitigated against boredom and facilitated forms of peer interaction within which alcohol played little, if any, part.

Second, legislative restrictions have significantly curtailed contemporary young people’s access to spaces licensed to sell alcohol and young people have responded with a shift away from public sites of alcohol-related socialisation, such as pubs. Drinking outside in parks or ‘the woods’ was also frowned upon and considered a mark of immaturity, or an unnecessary risk. Consequently, underage drinking was largely limited to parties within private homes, at weekends, or on special occasions. Drinking occasions were also timed to ensure they did not coincide with exams or impede study.

Third, alcohol was argued to have lost much of its potency as a marker of rebellion within youth culture: ‘you’ve not got the people trying to be like “Oh, I’m breaking the rules, I’m doing something I shouldn’t”, trying to get attention’ (Kelly, female, C2, rural). Young people across the age range noted both a lessening of pressure from peers to consume alcohol (compared with what they assumed had been the case previously) and a greater acceptance of abstinence. Nevertheless, alcohol retained value as a social lubricant for university students and there was a perception of other – and othered—manifestations of peer culture, within which alcohol consumption was more prevalent.

It probably varies a lot around the UK, […] where in some parts it’s kind of cool to go out drinking both days of the weekend like Friday, Saturday, Sunday, like, skipping school to go and get mashed or whatever, but then I kind of hear that’s just a bit desperate, like. (George, male, C2, urban affluent)

Changes in youth cultures and in young people’s experiences and places of socialisation were the second most common theme in the survey data (27%). Within this theme, and consistent with the interview data, three sub-themes were identified. First, alcohol was described as no longer highly valued in youth culture, partly due to its ubiquity, and a resultant lack of ‘hype’ or ‘coolness’ around it: ‘It’s become almost normalised to drink alcohol as you grow up you realise it’s not as rebellious as it seems and it loses its thrill in a way’ (C1 female). Second, young people described themselves as being able to enjoy themselves without recourse to alcohol (‘They don’t need it to have fun’, C1 male). Third, relative to prior generations, young people described themselves as having less free time, as socialising less frequently, and as socialising in ways that did not require leaving the home and/or face-to-face interaction.

The affordability of alcohol

Young people commonly referred to cost when discussing the decline in youth alcohol consumption. However, this played out quite differently among young people from different contexts. Young people in the affluent schools emphasised the relative cost of alcohol within a broader landscape of purchasing decisions. Although they had access to money to spend, they preferred to use this to purchase food, clothes, books or public transport rather than to buy alcohol:

Interviewer: What is it you choose to spend your money on then? Tom: Going to town, snacks from Sainsbury’s [ major supermarket chain ] and stuff. (male, C1, urban affluent school).

A few of the C2, affluent young people also reported saving their money for significant projects: university or to take holidays with friends. In contrast, young people from the deprived and rural schools, and from the FE colleges, indicated that they lacked adequate access to financial resources and the cost of alcohol was seen to be a deterrent to drinking, particularly when purchased in city centre locations. Maisie, for example, declared drinking in town to be: ‘More expensive, innit [isn’t it]’ (female, C1, rural school).

Whilst recognising that alcohol pricing might deter young people from some consumption practices, participants also pointed to taking alcohol from parental stores or purchasing cheap forms of alcohol as low-cost alternatives.

Cost was the third most commonly cited reason for the decline amongst survey responses (22%). In contrast to the interview data, where perspectives were differentiated most obviously by socio-economic status, survey responses referring to costs were differentiated by age. Reflecting the reality that most underage supply of alcohol is social [ 48 ], C2(29%) – not C1 (10%)—respondents tended to assert the high cost of alcohol as a plausible contributor to the decline in youth drinking.

Displacement of alcohol by other substances

All references during interviews to the displacement of alcohol by other substances occurred in discussions with C2 participants, potentially reflecting the greater likelihood of older adolescents having direct or indirect experience of wider substance use. Faith (female, C2 further education college), for example, explained that ‘there’s other things like drugs. If they’re not drinking alcohol I feel like they might be doing drugs such as weed.’ Weed (cannabis) was the most frequently mentioned alternative substance in all educational contexts.

Displacement of alcohol by other drugs was considered to be driven by ease of access: ‘it’s just easier to get other things now than it is to get alcohol because you don’t need ID to go and buy some drugs off some random man, do you?’ (Annabelle, female, C2, rural). For those in the deprived school where limited financial resources were noted as a barrier to alcohol use, drugs could also offer a cheaper alternative: ‘obviously alcohol’s monitored, it’s taxed, things like that, but obviously you can’t go to the shop and buy Spice, meaning you’re going to get it for less.’ (Liam, male, C2, urban deprived).

Further, the relative risk of using cannabis, compared with consuming alcohol, was thought to be low: cannabis was argued to have ‘far more benefits than disadvantages’ (Charlotte, female, C2,urban affluent). Cannabis was felt to allow young people to experience a pleasurable ‘high’ without the risk of a hangover the following day and, for affluent young people, the consequent negative effects that this could have on school, university or other work. In this way, the displacement of alcohol by cannabis was framed as a positive choice – derived from young people’s future orientations toward their education and their health.

Reflecting interview responses, age was also an important intersection in the survey data. As noted earlier: 21% of C2 respondents cited drug substitution as a plausible driver of decline, but only 10% of C1 respondents did. Overall 17% of respondents suggested that the substitution of alcohol by other substances might be contributing to the decline in youth drinking. The ready availability and the low cost of alternative substances, in comparison with the cost of alcohol, was reaffirmed by survey respondents.

Access and the regulatory environment

In interviews, young people across contexts and age cohorts, referred to a stricter regulatory environment as a reason for the decline in youth alcohol consumption. Participants cited family stories as key to their understandings of such changes. The penalties imposed on retailers who sell alcohol to young people were highlighted, in particular ‘Challenge / Think 25’ (a scheme that encourages retailers to check the identification of anyone who looks under 25 to prevent sales to under-18 s). Olivia, for example, noted:

Well I would have said it’s got a lot stricter, like, whenever I talk to my mum about it or my grandparents, like, my granny was talking the other day about it and she was saying that, you know, she’d go to the bar at fourteen and get served and not be questioned. (Olivia, female, C2, university student).

Although increased regulation could make access to alcohol more difficult, young people described strategies used to mitigate the deterrent effect. These included buying or borrowing identification in order to purchase alcohol, or drawing on parents’ willingness to supply alcohol to young people.

Perhaps reflecting the ability of young people to bypass restrictions on their access to alcohol (or their lack of desire, or need to buy alcohol), the regulatory environment was only cited in 11% of survey responses. Stricter laws, more stringent enforcement, and policing of regulations, and increasing surveillance of licensed venues were nonetheless considered to be contributory factors to reductions in youth drinking within survey data.

Disputing the decline

Few young people were aware of the decline in youth drinking. Indeed, a notable minority argued that alcohol remained highly visible in their everyday lives or peer relationships. The claim that drinking was in decline was therefore openly challenged by a number of participants from all educational contexts. Charlotte (female, C2, urban affluent school), for example, noted that: ‘I honestly don’t feel that there’s a visible decline, obviously we didn’t see our parents when they were teenagers, but I wouldn’t say we don’t drink a lot’.

The same scepticism was evident but less prominent in survey responses, being cited by only 9% of respondents. While the majority of such respondents simply denied that there had been a decline, with statements such as “They’re not [ drinking less ]”, some drew on personal experience to report heavy drinking either in their neighbourhood or amongst their peers. A small number of respondents suggested that that drinking had been masked, rather than reduced, by young people’s increasing skill in hiding their alcohol consumption from the adult gaze: “they’re just sneaky about it” (C1, girl) and are “doing it more secretly” (C2, boy).

Future orientations

A number of C2 young people in the affluent schools described their generation as more mature and responsible than previous generations and more concerned about ‘doing well’ to secure their futures.

‘I think especially like in sixth form [ the final two years of secondary school education, typically ages 16-18 ], like, it is a lot of work, we have like a lot of homework and everything and I feel like everyone wants to do good’ (Agnes, female, C2, urban affluent).

George and Alice (male and female, C2,urban affluent) also noted, they did not want to ‘throw away’ the opportunities that school offered them and young people in the affluent school were keen to achieve their academic potential and to study at university. School-related work was therefore an important structuring element in their everyday lives, as Iqbal (male, C2, urban affluent) made clear. He described spending ‘a few hours every day or something like that, just to like get homework done literally and keep up with notes, you’ve got to do a set amount’.

Focussing on educational achievement was seen as key to optimising young people’s futures and therefore as antithetical to drinking. As such, it was a plausible reason from the participants’ perspective for the decline in youth alcohol consumption.

Although ‘future orientations’ was amongst the least frequently cited reasons for the decline in the survey data (8%), a concern for young people’s future wellbeing was nonetheless evident. One young man (C1) noted: ‘We’re more worried about our futures than anyone so far – we don’t have the time or the privilege to waste getting drunk’. In contrast to the interview data where there was a predominance of data from C2 participants from the affluent school, evidence that concern for the future constituted a reason for declines in youth drinking emerged in the survey at a consistent level across age cohorts (8%); there was no socio-economic data to cross-reference. The aforementioned absence of data relating to ‘future orientations’ from specific subsets of young people within interviews cannot necessarily be interpreted as indicative of a difference in mind-set, however.

Parenting and the home environment

Young people in interviews highlighted changes in parenting practices as significant for the decline in youth drinking. Nafeesa (female, C2, further education college), for example, suggested: ‘I think parents probably might be stricter and might have an influence’. Contemporary parents were described as more concerned about under-age drinking than previous generations of parents and were thought to maintain closer surveillance over their children. C1 young people asserted that their parents would not wish them to drink at all while, within C2 accounts, parents were noted to advocate responsible drinking practices.

With the exception of families with religious beliefs that did not allow the consumption of alcohol, the majority of young people noted the continuing presence – rather than the absence—of alcohol and its ready accessibility in their home environments. Young people were therefore often able to access alcohol in the home either without parental permission—by ‘sneaking’ a drink (Jessica, female, C1, urban deprived), or with parental permission as part of their induction into ‘responsible drinking’. For example, Kelly (female, C2, rural), noted that her ‘first taste’ of alcohol was provided by her mum, at home.

Similar issues were raised by survey respondents. Although changes in parenting were least commonly noted as potential contributors to the decline in youth drinking (6%), similar sub-themes were identifiable in the free-text data. Respondents described contemporary parents as ‘stricter’, more controlling or more protective. However, a small number suggested that rather than being more controlling, some parents were more lenient and permissive, normalising drinking ‘so it becomes less of a taboo’ (C1 female), and ‘Because our parents let us drink small amounts younger, therefore meaning that as we get older, the urge to drink is much less severe’ (C1, male).

The research identified eight key themes that young people used to explain the decline in youth drinking and these were largely consistent across the two phases of the research. The themes were: Disputing the decline; The affordability of alcohol; Access and the regulatory environment; Parenting and the home environment; Future Orientations; Displacement of alcohol by other substances; The potential for alcohol-related harm; and Contemporary youth cultures and places of socialisation. The survey data additionally demonstrated a degree of heterogeneity in the experiences and perspectives of different groups of young people, such that those of different ages, gender, and socio-economic position appeared more or less likely to identify particular explanations for the decline.

The key themes derived from young people’s perspectives resonated strongly with reasons for the decline of youth drinking that have been hypothesised in the academic literature. Building on this, we further describe the importance of place and the responsibilisation of youth in shaping contemporary youth drinking practices in England. While both the qualitative data and the survey responses addressed a range of factors thought to be contributing to the decline in youth alcohol consumption, changing notions of risk and the ways these are interwoven with shifting social contexts appear to underpin many of these. In some cases, risk related to young people’s perceptions of risks to themselves, while in other cases risk related more to others’ perceptions of risks associated with young people.

For example, respondents highlighted the stringent regulatory retail environment for alcohol and the difficulties that under-age consumers had in accessing alcohol from licensed vendors. Regulatory changes in the UK have, to some extent, been driven by the desire to prevent binge drinking and the crime and anti-social behaviour associated with it, and to deter underage drinking. This arises in part from the growing understanding of the potential and specific damages of alcohol to young people [ 49 ], as well as the perceived threat that disorderly behaviour by young people poses to wider society [ 50 ].

Partly as a result of these regulatory constraints on access to alcohol and also the high cost of alcohol in licensed premises [ 51 ], drinking was almost entirely limited to the home for today’s underage drinkers. Domestic spaces were also key sites for drinking and ‘pre-drinking’ by those aged 18 and over [ 52 , 53 , 54 ]. However, this ‘homification’ of young people’s alcohol consumption also arises from other non-risk related factors. In the UK context, for example, specific policies targeting anti-social behaviour have sought to problematise and diminish young people’s presence and visibility within outdoor public spaces (for example, [ 55 ]). Such policies, we argue, reflect well-established contentions that some young people are seen to be ‘risky’ in public spaces, while others are ‘at risk’ [ 56 ]. And as James ([ 38 ]:15) has noted, young people’s social embeddedness means that they are, inevitably, influenced by such cultural moralities and institutional constraints.

Young people highlighted that underage drinking has become less socially acceptable to contemporary youth. Both displays of public drunkenness (in digital or physical spaces) and drinking in outdoor spaces – a practice reported for previous generations of youth, were denounced. This was particularly true within affluent and Higher Education contexts, perhaps suggesting that the ‘sensible, low-risk drinking message’ advocated within the English National Alcohol Strategy 2007 [ 57 ] has perfused cultural sensibilities in at least some sub-groups of young people. In addition to their denouncement of risky drinking, however, participants also described diversification of young people’s leisure-time activities – often including the physically-distanced use of digital media and/or gaming – that have opened up opportunities for young people to socialise in ways that do not involve alcohol consumption [ 30 ] and which, often, exclude the use of outdoor and public spaces.

Although evidence for changes in parenting styles over time is sparse [ 58 ], young people postulated that parenting had changed toward greater levels of strictness and surveillance. In general terms, this reaffirms accounts describing the intensification of contemporary parenting and greater levels of risk aversion amongst contemporary parents [ 59 ]. In terms of alcohol drinking specifically, it also echoes Larm et al.’s [ 58 ] finding that parental monitoring and restrictive parental attitudes toward alcohol have increased during the period of declining youth drinking. Moreover, some young people in our study suggested a more complex relationship between changes in parenting and trends in youth drinking, perhaps reflecting the diversities in familial adult–child relations, characterised by Zeiher [ 40 ] as dependent, independent and interdependent. Young people in our study argued that it is the relative leniency of contemporary parenting that may support declines in drinking by reducing the need for young people to rebel against parental rules. Nevertheless, findings in the broader alcohol literature suggest that parents harbour concerns that ‘strictness’ in relation to alcohol consumption can be counter-productive [ 6 , 60 , 61 , 62 ]. Any association between particular parenting styles and the emergence of recent alcohol trends is therefore unclear.

Young people’s suggestion that they exhibit greater maturity and responsibility than previous generations was closely aligned to how they made sense of the ‘risks’ posed by uncertain futures [ 63 ]. Educational success was considered key to some young people’s accomplishment within an increasingly competitive global economy. Consequently, young people restricted their drinking occasions to time periods when alcohol consumption would not impede their attainment. However, an important caveat to this finding is that a number of interview respondents were at a time in their education where they were due to sit national examinations and this may have sharpened the importance of educational success in their mindsThis finding aligns with the reduced frequency of alcohol consumption amongst 11–24 year olds in England [ 4 ]. The lack of references to the importance of education amongst deprived interview respondents, however, potentially reaffirms the centrality of class as a critical factor in the future economic security, and the educational experiences and aspirations of today’s young people [ 50 ]. It also confirms and reinforces the need to understand how perspectives and expectations, as they relate to alcohol consumption, manifest for individual young people who are variably located with respect to such issues as class, ethnicity, gender and age.

While the UK Office for National Statistics (ONS) [ 64 ] has described today’s young people as ‘Generation Sensible’ because they’shun alcohol, tobacco and even sex’, declines in youth drinking have also been accompanied by declines in youth drug taking in England [ 42 ]. Despite this apparent risk aversion, young people in our study – particularly those aged-16–18 for whom drugs were visible in their everyday lives—considered drug substitution a plausible reason for declines in alcohol consumption. They emphasised cannabis as a key substitute for alcohol, cohering with data demonstrating that this is the most commonly used drug amongst young people [ 65 ] and reinforcing the suggestion that polices designed to limit alcohol use may have the unintended consequences of increasing cannabis use among some young people [ 66 ]. Cannabis was seen to be an accessible, low cost substitute for alcohol, echoing findings from a recent review by Subbaraman [ 67 ], which suggests that substitution is likely to occur in environments in which cannabis can be obtained with relative ease. However, importantly, substituting alcohol with cannabis was viewed as a risk-reducing activity. Our respondents argued cannabis has positive benefits for young people. They thought it was less harmful and less likely to be associated with negative effects on their school or work lives when compared to alcohol.

Alcohol–related harm was strongly associated, by young people, with notions of binge drinking [ 68 ]. In our study, young people sought to distance themselves from the notion of binge drinking and from the pejorative associations between youth and excessive (‘morally questionable, unregulated’ ([ 69 ]:154)) alcohol consumption that have been the subject of sustained media and political condemnation [ 70 , 71 , 72 , 73 ]. Young people sought to distance their own ‘unproblematic’ or ‘social drinking’ from problematic ‘binge drinking’. This distinction, which drew upon ‘subjective personal assessment(s) of drunkenness’ ([ 73 ]:212) was well illustrated by one participant, Greg, who noted that 6 or 8 units of alcohol consumed over a short period of time would be considered to be binge drinking [ 73 ]. Yet, his own consumption of ‘maybe 3 pints’ over a couple of hours was deemed acceptable, despite the equivalence in terms of units of alcohol (Greg, male, C2, University Student) [ 57 ]. Our findings therefore further illustrate the importance that contemporary young people attribute to self-governance, individualised management of risks and deliberative and controlled attitudes to pleasure [ 37 , 69 , 74 , 75 ]. They also highlight that risks assumed particular significance in light of young people’s future-oriented concerns and were intentionally moderated in light of such concerns.

This study’s young-person-centred approach provides important, contextualised understandings of the decline in youth drinking and, through this, extends the extant academic and policy literature. Additionally, interview data was generated with a diverse sample. Close alignment between the questions asked in the survey and the interview allows critical comparison between the two datasets. This is a novel approach in this field.

Our commitment to a child and young person centred approach throughout the research process enabled the active participation of young people in data generation, supported young people’s agency and demonstrated the extent to which individual young people’s expressions of their agency are inevitably influenced by their social context [ 76 ]: as Smart [ 77 ] has noted, young people’s lives are characterised by ‘”connectedness and embeddedness in and with the social and the cultural” ([ 77 ]:188). This interconnectedness, and young people’s embeddedness within particular social and cultural contexts, is reflected in our findings, providing a reminder of the need to recognise diversity between young people, as well as the commonality within the themes presented in this paper.

Limitations

A number of limitations to this study need to be acknowledged. While this paper presents findings from England, all data were generated with 12–19 year- olds in one post-industrial northern city. The potential for national, regional and/or local variability and amongst young people up to the age of 24 (who have also shown declining consumption) merits exploration. Further, recruitment of rural schools was challenging. The catchment areas of the rural schools that were recruited included young people living in rural, peri-urban and urban areas who were also relatively, socio-economically deprived (as assessed by proportion of Free School Meal recipients). Moreover, we were unable to recruit young people who were not participating in formal education (those not in employment, education or training – often referred to as NEETs), despite identifying the importance of understanding their perspectives.

While the sample for phase one of the study was ethnically and socioeconomically diverse we did not collect data regarding ethnicity, socioeconomic position or urban/rural location for our phase two participants. The relative diversity of survey respondents is therefore unknown. Female and C2 survey respondents also outnumbered male and C1 respondents. Interpretation of the frequencies of responses by theme should be viewed in light of this imbalance, although the purpose of the survey was to provide indicative evidence of the prevalence of different perspectives rather than representative population data.

A further important limitation was associated with the need to curtail interviews in schools and colleges when students had to move to their next lesson, meaning that not all participants were asked to speculate on reasons for the decline.

Implications for policy and practice

This paper demonstrates the importance of understanding alcohol consumption within the context of broader youth cultures and consumption practices, as well as wider public policy affecting youth [ 78 ]. Through this, the salience of risk in shaping youth behaviours is highlighted. Moreover, this paper emphasises the necessity of approaches to health promotion and protection that do not attribute primacy to one factor, but appreciate the interconnections and overlap between individual drivers of health trends.

Understanding young people’s own perspectives on factors contributing to the decline in alcohol consumption could help to sensitive and optimise public health policies aimed at young people in the future, for as James ([ 38 ]:174)points out, what young people do or say “can have an effect on other people, ideas, events and also on the ways in which policy interventions in their lives take root or not”.

Implications for research

The reasons highlighted by young people as drivers of declines in youth alcohol drinking may be more or less salient for different groups. Although our analyses highlight gendered, age-based and socioeconomic divergences in the data, particularly in relation to affordability, other substance use, further enquiry in relation to these intersections and urbanity/rurality would be of value. Additional qualitative enquiry with older age cohorts would complement and permit further interrogation of the assumptions young people in this study make about changes in youth culture over time and the experiences of prior generations of young people. 

This paper highlights the commonality between the reasons young people assert and those given attention in the academic and policy literature. Importantly, the divergent ways in which declines in youth drinking are understood and experienced between different groups of young people. We conclude that there is a perceived cultural shift between generations of young people, manifesting in terms of their spaces and places of socialisation, and shifting attitudes towards risk, self-governance and the future.

FE (Further Education) colleges provide educational opportunities for students aged 16 or over in England. Students usually follow courses that are necessary to progress into Higher Education (the University sector), or into a specific career path.

Availability of data and materials

The datasets used and/or analysed during the current study are available in anonymised format from the corresponding author on reasonable request.

Abbreviations

Not in employment, education or training

United Kingdom

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Acknowledgements

The authors would like to thank participating educational establishments, young people and their families for their time and effort expended in taking part in the study.

This work was supported by Wellcome (Grant Number: 208090/Z/17/Z).

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VW, PC, and HF conceived and designed the paper. VW and MO undertook design of the online survey and collection of survey data. VW, HF, and PC undertook design of interview methods and interview-based data collection. Thematic analysis of interview data was undertaken by VWPC and HF; content analysis of survey data was undertaken by VW and PC. These authors also wrote the paper. All authors contributed comments leading to substantive revisions of the paper by VW. All authors read and approved the final manuscript.

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Whitaker, V., Curtis, P., Fairbrother, H. et al. Young people’s explanations for the decline in youth drinking in England. BMC Public Health 23 , 402 (2023). https://doi.org/10.1186/s12889-022-14760-y

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Underage Alcohol Use

Late adolescence (i.e., the age-group between 16 and 20 years) is characterized by significant changes in neurological and cognitive processes, behavioral and social functioning, and relational and physical contexts as the individual moves toward adulthood. In this age-group, major role transitions affect almost every aspect of life. Moreover, brain development continues—and with it the development of cognitive functions, working memory, emotional and behavioral self-regulation, and decisionmaking. The adolescent’s social and emotional development also continues to evolve, affecting interactions with parents, siblings, peers, and first romantic relationships. All of these changes impact drinking behavior during late adolescence, and, in fact, alcohol use, binge drinking, and heavy drinking are particularly prevalent in youth ages 16–20. Determining the common trajectories of drinking behavior in this age–group is important for understanding how adolescent alcohol use helps shape adult outcomes and for identifying risk and protective factors. It also is important to study the short- and long-term consequences of adolescent alcohol use and abuse, including alcohol’s effects on the developing adolescent brain and accomplishment of important developmental tasks of this age.

The preceding articles in this journal issue have reviewed the developmental processes and mechanisms that are characteristic of childhood and early adolescence. Continuing this review, this article focuses on late adolescence—the period between ages 16 and 20—which is characterized by increasing autonomy and independence as individuals move toward adulthood. (For more information on the definitions of adulthood, see textbox “ What Constitutes Adulthood? ”) This period is marked by significant changes in neurological and cognitive processes, behavioral and social functioning, and relational and physical contexts. It also is a time when alcohol consumption may escalate and, in many adolescents, can include binge and heavy drinking. In fact, the prevalence of onset of alcohol use disorders (AUDs) is higher in 18- to 20-year-olds than any other time across the life span.

What Constitutes Adulthood?

The definition of adulthood depends on the context. Adult legal status is generally determined chronologically, and in the United States and much of the Western world, the “age of majority,” when a person attains most rights, is age 18. The most common rights conferred at this age are voting, contractual capacity, and financial responsibility. Some legal obligations, on the other hand, attach earlier. For example, in most States, adolescents can be held criminally responsible and become subject to the jurisdiction of the criminal court at age 16. Conversely, a few privileges are accorded at a later age, including eligibility to rent a car (minimum age ranging from 21 years up to 25 years) and the right to purchase alcohol (age 21). Developmentalists point to different hallmarks when defining adulthood, including finding a life partner, settling into a career path, and having children. Substantial variability exists in the timing and sequence of these milestones, and today youth are reaching adult independence and responsibilities at later ages than in prior generations. Scientists have termed this extension of adolescence (ages 18–25) “emerging adulthood” ( Arnett 2004 ), which is seen as continued preparation for full adult status.

The interrelated cognitive, biological, social, and affective changes that unfold during late adolescence interact and ultimately influence an adolescent’s risk of developing alcohol-related problems. Alcohol involvement in adolescence has short- and long-term consequences on health and well-being. Problematic drinking has the potential to redirect the normative course of adolescent development in ways that increase risk not only for AUDs but also for a range of mental health and social problems. After summarizing the normative development of 16- to 20-year-olds, this article reviews the alcohol use patterns of this age-group, as well as the risk and protective processes shaping alcohol use. Finally, the consequences of adolescent alcohol use and abuse are discussed.

Normative Development for Ages 16–20: An Overview

During late adolescence, development continues to unfold as new challenges emerge that require adaptation to the increasing responsibilities and changing circumstances of young adulthood. Changes occur both within the individual and in the adolescent’s physical, relational, and social contexts, with major role transitions affecting every domain of life ( Schulenberg et al. 1997 ).

Developmental Tasks and Transitions

The following are the key developmental tasks and transitions from ages 16 to 20:

• Taking increasing responsibility for one’s daily life, behavior, and future;
• Moving toward less dependent and more mature relationships with the family of origin;
• Moving toward more mature relationships with peers;
• Obtaining a driver’s license and driving, often with a graduated increase in privileges and responsibilities (e.g., learner’s permit, provisional license);
• Exploring romantic and sexual relationships and beginning to date;
• Achieving the age of majority with its associated rights and privileges as well as increased accountability, such as financial responsibility, legal liability, and voting;
• Leaving home and living on one’s own;
• Preparing for and initiating adult occupational roles (e.g., by finishing high school, pursuing postsecondary education, and/or seeking formal paid employment); and
• Cohabitation, engagement, marriage, and/or childbearing for some individuals.

Key Developmental Contexts

The period between ages 16 and 20 is characterized by major role transitions in almost every domain of life ( Schulenberg et al. 1997 ). However, although all youth are moving toward greater independence, the timing, sequence, and occurrence of role changes differ greatly among adolescents ( Hogan and Astone 1986 ). Compared with earlier developmental transitions, those that occur during late adolescence are less constrained by age and reflect the greater number of options available to older youth. Therefore, individual differences become increasingly important during late adolescence.

Physical Contexts

Although virtually all younger children attend school, for older adolescents this is not the case. For example, 86 percent of adolescents complete high school, but only 62 percent of those enroll in college the year after their high school graduation; others enter the workforce or join the military. Compared with younger adolescents, the living situations of older adolescents are more diverse, reflecting academic and vocational choices as well as family and other circumstances ( Brown 2008 ).

Societal and Cultural Influences

The salience of social and cultural influences increases during late adolescence. Their impact on academic achievement, dating and finding a romantic partner, leaving the parental home, becoming a parent, and many other contexts and transitions differs in complex ways by gender, ethnicity, socioeconomic status, neighborhood, and country of origin, in part because of the diversity of available options and supports ( Settersten et al. 2005 ).

Development Across Multiple Domains

Brain maturation.

Contrary to what scientists once thought, the brain continues to develop throughout adolescence and into young adulthood, and different regions mature at different times in development ( Spear 2000 ). A number of neuro-maturational processes occur during late adolescence that underlie improvements in cognitive functioning and neural efficiency ( Gogtay et al. 2004 ). These processes include synaptic refinement—which sometimes is referred to as “synaptic pruning” to describe the reduction of synapses and can be detected as a decrease in cortical gray matter volumes ( Giedd et al. 1999 ; Gogtay et al. 2004 )—and an increase in myelin, 1 which can be detected as an increase in white-matter volumes ( Giedd et al. 1999 ; Paus et al. 1999 ). Together, these changes enhance the efficiency and speed of transmission of neural signals, thereby increasing the capacity for more complex higher-order reasoning and processing. This period of active brain development appears to make the brain more vulnerable to neurotoxic processes, including those attributable to heavy alcohol exposure ( Spear 2000 ).

Cognitive Development

Executive functions mediate the complex interplay between thinking, emotion, and social judgment. They include goal directedness, independent initiation of behavior, inhibition of inappropriate behavior, flexibility, abstract reasoning, reward appraisal (i.e., evaluating reward likelihood and using reward appraisal to guide behavior), and social appraisal (i.e., understanding social norms and incorporating social information into decisionmaking). Executive functions allow individuals to consider goals, social contexts, and rewards, as well as to regulate response initiation and inhibition. They are pivotal to the two primary cognitive tasks of adolescence: development of the capacity to integrate information from diverse sources relevant to a goal and development of personal rule sets that efficiently guide behavior toward future goals. (For the role of poor executive functions in risk of alcohol abuse, see textbox “ Poorly Developed Executive Functions May Predispose to Alcohol Abuse .”)

Poorly Developed Executive Functions May Predispose to Alcohol Abuse

Research has confirmed an association between executive functions and alcohol and other drug abuse in adolescents. Poorly developed executive functions are characteristic of youth at high risk for developing alcohol/ substance abuse problems, such as adolescents with conduct disorder, adolescents with high MacAndrew addiction scale scores on the Minnesota Multiphasic Personality Inventory (MMPI), and children of alcoholics. Adolescents with attentional disorders (which by definition indicate impaired executive functioning) have high rates of alcohol and other drug abuse and dependence, especially when they also have a conduct disorder. Executive function scores also predict age at first drink, which is consistent with the finding that students using alcohol prior to the 6th grade have less well-developed decision-making skills. In children of alcoholics, executive function scores predict reactive aggression and the number of drinks per drinking occasion.

In addition, less well-developed executive functioning can combine with coping styles and temperament to increase adolescent vulnerability to substance abuse. Poorer executive functioning in social drinkers has been associated with lessened awareness of abuse consequences and may alter the effectiveness of prevention programs aimed at adolescents.

Part of an adolescent’s improvement in inhibitory control, which develops throughout adolescence, may simply be attributed to increases in the speed of processing within the brain ( Christ et al. 2001 ). The strategic, supervisory, and self-monitoring aspects of executive functioning continue to develop in adolescence, particularly the effective use of available strategies ( Suzuki-Slakter 1988 ). Studies have revealed differences between boys and girls in executive function development. Whereas girls may develop flexible control of verbal processing more quickly than boys, who may not achieve mature verbal control until their late teens ( Levin et al. 1991 ), girls generally lag behind boys in development of the abilities to perform certain nonverbal tasks ( Davies 1999 ).

Working Memory

The term “working memory” refers to a set of interrelated cognitive processes that result in the ability to temporarily maintain and manipulate information ( Baddeley 2000 ). This ability is central to language comprehension, abstract reasoning, learning, and memory. Verbal and spatial working memory abilities improve throughout childhood and adolescence, and working memory for spatial stimuli in particular continues to mature during adolescence ( Luna et al. 2004 ). For example, older adolescents are more accurate and react more quickly than younger adolescents during tasks involving spatial working memory ( Kwon et al. 2002 ). Brain-imaging research suggests that adolescents and adults activate similar brain regions when performing working memory tasks ( Thomas et al. 1999 ), although adolescents show greater and more widespread activation relative to adults ( Klingberg et al. 2002 ; Kwon et al. 2002 ). Compared with younger adolescents, older adolescents show increased activation of frontal and parietal brain regions during working memory tasks.

Development of Emotional and Behavioral Self-Regulation

Self-regulation is the ability to control emotion and behavior, plan behaviors, and resist the impulse to engage in behaviors that result in immediate or delayed negative consequences. Individuals with poorer self-regulation tend to have problems in adolescence and adulthood. One way to measure self-regulation is by maternal report; such studies indicate that self-regulation increases throughout childhood and early adolescence and is relatively stable by late adolescence, with higher levels for girls than boys ( Raffaelli et al. 2005 ). Of note, poor self-regulation early in life, such as the inability or unwillingness to inhibit behavioral impulses in preschool-aged ( Caspi et al. 1996 ) or in elementary school–aged ( Elkins et al. 2007 ) children, predicts AUD risk in late adolescence and early adulthood.

The ability to regulate behavioral impulses is especially important during adolescence, when exposure to risk situations increases. Interestingly, by age 15, adolescents appear to be as capable as adults at logically assessing the likelihood of risk and their own vulnerability to risk; however, adolescents are more likely than adults to engage in risky behaviors ( Reyna 2006 ). Their propensity toward risk taking appears to be linked to the way adolescents process social and emotional cues. Adolescent risk taking may serve a social function because studies show that risk taking increases when adolescents are in the presence of their peers ( Gardner and Steinberg 2005 ). Emotionally charged situations also accelerate adolescent risk taking, possibly reflecting the differential maturation of the brain regions governing emotions compared with those involved in self-regulation ( Steinberg 2004 ).

Decisionmaking

Decisionmaking is the complex process of choosing an action among different options with various possible outcomes. It involves multiple and sequential use of cognitive processes—for example, logical reasoning ( Mueller et al. 2001 )—as well as management of reasoning biases and judgment of reasoning success ( Klaczynski 2001 ). All of these abilities develop across adolescence, albeit at different rates ( Ormond et al. 1991 ). In particular, social judgment and social problem solving also improve throughout adolescence into early adulthood ( Cauffman and Steinberg 2000 ).

Decisionmaking is related to the likelihood of alcohol abuse, particularly when decisions are related to risk taking and the assessment of possible consequences. Youth at risk for AUDs and those with more extensive alcohol use histories exhibit a pattern of riskier decisionmaking than nonusing teens ( Lejuez et al. 2003 ). For example, a study involving a gambling task found that although most adolescents performed like adults, adolescents at risk for substance involvement took greater risks in making decisions ( Ernst et al. 2003 ).

Sleep Changes

In general, a teenager needs approximately 8.5 to 9.25 hours of sleep per night, a requirement that remains stable throughout adolescence. In addition, sleep patterns shift progressively later—that is, teenagers often do not feel physiologically tired until late at night and find it difficult to wake up in the morning. For high-school students who have to get up early, going to bed late results in a sleep deficit because their average weeknight sleep duration is only 7 to 7.75 hours per night ( Wolfson and Carskadon 1998 ). This sleep deficit accumulates over time, despite “catchup” weekend sleep, and results in excessive daytime sleepiness for many. The potential consequences of poor sleep and daytime sleepiness include poor academic performance; accidents from driving while drowsy; negative mood; self-medication with stimulants, alcohol, and other drugs of abuse; and disruption of a variety of cognitive functions ( Drummond and Brown 2001 ; Roehrs et al. 1994 ).

Social and Emotional Development Relationships With Parents

As adolescents move toward adulthood, continued support from, and attachment to, parents remains important ( Settersten et al. 2005 ). The emotional and financial support and sense of security parents can provide may make it easier for adolescents to continue their education and help launch them toward adult life. Although leaving home means that young people spend less time with their parents, the quality of the relationship typically improves ( Aseltine and Gore 1993 ). Importantly, the family values that youth have incorporated generally will continue to inform their choices, including those about alcohol use ( Brody et al. 2000 ). Nevertheless, alcohol involvement increases in parallel with individuation from parents ( Baer and Bray 1999 ) and the decreased parental monitoring that accompanies it ( Barnes et al. 2000 ); moreover, it increases following transition to independent living ( Kypri et al. 2004 ).

Children from the same family experience influences that are shared (e.g., the environment their parents create in the home) and others which are not (e.g., different friends). In addition, biological siblings have some genes in common. This shared genetic background is one contributor to similar outcomes among siblings. Importantly, siblings also influence one another directly, including with respect to alcohol use. Studies have shown that alcohol use by younger siblings is associated with use by their older brothers and sisters ( McGue et al. 1996 ; Windle 2000 ). Both the alcohol behavior of older siblings and the younger siblings’ perception of that behavior are important factors. The mechanisms by which older siblings influence substance use may include modeling alcohol use, providing access to alcohol, exerting direct social influence, and influencing cognitions regarding alcohol use.

Peer Relationships and Culture

Increases in the importance of peer relationships and exposure to cultural norms and influences may encourage experimentation with alcohol and/or its heavy use ( Brown and Abrantes 2005 ). This experimentation, although potentially dangerous, also may serve a developmental function, particularly with regard to identity exploration and bonding with peers. Certain aspects of social life that are appealing to adolescents may center around drinking contexts, and sociability expressed while drinking may be perceived as an indicator of successful peer relationships and bonding ( Maggs 1997 ). The media further influence adolescents’ perception of use, myths, and other factors that promote experimentation with alcohol. However, the extent of these influences on drinking outcomes varies among adolescents.

Peer influences profoundly affect the risk for alcohol use and abuse in late adolescence ( Brown and Abrantes 2005 ). They may be especially important during periods of change and/or adaptation to new environments. Peers influence adolescents’ drinking behavior through several pathways:

• Modeling and/or directly encouraging specific behaviors, including alcohol use;
• Seeking out and being selected by peers who have similar goals, values, and behaviors;
• Overestimating the prevalence of peer drinking, which can promote heavy drinking; and
• Shifting contexts, such as college or independent living, that alter perceived norms and may minimize the experience of adverse consequences of excessive alcohol use.

The media, which often depict drinking, physical aggression, interpersonal conflict, and unprotected sex, reflect and influence popular culture. Drinking often is portrayed as glamorous and risk-free, thereby augmenting peer influences that encourage alcohol consumption ( Brown and Witherspoon 2002 ).

Romantic Relationships and Sexuality

Dramatic changes in sexual feelings, the development of sexual identity, and experimentation with romantic relationships and sexual behaviors are characteristic changes during adolescence. Brooks-Gunn and Paikoff (1997) have identified four developmental challenges in the domain of adolescent sexuality:

• Becoming comfortable with one’s own maturing body;
• Accepting feelings of sexual arousal;
• Understanding that sexual behaviors should be mutually voluntary; and
• Practicing safe sex.

During late adolescence and young adulthood, individuals become intensely interested in finding a romantic partner. Romantic relationships progress from heterosexual group interactions to group dating and, ultimately, to pairing off as couples. During this time, individuals come to rely emotionally more on their romantic partners than their friends ( Kuttler and La Greca 2004 ). Approximately 70 percent of adolescents have engaged in sexual intercourse by the age of 18, most with a single partner and infrequently ( Alan Guttmacher Institute 1994 ).

Early sexual maturation can be a risk for alcohol use among girls. Girls who mature early are more likely to have older boyfriends, which may increase access to alcohol and pressure to drink. Girls whose boyfriends are at least 2 years older become more involved in all forms of sexual intimacy and are more likely to have sex under the influence of alcohol and to experience sexual coercion ( Gowen et al. 2004 ).

Because alcohol often is available at venues frequented by teens, adolescents looking to socialize with peers and/or seeking romantic attachments may be drawn to these contexts. In these situations, positive expectancies about alcohol’s social and sexual enhancement properties can increase the motivation to drink ( Goldman 2002 ). In addition, alcohol lowers inhibitions, which can lead teens to behave in ways they might not otherwise, including unplanned and unprotected sexual activity.

Emotional Changes and Mental Health Problems

The neurohormonal changes and brain maturation associated with the onset of and progression through puberty, coupled with the increase in environmental stressors such as school transitions (e.g., progression into high school and college), greater academic demands, transition to first work environments, and exposure to new social situations, contribute to the development of negative emotional states (i.e., negative affect) and emotional volatility and distress. Not surprisingly, numerous mental health problems, including depression, anxiety, suicidal ideation, and delinquent behaviors, increase during this period. These mental health problems often co-occur with AUDs ( Abrantes et al. 2003 ; Kandel et al. 1999 ). Moreover, intensive and protracted alcohol use can provoke deviant behaviors as well as depression and anxiety ( Abrantes et al. 2003 ; Brown and Abrantes 2005 ). Youth with comorbid disorders require special attention as they are more difficult to treat successfully ( Tomlinson et al. 2004 ).

Alcohol Use in the 16–20 Age-Group

By late adolescence, most youth have initiated alcohol use. Between the ages of 16 and 20, drinking, binge drinking, and heavy drinking all increase substantially. As a result, a number of youth begin to experience problems related to their alcohol use.

Prevalence of Alcohol Use

According to the Monitoring the Future Study, almost two-thirds of 10th-grade students reported having tried alcohol at least once in their lifetime, and two-fifths reported having been drunk at least once ( Johnston et al. 2006 a ). Among 12th-grade students, these rates had risen to over three-quarters who reported having tried alcohol at least once and nearly three-fifths who reported having been drunk at least once. In terms of current alcohol use, 33.2 percent of the Nation’s 10th graders and 47.0 percent of 12th graders reported having used alcohol at least once in the past 30 days; 17.6 percent and 30.2 percent, respectively, reported having been drunk in the past 30 days; 21.0 percent and 28.1 percent, respectively, reported having had five or more drinks in a row in the past 2 weeks (sometimes called binge drinking); and 1.3 percent and 3.1 percent, respectively, reported daily alcohol use ( Johnston et al. 2006 a ).

Alcohol consumption continues to escalate after high school. In fact, 18-to 24-year-olds have the highest levels of alcohol consumption and alcohol dependence of any age-group. In the first 2 years after high school, lifetime prevalence of alcohol use (based on 2005 follow-up surveys from the Monitoring the Future Study) was 81.8 percent, 30-day use prevalence was 59 percent, and binge-drinking prevalence was 36.3 percent ( Johnston et al. 2006 b ). Of note, college students on average drink more than their noncollege peers, even though they drank less during high school than those who did not go on to college ( Johnston et al. 2006 a , b ; Schulenberg and Maggs 2002 ). For example, in 2005, the rate of binge drinking for college students (1 to 4 years beyond high school) was 40.1 percent, whereas the rate for their noncollege age mates was 35.1 percent.

Alcohol use and problem drinking in late adolescence vary by sociodemographic characteristics. For example, the prevalence of alcohol use is higher for boys than for girls, higher for White and Hispanic adolescents than for African-American adolescents, and higher for those living in the north and north central United States than for those living in the South and West. Some of these relationships change with early adulthood, however. For example, although alcohol use in high school tends to be higher in areas with lower population density (i.e., rural areas) than in more densely populated areas, this relationship reverses during early adulthood ( Johnston et al., 2006 a , b ). Lower economic status (i.e., lower educational level of parents) is associated with more alcohol use during the early high school years; by the end of high school, and during the transition to adulthood, this relationship changes, and youth from higher socioeconomic backgrounds consume greater amounts of alcohol.

Topography and Trajectories of Drinking

As adolescents seek increasing autonomy, build social and intimate relationships, explore their own identities, and take risks on the way to becoming independent adults, they may believe that alcohol can help them achieve these goals. Therefore, alcohol (and other drug) use during adolescence and early adulthood may be viewed as developmentally driven risk-taking behavior. This underscores the need to consider: (1) the trajectories of alcohol use and problem drinking over time and (2) the relationship of alcohol use and problems to developmental tasks.

Trajectories of Alcohol Use and Problem Drinking Over Time

It is essential to investigate how individuals and subgroups of adolescents differ in their patterns of alcohol use (e.g., overall use level, rate of escalation, age at peak use, and rate of decline) as they transition from adolescence into adulthood. This longitudinal approach provides information about both societal trends and common drinking trajectories throughout adolescence.

There are two main types of studies that are used for these purposes. One of these uses an approach called growth models. Findings from such studies indicate that, in general, alcohol use and heavy drinking increase from early adolescence through the early twenties, with marked individual differences in the rates of change. The use of such growth models allows researchers to predict individual differences in levels of use as well as to correlate change in alcohol use with change in other behavioral and social constructs to understand how alcohol use “travels together” with other personal and environmental features.

Another type of study is known as multiple-trajectory study. This approach groups individuals into multiple, relatively homogenous groups according to their distinctive drinking patterns. Analysis of several multiple-trajectory studies ( Maggs and Schulenberg 2005 ) found that the most commonly observed trajectory subgroups in the general population of youth included abstainers; light drinkers; or, very rarely, heavy drinkers across all the time periods measured (see table ). Depending on the definitions used in different studies for these levels of alcohol consumption, estimates of the proportion of young people in the low-risk group range from about one-fifth to over two-thirds. In addition, about one-third of adolescents and emerging adults are stable moderate drinkers who engage in some steady but limited heavy drinking across adolescence and young adulthood. Together, these two broad categories comprising relatively low-risk drinkers include a large proportion of all young people.

Alcohol Use Trajectory Groups Identified in Community-Based Research on Adolescents

SOURCE: Brown et al. 2008 .

Many studies also identified groups of chronic heavy drinkers and late-onset heavy drinkers. These two groups are distinguished by the age when the subjects start drinking heavily. Chronic heavy drinkers typically start drinking heavily at a relatively young age and tend not to decrease their drinking in their twenties (e.g., Schulenberg et al. 1996 ). By contrast, the late-onset heavy-drinking subgroup start to drink later, but their use escalates rapidly. “Fling” drinkers make up 10 percent to 12 percent of the adolescent and young adult population ( Schulenberg et al. 1996 ). They experience a period of developmentally limited heavy drinking that peaks in late adolescence or early adulthood and then declines. Another group, referred to as decreasers, begin heavy drinking at an early age and reduce their use significantly during or shortly after high school. About 10 percent of adolescents and young adults fall into this subgroup that appears to be more common in older adolescent and young adulthood samples than in younger samples. With all of these classifications, however, it is important to keep in mind that substantial fluctuations in adolescent drinking can occur within the course of a single year with 10 to 17 percent of high-school students decreasing or stopping their drinking every year ( Brown 2001 ). These changes may be tied to personal change efforts ( Brown 2001 ) or environmental factors ( Greenbaum et al. 2005 ). Youth receiving alcohol treatment similarly display divergent trajectories ( Chung et al. 2003 ; Myers et al. 2007 ).

Risk and Protective Processes

Substantial research has established the major risk and protective factors that influence alcohol use and abuse in late adolescence. For example, adolescent abusers are more likely than nonabusers to:

• Have a positive family history of alcoholism;
• Have preexisting mental health problems;
• Have low levels of self-regulation;
• Have been victims of sexual or physical abuse;
• Come from broken families and/or have parents who poorly monitor their activities;
• Hold beliefs that encourage excessive alcohol use; and
• Be exposed to deviant peer models.

Conversely, adolescents who do not abuse alcohol are more likely to have good relationships with their family, a positive attitude about school, and long-term goals and aspirations.

Studies suggest that both inherited and environmental factors, as well as their interactions, strongly influence drinking behavior ( McGue et al. 1996 ). Importantly, the influence of genes relative to environment varies across drinking behaviors (e.g., initiation, escalation, and dependence); moreover, genetic influences on adolescent drinking behavior appear to strengthen from mid-adolescence to late adolescence ( Rose et al. 2001 ). Finally, whereas some genetic factors that influence problem drinking are specific to alcohol, others influence a range of disinhibited behaviors in late adolescence and early adulthood ( Krueger et al. 2002 ).

Adolescent alcohol use and abuse often co-occur with other adolescent problem behaviors, including tobacco and illicit drug use, early sexual behavior, antisocial behavior, and poor academic performance. It is not clear whether alcohol use increases the likelihood of other adolescent risk behaviors ( Kandel et al. 1999 ) or if underlying factors increase risk for a constellation of problem behaviors ( McGue et al. 2001 ; Vanyukov et al. 2003 ). Although the two perspectives are different, they are not incompatible. Adolescent alcohol use may reflect an underlying disposition toward under-controlled behavior and also alter the course of adolescent behavior in a way that increases the likelihood of negative outcomes.

In part, the increase in problem drinking during late adolescence may be developmentally driven. Important contextual transitions, such as leaving home/moving out for the first time or moving from high school and entering college, also can significantly influence drinking behavior ( Kypri et al. 2004 ). Studies further suggest that the college environment itself may promote drinking. Whereas college students are less likely to have been binge drinkers in high school than their noncollege peers, they are more likely to binge drink once they enter college ( Timberlake et al. 2007 ). Differences in drinking behavior between college students and their noncollege peers are not necessarily large; however, there may be differences in patterns of drinking (e.g., college students tend to engage in more binge drinking but less daily drinking). The influence of college on drinking behavior is, in most cases, transitory in nature ( Bartholow et al. 2003 ), although it may have long-term consequences. Other transitions also can increase the risk for problem alcohol use if they occur earlier than is typical. For example, teenagers who get married, become parents ( Martino et al. 2004 ), or work more than 20 hours per week ( Mortimer and Staff 2004 ) are at increased risk of problem drinking relative to adolescents whose course of social development is more normative.

During late adolescence, differences in drinking behavior between boys and girls begin to emerge and become consequential ( Johnston et al. 2006 a ). For example, adolescent girls are as likely as adolescent boys to have tried alcohol but are less likely to engage in problematic or binge drinking or be diagnosed with an AUD. The factors that put boys and girls at risk also can be different. For example, adolescent girls are more likely than adolescent boys to be victims of abuse ( Champion et al. 2004 ) and to suffer from depression and anxiety ( Poulin et al. 2005 ), both of which are associated with elevated rates of drinking. Adolescent boys, in contrast, are more likely to suffer from externalizing psychopathology and to score high on measures of impulsivity, which are associated with elevated drinking rates ( Caspi et al. 1996 ). Importantly, adolescents who exhibit a range of developmental psychopathology (both internalizing and externalizing) are among those at highest risk for excessive alcohol involvement.

The term “resilience” denotes positive developmental outcomes in individuals despite significant adversity in their lives. This can mean either that potential problems fail to emerge or that existing problems resolve under adverse circumstances. Patterns of resilient behavior can provide important information about normal development as well as the development of problem behaviors and may provide insight into effective preventive strategies. The concept of resilience is important in understanding how youth with genetic or environmental risk factors for alcohol dependence can overcome their developmental liabilities ( Zucker et al. 2003 ). Biological, cognitive, social, and emotional characteristics all can contribute to resilience. In particular, certain integrative skills, such as self-organization and emotional regulation that emerge in late adolescence, promote resilience and may protect against trajectories of protracted heavy alcohol involvement.

The Consequences of Adolescent Alcohol Use and Abuse

Another important aspect of studies of underage drinking is to determine how alcohol consumption during adolescence affects subsequent development. Some of the challenges are to understand to what extent outcomes are directly related to alcohol use and to evaluate the relative influence of factors that precede or occur with alcohol involvement. For example, early externalizing disorders (e.g., conduct disorder) are associated with risk for a range of enduring, adverse behavioral outcomes, including excessive alcohol and other drug involvement. Adolescent alcohol involvement itself can disrupt social and emotional development as well as interfere with academic progress.

More specifically, alcohol-related problems and consequences include social problems (e.g., physical or verbal aggression and relationship difficulties), legal problems (e.g., arrests for driving while intoxicated and public inebriation), educational/vocational problems (e.g., academic difficulties, termination from employment, and failure to achieve career goals), and medical problems (e.g., unintentional injury, liver disease, and central nervous system disease). A variety of studies have demonstrated associations between adolescent alcohol involvement and a range of adverse consequences, including academic problems, social problems, hangovers, unplanned and risky sex, aggression and victimization, unintentional injuries (especially motor vehicle crashes), various physical and emotional problems, and suicidality ( Tomlinson et al. 2004 ). These consequences may directly result from alcohol consumption and/or from factors associated with drinking ( Stice et al. 1998 ). For certain outcomes, their relationship with alcohol consumption is clear (e.g., experiencing blackouts or alcohol-related arrests or having other people complain about one’s drinking). For other outcomes, the relationship may be less apparent (e.g., getting into fights, skipping a class because of one’s drinking, or suffering from depression). Therefore, adolescents may not attribute these problems to their alcohol consumption even if they are a consequence of alcohol involvement (e.g., conflict with parents).

Alcohol and the Developing Adolescent Brain

During adolescence, the brain undergoes significant maturation in specific regions. As noted in the preceding article by Windle and colleagues (see pp. 30–40 of this issue), the limbic system, which regulates emotional tone and reactivity, matures in early adolescence. In contrast, self-regulation and a broad range of higher-level cognitive functions, which are governed by the frontal cortex, develop more gradually throughout adolescence and into early adulthood as a function of age and experience.

Late adolescence is a time when many individuals escalate their drinking, raising concerns about effects of heavy drinking on neurodevelopment during this period. Research on adolescent animals as well as limited studies with human adolescents show the potential for adolescent alcohol use to induce functional and/or structural changes in the brain as well as neurocognitive deficits ( McQueeny et al. 2009 ; Spear 2000 ). For example, in a study of adolescents with AUDs, protracted heavy alcohol use was associated with deficits in memory retrieval and visuospatial functioning ( Brown et al. 2000 ). In addition, imaging studies of brain structure ( Nagel et al. 2004 ) and longitudinal neurocognitive evaluations of clinical and community samples of adolescent drinkers ( Brown et al. 2000 ) found differences between heavily alcohol-involved adolescents and control subjects. Thus, late adolescents and young adults who persisted in heavy drinking showed greater deficits; however, it is not yet clear what levels and duration of alcohol exposure produce significant and long-lasting changes in brain function and what other factors may contribute to these changes.

Research has shown that adolescent animals are more vulnerable than adults to the adverse effects of alcohol on specific brain regions, including the hippocampus and areas of the frontal cortex ( Spear 2000 ). For example, acute alcohol exposure in rats at both high and low doses inhibits memory formation, which is a function of the hippocampus, with adolescent rats being especially sensitive to these effects. Animal research also has shown that repeated exposure to very high levels of alcohol is particularly harmful to the brain and is associated with reduced formation of new nerve cells (i.e., neurogenesis) in the rat hippocampus ( Nixon and Crews 2002 ) and long-term alteration of brain-signaling functions involving the neurotransmitter serotonin ( Obernier et al. 2002 ). Taken together, these lines of research heighten concern about the patterns of binge drinking (so prevalent among human adolescents) that can result in extremely high blood alcohol levels.

Animal studies also suggest that, in contrast to their elevated sensitivity to the cognition-impairing effects of alcohol, adolescents are less sensitive than adults to other effects of alcohol. For example, adolescent rats are less sensitive to alcohol’s motor-impairing and sedating effects ( Little et al. 1996 ). If human adolescents also are less sensitive to these cues, which typically moderate alcohol consumption (i.e., sedation and locomotor impairment), this may explain, at least in part, their typical patterns of drinking. Further, it appears that in adolescent, but not adult, rats repeated exposure to very high levels of alcohol may further reduce sensitivity to these aversive effects ( Graham and Diaz-Granados 2006 ) and has been associated with increased tolerance. In humans, reduced sensitivity to the motor-impairing and aversive effects of alcohol has been shown to be a potent risk factor for the development of alcoholism ( Schuckit and Smith 1996 ). Therefore, the reduced sensitivity that can result from heavy alcohol use during adolescence may contribute to increased risk for future alcohol dependence.

Adolescent Alcohol Involvement and Future Alcohol and Other Substance Involvement

Several studies have followed adolescent drinkers into their third decade of life. In general, these studies found that drinking patterns during late adolescence are associated with future negative alcohol-related outcomes, including diagnoses of AUDs during the third decade of life ( Chassin et al. 2002 ; Wells et al. 2004 ). In addition, studies found that greater intensity of use (e.g., greater maximum number of drinks per occasion in the recent past at age 16) predicted a higher likelihood of being diagnosed with an AUD ( Wells et al. 2004 ). Thus, the relationship between alcohol involvement in later adolescence and alcohol involvement in early adulthood appears to be robust across a number of studies, even when controlling for a variety of competing factors.

Additional studies have attempted to relate various aspects of middle- or late-adolescent drinking behavior to later outcomes in developmentally important domains other than alcohol use. Although strong associations exist between drinking patterns at age 16 and educational, occupational, and emotional outcomes, few can be attributed exclusively to early alcohol use. When demographic and background variables are controlled, alcohol involvement at age 16 appears to independently predict noncannabis drug dependence at age 25, number of sexual partners, and property and violent offenses ( Wells et al. 2004 ).

Longitudinal studies that investigated the long-term correlates of late-adolescent drinking found that alcohol involvement in adolescence was associated with adult drug dependence, antisocial behavior, and depression ( Hill et al. 2000 ; Wells et al. 2004 ). Adult antisocial behavior is associated with being drunk by age 18 even in the absence of childhood conduct problems. Less is known about the association between adolescent alcohol involvement and other domains of adult functioning. For example, although adolescent alcohol involvement is associated with educational problems in both secondary and higher education, it is not clear if the effects are uniquely attributable to alcohol.

Late adolescence spans ages 16–20. It is a period of extensive and rapid transition in virtually every domain of life functioning, as well as of continued neurologic, cognitive, and social maturation. Increased autonomy, reduced parental monitoring, and greater involvement with peers all create the opportunities for psychological growth as well as a context for the emergence of problem drinking. In fact, during late adolescence many youth escalate their drinking, resulting for some in alcohol-related problems that may include AUDs. Although problem drinking may represent a transient phase in the lives of many adolescents, for others it can have profound and life-altering effects.

This article has reviewed some of the major developmental processes, transitions, and tasks in late adolescence as they relate to alcohol use and its consequences, including developmentally related effects and alcohol-specific risk and protective factors. The following article by Spoth and colleagues (pp. 53–66 ) examines the prevention and reduction of alcohol use and AUDs in adolescents.

F inancial D isclosure

The authors declare that they have no competing financial interests.

1 Myelin is a white fatty material composed mainly of alternating layers of lipids and lipoproteins that covers the extensions of many nerve cells in order to insulate them and make nerve signal transmission faster and more effective. Because of myelin’s white color, myelin-covered nerve fiber bundles in the brain are referred to as white matter, as opposed to gray matter, which refers to brain structures composed mainly of nerve cell bodies.

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Reducing Underage Drinking: A Collective Responsibility (2004)

Chapter: 3. consquences of underage drinking, 3 consequences of underage drinking.

U nderage drinking, especially heavy drinking and frequent, heavy drink ing, is associated with numerous negative consequences. The consequences of alcohol use can be acute and immediate outcomes of a single episode of alcohol-impaired functioning, such as accidental death and injury, or they can be the accumulated and diverse effects of a chronic pattern of drinking, such as poor school performance and fractured relationships secondary to alcohol abuse and addiction. By ages 19 and 20, 70 percent of all drinkers engage in heavy drinking, suggesting that the majority of young people are at great risk of making poor decisions that have significant long-term consequences (Flewelling et al., 2004). But underage drinkers need not drink heavily to be at high risk of experiencing negative consequences. The crash risk associated with driving after drinking is higher for youths than for adults at all blood alcohol content (BAC) levels (Hingson and Kenkel, 2004). In other words, adolescents and young adults do not need to drink heavily to significantly increase their risk of negative consequences.

This chapter reviews some of the acute and chronic consequences of underage drinking. It covers such problems as drunk driving, as well as a range of other common consequences of acute impairment, such as violence. It also discusses long-term consequences of early drinking, including recent research on the possible effects of early onset of alcohol use on adolescent brain development.

Many adults may assume that the risks and potential consequences of underage drinking are more or less the same as they are for adults, but

research suggests that the dangers of youth drinking are magnified. In 2000, 36.6 percent of youths (under age 21) traffic fatalities involved alcohol, a rate slightly lower than the rate for adults (41.7 percent). However, when the denominator is the number of licensed drivers, drinking drivers under age 21 are involved in fatal crashes at twice the rate of adult drivers (National Highway Traffic Safety Administration, 2002a). Moreover, alcohol use among youths is strongly correlated with violence, risky sexual behavior, poor school performance, suicide, and other harmful behaviors (Hingson and Kenkel, 2004). College students are also significantly and negatively affected by their peer’s drinking (Wechsler, 1996; Wechsler et al., 2001a, 2001b, 2001c), including being assaulted, having one’s property damaged or experiencing an unwanted sexual advance. Recent research also suggests that adolescent drinking can inflict permanent damage on the developing brain (Brown and Tapert, 2004). And as noted in Chapter 2 , early onset of alcohol use greatly increases the probability of adult alcohol dependence. In addition to the negative consequences to individual youth who drink, the costs of underage drinking to society—in lost lives, lost productivity, and increased health care costs—are substantial.

CONSEQUENCES OF ACUTE IMPAIRMENT

Alcohol impairs one’s decision-making capacity. As a result, young people who drink are more likely to engage in risk-taking behavior that can result in illness, injury, and death. Acute consequences of underage drinking include unintentional death and injury associated with driving or engaging in other risky tasks after drinking, homicide and violence, suicide attempts, sexual assault, risky sexual behavior, and vandalism and property damage. In addition, these consequences appear to be more severe for those who start drinking at a young age. Hingson and Kenkel (2004), report on a series of studies that controlled for history of alcohol dependency, frequency of heavy drinking, years of drinking, age, gender, race or ethnicity, history of cigarette smoking, and illicit drug use. These studies reveal that youth who started drinking before age 15, compared to those who waited until they were 21, were 12 times more likely to be unintentionally injured while under the influence of alcohol, 7 times more likely to be in a motor vehicle crash after drinking, and 10 times more likely to have been in a physical fight after drinking.

Drinking and Driving

The consequences of driving after drinking have received intense media attention and targeted policy responses. Laws have been passed to lower allowable blood alcohol content levels for underage drivers to near zero

(typically 0.02, compared with the adult limit of 0.08 or 0.10). Although alcohol-related youth motor vehicle fatalities have decreased substantially over the past decade or so, youth are still overrepresented in alcohol-related fatal crashes compared with the older population. In 2000, 69 percent of youths who died in alcohol-related traffic fatalities involved young drinking drivers. It remains a very serious issue with extreme consequences, not only for the young driver but also for innocent victims. While only 7 percent of licensed drivers in 2000 were aged 15 to 20, they represented approximately 13 percent of drivers involved in fatal crashes who had been drinking (National Highway Traffic Safety Administration, 2002b). According to Grunbaum et al. (2002), 38.3 percent of Latinos, 30.3 percent of whites, and 27.6 percent of African Americans in this age group rode with a driver who had been drinking alcohol. And 14.7 percent of whites, 13.1 percent of Latinos, and 7.7 percent of African Americans aged 15 to 20 admitted to driving a car after drinking alcohol.

Alcohol-related traffic fatalities constituted almost 37 percent of all fatal youth traffic fatalities (National Highway Traffic Safety Administration, 2002b). Youths who drive after drinking are more likely to be in a crash than youths who have not had a drink, and the crashes underage drinkers are involved in tend to be more severe than those of adults, resulting in a greater number of deaths and more serious injury. Underage drinkers present greater risks than adults when driving, even at lower BAC levels. More 19-year-olds died in alcohol-related crashes with relatively low BAC levels than any other age (National Highway Traffic Safety Administration, 2002b).

When young people drink and get into a car, they also tend to make poor decisions that bear on their safety. For example, young people who have been drinking are less likely to wear a safety belt. They are more likely to get in a car with an intoxicated driver: 41 percent of frequent heavy drinkers reported riding with an intoxicated driver, compared with only 14 percent of those who never drank (Hingson and Kenkel, 2004). In alcohol-related traffic crashes, there were three times more deaths among young people who were not wearing their seat belts than among those who were wearing them. In sum, alcohol-related crashes involving underage drinkers are more likely to result in death and serious injury than those involving other drivers.

Homicide, Suicide, and Unintentional Injuries

Alcohol is implicated in a large proportion of unintentional deaths and injuries caused by other forms of dangerous behavior than driving. In 1999, nearly 40 percent of people under age 21 who were victims of drownings, burns, and falls tested positive for alcohol. Youth constituted 7 percent of

nonfatal and 30 percent of fatal alcohol-related drownings and burns (Levy et al., 1999).

Drinking not only increases one’s risk of being involved in a traffic accident or suffering another unintentional injury, it is also implicated in deaths and injuries associated with violence and suicidal behavior. Frequent heavy alcohol use is associated with increased feelings of hopelessness, suicide ideation, and suicide attempts. Alcohol has been reported to be involved in 36 percent of homicides, 12 percent of male suicides, and 8 percent of female suicides involving people under 21—a total of about 1,500 homicides and 300 suicides in 2000. Homicide is the second leading cause of death for 15- to 24-year-olds (Centers for Disease Control and Prevention, 2001). By racial and ethnic group, deaths due to homicide for ages 15 to 24 are the leading cause of death for African Americans, second for Latinos, and fourth for whites. In that age group, suicide is the second leading cause of death for whites, third for Latinos, and third for African Americans (Anderson, 2002). Caetano and Clark (1998) report that the incidence of social consequences from drinking among Latinas is almost three times higher than for white females, despite generally lower rates of drinking.

According to Levy et al. (1999), individuals under the age of 21 commit 45 percent of rapes, 44 percent of robberies, and 37 percent of other assaults, and it is estimated that 50 percent of violent crime is alcohol-related (Harwood et al., 1998). 1 A report by the National Center on Addiction and Substance Abuse (1994) found that on college campuses 95 percent of all violent crime and 90 percent of college rapes involve the use of alcohol by the assailant, victim, or both. Although it is difficult to disentangle alcohol use from other possible contributing factors, such as depression, emerging evidence demonstrates a causal link between alcohol and suicide (Light et al., 2003).

Sexual Activity

Sexual violence and unplanned and unprotected sexual activity constitute yet another set of alcohol-related problems. As reported in A Call to Action: Changing the Culture of Drinking at U.S. Colleges (National

Institute on Alcohol Abuse and Alcoholism [NIAAA], 2002) more than 70,000 students aged 18 to 24 are victims of alcohol-related sexual assault or date rape. Studies of date rape and sexual assault on college campuses suggest that alcohol use factors into the behavior of both assailants and victims. For example, Harrington and Leitenberg (1994) found that date rape victims who reported being at least “somewhat drunk” at the time of the assault believed that their assailants were also under the influence of alcohol. A study of assailants showed that 44 percent of the men had been drinking when they committed a sexual assault (Abbey et al., 1996). Given that many sexual assaults—especially acquaintance rape—are believed to be unreported, it is possible that alcohol figures into many more assaults than these studies indicate.

In addition to being more vulnerable to experiencing (or committing) sexual assault, young people who are drinking are also more likely to engage in risky sexual behavior. According to research by the Kaiser Family Foundation, young people are more likely to engage in consensual sexual activity after drinking and report that they “do more” sexually while using alcohol than they had planned. According to Strunin and Hingson (1992), 44 percent of sexually active teenagers report that they are more likely to have intercourse if they have been drinking. Based on analysis of 2001 Youth Risk Behavior Surveillance data, Grunbaum and colleagues (2002) report that 23.4 percent of white youth, 24.1 percent of Latino youth, and 17.8 percent of African American youth reported using alcohol or other drugs at the time of their last sexual intercourse.

Young people are less likely to use a condom if they have been drinking, which puts them at risk for unplanned pregnancies and contracting sexually transmitted diseases and HIV (the virus that causes AIDS). More disturbing still is that young people seem to be aware that using alcohol influences their decisions about sexual behavior: 29 percent of 15- to 17-year-olds and 37 percent of 18- to 24-year-olds said that alcohol or drugs influenced their decision to do something sexual. In other words, young people choose to drink even though they realize that alcohol affects their decision making and may cause them to engage in sexual behaviors they would not do while sober.

Early onset of alcohol use has also been associated with unplanned and unprotected sex. A college survey conducted by the Boston University School of Public Health showed that among drinkers, those who had their first drink before the age of 13 were twice as likely to have unplanned sex and more than twice as likely to have unprotected sex (Hingson and Kenkel, 2004).

Vandalism and Property Damage

Vandalism and property damage represent yet another set of consequences influenced by alcohol. Intoxicated youth are more likely to commit these acts regardless of their age, but vandalism and property damage are a particular problem on college campuses. Wechsler et al. (2002) report that about 11 percent of college students admitted to having damaged property while drinking. The cost of these behaviors is picked up by the college or by the local communities if the vandalism happens off campus.

LONG-TERM CONSEQUENCES

A single episode of alcohol-impaired judgment can have immediate consequences (leading to death, injury, or arrest, for example) with long-term effects. In addition, heavy alcohol use at a young age has been implicated in long-term changes in the youths’ life prospects. Individuals who begin drinking before age 15 appear to be at greater risk for serious life-long problems (Hingson and Kenkel, 2004). For example, young people who begin drinking before age 15 are significantly more likely to develop alcohol dependence than those who begin drinking at older ages. Youth who begin drinking before the age of 15 have a 41 percent chance of future alcohol dependence, compared with a 10 percent chance for those who begin after the legal drinking age (Grant and Dawson, 1997). Some become dependent during adolescence. 2 Analyses of the 1999 Harvard School of Public Health National College Alcohol Survey of students age 19 or older, after controlling for a variety of factors, found that the earlier they had first drunk to intoxication, the more likely they were to experience alcohol dependence and frequent heavy drinking in college (Gruber et al., 1996).

Frequent heavy use is associated with low self-esteem, depression (which is probably related to greater suicide attempts among underage drinkers), conduct disorders, antisocial behavior, dependency on other drugs and tobacco, and anxiety (Brown and Tapert, in press). Adolescents and college-age students who use alcohol have higher rates of academic problems and poor performance than nondrinkers. A Call to Action (NIAAA, 2002) noted that about 25 percent of college students report that using alcohol resulted in problematic consequences, such as missing classes, falling behind in school work, performing badly on papers and exams, and receiving lower grades overall.

Chronic health problems resulting from heavy alcohol use are generally not observed in adolescents because such effects take longer to accumulate. However, heavy drinking during adolescence, especially if this behavior is continued in adulthood, places a person at risk of such health problems as pancreatitis, hepatitis, liver cirrhosis, hypertension, and anemia. Chronic liver disease and cirrhosis among Latinos and American Indian and Alaskan natives are the sixth leading cause of death among these groups (Anderson, 2002). Recent research suggests that drinking during puberty may have deleterious effects on bone density development: for young women, failing to develop maximal bone density during adolescence puts them at risk later in life for osteoporosis.

Effects on the Adolescent Brain

New research on adolescent brain development suggests that early heavy alcohol use may also have negative effects on the actual physical development of brain structure (Brown and Tapert, 2004). Contrary to earlier beliefs, the brain continues to change physiologically well beyond childhood. Brain growth among infants and children is focused essentially on volume—creating as many brain cells with as many connections to other brain cells as possible. During adolescence, development shifts from producing a great number of neurons to creating efficient neural pathways, which occurs in two ways. First, the structure of neurons changes as they become encased by an insulating tissue (myelin) that helps to speed the movement of the electric impulses carried by brain cells. This change means that adults can relay information from one part of the brain to another more rapidly than can children. In adolescence, this myelination occurs predominantly in the frontal and prefrontal lobes, the part of the brain responsible for important functions such as planning, organization, and halting an impulse. The second change in brain development has to do with synaptic refinement, the process by which connections between brain cells are pruned and eliminated so that only the most efficient connections are used and maintained. Like myelination, synaptic refinement also contributes to increasing the speed and efficiency of transmitting information from one part of the brain to another, which in turn improves reaction time. Adolescent brain developments occur in areas of the brain critical for considering the consequences of actions and important for stress responses and managing drives (Spear, 2002).

Recent studies based on animal models suggest that alcohol use during adolescence may have deleterious effects on myelination and synaptic refinement. Rats that were given doses of alcohol in quantities and frequency that mimic the use of frequent heavy adolescent drinkers had problems with memory tasks (White et al., 2000). Another study showed that heavy alco-

hol use caused damage to the frontal regions of the brain (Crews et al., 2000).

New research using magnetic resonance imaging (MRI) technology to obtain a portrait of adolescent human brains support these animal studies, showing that the brain structure of youths with alcohol-use disorders is adversely affected. The hippocampus, which is responsible for forming new memories, was noticeably smaller in youth who abuse alcohol than in their nondrinking peers (De Bellis et al., 2000). Youth with alcohol-use disorders also performed worse on memory tests than nondrinkers, further suggesting that the structural difference in hippocampus size was affecting brain functioning. Neuropsychological studies also suggest that alcohol use during adolescence may have a direct effect on brain functioning: negative effects included decreased ability in planning and executive functioning, memory, spatial operations, and attention—all of which are important to academic performance and future functioning (Giancola and Mezzich, 2000; Brown et al., 2000; Tapert and Brown, 1999; Tapert et al., 2001).

THE CAUSATION QUESTION

Many consequences—both immediate and long-term—are correlated with youthful drinking. In the case of immediate consequences, drinking impairs one’s perceptual and motor skills, and this impairment clearly increases the risk of a car crash if one drives after drinking—a risk that is demonstrably higher for young drivers. Similarly, the disinhibiting effect of alcohol use impairs judgment and increases the risk of violence and unprotected sexual intercourse. In this sense, the causal link between alcohol use and the outcomes and problem behaviors just reviewed is not in doubt. The empirical evidence also shows a clear correlation between early drinking and problematic adult drinking and other related longer term problems: that is, the earlier that young people start drinking, the more likely they are to have problems in their adult lives.

However, these outcomes and behaviors may not be entirely attributable to alcohol. For example, some youths who have alcohol-related crashes or engage in alcohol-related violence or other risk-taking behavior may have been otherwise strongly predisposed to engage in problem behaviors of all sorts due to genetics, family circumstances, or other factors. Similarly, the higher rates of alcohol dependence, disease, and dysfunction among adults who began heavy drinking as youths may not be attributable to the early drinking per se. Some of these long-term outcomes are also consistent with the possibility that some individuals have a particular vulnerability to developing bad drinking habits and that one of the characteristics of these individuals is that they start drinking early. (For example, children of alco-

holics are more likely than children of nonalcoholics to start drinking during adolescence [NIAAA, 1997].)

Some of the strongest evidence of the causal role of alcohol in negative outcomes is derived from studies designed to assess the effects of policy interventions targeted on underage alcohol consumption. It is clear from these studies that reducing alcohol consumption among young people reduces such immediate outcomes as deaths, crime, and other consequences of impaired behavior. For example, research has shown that policies that affect alcohol availability, including excise tax rates and the minimum drinking age, have measurable effects on such outcomes as crime, highway fatalities, tobacco and drug use, and sexually transmitted diseases with greater availability associated with increases in these outcomes (Chaloupka, 2004; Chesson et al., 1997; Coate and Grossman, 1988; Cook, 1981; Cook and Moore, 1993a, 1993b; Cook and Tauchen, 1982, 1984; Kenkel, 2000; Ohsfeldt and Morrisey, 1997; Pacula, 1998; Ruhm, 1996; Saffer and Grossman, 1987; Wagenaar and Toomey, 2002). Given that the only plausible mechanisms by which such policies could affect these outcomes are through their effects on the volume and patterns of alcohol consumption, it is logical to conclude that alcohol consumption is indeed a causal agent for these outcomes.

In the case of long-term negative outcomes, the key question is whether reducing underage drinking would also reduce those outcomes. To the extent that individual vulnerability plays a large role, merely delaying the onset of drinking would not necessarily have much of an effect; the vulnerable people would eventually end up as problematic drinkers regardless of when they started. Moreover, many underage individuals who start heavy drinking in their late teens give it up as they reach their late 20s and 30s. The committee has carefully considered the evidence on this important issue—the extent to which early drinking causes later drinking problems, reduces them, or has no effect at all. Clearly predisposition and early alcohol use interact, and the effect of alcohol varies according to the degree of vulnerability of different individuals. However, notwithstanding the complexity of the inquiry, the committee concludes that the evidence establishes a prima facie case regarding the negative effects of early drinking on long-term welfare.

We think that prudent parents and a prudent society should assume, based on the current evidence, that underage drinking increases the risk of future drinking problems and contributes independently to the many deficits experienced by early drinkers over the course of their lives. However, additional research to further refine understanding of the interaction of the multiple interrelated factors on long-term outcomes is warranted.

SOCIAL COSTS

It has become standard practice in formal assessments of the social burden of an illness or harmful activity to translate the resulting disability and death into dollar figures. Underage drinking is no exception. For example, a recent report concluded that the cost of alcohol use by youth was $53 billion in 1996, including $19 billion from traffic crashes and $29 billion from violent crime (Pacific Institute for Research and Evaluation [PIRE]). If the costs of other consequences—such as low academic performance or medical costs other than those associated with traffic crashes—were quantified, it is possible that the cost would be even higher. Since numbers of this sort are potentially important in setting public priorities, it is worth understanding some of the controversies and practical difficulties in making such estimates (see Chapter 4 ; Cook and Ludwig, 2000; Cook, 1991).

Policy Relevance

It is natural to measure the burden of underage drinking in terms of the incidence of various consequences. As we have seen, those consequences include violent death, disability, disease, reduced academic and occupational achievement, and property damage, among many others. Estimating the causal role that underage drinking plays in each of these outcomes is the very big and difficult challenge for epidemiologists. But even with reliable estimates for the contribution of underage drinking for each consequence, one would be left with the question of how to sum them up. A summary statistic is useful in assigning relative priority to this particular problem in comparison with all the other problems requiring public attention. A summary statistic quoted in dollar terms is particularly useful because it lends itself to comparison with the budget costs of policies to remediate the problem.

What question is to be answered by the estimate of social cost? Ultimately the question is something like the following: “How much would Americans’ overall standard of living improve if underage drinking were somehow eliminated?” In the PIRE study (1999) it is noted that the “cost” of underage drinking, based on the given assumptions, equaled $530 per year for every household in the United States; the suggestion is that eliminating underage drinking would be the equivalent of adding that amount to average household income.

Of course in practice there is no way to entirely eliminate underage drinking. But the total cost is nonetheless of some interest as a guide to how underage drinking can be compared with, say, cancer or illiteracy or terrorism in setting national priorities. The total is also useful to the extent that a

partial reduction in underage drinking may confer benefit in proportion to the total. Thus, the study suggests that a 10 percent reduction would be worth about $53 per household, or 10 percent of the total cost per household. Of course, a complete analysis would require an assessment of the costs of achieving the reduction as well as the benefit; if the 10 percent reduction is achieved through a set of programs that cost $10 billion, then the net gain per household would be just $43.

An Accounting Framework

There are two problems in doing this sort of accounting exercise well. First is the epidemiologist’s problem of discerning the actual consequences of eliminating (or reducing) underage drinking. What reduction would there be in highway crashes, crime, and school dropouts and in all the long-term effects of these events? All such consequences are the result of complex multicausal processes; knowing that there is alcohol involvement in some percentage of such cases leaves one far short of knowing the causal importance of drinking. A further complication is introduced by the realization that the actual effects of a reduction in underage drinking will depend not just on how much of a reduction is accomplished, but also on what sort of collateral consequences will occur. What effect will that intervention have on routine activities, such as weekend driving with friends, the use of other illicit drugs, or dating? The answers may be important in influencing the net consequences, which may well depend on the nature of an intervention to prevent or reduce underage drinking.

The second problem is to develop and implement a sound accounting system for translating outcomes into a measure of social burden. The choice of accounting rules in this context necessarily reflects decisions about deep issues in understanding the public good. Two specific issues are particularly thorny: whose preference should count in defining relevant consequences? Should the social cost computation include subjective losses or only production losses?

The presumption in our society is that the public good is the sum of individual preferences. A reasonable exception may be the preferences of teenagers, who tend to place too little emphasis on their long-term well-being and too much emphasis on pleasing their peers. That commonsense view of adolescent human nature, coupled with the fact that underage drinking is illegal, provides some justification for ignoring the pleasures of drinking as perceived by teens and accounting only for the harmful consequences.

Although few people think that the value of the life of someone killed or permanently disabled by a drunken teenager is limited to his or her lost earnings, that in fact has been the accounting rule used in the traditional

“cost of illness” method of accounting. That method stipulates that the social cost of a harmful activity or illness is the sum of direct costs (property damage, medical costs, and so forth) and indirect costs (lost productivity). Lost productivity has little relationship to the value that individuals and those who care about them place on the value of health and continued life.

A comprehensive accounting framework, then, should take account of both tangible and intangible costs associated with the consequences of underage drinking. The PIRE analysis cited above does just that. Of the $53 billion in costs estimated for 1996, all but $4 billion is the result of lost quality and quantity of life. 3

While this report is not the place to explain the methods used to arrive at this result, we note that it is based on the underlying principle that (adult) preferences should guide the valuation. Those preferences are observed in a generic sense in a variety of settings and choices, where people make risky decisions. For example, wages for risky jobs tend to be higher than safe jobs requiring comparable skill and effort: the “risk premium” reflects the amount that workers must be compensated to take on additional risk, and thereby form a useful basis for assessing the average “value of life.” Note that what is being valued is not literally life itself, but rather a slight reduction in the probability of continued life. This valuation of small changes in safety is relevant for a forward-looking assessment. In assessing a proposed policy to reduce underage drinking, one does not know the identity of which lives will be saved; rather, the prospective accomplishment is a general reduction in risk for all, and that is what is to be valued.

The PIRE study is somewhat incomplete. For example, the study’s estimate does not include medical costs other than those associated with traffic crashes (Hingson and Kenkel, 2004). Perhaps most important is that it neglects the possibility that drinking by teens may cause mild brain damage and lead to impaired academic performance and early termination of schooling. It also takes no account of the possibility that underage drinking engenders a greater likelihood of subsequent problems with alcohol dependence and abuse. In these respects the $53 billion appears to be an underestimate of the social costs of underage drinking.

In sum, the cost of underage drinking to society is substantial. Society is affected by loss of young lives, lost productivity and significant health care costs and stands to gain from reductions in underage drinking. The committee concludes that the PIRE estimate of $53 billion, while perhaps somewhat low, is a reasonable starting point for assessing social costs.

Alcohol use by young people is extremely dangerous - both to themselves and society at large. Underage alcohol use is associated with traffic fatalities, violence, unsafe sex, suicide, educational failure, and other problem behaviors that diminish the prospects of future success, as well as health risks – and the earlier teens start drinking, the greater the danger. Despite these serious concerns, the media continues to make drinking look attractive to youth, and it remains possible and even easy for teenagers to get access to alcohol.

Why is this dangerous behavior so pervasive? What can be done to prevent it? What will work and who is responsible for making sure it happens? Reducing Underage Drinking addresses these questions and proposes a new way to combat underage alcohol use. It explores the ways in which may different individuals and groups contribute to the problem and how they can be enlisted to prevent it. Reducing Underage Drinking will serve as both a game plan and a call to arms for anyone with an investment in youth health and safety.

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