Chapter One
Executive Summary
Alcohol use by young people is dangerous, not only because of the risks associated with acute impairment, but also because of the threat to their long-term development and well-being. Traffic crashes are perhaps the most visible of these dangers, with alcohol being implicated in nearly one-third of youth traffic fatalities. Underage alcohol use is also associated with violence, suicide, educational failure, and other problem behaviors. All of these problems are magnified by early onset of teen drinking: the younger the drinker, the worse the problem. Moreover, frequent heavy drinking by young adolescents can lead to mild brain damage. The social cost of underage drinking has been estimated at $53 billion including $19 billion from traffic crashes and $29 billion from violent crime.
More youth drink than smoke tobacco or use other illegal drugs. Yet federal investments in preventing underage drinking pale in comparison with resources targeted (mostly to youths) at preventing illicit drug use. In fiscal 2000, $71.1 million was targeted at preventing underage alcohol use by the U.S. Departments of Health and Human Services (HHS), Justice, and Transportation. In contrast, the fiscal 2000 federal budget authority for drug abuse prevention (including prevention research) was 25 times higher, $1.8 billion; for tobacco prevention, funding for the Office of Smoking and Health, only one of several HHS agencies involved with smoking prevention, was approximately $100 million, with states spending a great deal more with resources from the states'' Medicaid reimbursement suits against the tobacco companies.
Although it is illegal to sell or give alcohol to youths under age 21, they do not have a hard time getting it, and they often get it from adults. More than 90 percent of twelfth graders report that alcohol is "very easy" or "fairly easy" to get. And when underage youths drink, they drink more heavily and recklessly than adults. They report that they "usually" drink an average of four and a half drinks, an amount very close to the threshold of five drinks typically used to define heavy drinking (also referred to as binge drinking). In contrast, adult drinkers report usually drinking fewer than three drinks.
In response to a congressional request in the HHS fiscal 2002 appropriations act, the Board on Children, Youth, and Families of the National Research Council and the Institute of Medicine formed the Committee on Developing a Strategy to Reduce and Prevent Underage Drinking. The committee was directed to review a broad range of federal, state, and nongovernmental programs, from environmental interventions to programs focusing directly on youth attitudes and behaviors, and to develop a cost-effective strategy to reduce and prevent underage drinking. In conducting this review, the committee relied on the available scientific literature, including a series of papers written for the committee, public input, and its expertise.
The committee conducted its work within the framework of the current national policy establishing 21 as the minimum legal drinking age in every state. We concentrated more on population-based primary prevention approaches rather than on individually oriented approaches.
STRATEGY OVERVIEW
The committee reached the fundamental conclusion that underage drinking cannot be successfully addressed by focusing on youth alone. Youth drink within the context of a society in which alcohol use is normative behavior and images about alcohol are pervasive. They usually obtain alcohol-either directly or indirectly-from adults. Efforts to reduce underage drinking, therefore, need to focus on adults and must engage the society at large.
The preeminent goal of the recommended strategy is to create and sustain a broad societal commitment to reduce underage drinking. Such a commitment will require participation by multiple individuals and organizations at the national, state, local, and community levels who are in a position to affect youth decisions-including parents and other adults, alcohol producers, wholesalers and retail outlets, restaurants and bars, entertainment media, schools, colleges and universities, the military, landlords, community organizations, and youths themselves. The nation must collectively pursue opportunities to reduce the availability of alcohol to underage drinkers, the occasions for underage drinking, and the demand for alcohol among young people.
THE STRATEGY
The committee''s proposed strategy for broad societal commitment to reduce underage drinking has ten main components.
National Adult-Oriented Media Campaign
Most adults express concern about youth drinking and support public policy actions to reduce youth access to alcohol. Nonetheless, youth obtain alcohol from adults. Parents tend to dramatically underestimate underage drinking generally and their own children''s drinking in particular. The first component in the strategy calls for the development of a media campaign, including rigorous formative research on effective messages, aimed at increasing specific actions by adults meant to reduce underage drinking and decreasing adult conduct that facilitates underage drinking.
Recommendation 6-1: The federal government should fund and actively support the development of a national media effort, as a major component of an adult-oriented campaign to reduce underage drinking.
Partnership to Prevent Underage Drinking
Despite laws that aim to preclude drinking by those under the age of 21, a significant amount of underage drinking occurs, generating revenues for producers, wholesalers, and retailers of alcoholic beverages, especially beer. The alcohol industry has declared its commitment to reducing underage drinking and has invested in programs with that aim. However, the outcomes of these efforts are not always apparent, and the motives are sometimes questioned. A partnership between the alcohol industry, government, and other private partners would facilitate a coordinated, evidence-based approach to reduce and prevent underage drinking.
Recommendation 7-1: All segments of the alcohol industry that profit from underage drinking, inadvertently or otherwise, should join with other private and public partners to establish and fund an independent nonprofit foundation with the sole mission of reducing and preventing underage drinking.
Alcohol Advertising
A substantial proportion of alcohol advertising reaches an underage audience and is presented in a style that is attractive to youths. For example, television alcohol advertisements routinely appear on programs for which the percentage of underage viewers is greater than the percentage of underage youths in the population. Although a clear causal link between advertising and youth consumption has not been established, youth exposure to advertising and marketing of products with particular appeal to youths should be reduced. Strengthened self-regulation would be in keeping with the industry''s stated commitment to avoid sale to minors and with recommendations by the Federal Trade Commission (FTC) in 1999 regarding industry advertising standards. Only one company has adopted the FTC''s 1999 recommendation that the industry create independent external review boards to address complaints regarding violations of advertising codes. In light of constitutional constraints on direct advertising restrictions, and to enable the industry to be responsive to public concerns about advertising, the most fruitful governmental response would be to facilitate public awareness of advertising practices.
Recommendation 7-2: Alcohol companies, advertising companies, and commercial media should refrain from marketing practices (including product design, advertising, and promotional techniques) that have substantial underage appeal and should take reasonable precautions in the time, place, and manner of placement and promotion to reduce youthful exposure to other alcohol advertising and marketing activity. Recommendation 7-3: The alcohol industry trade associations, as well as individual companies, should strengthen their advertising codes to preclude placement of commercial messages in venues where a significant proportion of the expected audience is underage, to prohibit the use of commercial messages that have substantial underage appeal, and to establish independent external review boards to investigate complaints and enforce the codes. Recommendation 7-4: Congress should appropriate the necessary funding for the U.S. Department of Health and Human Services to monitor underage exposure to alcohol advertising on a continuing basis and to report periodically to Congress and the public. The report should include information on the underage percentage of the exposed audience and estimated number of underage viewers of print and broadcasting alcohol advertising in national markets and, for television and radio broadcasting, in a selection of large local or regional markets.
Entertainment Media
Since artistic expression inevitably reflects the culture in which it is embedded, it is hardly surprising that alcohol use and alcohol products are frequently displayed or mentioned in prime-time television, movies, and music. Although the viewing or listening audiences for most of these media products are predominantly adult, some of them are disproportionately underage, and even the predominantly adult audiences inevitably include large numbers of young people. As in the case of commercial alcohol advertising, the entertainment media have a social responsibility to eschew displays or lyrics that portray underage drinking in a favorable light or that glamorize or promote alcohol consumption in products that are targeted toward or likely to be heard or viewed by large underage audiences. Labeling and notice requirements have been voluntarily adopted in analogous contexts. Although the industry restrictions should be undertaken on a voluntary basis, some independent oversight and public awareness of these standards is warranted.
Recommendation 8-1: The entertainment industries should use rating systems and marketing codes to reduce the likelihood that underage audiences will be exposed to movies, recordings, or television programs with unsuitable alcohol content, even if adults are expected to predominate in the viewing or listening audiences Recommendation 8-2: The film rating board of the Motion Picture Association of America should consider alcohol content in rating films, avoiding G or PG ratings for films with unsuitable alcohol content, and assigning mature ratings for films that portray underage drinking in a favorable light. Recommendation 8-3: The music recording industry should not market recordings that promote or glamorize alcohol use to young people; should include alcohol content in a comprehensive rating system, similar to those used by the television, film, and video game industries; and should establish an independent body to assign ratings and oversee the industry code. Recommendation 8-4: Television broadcasters and producers should take appropriate precautions to ensure that programs do not portray underage drinking in a favorable light, and that unsuitable alcohol content is included in the category of mature content for purposes of parental warnings. Recommendation 8-5: Congress should appropriate the necessary funds to enable the U.S. Department of Health and Human Services to conduct a periodic review of a representative sample of movies, television programs, and music recordings and videos that are offered at times or in venues likely to have a significant youth audience (e.g., 15 percent) to ascertain the nature and frequency of lyrics or images pertaining to alcohol. The results of these reviews should be reported to Congress and the public. Limiting Access
Limiting youth access to alcohol has been shown to be effective in reducing and preventing underage drinking and drinking-related problems. Since 21 became the nationwide legal drinking age, there have been significant decreases in drinking, fatal traffic crashes, alcohol-related crashes, and arrests for "driving under the influence" (DUI) among young people. Given the widespread availability of alcohol and easy access by underage drinkers, minimum drinking age laws must be enforced more effectively, along with social sanctions. The effectiveness of underage drinking laws could be enhanced through such approaches as compliance checks, server training, zero tolerance laws, and graduated driver licensing laws.
Recommendation 9-1: The minimum drinking age laws of each state should prohibit purchase or attempted purchase, possession, and consumption of alcoholic beverages by persons under 21; possession of and use of falsified or fraudulent identification to purchase or attempt to purchase alcoholic beverages; provision of any alcohol to minors by adults, except to their own children in their own residences; and underage drinking in private clubs and establishments. Recommendation 9-2: States should strengthen their compliance check programs in retail outlets, using media campaigns and license revocation to increase deterrence. Communities and states should undertake regular and comprehensive compliance check programs, including notification of retailers concerning the program and follow-up communication to them about the outcome (sale/no sale) for their outlet. Enforcement agencies should issue citations for violations of underage sales laws, with substantial fines and temporary suspension of license for first offenses and increasingly stronger penalties thereafter, leading to permanent revocation of license after three offenses. Communities and states should implement media campaigns in conjunction with compliance check programs detailing the program, its purpose, and outcomes. Recommendation 9-3: The federal government should require states to achieve designated rates of retailer compliance with youth access prohibitions as a condition of receiving relevant block grant funding, similar to the Synar Amendment''s requirements for youth tobacco sales. Recommendation 9-4: States should require all sellers and servers of alcohol to complete state-approved training as a condition of employment. Recommendation 9-5: States should enact or strengthen dram shop liability statutes to authorize negligence-based civil actions against commercial providers of alcohol for serving or selling alcohol to a minor who subsequently causes injury to others, while allowing a defense for sellers who have demonstrated compliance with responsible business practices. States should include in their dram shop statutes key portions of the Model Alcoholic Beverage Retail Licensee Liability Act of 1985, including the responsible business practices defense. Recommendation 9-6: States that allow Internet sales and home delivery of alcohol should regulate these activities to reduce the likelihood of sales to underage purchasers. States should require all packages for delivery containing alcohol to be clearly labeled as such; require persons who deliver alcohol to record the recipient''s age identification information from a valid government-issued document (such as a driver''s license or ID card); and require recipients of home delivery of alcohol to sign a statement verifying receipt of alcohol and attesting that he or she is of legal age to purchase alcohol.
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Excerpted from REDUCING UNDERAGE DRINKING Copyright © 2004 by National Academy of Sciences. Excerpted by permission.
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