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11. Young People and Alcohol

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Summary:

  • It is generally accepted that young people are at increased risk from certain drinking behaviors. In many countries, young males are more likely to consume alcohol and to display risky drinking behaviors than females.
  • While many factors influence how young people learn to drink and how drinking patterns develop, it has been shown that parents and peers play an important role.
  • Culture is a determining factor in setting norms and expectancies around drinking and in influencing whether, how, and how much young people drink.
  • Although most countries set minimum drinking and purchase ages, there is no universal agreement on the age at which alcohol intake becomes appropriate.
  • Prevention and intervention measures range from limiting young people’s access to alcohol through legal, economic, and social structures to educating young people, servers and retailers, medical professionals, and parents about risks and strategies to reduce the potential for harm.
  • For examples of interventions, see the online database Initiatives Reporting: Industry Actions to Reduce Harmful Drinking.

Drinking among young people is an issue of public health and policy concern in countries around the world. Not all young people drink, and, among those who do, not all do so in a harmful way. However, certain drinking patterns and general risk-taking behavior among youths may place them at considerable risk for harm. Prevention approaches targeted at this population group should aim to ensure that this risk for harm is minimized.

Defining “young people”

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There is currently no consensus regarding the age threshold at which an individual ceases to be a “young person” and becomes an adult. A World Health Organization (WHO) Study Group has defined a young person as someone between the ages of 10 and 24 years ([1], pp. 11-12). For the purposes of alcohol consumption, a number of countries have a legally mandated threshold around drinking, which may or may not coincide with the age of majority for other activities ([2]; see also MODULE 12: Legal Age Limits and ICAP Policy Table: Minimum Age Limits Worldwide).

In developing policy and prevention approaches, it is important to differentiate between young people who are above the legal drinking age and those who are below it. The legal implications of drinking are different for the two groups, as well as for those who sell and serve them alcohol.

Social considerations

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Internationally, experiences with alcohol are relatively common among young people. Drinking before adulthood, however, is generally discouraged in most countries, although young people may be introduced to alcohol at an earlier age in some societies, typically within the family and in the context of meals or celebrations. Such an integrative and relatively permissive approach to drinking is commonly found in cultures with a “Mediterranean” drinking style [3-5].

In general, studies have shown that young males are more likely to drink and do so in higher quantities than young females. However, recent data suggest that in some countries the gender gap among young people is narrowing, with girls and young women “catching up” with their male peers [6-17]. These findings include not only the quantity of alcohol consumption but also frequency and drinking patterns.

Comparative studies across countries suggest that overall drinking culture is an important determinant of how young people drink. Within Mediterranean cultures, for example, young people are more likely to drink and drink more often than their counterparts in other regions [6, 7, 16-19]. At the same time, they are also less likely to engage in excessive and extreme drinking patterns, to get drunk, or to display otherwise problematic drinking behaviors. By contrast, their counterparts in Scandinavia are more likely to drink in a problematic and risky way. This comparison, in addition to other analyses [3, 5, 20-22], suggests that culture plays a prominent role in setting norms and expectancies around drinking, including young people’s drinking.

In addition to culture, other key factors help shape young people’s attitudes toward alcohol consumption. For example:

  • Parental influence and drinking habits play a strong role in shaping drinking behavior in young people [23-32].
  • Family structure can be a protective or a risk factor in the development of drinking patterns. Young people who have a close relationship with their parents and are surrounded by strong family support are less likely to experience problems than those whose families are not intact or who lack adult support and supervision [28-30, 33-39].
  • Peers and friends also play an important role in young people’s decisions on whether and how to drink [28-30, 32, 39-47].
  • Religiosity and active religious involvement appear to have a protective effect on young people’s drinking [48-51].
  • In general, young people involved in extracurricular activities are less likely to experience alcohol-related problems [52], although some evidence exists that youths participating in sports may be more prone to risky drinking practices [52-57].
  • Alcohol expectancies and drinking motives have also been shown to play an important role in shaping drinking patterns of young people. Young people most commonly report drinking for social motives, which is associated with moderate alcohol use. However, young people who drink to cope with negative emotions experience higher rates of alcohol-related problems [58, 59].

Drinking during adolescence may be a predictor of future alcohol misuse and other risky behaviors [60-63]. However, it is unclear as to whether beginning to drink at an earlier age itself increases the likelihood of harmful tendencies in adulthood [63-66]. It may be that early drinking is not the cause but an indicator of other problems and may be coupled with a number of factors and behaviors, such as family troubles or mental illness [39, 65-67].

While alcohol consumption among young people is an area of concern for a variety of social and health reasons, there is also evidence that the majority of youths grow out of their harmful and reckless drinking patterns over time [68-71]. In general, as responsibilities associated with employment, marriage, and children take on a larger role, drinking tends to decrease, as do drinking problems in most people [72-74].

Much Much attention has been given to research on heavy episodic (or “binge”) drinking and related patterns among young people. These behaviors have been studied particularly well among student populations [6, 7, 16, 17, 69, 75, 76]. Social consequences of such consumption include negative effects on studies and academic achievement, family conflict, and risky sexual behavior (see MODULE 6: Binge Drinking; see also [77-83]).

Health considerations

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Several areas have been identified where risk for harm may be increased for young people. In comparison to adults, youths have a greater sensitivity to the effects of alcohol due to developmental changes that occur during childhood and adolescence, potentially resulting in greater risk of physiological damage [79, 84]. The developing brain appears to be more sensitive to disruption by chronic drinking than the mature adult brain [84-86]. As a result, heavy consumption during adolescence may affect the development of certain brain regions [86-88], including the hippocampus, involved in learning and memory [89]. In addition, animal and human studies suggest that early heavy alcohol consumption may have a number of deleterious effects on bone metabolism [90-92] and endocrine development [93, 94].

In addition, alcohol misuse and harmful drinking patterns among young people are correlated with injuries, for example as a result of acute intoxication, traffic crashes, or assault [95-98]. Alcohol-impaired driving among youths accounts for a large proportion of those hurt or killed in road traffic crashes (see MODULE 15: Drinking and Driving and ICAP Issues Briefing: Alcohol-Impaired Driving; see also [99, 100]). For some young people, risky sexual behavior may accompany heavy drinking or intoxication and can result in unwanted pregnancy, sexually transmitted infections, and sexual assault and date rape [80, 101, 102]. Heavy and harmful drinking patterns by young people have been correlated with negative health outcomes in adulthood, including alcohol dependence and problem drinking [79, 82, 84, 103].

Another area for concern is prenatal exposure to high levels of alcohol due to maternal drinking patterns. Such exposure has been associated with a range of developmental problems in children and adolescents that may persist into adulthood. These include fetal alcohol syndrome (FAS) and other conditions (see MODULE 10: Drinking and Pregnancy and ICAP Health Briefing: Fetal Alcohol Exposure; see also [104-107]).

A number of risk factors for alcohol misuse among young people have been identified [108]. Genetic predisposition may play a role in the development of alcohol dependence [109-111] and in relative insensitivity to the effects of alcohol [112, 113]. Alcohol problems in some youths may be related to heavy maternal drinking during pregnancy [114, 115]. Various other stressors and environmental factors, such as living with a parent who is an alcohol abuser [116] or heavy drinking within the immediate peer group [30, 44, 45, 117], may also contribute to alcohol problems in young people. However, youths are generally responsive to treatment and intervention, and targeted approaches have been developed to specifically meet their needs (see MODULE 17: Alcohol Dependence and Treatment and MODULE 18: Screening and Brief Intervention).

Implications for policy and prevention

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A variety of measures have been implemented around the world to limit drinking among young people. Yet how best to reduce risks among this population remains, at best, uncertain. No single strategy has been shown to be successful in all settings, and combined initiatives targeting particular behaviors or aspects of drinking may be a more useful approach.

Prevention and intervention measures range from limiting young people’s access to alcohol (e.g., through drinking age laws) to educating them about drinking patterns, outcomes, and coping skills. Approaches also differ with regard to the desired end goal—from, in some cases, complete abstinence to encouraging responsible consumption and minimizing risk [118]. Both approaches have strengths and weaknesses, but recent years have seen a gradual shift in alcohol policy from measures that address entire populations to those that target specific drinking behaviors and minimize harm for groups at risk.

Minimum age limits

Many countries where alcohol consumption is legal mandate a threshold age at which buying or drinking alcohol becomes permitted [2]. There is no universal agreement, however, on the exact age when alcohol consumption is considered appropriate. Legislation tends to reflect the prevailing cultural attitudes toward alcohol and drinking by young people. [119-123]. As a policy measure, the implementation of a minimum drinking age is effective only if it is enforced (see MODULE 12: Legal Age Limits and MODULE 15: Drinking and Driving).

Alcohol education

A variety of factors—such as family, peers, cultural and religious norms, media, and government policies—may contribute to young people’s first experience with alcohol and to the development of subsequent drinking patterns [124]. While all of these factors may play a role, evidence suggests that the strongest influence is that of parents and peers [29, 36].

There is evidence that alcohol education can raise awareness among young people and in some cases change their behavior around drinking ([118]; see also MODULE 1: Alcohol Education). Several approaches have shown particular promise. The social norms approach relies on changing perceptions among young people about how much their peers actually drink (see MODULE 3: Social Norms Marketing; see also [125-129]). Integrative education that also includes family and the community has been found to be particularly effective [130-136]. There is also evidence that life skills training, when incorporated into a general approach to teaching about health and lifestyle issues, can be useful in changing behavior (see MODULE 2: Life Skills; see also [118, 137-140]).

Marketing and advertising

The relationship between beverage alcohol marketing and young people’s drinking is the focus of considerable attention in research, prevention, and policy [141-145]. While there is strong evidence that advertising and marketing are effective in changing brand choices, reviews of the evidence indicate that there is little to no effect on young people’s drinking behavior [141, 144, 146-149].

Most producers of beverage alcohol and related organizations, such as trade associations, have strict rules of conduct around marketing. Internal company guidelines and industry-wide codes exist in which special attention is paid to young people and safeguards around them ([143, 150]; see also ICAP Guiding Principles: Self-Regulation of Marketing Communications for Beverage Alcohol).

Other targeted interventions 

Other targeted interventions have been developed to ensure that risk for harm is minimized for young people who drink. Drink-drive laws in a number of countries set a more stringent standard for permissible blood alcohol content (BAC) for individuals under the legal drinking age (see MODULE 16: Blood Alcohol Concentration Limits and ICAP Policy Table: Blood Alcohol Concentration [BAC] Limits Worldwide). Similarly, in some countries young people are issued graduated driver’s licenses that may restrict the hours during which they are permitted to drive (see MODULE 15: Drinking and Driving and ICAP Issues Briefing: Alcohol-Impaired Driving). As with other measures aimed at minimizing harm through the imposition of legislated means, the effectiveness of these approaches hinges heavily upon enforcement.

In In some jurisdictions, individuals must display identification with proof of age for admission into certain establishments or to be served beverage alcohol (see MODULE 12: Legal Age Limits).

Where beverage alcohol is served or sold, training staff to deal with young people can also help reduce the risk for harm. Severs and retailers may be trained to request age identification, and such IDs may also be mandated by law (see MODULE 4: Responsible Hospitality and ICAP Toolkits: Responsible Hospitality Guides). Servers can be trained to deal with patrons under the legal drinking age who are refused service or access.

Healthcare professionals can be trained to deliver screening and brief interventions. Programs providing screening and brief interventions have been shown to be effective in reducing consumption, number of heavy drinking days, and alcohol-related problems among young people [151-157]. College or university settings are often used for screening and brief intervention programs for young people and have been shown to be effective in reducing quantity and frequency of consumption and binge drinking ([158-175]; see also MODULE 18: Early Identification and Brief Intervention).

Conclusions

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Most young people have some experience with alcohol before reaching adulthood and before they are legally allowed to drink. The cultural acceptability of drinking plays a role in setting legally mandated drinking ages in different countries. It also influences attitudes around drinking and how young people are introduced to alcohol. There is an imperative to ensure that the laws in a given country are observed and that young people are kept out of harm’s way.

Among young people who drink, those who misuse alcohol face considerable risks for health, injury, and social problems. Developmental changes during childhood and adolescence may make young people more susceptible to harm—particularly neurological harm—from alcohol misuse. Dangerous patterns of drinking and risk-taking behaviors place many young people at heightened risk, including from drinking and driving.

A variety of legal, economic, and social measures aimed at preventing underage drinking and at reducing risks are undertaken around the globe. Family, peers, media, government regulation, and culture blend together in creating the environment in which the young begin drinking. Much progress has been made in understanding the mechanisms shaping young people’s consumption. Much more, however, remains to be learned in order to enhance the effectiveness of prevention and intervention programs for this group.

POLICY OPTIONS: Young People and Alcohol

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In developing policies and approaches, consideration of a number of key elements is required. While some may be necessary at a minimum and under most conditions, others may not be appropriate in all cases, or may be difficult to implement. The list below offers a menu of areas that need to be addressed, based on effective approaches that have been implemented elsewhere. Specific examples are provided in the online database Initiatives Reporting: Industry Actions to Reduce Harmful Drinking.

Policies

Clear definition of legal threshold for drinking and purchase of beverage alcohol.

  • Consideration of local drinking culture and realistic limits.
  • Harmonization of drinking/purchase age with other legal age limits (e.g., age of legal majority, driving age).

Marketing and advertising standards regarding young people.

  • Ensure that commercial communications do not target those under the legal age.
  • Voluntary codes and self-regulation by industry to ensure compliance.
  • Mandated compliance where self-regulation is not effective.

Continued and visible enforcement of rules around drinking age.

  • Ensure awareness of punitive measures for noncompliance.

Education and prevention

Provision of accurate and balanced information for young people and drinking, including both health and social implications. Culturally appropriate prevention and education.

Education of young people about drinking patterns and outcomes.

  • Availability of various approaches including social norms, life skills, and others, as appropriate.
  • Involve families, peers, educators, and others in broader initiatives.
  • Implement combined approaches.

Education of servers and retailers.

  • Ensure awareness of legal age limits and penalties.
  • Provide server training to manage underage individuals in establishments and venues.

Education and training for professionals working with young people.

  • Health professionals trained to provide screening and brief interventions for young people.
  • Training of educators to address drinking, including within school curricula on health.
  • Ensure that social workers and others are skilled to recognize problematic drinking patterns.

Education of parents to discuss and address drinking among young people.

  • Ensure support for parents, including specific relevant materials and resources.

Intervention and treatment

Access to treatment for young people with alcohol problems or dependence.

  • Availability of appropriate screening instruments and intervention approaches.
  • Tailored treatment to address specific needs of young people.

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