U.S. Department of Health

& Human Services 

National Institutes of Health 

National Institute on Alcohol Abuse 

and Alcoholism 

Number 67 January 2006 

UNDERAGE DRINKING


Why Do Adolescents Drink, 


What Are the Risks, and How Can


Underage Drinking Be Prevented?


Alcohol is the drug of choice among youth. Many young 

people are experiencing the consequences of drinking too 

much, at too early an age. As a result, underage drinking is 

a leading public health problem in this country. 

Each year, approximately 5,000 young people under the 

age of 21 die as a result of underage drinking; this includes 

about 1,900 deaths from motor vehicle crashes, 1,600 as a 

result of homicides, 300 from suicide, as well as hundreds 

from other injuries such as falls, burns, and drownings (1–5). 

Yet drinking continues to be widespread among adolescents, as shown by nationwide surveys as well as studies 

in smaller populations. According to data from the 2005 

Monitoring the Future (MTF) study, an annual survey 

of U.S. youth, three-fourths of 12th graders, more than 

two-thirds of 10th graders, and about two in every five 

8th graders have consumed alcohol. And when youth 

drink they tend to drink intensively, often consuming four 

to five drinks at one time. MTF data show that 11 percent 

of 8th graders, 22 percent of 10th graders, and 29 percent 

of 12th graders had engaged in heavy episodic (or “binge1

”) 

drinking within the past two weeks (6) (see figure). 

Research also shows that many adolescents start to drink 

at very young ages. In 2003, the average age of first use of 

alcohol was about 14, compared to about 17 1/2 in 1965 

(7,8). People who reported starting to drink before the age 

of 15 were four times more likely to also report meeting the 

criteria for alcohol dependence at some point in their lives 

(9). In fact, new research shows that the serious drinking 

problems (including what is called alcoholism) typically 

associated with middle age actually begin to appear much 

earlier, during young adulthood and even adolescence. 

1 The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines binge drinking as 

a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 grams percent or above. For the typical adult, this pattern corresponds to consuming five or more drinks 

(men), or four or more drinks (women), in about 2 hours. 

Other research shows that the younger children and adolescents are when they start to drink, the more likely they 

will be to engage in behaviors that harm themselves and others. For example, frequent binge drinkers (nearly 1 million 

high school students nationwide) are more likely to engage 

in risky behaviors, including using other drugs such as 

marijuana and cocaine, having sex with six or more partners, 

and earning grades that are mostly Ds and Fs in school (10). 

Why Do Some Adolescents 

Drink? 

As children move from adolescence to young adulthood, 

they encounter dramatic physical, emotional, and lifestyle 

changes. Developmental transitions, such as puberty and 

increasing independence, have been associated with alcohol use. So in a sense, just being an adolescent may be a 

key risk factor not only for starting to drink but also for 

drinking dangerously. 

Risk-Taking—Research shows the brain keeps developing 

well into the twenties, during which time it continues 

to establish important communication connections and 

further refines its function. Scientists believe that this 

lengthy developmental period may help explain some of 

the behavior which is characteristic of adolescence—such 

as their propensity to seek out new and potentially dangerous situations. For some teens, thrill-seeking might include 
experimenting with alcohol. Developmental changes also 

offer a possible physiological explanation for why teens 

act so impulsively, often not recognizing that their 

actions—such as drinking—have consequences. 

Expectancies—How people view alcohol and its effects 

also influences their drinking behavior, including whether 

they begin to drink and how much. An adolescent who 

expects drinking to be a pleasurable experience is more 

likely to drink than one who does not. An important area 

of alcohol research is focusing on how expectancy influences 

drinking patterns from childhood through adolescence 

and into young adulthood (11–14). Beliefs about alcohol 

are established very early in life, even before the child 

begins elementary school (15). Before age 9, children 

generally view alcohol negatively and see drinking as 

bad, with adverse effects. By about age 13, however, their 

expectancies shift, becoming more positive (11,16). As 

would be expected, adolescents who drink the most also 

place the greatest emphasis on the positive and arousing 

effects of alcohol. 

Sensitivity and Tolerance to Alcohol—Differences between 

the adult brain and the brain of the maturing adolescent 

also may help to explain why many young drinkers are 

able to consume much larger amounts of alcohol than 

adults (17) before experiencing the negative consequences 

of drinking, such as drowsiness, lack of coordination, and 

withdrawal/hangover effects (18,19). This unusual tolerance may help to explain the high rates of binge drinking 

among young adults. At the same time, adolescents appear 

to be particularly sensitive to the positive effects of drinking, such as feeling more at ease in social situations, and 

young people may drink more than adults because of 

these positive social experiences (18,19). 

Personality Characteristics and Psychiatric Comorbidity— 

Children who begin to drink at a very early age (before 

age 12) often share similar personality characteristics that 

may make them more likely to start drinking. Young 

people who are disruptive, hyperactive, and aggressive— 

often referred to as having conduct problems or being 

antisocial—as well as those who are depressed, withdrawn, 

or anxious, may be at greatest risk for alcohol problems 

(20). Other behavior problems associated with alcohol 

use include rebelliousness (21), difficulty avoiding harm 

or harmful situations (22), and a host of other traits seen 

in young people who act out without regard for rules or 

the feelings of others (i.e., disinhibition) (23–25). 

Hereditary Factors—Some of the behavioral and physiological factors that converge to increase or decrease a person’s 

TREATMENT: AN UNMET NEED


A major unmet need exists in the treatment of alcohol use disorders: In 2002, 1.4 million youth met the criteria 

for alcohol abuse or dependence, but only 227,000 actually received any treatment for these problems (1). 

Moreover, much of the treatment available today does not address the specific needs of adolescents (2). For 

example, most young people prefer easy access to treatment, with strategies tailored to their age group (3), and 

treatments that do not remove them from their home or academic settings (2). Youth perceive traditional services 

(e.g., alcoholism treatment programs, Alcoholics Anonymous) as less helpful than brief interventions tailored to 

their concerns (4). Consequently, alternative formats, attention to developmental transitions, and social marketing 

are needed to better address alcohol problems that emerge during adolescence. 

Adolescent Treatment Interventions—Complex interventions have been developed and tested in adolescents 

referred for treatment of alcohol and other drug disorders. Many of these patients are likely to have more than 

one substance use disorder (e.g., alcohol and marijuana) and to have other psychiatric disorders as well (e.g., 

depression, anxiety, or conduct disorder). Brief interventions are, as a rule, delivered to adolescents in general 

medical settings (e.g., primary care clinics, emergency rooms) or in school-based settings. These settings offer 

an excellent opportunity for intervening with adolescents to address their drinking before they progress to serious 

alcohol use disorders and to prevent the development of alcohol-related problems (5). 

References 

(1) Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2002 National Survey on Drug Use and Health: National Findings. 

NHSDA Series H–22, DHHS Pub. No. SMA 03–3836. Rockville, MD: SAMHSA, Office of Applied Studies, 2003. Available online at: http://www.oas.samhsa.gov/nhsda/2k2nsduh/Results/2k2Results.htm. (2) Brown, S.A. Facilitating change for adolescent alcohol problems: A multiple options approach. In: Wagner, 

E.F., and Waldron, H.B., eds. Innovations in Adolescent Substance Abuse Intervention. Oxford, England: Elsevier Science, 2001. pp. 169–187 (3) Metrik, J.; 

Frissell, K.C.; McCarthy, D.M.; et al. Strategies for reduction and cessation of alcohol use: What do adolescents prefer? Alcoholism: Clinical and Experimental 

Research 27:74–80, 2003. PMID: 12544009 (4) D’Amico, E.J.; McCarthy, D.M.; Metrik, J.; and Brown, S.A. Alcohol-related services: Prevention, secondary 

intervention and treatment preferences of adolescents. Journal of Child & Adolescent Substance Abuse 14:61–80, 2004. (5) Wagner, E.F.; Brown, S.A.; Monti, P.; 

et al. Innovations in adolescent substance abuse intervention. Alcoholism: Clinical and Experimental Research 23:236–249, 1999. PMID: 10069552 

2

risk for alcohol problems, including tolerance to alcohol’s 

effects, may be directly linked to genetics. For example, 

being a child of an alcoholic or having several alcoholic 

family members places a person at greater risk for alcohol 

problems. Children of alcoholics (COAs) are between 4 

and 10 times more likely to become alcoholics themselves 

than are children who have no close relatives with alcoholism (26). COAs also are more likely to begin drinking 

at a young age (27) and to progress to drinking problems 

more quickly (9). 

Research shows that COAs may have subtle brain differences which could be markers for developing later alcohol 

problems (28). For example, using high-tech brain-imaging 

techniques, scientists have found that COAs have a distinctive feature in one brainwave pattern (called a P300 

response) that could be a marker for later alcoholism risk 

(29,30). Researchers also are investigating other brainwave 

differences in COAs that may be present long before they 

begin to drink, including brainwave activity recorded during sleep (31) as well as changes in brain structure (32) 

and function (33). 

Some studies suggest that these brain differences may be 

particularly evident in people who also have certain behavioral 

traits, such as signs of conduct disorder, antisocial personality disorder, sensation-seeking, or poor impulse control 

(34–38). Studying how the brain’s structure and function 

translates to behavior will help researchers to better understand how predrinking risk factors shape later alcohol use. 

For example, does a person who is depressed drink to alleviate his or her depression, or does drinking lead to changes 

in his brain that result in feelings of depression? 

Other hereditary factors likely will become evident as 

scientists work to identify the actual genes involved in 

addiction. By analyzing the genetic makeup of people and families with alcohol dependence, researchers have found 

specific regions on chromosomes that correlate with a risk 

for alcoholism (39–41). Candidate genes for alcoholism 

risk also have been associated with those regions (42). The 

goal now is to further refine regions for which a specific 

gene has not yet been identified and then determine how 

those genes interact with other genes and gene products 

as well as with the environment to result in alcohol 

dependence. Further research also should shed light on 

the extent to which the same or different genes contribute 

to alcohol problems, both in adults and in adolescents. 

Environmental Aspects—Pinpointing a genetic contribution will not tell the whole story, however, as drinking behavior reflects a complex interplay between inherited and environmental factors, the implications of which are only 

beginning to be explored in adolescents (43). And what 

influences drinking at one age may not have the same impact at another. As Rose and colleagues (43) show, genetic factors appear to have more influence on adolescent drinking behavior in late adolescence than in mid-adolescence. 

Environmental factors, such as the influence of parents and 

peers, also play a role in alcohol use (44). For example, 

parents who drink more and who view drinking favorably 

Binge Drinking 

Percent of young people drinking 5+ 

drinks at one time in the last 2 weeks. 

Source: www.monitoringthefuture.org/data/05data.html#2005data-drugs. 

0

2 0

40

60

80

10 0

75 '77 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '0 5

12th Grade

10th

8th Grade

Year 

 Grade

may have children who drink more, and an adolescent girl 

with an older or adult boyfriend is more likely to use alcohol and other drugs and to engage in delinquent behaviors (45). 

Researchers are examining other environmental influences 

as well, such as the impact of the media. Today alcohol is 

widely available and aggressively promoted through television, radio, billboards, and the Internet. Researchers are 

studying how young people react to these advertisements. 

In a study of 3rd, 6th, and 9th graders, those who found alcohol ads desirable were more likely to view drinking 

positively and to want to purchase products with alcohol logos (46). Research is mixed, however, on whether these 

positive views of alcohol actually lead to underage drinking. 

What Are the Health Risks? 

Whatever it is that leads adolescents to begin drinking, 

once they start they face a number of potential health risks. 

Although the severe health problems associated with 

harmful alcohol use are not as common in adolescents as 

they are in adults, studies show that young people who 

drink heavily may put themselves at risk for a range of 

potential health problems. 

Brain Effects—Scientists currently are examining just 

how alcohol affects the developing brain, but it’s a difficult task. Subtle changes in the brain may be difficult to 

detect but still have a significant impact on long-term 

thinking and memory skills. Add to this the fact that adolescent brains are still maturing, and the study of alcohol’s 

effects becomes even more complex. Research has shown 

that animals fed alcohol during this critical developmental 

stage continue to show long-lasting impairment from alcohol 

3 
as they age (47). It’s simply not known how alcohol will 

affect the long-term memory and learning skills of people 

who began drinking heavily as adolescents. 

Liver Effects—Elevated liver enzymes, indicating some 

degree of liver damage, have been found in some adolescents who drink alcohol (48). Young drinkers who are 

overweight or obese showed elevated liver enzymes even 

with only moderate levels of drinking (49). 

Growth and Endocrine Effects—In both males and females, 

puberty is a period associated with marked hormonal 

changes, including increases in the sex hormones, estrogen and testosterone. These hormones, in turn, increase 

production of other hormones and growth factors (50), 

which are vital for normal organ development. Drinking 

alcohol during this period of rapid growth and development (i.e., prior to or during puberty) may upset the critical hormonal balance necessary for normal development 

of organs, muscles, and bones. Studies in animals also 

show that consuming alcohol during puberty adversely 

affects the maturation of the reproductive system (51). 

Preventing Underage 

Drinking Within a 

Developmental Framework 

Complex behaviors, such as the decision to begin drinking 

or to continue using alcohol, are the result of a dynamic 

interplay between genes and environment. For example, 

biological and physiological changes that occur during 

adolescence may promote risk-taking behavior, leading to 

early experimentation with alcohol. This behavior then shapes 

the child’s environment, as he or she chooses friends and 

situations that support further drinking. Continued drinking may lead to physiological reactions, such as depression 

or anxiety disorders, triggering even greater alcohol use or 

dependence. In this way, youthful patterns of alcohol use can 

mark the start of a developmental pathway that may lead 

to abuse and dependence. Then again, not all young people 

who travel this pathway experience the same outcomes. 

Perhaps the best way to understand and prevent underage 

alcohol use is to view drinking as it relates to development. 

This “whole system” approach to underage drinking takes 

into account a particular adolescent’s unique risk and protective factors—from genetics and personality characteristics 

to social and environmental factors. Viewed in this way, 

development includes not only the adolescent’s inherent 

risk and resilience but also the current conditions that help 

to shape his or her behavior (52). 

Children mature at different rates. Developmental research 

takes this into account, recognizing that during adolescence 

there are periods of rapid growth and reorganization, alternating with periods of slower growth and integration of 

body systems. Periods of rapid transitions, when social or 

cultural factors most strongly influence the biology and 

behavior of the adolescent, may be the best time to target 

delivery of interventions (53). Interventions that focus on 

these critical development periods could alter the life course 

of the child (54), perhaps placing him or her on a path to 

avoid problems with alcohol. 

To date, researchers have been unable to identify a single 

track that predicts the course of alcohol use for all or 

even most young people. Instead, findings provide strong 

evidence for wide developmental variation in drinking 

patterns within this special population (55,56). 

Interventions for Preventing 

Underage Drinking 

Intervention approaches typically fall into two distinct 

categories: (1) environmental-level interventions, which 

seek to reduce opportunities for underage drinking, 

increase penalties for violating minimum legal drinking 

age (MLDA) and other alcohol use laws, and reduce 

community tolerance for alcohol use by youth; and (2) 

individual-level interventions, which seek to change 

knowledge, expectancies, attitudes, intentions, motivation, 

and skills so that youth are better able to resist the prodrinking influences and opportunities that surround them. 

Environmental approaches include: 

Raising the Price of Alcohol—A substantial body of research 

has shown that higher prices or taxes on alcoholic beverages 

are associated with lower levels of alcohol consumption and 

alcohol-related problems, especially in young people (57–60). 

Increasing the Minimum Legal Drinking Age—Today all 

States have set the minimum legal drinking at age 21. 

Increasing the age at which people can legally purchase 

and drink alcohol has been the most successful intervention to date in reducing drinking and alcohol-related crashes 

among people under age 21 

(61). NHTSA (1) estimates 

that a legal drinking age of 

21 saves 700 to 1,000 lives 

annually. Since 1976, these 

laws have prevented more 

“Youthful patterns of alcohol use can mark 

the start of a developmental pathway that 

may lead to abuse and dependence.” 

4

than 21,000 traffic deaths. Just how much the legal drinking age relates to drinking-related crashes is shown by a 

recent study in New Zealand. Six years ago that country 

lowered its minimum legal drinking age to 18. Since then, 

alcohol-related crashes have risen 12 percent among 18- to 

19-year-olds and 14 percent among 15- to 17-year-olds (62). 

Clearly a higher minimum drinking age can help to reduce 

crashes and save lives, especially in very young drivers. 

Enacting Zero-Tolerance Laws—All States have zerotolerance laws that make it illegal for people under age 21 

to drive after any drinking. When the first eight States to 

adopt zero-tolerance laws were compared with nearby 

States without such laws, the zero-tolerance States showed 

a 21-percent greater decline in the proportion of singlevehicle night-time fatal crashes involving drivers under 

21, the type of crash most likely to involve alcohol (63). 

Stepping up Enforcement of Laws—Despite their demonstrated benefits, legal drinking age and zero-tolerance laws 

generally have not been vigorously enforced (64). Alcohol 

purchase laws aimed at sellers and buyers also can be effective 

(65), but resources must be made available for enforcing 

these laws. 

Individual-focused interventions include: 

School-Based Prevention Programs—The first school-based 

prevention programs were primarily informational and 

often used scare tactics; it was assumed that if youth 

understood the dangers of alcohol use, they would choose 

not to drink. These programs were ineffective. Today, better 

programs are available and often have a number of elements 

in common: They follow social influence models and include 

setting norms, addressing social pressures to drink, and 

teaching resistance skills. These programs also offer interactive and developmentally appropriate information, include 

peer-led components, and provide teacher training (66). 

Family-Based Prevention Programs—Parents’ ability to 

influence whether their children drink is well documented 

and is consistent across racial/ethnic groups (67,68). 

Setting clear rules against drinking, consistently enforcing those rules, and monitoring the child’s behavior all 

help to reduce the likelihood of underage drinking. The 

Iowa Strengthening Families Program (ISFP), delivered 

when students were in grade 6, is a program that has shown 

long-lasting preventive effects on alcohol use (69,70). 

Selected Programs Showing 

Promise 

Environmental interventions are among the recommendations included in the recent National Research Council 

(NRC) and Institute of Medicine (IOM) report on underage 

drinking (71). These interventions are intended to reduce 

Who Drinks? 

Rates of drinking and alcohol-related problems are 

highest among White and American Indian or Alaska 

Native youth, followed by Hispanic youth, African 

Americans, and Asians. 

Prevalence rates of drinking for boys and girls are 

similar in the younger age groups; among older 

adolescents, however, more boys than girls engage 

in frequent and heavy drinking, and boys show 

higher rates of drinking problems. 

commercial and social availability of alcohol and/or 

reduce driving while intoxicated. They use a variety of 

strategies, including server training and compliance checks 

in places that sell alcohol; deterring adults from purchasing 

alcohol for minors or providing alcohol to minors; restricting 

drinking in public places and preventing underage drinking parties; enforcing penalties for the use of false IDs, 

driving while intoxicated, and violating zero-tolerance laws; 

and raising public awareness of policies and sanctions. 

The following community trials show how environmental 

strategies can be useful in reducing underage drinking and 

related problems. 

The Massachusetts Saving Lives Program—This intervention was designed to reduce alcohol-impaired driving 

and related traffic deaths. Strategies included the use of 

drunk driving checkpoints, speeding and drunk driving 

awareness days, speed-watch telephone hotlines, high 

school peer-led education, and college prevention programs. 

The 5-year program decreased fatal crashes, particularly 

alcohol-related fatal crashes involving drivers ages 15–25, 

and reduced the proportion of 16- to 19-year-olds who 

reported driving after drinking, in comparison with the 

rest of Massachusetts. It also made teens more aware of 

penalties for drunk driving and for speeding (72). 

The Community Prevention Trial Program—This program was designed to reduce alcohol-involved injuries 

and death. One component sought to reduce alcohol 

sales to minors by enforcing underage sales laws; training 

sales clerks, owners, and managers to prevent sales of 

alcohol to minors; and using the media to raise community awareness of underage drinking. Sales to apparent 

minors (people of legal drinking age who appear younger 

than age 21) were significantly reduced in the intervention communities compared with control sites (73). 

Communities Mobilizing for Change on Alcohol—This 

intervention, designed to reduce the accessibility of alcoholic beverages to people under age 21, centered on policy 

changes among local institutions to make underage 

5

drinking less acceptable within the community. Alcohol 

sales to minors were reduced: 18- to 20-year-olds were 

less likely to try to purchase alcohol or provide it to 

younger teens, and the number of DUI arrests declined 

among 18- to 20-year-olds (74,75). 

Multicomponent Comprehensive Interventions—Perhaps 

the strongest approach for preventing underage drinking 

involves the coordinated effort of all the elements that 

influence a child’s life—including family, schools, and 

community. Ideally, intervention programs also should 

integrate treatment for youth who are alcohol dependent. 

Project Northland is an example of a comprehensive 

program that has been extensively evaluated. 

Project Northland was tested in 22 school districts in 

northeastern Minnesota. The intervention included (1) 

school curricula, (2) peer leadership, (3) parental involvement programs, and (4) communitywide task force 

activities to address larger community norms and alcohol 

availability. It targeted adolescents in grades 6 through 12. 

Intervention and comparison communities differed significantly in “tendency to use alcohol,” a composite measure that combined items about intentions to use alcohol 

and actual use as well as in the likelihood of drinking “five 

or more in a row.” Underage drinking was less prevalent 

in the intervention communities during phase 1; higher 

during the interim period (suggesting a “catch-up” effect 

while intervention activities were minimal); and again lower 

during phase 2, when intervention activities resumed (76). 

Project Northland has been designated a model program 

by the Substance Abuse and Mental Health Services 

Administration (SAMHSA), and its materials have been 

adapted for a general audience. It now is being replicated 

in ethnically diverse urban neighborhoods. 

Conclusion 

Today, alcohol is widely available and aggressively promoted 

throughout society. And alcohol use continues to be regarded, 

by many people, as a normal part of growing up. Yet underage drinking is dangerous, not only for the drinker but also 

for society, as evident by the number of alcohol-involved 

motor vehicle crashes, homicides, suicides, and other injuries. 

People who begin drinking early in life run the risk of 

developing serious alcohol problems, including alcoholism, later in life. They also are at greater risk for a 

variety of adverse consequences, including risky sexual 

activity and poor performance in school. 

Identifying adolescents at greatest risk can help stop problems before they develop. And innovative, comprehensive 

approaches to prevention, such as Project Northland, are 

showing success in reducing experimentation with alcohol 

as well as the problems that accompany alcohol use by 

young people. 

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11888042 

7

Resour ces 

Source material for this Alcohol Alert originally appeared in 

Alcohol Research & Health,Volume 28, Number 3, 2004/2005. 

For more information on underage drinking, see also: 

Make a Difference:Talk to Your Child About Alcohol—a research 

based booklet geared to parents and caregivers of young 

people ages 10 to 14. Covers a wide range of topics, from 

strategies for preventing underage drinking to recognizing 

the warning signs of a drinking problem. 

NIAAA’s Web site for middle schoolers, www.theCoolSpot.gov— 

offers an interactive tool designed especially for young teens. 

Provides information about alcohol in a fun, engaging way, 

including how to say “no” to drinking and compelling reasons 

not to drink. 

A Family History of Alcoholism:Are You at Risk?—contains basic information 

for anyone who is concerned about a family history of alcoholism. Lists 

organizations that can help relatives or friends of alcoholics. 

For these and other resources, visit NIAAA’s Web site, www.niaaa.nih.gov 

▲

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Full text of this publication is available on NIAAA’s World Wide Web site at http://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


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