U.S. Department of Health

& Human Services 

National Institutes of Health 

National Institute on Alcohol Abuse 

and Alcoholism 

Number 73 October 2007 

UNDERAGE DRINKING— 

Highlights From The Surgeon 

General’s Call to Action To 

Prevent and Reduce Underage 

Drinking 

In March 2007, the Acting Surgeon General of the 

United States issued a Call to Action To Prevent and 

Reduce Underage Drinking. The National Institute on 

Alcohol Abuse and Alcoholism’s (NIAAA’s) Underage 

Drinking Research Initiative provided much of the scientific foundation for that document. The Call to Action 

highlights the nature and extent of underage drinking and 

its consequences. It suggests a new, more comprehensive 

and developmentally sensitive approach to understanding, preventing, and reducing underage drinking. 

Importantly, the Call to Action emphasizes that everyone has a role in preventing and reducing underage 

drinking—parents, schools, communities, colleges and 

universities, the health care system, the criminal and 

juvenile justice systems and law enforcement, and governments and policymakers. Later in 2007, the Surgeon 

General also issued three separate guides—for families, 

educators, and communities—based on the Call to Action. 

Goals of the Call to Action 

In order to prevent and reduce underage drinking, the 

Surgeon General’s Call to Action sets forth the following 

six goals: 

Goal 1: Foster changes in American society that facilitate 

healthy adolescent development and that help 

prevent and reduce underage drinking. 

Goal 2: Engage parents and other caregivers, schools, 

communities, all levels of government, all social 

systems that interface with youth, and youth 

themselves in a coordinated national effort to 

prevent and reduce underage drinking and its 

consequences. 

Goal 3: Promote an understanding of underage alcohol 

consumption in the context of human development 

and maturation that takes into account individual 

adolescent characteristics as well as environmental, ethnic, cultural, and gender differences. 

Goal 4: Conduct additional research on adolescent 

alcohol use and its relationship to development. 

Goal 5: Work to improve public health surveillance on 

underage drinking and on population-based risk 

factors for this behavior. 

Goal 6: Work to ensure that policies at all levels are 

consistent with the national goal of preventing 

and reducing underage alcohol consumption. 

Strategies outlined in the Call to Action address: 

1) Changing the culture by challenging norms and 

expectations surrounding underage drinking; 

2) Preventing adolescents from starting to drink; 

3) Delaying initiation of drinking; 

4) Intervening early, especially with high-risk youth; 

5) Reducing drinking and its negative consequences, 

including the progression to alcohol use disorders 

(AUDs) among those who already have started 

drinking; and 

6) Identifying adolescents who have AUDs and therefore could benefit from treatment and recovery 

support services (1). 
 

 

The Nature and 

Extent of Underage 

Alcohol Use 

Underage drinking is a significant but often
 

overlooked problem in the United States.
 

Young people between the ages of 12 and
 

20 are more likely to use alcohol than use
 

tobacco or illicit drugs, including marijuana
 

(2–4) (see figure 1). Although adolescents
 

tend to drink less frequently than adults,
 

they drink considerably more per occasion—
 

5 drinks on average. Underage alcohol use,
 

and especially binge drinking1

—a particularly
 

harmful pattern of drinking—puts individuals
 

at risk for a range of problems (4).
 

Despite the high prevalence of and the problems 

associated with underage drinking, many adults 

do not realize the extent of the problem, or do not 

view underage drinking as harmful. Many see alcohol 

use by teens as a “rite of passage” and may even facilitate 

it (1). Challenging this culture of acceptance is key to 

preventing and reducing underage drinking. 

Alcohol use is intertwined with growing up in the 

United States. Both drinking and binge drinking ramp 

up dramatically during the teen years and into early 

adulthood (4). By age 15, approximately 50 percent 

of boys and girls have had a whole drink of alcohol; 

by age 21, approximately 90 percent have done so 

(see figure 2). Even more worrisome is the fact that 

many youth engage in binge drinking. National surveys 

indicate an increase in binge drinking days for girls 

through age 18 and boys through age 20 (see figure 3). 

Among college students, about 80 percent drink alcohol, 

about 40 percent binge drink, and about 20 percent 

binge drink three or more times within a 2-week 

period (5). Among underage military personnel, 62.3 

More Adolescents Use Alcohol Than Use 

Cigarettes or Marijuana 

percent report drinking alcohol at least once a year, 

and 21.3 percent report heavy alcohol use (6).2 

The number of young people who drink and the way 

they drink results in a wide range of negative consequences affecting large numbers of underage drinkers 

and those around them. These consequences include 

risky sexual behavior; physical and sexual assaults; 

potential effects on the developing brain; problems in 

school, at work, and with the legal system; various types 

of injury; car crashes; homicide and suicide; and death 

from alcohol poisoning. 

In addition, early initiation of drinking is associated 

with alcohol dependence both during adolescence and 

later in life. According to a landmark survey on the 

drinking habits of Americans, the National Epidemiologic 

Survey on Alcohol and Related Conditions (NESARC), 

the highest prevalence of alcohol dependence3 is 

among 18- to 20-year-olds (7). 

“

Research tells us that 

underage drinking can 

derail healthy development.” 

– Ting-Kai Li, M.D., Director, 

National Institute on Alcohol Abuse and Alcoholism 

1 Most college drinking studies define binge drinking as “5 or more 

drinks in a row for men and 4 or more drinks in a row for women” 

(National Institute on Alcohol Abuse and Alcoholism [NIAAA], National 

Advisory Council). However, in 2004, the National Advisory Council 

revised the definition of binge drinking as follows: “a pattern of drinking 

alcohol that brings blood alcohol concentration (BAC) to 0.08 gram 

percent or above. For the typical adult, this pattern corresponds to 

consuming 5 or more drinks (male) or 4 or more drinks (female) in 

about 2 hours” (NIAAA National Advisory Council). 

2 In this survey, heavy alcohol use refers to drinking 5 or more drinks 

at least once a week per typical drinking occasion. 

3 As defined in the most recent editions of the Diagnostic and 

Statistical Manual of Mental Disorders (DSM–IV and DSM–IV–TR). 

Figure 1: Past-Month Adolescent Alcohol, Cigarette, and Marijuana 

Use by Grade. 

Source: Data from 2006 Monitoring the Future Survey 

Percent

8th 10th Grade 12th

Alcohol Cigarettes Marijuana

0

0

20

0

40

50

2
 
 

Alcohol Use Increases Dramatically 

During Adolescence 

10

30

90

100

1213141516171819202122–2324–2526–2930–3435–4950–64 65+

Age

Pe t

Male

Female

Male

20

40

00

The Connection Between 

Adolescent Development 

and Alcohol Use 

Why is alcohol so appealing to young people, and why 

does drinking escalate so dramatically during adolescence? As detailed in the Call to Action, research shows 

that a variety of social, cultural, and biological factors 

influence an adolescent’s decision to drink, and that 

drinking is linked not only to individual risk factors 

but also to adolescent development. Recognizing 

that adolescents operate within many different 

social systems, all of which can influence their 

drinking behavior, environmental factors 

must also be considered. Understanding 

all these factors, including the processes of 

adolescent development, is vital to creating 

effective interventions and identifying young 

people who may be especially vulnerable to 

developing problems with alcohol. 

Developmental factors. Adolescence is a key 

period in human development, a time of dramatic changes—both biological and social. 

Puberty, the hallmark of early adolescence, 

brings important physical and psychological 

changes. A number of social transitions also 

characterize adolescence, both those imposed 

on youth, such as the transitions from elementary to middle to high school, and those 

Figure 2: Percentage of Americans Who Have Ever Drunk Alcohol 

(A Whole Drink). 

Source: SAMHSA data from 2005 National Survey on Drug Use and Health (NSDUH) 

time with family and more with friends. 

Each of these transitions can increase 

social pressures, stresses, and expectations 

that contribute to underage drinking. 

During adolescence the tendency to take 

risks also increases, as adolescents seek 

greater independence and new experiences. 

Research indicates that risk taking during 

adolescence is in part biologically driven. 

Normal changes in structure, neuron connectivity (e.g., “wiring”), and physiology 

that occur at different times in various 

regions of the developing brain may help 

explain the changing balance between 

emotions and self-regulation in adolescence 

(8). For example, the limbic system, a part 

of the brain associated with risk taking and 

novelty- and sensation-seeking, matures 

earlier than the frontal cortex, which is 

associated with judgment, self-regulation, and impulse 

control (9). 

Research with animals suggests that adolescents may 

experience alcohol’s effects differently from adults, and 

this may affect their drinking behavior, in particular 

their tendency to binge drink. Animal studies suggest 

that adolescents tend to be more sensitive than adults 

to the stimulating effects of alcohol and less sensitive 

to some of its more unpleasant effects, including 

sedation, hangover, and loss of muscular coordination 

initiated by young people themselves, such 

as changing peer groups and spending less 

Among Adolescents Who Drink, the Number of 

Binge Drinking Days Increases With Age 

Figure 3: Number of Days in the Past 30 in Which Drinkers 

Consumed 5 or More Drinks, by Age and Gender. 

Source: SAMHSA data from 2005 NSDUH 

0

2

4

5

Days

Age

Ma e

ema e

0

2

3

4

4 5 6 7 8 9 20 2 22 2 24 25 26 29 0 4 5 49 50 64 65+

3
 
 

 

 

 

(ataxia) (for review, see 10 and 11). This may conmmon among 

 for negative 

engage in activiform (such as 

a (1). 

’ expectations 

expect” to expe­

 drinking. As 

ents who view 

 to drink than 

 It also is worth 

dren mature. 

’s expectations 

tive to primarily 

lescence in 

l use, certain 

lar risk for 

vels of impuln; conduct 

rm avoidance, 

ive consequences 

aging in risky 

scence may be 

ental disortribute to binge drinking, a practice co

adolescents that puts them at high risk

consequences. For example, they may 

ties that they are too intoxicated to per

driving) or to drink to the point of com

Finally, research shows that adolescents

about alcohol use—that is, what they “

rience when drinking—influence their

discussed in the Call to Action, adolesc

alcohol more positively are more likely

those who view alcohol negatively (1).

noting that expectations change as chil

Between the ages of 9 and 13, children

about alcohol shift from primarily nega

positive (12,13). 

Individual risk factors. Although ado

general brings increased risk for alcoho

factors put some individuals at particu

abusing alcohol. These include high le

siveness, novelty seeking, and aggressio

or behavior problems (14); and low ha

or a tendency not to consider the negat

of one’s actions (15). Additionally, eng

behaviors in childhood and early adole

associated with later alcohol use (16). M

ders, including depression and anxiety, 

also are correlated with adolescent alcohol use. Mental disorders and underage 

alcohol use can be interdependent: adolescents may use alcohol to cope with 

depression and anxiety, and alcohol consumption may raise levels of depression 

and anxiety (1). It also is important to 

recognize that children of alcoholics are 

at increased risk for developing problems with alcohol. These individuals are between 4 

and 10 times more likely to become alcoholics than 

those with no family history of alcoholism (17). 

Conclusion: Challenging 

a Culture of Acceptance 

As demonstrated in the Call to Action, underage drinking is linked to a complex array of social, cultural, and 

biological factors. Efforts to address it must therefore 

take into account the complex dynamics of adolescent 

development, environmental influences, and the role 

of individual characteristics in an adolescent’s decision 

to drink (1). In addition, because adolescents become 

increasingly involved in social systems outside the 

family as they mature, it is incumbent on these systems 

to take an active role along with parents in discouraging the use of alcohol by young people and helping 

those already using alcohol to change their behavior. 

In the Call to Action the Surgeon General calls on all 

Americans to commit to changing the culture around 

underage drinking in the United States. Parents, 

schools, communities, colleges and universities, the 

health care system, the criminal and juvenile justice 

systems and law enforcement, and governments and 

policymakers—all must work to prevent and reduce 

underage drinking. 

According to the Acting Surgeon General, “a significant point of the Call to Action is this: Underage alcohol 

use is not inevitable, and schools, parents, and other 

adults are not powerless to stop it” (1). The Call to 

Action is a wake-up call to American society. The 

Nation as a whole must mobilize to prevent and 

reduce underage drinking and the adverse personal, 

social, and economic consequences associated with it. 

References 

(1) U.S. Department of Health and Human Services. The Surgeon 

General’s Call to Action To Prevent and Reduce Underage Drinking. 

Washington, DC: U.S. Department of Health and Human Services, 

Office of the Surgeon General, 2007. (2) Johnston, L.D.; O’Malley, P. 

“

We can no longer ignore 

what alcohol is doing to 

our children.

– Rear Admiral Kenneth Moritsugu, M.D., M.P

” 

.H., 

Acting Surgeon General of the United States 

4
 
 

M.; Bachman, J. G.; et al. Monitoring the Future, National Survey 

Results on Drug Use, 1975–2005. Volume I: Secondary School 

Students. NIH Pub. No. 06–5883. Bethesda, MD: National Institute on 

Drug Abuse, 2006. Available online at: http://www.monitoringthefuture.org/pubs/monographs/vol1_2005.pdf. (3) Johnston, L.D.; 

O’Malley, P.M.; Bachman, J.G.; et al. Teen Drug Use Continues Down 

in 2006, Particularly Among Older Teens; but Use of Prescription-Type 

Drugs Remains High. Ann Arbor, MI: University of Michigan News and 

Information Services, 2006. Available online at: www.monitoringthefuture.org. (4) Substance Abuse and Mental Health Services 

Administration (SAMHSA). Results From the 2005 National Survey 

on Drug Use and Health: National Findings. NSDUH Series H–30, 

DHHS Pub. No. SMA 06–4194. Rockville, MD: SAMHSA, Office of 

Applied Studies, 2006. (5) National Institute on Alcohol Abuse and 

Alcoholism (NIAAA). A Call to Action: Changing the Culture of 

Drinking at U.S. Colleges. Bethesda, MD: NIAAA, 2002. Available 

online at: http://www.collegedrinkingprevention.gov/NIAAACollege 

Materials/TaskForce/TaskForce_TOC.aspx. (6) Bray, R.M.; Hourani, 

L.L.; Olmsted, K.L.R.; et al. 2005 Department of Defense Survey of 

Health Related Behaviors Among Military Personnel. Research 

Triangle Park, NC: RTI International, 2006. Available at 

http://www.ha.osd.mil/special_reports/2005_Health_Behaviors_Survey 

_ 1-07.pdf. (7) Grant, B.F.; Dawson, D.A.; Stinson, F.S.; et al. The 12­

month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991–1992 and 2001–2002. Drug and Alcohol 

Dependence 74:223–234, 2004. PMID: 15194200 (8) Restak, R. The 

Secret Life of the Brain. Washington, DC: National Academies Press, 

2001. (9) Dahl, R.E. Adolescent brain development: A period of vulnerabilities and opportunities. Keynote address. Annals of the New 

York Academy of Sciences 1021:1–22, 2004. PMID: 15251869 (10) 

Spear, L.P. The adolescent brain and age-related behavioral manifestations. Neuroscience and Biobehavioral Reviews 24:417–463, 2000. 

PMID: 10817843 (11) Spear, L.P., and Varlinskaya, E.I. Adolescence: 

Alcohol sensitivity, tolerance, and intake. In: Galanter, M., ed. Recent 

Developments in Alcoholism, Vol. 17: Alcohol Problems in Adolescents 

and Young Adults: Epidemiology, Neurobiology, Prevention, Treatment. 

New York: Springer, 2005. pp. 143–159. PMID: 15789864 (12) Dunn, 

M.E., and Goldman, M.S. Empirical modeling of an alcohol expectancy memory network in elementary school children as a function of 

grade. Experimental and Clinical Psychopharmacology 4:209–217, 

1996. (13) Dunn, M.E., and Goldman, M.S. Age and drinking-related 

differences in the memory organization of alcohol expectancies in 3rd, 

6th, 9th, and 12th grade children. Journal of Consulting and Clinical 

Psychology 66:579–585, 1998. PMID: 9642899 (14) Gabel, S.; 

Stallings, M.C.; Schmitz, S.; et al. Personality dimensions and substance misuse: Relationships in adolescents, mothers and fathers. 

American Journal on Addictions 8:101–113, 1999. PMID: 10365190 

(15) Jones, S.P., and Heaven, P.C. Psychosocial correlates of adolescent drug-taking behavior. Journal of Adolescence 21:127–134, 1998. 

PMID: 9585491 (16) Soloff, P.H.; Lynch, K.G.; and Moss, H.B. 

Serotonin, impulsivity, and alcohol use disorders in the older adolescent: A psychobiological study. Alcoholism: Clinical and Experimental 

Research 24:1609–1619, 2000. PMID: 11104107 (17) Russell, M. 

Prevalence of alcoholism among children of alcoholics. In: Windle, M., 

and Searles, J.S., eds. Children of Alcoholics: Critical Perspectives. 

New York: Guilford, 1990. pp. 9–38. 

5
 
Resources 

▲ 

The Surgeon General’s Call to Action To Prevent and Reduce Underage Drinking. This Call 

to Action was developed by the U.S. Surgeon General’s Office in collaboration with NIAAA and the 

Substance Abuse and Mental Health Services Administration (SAMHSA) to focus national attention 

on the persistent problem of underage drinking. It contains concrete and practical suggestions for 

parents, schools, communities, colleges and universities, the health care system, the criminal and 

juvenile justice systems and law enforcement, and governments and policymakers on how they 

can make a difference. 

▲ 

A Guide to Action for Educators,A Guide to Action for Families, and A Guide to Action 

for Communities. The Surgeon General’s Office has developed three guides specifically for 

parents, educators, and members of the community based on the Call to Action. These guides 

offer practical suggestions on what members of each of these groups can do to prevent and 

reduce underage drinking. 

To order this Call to Action or any of the Guides, contact SAMHSA’s National Clearinghouse 

for Alcohol and Drug Information at 1–800–729–6686 or visit http://ncadi.samhsa.gov/. 

These publications are also available online at http://www.surgeongeneral.gov/topics/ 

underagedrinking. 

Full text of this publication is available on NIAAA’s World Wide Web site at www.niaaa.nih.gov. 

All material contained in the Alcohol Alert is in the public domain and may be used or reproduced 

without permission from NIAAA. Citation of the source is appreciated.
 

Copies of the Alcohol Alert are available free of charge from the National Institute on Alcohol Abuse and Alcoholism
 

Publications Distribution Center, P.O. Box 10686, Rockville, MD 20849–0686.
 

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