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REDUCING UNDERAGE DRINKING

A COLLECTIVE RESPONSIBILITY

Committee on Developing a Strategy to Reduce and Prevent Underage Drinking

Richard J. Bonnie and Mary Ellen O’Connell, Editors

Board on Children, Youth, and Families

Division of Behavioral and Social Sciences and Education

NATIONAL RESEARCH COUNCIL

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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Reducing Underage Drinking: A Collective Responsibility REDUCING UNDERAGE DRINKING A COLLECTIVE RESPONSIBILITY Committee on Developing a Strategy to Reduce and Prevent Underage Drinking Richard J. Bonnie and Mary Ellen O’Connell, Editors Board on Children, Youth, and Families Division of Behavioral and Social Sciences and Education NATIONAL RESEARCH COUNCIL INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Reducing Underage Drinking: A Collective Responsibility THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This project, N01-OD-4-2139, Task Order No. 109, received support from the evaluation set-aside Section 513, Public Health Service Act, of the U.S. Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the U.S. Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government. Library of Congress Cataloging-in-Publication Data Reducing underage drinking : a collective responsibility / Committee on Developing a Strategy to Reduce and Prevent Underage Drinking ; Richard J. Bonnie and Mary Ellen O’Connell, editors. p. ; cm. Includes bibliographical references. ISBN 0-309-08935-2 (hardback with CD-ROM) 1. Teenagers—Alcohol use—Prevention. 2. Youth—Alcohol use—Prevention. 3. Alcoholism—Prevention. 4. Drinking of alcoholic beverages—Prevention. 5. Community organization. [DNLM: 1. Alcohol Drinking—prevention & control—Adolescent—United States. 2. Alcohol Drinking—epidemiology—Adolescent—United States. 3. Alcohol-Related Disorders—prevention & control—Adolescent—United States. 4. Mass Media—United States. WM 274 R321 2003] I. Bonnie, Richard J. II. O’Connell, Mary Ellen, 1960- III. National Research Council (U.S.). Committee on Developing a Strategy to Reduce and Prevent Underage Drinking. RJ506.D78R43 2003 362.292’7’08350973—dc22 2003018014 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. Printed in the United States of America. Cover: First Night celebrations are meant to recapture the symbolic significance of the passage from the old year to the new; to unite the community through a shared cultural celebration; to deepen and broaden the public appreciation of the visual and performing arts; to help revitalize the urban core of a community; and to offer a family-friendly, alcohol-free alternative to traditional New Year’s Eve revelry. For more information or to find a First Night Celebration near you go to www.firstnight.com. Copyright 2004 by the National Academy of Sciences. All rights reserved. Suggested citation: National Research Council and Institute of Medicine (2004). Reducing Underage Drinking: A Collective Responsibility. Committee on Developing a Strategy to Reduce and Prevent Underage Drinking, Richard J. Bonnie and Mary Ellen O’Connell, Editors. Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press.

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Reducing Underage Drinking: A Collective Responsibility THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Reducing Underage Drinking: A Collective Responsibility COMMITTEE ON DEVELOPING A STRATEGY TO REDUCE AND PREVENT UNDERAGE DRINKING RICHARD J. BONNIE (Chair), School of Law, University of Virginia MARILYN AGUIRRE-MOLINA, Mailman School of Public Health, Columbia University PHILIP J. COOK, Department of Public Policy Studies, Duke University JUDITH A. CUSHING, The Oregon Partnership, Portland JOEL W. GRUBE, Prevention Research Center, Berkeley, California BONNIE L. HALPERN-FELSHER, Department of Pediatrics, University of California, San Francisco WILLIAM B. HANSEN, Tanglewood Research Inc., Greensboro, North Carolina DENISE HERD, School of Public Health, University of California, Berkeley ROBERT HORNIK, Annenberg School for Communication, University of Pennsylvania, Philadelphia JANIS JACOBS, Undergraduate Education and International Programs, Pennsylvania State University MARK H. MOORE, John F. Kennedy School of Government, Harvard University DANIEL A. TRUJILLO, Department of Community Development and Substance Abuse Programs, Massachusetts Institute of Technology MARY ELLEN O’CONNELL, Study Director JOAH IANNOTTA, Research Associate SUSAN McCUTCHEN, Research Associate ANTHONY MANN, Senior Project Assistant MICHAEL BIEHL, Consultant

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Reducing Underage Drinking: A Collective Responsibility BOARD ON CHILDREN, YOUTH, AND FAMILIES MICHAEL COHEN (Chair), Department of Pediatrics, Montefiore Medical Center, Bronx, New York JAMES A. BANKS, Center for Multicultural Education, University of Washington, Seattle THOMAS DEWITT, Children’s Hospital Medical Center of Cincinnati, Ohio MARY JANE ENGLAND, Regis College, Weston, Massachusetts BRENDA ESKENAZI, School of Public Health, University of California, Berkeley MINDY FULLILOVE, Department of Psychiatry, Columbia University PATRICIA GREENFIELD, Department of Psychology, University of California, Los Angeles RUTH T. GROSS, Department of Pediatrics, Stanford University NEAL HALFON, School of Public Health, University of California, Los Angeles MAXINE HAYES, Washington State Department of Health, Olympia MARGARET HEAGARTY, Harlem Hospital Center, Columbia University (retired) RENÉE R. JENKINS, Department of Pediatrics and Child Health, Howard University, Washington, DC HARRIET KITZMAN, School of Nursing, University of Rochester, New York SANDERS KORENMAN, School of Public Affairs, Baruch College, City University of New York HONORABLE CINDY LEDERMAN, Juvenile Justice Center, Miami, Florida GARY SANDEFUR, Department of Sociology, University of Wisconsin-Madison RUTH STEIN, Department of Pediatrics, Montefiore Medical Center, Bronx, New York ELLEN WARTELLA, College of Communication, University of Texas

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Reducing Underage Drinking: A Collective Responsibility Acknowledgments In addition to the expertise and hard work of the committee members, we benefited from the expertise and intellectual insights of a range of leaders in the field who enthusiastically contributed to the project. Numerous leading researchers wrote papers on a range of topics that helped to inform the work of the committee; see Appendix D for a list of their names. Most of these papers were presented by the lead author and discussed at an October 2002 workshop, and many of the papers are on the CD-ROM attached to the inside back cover. The many participants at this workshop (see Appendix B) helped to enrich the discussion. The committee is grateful for their insights. The committee would also like to acknowledge contributions of Robert Pandina, Rutgers University, who shared his extensive expertise as a respondent at the workshop. In November 2002 numerous individuals and organizations concerned with underage drinking provided written and verbal comments to the committee on their research findings, priorities, and concerns. We are thankful for the tireless, continued efforts of these groups; see Appendix C for the meeting agenda and participants. The committee also thanks Jeff Arnett, University of Maryland, for his insightful comments on youth perspectives at the November meeting. Dozens of stakeholders and scientists provided program materials, literature, and other written materials or responded to requests for information from the committee; see Appendix D. This report has been reviewed in draft form by individuals chosen for

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Reducing Underage Drinking: A Collective Responsibility their diverse perspectives and technical expertise, in accordance with procedures approved by the Report Review Committee of the National Research Council (NRC). The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: David S. Anderson, Center for the Advancement of Public Health, George Mason University; Johnnetta Davis-Joyce, Pacific Institute for Research and Evaluation, Calverton, MD; Mary Jane England, Regis College; Susan Ennett, Department of Health Behavior and Health Education, University of North Carolina; Rob MacCoun, Goldman School of Public Policy and Boalt Hall School of Law, University of California at Berkeley; Michael Moore, Darden School of Business, University of Virginia; Rosalie Pacula, RAND, Santa Monica, CA; Seth J. Schwartz, Center for Family Studies, Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine; Jose Szapocznik, Center for Family Studies, Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine; Larry Wallack, School of Community Health, Portland State University; and Henry Wechsler, Harvard School of Public Health. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by David S. Cordray, Institute for Public Policy Studies, Vanderbilt University, and John E. Dowling, The Biological Laboratories, Harvard University. Appointed by the National Research Council, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. Several people reviewed specific papers to add to the assessment of committee members and staff and the comments on them from workshop participants. The committee thanks the following people for their review of one or more papers: George Balch, Balch Associates; Maxine Hayes, Washington State Department of Health; Ralph Hingson, Department of Social and Behavioral Sciences, Boston University; Bernard Murphy, Center for Policy Analysis and Training, Pacific Institute for Research and Evaluation; Robert Pandina, Center for Alcohol Studies, Rutgers University; Cheryl Perry, Division of Epidemiology, School of Public Health,

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Reducing Underage Drinking: A Collective Responsibility University of Minnesota; Henry Saffer, National Bureau of Economic Research; and Susan Tapert, Department of Psychiatry, University of California, San Diego. The committee recognizes the support provided by members of the Board on Children, Youth, and Families under the leadership of Michael Cohen. We are grateful for the leadership and support of Susanne Stoiber, executive officer of the Institute of Medicine; Michael Feuer, executive director of the NRC’s Division of Behavioral and Social Sciences and Education; his predecessor, Barbara Torrey; Jane Ross, director of the Center for Economic and Social Sciences; and Susan Cummins, former director of the Board on Children, Youth, and Families. Finally, the committee benefited from the support and assistance of several members of The National Academies staff. Joah Iannotta and Susan McCutchen provided valuable assistance in collecting, summarizing, and organizing materials and helping draft sections of the report. The research needs of the project were greatly aided by the able assistance of Georgeann Higgins of the NRC library. Anthony Mann managed numerous and sometimes complicated administrative responsibilities. We are indebted to Eugenia Grohman, who worked with us on several revisions and provided superb editorial guidance; and Yvonne Wise, who helped prepare the report for publication. We also acknowledge Michael Biehl, University of California, San Francisco, who tirelessly prepared analyses of National Household Survey on Drug Abuse data and provided invaluable assistance to the committee. Richard J. Bonnie, Chair Mary Ellen O’Connell, Study Director Committee on Developing a Strategy to Reduce and Prevent Underage Drinking

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Reducing Underage Drinking: A Collective Responsibility Contents Preface   xv Executive Summary   1 1   Introduction: The Challenge   13 PART I   UNDERAGE DRINKING IN THE UNITED STATES     2   Characteristics of Underage Drinking   35 3   Consequences of Underage Drinking   58 4   Understanding Youth Drinking   70 PART II   THE STRATEGY     5   Designing the Strategy   89 6   National Media Campaign   108 7   Alcohol Industry   125

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Reducing Underage Drinking: A Collective Responsibility *   The background papers are not printed in this book but are on the CD-ROM attached to the inside back cover. 8   Entertainment Industries   145 9   Access   158 10   Youth-Oriented Interventions   185 11   Communities   216 12   Federal and State Governments   232 References   250 Appendixes     A   Statement of Task   283 B   Agenda and Participants, October 10-11, 2002 Public Workshop   284 C   Agenda and Participants, November 18, 2002 Open Committee Meeting and Public Forum   289 D   Other Public Contributors   292 E   Biographical Sketches of Committee Members and Staff   296 Index   303 BACKGROUND PAPERS* 1   The Epidemiology of Underage Drinking in the United States: An Overview Robert L. Flewelling, Mallie J. Paschall, and Christopher Ringwalt   319 2   Social, Health, and Economic Consequences of Underage Drinking Ralph Hingson and Donald Kenkel   351

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Reducing Underage Drinking: A Collective Responsibility 3   Health Consequences of Adolescent Alcohol Involvement Sandra A. Brown and Susan F. Tapert   383 4   Developmental and Environmental Influences on Underage Drinking: A General Overview Bonnie L. Halpern-Felsher and Michael Biehl   402 5   Perceptions of Risk and Social Judgments: Biases and Motivational Factors Janis E. Jacobs   417 6   Alcohol Use and Misuse: Prevention Strategies with Minors William Hansen and Linda Dusenbury   437 7   Supply Side Approaches to Reducing Underage Drinking: An Assessment of the Scientific Evidence Harold D. Holder   458 8   Effectiveness of Sanctions and Law Enforcement Practices Targeted at Underage Drinking Not Involving Operation of a Motor Vehicle Thomas L. Hafemeister and Shelly L. Jackson   490 9   The Effects of Price on Alcohol Use, Abuse, and Their Consequences Frank J. Chaloupka   541 10   Media Intervention Impact: Evidence and Promising Strategies Charles Atkin   565 11   Alcohol in the Media: Drinking Portrayals, Alcohol Advertising, and Alcohol Consumption Among Youth Joel W. Grube   597 12   Alcohol Advertising and Promotion David Jernigan and James O’Hara   625 13   Drinking and Coming of Age in a Cross-Cultural Perspective Robin Room   654

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Reducing Underage Drinking: A Collective Responsibility 14   Preventing Underage Drinking in American Indian and Alaska Native Communities: Contexts, Epidemiology, and Culture Douglas K. Novins, Paul Spicer, Janette Beals, and Spero M. Manson   678 15   Teen Treatment: Addressing Alcohol Problems Among Adolescents Rosalind Brannigan, Mathea Falco, Linda Dusenbury, and William B. Hansen   697 16   Youth Smoking Prevention Policy: Lessons Learned and Continuing Challenges Paula M. Lantz   716

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Reducing Underage Drinking: A Collective Responsibility Preface By the time children are seniors in high school, about 30 percent are drinking heavily at least once a month. And 40 percent of full-time college students and more than 36 percent of other young adults (ages 18-22) report heavy drinking. The consequences and costs of youthful alcohol use are enormous. Many of these harmful consequences are immediate and all too evident—injuries due to impaired driving or violence, sexual assault and unwanted pregnancies, and educational failure. The best available estimate places the annual social cost of underage drinking at $53 billion, far exceeding the costs of youthful use of illegal drugs. In recognition of the enormity of the problem, Congress asked the National Academies to develop a strategy for reducing and preventing underage drinking. This is a daunting challenge. To what extent can public policy really affect underage drinking when alcohol is so widely used and approved by adults and when youthful indulgence is so often overlooked or condoned? After all, “kids will be kids.” Presumably, the answer depends on whether instruments of public policy can affect the main determinants of underage drinking, particularly the factors associated with the most harmful features of underage alcohol use. Some people believe that the dangers of underage drinking are at least partly attributable to the very fact that it is “underage” (i.e., illegal) conduct. Obviously, lowering the minimum drinking age would (by definition) reduce the amount of “underage” drinking. More importantly, according to some experts, at least some of the harmful drinking practices of underage

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Reducing Underage Drinking: A Collective Responsibility drinkers would not occur if their drinking were lawful. People who hold this view often point to European countries with lower drinking ages where, they claim, young people learn to drink under the supervision of adults and are not as inclined to drink heavily. The facts do not support this view, however. As the committee demonstrates in this report, countries with lower drinking ages are not better off than the United States in terms of the harmful consequences of youths’ drinking. And one thing we do know for sure is that raising the drinking age to 21 in the United States has saved many thousands of lives. That is why Congress enacted the National Minimum Drinking Age Act of 1984, using the leverage of federal highway funds to induce every state to raise the drinking age to 21. It turns out that the patterns and consequences of youthful drinking are closely related to the overall extent and patterns of drinking in the society, and they are affected by the same factors that affect the patterns of adult consumption. From this standpoint, it is possible that the most effective way to reduce the extent and adverse consequences of youthful drinking would be to reduce the extent and consequences of adult drinking. It is clear, however, that Congress intended for the committee to focus on youth drinking, rather than developing a strategy targeting adult drinking as well as youth drinking. This is what the committee has done. The report outlines the committee’s proposed strategy in detail. Substance abuse prevention is typically targeted on young people themselves—to persuade them to abstain and try to keep the dangerous substance out of their hands. At the center of the committee’s strategy, however, is the judgment that parents and adults must be the main target of a strategy to reduce and prevent underage drinking. In requesting this report, Congress was specifically seeking advice about the message that should be conveyed to young people, especially in a national media campaign. However, in the committee’s view, if we do no more than pepper kids with anti-drinking messages, things are not likely to get any better. We have to do more. We have to resolve, as a national community, to reduce underage drinking and the problems associated with it and to take comprehensive measures to achieve this goal. If we do this without equivocation, there is a reasonable prospect of success. And success—measured in many thousands of young lives and futures saved—is well worth the investment. Richard J. Bonnie, Chair Committee on Developing a Strategy to Reduce and Prevent Underage Drinking

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Reducing Underage Drinking: A Collective Responsibility REDUCING UNDERAGE DRINKING

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