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1
Introduction: The Challenge

Alcohol use by children, adolescents, and young adults under the legal drinking age of 21 produces human tragedies with alarming regularity. Motor vehicle crashes, homicides, suicides, and other unintentional injuries are the four leading causes of death of 15- to 20-year-olds, and alcohol is a factor in many of these deaths. Indeed, so many underage drinkers die in car crashes that this problem, by itself, is a major national concern. In relation to the number of licensed drivers, young people under age 21 who have been drinking are involved in fatal crashes at twice the rate of adult drivers (National Highway Traffic Safety Administration, 2002a).

Car crashes are the most visible and most numbing consequences of underage drinking, but they represent only a small proportion of the social toll that underage drinking takes on the present and future welfare of society. Other damaging problems include dangerous sexual practices that lead to both serious disease and unwanted pregnancies, unintentional injuries, fights, and school failures that lead to expulsions or withdrawals. Levy et al. (1999) estimated that in 1996 underage drinking led to 3,500 deaths, 2 million nonfatal injuries, 1,200 cases of fetal alcohol syndrome, and 57,000 cases of treatment for alcohol dependence. Worse yet, underage drinking reaches into the future by impeding normal development and constricting future opportunities. Conservatively estimated, the social cost of underage drinking in the United States in 1996 was $52.8 billion (Pacific Institute for Research and Evaluation, 1999).



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Reducing Underage Drinking: A Collective Responsibility 1 Introduction: The Challenge Alcohol use by children, adolescents, and young adults under the legal drinking age of 21 produces human tragedies with alarming regularity. Motor vehicle crashes, homicides, suicides, and other unintentional injuries are the four leading causes of death of 15- to 20-year-olds, and alcohol is a factor in many of these deaths. Indeed, so many underage drinkers die in car crashes that this problem, by itself, is a major national concern. In relation to the number of licensed drivers, young people under age 21 who have been drinking are involved in fatal crashes at twice the rate of adult drivers (National Highway Traffic Safety Administration, 2002a). Car crashes are the most visible and most numbing consequences of underage drinking, but they represent only a small proportion of the social toll that underage drinking takes on the present and future welfare of society. Other damaging problems include dangerous sexual practices that lead to both serious disease and unwanted pregnancies, unintentional injuries, fights, and school failures that lead to expulsions or withdrawals. Levy et al. (1999) estimated that in 1996 underage drinking led to 3,500 deaths, 2 million nonfatal injuries, 1,200 cases of fetal alcohol syndrome, and 57,000 cases of treatment for alcohol dependence. Worse yet, underage drinking reaches into the future by impeding normal development and constricting future opportunities. Conservatively estimated, the social cost of underage drinking in the United States in 1996 was $52.8 billion (Pacific Institute for Research and Evaluation, 1999).

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Reducing Underage Drinking: A Collective Responsibility For many children, alcohol use begins early, during a critical developmental period: in 2002, 19.6 percent of eighth graders were current users of alcohol (use within the past 30 days), which can be compared with 10.7 percent who smoked cigarettes and 8.3 percent who used marijuana. Among each older age cohort of high school students, the prevalence, frequency, and intensity of drinking increase, contributing to increasing rates of educational failure, injury, and death as children move from grade to grade. By the time young people are seniors in high school, almost three-quarters (71.5 percent) report having drunk in the past year, almost half (48.6 percent) are current drinkers, and more than one-quarter (28.6 percent) report having had five or more drinks in a row in the past 2 weeks (Johnston et al., 2003). Among 18- to 22-year-olds, 41.4 percent of full-time college students and 35.9 percent of other young adults report heavy drinking (Substance Abuse and Mental Health Services Administration, 2002). Heavy childhood and teenage drinking injures the developing brain and otherwise interferes with important developmental tasks. In addition, children and adolescents who begin drinking early are more likely than others to wind up with alcohol problems throughout their adult lives. The public is certainly aware of these problems, especially drunk driving by teens. However, recent surveys demonstrate that parents underestimate the prevalence and intensity of alcohol use by their own children and by the underage population (see Chapter 6). Moreover, as measured by media attention and government expenditures, public concern about teenage alcohol use has not been remotely commensurate with the magnitude of the problem. A telling measure of the current societal response is the large gap in the federal government’s investment in discouraging illicit drug use among teenagers and in discouraging underage drinking, given that the social damage from underage alcohol use far exceeds the harms caused by illicit drug use. In fiscal 2000, the nation spent approximately $1.8 billion on preventing illicit drug use (Office of National Drug Control Policy, 2003), which was 25 times the amount, $71.1 million, targeted at preventing underage alcohol use (U.S. General Accounting Office, 2001). The amount spent on preventing underage drinking also appears to be less than the amount spent on preventing tobacco use: in fiscal 2000, the Office of Smoking and Health, only one of many agencies in the Department of Health and Human Services concerned with smoking prevention, spent approximately $100 million. In addition, the states spent a great deal more, including funds generated by the agreement that settled the states’ Medicaid reimbursement suits against the tobacco companies. There are signs that public attention to underage drinking is increasing and that the public recognizes the need to address the problem more aggressively than has thus far occurred. A recent study on public attitudes toward

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Reducing Underage Drinking: A Collective Responsibility underage drinking (Wagenaar et al., 2002) shows almost universal recognition of this problem. In fact, 98 percent of adults polled said they were concerned about teen drinking and 66 percent said they were “very concerned.” Moreover, a majority of respondents favored strong regulatory actions, such as additional controls on alcohol sales and advertising that would “make it harder for teenagers to get alcoholic beverages.” In 1999, Mothers Against Drunk Driving (MADD) added the goal of reducing underage drinking to its mission statement, and its activities and public statements increasingly reflect this focus (e.g., Mothers Against Drunk Driving, 2002). Underage drinking has also won the attention of the spouses of the nation’s governors, many of whom have come together to form the Leadership to Keep Children Alcohol Free, in collaboration with the Robert Wood Johnson Foundation (RWJF) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA, part of the National Institutes of Health). In collaboration with the American Medical Association (AMA), the RWJF has also provided long-term support to 12 community and 10 university-based coalitions with the specific mission of reducing and preventing underage drinking. The AMA has itself also become increasingly active on the issue of underage drinking, calling for tighter regulation of alcohol availability, higher excise taxes, and restrictions on alcohol advertising. Members of the alcohol industry also have continued their efforts to discourage underage drinking through responsible drinking campaigns and approaches such as server, parent, and youth-oriented education and involvement in prevention efforts on college campuses. Underage drinking has also begun to attract increased government attention in Washington. The U.S. Federal Trade Commission (FTC), at the request of Congress, recently reviewed the alcohol industry’s advertising and marketing practices. Its report (U.S. Federal Trade Commission, 1999) called on alcohol companies to move toward the “best practices” in the industry “to reduce underage alcohol ad exposure.” In 2003 Congress called on the FTC to revisit its inquiry into alcohol advertising and youth and to investigate if and how the recommendations issued in its 1999 report have been implemented by the alcohol industry. Advocacy groups have also urged Congress to include underage alcohol use in the major media campaign being waged against illegal drug use under the auspices of the Office of National Drug Control Policy. THE COMMITTEE STUDY In 2001 Congress responded to the increasing level of public concern about underage alcohol consumption by appropriating funds for a study by The National Academies. Acting through the NIAAA and the Substance

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Reducing Underage Drinking: A Collective Responsibility Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services (HHS), Congress requested1 The National Academies to undertake an examination of the pertinent literature, to “review existing federal, state, and nongovernmental programs, including media-based programs, designed to change the attitudes and health behaviors of youth,” and to “develop a cost effective strategy for reducing and preventing underage drinking.” Based on consultations with several of the Academies’ standing advisory boards, members of the Academies, and the Academies’ governing bodies, the final statement of task directs the committee to examine programs ranging from environmental interventions (e.g., taxation, access restrictions) to programs focusing directly on the attitudes and behavior of young people (see Appendix A for the full statement of task). In response, the Board on Children, Youth, and Families (BCYF) of the National Research Council and the Institute of Medicine of the National Academies established a committee of 12 members with special expertise in key domains relating to underage drinking. To supplement the expertise of its members, the committee commissioned a set of papers to provide systematic reviews of the scientific literature on determinants of underage drinking and effective ways of reducing it. Topics explored in these papers include the demographics of underage drinking; its economic and social costs; adolescent decision making and risk and protective factors; and the effectiveness of various prevention programs and approaches, including media campaigns, school-based education, pricing, and access. Draft papers were presented at public meetings in October and November 2002 (see Appendixes B and C) and subsequently reviewed and revised.2 Numerous programs with the common goal of reducing underage drinking have been implemented at the national, state, and local levels, by governments and nonprofit and grassroots organizations. At the federal level, the Departments of Health and Human Services (HHS), Justice, and Transportation operate several programs that specifically target underage drinking. Seven other federal agencies fund efforts that include underage alcohol use within a broader mandate (U.S. General Accounting Office, 2001). Similarly, numerous state-level agencies administer programs to reduce underage drinking. In most states, the health, human service, transportation, criminal justice, and education departments play some role. State alcohol beverage control bodies also play a role. Many communities, colleges and universities, and grassroots organizations across the country have initiated 1   Department of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2002, H.R. 3061. 2   A select compilation of these papers is available as a CD-ROM attached to the inside back cover.

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Reducing Underage Drinking: A Collective Responsibility efforts to reduce underage drinking and its associated problems in their communities. The alcohol industry also has implemented a range of efforts with the goal of reducing underage drinking. The committee reviewed the 2001 report of the General Accounting Office on federal programs. This report focused on federal funding that targets underage drinking or includes underage drinking within a broader mandate. It does not include evidence on the effectiveness of specific programs. For the programs operated by the Departments of Transportation and Justice, the report provides general information on the types of activities funded—traffic safety and enforcement of underage drinking laws, respectively. No information is provided on the HHS-funded programs or activities, the largest overall funder of targeted underage drinking activities (see Chapter 12), probably because the funds generally do not represent a national program but, rather, funding for select state or local programs or research aimed at specific aspects of the problem. Although HHS has funded evaluations of specific state and community-level programs, the committee is not aware of any national-level HHS evaluations, or national evaluations of the Department of Transportation program. Each of the federal agencies have initiatives to highlight promising practices, based on varying levels of evidence. Evaluations of state or local programs that receive federal funding that are available in the literature, are reflected in the papers prepared for the committee’s study. The largest single federal program that targets underage drinking is the Enforcing the Underage Drinking Laws (EUDL) Program, operated by the Department of Justice’s Office of Juvenile Justice and Delinquency Prevention (OJJDP). A national evaluation of this program is in its fourth year, with only very preliminary outcomes information now available (see Chapter 9). The training and technical assistance center funded by the EUDL program produces a variety of materials that highlight best practices, many of which were reviewed by the committee. The committee also reviewed written materials submitted by numerous organizations and individuals and considered both written and oral information presented at a public meeting held on November 21, 2002, by a wide range of organizations and people (see Appendix C). This input highlighted programs or approaches considered effective by diverse communities and provided insights into their attitudes and experiences. The judgments provided through this process regarding effectiveness of particular programs or interventions were primarily subjective or based on informal evaluations. Industry representatives provided extensive materials that were reviewed by the committee on the multiple activities they fund to reduce underage drinking. Included were descriptive materials such as summaries, brochures, pamphlets, videos, and guidebooks; testimonials from commu-

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Reducing Underage Drinking: A Collective Responsibility nity representatives on the utility of specific activities, and an evaluation of Alcohol 101, an industry-funded college-based intervention (see Chapter 7 for further discussion of these activities). The committee’s basic charge is to provide science-based recommendations about how best to prevent and reduce underage drinking. Based on its expertise, consideration of public input, and review of the available scientific literature, including the papers written for the committee, the committee identified eight categories of programs or interventions and presents the evidence for each in the relevant chapter: media campaigns designed to discourage underage drinking directly, to affect the behavior of adults, and to build a broader public awareness of the nature and magnitude of the problem (Chapter 6 for adult-oriented campaigns and Chapter 10 for youth-oriented campaigns); measures to curtail or counteract activities by individuals or businesses, including alcohol marketing practices, that tend to encourage or facilitate underage drinking (Chapters 7 and 8); measures restricting youth access to alcohol in both commercial and noncommercial settings, together with programs enforcing these laws (Chapter 9); measures to reduce alcohol-related social harms by enforcing compliance with underage drinking restrictions, such as zero tolerance laws and other programs to reduce alcohol-related traffic injuries and criminal behavior (Chapter 9); educational activities undertaken by schools, colleges and universities, faith-based institutions, healthcare organizations, alcohol companies, parent associations, and other entities designed to discourage underage drinking (Chapter 10); community-based initiatives designed to tailor comprehensive approaches to the specific underage drinking problems of local communities (Chapter 11); screening, counseling, and treatment programs to assist underage drinkers who have developed alcohol problems (Chapter 11); and methods of increasing the price of alcohol to underage purchasers, including increases in excise taxes (Chapter 12). It is important to recognize that implementation of any national “strategy” will depend on the cooperative actions of thousands of organizations and millions of individuals who have their own ideas about what is likely to be effective and valuable. These organizations include agencies at all levels of government (federal, state, and local) with an interest in underage drinking (e.g., alcoholic beverage control commissions, schools, and agencies responsible for law enforcement, substance abuse prevention, social ser-

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Reducing Underage Drinking: A Collective Responsibility vices, and public health). It also includes all the companies and establishments involved in producing, distributing, and selling alcohol—including distillers, vintners, breweries, package stores, and bars—as well as the advertising agencies that advise companies about how to position their products in different segments of the markets they seek to reach. It includes entertainment companies and other organizations that shape popular culture and affect young people’s attitudes about alcohol. A key role in any national response to the problem is played by parents who set models of drinking behavior for their children and who can affect the conditions under which their children have access to alcohol products. Of course, youths themselves make important decisions—not only about their own drinking, but also about how they view the drinking of their friends and peers. The scope of the current efforts of many national, state, local, and nongovernmental group initiatives to prevent underage drinking or the consequences of drinking, particularly drinking and driving, is impressive. These programs include educational interventions, media campaigns, and activities to support enforcement of minimum drinking age laws. Young people themselves have organized efforts to discourage drinking among their peers. While few of these activities have been evaluated in any formal way, a successful national strategy will require the continued involvement, wisdom, and experience of the range of people and organizations that have been committed to preventing and controlling underage drinking. A CHALLENGING TASK The committee was charged with “developing a cost-effective strategy for preventing and reducing underage drinking.” As we set about this important task, it soon became evident that preventing and reducing underage alcohol use poses unusual challenges. Four of those challenges are the pervasiveness of drinking in the United States, the need for a broad consensus for a national strategy, ambivalence about goals and means, and commercial factors. Pervasiveness of Drinking Alcohol is readily available to adults (those over 21) through a large number of outlets for on-premise or off-premise consumption. About half of U.S. adults currently drink alcohol; among drinkers, the mean number of drinking days per month in 1999 was approximately eight.3 3   Based on the committee’s analysis of 2000 data from the National Household Survey on Drug Abuse.

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Reducing Underage Drinking: A Collective Responsibility Notwithstanding the legal ban, alcohol is also readily available to underage drinkers. In recent surveys of high school students, 94.7 percent of twelfth graders and 67.9 percent of eighth graders reported that alcohol is “fairly” or “very” easy to get (Johnston et al., 2003). Purchase surveys reveal that from 30 to 70 percent of outlets may sell to underage buyers, depending in part on their geographic location (Forster et al., 1994, 1995; Preusser and Williams, 1992; Grube, 1997). Focus groups have also indicated that underage youths typically procure alcohol from commercial sources and adults or at parties where parents and other adults have left the youths unchaperoned (Jones-Webb et al., 1997; Wagenaar et al., 1993). Wagenaar et al. (1996) reported that 46 percent of ninth graders, 60 percent of twelfth graders, and 68 percent of 18- to 20-year-olds obtained alcohol from an adult on their last drinking occasion. Commercial outlets were the second most prevalent alcohol source for youths 18 to 20. For younger adolescents, the primary sources of alcohol are older siblings, friends and acquaintances, adults (through third-party transactions), and at parties (Harrison et al., 2000; Jones-Webb et al., 1997; Schwartz et al., 1998; Wagenaar et al., 1993). National surveys of college student drinking find that a large percentage of college youth report they do not have to pay anything for alcohol, presumably because they are at a party where someone else is supplying the alcohol (Wechsler et al., 2000). American culture is also replete with messages touting the attractions of alcohol use, which often imply that drinking is acceptable even for people under 21. Recent content analyses of television showed that alcohol use was depicted, typically in a positive light, in more than 70 percent of episodes sampled from prime-time programs shown in 1999 (Christensen et al., 2000), and in more than 90 percent of the 200 most popular movie rentals for 1996-1997 (Roberts et al., 1999b). Roberts et al. (1999b) also found that 17 percent of 1,000 of the most popular songs in 1996-1997 across five genres of music that are popular with youth contained alcohol references, including almost one-half of the rap music recordings. Positive images are also disseminated by the alcohol industry, which spent $1.6 billion on advertising in 2001 and at least twice that amount in other promotional activity. Thus, overall, young people are exposed to a steady stream of images and lyrics presenting alcohol use in an attractive light. Need for Consensus An effective strategy to reduce a behavior as pervasive and widely facilitated as underage drinking will depend on a public consensus about both goals and means, which will require an unequivocal commitment from a broad array of public and private institutions. If the nation is to succeed in promoting abstention or reduced consumption by minors in a country

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Reducing Underage Drinking: A Collective Responsibility that has more than 120 million drinkers, the need to do so has to be understood and embraced by many people in a position to reduce drinking opportunities for minors. An effective strategy will depend on adoption of public policies by authoritative decision makers about how to use tax money and public authority—for example, whether to use federal dollars to fund a national media campaign, how to enforce existing state laws banning sales to underage drinkers, or how local school boards should discipline students who drink. The process of enacting such policies will require some degree of public consensus, but this is only the start. Ultimately, the effectiveness of government policies will depend on how enthusiastically a great many public and private agencies join in the effort to implement them. If parents, animated by a national media campaign, join local police and school boards in concerted efforts to discourage underage drinking and if alcohol distributors join with regulatory agencies to find means to deny underage drinkers easy access to alcohol, then the impact of government policies will be increased. In short, a public consensus to deal determinedly and effectively with underage drinking is needed not only to generate support for adopting strong policies, but also to make them effective. Conversely, both enactment and implementation will be seriously impeded if the public is divided or ambivalent about the importance of reducing underage drinking. It is here that the greatest challenge lies. In the nation’s diverse society, communities have differing beliefs and sensibilities about the consumption and social meaning of alcohol use in general, as well as about what should be expected and demanded of young people during the transition between childhood and adulthood. These differences contribute to varying beliefs, varying public policies, and varying individual practices regarding underage access to alcohol. Although the vast majority of families would agree that the nation as a whole has a powerful interest in reducing the negative consequences of underage drinking on society and on the youths themselves, individuals, families, groups, and communities all have different views on the wisdom and propriety of various approaches to the problem. In this respect, surveys that show that certain steps by governments (e.g., increasing alcohol excise taxes or restricting advertising) are widely supported obscures disagreements about whether young people should be severely punished for using alcohol, whether parents should be punished for allowing parties with alcohol for youth in their homes, or whether the legal drinking age should be 21. Ambivalence About Goals and Means The problem of mustering a societal consensus to achieve an objective as subtle, complex, and contested as reducing underage drinking can be

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Reducing Underage Drinking: A Collective Responsibility seen most sharply when one compares underage drinking with illegal drug use and underage smoking. The goal of the nation’s policy toward illegal drugs and tobacco—abstention by everyone—is both unambiguous and widely, if not universally, embraced. Thus, the nation aims to discourage and suppress nonmedical use of marijuana, cocaine, and other controlled substances by everyone (whatever their age) through a comprehensive legal regime prohibiting the manufacture, distribution, and possession of these drugs for nonmedical purposes. Even though tobacco products, by contrast, are lawfully available to adults, the nation’s clearly expressed goal is to discourage tobacco use by everyone, by preventing initiation and promoting cessation. The messages to young people and adults in these two contexts are identical: indeed, because few people take up smoking as adults, the overall success of the nation’s anti-tobacco policy depends substantially on the success of its efforts to prevent initiation among young people. The task of developing a strategy for preventing and reducing alcohol use among young people, in contrast, faces an uncertain policy goal. A strong cultural, political, economic, and institutional base supports certain forms of drinking in the society. Unlike the goals for illegal drugs and tobacco, the nation does not aim to discourage or eliminate alcohol consumption by adults. It is probably a fair characterization to say that the implicit aims of the nation’s current alcohol policy are to discourage excessive or irresponsible consumption that puts others at risk, while being tolerant of moderate consumption (at appropriate places and times) by adults (especially in light of the possible health benefits of moderate use for some populations over 40). For example, as long as others are not endangered or offended, attitudes toward intoxication (per se) vary according to religious beliefs and personal moral standards. In short, current alcohol policy rests on a collective judgment, rooted in the Prohibition experience, that the wisdom and propriety of alcohol use among adults should be left to the diverse moral judgments of the American people. This is not to say that everyone supports this stance of government neutrality. Many public health experts would like to take steps (short of prohibition) to suppress alcohol consumption as a way of reducing alcohol problems, and some conservative religious groups would take a more aggressive public stance against intoxication itself. However, the current stance of tempered neutrality seems to be widely accepted and therefore fairly stable. In this policy context, the message to young people as well as adults about alcohol use is both subtle and confusing. The message to young people is “wait” or “abstain now,” rather than “abstain always,” as it is with tobacco and illegal drugs. Unlike the policies for those other products, the ban on underage alcohol use explicitly represents a youth-only rule, and its violation is often viewed as a rite of passage to adulthood. The problem

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Reducing Underage Drinking: A Collective Responsibility is exacerbated because the age of majority is higher for alcohol than it is for any other right or privilege defined by adulthood (e.g., voting, executing binding contracts). Explaining convincingly—to young people as well as adults—why alcohol use is permissible for 21-year-olds but not for anyone younger is a difficult but essential task for reducing or preventing underage drinking. There is also confusion about whether messages to young people should emphasize abstention, perhaps drawing together alcohol, tobacco, and illegal drugs, or whether messages should focus on the dangers of intoxication and heavy drinking. Many people believe that abstention messages are more appropriate (and more likely to be effective) for younger teens than for older teens and college students. This overall debate raises the same question posed by all wait rules: What is the age of demarcation between childhood and adulthood (see, generally, Zimring, 1982; Kett, 1977). The argument has been given a raw edge by the trend, in recent years, to curtail the jurisdiction of juvenile courts and to prescribe severe punishments, including the death penalty, for teenagers who commit crimes (Fagan and Zimring, 2000). Commercial Factors Alcohol is a $116 billion-per-year industry in the United States, catering to the tastes and needs of the more than 120 million Americans who drink. All states generate revenue from the sale of alcohol, either through excise taxes or product mark-ups, and 18 states participate in the alcohol market through retail and/or wholesale monopolies over distribution of certain alcoholic beverages. A strategy to suppress underage alcohol use must somehow be implemented in the very midst of a society replete with practices and messages promoting its use, and with a strong sector of deeply vested economic interests and the accompanying political and economic power. A significant level of underage use is inevitable under these circumstances—as an inevitable spillover effect, even if unintended by the industry—no matter what strategy is implemented. Foster et al. (2003) recently estimated that underage drinkers account for 19.7 percent of all drinks consumed and 19.4 percent of the revenues of the alcohol industry (about $22.5 billion). On the basis of the committee’s independent calculations, we conclude that youth consumption falls somewhere between 10 and 20 percent of all drinks and accounts for a somewhat lower, although still significant, percentage of total expenditures (see Chapter 2). Although a similar challenge confronts tobacco control policy makers in the effort to prevent youthful use of tobacco products, the potency and impact of tobacco industry activity are gradually being lessened by the growing consensus that tobacco is a deadly and disapproved product, that

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Reducing Underage Drinking: A Collective Responsibility the industry has misled its customers for decades, and that aggressive regulation is needed to prevent young people from using tobacco and otherwise to protect the public health. It is generally believed that the tobacco industry has targeted young people to maintain demand for tobacco products as older consumers quit or die, notwithstanding the industry’s professed efforts, in the wake of the Master Settlement Agreement, to discourage underage use of their products. In short, public health officials and the major tobacco companies are not on the same side, and “big tobacco” is regarded as the enemy of the public’s health. In contrast, the alcohol industry is diverse and uniformly acknowledges the dangers of underage drinking. Alcohol experts generally assume that the level of adult demand for alcohol products will not be substantially affected, over the long term, by reducing underage consumption—although getting young people to wait will obviously reduce the overall level of consumption. Thus, while the commercial interests of the alcohol industry are not perfectly aligned with the public health, they are not as antagonistic to the public health as the interests of the tobacco industry. In any case, a strategy for preventing and reducing underage drinking will have a much better chance for success if it attracts the active cooperation, and at least the acquiescence, of various segments of the alcohol industry. The effectiveness of any policy focused explicitly on reducing underage drinking will be limited by the existence of a large legitimate practice of drinking and by the power of a large industry responding to legitimate consumer demand. When alcohol is available in many home liquor cabinets, the success of strategies to discourage young people from buying at package stores will be much different than in a world where relatively few parents have stocks of alcohol. The widespread legal use of alcohol in the society affects not only cultural and individual attitudes toward drinking, but also the extent to which any youth-oriented control regime can be effective in reducing opportunities for youths’ access to alcohol and drinking opportunities. One can establish a clear-cut boundary between acceptable drinking and unacceptable drinking at conceptual, policy, and legal levels, but it must be understood not only that different communities will construct that boundary differently as a matter of policy but also that the scope created for legal drinking has a profound, practical effect on the effectiveness of other policy instruments in discouraging unwanted, underage drinking. In sum, the committee set about its task of developing a strategy for preventing and reducing underage drinking while being fully aware of the complexity of defining the public interest in this area and mindful of the severe constraints within which the strategy must be framed and implemented.

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Reducing Underage Drinking: A Collective Responsibility UNDERLYING ASSUMPTIONS In conducting its work, the committee did not begin with a blank slate. Instead, we were asked to develop a national strategy given the basic framework of the nation’s current policy toward underage drinking. That policy aims to delay drinking by young people as long as possible and forbids lawful access to alcohol for people under 21. Some people argue that the delay strategy is misguided and that the legal drinking age should be lower than 21 (typically 18). According to this view, allowing drinking at younger ages would mitigate youthful desire for alcohol as a “forbidden fruit”; would provide opportunities to “learn” to drink, thereby reducing harms; and would bring the age at which youth are allowed to drink into alignment with the age at which they can join the military, vote, and participate in other aspects of adult life. Whatever the merits of this view, the committee believes that Congress intended us to work within the framework of current law, anchored in the National Minimum Drinking Age Act of 1984, and that reconsideration of the 21-year-old drinking age, and of the premises on which it is predicated, is beyond our mandate. Moreover, as a practical matter, the current policy framework, though disputed by some, rests on a strong scientific foundation, is widely accepted, and is certain to be preserved for the foreseeable future. Because the current policy framework provides the foundation for the committee’s work, and for the strategy recommended in this report, it is useful to summarize it here and to highlight its basic rationale. Evolution of Current Policy Until the last decades of the 19th century, society relied largely on nonlegal mechanisms of social control to constrain youthful drinking. However, in the wake of urbanization, immigration, and industrialization, alcohol came under tighter control, including bans against selling it to people under the legal age (Mosher et al., 2002). After the repeal of Prohibition in 1933, it became settled that decisions about alcohol control rested with the states, and the structure of modern alcohol regulation took shape. Until 1970, the minimum drinking age in most states was 21. Between 1970 and 1976, 21 states reduced the minimum drinking age to 18, and another 8 states reduced it to 19 or 20 (usually as part of a more general statutory reform reducing the age of majority to 18) (Wagenaar, 1981). Proposals to restore a higher age were soon introduced, however, largely because alcohol-related automobile crashes had significantly increased among teenagers and young adults. Of the 29 states that lowered their drinking age, 24 raised the age again between 1976 and 1984. By that time, only three states allowed 18-year-olds to drink all types of alcoholic bever-

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Reducing Underage Drinking: A Collective Responsibility ages, while five others (including the District of Columbia) allowed 18-year-olds to drink beer and light wine while setting the age limit for distilled spirits and wine with high alcohol content at 21. Thirteen states set a uniform age of 19, and four others allowed 19-year-olds to drink beer and set the limit at 21 for other alcoholic beverages. Four states set the age at 20 for all alcohol, and the remaining 22 states set a uniform age of 21 (Bonnie, 1985). In 1984 Congress enacted the National Minimum Drinking Age Act, as recommended by the Presidential Commission on Drunk Driving, using the threat of withholding 10 percent of federal highway funds to induce states to set the minimum drinking age at 21 for all alcoholic beverages. All states eventually complied and have a variety of mechanisms in place to enforce this restriction The Goal of Delay The explicit aim of existing policy is to delay underage alcohol use as long as possible and, even if use begins, to reduce its frequency and quantity as much as possible. Most people recognize that drinking itself is not the issue. Rather, the underlying challenge is protecting young people while they are growing up. Children and adolescents need to be protected in the first instance from the immediate harms that can occur when they are drinking. But they also need to be protected from the possibility that they will mortgage their own future prospects by initiating practices that could cause them permanent harm during a critical developmental period and that could lead to patterns of drinking that will worsen as they grow older. The question is how best to go about that protective task. As indicated, some people argue that the most sensible approach is to permit drinking by young people (at least older teens) rather than trying to suppress it. In their view, a “wait” rule is not the best way to reduce the problems associated with underage drinking—at least in a society in which it is bound to occur with considerable frequency anyway. They would allow youthful drinking and focus on supervision rather than drinking per se (at least for older adolescents). In their view, a “learner’s permit” for drinking is preferable to a prohibition that drives underage drinking into the shadows and sacrifices the opportunity for supervision. A learner’s permit approach could be implemented in a variety of ways, such as by permitting youth access to only certain kinds of alcohol during the learning period (analogous to a graduated driving license) and by prescribing particular requirements for adult supervision. If the drinking age were lowered, the critical question is whether the intensity of youthful drinking, and the accompanying problems, would decrease, as contended by proponents of the learner’s permit approach.

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Reducing Underage Drinking: A Collective Responsibility Admittedly, the current approach may create incentives for heavy unsupervised drinking on the occasions where alcohol is available. However, as discussed in Chapter 9, young people who drink tend to do so heavily even in societies with a learner’s permit approach. In addition, a substantial body of scientific evidence shows that raising the minimum drinking age reduced alcohol-related crashes and fatalities among young people (Cook and Tauchen, 1984; U.S. General Accounting Office, 1987; Wagenaar and Toomey, 2002) as well as deaths from suicide, homicide, and nonvehicle unintentional injuries (Jones et al., 1992; Parker and Rebhun, 1995). Increasing the minimum drinking age to 21 is credited with having saved 18,220 lives on the nation’s highways between 1975 and 1998 (National Highway Traffic Safety Administration, 1998). Voas, Tippetts, and Fell (1999), using data from all 50 states and the District of Columbia for 1982 through 1997, concluded that the enactment of the uniform 21-year-old minimum drinking age law was responsible for a 19 percent net decrease in fatal crashes involving young drivers who had been drinking, after controlling for driving exposure, beer consumption, enactment of zero tolerance laws, and other relevant changes in the laws during that time. These findings reinforce the decision by Congress to act in 1984. In short, current national policy rests on the view, supported by substantial evidence, that delaying drinking reduces problem drinking and its consequences. The nation’s legislators and public health leaders have reached the nearly uniform judgment that the benefits of setting it at 21 far exceed the costs of doing so. The Instrumental Role of the Law Our earlier comparison among alcohol, tobacco, and illegal drugs raises another important preliminary question—about the role of the law in the prevention of underage drinking. It is possible to imagine an official policy aiming to delay and discourage underage drinking that does not rely in any way on the coercive authority of the state to implement this policy: instead of banning underage access to alcohol by law, society might rely entirely on parenting, education, community expectations, and other mechanisms of social control to suppress youthful drinking and, for older teens, to transmit the desired drinking-related norms and to encourage adults to refrain from supplying youths with alcohol or otherwise facilitating their drinking. Various forms of social disapproval, including social and economic sanctions (e.g., not patronizing stores or bars that serve minors) can be imagined. In contrast, the United States has decided that there must be laws against supplying alcohol to young people and that it should also be illegal for young people to possess or use alcohol, at least in public. Thus, because

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Reducing Underage Drinking: A Collective Responsibility the law plays such a central role in the nation’s policy toward underage drinking, it is essential to clarify the functions that these laws should reasonably be expected to serve. At the outset, it should be emphasized that a secular society seeks to delay underage drinking because it is dangerous to youths and others, not because it is inherently evil or wrong. The ban on underage drinking is an age-specific prohibition, implying that the aim is to delay alcohol use, not to condemn it or inoculate against it. For this reason, the prohibition is distinctly instrumental in nature and is not grounded in the moral disapproval that characterizes many legal prohibitions. To use a traditional legal classification, underage drinking is an example of a prohibition that is malum prohibitum (wrong because it is prohibited) rather than malum in se (wrong in itself). Punishment for an underage drinker, or even for an adult facilitator, is not an expression of public moral condemnation as is, for example, punishment for child sexual abuse or robbery. Enforcement of prohibitions against immoral behavior serves the twin goals of reducing the harmful behavior and condemning and punishing the perpetrator for the transgression. The prohibition of underage drinking does not aim to serve this second (retributive) objective in any strong sense. Its aim is exclusively instrumental. Consequently, the measure of the prohibition’s effectiveness, and of the social policy it implements, has to be whether it reduces or avoids the dangerous consequences associated with youthful drinking. Law is a blunt instrument. It is not self-executing, and it requires the affirmative support of a substantial proportion of the population and of those who are expected to enforce it. These characteristics of a law are particularly important for instrumental prohibitions, such as the ban against underage drinking, because the level of compliance will depend heavily on the willingness of a large number of individuals to adhere to the law simply because they accept its moral authority to command their obedience. That is, a legal norm of this kind, which affects so many people in so many everyday social and economic contexts, cannot be successfully implemented based on deterrence (the threat of punishment) alone. It must rely heavily on the “declarative” or “expressive” function of the law: by forbidding the conduct, it aims to shape people’s beliefs and attitudes about what is acceptable social behavior and thereby to draw on their disposition to obey. Since the ultimate goal is to protect youths (and others within the zone of danger) from harmful consequences, one might wonder whether it is possible to implement an underage alcohol policy by focusing exclusively on the dangerous behavior rather than the drinking itself. In theory, it might be possible to define the prohibited conduct exclusively in relation to the magnitude of the risk: for example, “don’t drive a car after having had alcohol” or “don’t give alcohol to a youth who intends to drive a car or is

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Reducing Underage Drinking: A Collective Responsibility otherwise likely to behave dangerously.” However, any such dangerous drinking prohibitions are extremely difficult to implement successfully and would not exert a sufficient deterrent by themselves to prevent the risky behaviors associated with underage alcohol use. As the nation’s lawmakers have concluded, only a categorical prohibition of underage access to alcohol has any realistic chance of doing that, especially in a large industrial society in which the risks are pervasive (and magnified by developmental vulnerability) and where young people have large periods of time outside parental supervision and outside the reach of formal social controls. It is also relevant to note that at least one of the risks associated with underage drinking is intrinsic to the drinking itself—the permanent damage of alcohol consumption on the adolescent brain (see Chapter 3). Given an age-based categorical prohibition aiming to serve exclusively instrumental aims, other policy judgments are needed regarding the scope of the restrictions, the severity of the prescribed sanctions, and the resources and tools that should be used to enforce the law. Banning commercial distribution of alcohol to underage persons is an essential element of the prohibition, but what about noncommercial distribution? Even if noncommercial distribution is banned, what about parental distribution to their own children in their own home? (Many states do not prohibit this distribution.) Is it also necessary to penalize young people who purchase or consume alcohol? Even in their own homes? What enforcement strategies should be used? And how severe should the sanctions be? These issues are addressed in Chapter 9. The answers require careful assessment of the possible benefits (in reducing harms associated with underage drinking) and the costs of any particular strategy. The degree of public support and the difficulty of enforcement bear on both the potential effectiveness and on the possible costs. A POPULATION PERSPECTIVE In requesting the National Academies to develop a strategy for reducing and preventing underage drinking, Congress clearly anticipated that we would do so from a public health perspective, reviewing the etiology and consequences of alcohol use by the underage population and assessing the effectiveness of interventions that might be deployed to reduce the prevalence of drinking in this population, particularly the patterns of consumption most clearly associated with alcohol problems. (The outcomes of interest in assessing the effectiveness of interventions are discussed in Chapter 5.) Recognizing that underage drinking substantially increases the short-term risks of death, injury, and other harms, as well as long-term risks of alcoholism and other dysfunction, a population-oriented strategy aims to lower the mean level of risk in the underage population in order “to shift

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Reducing Underage Drinking: A Collective Responsibility the whole distribution of exposure in a favorable direction,” typically by “altering some of society’s norms of behavior” (Rose, 1985, p. 371). Accordingly, we emphasize the population-oriented tools of primary prevention, rather than the individually oriented methods of secondary or tertiary prevention. Thus, identification and treatment of youths with drinking problems, or at high risk for developing such problems, and the challenge of instilling habits of responsible drinking as young people mature are addressed only incidentally in this report. These issues are important for improved policy and practice, but they are peripheral to our basic charge—delaying underage drinking and reducing its prevalence. In developing a strategy to delay and reduce underage drinking, the committee has tried to understand the problem from two angles. First, we looked at the problem from the viewpoint of a young person deciding whether and under what circumstances to use alcohol. Our framework draws on the developing literature regarding adolescent decision making, especially in relation to health and risk behaviors. We pay particular attention to youthful decision-making abilities at various ages in the context of the changing social realities of teenage alcohol use. Some components of a comprehensive strategy must aim to help young people make the right decisions, depending on their age and developmental stage, taking account of the dangers of alcohol use at varying points in development. It is not enough, however, to try to persuade young people to make the right choices. If the strategy relied exclusively on tools directed at changing the attitudes and behavior of underage youths, it would not have much chance of succeeding. To complement a youth-centered decision-making perspective, the committee also drew on the multidisciplinary perspective used by public policy analysts. This framework combines the disciplines of epidemiology, economics, health communications, law, and other social sciences to envision the array of policy instruments that can be brought to bear on the problem and to assess their probable effectiveness and costs, used alone or in combination. OVERVIEW OF THE REPORT Although the committee’s recommended strategy responds to a congressional request, the report is intended for a broad audience, including parents, businesses, alcohol companies, educators, state and local policy makers and legislators, healthcare producers and retailers, practitioners, and community organizers. Our work is presented in two parts. Part I, Chapters 2 through 4, provides important contextual information about underage drinking and its consequences and determinants. Chapter 2 discusses key definitions and presents pertinent demographic and epidemiological data regarding the scope of underage drinking and the

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Reducing Underage Drinking: A Collective Responsibility characteristics of underage drinkers. It includes data on the prevalence of alcohol use and drinking behavior by gender, race, and ethnicity as well as comparisons of youth and adult drinking patterns. Chapter 3 provides an account of the social consequences and costs of underage drinking. Chapter 4 offers a context for the underlying reasons, motivations, social influences, and risk factors that influence young people’s decisions about drinking. The chapter explores the specific motivations and influences relevant to young people’s drinking behavior and attempts to answer why some young people choose to drink and do so intensively while others choose to drink moderately or not at all. The chapter also discusses the social environment in which young people are immersed and the ways that community and social factors affect underage drinking. Part II, Chapters 5 through 12, presents the committee’s recommended strategy to prevent and reduce underage drinking. In each of these chapters, the committee summarizes what is known about the effectiveness of existing programs or interventions in the pertinent domain and presents its conclusions and recommendations. The committee has tried to be realistic in assessing the potential effectiveness of efforts to prevent and reduce underage drinking. The committee assumes that most adults in the United States will continue to use alcohol and that most drinkers will begin their alcohol use sometime before they are 21, despite laws and policies to the contrary. Within that constraint, however, there is substantial room for preventing and reducing underage drinking in the United States, and this part of the report explores various tools that can be used in this effort. At the heart of the committee’s proposed strategy is the effort to foster a collective societal acceptance of responsibility for reducing underage drinking. Although continued efforts to speak directly to young people about the dangers of alcohol use are an important component of the committee’s proposed strategy, the committee believes that the highest priority should be given to changing the attitudes and behaviors of adults. Adults often facilitate or enable underage drinking directly by supplying alcohol to young people, by failing to take effective precautions to prevent it, or by sending the message that alcohol use is to be expected. Few programs currently seek to influence parents to alter their behaviors and attitudes toward youth drinking as a way of reducing youth access to alcohol, changing permissive social norms about underage drinking, and galvanizing community action. In Chapter 5 we explain our interpretation of the committee’s charge and some of the key assumptions underlying the strategy, including the criteria for assessing effectiveness and cost. This chapter is the foundation for the rest of the report. In Chapter 6 we discuss development of a national media effort as a major component of a campaign aimed at educating parents and other adults about underage drinking and ways adults can help

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Reducing Underage Drinking: A Collective Responsibility reduce opportunities for youth drinking. In Chapter 7 we discuss how the alcoholic beverage industry can become a partner in the overall effort by helping to establish and fund an independent nonprofit organization charged with reducing underage drinking and by exercising greater self-restraint in advertising and promotional activity. Our messages to the alcohol industry (and other industries that benefit from a large alcohol market) are clear: Your efforts to satisfy and expand the legitimate adult market for alcohol inevitably spill over to a large underage market. Even if you do not intend to stimulate or satisfy underage demand, you derive financial benefits from it. As a society, we cannot have a substantial impact on underage drinking without your active engagement in this effort. Chapter 8 issues a similar challenge to the entertainment media, urging more attentive self-regulation to reduce exposure of children and adolescents to lyrics and images that portray drinking in an attractive way. The committee believes that market incentives can be used to reward companies, including entertainment media, who take meaningful steps to help reduce underage drinking, and to punish companies that do not. Chapter 9 explores ways to reduce youth access to alcohol through both commercial and noncommercial channels. Chapter 10 explains why the committee does not recommend a youth-oriented national media campaign at this time, preferring instead a cautious program of research and development. It also addresses educational efforts in schools, colleges, and other settings designed to persuade young people to choose not to drink and to reduce alcohol problems. The chapter also briefly discusses programs for assisting youths with alcohol problems. Chapter 11 reviews the potential advantages of mobilizing communities to implement locally specific efforts to reduce underage drinking. Chapter 12 identifies several ways in which the federal and state governments can help implement the proposed strategy, including through increases in excise taxes. Regulatory action by the government is not at the center of the committee’s proposed strategy. The major priority, in the committee’s view, is to galvanize the necessary societal commitment to prevent and reduce underage drinking. Thus, the committee focuses its attention on community action, business responsibility, public-private partnerships, and all the other institutional expressions of a genuine social movement. In this context, government has a supportive, but nonetheless indispensable, role—to provide funding (possibly through increased excise taxes on alcohol) and technical support to strengthen and enforce access restrictions, to keep regulatory pressure on the alcohol industry to act responsibly, and to monitor the effectiveness of the overall strategy.