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Social, Health, and Economic Consequences of Underage Drinking*

Ralph Hingson and Donald Kenkel

Since 1988, it has been illegal for someone under the age of 21 to drink alcohol in all 50 states. This was a reversal of an earlier policy trend: In the wake of the 1972 constitutional amendment that extended the right to vote to 18-year-olds, 29 states had also lowered their legal drinking ages. Higher traffic fatalities and other problems experienced in those states were part of the impetus for the national drinking age of 21. This national drinking age has been a clear policy success (U.S. General Accounting Office, 1987; Jones, Pieper, and Robertson, 1992; Shultz et al., 2001; Wagenaar and Toomey, 2002). However, as we will discuss, many underage youth continue to consume alcohol and to experience alcohol related problems.

In the remaining sections of this chapter, we review evidence on the health and social consequences of underage drinking. Research from different perspectives—in terms of disciplines, data, and methods—helps to document these consequences. High-quality data document some of the immediate consequences of underage drinking, such as the number of traffic fatalities that involve underage drinkers. Self-reported data further suggest that a variety of health risks are associated with underage drinking. An intriguing line of emerging research suggests that age of drinking initiation may be a risk factor for adult drinking problems. These patterns should be

*  

This article is dedicated to Terry Sterling, age 19, who died as the result of an alcohol overdose December 1, 2000, during a fraternity hazing ritual.



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Reducing Underage Drinking: A Collective Responsibility 2 Social, Health, and Economic Consequences of Underage Drinking* Ralph Hingson and Donald Kenkel Since 1988, it has been illegal for someone under the age of 21 to drink alcohol in all 50 states. This was a reversal of an earlier policy trend: In the wake of the 1972 constitutional amendment that extended the right to vote to 18-year-olds, 29 states had also lowered their legal drinking ages. Higher traffic fatalities and other problems experienced in those states were part of the impetus for the national drinking age of 21. This national drinking age has been a clear policy success (U.S. General Accounting Office, 1987; Jones, Pieper, and Robertson, 1992; Shultz et al., 2001; Wagenaar and Toomey, 2002). However, as we will discuss, many underage youth continue to consume alcohol and to experience alcohol related problems. In the remaining sections of this chapter, we review evidence on the health and social consequences of underage drinking. Research from different perspectives—in terms of disciplines, data, and methods—helps to document these consequences. High-quality data document some of the immediate consequences of underage drinking, such as the number of traffic fatalities that involve underage drinkers. Self-reported data further suggest that a variety of health risks are associated with underage drinking. An intriguing line of emerging research suggests that age of drinking initiation may be a risk factor for adult drinking problems. These patterns should be *   This article is dedicated to Terry Sterling, age 19, who died as the result of an alcohol overdose December 1, 2000, during a fraternity hazing ritual.

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Reducing Underage Drinking: A Collective Responsibility viewed with some caution, however, both because of the shortcomings of self-reported data and because of the difficulty of determining the extent to which underage drinking causes other health risks rather than simply being associated with these risks. We then explore research on the economic consequences of underage drinking, including both immediate health care expenditures and earnings losses experienced by underage drinkers over their entire life-course. Finally, we present a brief discussion and conclusion about the program and policy implications of the social and economic consequences of underage drinking. UNDERAGE ALCOHOL CONSUMPTION Despite the legal drinking age of 21 in all states, according to the 2001 National Household Survey on Drug Abuse (NHSDA) (N = 68,929 age 12 and over, 32,002 ages 12 to 20, response rate 67 percent), 28.5 percent of persons ages 12 to 20 reported using alcohol in 2001 at some point in the 30 days prior to the survey (Substance Abuse and Mental Health Services Administration [SAMHSA] 2002). Projected onto the U.S. population that age, 10.1 million persons ages 12 to 20 drank in the past 30 days. Nearly 6.8 million, or 19 percent, were binge drinkers (consumed 5 or more drinks on an occasion at least once in the past 30 days). More than 2 million, or 6 percent, drank 5 or more drinks on at least 5 occasions in the past 30 days. Since 1980, the average age people began drinking has dropped from 17.4 to 15.9 years old (SAMHSA, 2002). Males ages 12 to 20 were more likely to report binge drinking in the past month than their female peers (22 percent versus 16 percent). Binge drinking was reported by 21.7 percent of underage whites and 18.5 percent of underage American Indians or Alaska Natives, but only by 10.7 percent of underage Asians and 10.5 percent of underage blacks. Among persons under age 21, those ages 18 to 20 were the most likely to drink. Just over half drank in the past month, 30 percent reported binge drinking at least once in the past 30 days, and 13 percent reported consuming 5 or more drinks on at least 5 occasions in the past 30 days. The Centers for Disease Control and Prevention’s (CDC’s) National Youth Risk Behavior Survey examined a national random sample of high school students (Grunbaum et al., 2002), nearly all of whom are ages 14 to 18. Completed for CDC in 2001, the survey used a three-stage probability sample to obtain 13,601 completed questionnaires from a representative sample of high school students in public and private schools in the United States, with a response rate of 65 percent. Large numbers in that age group also drink and drink heavily. That survey showed 47 percent of high school students drank alcohol in the past month. Projected to the U.S. high school student population, 7,018,364 drank alcohol in the past month. Thirty-

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Reducing Underage Drinking: A Collective Responsibility four percent, or more than 5 million, drank 5 or more drinks within a two-hour period on at least one occasion in the previous month. Seventy-eight percent, or more than 11.6 million, had consumed alcohol at some point in their lives and 29 percent, or 4.3 million, reported starting to drink before age 13. Thirteen percent, or 1.9 million, drove after drinking in the past 30 days and 31 percent, or 4.6 million, rode with a drinking driver. Five percent, or more than 700,000, drank at school in the past 30 days. For some, heavy drinking begins even before high school. In 2001, according to the NHSDA, 2 percent of 12-year-olds and 3 percent of 13-year-olds consumed 5 or more drinks on at least one occasion in the past 30 days. HEALTH RISKS ASSOCIATED WITH UNDERAGE DRINKING Not only is drinking by persons underage an illegal activity, but persons that age who drink are more likely than those who do not to engage in behaviors that pose a risk to their health and the health of others. Deaths Associated with Underage Drinking Traffic Crash Deaths The greatest single mortality risk posed by underage drinking is traffic crashes. Traffic crashes are the leading cause of death in the United States for persons ages 4 to 34 (National Highway Traffic Safety Administration [NHTSA] 2002). According to the Fatality Analysis Reporting System of the NHTSA, in 2001, 39 percent of traffic deaths by those ages 16 to 20 involved a driver, passenger, or pedestrian who had been drinking (2,365/ 6,051) (NHTSA, 2001). Of course it is possible that some of the drinking drivers in those fatal crashes were 21 or older. In 2001, 1,884 drivers under age 21 in fatal motor vehicle crashes had positive blood alcohol levels, including 45 of whom were under age 16. Of those drivers, 1,109 died in those crashes. Many persons other than the drinking driver were also killed in those crashes. In 2001, 1,099 persons other than drinking drivers under age 21 died in fatal crashes when those drivers under age 21 were involved. Six hundred thirty were under age 21, and most of them (587) were passengers either in the vehicle driven by or struck by the drinking driver under age 21. Epidemiologic research comparing drivers in single-vehicle fatal crashes with drivers operating motor vehicles at similar times on the same roadways who were not involved in fatal crashes has revealed that each 0.02 percent increase in blood alcohol level nearly doubles the risk of single-vehicle fatal crash involvement and that the risk of death increases with each drink

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Reducing Underage Drinking: A Collective Responsibility more for younger drivers than it does for drivers above the age of 21 (Zador, 1991). A more recent national analysis found that in all age and gender groups, there was at least an 11-fold increased risk of single-vehicle fatal crash involvement at a blood alcohol level of 0.08 percent (the legal limit for intoxication for adults in most states). However, for male drivers ages 16 to 20, there was a 52-fold increased single-vehicle fatal crash risk (Zador, Krawchek, and Voas, 2000). The National Survey of Drinking and Driving conducted for NHTSA in 1999 (National Highway Traffic Safety Administration, 2000) reported that 2 percent of 16- to 20-year-old drivers drove within two hours of drinking in the past month. Though this percentage is substantially lower than the 12 percent reported by all drivers ages 16 and older, drivers ages 16 to 20 drove 12 million times in the preceding year within two hours of drinking (95 percent CI 4, 119). Those drinking driving trips averaged 11 miles in length compared to 14 for all drinking driving trips among drivers ages 16 and older. Particularly disturbing, however, was that when NHTSA calculated the average blood alcohol concentration (BAC) of drivers during their most recent drinking driving trip—based on weight, hours of drinking, gender, volume of consumption, length of drinking episode—and time since last drink, the average calculated BAC for 16- to 20-year-old drivers was 0.10 percent, more than 3 times the level for drivers of all ages and at or above the legal limit for adult drivers in every state. A 170-pound man would have to consume 5 drinks in an hour on an empty stomach to reach a blood alcohol level of 0.10 percent. Furthermore, 40 percent of those 16-to 20-year-olds were driving with another passenger in the vehicle during their most recent drinking driving trip, thereby risking not only their own life but the lives of others. Four percent were driving with children under the age of 15. Of note, 44 percent of the 16- to 20-year-old drinking drivers believed they were driving at levels that exceeded the legal limit. In other words, nearly half reported engaging in behavior they knew was illegal. Of parallel concern, it is illegal for all persons under age 21 to drive after any drinking, and 56 percent, a majority, who did so did not recognize that they were engaging in illegal behavior. Studies of states that adopted laws making it illegal for persons under 21 to drive after drinking relative to other states have achieved 18 percent declines in driving after any drinking, 23 percent declines in driving after 5+ drinks (Wagenaar, 2001), and 21 percent decline in the type of fatal crash most likely to involve alcohol (single vehicle at night) among drivers under 21 (Hingson, Heeren, and Winter, 1994). In studies where teen awareness of the law has been heightened, significantly greater declines in alcohol-related crashes among drivers under 21 have been recorded (Blomberg, 1992).

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Reducing Underage Drinking: A Collective Responsibility Other Unintentional Injury Deaths Of course, traffic fatalities are not the only type of injury death that has been linked to alcohol. In 2000 there were 15,733 unintentional injury deaths among persons under 21. Of those, 8,797 were traffic deaths and 6,936 were from other causes (e.g., drowning, burns, falls) (National Center for Health Statistics, 2002). A review of more than 300 medical examiner studies in the United States over a 20-year period (Smith, Branas, and Miller, 1999) revealed that the percentage of nontraffic unintentional injury deaths that test positive for alcohol closely corresponds to the percentage of motor vehicle deaths that are alcohol related: 38 percent versus 40 percent. Among persons under age 21, 34 percent of unintentional traffic deaths (2,956/8,797) are alcohol related. If 34 percent of unintentional injury deaths other than motor vehicle deaths among persons under 21 were alcohol related, then 2,358 unintentional injury nontraffic deaths among persons under 21 were alcohol related. Intentional Injury Deaths Among adults alcohol was also found to be present in 47 percent of homicides and 29 percent of suicide deaths (Smith et al., 1999). In 2000 there were 4,314 homicides and 2,905 suicides among those under the age of 21. It has been reported that among persons under 21, 36 percent of homicide deaths, 12 percent of male suicide deaths, and 8 percent of female suicide deaths were alcohol related (Levy, Miller, and Lox, 1999). If correct, more than 1,500 homicides and 300 suicides in 2000 among persons under 21 were alcohol related. Self-Reports of Health Risks Associated with Underage Drinking Drinking, especially frequent heavy drinking, has been associated with a variety of health risks behaviors among adolescents. An association, of course, does not mean alcohol use causes the other risky behaviors, but it can certainly increase risks to health. For example, if frequent heavy drinkers drive after drinking more often, their risk of traffic crash involvement is higher. If they are also less likely to wear safety belts, then their risk of being injured or killed in those crashes is also higher. When asked about their drinking in the past 30 days, 28 percent of high school students responding to the National Youth Risk Behavior Survey (Grunbaum et al., 2002) reported at least one occasion when they drank 5 or more drinks. Nine percent reported one such occasion. Six percent reported two occasions, another 6 percent reported 3 to 5 and 7 percent drank 5+ drinks on at least 6 occasions. Nine percent of the

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Reducing Underage Drinking: A Collective Responsibility sample drank in the past 30 days, but never as many as five drinks at one sitting. Drinkers were more likely than nondrinkers to engage in a variety of behaviors that pose a risk to health, and the more frequently respondents reported heavy drinking (5 or more on an occasion), the greater their likelihood of engaging in behaviors that pose a risk to health. Risks in Traffic As Tables 2-1a and 2-1b show, a greater percentage of those who drank compared to those who never drank engaged in behaviors in traffic that increased their risk of being in a motor vehicle crash and being injured if in a crash. Moreover, the more frequently respondents drank 5 or more drinks, the greater the percentage who engaged in risky behaviors in traffic. Only 3 percent of respondents who never drank said they never wore safety belts compared to 15 percent of those who drank 5+ at least 6 times in the past month (frequent heavy drinkers). Only 14 percent of those who never drank rode with a driver who had been drinking, compared to 80 percent of frequent heavy drinkers. Of course, none who never drank drove after drinking, while 41 percent of frequent heavy drinkers did so. Twenty-two percent of respondents said they rode on a motorcycle and 63 percent on a TABLE 2-1a Traffic Risks According to Frequency of Drinking 5+ Drinks on an Occasion in the Past 30 Days   Never Drank Drank Not 5+ 1 2 3-5 6+ N = 7,228 2,187 1,248 840 845 891 Of Motorcyclists Never Wear a Helmet 27% 29% 33% 36% 42% 45% Of Bicyclists Never Wear a Helmet 73% 81% 86% 88% 89% 92%   SOURCE: Youth Risk Behavior Survey (YRBS) (2001). TABLE 2-1b Traffic Risks According to Frequency of Drinking 5+ Drinks on an Occasion in the Past 30 Days   Never Drank Drank Not 5+ 1 2 3-5 6+ N = 7,228 2,187 1,248 840 845 891 Never Wear Seat Belt 3% 3% 5% 7% 10% 15% Ride with Drinking Driver 14% 31% 50% 60% 69% 80% Drive after Drinking 0% 11% 13% 32% 43% 41%   SOURCE: Youth Risk Behavior Survey (YRBS) (2001).

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Reducing Underage Drinking: A Collective Responsibility bicycle in the past 30 days. Of those who never drank, 27 percent said they never wore helmets on motorcycles and 73 percent said they never wear bicycle helmets. In contrast, among frequent heavy drinkers, 45 percent never wear motorcycle helmets and 92 percent never wear bicycle helmets. Weapons and Violence Compared to nondrinkers, a greater percentage of drinkers and especially frequent heavy drinkers carried weapons, engaged in physical violence (Tables 2-2a and 2-2b), felt sad or hopeless, attempted suicide (Table 2-3), engaged in other psychoactive drug use (Tables 2-4a, 2-4b, and 2-4c), had sex at an earlier age, had more partners, and were more likely to have unprotected sex and to have been or gotten someone pregnant (Tables 2-5a, 2-5b, and 2-5c). Among nondrinkers, 10 percent carried a weapon and 3 percent a gun in the past 30 days. Forty-four percent of frequent heavy drinkers carried a weapon and 22 percent a gun in the past 30 days. Not only were the frequent heavy drinkers more likely to carry weapons and TABLE 2-2a Weapons and Violence According to Frequency of Drinking 5+ Drinks on an Occasion in the Past 30 Days   Never Drank Drank Not 5+ 1 2 3-5 6+ N = 7,228 2,187 1,248 840 845 891 Carry Weapon 10% 18% 22% 26% 28% 44% Carry Gun 3% 4% 8% 8% 11% 22% Weapon at School 3% 6% 9% 10% 13% 20% In a Fight Past Year 23% 35% 43% 46% 52% 62% Injured in a Fight Past Year 2% 4% 7% 6% 7% 13%   SOURCE: Youth Risk Behavior Survey (YRBS) (2001). TABLE 2-2b Weapons and Violence According to Frequency of Drinking 5+ Drinks on an Occasion in the Past 30 Days   Never Drank Drank Not 5+ 1 2 3-5 6+ N = 7,228 2,187 1,248 840 845 891 Fight at School Past Year 9% 13% 17% 17% 19% 74% Threatened at School 6% 8% 11% 12% 12% 19% Boy/Girlfriend Hit/Slapped Past Year 6% 10% 11% 15% 17% 23% Forced to Have Sex 5% 8% 9% 12% 13% 18%   SOURCE: Youth Risk Behavior Survey (YRBS) (2001).

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Reducing Underage Drinking: A Collective Responsibility TABLE 2-3 Depressed Mood and Suicidal Behavior According to Frequency of Drinking 5+ Drinks on an Occasion in the Past 30 Days   Never Drank Drank Not 5+ 1 2 3-5 6+ N = 7,228 2,187 1,248 840 845 891 Felt Sad or Hopeless 24% 34% 36% 40% 36% 40% Ever Attempted Suicide 4% 9% 10% 15% 14% 18% Injured in a Suicide Attempt 1% 2% 3% 5% 5% 9%   SOURCE: Youth Risk Behavior Survey (YRBS) (2001). TABLE 2-4a Substance Use According to Frequency of Drinking 5+ Drinks on an Occasion in the Past 30 Days   Never Drank Drank Not 5+ 1 2 3-5 6+ N = 7,228 2,187 1,248 840 845 891 Used Marijuana at School Past 30 Days 1% 5% 8% 12% 17% 27% Ever Used Cocaine 3% 7% 14% 20% 28% 43% Cocaine Use Past 30 Days 0% 2% 6% 8% 14% 26% Ever Sniff Glue 6% 14% 17% 21% 24% 32%   SOURCE: Youth Risk Behavior Survey (YRBS) (2001). TABLE 2-4b Substance Use According to Frequency of Drinking 5+ Drinks on an Occasion in the Past 30 Days   Never Drank Drank Not 5+ 1 2 3-5 6+ N = 7,228 2,187 1,248 840 845 891 Ever Used Heroin <1% 1% 3% 6% 7% 15% Ever Used Methamphetamine 2% 6% 13% 29% 27% 37% Ever Used Steroids 1% 3% 5% 9% 11% 18%   SOURCE: Youth Risk Behavior Survey (YRBS) (2001). TABLE 2-4c Substance Use According to Frequency of Drinking 5+ Drinks on an Occasion in the Past 30 Days   Never Drank Drank Not 5+ 1 2 3-5 6+ N = 7,228 2,187 1,248 840 845 891 Ever Inject Drugs <1% 1% 2% 4% 5% 13% Past Year Offered Drugs at School 19% 32% 37% 42% 48% 57%   SOURCE: Youth Risk Behavior Survey (YRBS) (2001).

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Reducing Underage Drinking: A Collective Responsibility TABLE 2-5a Sexual Risk Behaviors According to Frequency of Drinking 5+ Drinks on an Occasion in the Past 30 Days   Past 30 Days Never Drank Drank Not 5+ 1 2 3-5 6+ N = 7,228 2,187 1,248 840 845 891 Ever Had Sex 34% 56% 62% 71% 74% 87% Sex Before Age 13 5% 8% 9% 10% 11% 18% Sex with 6+ Partners 4% 9% 9% 13% 17% 31%   SOURCE: Youth Risk Behavior Survey (YRBS) (2001). TABLE 2-5b Sexual Risk Behaviors According to Frequency of Drinking 5+ Drinks on an Occasion in the Past 30 Days   Past 30 Days Never Drank Drank Not 5+ 1 2 3-5 6+ N = 7,228 2,187 1,248 840 845 891 3+ Sex Partners Past 3 Months 2% 4% 5% 8% 10% 20% Alcohol or Drugs Before Last Sexual Intercourse 3% 9% 16% 23% 36% 52%   SOURCE: Youth Risk Behavior Survey (YRBS) 2001. TABLE 2-5c Sexual Risk Behaviors According to Frequency of Drinking 5+ Drinks on an Occasion in the Past 30 Days   Past 30 Days Never Drank Drank Not 5+ 1 2 3-5 6+ N = 7,228 2,187 1,248 840 845 891 Birth Control Last Sex 83% 85% 88% 86% 83% 82% Been/Gotten Someone Pregnant 5% 7% 7% 11% 11% 19% Used Condom Last Sex 63% 61% 64% 62% 57% 54%   SOURCE: Youth Risk Behavior Survey (YRBS) 2001. guns, they were more likely to be in fights in the past year than nondrinkers (62 percent versus 23 percent) and in fights at school (7 percent versus 9 percent). Not surprisingly, they were more likely to have been injured in a fight in the past year (13 percent versus 2 percent) and to feel unsafe or threatened at school (1 percent or 19 percent, respectively, versus 6 percent of nondrinkers). Twenty-three percent of frequent heavy drinkers reported being hit/ slapped by a boyfriend or girlfriend in the past year, compared to 6 percent of nondrinkers. Eighteen percent of the frequent heavy drinkers said they

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Reducing Underage Drinking: A Collective Responsibility were forced to have sex in the past year, compared to 5 percent of nondrinkers. Suicidal Behaviors Frequent heavy drinkers were more likely to report feeling helpless or sad than nondrinkers (40 percent versus 18 percent), to report suicide attempts in the past year (18 percent versus 4 percent), and to have been injured in a suicide attempt (9 percent versus 1 percent). Tobacco and Illicit Drugs Compared to nondrinkers, frequent heavy drinkers were more likely to have used tobacco products: cigarettes (94 percent versus 46 percent), snuff (32 percent versus 2 percent), and cigars (51 percent versus 4 percent). They were dramatically more likely in the past 30 days than nondrinkers to have used marijuana (73 percent versus 7 percent), to have used cocaine (26 percent versus 0 percent), to have sniffed glue (32 percent versus 2 percent), and to have used heroin (15 percent versus <1 percent), methamphetamines (37 percent versus 2 percent), steroids (18 percent versus 2 percent), and illegal injected drugs (13 percent versus <1 percent). First exposure to drugs began at a younger age among frequent heavy drinkers, with 37 percent using marijuana before age 13, compared to only 4 percent of nondrinkers. A recent analysis of the National Longitudinal Study of Adolescent Health (AdHealth, N = 4,831) revealed that the proportion of persons who use alcohol and tobacco both steadily increase during each consecutive year of adolescence and young adulthood (Jackson, Sher, Cooper, and Wood, 2002). Prior alcohol use more strongly predicted tobacco use than the reverse. In other words, initiation of smoking was a function of prior drinking more so than drinking was a function of prior smoking. The disinhibitory effects of alcohol may reduce resistance to smoking and lead to initiation of use (Sheffiman and Balabanis, 1995). Although the exact mechanism by which drinking increases the likelihood of smoking has yet to be determined, the findings suggest that the negative consequences of early drinking include heavier smoking and the attendant health consequences of that heavier smoking. Kandel, Yamaguchi, and Chen (1992) and Kandel and Yamaguchi (1993) analyzed drug use behavior among a random sample of New York high school students and identified a clear sequential pattern of drug involvement with the earliest stages involving use of either alcohol or cigarettes. In this sequence of use, alcohol was generally the drug of first use among males, whereas cigarette and tobacco use most often preceded use of marijuana and other drugs among females. Subsequent stages involved use

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Reducing Underage Drinking: A Collective Responsibility of marijuana and then other illicit and/or prescribed drugs. For example, use of marijuana typically preceded use of crack. Morral, McCaffrey, and Paddock (2002) have published an analysis of the U.S. Household Survey of Drug Use to test a theory of marijuana use as a “gateway” to the use of other drugs. Their analyses did not disprove a gateway effect, but instead demonstrated another plausible alternative. A general drug use propensity may contribute to both marijuana use and the use of other drugs. Whether such an alternative explanation also could explain the association between alcohol and later marijuana and other illicit drug use has yet to be tested. Sexual Behaviors According to the National Youth Risk Behavior Survey (Grunbaum et al., 2002), frequent heavy drinkers relative to nondrinkers were also more likely to have had sexual intercourse (87 percent versus 34 percent), sex before age 13 (18 percent versus 5 percent), and sex with at least 6 different partners (31 percent versus 4 percent), and sex with at least 3 partners in the past month (20 percent versus 2 percent). Given their heavier drinking and drug use, frequent heavy drinkers not surprisingly were more likely than nondrinkers to have used alcohol or drugs prior to their last intercourse (52 percent versus 3 percent). Despite their far greater frequency of sexual activity with multiple partners, frequent heavy drinkers were no more likely to use birth control during their last sex (82 percent versus 83 percent) and were less likely to have used a condom (54 percent versus 63 percent). Frequent heavy drinkers were more likely to report having been pregnant or causing someone else to become pregnant (19 percent versus 5 percent) (Grunbaum et al., 2002). Adolescents in other surveys report they were more likely to have unplanned sexual intercourse when they or a potential partner had been drinking (Strunin and Hingson, 1992). Moreover, young persons who are sexually active are more likely to have unprotected sex when they have intercourse after drinking than when they have intercourse when they have not been drinking (Strunin and Hingson, 1992; Hingson, Strunin, Berlin, and Heeren, 1990; Leigh and Stall, 1993; Stall, McResnick, Wiley, Coates, and Ostrow, 1996). These findings are important because annually more than 900,000 adolescents become pregnant and most teen pregnancies are unplanned (Henshaw, 1998). Furthermore, adolescents are overrepresented in the nearly 1 million cases of sexually transmitted infection, including chlamydia, gonorrhea, and syphilis (CDC, 1999), which in turn heighten risk of HIV infection. To date in the United States, 138,153 AIDS cases among 13-to 29-year-olds have been reported (U.S. Department of Health and Human

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Reducing Underage Drinking: A Collective Responsibility Immediate Economic Consequences of Underage Drinking: Health Care Expenditures The immediate consequences of underage drinking are estimated to include at least $8.4 billion of health care expenditures. These expenditures due to underage drinking represent a societal loss because societal resources have been diverted away from other valuable uses. Health care expenditures related to underage drinking include expenditures for alcohol abuse services and expenditures for the medical consequences of alcohol abuse. We estimate that $7.3 billion are spent annually in the United States for alcohol abuse services for underage drinkers. This estimate is based in part on data from the National Survey of Substance Abuse Treatment Services. These data indicate that in 1998, 138,000 youths ages 12 to 17 were admitted to substance abuse treatment (Substance Abuse and Mental Health Services Administration, 2002). Of these, 9 percent of youth admissions involved alcohol abuse only, and half involved both alcohol and marijuana. Assuming that half of the treatment expenditures for admissions that involved both alcohol and marijuana were for the treatment of the alcohol abuse, we estimate that an equivalent of 47,000 youth were treated for alcohol abuse. The NLAES provides information on youth over 17, but still underage. These data show that 3 percent of young adults ages 18 to 20 sought treatment for alcohol problems. Based on the current population in that age group, this suggests an additional 356,520 young adults were treated. At an average estimated treatment cost of $18,000 (Goodman, Nishiura, and Humphreys, 1997), this means the United States spent $7.3 billion for alcohol abuse services for slightly over 400,000 underage drinkers in treatment. To develop this estimate, we also assumed but do not know for certain that the average treatment costs for youths and adults are the same. The estimate may be high or low depending on whether average treatment costs for youth are higher or lower than costs for adults. Expenditures for medical consequences related to alcohol abuse by underage drinkers are estimated based on medical expenditures related to traffic crashes that involved an underage drinking driver. Levy et al., (1999a) estimated that these medical care costs total about $1.1 billion. This estimate omits costs related to medical consequences of underage drinking other than traffic crashes. Life-Course Consequences Many underage drinkers are in high school or college; in economic terms they are investing in their human capital. If underage drinkers invest in less human capital than their nondrinking peers, later in life they may be less productive workers who earn less and suffer a lower standard of living.

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Reducing Underage Drinking: A Collective Responsibility Although these losses are mainly borne by the underage drinkers themselves, the rest of society shares some of the losses to the extent that over their lifetimes, less productive workers receive more antipoverty transfer payments, pay less in taxes, and generate less economic surplus. Econometric studies provide fairly consistent evidence that underage drinking problems result in less investment in schooling and other aspects of human capital. Mullahy and Sindelar (1989) analyzed Wave I (1980-1981) of the Epidemiologic Catchment Area (ECA) data set. The rich ECA data allowed Mullahy and Sindelar to control statistically for a variety of factors related to educational attainment, including family background measures such as father’s education and occupation, and whether the youth suffered from other mental disorders as a teenager. After controlling for these factors, Mullahy and Sindelar estimated that males who experience symptoms of alcoholism before the age of 18 attain on average 1.5 fewer years of schooling. Early symptoms of alcoholism were also associated with a lower probability of later employment in a white-collar professional occupation. Yamada, Kendix, and Yamada (1996) analyzed data from the National Longitudinal Survey of Youth-1979 (NLSY79). This study was also able to control statistically for a range of other determinants of educational attainment, including family background and the student’s academic aptitude test score. Yamada and colleagues (1996) estimated that youth who were frequent drinkers have a high school graduation rate that is 4.3 percentage points below that of their peers. Several studies have extended this line of research to estimate the causal impact of drinking on college attainment. Cook and Moore (1993) used the NLSY79 data to investigate the relationship between heavy drinking in high school and the number of years of college eventually completed. A major concern of this study is that observed patterns of drinking and schooling reflect intertwined decisions, making it difficult to know the extent to which drinking causes the reduced educational attainment. To address this concern, Cook and Moore (1993) relied on the natural or quasi-experiments created by differences in states’ alcohol control policies. They estimated that controlling for other factors, students who spend their high school years in states with relatively high beer taxes and minimum legal drinking ages are more likely to graduate college. Using data from the 1993 College Alcohol Study, Wolaver (2002) estimated that high school drinking has small residual effects on college study hours, grade point average (GPA), and declaration of college major; she estimated that drinking while in college has much stronger effects on college outcomes. By combining the results of her study with estimates from labor economics on the returns to college GPA and major, Wolaver estimated that high school and college drinking will eventually translate into substantial earnings losses later in life. For example, she estimated that because of the effects of college drink-

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Reducing Underage Drinking: A Collective Responsibility ing on choice of major, college-educated males’ future annual earnings are reduced by 1.6 percent to 3.7 percent, while college-educated females’ future annual earnings are reduced by 2 percent to 9.8 percent. The econometric estimates we have reviewed suggest that even those underage drinkers who do not experience alcohol problems as adults may experience reduced earnings and a lower standard of living over their life-course because of their high school and college drinking. Other evidence suggests that the earnings losses may be even larger for those underage drinkers who continue to abuse alcohol as adults. A long line of economics research examines the extent to which current alcohol problems reduce the earnings of working adults (for example, Rice et al., 1990; Mullahy and Sindelar, 1989; 1993, 1994; Kenkel and Ribar, 1994; and National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism [NIDA/NIAAA], 1998). Although the evidence is somewhat inconsistent, prime-age males with drinking problems appear to earn less, but so do abstainers, compared to their moderate drinking peers (Cook and Moore, 2000). The positive association between moderate drinking and earnings could reflect a causal impact, where moderate drinking improves health and worker productivity. However, ongoing research is also exploring other possible explanations for the association. The studies that find a positive impact of moderate drinking have not examined underage drinking, and it seems highly unlikely that underage drinking that persists as problematic adult drinking will have beneficial productivity effects. Most of the studies of adult problem drinking and earnings control for other differences between problem and nonproblem drinkers to focus on the direct impact of alcohol problems on earnings. As Mullahy and Sindelar emphasize, this approach underestimates the total impact of alcohol problems if the alcohol problems are the root causes of some of the other differences. Accounting for the indirect effects of problem drinking through lower schooling attainment and occupational choices substantially increases estimates of the earnings losses associated with problem drinking (Mullahy and Sindelar, 1989, 1993, 1994; Kenkel and Ribar, 1994). In addition, early drinking together with an adult drinking problem may have an interactive or synergistic effect on earnings. NIDA/NIAAA (1998) reported the results of the econometric analysis of the NLAES data used to estimate the productivity effects of alcohol abuse. The results indicated that early initiation of drinking plays an important role in determining worker productivity later in life. Males who met criteria for alcohol dependence and who also initiated drinking before the age of 15 on average earned 13.1 percent less than their nondependent counterparts. Males who met criteria for alcohol dependence, but who were not early initiators on average, earned only 4.4 percent less. If alcohol-dependent males who initiated drinking while underage experienced the same earn-

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Reducing Underage Drinking: A Collective Responsibility ings losses as alcohol-dependent males who initiated drinking later in life, the NIDA/NIAAA productivity costs of alcohol abuse would fall from $84 billion to $51 billion. The difference of $33 billion is an estimate of the portion of the productivity costs currently suffered by alcohol-dependent males that is associated with their previous underage drinking. Of course, association does not prove causation: It is a challenging research question to determine the extent to which the future productivity losses are indeed due to the earlier underage drinking. Yet another channel for underage drinking to have adverse economic consequences over the life-course is if early drinking is a contributory causal factor in adult drinking problems. As described earlier, in the NLAES data earlier age of drinking is associated with higher rates of subsequent problem drinking and alcohol related unintentional injuries. Cook and Moore (2001) reported new econometric evidence that suggests early drinking is causally related to later drinking. They again relied on the natural or quasiexperiments created by state alcohol control policies to study the persistence of youthful drinking. They found that respondents to the NLSY79 who at age 14 lived in a state where the legal drinking age was 18 instead of 21 were more likely to binge drink years later as adults. This evidence that underage drinking increased the risks of adult drinking problems means that some of the earnings losses experienced by adult problem drinkers actually can be traced back to their underage drinking. DISCUSSION No matter how careful the assumptions used in this chapter were to estimate the magnitude of injury mortality associated with underage drinking, it would be preferable if all persons who die from unintentional and intentional injury deaths were tested for alcohol. That would provide a more accurate assessment of the magnitude of alcohol related injury deaths among youth and would, if continued over time, permit more informative analyses of the impact of program and policy changes to reduce underage drinking-related deaths. Part of the reason progress has been made in reducing alcohol related traffic deaths in the past two decades is that most drivers who die in traffic crashes are tested for alcohol. This allows comparison of states before and after new drunk driving and other alcohol regulations with states that do not make those changes to assess whether the regulations produce reductions in fatal crashes involving alcohol. Testing is needed not only for traffic deaths, but for deaths from other unintentional injuries (e.g., falls, drownings, burns, overdoses) as well as intentional injuries such as homicide and suicide. Also, while research needs to be done to determine whether delaying the onset of drinking will prevent alcohol related problems and economic

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Reducing Underage Drinking: A Collective Responsibility consequences later in life, we believe findings outlined in this volume provide important information for physicians and other health care providers to share with their adolescent patients about risks associated with early age of drinking onset. They should explore the age their patients started to drink and advise their patients that people who start drinking at early ages not only have an increased risk of developing alcohol dependence, but they also have an increased risk of experiencing motor vehicle and other unintentional injuries and alcohol related violence, which are the major causes of death among adolescents and young adults. They should point out that decisions about underage drinking and schooling may have lifetime economic consequences as well as sometimes literally being a matter of life and death. Treatment interventions to reduce drinking have been found to reduce alcohol related traffic injuries, violence, and other harms associated with alcohol abuse. A systematic review of randomized control trials to reduce alcohol dependence and abuse (Dinh-Zarr, Diguiseppi, Heitman, and Roberts, 1986) reported reductions in alcohol related traffic crashes, aggressive behavior (Potamainos, North, Meade, Townsend, and Peters, 1986), assaults (Sitharthan, Kavanaugh, and Sayer, 1996) and domestic violence (Barber and Crisp, 1995), and criminal and domestic violence (Toteva and Mi’anov, 1996) associated with posttreatment reductions in drinking. A more recent randomized trial evaluated a brief motivational intervention to reduce drinking among injured problem drinkers (Gentilello, Rivara, Donovan et al., 1999). One year later, the intervention group averaged 3 drinks less per day and experienced a 47 percent reduction in emergency department, trauma center, and hospital injury admissions. The greatest declines involved intentional injuries and were among mild to moderate drinkers. Similar benefits have been observed in a separate experimental evaluation of adolescents positive for being treated in an emergency department (Monti et al., 1999). A brief motivational intervention for older adolescents (mean age 18) produced a significantly lower incidence at 6-month follow-up of alcohol related injuries and alcohol related problems with dates, friends, police, and parents and at school and a lower incidence of driving while intoxicated than experienced by those who received standard care. Both intervention and comparison groups experienced significant posttreatment declines in drinking. Furthermore, results on age or drinking onset reinforce the need for policies that reduce adolescent drinking, such as the minimum legal drinking age of 21. That law has been found to reduce drinking, alcohol related traffic deaths, and deaths from unintentional injuries under the age of 21 (U.S. General Accounting Office, 1987; Jones et al., 1992; Shultz et al., 2001; Wagenaar and Toomey, 2002). Some studies (Davis and Reynolds, 1990; Parker, 1995), but not all (Hughes and Dodder, 1992; Engs and

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Reducing Underage Drinking: A Collective Responsibility Hanson, 1986), have also found that raising the minimum legal drinking age is associated with declines in fighting among the age groups targeted by the law, and one study reported that increases in the legal drinking age was associated with reductions in sexually transmitted diseases among adolescents (Harrison and Kasslet, 2000). One multistate study found that person who were raised in states with a drinking age of 21 relative to younger ages were not only less likely to drink when they were under age 21, but they were less likely to drink when ages 21 to 25 (O’Malley and Wagenaar, 1991). Community-based programs that use compliance check surveys to assess the extent of sales of alcohol to minors and that increase enforcement to prevent sales to underage persons can reduce underage drinking (Wagenaar, Murray, Gehan et al., 2000) and alcohol related traffic crashes and assault injuries (Holder, Gruenwald, Ponick et al., 2000). Whether these community-based programs to heighten enforcement of laws to prevent underage drinking also reduce other health, social, and economic consequences associated with underage drinking during both adolescence and adult years warrants immediate investigation. REFERENCES Akers, R.L. (1977). Deviant behavior: A social learning approach (2nd ed.). Belmont, CA: Wadsworth. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, Fourth Edition. Washington, DC: Author. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. NJ: Prentice-Hall. Barber, J.G., and Crisp, B.R. (1995). The pressure to change approach to working with the partners of heavy drinkers. Addiction, 90, 269-276. Barnes, G.M., Welte, J.W., and Dintcheff, B. (1992). Alcohol misuse among college students and other young adults: Findings from a general population study in New York State. International Journal of the Addictions, 27, 917-934. Blomberg, R. (1992). Lower BAC limits for youth: Evaluation of the Maryland .02 laws. DOT HS 807 859 Technical Summary. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration. Brook, J.S., Brook, D.W., Gordon, A.S., Whiteman, M., and Cohen, P. (1990). The psychosocial etiology of adolescent drug use: A family interactional approach. Genetic, Social, and General Psychology Monographs, 116, 111-267. Centers for Disease Control and Prevention. (1999). STD surveillance 1998. Atlanta: Georgia Department of Health and Human Services, Division of STD Prevention. Centers for Disease Control and Prevention. (2001). Division of HIV/AIDS prevention surveillance report. Atlanta: National Center for HIV, STD and TB Prevention Chassin, L., Pitts, S., and Prost, J. (2002). Binge drinking trajectories from adolescence to emerging adulthood in a high risk sample: Predictors and substance abuse outcomes. Journal of Consulting and Clinical Psychology, 70(1), 67-78. Chou, S.P., and Pickering, R.P. (1992). Early onset of drinking as a risk factor for lifetime related problems. British Journal of Addictions, 87, 1199-1204.

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