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Office of the Surgeon General (US); National Institute on Alcohol Abuse and Alcoholism (US); Substance Abuse and Mental Health Services Administration (US). The Surgeon General's Call to Action To Prevent and Reduce Underage Drinking. Rockville (MD): Office of the Surgeon General (US); 2007.

Cover of The Surgeon General's Call to Action To Prevent and Reduce Underage Drinking

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

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Section 4: Taking Action: A Vision for the Future

Underage alcohol use is a complex problem that has proved resistant to solution for decades. Established and emerging research, however, suggests a new evidence-based approach with considerable promise. It is that approach—and the possibilities it holds for the Nation's youth—that inspires the vision of The Surgeon General's Call to Action To Prevent and Reduce Underage Drinking.

PRINCIPLES

The Call to Action is based on several overarching principles from which its goals and the means for achieving them were derived. These principles are:

1.

Underage alcohol use is a phenomenon that is directly related to human development. Because of the nature of adolescence itself, alcohol poses a powerful attraction to adolescents, with unpredictable outcomes that can put any child at risk.

2.

Factors that protect adolescents from alcohol use as well as those that put them at risk change during the course of adolescence. Internal characteristics, developmental issues, and shifting factors in the adolescent's environment all play a role.

3.

Protecting adolescents from alcohol use requires a comprehensive, developmentally based approach that is initiated before puberty and continues throughout adolescence with support from families, schools, colleges, communities, the health care system, and government.

4.

The prevention and reduction of underage drinking is the collective responsibility of the Nation. Scaffolding the Nation's youth is the responsibility of all people in all of the social systems in which adolescents operate: family, schools, communities, health care systems, religious institutions, criminal and juvenile justice systems, all levels of government, and society as a whole. Each social system has a potential impact on the adolescent, and the active involvement of all systems is necessary to fully maximize existing resources to prevent underage drinking and its related problems. When all the social systems work together toward the common goal of preventing and reducing underage drinking, they create a powerful synergy that is critical to realize the vision.

5.

Underage alcohol use is not inevitable, and parents and society are not helpless to prevent it.

GOALS

The healthy development of America's youth is a national goal that is threatened by underage alcohol consumption and the adverse consequences it can bring. In sometimes subtle and sometimes dramatic ways, underage alcohol use can sidetrack the trajectory of a child's life—or end it. The freedom to fulfill one's potential and to develop without the impairment of alcohol's negative consequences is a significant part of the vision for the future described in this Call to Action. The fulfillment of that vision rests on the achievement of six goals that the Surgeon General has proposed for the Nation. Those goals are:

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.

TAKING ACTION

It is a basic assumption of the Call to Action that the goals represent a series of coordinated actions that are mutually supportive and mutually necessary. These goals are not standalone objectives but highly integrated components of an overall approach to prevent and reduce underage drinking in America.

This section of the Call to Action describes the rationale that supports each of the six goals. It identifies challenges associated with realizing those goals and suggests specific strategies for achieving them. These strategies emanate from the integration of a broad body of scientific knowledge. Some are derived directly from empirical studies, whereas others are extensions of the cumulative knowledge accrued in multiple fields.

Goal 1: Foster Changes in American Society That Facilitate Healthy Adolescent Development and That Help Prevent and Reduce Underage Drinking.

Rationale

Culture generally is thought to mean the set of attitudes, values, norms, customs, and beliefs that distinguishes one group of people from another group. Nations, communities, ethnic and religious groups, schools, and peer groups all have distinct cultures. The various cultures in which an adolescent lives have a significant influence on his or her decisions about alcohol use. The attitudes and values of an adolescent's community with regard to underage alcohol use and appropriate adult use form an important part of the social structure that protects youth from alcohol use—or puts them at risk—because they determine the extent to which the community itself and the adults within that community will encourage or discourage underage drinking.

Alcohol, in its many forms, is familiar to children and adolescents and often appears relatively benign, if not openly enticing. Yet it is not benign for underage drinkers. Reducing cultural forces that encourage or support underage alcohol consumption lessens both the attraction of alcohol and the likelihood that it will be consumed by youth.

A culture in which youth feel that underage drinking is accepted, acceptable, or even expected promotes underage drinking. Society as a whole needs to send the message that it strongly disapproves of underage alcohol use because of its potentially adverse consequences and that it will not condone or permit it. At the same time, it is necessary to work to increase those societal forces that facilitate and support an alcohol-free childhood and adolescence.

Challenges

Culture is complex, and changing it requires sustained efforts on the part of multiple segments of society. The culture around drinking in the United States is especially difficult to change because alcohol use is embedded in American society, is legal and acceptable for most adults, and is often regarded as a rite of passage for youth. Many young people believe that drinking is not only acceptable but expected of them and a way for them to feel more grownup. Finally, alcohol holds a powerful attraction for adolescents because of the nature of adolescence itself.

Strategies

For parents and other caregivers: Parents have a responsibility to help shape the culture in which their adolescents are raised, particularly the culture of their schools and community. Parental strategies include the following:

  • Partner with other parents in their child's network to ensure that parties and other social events do not allow underage alcohol consumption, much less facilitate its use or focus on it.
  • Collaborate with other parents in coalitions designed to ensure that the culture in the schools and community support and reward an adolescent's decision not to drink.
  • Serve as a positive role model for adolescents by not drinking excessively, by avoiding alcohol consumption in high-risk situations (e.g., when driving a motor vehicle, while boating, and while operating machinery), and by seeking professional help for alcohol-related problems.

For colleges and universities: Given the prevalence of underage drinking on college campuses, institutions of higher education should examine their policies and practices on alcohol use by their students and the extent to which they may directly or indirectly encourage, support, or facilitate underage alcohol use. Colleges and universities can change a campus culture that contributes to underage alcohol use. Some measures to consider are to:

  • Establish, review, and enforce rules against underage alcohol use with consequences that are developmentally appropriate and sufficient to ensure compliance. This practice helps to confirm the seriousness with which the institution views underage alcohol use by its students.
  • Eliminate alcohol sponsorship of athletic events and other campus social activities.
  • Restrict the sale of alcoholic beverages on campus or at campus facilities, such as football stadiums and concert halls.
  • Implement responsible beverage service policies at campus facilities, such as sports arenas, concert halls, and campus pubs.
  • Hold all student groups on campus, including fraternities, sororities, athletics teams, and student clubs and organizations, strictly accountable for underage alcohol use at their facilities and during functions that they sponsor.
  • Eliminate alcohol advertising in college publications.
  • Educate parents, instructors, and administrators about the consequences of underage drinking on college campuses, including secondhand effects that range from interference with studying to being the victim of an alcohol-related assault or date rape, and enlist their assistance in changing any culture that currently supports alcohol use by underage students.
  • Partner with community stakeholders to address underage drinking as a community problem as well as a college problem and to forge collaborative efforts that can achieve a solution.
  • Expand opportunities for students to make spontaneous social choices that do not include alcohol (e.g., by providing frequent alcohol-free late-night events, extending the hours of student centers and athletics facilities, and increasing public service opportunities).

For communities: Adolescents generally obtain alcohol from adults who sell it to them, purchase it on their behalf, or allow them to attend or give parties where it is served. Therefore, it is critical that adults refuse to provide alcohol to adolescents and that communities value, encourage, and reward an adolescent's commitment not to drink. A number of strategies can contribute to a culture that discourages adults from providing alcohol to minors and that supports an adolescent's decision not to drink. Communities can:

  • Invest in alcohol-free youth-friendly programs and environments.
  • Widely publicize all policies and laws that prohibit underage alcohol use.
  • Work with sponsors of community or ethnic holiday events to ensure that such events do not promote a culture in which underage drinking is acceptable.
  • Urge the alcohol industry to voluntarily reduce outdoor alcohol advertising.
  • Promote the idea that underage alcohol use is a local problem that local citizens can solve through concerted and dedicated action.
  • Establish organizations and coalitions committed to establishing a local culture that disapproves of underage alcohol use, that works diligently to prevent and reduce it, and that is dedicated to informing the public about the extent and consequences of underage drinking.
  • Work to ensure that members of the community are aware of the latest research on adolescent alcohol use and, in particular, the adverse consequences of alcohol use on underage drinkers and other members of the community who suffer from its secondhand effects. An informed public is an essential part of an overall plan to prevent and reduce underage drinking and to change the culture that supports it.
  • Change community norms to decrease the acceptability of underage drinking, in part, through public awareness campaigns.
  • Focus as much attention on underage drinking as on tobacco and illicit drugs, making it clear that underage alcohol use is a community problem. When the American people rejected the use of tobacco and illicit drugs as a culturally acceptable behavior, the use of those substances declined, and the culture of acceptance shifted to disapproval. The same change process is possible with underage drinking.

For the criminal and juvenile justice systems and law enforcement: 16 The justice system and law enforcement can:

  • Enforce uniformly and consistently all policies and laws against underage alcohol use and widely publicize these efforts.
  • Gain public support for enforcing underage drinking laws by working with other stakeholders to ensure that the public understands that underage drinking affects both the public health and safety.
  • Work with State, Tribal, and local coalitions to reduce underage drinking.

For the alcohol industry: The alcohol industry has a public responsibility relating to the marketing of its product, since its use is illegal for more than 80 million underage Americans. That responsibility can be fulfilled through products and advertising design and placement that meet these criteria:

  • The message adolescents receive through the billions of dollars spent on industry advertising and responsibility campaigns does not portray alcohol as an appropriate rite of passage from childhood to adulthood or as an essential element in achieving popularity, social success, or a fulfilling life.
  • The placement of alcohol advertising, promotions, and other means of marketing do not disproportionately expose youth to messages about alcohol.17
  • No alcohol product is designed or advertised to disproportionately appeal to youth or to influence youth by sending the message that its consumption is an appropriate way for minors to learn to drink or that any form of alcohol is acceptable for drinking by those under the age of 21.
  • The content and design of industry Web sites and Internet alcohol advertising do not especially attract or appeal to adolescents or others under the legal drinking age.

For the entertainment and media industries: Because of their reach and potential impact, the entertainment and media industries have a responsibility to the public in the way they choose to depict alcohol use, especially by those under the age of 21, in motion pictures, television programming, music, and video games. That responsibility can be fulfilled by creating and distributing entertainment that:

  • Does not glamorize underage alcohol use.
  • Does not present any form of underage drinking in a favorable light, especially when entertainment products are targeted toward underage audiences or likely to be viewed or heard by them.
  • Seeks to present a balanced portrayal of alcohol use, including its attendant risks.
  • Avoids gratuitous portrayals of alcohol use in motion pictures and television shows that target children as a major audience. This is important because children's expectations toward alcohol and its use are, in part, based on what they see on the screen (Dunn and Yniguez 1999; Kulick and Rosenberg 2001; Sargent et al. 2006).

For governments and policymakers: Governments and policymakers can:

  • Focus as much attention on underage drinking as on tobacco and illicit drugs, making it clear that underage alcohol use is an important public health problem.
  • Ensure that all communications are clearly written and culturally sensitive.

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.

Rationale

It is easy to assign to someone else responsibility for changing public attitudes toward underage drinking and for reducing its prevalence. However, the responsibility for preventing and reducing underage alcohol use belongs to everyone in America. It will take a national commitment with active participation by the citizenry as a whole to achieve the vision of the Call to Action and to accomplish the goals that support it. Cooperation, coordination, and collaboration among parents, schools, communities, private sector organizations, governmental entities, and young people themselves all will be required.

The developmental approach to understanding underage alcohol use makes it clear that adolescents require external support to resist the considerable temptation to use alcohol. Particularly in highly emotional situations or social settings where the pressure to drink is strong, adolescents may not be in a position to make decisions that reject alcohol use without some degree of protective support from their environment. For example, adolescents may be tempted to drink in order to fit in with their peers, gain status, or protect themselves from ridicule. The external support they need to resist drinking in such situations might come from family, other peers, a respected adult, community norms, and policies and laws promulgated by various levels of government that, in combination, provide protection from the negative influences in the adolescent's environment. In some cases, it may be a parental rule or a law that restricts an adolescent's choices and keeps him or her from drinking, as happens, for example, when laws setting the minimum legal drinking age at 21 reduce an underage adolescent's access to alcohol.

Challenges

For the most part, parents and other adults underestimate the number of adolescents who use alcohol, how early drinking begins, the amount of alcohol adolescents consume, the various risks to adolescents, and the extent and nature of the consequences to both drinkers and nondrinkers. In addition, parents and other adults often are unaware of effective prevention and reduction strategies, principles, and techniques that can be used to protect their teenagers from alcohol use and its consequences. Because greater knowledge will increase the sense of urgency among adults to act more decisively in this area and to utilize the most effective means possible to protect adolescents from underage drinking, all sectors must be engaged in reaching out to their respective audiences.

Strategies

Strategy 1: Provide positive scaffolding for children and adolescents to protect them from alcohol use.

For parents and other caregivers: Throughout a child's life, parental actions do make a difference. Parents can facilitate healthy development and help protect their children from the consequences of alcohol use by increasing protective factors and reducing risk factors related to alcohol use. A developmental approach to preventing and reducing underage drinking suggests such steps as these that parents can take to protect their children and adolescents:

  • Create a stable family environment and practice, as parents, being supportive, involved, and loving. Research indicates that children of such parents have better developmental outcomes and are less likely to use alcohol than children raised in less supportive homes. Parental support includes monitoring an adolescent's activities and supporting his or her independence while setting appropriate limits (Barnes et al. 2000; Bogenschneider et al. 1998; Davies and Windle 2001; DiClemente et al. 2001; Reifman et al. 1998; Steinberg et al. 1994).
  • Provide opportunities for the adolescent to be valued at home, for example, by contributing to the family's well-being (e.g., chores, part-time job, caring for a younger sibling).
  • Facilitate a willingness on the part of the adolescent to share information about his or her life. Research indicates that such adolescent sharing may be associated with better outcomes around alcohol use, and, therefore, the source of parental information about their children's activities is important (Stattin and Kerr 2000).
  • Recognize that regardless of how close the parent-child relationship may be, that relationship alone is not sufficient to prevent underage alcohol use. Parents must support construction of scaffolds in the other social systems that influence their adolescent's behavior: schools, community, institutions, government, and the culture as a whole. It is the combined strength afforded by the interactions of all the scaffolds in all the social systems that is most effective in preventing underage drinking.
  • Clearly and consistently communicate with their underage children so that the expectation that they are not to drink is understood.
  • Know the basic facts and statistics about underage alcohol use and its consequences. Armed with this knowledge, parents will feel more confident when they talk with their children about alcohol.
  • Reduce or eliminate adolescent access to alcohol and do not provide alcohol to adolescents. To do otherwise sends a mixed message at best, or a supportive message at worst, about underage alcohol use.
  • Ensure that all parties attended by their adolescents are properly supervised and alcohol free, including the parties their own children give.
  • Respond to known instances of alcohol use with appropriate disciplinary actions.
  • Recognize the link between adolescent alcohol use and suicide, other substance use, mental disorders, and risky sexual behaviors.
  • Seek professional intervention if they have concerns about their child's alcohol involvement.
  • Support enforcement and criminal or juvenile justice systems' efforts to uphold underage drinking laws.

Parental monitoring

Monitoring by parents and other caregivers is associated with better outcomes around adolescent alcohol use. As part of effective monitoring, parents and other caregivers should:

  • Be aware of their adolescent's whereabouts.
  • Know their adolescent's friends.
  • Be knowledgeable of their adolescent's activities.
  • Enforce the parental rules they've set.
  • Strengthen their adolescent's skills in refusing alcohol.

Factors that increase risk

Parents and other caregivers should be aware of specific factors that may increase the risk of their adolescent becoming involved with alcohol or experiencing an adverse alcohol-related consequence. These factors include:

  • A history of conduct problems.
  • Depression and other mental disorders.
  • A family history of alcohol dependence, which raises the risk of problematic alcohol involvement.
  • Significant transitions (such as acquisition of a driver's license, a parental divorce, graduation from middle school to high school, or the move from high school to college or the workforce), which may increase the adolescent's stress level and/or exposure to different peers and opportunities, making it more likely that he or she will use alcohol.
  • Interaction with peers involved in deviant activities.

An ongoing dialog

Parents and other caregivers should initiate and sustain with their adolescent an ongoing dialog about alcohol, as with other risky behaviors. In that dialog, parents should:

  • Encourage input from their adolescent and respect that input.
  • Enhance their adolescent's knowledge about drinking and its consequences.
  • Clarify parental expectations.
  • Set clear rules around not drinking.
  • Establish specific consequences for alcohol use.
  • Set clear limits, including never driving with any alcohol in their system or riding with a driver who has been drinking.
  • Discuss laws concerning underage drinking, such as minimum legal drinking age and zero tolerance.18

For schools: School has a significant impact on an adolescent's life. The climate and cohesiveness of a school can play an important role in the development of an adolescent's self-identity, because students who are involved with their schools have increased opportunities for building self-confidence, developing relationships with others, and achieving success in their areas of interest. Schools can:

  • Work to increase students' involvement in their school, a factor that has been found to predict less alcohol use (Catalano et al. 2004).
  • Produce an environment that allows students to explore their talents and follow their passions, be they academic, musical, sports, or social and community causes.
  • Provide positive outlets for adolescents' considerable energy and opportunities for validation and belonging.
  • Serve as the source of a mentor, a valued teacher, or another caring adult, which has been shown to increase positive outcomes in adolescents.
  • Implement evidence-based programs and practices to prevent underage drinking.
  • Provide information to parents on the consequences of underage alcohol use, school policies and practices on alcohol use, and local resources.
  • Recognize that significant social transitions, such as moving from elementary school to middle school, moving from middle school to high school, and obtaining a driver's license, are accompanied by increasing responsibility, added freedom, greater social pressure, and/or more demanding academic requirements. These factors may make it more likely that adolescents will use alcohol, in part because they increase adolescent stress levels. At such times of potentially increased risk, teachers and staff can be particularly alert and supportive, making a special effort to connect students at high risk or evidencing increased stress with an adult who can serve as a mentor and confidant.
  • Recognize that children who mature earlier or later than the majority of their peers may be at increased risk.
  • Provide and promote multiple venues where adolescents can get together with their friends.

For colleges and universities: Colleges should be safe places where students can thrive academically, grow personally, and mature socially without peer pressure to use alcohol. However, colleges can be settings where underage alcohol use is facilitated—inadvertently or otherwise—and even openly accepted as a rite of passage and actively encouraged by some students and organizations. In fact, some parents and administrators appear to accept a culture of drinking as an integral part of the college experience. Such attitudes need to change and can change through a recognition of the seriousness of the consequences of underage drinking in a university environment and a recognition of the university's responsibility to keep its campus safe for its students. Institutions of higher learning that accept this responsibility can build a developmentally appropriate protective scaffolding around their underage students by taking the following actions:

  • Foster a culture in which alcohol does not play a central role in college life or the college experience.
  • Recognize that the early part of freshman year is a time of increased risk for alcohol use.
  • Provide appealing, alcohol-free locations (e.g., coffeehouses and food courts) where students can gather with their friends to socialize or study.
  • Expand opportunities for students to make spontaneous social choices that do not include alcohol (e.g., by providing frequent alcohol-free late-night events, extending hours of student centers and athletics facilities, and increasing public service opportunities).
  • Offer alcohol-free dormitories19 that promote healthy lifestyles.
  • Provide easy access to information about alcohol's effects, the risks of using alcohol, and the school's alcohol policies.
  • Provide referral and facilitate access to brief motivational counseling and treatment for alcohol and mental health problems as appropriate.

For communities: Communities can:

  • Provide appealing, alcohol-free locations where adolescents can gather with their friends.
  • Provide youth with opportunities to express their interests, explore their talents, pursue their passions, achieve success, commit themselves to positive endeavors, and earn status among their peers without having to use alcohol.
  • Increase volunteer opportunities, including opportunities for younger adolescents, because they offer a way to experience self-fulfillment and achieve a sense of meaning and purpose.
  • Work to ensure access to education about alcohol use and its consequences, brief motivational counseling, and treatment for alcohol use disorders (AUDs).

For the criminal and juvenile justice systems and law enforcement: The justice system and law enforcement can:

  • Increase the knowledge of judges and others in the justice system about the nature and scope of underage drinking and make them more aware that youth experiencing stressful events such as divorce or abuse may be at increased risk for alcohol involvement.
  • Increase the knowledge of judges and others in the justice system about adolescent development and the nature and scope of consequences resulting from underage alcohol use.
  • Require appropriate therapeutic interventions for parents with substance use disorders who are before the courts, because their children are at heightened risk for underage drinking.
  • Improve identification of AUDs and work to ensure timely access to treatment.

Strategy 2: Decrease the risk of adolescent alcohol use and the associated negative consequences.

For parents and other caregivers:

  • The action steps in strategy 1 are applicable here.
  • Be aware that scare tactics are ineffective (Perry et al. 2003).

For schools: Schools can:

  • Discourage violation of alcohol rules by consistently enforcing them.
  • Provide students with the knowledge, skills, and motivation they need to resist peer and other pressures to drink (rather than using scare tactics, which have been shown to be ineffective).
  • Identify students who are using alcohol and refer them for appropriate interventions.
  • Ensure that school nurses are trained to recognize alcohol-related problems, to intervene appropriately when problems are found, and to be familiar with the referral network.
  • Work with the community to ensure that the necessary infrastructure is in place so that students who need services and treatment can be referred to the appropriate personnel or health care provider.

For colleges and universities: Colleges and universities have a responsibility to reduce risk factors associated with underage alcohol use and an obligation to students to protect them from adverse consequences of their own or others' alcohol use, such as accidents, assaults, and rapes. Some of the measures available to colleges are to:

  • Establish clear policies with specific penalties and consistent enforcement that prohibit alcohol use on campus by underage students.
  • Distribute the school's alcohol policy to all incoming and returning students and their parents. Display the alcohol policy prominently on the school Web site and post it in school venues such as dormitories and sports facilities.
  • Require all student groups, including fraternity and sorority members, athletes, and members of student organizations and clubs, to comply with campus and community policies related to alcohol use.
  • Restrict or eliminate alcohol sales at concerts and at athletic and other campus events.
  • Reinstate Friday classes to shorten the elongated weekend.
  • Ensure that the student health center provides screening, brief motivational interventions, and/or referral to treatment for students concerned about their drinking and/or at high risk for alcohol-related problems (e.g., those who binge drink or those with a mental disorder requiring treatment).
  • Work with the local community to coordinate efforts at preventing and reducing underage drinking on and around campus. Easy access to alcohol on a college campus can undermine community efforts to reduce alcohol use by junior high and high school students.
  • Work with the local community to control or reduce the number of bars and other alcohol outlets located near the campus and to eliminate or restrict high-volume, low-price drink specials and other promotions that encourage underage drinking. Easy, low-cost access to alcohol for underage youth off campus can undermine efforts on campus to reduce underage drinking.
  • Work with the local community to ensure that bars and other alcohol outlets located near the campus comply with server training regulations and enforce all policies and laws with respect to underage youth.
  • Work with the community to eliminate loud house parties and other disruptive events in which underage alcohol use is likely to be involved.

For communities: Communities can:

  • Make adequate, affordable services available to youth who are at high risk of developing alcohol-related problems (e.g., those who binge drink or those who have a mental disorder needing treatment).
  • Make adequate, affordable services available to youth identified as having AUDs.

For the criminal and juvenile justice systems and law enforcement: The justice system and law enforcement can:

  • Provide screening and appropriate interventions for youth who interface with the criminal justice system, including those who are incarcerated (e.g., in juvenile correctional facilities, detention centers, or jails). Although prisons often have such programs, jails usually do not; these programs provide a unique opportunity to intervene with high-risk youth.

For the health care system: The health care system is a powerful arena for screening, referrals, and interventions around underage drinking. The health care system can:

  • Identify adolescents who use alcohol (e.g., when providing clinical preventive services and in the emergency department) and intervene where appropriate, including with those youth who may not meet the diagnostic criteria for alcohol abuse or dependence and those at high risk. Interventions also should address coexisting mental health and substance use problems in an integrated manner.
  • Work in collaboration with parents, schools, and communities to develop and maintain a system for screening and referring adolescents with alcohol problems.
  • Provide expanded services that are developmentally appropriate for adolescents and create a functional referral network so adolescent patients can be directed to appropriate services (lack of a referral system often is cited as a reason not to screen for alcohol use).
  • Educate families, schools, and the community about the effectiveness of prevention efforts.
  • Inform the public of the adverse consequences of underage drinking.
  • Encourage partnerships between parents, schools, health care providers, faith-based groups, and other community organizations in prevention and reduction efforts aimed at underage drinking.
  • Promote research on underage drinking in the context of adolescent development.

Strategy 3: Raise the “cost” of underage alcohol use.

The “cost” of underage drinking refers not just to the price of alcohol but to the total sacrifice in time, effort, and resources required to obtain it as well as to penalties associated with its use. Research indicates that increasing the cost of drinking can positively affect adolescent decisions about alcohol use (Coate and Grossman 1988; Grossman et al. 1987, 1998; Kenkel 1993; Ruhm 1996; Sutton and Godfrey 1995). In addition to price, the cost of underage drinking can be affected by a variety of measures:

  • Enforcement of minimum drinking age laws and other measures that directly reduce alcohol availability. Enforcement should target underage drinkers, merchants who sell alcohol to youth, and people who provide alcohol to youth.
  • Appropriate parental penalties for adolescent alcohol use, such as loss of privileges (e.g., allowance, going out with friends, use of the car).
  • Holding adults accountable for underage drinking at house parties, even when those adults are not at home.
  • Enforcement of zero-tolerance laws that ban underage youth from driving with a blood alcohol content (BAC) above detectable levels.
  • Any measure that decreases the availability of alcohol to youth and so raises the cost of getting it.
  • Elimination of low-price, high-volume drink specials, especially in proximity to college campuses, military bases, and other locations with a high concentration of youth.

In raising the cost of underage drinking, care has to be taken to balance the conflicting goals of different parties, including adults for whom alcohol use is legal, and to avoid unintended consequences. For example, if the penalty for underage alcohol use at an institution of higher learning is too severe, it may be entered on a student's permanent record, potentially restricting future educational and employment opportunities. In addition, there may be reasons to invoke civil rather than criminal penalties for certain adult infractions, such as violating social host laws. Some strategies also will have an impact on adults, forcing a decision on what additional cost society is willing to bear in order to protect its youth from the adverse consequences of alcohol use.

For communities: Communities can:

  • Publicize existing laws against underage alcohol use as well as their enforcement.
  • Publicize existing laws that reduce alcohol availability to minors and underage access to alcohol, including age verification of Internet and other alcohol sales, as well as their enforcement.
  • Restrict adolescent access to alcohol as is appropriate for community norms and goals.

For the criminal and juvenile justice systems and law enforcement: The justice system and law enforcement can:

  • Enforce consistently and uniformly all existing laws against underage alcohol use.
  • Enforce consistently and uniformly existing laws that reduce alcohol availability to minors and underage access to alcohol, including age verification for Internet and other alcohol sales.

For governments and policymakers: Like schools and communities, governments at all levels—including local, Tribal, State, and Federal—can increase the cost of adolescent alcohol use and restrict adolescent access to alcohol by:

  • Coordinating efforts by the public and private sectors to increase public knowledge of the scope of the problem of underage drinking in the United States, the adverse consequences that accompany it, the public health and safety problem it creates, and effective measures for preventing and reducing it, with special emphasis on the Nation's collective responsibility to do so.
  • Supporting adequate enforcement of laws and regulations.

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 Ethnic, Cultural, and Gender Differences.

Rationale

Underage alcohol use is strongly influenced by human development and the unique characteristics of adolescence. To properly deal with its threat requires some understanding of the complex interplay of developmental, individual, and environmental forces creating the risk and protective factors that lead adolescents toward or away from alcohol use.

Challenges

Adolescence is a developmental period characterized by special vulnerabilities to alcohol use and by an especially wide range of individual differences in maturation. Just as a 12yearold and a 15yearold are very different, so there is considerable variability among 12yearolds themselves. As a result, strategies and scaffolds designed to protect adolescents from alcohol use must be tailored to the particular adolescent as well as to adolescents as a group, which means not only to the general attributes of adolescents but also to a particular adolescent's maturational stage, to his or her individual characteristics, and to the particulars of the environment in which the adolescent lives. Furthermore, the components of the scaffold should evolve as the adolescent matures.

Strategies

For parents and other caregivers:

  • Youth of different ages are developmentally different and require different strategies, approaches, and types of scaffolds that are developmentally appropriate. Risk and protective factors related to alcohol use shift throughout adolescence, and parents need to be alert to these shifts.
  • The protective scaffolding that parents provide to support the positive development of their children in relation to alcohol use should begin before puberty and continue throughout the span of adolescence into young adulthood.
  • Parents need to appreciate that the nature of adolescence makes alcohol especially appealing to youth and understand how, from a developmental perspective, to reduce that appeal and the demand it creates for alcohol.
  • Parents need to be aware of adolescents' particular vulnerability to alcohol's effects.
  • During periods of high stress, such as a parental divorce, and during times of significant social transitions, such as the move from elementary school to middle school and from middle school to high school, the risk for alcohol involvement may increase. Parents need to be especially watchful during these periods and, if necessary, temporarily increase the supportive scaffolding around their adolescents.

For schools:

  • Schools should be sensitive to the complex nature of the relationship between alcohol use and development and to the developmental needs of adolescents, both as a group and individually, when implementing programs related to alcohol use.
  • Sanctions for infractions of alcohol use policies should be developmentally appropriate and avoid unintended outcomes. For example, suspension from school may provide additional free time for drinking whereas required participation in student/parent education programs and community service does not.

For communities:

  • Communities need to work to address underage drinking in the context of overall adolescent development. This includes making a commitment to provide as many opportunities for positive experiences as possible for all youth but especially for those at high risk for alcohol use and other negative outcomes.
  • Recognize that status is especially important to adolescents and provide positive ways for adolescents of different genders, socioeconomic backgrounds, ethnicity, and race to achieve status.
  • Communities can encourage identification and early intervention for high-risk youth.

For the health care system: Health care practitioners can:

  • Be sensitive to adolescence as a time of risk for alcohol use as well as be aware of individual differences in development and other personal characteristics in the adolescent that may heighten that risk.
  • Discuss alcohol use with their young patients, taking into account the latest scientific information about the relationship of alcohol to human maturation.
  • Identify alcohol use in their adolescent patients.
  • Be familiar with and strengthen referral networks for adolescents.
  • Make education about alcohol use and its consequences and brief motivational intervention widely available.

For the criminal and juvenile justice systems and law enforcement:

  • Penalties for violations should be developmentally appropriate and avoid unintended outcomes. For example, community service can serve both as a penalty (loss of leisure time) as well as an opportunity for personal growth.

For governments and policymakers: Governments and policymakers can:

  • Understand, through a developmental perspective, why merely providing adolescents with information about alcohol is ineffective in preventing and reducing underage alcohol use.
  • Understand why restrictions on adolescent access to alcohol and on alcohol availability need to be in place to prevent and reduce underage alcohol use and its consequences.
  • Give careful consideration to providing special protection for populations at high risk.

Goal 4: Conduct Additional Research on Adolescent Alcohol Use and Its Relationship to Development.

Rationale

New, more effective, and enduring interventions are needed to prevent and reduce underage drinking as well as to treat youth with AUDs. Existing interventions should be refined on the basis of the latest scientific findings, including research on adolescent development. To understand more about underage alcohol use, including the risk and protective factors associated with it, additional knowledge about alcohol and its relationship to adolescence will be required. By studying the problem of underage alcohol use in the context of adolescence as a developmental phenomenon and as a function of individual characteristics and environmental factors, it will be possible to increase understanding of the problem and to improve the effectiveness of interventions.

Challenges

Underage alcohol use is a complex phenomenon driven by multiple interrelated, interacting causes. It is highly dependent on the individual adolescent and on the developmental stage of that adolescent as well as on the environment in which the adolescent lives. Additional research will be necessary to specify how the risk and protective factors around underage alcohol use unfold during adolescence and interact with biological and social development and how parents, schools, communities, and the Nation can more effectively protect their youth from alcohol use.

Strategies

  • Develop and implement new and more potent prevention and reduction approaches based on the latest scientific data, including advances in understanding the role of human maturation and development in adolescent alcohol use.
  • Conduct additional research to refine interventions and identify risk and protective factors on the basis of gender, ethnicity, and socioeconomic level, particularly in potentially high-risk cases such as early-maturing adolescents and children with a family history of alcohol dependence.
  • Conduct research to better understand the short- and, especially, the intermediate- and long-term consequences of underage alcohol use, particularly as it relates to brain development and function, organ maturation, and susceptibility to later AUDs.
  • Better understand how adult drinking behavior influences underage alcohol use.
  • Evaluate interventions, including media messages and educational programs, to determine those that are most effective.
  • Conduct studies and/or amend ongoing surveys to collect more detailed data on actual adolescent alcohol consumption (e.g., actual consumption as a category rather than “5+ drinks”), on preadolescent alcohol use, and on secondhand effects.
  • Conduct animal studies to develop data on alcohol's effect on maturation processes and on brain and organ development and function, because animal research makes it possible to perform certain studies that cannot be conducted in human adolescent research.
  • Conduct research to identify genetic influences on both alcohol use and the development of alcohol-related problems in adolescents.
  • Conduct research to refine the diagnostic criteria used for identifying alcohol problems in youth that require intervention.
  • Track policy changes at the State level (because underage drinking policies vary widely across States) and evaluate their impact on underage alcohol use and consequences.20

Goal 5: Work to Improve Public Health Surveillance on Underage Drinking and on Population-Based Risk Factors for This Behavior.

Rationale

State, Tribal, and local public health agencies; policymakers; and the general public need complete and timely information on patterns and trends in youth alcohol consumption in order to develop and evaluate prevention strategies.

Challenges

Despite the extent and impact of underage drinking, gaps remain in our knowledge of alcohol use by youth, which undermine our ability to effectively address this important public health problem.

Strategies

  • Collect more detailed data on the quantity and frequency of adolescent alcohol consumption.
  • Collect information on the secondhand effects of underage drinking.
  • Collect information on preadolescent alcohol use.
  • Routinely test all injury deaths in people under age 21 for alcohol involvement to better estimate the extent of alcohol-related consequences.
  • Conduct ongoing public health surveillance on the type(s) of alcohol and the quantity and frequency with which they are used by age.
  • Conduct ongoing, independent monitoring of alcohol marketing to youth to ensure compliance with advertising standards.
  • Build State and Federal public health capacity in alcohol epidemiology to ensure the timely analysis and dissemination of these and other data on underage drinking and to ensure that these data are used to support public health practice.
  • Support close collaboration between State and Federal public health and substance abuse agencies in the assessment of underage drinking and related harms and in the design and evaluation of population-based prevention strategies.
  • When appropriate, engage youth in the process of collecting data related to underage drinking.
  • When appropriate, conduct multimethod research using ethnographic methods in addition to epidemiological and experimental studies.

Goal 6: Work to Ensure That Policies at All Levels Are Consistent With the National Goal of Preventing and Reducing Underage Alcohol Consumption.

Rationale

Policymakers and administrators at all levels of government have a responsibility to develop and implement appropriate policies that facilitate safe adolescent development, protect against underage alcohol use and its consequences, and avoid creating unacceptable risk around alcohol use.

Challenges

The goal of policies and laws directed toward underage alcohol use is to reduce underage demand for alcohol, prevent underage access to alcohol, and ensure that adolescents who need some form of intervention concerning their alcohol use receive it. Among the challenges in this area is ensuring that penalties for underage alcohol use are appropriate (i.e., neither too lenient to be effective nor too harsh to prevent enforcement), well publicized, and uniformly enforced. A further complication is the need to balance the interests of competing parties and to weigh the impact of such laws on nonadolescent members of society, such as adults and young adults over 21.

Strategies

For parents and other caregivers: The influence of parents alone is not sufficient to prevent adolescents from using alcohol. Adolescents need additional scaffolding from their schools and communities in the form of policies designed to protect them from alcohol use and its consequences. Parents can:

  • Work with the schools to ensure that protective rules around adolescent alcohol use are in place, that the penalties are well known, and that enforcement is sure and uniform.
  • Work with organizations and institutions in the community to develop a broad commitment to preventing and reducing underage drinking through appropriate policies, recognizing that adolescent alcohol use is not a parental problem alone but a community problem that requires a collaborative effort to solve.

For schools: Schools can play a significant role in preventing and reducing underage alcohol use. They can:

  • Establish and enforce strict policies against alcohol use on campus.
  • Sponsor only interventions that research has confirmed are effective in preventing and reducing underage alcohol use.

For colleges: Colleges can support the national goal of preventing and reducing underage drinking. They can:

  • Establish and enforce clear policies that prohibit alcohol use by underage students on their campuses.
  • Sponsor only interventions that research has confirmed are effective in preventing and reducing underage alcohol use.

For communities: By publicizing both penalties and enforcement of laws against providing alcohol to minors, driving under the influence (DUI), and drinking before age 21, communities emphasize their seriousness about preventing and reducing underage drinking. Communities have at their disposal a variety of additional measures to reduce underage drinking. These measures include:

  • Implementing an ongoing media campaign that makes people within the jurisdiction aware of existing policies and laws designed to restrict underage access to alcohol and the penalties for violating such laws.
  • Requiring compliance training as a condition of employment for all sellers and servers of alcohol in restaurants and bars.
  • Supporting enforcement of penalties for use of false IDs.
  • Restricting drinking in public places, including at community events.
  • Providing for restrictions on youthful drivers, which gradually are removed based on age and driving experience.
  • Detecting and stopping underage drinking parties.
  • Conducting regular and comprehensive programs to check restaurants, retail outlets, and other vendors of alcohol products for compliance with underage drinking laws (e.g., through keg registration programs) and applying substantial fines that increase with each violation and temporary or permanent license revocation for repeated violations.

For the criminal and juvenile justice systems and law enforcement: The justice system and law enforcement can:

  • Enforce consistently and uniformly all laws related to underage alcohol use, including those against the use of false IDs, those that restrict drinking in public places, and those related to vendors of alcohol products.
  • Enforce graduated driver's license laws for novice teenage drivers that include nighttime driving restrictions, requiring novice drivers to drive accompanied by an adult parent or guardian, and restricting the number of other teenage passengers.
  • Enforce zero-tolerance laws and laws addressing driving risks associated with driving after drinking among people under the age of 21 (e.g., speeding, running red lights, and failure to wear safety belts).
  • Seek to provide appropriate screening and interventions in all criminal justice settings that interface with adolescents.

For professional health care associations: To ensure that all who need it receive appropriate care, including screening, assessment, and treatment for heavy drinking and alcohol-related problems (including AUDs), professional health care associations can:

  • Support widespread dissemination and implementation of screening and brief motivational interventions, particularly in emergency departments and trauma centers.
  • Support provision of a full range of treatment services.

For governments and policymakers: Like communities, governments at all levels have a variety of means to prevent and reduce underage drinking. Governments can consider measures that:

  • Support use of cost-effective technologies, such as the Internet, to make education about alcohol use and its consequences and brief motivational interventions more accessible and affordable.
  • Encourage early intervention for high-risk children and access to a full range of treatment options for youth with alcohol problems.

Footnotes

16

For the purposes of this document, law enforcement includes any enforcement agency that provides agents or officers who can enforce or regulate any Federal, State, Tribal, or local law or ordinance.

17

The U.S. Federal Trade Commission currently is conducting a study of alcohol advertising and marketing, including the effectiveness of industry efforts to prevent undue exposure of youth to messages about alcohol.

18

Zero-tolerance laws prohibit a driver under the age of 21 with any detectable amount of alcohol in his or her system from operating a vehicle.

19

Offering this lifestyle option to students does not imply that underage alcohol use is either appropriate or acceptable in dormitories that are not designated as alcohol-free.

20

The Alcohol Policy Information System (APIS; http://www​.alcoholpolicy.niaaa.nih.gov) is an online resource that provides detailed information on a wide variety of alcohol-related policies in the United States at both State and Federal levels. It features compilations and analyses of alcohol-related statutes and regulations.

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