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Executive Summary

Alcohol use by young people is dangerous, not only because of the risks associated with acute impairment, but also because of the threat to their long-term development and well-being. Traffic crashes are perhaps the most visible of these dangers, with alcohol being implicated in nearly one-third of youth traffic fatalities. Underage alcohol use is also associated with violence, suicide, educational failure, and other problem behaviors. All of these problems are magnified by early onset of teen drinking: the younger the drinker, the worse the problem. Moreover, frequent heavy drinking by young adolescents can lead to mild brain damage. The social cost of underage drinking has been estimated at $53 billion including $19 billion from traffic crashes and $29 billion from violent crime.

More youth drink than smoke tobacco or use other illegal drugs. Yet federal investments in preventing underage drinking pale in comparison with resources targeted (mostly to youths) at preventing illicit drug use. In fiscal 2000, $71.1 million was targeted at preventing underage alcohol use by the U.S. Departments of Health and Human Services (HHS), Justice, and Transportation. In contrast, the fiscal 2000 federal budget authority for drug abuse prevention (including prevention research) was 25 times higher, $1.8 billion; for tobacco prevention, funding for the Office of Smoking and Health, only one of several HHS agencies involved with smoking prevention, was approximately $100 million, with states spending a great deal more with resources from the states’ Medicaid reimbursement suits against the tobacco companies.

Although it is illegal to sell or give alcohol to youths under age 21, they



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Reducing Underage Drinking: A Collective Responsibility Executive Summary Alcohol use by young people is dangerous, not only because of the risks associated with acute impairment, but also because of the threat to their long-term development and well-being. Traffic crashes are perhaps the most visible of these dangers, with alcohol being implicated in nearly one-third of youth traffic fatalities. Underage alcohol use is also associated with violence, suicide, educational failure, and other problem behaviors. All of these problems are magnified by early onset of teen drinking: the younger the drinker, the worse the problem. Moreover, frequent heavy drinking by young adolescents can lead to mild brain damage. The social cost of underage drinking has been estimated at $53 billion including $19 billion from traffic crashes and $29 billion from violent crime. More youth drink than smoke tobacco or use other illegal drugs. Yet federal investments in preventing underage drinking pale in comparison with resources targeted (mostly to youths) at preventing illicit drug use. In fiscal 2000, $71.1 million was targeted at preventing underage alcohol use by the U.S. Departments of Health and Human Services (HHS), Justice, and Transportation. In contrast, the fiscal 2000 federal budget authority for drug abuse prevention (including prevention research) was 25 times higher, $1.8 billion; for tobacco prevention, funding for the Office of Smoking and Health, only one of several HHS agencies involved with smoking prevention, was approximately $100 million, with states spending a great deal more with resources from the states’ Medicaid reimbursement suits against the tobacco companies. Although it is illegal to sell or give alcohol to youths under age 21, they

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Reducing Underage Drinking: A Collective Responsibility do not have a hard time getting it, and they often get it from adults. More than 90 percent of twelfth graders report that alcohol is “very easy” or “fairly easy” to get. And when underage youths drink, they drink more heavily and recklessly than adults. They report that they “usually” drink an average of four and a half drinks, an amount very close to the threshold of five drinks typically used to define heavy drinking (also referred to as binge drinking). In contrast, adult drinkers report usually drinking fewer than three drinks. In response to a congressional request in the HHS fiscal 2002 appropriations act, the Board on Children, Youth, and Families of the National Research Council and the Institute of Medicine formed the Committee on Developing a Strategy to Reduce and Prevent Underage Drinking. The committee was directed to review a broad range of federal, state, and nongovernmental programs, from environmental interventions to programs focusing directly on youth attitudes and behaviors, and to develop a cost-effective strategy to reduce and prevent underage drinking. In conducting this review, the committee relied on the available scientific literature, including a series of papers written for the committee, public input, and its expertise. The committee conducted its work within the framework of the current national policy establishing 21 as the minimum legal drinking age in every state. We concentrated more on population-based primary prevention approaches rather than on individually oriented approaches. STRATEGY OVERVIEW The committee reached the fundamental conclusion that underage drinking cannot be successfully addressed by focusing on youth alone. Youth drink within the context of a society in which alcohol use is normative behavior and images about alcohol are pervasive. They usually obtain alcohol—either directly or indirectly—from adults. Efforts to reduce underage drinking, therefore, need to focus on adults and must engage the society at large. The preeminent goal of the recommended strategy is to create and sustain a broad societal commitment to reduce underage drinking. Such a commitment will require participation by multiple individuals and organizations at the national, state, local, and community levels who are in a position to affect youth decisions—including parents and other adults, alcohol producers, wholesalers and retail outlets, restaurants and bars, entertainment media, schools, colleges and universities, the military, landlords, community organizations, and youths themselves. The nation must collectively pursue opportunities to reduce the availability of alcohol to underage

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Reducing Underage Drinking: A Collective Responsibility drinkers, the occasions for underage drinking, and the demand for alcohol among young people. THE STRATEGY The committee’s proposed strategy for broad societal commitment to reduce underage drinking has ten main components. National Adult-Oriented Media Campaign Most adults express concern about youth drinking and support public policy actions to reduce youth access to alcohol. Nonetheless, youth obtain alcohol from adults. Parents tend to dramatically underestimate underage drinking generally and their own children’s drinking in particular. The first component in the strategy calls for the development of a media campaign, including rigorous formative research on effective messages, aimed at increasing specific actions by adults meant to reduce underage drinking and decreasing adult conduct that facilitates underage drinking. Recommendation 6-1: The federal government should fund and actively support the development of a national media effort, as a major component of an adult-oriented campaign to reduce underage drinking. Partnership to Prevent Underage Drinking Despite laws that aim to preclude drinking by those under the age of 21, a significant amount of underage drinking occurs, generating revenues for producers, wholesalers, and retailers of alcoholic beverages, especially beer. The alcohol industry has declared its commitment to reducing underage drinking and has invested in programs with that aim. However, the outcomes of these efforts are not always apparent, and the motives are sometimes questioned. A partnership between the alcohol industry, government, and other private partners would facilitate a coordinated, evidence-based approach to reduce and prevent underage drinking. Recommendation 7-1: All segments of the alcohol industry that profit from underage drinking, inadvertently or otherwise, should join with other private and public partners to establish and fund an independent nonprofit foundation with the sole mission of reducing and preventing underage drinking.

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Reducing Underage Drinking: A Collective Responsibility Alcohol Advertising A substantial proportion of alcohol advertising reaches an underage audience and is presented in a style that is attractive to youths. For example, television alcohol advertisements routinely appear on programs for which the percentage of underage viewers is greater than the percentage of underage youths in the population. Although a clear causal link between advertising and youth consumption has not been established, youth exposure to advertising and marketing of products with particular appeal to youths should be reduced. Strengthened self-regulation would be in keeping with the industry’s stated commitment to avoid sale to minors and with recommendations by the Federal Trade Commission (FTC) in 1999 regarding industry advertising standards. Only one company has adopted the FTC’s 1999 recommendation that the industry create independent external review boards to address complaints regarding violations of advertising codes. In light of constitutional constraints on direct advertising restrictions, and to enable the industry to be responsive to public concerns about advertising, the most fruitful governmental response would be to facilitate public awareness of advertising practices. Recommendation 7-2: Alcohol companies, advertising companies, and commercial media should refrain from marketing practices (including product design, advertising, and promotional techniques) that have substantial underage appeal and should take reasonable precautions in the time, place, and manner of placement and promotion to reduce youthful exposure to other alcohol advertising and marketing activity. Recommendation 7-3: The alcohol industry trade associations, as well as individual companies, should strengthen their advertising codes to preclude placement of commercial messages in venues where a significant proportion of the expected audience is underage, to prohibit the use of commercial messages that have substantial underage appeal, and to establish independent external review boards to investigate complaints and enforce the codes. Recommendation 7-4: Congress should appropriate the necessary funding for the U.S. Department of Health and Human Services to monitor underage exposure to alcohol advertising on a continuing basis and to report periodically to Congress and the public. The report should include information on the underage percentage of the exposed audience and estimated number of underage viewers of print and broadcasting alcohol advertising in national markets and, for television and radio broadcasting, in a selection of large local or regional markets.

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Reducing Underage Drinking: A Collective Responsibility Entertainment Media Since artistic expression inevitably reflects the culture in which it is embedded, it is hardly surprising that alcohol use and alcohol products are frequently displayed or mentioned in prime-time television, movies, and music. Although the viewing or listening audiences for most of these media products are predominantly adult, some of them are disproportionately underage, and even the predominantly adult audiences inevitably include large numbers of young people. As in the case of commercial alcohol advertising, the entertainment media have a social responsibility to eschew displays or lyrics that portray underage drinking in a favorable light or that glamorize or promote alcohol consumption in products that are targeted toward or likely to be heard or viewed by large underage audiences. Labeling and notice requirements have been voluntarily adopted in analogous contexts. Although the industry restrictions should be undertaken on a voluntary basis, some independent oversight and public awareness of these standards is warranted. Recommendation 8-1: The entertainment industries should use rating systems and marketing codes to reduce the likelihood that underage audiences will be exposed to movies, recordings, or television programs with unsuitable alcohol content, even if adults are expected to predominate in the viewing or listening audiences Recommendation 8-2: The film rating board of the Motion Picture Association of America should consider alcohol content in rating films, avoiding G or PG ratings for films with unsuitable alcohol content, and assigning mature ratings for films that portray underage drinking in a favorable light. Recommendation 8-3: The music recording industry should not market recordings that promote or glamorize alcohol use to young people; should include alcohol content in a comprehensive rating system, similar to those used by the television, film, and video game industries; and should establish an independent body to assign ratings and oversee the industry code. Recommendation 8-4: Television broadcasters and producers should take appropriate precautions to ensure that programs do not portray underage drinking in a favorable light, and that unsuitable alcohol content is included in the category of mature content for purposes of parental warnings. Recommendation 8-5: Congress should appropriate the necessary funds to enable the U.S. Department of Health and Human Services to conduct a periodic review of a representative sample of movies, televi-

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Reducing Underage Drinking: A Collective Responsibility sion programs, and music recordings and videos that are offered at times or in venues likely to have a significant youth audience (e.g., 15 percent) to ascertain the nature and frequency of lyrics or images pertaining to alcohol. The results of these reviews should be reported to Congress and the public. Limiting Access Limiting youth access to alcohol has been shown to be effective in reducing and preventing underage drinking and drinking-related problems. Since 21 became the nationwide legal drinking age, there have been significant decreases in drinking, fatal traffic crashes, alcohol-related crashes, and arrests for “driving under the influence” (DUI) among young people. Given the widespread availability of alcohol and easy access by underage drinkers, minimum drinking age laws must be enforced more effectively, along with social sanctions. The effectiveness of underage drinking laws could be enhanced through such approaches as compliance checks, server training, zero tolerance laws, and graduated driver licensing laws. Recommendation 9-1: The minimum drinking age laws of each state should prohibit purchase or attempted purchase, possession, and consumption of alcoholic beverages by persons under 21; possession of and use of falsified or fraudulent identification to purchase or attempt to purchase alcoholic beverages; provision of any alcohol to minors by adults, except to their own children in their own residences; and underage drinking in private clubs and establishments. Recommendation 9-2: States should strengthen their compliance check programs in retail outlets, using media campaigns and license revocation to increase deterrence. Communities and states should undertake regular and comprehensive compliance check programs, including notification of retailers concerning the program and follow-up communication to them about the outcome (sale/no sale) for their outlet. Enforcement agencies should issue citations for violations of underage sales laws, with substantial fines and temporary suspension of license for first offenses and increasingly stronger penalties thereafter, leading to permanent revocation of license after three offenses. Communities and states should implement media campaigns in conjunction with compliance check programs detailing the program, its purpose, and outcomes.

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Reducing Underage Drinking: A Collective Responsibility Recommendation 9-3: The federal government should require states to achieve designated rates of retailer compliance with youth access prohibitions as a condition of receiving relevant block grant funding, similar to the Synar Amendment’s requirements for youth tobacco sales. Recommendation 9-4: States should require all sellers and servers of alcohol to complete state-approved training as a condition of employment. Recommendation 9-5: States should enact or strengthen dram shop liability statutes to authorize negligence-based civil actions against commercial providers of alcohol for serving or selling alcohol to a minor who subsequently causes injury to others, while allowing a defense for sellers who have demonstrated compliance with responsible business practices. States should include in their dram shop statutes key portions of the Model Alcoholic Beverage Retail Licensee Liability Act of 1985, including the responsible business practices defense. Recommendation 9-6: States that allow Internet sales and home delivery of alcohol should regulate these activities to reduce the likelihood of sales to underage purchasers. States should require all packages for delivery containing alcohol to be clearly labeled as such; require persons who deliver alcohol to record the recipient’s age identification information from a valid government-issued document (such as a driver’s license or ID card); and require recipients of home delivery of alcohol to sign a statement verifying receipt of alcohol and attesting that he or she is of legal age to purchase alcohol. Recommendation 9-7: States and localities should implement enforcement programs to deter adults from purchasing alcohol for minors. States and communities should routinely undertake shoulder tap or other prevention programs targeting adults who purchase alcohol for minors, using warnings, rather than citations, for the first offense; enact and enforce laws to hold retailers responsible, as a condition of licensing, for allowing minors to loiter and solicit adults to purchase alcohol for them on outlet property; and use nuisance and loitering ordinances as a means of discouraging youth from congregating outside of alcohol outlets in order to solicit adults to purchase alcohol.

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Reducing Underage Drinking: A Collective Responsibility Recommendation 9-8: States and communities should establish and implement a system requiring registration of beer kegs that records information on the identity of purchasers. Recommendation 9-9: States should facilitate enforcement of zero tolerance laws in order to increase their deterrent effect. States should modify existing laws to allow passive breath testing, streamlined administrative procedures, and administrative penalties and implement media campaigns to increase young peoples’ awareness of reduced blood alcohol content (BAC) limits and of enforcement efforts. Recommendation 9-10: States should enact and enforce graduated driver licensing laws. Recommendation 9-11: States and localities should routinely implement sobriety checkpoints. Recommendation 9-12: Local police, working with community leaders, should adopt and announce policies for detecting and terminating underage drinking parties, including: routinely responding to complaints from the public about noisy teenage parties and entering the premises when there is probable cause to suspect underage drinking is taking place; routinely checking, as a part of regular weekend patrols, open areas where teenage drinking parties are known to occur; and routinely citing underage drinkers and, if possible, the person who supplied the alcohol when underage drinking is observed at parties. Recommendation 9-13: States should strengthen efforts to prevent and detect use of false identification by minors to make alcohol purchases. States should prohibit the production, sale, distribution, possession, and use of false identification for attempted alcohol purchase; issue driver’s licenses and state identification cards that can be electronically scanned; allow retailers to confiscate apparently false identification for law enforcement inspection; and implement administrative penalties (e.g., immediate confiscation of a driver’s license and issuance of a citation resulting in a substantial fine) for attempted use of false identification by minors for alcohol purchases.

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Reducing Underage Drinking: A Collective Responsibility Recommendation 9-14: States should establish administrative procedures and noncriminal penalties, such as fines or community service, for alcohol infractions by minors. Youth-Oriented Interventions Although the proposed strategy focuses mainly on adult attitudes and behavior toward underage drinking and on reducing the availability of alcohol to underage youth, approaches that directly target youth are also needed. A national youth-oriented media campaign to reduce and prevent underage drinking would be premature in the absence of more evidence supporting this approach. However, effective education-oriented approaches in schools and other settings aimed at preventing alcohol use by youths, as well as interventions with youths who have already developed alcohol problems, play a role. Interventions that rely on provision of information alone, or that focus on increasing self-esteem or resisting peer pressure, have not been demonstrated to be effective. Residential colleges and universities have witnessed serious drinking problems among students under 21. Despite efforts by nearly all campuses to address this problem, heavy drinking has not declined over the past decade. Residential colleges and universities are in a unique position to develop and evaluate comprehensive approaches that address both individual and population-level issues. Recommendation 10-1: Intensive research and development for a youth-focused national media campaign relating to underage drinking should be initiated. If this work yields promising results, the inclusion of a youth-focused campaign in the strategy should be reconsidered. Recommendation 10-2: The U.S. Department of Health and Human Services and the U.S. Department of Education should fund only evidence-based education interventions, with priority given both to those that incorporate elements known to be effective and those that are part of comprehensive community programs. Recommendation 10-3: Residential colleges and universities should adopt comprehensive prevention approaches, including evidence-based screening, brief intervention strategies, consistent policy enforcement, and environmental changes that limit underage access to alcohol. They should use universal education interventions, as well as selective and indicated approaches with relevant populations.

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Reducing Underage Drinking: A Collective Responsibility Recommendation 10-4: The National Institute on Alcohol Abuse and Alcoholism and the Substance Abuse and Mental Health Services Administration should continue to fund evaluations of college-based interventions, with a particular emphasis on targeting of interventions to specific college characteristics, and should maintain a list of evidence-based programs. Recommendation 10-5: The U.S. Department of Health and Human Services and states should expand the availability of effective clinical services for treating alcohol abuse among underage populations and for following up on treatment. The U.S. Department of Education, the U.S. Department of Health and Human Services, and the U.S. Department of Justice should establish policies that facilitate diagnosing and referring underage alcohol abusers and those who are alcohol dependent for clinical treatment. Community Interventions Community mobilization can be a powerful vehicle to implement and support interventions, especially those that target community-level policies and practices. Communities can design multipronged comprehensive initiatives that rely on scientifically based strategies and are responsive to the specific problems of their communities. College campuses and local communities have a reciprocal influence on one another in relation to student alcohol use and the need to develop complementary strategies. Recommendation 11-1: Community leaders should assess the underage drinking problem in their communities and consider effective approaches—such as community organizing, coalition building, and the strategic use of the mass media—to reduce drinking among underage youth. Recommendation 11-2: Public and private funders should support community mobilization to reduce underage drinking. Federal funding for reducing and preventing underage drinking should be available under a national program dedicated to community-level approaches to reducing underage drinking, similar to the Drug Free Communities Act, which supports communities in addressing substance abuse with targeted, evidence-based prevention strategies. Government Assistance and Coordination The ultimate responsibility for preventing and reducing underage drinking lies with the entire national community, not with government alone.

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Reducing Underage Drinking: A Collective Responsibility However, the federal and state governments have important responsibilities in addition to enforcing the law. These responsibilities include funding media campaigns, supporting community efforts, monitoring alcohol and entertainment industry portrayals of drinking, monitoring trends in underage drinking and the effectiveness of efforts to reduce it, coordinating multiple agency activities, and supporting continued research and evaluation. Recommendation 12-1: A federal interagency coordinating committee on prevention of underage drinking should be established, chaired by the secretary of the U.S. Department of Health and Human Services. Recommendation 12-2: A National Training and Research Center on Underage Drinking should be established in the U.S. Department of Health and Human Services. This body would provide technical assistance, training, and evaluation support and would monitor progress in implementing national goals. Recommendation 12-3: The secretary of the U.S. Department of Health and Human Services should issue an annual report on underage drinking to Congress summarizing all federal agency activities, progress in reducing underage drinking, and key surveillance data. Recommendation 12-4: Each state should designate a lead agency to coordinate and spearhead its activities and programs to reduce and prevent underage drinking. Recommendation 12-5: The annual report of the secretary of the U.S. Department of Health and Human Services on underage drinking should include key indicators of underage drinking. Recommendation 12-6: The Monitoring the Future Survey and the National Survey on Drug Use and Health should be revised to elicit more precise information on the quantity of alcohol consumed and to ascertain brand preferences of underage drinkers. Alcohol Excise Taxes Alcoholic beverages are far cheaper (after adjusting for overall inflation) today than they were in the 1960s and 1970s. While raising excise taxes, and therefore prices, would have some effect on alcohol use by adults, price has been documented to have a differential effect on youth alcohol consumption patterns. Taxes can also be a source of revenue for funding strategies aimed at reducing underage drinking and its associated harms.

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Reducing Underage Drinking: A Collective Responsibility Recommendation 12-7: Congress and state legislatures should raise excise taxes to reduce underage consumption and to raise additional revenues for this purpose. Top priority should be given to raising beer taxes, and excise tax rates for all alcoholic beverages should be indexed to the consumer price index so that they keep pace with inflation without the necessity of further legislative action. Research and Evaluation Rigorous research and evaluation are needed to assess the effectiveness of specific interventions and to ensure that future refinements of the strategy are grounded in evidence-based approaches. Research related to prototype development for the proposed adult media campaign is a core component of the strategy outlined in this report. In addition, continued research and evaluation are necessary to develop new approaches aimed at reaching all segments of the underage population. Recommendation 12-8: All interventions, including media messages and education programs, whether funded by public or private sources, should be rigorously evaluated, and a portion of all federal grant funds for alcohol-related programs should be designated for evaluation. Recommendation 12-9: States and the federal government—particularly the U.S. Department of Health and Human Services and the U.S. Department of Education—should fund the development and evaluation of programs to cover all underage populations. In sum, our proposed strategy calls for development of a national campaign to engage adults in a concerted effort to stop enabling or ignoring youth drinking. The proposed strategy calls on the alcohol industry to enter a partnership with government and other private funders to implement a coordinated, evidence-based approach to reducing underage drinking. It proposes steps to increase compliance with laws against selling or providing alcohol to minors. It calls for reducing youth exposure to alcohol advertising or music and other entertainment with products and ads that glorify drinking. It recognizes the potential importance of school-based education approaches and the need for residential colleges and universities to implement comprehensive approaches. It calls on local leaders to apply the multiple tools available to address underage drinking within the context of their communities. And it challenges federal and state governments to coordinate their efforts and to raise excise taxes to reduce underage consumption and raise revenues for the proposed strategy. Finally, it recommends ongoing monitoring and continued research and evaluation to facilitate continued refinement of the strategy and its implementation.