National Institute on Alcohol Abuse and Alcoholism No. 59 April 2003 

Underage Drinking: A Major Public Health Challenge 

By the time they reach the eighth grade, nearly 50 percent of adolescents have had 

at least one drink, and over 20 percent report having been “drunk” (1). Approximately 20 percent 

of 8th graders and almost 50 percent of 12th graders have consumed alcohol within the past 

30 days (1). Among 12th graders, almost 30 percent report drinking on 3 or more occasions per 

month (2). Approximately 30 percent of 12th graders engage in heavy episodic drinking, now 

popularly termed “binge” drinking—that is, having at least five or more drinks on one occasion within the past 2 weeks—and it is estimated that 20 percent do so on more than one occasion (2). 

Apart from being illegal, underage drinking poses a high risk to both the individual and 

society (3). For example, the rate of alcohol-related traffic crashes is greater for drivers ages 

16 to 20 than for drivers age 21 and older (4). Adolescents also are vulnerable to alcoholinduced brain damage, which could contribute to poor performance at school or work. In addition, 

youthful drinking is associated with an increased likelihood of developing alcohol abuse or 

dependence later in life. Early intervention is essential to prevent the development of serious 

alcohol problems among youth between the ages of 12 and 20. This Alcohol Alert describes 

some of the most harmful consequences of underage drinking as well as prevention and treatment approaches that can be applied successfully to meet the unique needs of this age group. 

Injury and Social Consequences 

Underage alcohol use is more likely to kill young people than all illegal drugs combined (5,6). 

Some of the most serious and widespread alcohol-related problems among adolescents are 

discussed below. For a more detailed discussion of alcohol problems in the college-age 

population, see Alcohol Alert No. 58 (7). 

Drinking and Driving. Motor vehicle crashes are the leading cause of death among youth 

ages 15 to 20 (8). Adolescents already are at increased risk through their relative lack of 

driving experience (9), and drivers younger than 21 are more susceptible than older drivers to 

the alcohol-induced impairment of driving skills (4,9). The rate of fatal crashes among alcoholinvolved drivers between 16 and 20 years old is more than twice the rate for alcohol-involved 

drivers 21 and older (10). 

Suicide. Alcohol use interacts with conditions such as depression and stress to contribute 

to suicide, the third leading cause of death among people between the ages of 

14 and 25 (11,12). In one study, 37 percent of eighth grade females who drank heavily reported 

attempting suicide, compared with 11 percent who did not drink (13). 

Sexual Assault. Sexual assault, including rape, occurs most commonly among women in 

late adolescence and early adulthood, usually within the context of a date (14). In one survey, 

approximately 10 percent of female high school students reported having been raped (5). 

Research suggests that alcohol use by the offender, the victim, or both, increases the likelihood 

of sexual assault by a male acquaintance (15). 

High-Risk Sex. Research has associated adolescent alcohol use with high-risk sex (for 

example, having multiple sexual partners and failing to use condoms). The consequences of 

high-risk sex also are common in this age group, particularly unwanted pregnancy and sexually 

transmitted diseases, including HIV/AIDS (5). According to a recent study, the link between 

high-risk sex and drinking is affected by the quantity of alcohol consumed. The probability of 

sexual intercourse is increased by drinking amounts of alcohol sufficient to impair judgment, 

Alcohol Alert, a publication of 

the National Institute on Alcohol 

Abuse and Alcoholism, provides 

timely information on alcohol 

research and treatment to 

health professionals and other 

interested people. This issue is 

the fifty-ninth in the series. 

Underage alcohol use 

is more likely to kill 

young people than all 

illegal drugs combined. 

A Commentary by NIAAA Director Ting-Kai Li, M.D................................................................3 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service • National Institutes of Health 
but decreased by drinking heavier amounts that result in feelings of nausea, passing out, or 

mental confusion (16). 

Alcohol’s Effects on the Brain 

Adolescence is the transition between childhood and adulthood. During this time, significant 

changes occur in the body, including rapid hormonal alterations and the formation of new networks in the brain (17). Adolescence is also a time of trying new experiences and activities 

that emphasize socializing with peers, and conforming to peer-group standards (18,19). 

These new activities may place young people at particular risk for initiating and continuing 

alcohol consumption. Exposing the brain to alcohol during this period may interrupt key 

processes of brain development, possibly leading to mild cognitive impairment as well as to 

further escalation of drinking. (For a review, see Reference 17.) 

Subtle alcohol-induced adolescent learning impairments could affect academic and 

occupational achievement (17). In one study, Brown and colleagues (20) evaluated shortterm memory skills in alcohol-dependent and nondependent adolescents ages 15 to 16. The 

alcohol-dependent youth had greater difficulty remembering words and simple geometric 

designs after a 10-minute interval. In this and similar studies (21,22), memory problems were 

most common among adolescents in treatment who had experienced alcohol withdrawal 

symptoms (20). The emergence of withdrawal symptoms generally indicates an established 

pattern of heavy drinking. Their appearance at a young age underscores the need for early 

intervention to prevent and treat underage drinking. 

Although the prevalence of high-risk drinking declines after early adulthood (23), alcoholinduced brain damage may persist. Memory impairment has been found in adult rats 

exposed to alcohol during adolescence (17). In addition, sophisticated imaging techniques 

revealed structural differences in the brains of 17-year-old adolescents who displayed alcoholinduced intellectual and behavioral impairment. Specifically, the hippocampus—a part of the 

brain important for learning and memory—was smaller in alcohol-dependent study participants 

than it was in nondependent participants (24). Adolescents who began drinking at an earlier 

age had proportionately smaller hippocampal volumes compared with those who began later 

(24), suggesting that the differences in size were alcohol induced. 

The Link Between Early Alcohol Use and Alcohol Dependence 

Early alcohol use may have long-lasting consequences. People who begin drinking before 

age 15 are four times more likely to develop alcohol dependence at some time in their lives 

compared with those who have their first drink at age 20 or older (25). It is not clear whether 

starting to drink at an early age actually causes alcoholism or whether it simply indicates an 

existing vulnerability to alcohol use disorders (26). For example, both early drinking and 

alcoholism have been linked to personality characteristics such as strong tendencies to act 

impulsively and to seek out new experiences and sensations (27). Some evidence indicates 

that genetic factors may contribute to the relationship between early drinking and subsequent 

alcoholism (28,29). Environmental factors may also be involved, especially in alcoholic 

families, where children may start drinking earlier because of easier access to alcohol in the 

home, family acceptance of drinking, and lack of parental monitoring (27,26). 

Prevention and Treatment 

The immediate and long-term risks associated with adolescent alcohol use underscore the 

need for effective prevention and treatment programs. Research on the personal, social, and 

environmental factors that contribute to the initiation and escalation of drinking is essential for 

the development of such programs. It should be noted that preventing and identifying alcohol 

use disorders in youth require different screening, assessment, and treatment approaches 

than those used for adults (30,31). For example, although relapse rates following alcoholism 

treatment are similar for both adults and adolescents, social factors such as peer pressure 

play a much larger role in relapse among adolescents (31). 

Personal factors such as childhood behavior problems (32) or a family history of alcohol use 

disorders (33) can help to identify high-risk youth and may suggest direction for interventions. 

Evidence suggests that the most reliable predictor of a youth’s drinking behavior is the drinking 

behavior of his or her friends (32,34). Many research-based interventions target the child’s 

relevant behavioral skills, such as his or her ability to react appropriately to peer pressure to 

drink, as well as his or her knowledge, attitudes, and intentions regarding alcohol use (35). 

Positive beliefs about alcohol’s effects and the social acceptability of drinking encourage the 

Subtle alcohol-induced 

adolescent learning 

impairments could 

affect academic 

and occupational 

achievement. 

People who begin 

drinking before age 15 

are four times more 

likely to develop alcohol 

dependence at some 

time in their lives 

compared with those 

who have their first 

drink at age 20 or older. 

Social factors such 

as peer pressure play 

a much larger role in 

relapse among 

adolescents. 

2

adolescent to begin and continue drinking. However, youth often overestimate how much 

their peers drink and how positive their peers’ attitudes are toward drinking. Consequently, 

most prevention programs include social norms education, which uses survey data to counter 

students’ misperceptions of their peers’ drinking practices and attitudes about alcohol (36,35). 

Family factors, such as parent-child relationships, discipline methods, communication, 

monitoring and supervision, and parental involvement, also exert a significant influence on 

youthful alcohol use (37,38). Accordingly, family-based prevention programs for youth have 

been developed—for example, Iowa’s Strengthening Families Program, which significantly 

delayed initiation of alcohol use by improving parenting skills and family bonding (37). The 

beneficial effects of this program on student alcohol involvement were still evident 

4 years after the intervention (39). 

Some school-based programs are aimed at adolescents who have already begun drinking. 

Preliminary research also has found promise in high school-based motivational programs that 

encourage self-change in problem drinkers (30). 

Policy and Community Strategies 

Another important factor in underage drinking is availability, that is, the degree of effort 

required to obtain alcohol, as determined by geographic, economic, and social factors 

(40,35). Consequently, interventions aimed at the individual must be supplemented by policy 

changes to help reduce youth access to alcohol and decrease the harmful consequences of 

established drinking (35). For example, raising the minimum legal drinking age in all States to 

21 saved an estimated 20,000 lives between 1975 and 2000 (8). In addition, all States now 

have zero-tolerance laws, which set the legal blood alcohol limit for drivers younger than age 

21 at 0.00 or 0.02 percent (41). This policy has been associated with a 20-percent decline in the 

proportion of single-vehicle, nighttime fatal crashes among drivers younger than age 21 (42,43). 

The drinking and driving laws described above were implemented in the absence of an 

accompanying increase in existing law enforcement levels. The effectiveness of such 

measures is enhanced by integrating them into community-based strategies that involve the 

cooperation of local government agencies, the law enforcement community, business leaders, 

and grassroots organizations (35). Communities Mobilizing for Change on Alcohol (CMCA) is 

an example of a community-wide program that focused on policy changes to reduce youth 

access to commercial and social sources of alcohol (44,35). Communities that adopted the 

program experienced significantly fewer arrests for drinking and driving among youth ages 18 

to 20 than did neighboring communities (45). 

Comprehensive Interventions. Project Northland is an example of a successful comprehensive intervention that incorporated family, school, and community components to prevent 

or reduce alcohol use among adolescents. To determine the program’s effectiveness, 

researchers began testing the students in grade six; and, after 3 years, the prevalence of 

alcohol use by eighth graders was lower in intervention communities than in comparison 

sites, and especially among students who had not yet started drinking when the program 

began (46). During the next 2 years, interventions were only minimal, and the differences in 

the measures of alcohol use between the two groups of students disappeared. However, 

resumption of Project Northland activities in grades 11 and 12 had a significant positive effect 

on the students’ tendency to avoid alcohol use and binge drinking. Taken together, these 

results show the effectiveness of continued, age-appropriate prevention activities for delaying 

or reducing underage drinking (47). 

Underage Drinking—A Commentary by NIAAA Director Ting-Kai Li, M.D. 

The immediate and long-term risks associated with adolescent alcohol use underscore the 

need for effective prevention and treatment programs. Research toward those ends is a top 

priority at NIAAA. Studies have revealed genetic, biologic, developmental, and environmental 

influences on underage drinking. 

Scientists have found that variability is a crucial aspect of alcohol problems across all age 

groups and thus is a key consideration in alcohol research. For example, there is a three- to 

fourfold between-individual variation in the rate of absorption, distribution, and elimination of 

alcohol (pharmacokinetics) and a two- to threefold between-individual variation in the sensitivity of the brain to the effects of a given concentration of alcohol (pharmacodynamics). 

Understanding the underlying causes of this variability, both genetic and nongenetic, should 

provide insights into underage drinking and binge-drinking patterns. 

Youth often overestimate 

how much their peers 

drink. 

Raising the minimum 

legal drinking age in all 

States to 21 saved an 

estimated 20,000 lives 

between 1975 and 2000. 

3

Through prevention and intervention strategies directed at the individual, family, school, and community, we aim to provide 

knowledge and change belief systems and social norms to reinforce the message that underage alcohol use is unacceptable. We 

also aim to enhance young peoples’ self-esteem, self-motivation and identity formation to enable them to take responsibility for 

their own health by making informed, deliberate, and healthy choices regarding alcohol use. 

Various intervention tools have brought about positive behavioral change with regard to underage drinking. Further studies will 

follow cohorts of young people from childhood through the college years, at different locations and in different settings, to determine 

whether these interventions are enduring and broadly applicable. Finding lasting solutions to such an entrenched problem will not 

be easy, but we are confident that diligent research efforts will meet this urgent challenge. 

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