MODULE
11
Defining
“young people”
Social considerations
Health considerations
Implications for policy
and prevention
Conclusions
Policy options
References
YOUNG PEOPLE
AND ALCOHOL
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.
11.1
■ 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.
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.
THE ICAP BLUE BOOK: Practical Guides for Alcohol Policy and Prevention Approaches
Defining “young people”
T
here 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.
THE ICAP BLUE BOOK
MODULE 11: Young People and Alcohol
11.2
Social considerations
I
nternationally, 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]. hese
indings 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.
his 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 inluence 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].
THE ICAP BLUE BOOK
• 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 efect on young people’s
drinking [48-51].
• In general, young people involved in extracurricular activities are less likely to experience alcoholrelated 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 [6063]. 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].
MODULE 11: Young People and Alcohol
11.3
Much attention has been given to research on heavy
episodic (or “binge”) drinking and related patterns
among young people. hese behaviors have been
studied particularly well among student populations
[6, 7, 16, 17, 69, 75, 76]. Social consequences of such
consumption include negative efects on studies and
academic achievement, family conlict, and risky
sexual behavior (see MODULE 6: Binge Drinking;
see also [77-83]).
THE ICAP BLUE BOOK
MODULE 11: Young People and Alcohol
11.4
Health considerations
S
everal 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].
SIn addition, alcohol misuse and harmful drinking
patterns among young people are correlated with
injuries, for example as a result of acute intoxication,
traic crashes, or assault [95-98]. Alcohol-impaired
driving among youths accounts for a large proportion of those hurt or killed in road traic crashes
(see MODULE 15: Drinking and Driving and
ICAP Issues Brieing: 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. hese
THE ICAP BLUE BOOK
include fetal alcohol syndrome (FAS) and other
conditions (see MODULE 10: Drinking and Pregnancy and ICAP Health Brieing: Fetal Alcohol
Exposure; see also [104-107]).
A number of risk factors for alcohol misuse among
young people have been identiied [108]. Genetic
predisposition may play a role in the development
of alcohol dependence [109-111] and in relative
insensitivity to the efects 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 speciically meet their
needs (see MODULE 17: Alcohol Dependence
and Treatment and MODULE 18: Early Identiication and Brief Intervention).
MODULE 11: Young People and Alcohol
11.5
Implications for policy and prevention
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 difer 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 speciic 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]. here is no universal agreement, however, on the exact age when
alcohol consumption is considered appropriate.
Legislation tends to relect 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 efective
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 irst
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 inluence is that of parents and
peers [29, 36].
THE ICAP BLUE BOOK
here 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. he 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 efective [130136]. here 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
he 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 efective in changing
brand choices, reviews of the evidence indicate that
there is little to no efect 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).
MODULE 11: Young People and Alcohol
11.6
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 Brieing: AlcoholImpaired Driving). As with other measures aimed
at minimizing harm through the imposition of legislated means, the efectiveness of these approaches
hinges heavily upon enforcement.
In some jurisdictions, individuals must display
identiication with proof of age for admission into
certain establishments or to be served beverage alcohol (see MODULE 12: Legal Age Limits).
THE ICAP BLUE BOOK
Where beverage alcohol is served or sold, training
staf to deal with young people can also help reduce
the risk for harm. Severs and retailers may be trained
to request age identiication, 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 efective 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 efective in reducing
quantity and frequency of consumption and binge
drinking ([158-175]; see also MODULE 18: Early
Identiication and Brief Intervention).
MODULE 11: Young People and Alcohol
11.7
Conclusions
M
ost 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.
THE ICAP BLUE BOOK
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 efectiveness of prevention and intervention
programs for this group.
MODULE 11: Young People and Alcohol
11.8
POLICY OPTIONS:
Young People and Alcohol
I
n 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 database Initiatives Reporting: Industry Actions to Reduce Harmful Drinking, at
http://initiatives.global-actions.org/
Policies
Clear deinition 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
efective.
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.
THE ICAP BLUE BOOK
• 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 of professionals dealing 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 speciic relevant materials and resources.
Intervention and treatment
Access to treatment for young people with alcohol
abuse problems or dependence.
• Availability of appropriate screening instruments
and intervention approaches.
• Tailored treatment to address speciic needs of
young people.
MODULE 11: Young People and Alcohol
11.9
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THE ICAP BLUE BOOK
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THE ICAP BLUE BOOK
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Journal of American College Health, 58(4), 357-364.
THE ICAP BLUE BOOK
168. Lau-Barraco, C., & Dunn, M. E. (2008). Evaluation
of a single-session expectancy challenge intervention
to reduce alcohol use among college students. Psychology of Addictive Behaviors, 22(2), 168-175.
169. Kypri, K., Langley, J. D., Saunders, J. B., CashellSmith, M. L., & Herbison, P. (2008). Randomized
controlled trial of web-based alcohol screening and
brief intervention in primary care. Archives of Internal
Medicine, 168(5), 530-536.
170. LaBrie, J. W., Hummer, J. F., Neighbors, C., &
Pedersen, E. R. (2008). Live interactive group-speciic
normative feedback reduces misperceptions and
drinking in college students: A randomized cluster
trial. Psychology of Addictive Behaviors, 22(1), 141-148.
171. LaBrie, J. W., Huchting, K., Tawalbeh, S., Pedersen,
E. R., hompson, A. D., Shelesky, K., et al. (2008). A
randomized motivational enhancement prevention
group reduces drinking and alcohol consequences
in irst-year college women. Psychology of Addictive
Behaviors, 22(1), 149-155.
172. Bingham, C. R., Barretto, A. I., Walton, M. A., Bryant, C. M., Shope, J. T., & Raghunathan, T. E. (2011).
Eicacy of a web-based, tailored, alcohol prevention/
intervention program for college students: 3-month
follow-up. Journal of Drug Education, 41(4), 405-430.
173. Butler, L. H., & Correia, C. J. (2009). Brief alcohol
intervention with college student drinkers: Faceto-face versus computerized feedback. Psychology of
Addictive Behaviors, 23(1), 163-167.
174. Simao, M. O., Kerr-Correa, F., Smaira, S. I., Trinca, L.
A., Floripes, T. M., Dalben, I., et al. (2008). Prevention of “risky” drinking among students at a Brazilian
university. Alcohol and Alcoholism, 43(4), 470-476.
175. Wood, M. D., Fairlie, A. M., Fernandez, A. C., Borsari, B., Capone, C., Laforge, R., et al. (2010). Brief
motivational and parent interventions for college
students: A randomized factorial study. Journal of
Consulting and Clinical Psychology, 78(3), 349-361.
MODULE 11: Young People and Alcohol
11.17