Alcohol Use Among Youth

Alcohol use by persons under age 21 has been identified as a major public health problem. Studies note that it increases the risks for disability, and may be detrimental to the developing brain. Minors who drink are more likely to commit suicide, break the law, or be victims of violence. Alcohol is implicated in nearly one-third of youth traffic fatalities. The total annual cost of underage drinking is estimated at $62 billion. While most laws intended to prevent underage drinking are passed at the state level, there has been legislative activity and interest at the federal level to support states’ efforts to curb the problem. This report describes the extent of underage alcohol use, recent legislative activity on this issue, and various policy implications.

Order Code RS22636 April 2, 2007 Alcohol Use Among Youth Andrew R. Sommers Analyst in Chronic Care and Disability Domestic Social Policy Division Ramya Sundararaman Analyst in Public Health Domestic Social Policy Division Summary Alcohol use by persons under age 21 has been identified as a major public health problem. Studies note that it increases the risks for disability, and may be detrimental to the developing brain. Minors who drink are more likely to commit suicide, break the law, or be victims of violence. Alcohol is implicated in nearly one-third of youth traffic fatalities. The total annual cost of underage drinking is estimated at $62 billion. While most laws intended to prevent underage drinking are passed at the state level, there has been legislative activity and interest at the federal level to support states’ efforts to curb the problem. This report describes the extent of underage alcohol use, recent legislative activity on this issue, and various policy implications. It will be updated as new data become available. Introduction On March 6, 2007, the U.S. Surgeon General issued an official call to increase efforts to curb underage drinking.1 “We can no longer ignore what alcohol is doing to our children,” said Acting Surgeon General Kenneth Moritsugu. “Alcohol,” he continued, “is the most heavily abused substance by America’s youth.”2 1 U.S. Department of Health and Human Services, The Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking, U.S. Department of Health and Human Services, Office of the Surgeon General, 2007, at [http://www.surgeongeneral.gov/]. 2 U.S. Department of Health and Human Services Press Office, Acting Surgeon General Issues National Call to Action on Underage Drinking, Office of the Surgeon General, Mar. 6, 2007, at [http://www.hhs.gov/news/press/2007pres/20070306.html]. CRS-2 In light of recent research demonstrating that alcohol may harm the adolescent brain and that individuals who start drinking before the age of 15 are five times more likely to have alcohol-related problems later in life, the Surgeon General announced six basic goals: ! ! ! ! ! ! Fostering changes in American society that facilitate healthy adolescent development and help prevent and reduce underage drinking. Engaging youth and all social systems that interface with youth in a coordinated effort to prevent and reduce drinking and its consequences. Promoting understanding of underage drinking in the context of development and maturation that considers individual adolescent characteristics and environmental, ethnic, cultural, and gender differences. Conducting additional research on adolescent alcohol use and its relationship to development. Improving surveillance on underage drinking and its risk factors. Ensuring that all policies are consistent with the goal of preventing and reducing underage alcohol consumption. Although drinking by persons under the age of 21 is illegal in all states, people age 12-20 drink almost 20% of alcohol consumed in the United States.3 In 2004, there were more than 142,000 emergency rooms visits by youth age 12-20 as a result of injuries and other conditions linked to alcohol consumption.4 Each year, approximately 5,000 young people under the age of 21 die as a result of underage drinking. The economic toll of underage drinking in the United States in 2001 was an estimated $61.9 billion.5 It has been reported that medical care, work loss, and pain and suffering directly associated with underage drinking costs $2,207 annually for each young person in the United States.6 Low educational achievement and high absenteeism rates are common among underage students who drink alcohol. These youth often have problems with social integration, are more prone to fighting, and are often disinclined to participate in healthier 3 Susan E. Foster, et al. “Alcohol Consumption and Expenditure for Underage Drinking and Adult Excessive Drinking,” Journal of the American Medical Association, 2003, 289(8): 989-95. 4 Office of Applied Studies, “Emergency Department Visits involving Underage Drinking,” The New DAWN Report, Issue 1, Rockville, MD: SAMSHA, 2006, at [https://dawninfo.samhsa.gov/ files/tndr02underagedrinking.htm]. 5 Excluding pain and suffering from these costs, the direct costs of underage drinking incurred exceed $20.3 billion each year; Ted R. Miller, David T. Levy, Rebecca S. Spicer, Dexter M. Taylor, “Societal Costs of Underage Drinking,” Journal of Studies on Alcohol, Vol. 67, 2006, pp. 519-528. 6 For alcohol-related fatalities, the costs of pain and suffering were computed based on the monetary values that people ascribed in experimental settings to not being killed. Similarly, the pain and suffering costs of nonfatal injuries were based on the values associated with different dimensions of functioning, cognition, mobility, sensation, and pain. Methodology details are outlined at [http://www.udetc.org/documents/UnderageMethods.pdf]. CRS-3 activities. They have a higher risk of being engaged in illegal activities and participating in unprotected sex.7 Surveillance Although many national surveys collect information about alcohol consumption, three federally funded studies most comprehensively cover aspects of underage drinking. National Survey on Drug Use and Health (NSDUH). NSDUH is the primary source of statistical information on illegal drug use by the U.S. population. Sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), NSDUH collects data in interviews at each respondent’s place of residence. Survey items aim to provide the drug prevention, treatment, and research communities with current, relevant information on the status of the nation’s drug usage, including national and state-level estimates of the past month, past year, and lifetime use of alcohol. NSDUH tracks trends in the use of alcohol and helps identify the consequences of underage alcohol use and the groups who are at greatest risk. Youth Risk Behavior Survey (YRBS). The YRBS monitors health risk behaviors, including underage drinking, that contribute to mortality, disability, and social problems among youth in the United States. The YRBS, which is conducted every two years, provides data representative of high school students throughout the United States. The YRBS is a national school-based survey fielded by the Centers for Disease Control and Prevention (CDC) and supplemented with data collected by state and local education and health agencies. Monitoring the Future (MTF). Funded by the National Institute on Drug Abuse, MTF annually surveys 8th, 10th, and 12th graders about substance use, including alcohol consumption. Respondents are asked about daily and monthly alcohol use, the quantity of alcohol consumed, and the number of episodes of heavy drinking in the past month. Unlike NSDUH or YRBS, MTF also explores issues of risk and ethics by asking, “How much do you think people risk harming themselves (physically or in other ways)” if they drink daily or if they drink heavily on the weekends. Similarly, survey participants are asked whether they “disapprove” of these behaviors. Each year, a random sample of 12thgrade MTF participants is selected for follow-up studies. These individuals are surveyed by mail every other year until age 30, then every fifth year until age 45. Data from these follow-up surveys allow researchers to investigate questions about the effects of alcohol use over time, such as: ! ! How is alcohol use affected by major transitions into and out of social environments (e.g., military service, civilian employment, college, unemployment) or social roles (e.g., marriage, pregnancy, parenthood)? How does the life course of individuals who used alcohol as teens differ from those who did not? Prevalence The consumption of alcohol by youth has dropped steadily over the last decade. In 2005, 74.3% reported having used alcohol on multiple occasions; 43.3% regularly 7 See [http://www.cdc.gov/alcohol/quickstats/underage_drinking.htm]. CRS-4 consumed alcohol; and 25.5% engaged in binge drinking.8 These figures represent absolute declines of 4.8%, 7.5%, and 7.9%, respectively, since 1997. Still, underage drinking remains a far more prevalent problem than the use of illicit drugs or tobacco products. According to Monitoring the Future, U.S. high school seniors are 50% more likely to have consumed alcohol more than once than to have ever tried illicit drugs or to have smoked tobacco.9 There are an estimated 11 million underage drinkers in the United States. More than 2 million are classified as heavy drinkers, and nearly 7.2 million are classified as binge drinkers, meaning that they have had more than five drinks on one occasion.10 Prevalence rates of alcohol consumption among preteen boys and girls are similar. Among teenagers, however, males report more current alcohol use (28.9% vs. 27.5%, respectively), and more frequent binge drinking (21.3% vs. 16.1%) and heavy drinking (7.6% vs. 4.3%) in 2005. Rates of binge drinking are highest among white (22.3%) and American Indian/Alaskan Native youth (18.1%), followed by Hispanic youth (17.9%), African American youth (9.1%), and Asian American youth (7.4%).11 Underage drinking varies by geographic region Since 2002, it has been higher in the Northeast (31.4%) and Midwest (31.0%) than in the South (26.4%) and West (26.0%).12 According to the 2005 NSDUH, underage drinking rates in 2005 were similar in urban and suburban areas (28.1% and 30.1%, respectively). The rate in rural areas, however, was markedly lower — 23%. While NSDUH and YRBS ask many similar questions regarding underage drinking, the Youth Risk Behavior Survey includes several unique, noteworthy findings. Among high school students surveyed in 2005, 26% had their first alcoholic drink before age 13, one in three had ridden with a driver who had been drinking alcohol, 10% had driven while drinking alcohol at some point in the past month, and 4.3% had consumed alcohol on school property.13 8 Centers for Disease Control and Prevention, 2005, Youth Risk Behavior Survey, available at [http://www.cdc.gov/yrbss]. 9 Lloyd D. Johnston, Patrick M. O’Malley, Jerald G. Bachman, et al., Monitoring the Future national survey results on drug use, 1975-2005. Volume I: Secondary school students, NIH Publication No. 06-5883, Bethesda, MD: National Institute on Drug Abuse, 2006. 10 SAMHSA, Results from the 2005 National Survey on Drug Use and Health: National Findings, NSDUH Series H - 30, HHS Pub. No. SMA 06 - 4194. Rockville, MD: SAMHSA, Office of Applied Studies, 2006. 11 NSDUH, 2005, at [http://oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm#3.2]. 12 U.S. Census regions are defined as follows: Northeast — Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Pennsylvania; Midwest — Ohio, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas; South — Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, Texas; West — Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Oregon, California, Alaska, Hawaii. 13 Centers for Disease Control and Prevention, 2005 Youth Risk Behavior Survey, 2005, op. cit. CRS-5 Policy Perspectives The 21st Amendment to the U.S. Constitution gives states the primary authority to regulate the sale and distribution of alcohol within their borders. Hence, most underage drinking prevention laws are passed by states. Today, all states have set the minimum legal drinking at age 21, and have passed zero-tolerance laws that make it illegal for people under age 21 to drive after drinking any alcohol. Despite their demonstrated benefits, legal drinking age laws and zero-tolerance laws generally have not been vigorously enforced.14 Alcohol purchase laws aimed at sellers and buyers also can be effective, but experts believe that more resources need to be made available for enforcing these laws.15 At the federal level, legislative activity has primarily been aimed at coordinating and supporting the states’ efforts. The following underage drinking prevention laws have been passed since the 106th Congress (1999-2000): ! ! ! ! ! ! Sober Truth on Preventing Underage Drinking Act (STOP Act):16 Mandates the Secretary of Health and Human Services to formally enhance the efforts of the Interagency Coordinating Committee on the Prevention of Underage Drinking. Science, State, Justice, Commerce, and Related Agencies Appropriations Act, 2006:17 Provides $25 million for grants to states to enforce minimum drinking age laws, and for technical assistance. Consolidated Appropriations Act, 2005:18 Provides $25 million for grants to states to enforce minimum drinking age laws, and for technical assistance. No Child Left Behind Act:19 Authorizes the Substance Abuse Mental Health Services Administration to award grants to local educational agencies to develop and implement programs to reduce alcohol abuse in secondary schools. National Police Athletic League Youth Enrichment Act:20 Provides for expansion of Police Athletic League Chapters to conduct underage drinking prevention activities in non-school hours. District of Columbia Appropriations Act, 2001:21 Provides $25 million for grants to states to enforce minimum drinking age laws, and for technical assistance. 14 Ralph K. Jones, and John H. Lacey, Alcohol and Highway Safety 2001: A Review of the State of Knowledge. DOT HS 809 383. Washington, DC: National Highway Traffic Safety Administration, 2001, at [http://www.nhtsa.dot.gov/people/injury/research/AlcoholHighway]. 15 David F. Preusser, A.F. Williams, H.B. Weinstein, “Policing underage alcohol sales,” Journal of Safety Research, Vol. 25, pp.127-133, 1994. 16 P.L.109-422, Sec, 2(c)(1), 120 Stat 2891. 17 P.L.109-108, Sec. 5(c), 119 Stat 2300. 18 P.L. 108-447, Sec. 2, Division B, Title I, 118 Stat. 2866. 19 P.L. 107-110, Title IV, Sec.4129, 115 Stat 1757. 20 P.L. 106-367, Sec.6(a)(2)(B)(I), 114 Stat 1414. 21 P.L. 106-553, Appendix B, Title I, 114, Stat. 2762A-65. P.L.106-553. CRS-6 ! Missing, Exploited, and Runaway Children Protection Act:22 Provides funding for community-based alcohol and drug abuse prevention and education services to street youth. Institute of Medicine Recommendations The 2003 Institute of Medicine (IOM) report on reducing underage drinking concluded that underage drinking cannot be successfully addressed by focusing on youth alone.23 Since minors “usually obtain alcohol — directly or indirectly — from adults,” the IOM contended, efforts to reduce drinking among teens should also be aimed at adults and industry. The IOM’s recommendations, discussed below, included community-based interventions and policy options to limit or prevent underage alcohol consumption. Prohibit alcohol advertisements from targeting youth. Long-term exposure to alcohol advertising and promotion increases the likelihood that children will drink. The IOM has called on the alcohol and entertainment industries to shield youth from unsuitable messages about drinking by ensuring that programs do not portray underage drinking in a favorable light. The IOM also suggested that Congress consider restrictions on the alcohol industry, analogous to those placed on the tobacco companies, to prevent marketing practices that disproportionately appeal to minors. Increasing alcohol prices through excise taxes. The current tax on alcohol has not kept pace with inflation, thus reducing the real price of alcohol over time. Thus, alcoholic beverages are cheaper today in real dollars than they were in the 1960s and 1970s. Research indicates that increases in alcohol price are associated with decreased underage drinking.24 Increasing excise taxes on alcohol, according to the IOM, could provide revenue for strategies to reduce underage drinking.25 Public awareness. Educating the public about the consequences and the existing laws regarding underage drinking could curtail access to and consumption of alcohol by minors. The IOM recommended that the federal government fund and support development of a national media effort as a major component of an adult-oriented campaign to reduce underage drinking. For these public education efforts to be effective, however, they would need to be combined with better enforcement of existing laws. Enforcement. The IOM suggested that states or the federal government could consider criminalizing the use of falsified or fraudulent identification in an attempt to purchase alcoholic beverages, as well as criminalizing the provision of any alcohol to minors by adults, except to their own children in their own residences. 22 P.L.106-71, Sec. 3(b)(1), 113 Stat. 1042. 23 Richard J. Bonnie and Mary Ellen O’Connell (eds.), Reducing Underage Drinking: A Collective Responsibility, Institute of Medicine, Committee on Developing a Strategy to Reduce and Prevent Underage Drinking, Washington, DC: National Research Council and the Institute of Medicine, 2003, available at [http://www.nap.edu/catalog/10729.html]. 24 Frank J. Chaloupka, Michael Grossman, and Henry Saffer, “The effects of price on alcohol consumption and alcohol-related problems,” Alcohol Research and Health, Vol. 26, No. 1, pp. 22-34, 2002. 25 If this policy option were pursued, the IOM emphasized that alcohol taxes would have to be indexed to the consumer price index in order to ensure they keep pace with inflation.