The USA: alcohol and young people today

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The US Centers for Disease Control and Prevention recently termed excessive alcohol consumption the third leading preventable cause of death in the nation, responsible for 75 766 deaths and 2.3 million years of potential life lost in 2001. Of those deaths, 4554 were among people under 21, the legal purchasing age for alcohol in all 50 states [1]. Substantial progress in reducing youth alcohol use in the United States ground to a halt in the early 1990s. In 2004, researchers at the National Institute on Alcohol Abuse and Alcoholism (NIAAA), analyzing the findings of three different federal surveys of youth alcohol use, concluded that while alcohol consumption among young people has decreased from its high point during the 1970s, in the past decade trends have stabilized at a ‘disturbingly high’ level [2]. According to one of these surveys, the average age at which 12–17-year-olds begin drinking is 13, and approximately 7000 children under age 16 begin drinking every day, for a total of 2.6 million new drinkers aged under 16 each year (personal communication, re: estimate, J. Gfroerer, 14 September 2004). Monitoring the Future, the national survey of drug use among schoolchildren, reports that 18.6% of 8th-graders, 35.2% of 10th-graders and 48% of 12th-graders have drunk alcohol in the past 30 days, and 6.2%, 18.5% and 32.5% of each grade, respectively, have been drunk in that same time period [3].

A growing body of research has documented the risks of early initiation into alcohol use in the United States. Young people who begin drinking before age 14 are five times more likely to experience alcohol-related injury later in life [4], while those who start before age 15 are four times as likely to develop alcohol dependence as people who delay initiation until the legal drinking age of 21 [5]. Recent studies have found that heavy exposure of the adolescent brain to alcohol may also interfere with brain development, causing loss of memory and other skills [6–8]. Imaging studies have revealed a smaller hippocampus (part of the brain important for learning and memory) in brains of 17-year-old alcohol-dependent adolescents compared to non-dependent peers [9]. Findings in a recent editorial co-authored by NIAAA Director Dr Ting-Kai Li document that onset of alcohol dependence peaks at age 18, while the occurrence of new cases drops dramatically after age 25 [10]. Dr Li testified to the US Congress that these findings have ‘led us to revise our entire perspective on alcohol dependence . . . [and] suggest that youth, encompassing the time of maximum vulnerability, must necessarily be the critical window of opportunity’[11].

This research on the extent, impact and significance of youth alcohol use has appeared at the same time that a significant natural experiment is occurring. In 1996, distilled spirits manufacturers quietly changed their self-regulatory code to permit them to advertise on US television. Shortly thereafter, companies began to develop and market a new class of beverages, variously dubbed ‘malternatives’, ‘flavored malt beverages’, ‘alcopops’ or ‘low-alcohol refreshers’. According to industry commentators, alcopops, many of which have sweet, fruity tastes, were designed for ‘entry-level drinkers’[12]. Although marketed as malt beverages some of these beverages carried distilled spirits brand names, enabling distillers to place their brands in a wider array of outlets, market them on television (even on the broadcast networks which maintain a ban on distilled spirits advertising) and make them more price-competitive by eluding the higher tax rates placed on distilled spirits. (These marketing advantages turn out to have been ill-gotten: subsequent tests by the federal Alcohol and Tobacco Tax and Trade Bureau determined that most alcopops are in fact distilled spirits under federal law, as despite the producers’ claims to the contrary, the bulk of alcohol in them was derived from distilled spirits [13]. The Bureau recently required that from 3 January 2006, the majority of alcohol in malt-based alcopops be derived from malt, but no sanctions have been levied on the producing companies for their history of misrepresentation [14]).

Alcohol companies backed alcopops with significant advertising support, spending $68 million in 2001, $169 million in 2002 and $79 million in 2003 on this category on television alone [15]. At the same time distillers increased spending on their distilled spirits brands on television, with most of their dollars buying advertising on cable outlets, which are more tightly segmented by age and thus deliver higher levels of youth exposure. From 513 cable advertisements at a cost of $1.3 million in 2001 to 33 126 advertisements at a cost of $35 million in 2003, distilled spirits advertising on cable television programs exploded over this period [15–17]. As a result, the number of television advertisements for alcohol ballooned from 208 909 in 2001 to 298 054 in 2003, while exposure of youth (measured in the advertising industry-standard metric of gross rating points) increased by 17%, with cable's share of youth exposure growing from 47% to 58% of total youth exposure. At the same time, the more expensive broadcast network advertising's share fell from 40% to 30%[15]. Cable's share of youth overexposure (defined as advertising shown when the percentage of youth in the viewing audiences exceeds the percentage of young people age 12–20 in the general population of people two and above) also grew from 64% to 76%.

Federal surveys only began measuring youth consumption of alcopops in 2003, a year after the category had peaked. In 2004, Monitoring the Future found that 30.4% of 8th-graders, 49.7% of 10th-graders and 55.8% of high school seniors had tried alcopops [3]. Federal surveys also fail to ask youth what brands of alcohol they prefer, so it is very difficult to link brand marketing strategies to youth consumption. Alcohol industry spokespeople continue to claim that alcohol advertising has no effect on youth alcohol consumption [18]. To address this question, in 1998 NIAAA funded four research groups to conduct longitudinal studies of the impact of exposure to alcohol advertising on youth. These groups are beginning to report their results, and mid-course reports at the Research Society on Alcoholism have suggested that they are finding effects [19]. Further insight comes from brain imaging work showing that teens with alcohol use disorders show greater activity in areas of the brain previously linked to reward, desire, positive affect and episodic recall in response to alcoholic beverage advertisements, and that the degree of brain response was highest in youths who consumed more drinks per month and reported greater desires to drink [20].

In sum, recent research findings in the United States suggest that adolescence is the critical point of intervention for the prevention of alcohol dependence, alcohol-related injury and other alcohol-related problems. Youth drinking has stabilized during the last decade at unacceptably high levels, despite substantial efforts to improve enforcement of minimum-age drinking laws. Two natural experiments are under way in which young people are being exposed to unprecedented amounts of alcohol advertising, on one hand for a new category of products that, with their sweet taste, low prices, wide availability and televised advertising easily appeal to new drinkers, and on the other hand for traditional distilled spirits products. At the same time, public health research evidence that alcohol advertising affects youth consumption is increasing. Yet federal surveys have largely missed the boat in terms of tracking youth consumption of alcopops, and shed no light on possible shifts in youth brand preferences because they do not ask what brands of alcohol youth prefer. Federal spending on alcohol continues to be dwarfed by hundreds of millions of dollars spent to educate the public about the dangers of ‘drugs’, meaning substances whose use is banned among the entire population (as opposed to alcohol, which is illicit only for youth).

Two of the federal surveys have found the prevalence of alcohol use and bingeing among girls rising more quickly than boys, and there is also evidence that girls’ exposure to alcohol advertising compared to women's is growing much more quickly than boys’ exposure compared to men's [21]. A new memoir chronicles the drinking career of a young American woman, in detail reminiscent of the 1980s cocaine memoirs. She begins drinking at 14, has her first blackout at 16, and experiences college through an alcoholic haze. At 23, she decides to quit but finds little in terms of treatment resources for people her age. Her words express the frustrations of her generation:

I am enraged by the alcohol industry, which alternates between pandering to women and using us to bait men. I’m sick of ad campaigns by Svedka vodka, which picture women kneeling to support trays of men's martinis, or holding glasses of vodka between their breasts. I’m sick of Wet gin by Beefeater . . . , the print ads of which say, ‘Your head is telling you to stay dry but your heart is shouting, Wet! Wet! Wet!’ as though alcohol were a necessary lubricant, the very ingredient that makes desire possible for women . . . I’m pissed at the government that would, through its allocation of dollars, have us believe that drug abuse is either a bigger issue or a more worthy one than underage drinking, neither of which is the case. And I’m sick of the ignorance that that lack of funding has generated, of the fathers who approach me at dinner parties with the 4-year-old girls clasped to their pant legs and say, ‘Yeah, but studies say kids can buy drugs more easily than they can buy alcohol.’ To which I always respond, ‘I guess that means you keep heroin in your liquor cabinet?’[22].

Legislation introduced in the US Congress would take the first steps toward a coordinated national response to underage drinking. Following-up on a recent report from the National Academy of Sciences [23], the legislation mandates an annual report on underage drinking, improved monitoring of youth drinking and brand preferences as well as youth exposure to advertising, and a pilot media campaign addressed to adults.

Given the slow pace both of research and of policy change, one wonders if we have already failed this generation. The challenge we face in the United States is how to bring our research agendas, epidemiological surveillance and prevention and treatment activities into line with the newly dawning awareness that our window of opportunity for preventing and reducing alcohol problems has narrowed considerably.

Ancillary