International Perspectives on Adolescent and YoungAdult Drinking

<strong>International</strong> <strong>Perspectives</strong> on Adolescent and YoungAdult DrinkingSalme K. Ahlström, Ph.D., and Esa L. Österberg, M.Sc.Alcohol consumption by adolescents and young adults varies greatly in different countries andcultures, in different population groups within a country, and over time. Analyses of per capitaconsumption in different countries provide some information on drinking patterns of youngpeople in various countries. Schoolbased surveys conducted in a variety of European countriesand in the United States offer more specific insight into the drinking behavior of this age group.Such surveys have analyzed variables such as age of onset of drinking; lifetime frequency ofdrinking; drinking to intoxication; frequency, amount, and timing of current drinking; and drinkingconsequences. These studies have demonstrated that drinking patterns of young people in, forexample, Scandinavian, AngloSaxon, and Mediterranean countries vary greatly. Further analyseshave explored the influence of social norms and related factors as well as alcohol availability andpricing on alcohol consumption among adolescents and young adults. The generalizability of thefindings is limited, however, by the fact that most studies have been conducted in the UnitedStates and Europe. KEY WORDS: young adult; adolescents; AOD (alcohol and other drug) consumption;AOD use frequency; AOD intake per occasion; AOD use pattern; age of AODU (alcohol and other druguse) onset; heavy drinking; AOD abstinence; factors determining AOD demand; AOD effects andconsequences; international AODR (alcohol and other drug related) problems; international aspects; ethnicdifferences; cultural patterns of drinking; gender differences; minimum drinking age laws; preventionthrough decreasing availability and accessibility; World Health Organization (WHO); European SchoolSurvey Project on Alcohol and Other Drugs (ESPAD)Studies conducted in various countrieshave demonstrated that boththe frequency of drinking alcoholicbeverages and the amount of alcoholconsumed per person or per occasionvary greatly among different countriesand cultures, among different populationgroups within a given country, and foreach population over time. Similarly,the rates of alcoholrelated problemsvary greatly among different countriesand among different population groups.These differences are found not onlyfor adult drinkers but also for adolescentsand young adults.One useful measure that can easilybe determined in many countries is thetotal alcohol consumption of the population,which can be converted to averageper capita consumption. This variableis related to the prevalence of heavyalcohol use and also is an importantindicator of the prevalence of alcoholrelatedproblems (Bruun et al. 1975;Edwards et al. 1994). The relationshipbetween average per capita consumptionand the level of alcoholrelatedproblems in a population is influencedby the following factors:• The number of drinkers in the populationand their drinking habits(Babor et al. 2003). For example,if total alcohol consumption can beattributed to only 20 percent of thepopulation, who mostly drink on theweekends (and the remaining populationdoes not drink), the prevalenceof heavy drinking and of alcoholrelatedproblems will be differentthan if alcohol consumption canbe attributed to 90 percent of thepopulation who generally have onlyone drink per day.SALME K. AHLSTRÖM, PH.D., is aresearch professor, and ESA L. ÖSTERBERG, M.SC., is a senior researcher,both in the Alcohol and Drug ResearchGroup, National Research and DevelopmentCentre for Welfare and Health,Helsinki, Finland.258Alcohol Research & Health

<strong>International</strong> <strong>Perspectives</strong>• The drinking culture and attitudestoward drinking and alcoholrelatedproblems. “Harmful” drinking andalcoholrelated problems are in partculturally defined—that is, a behavior(e.g., drinking to intoxication) consideredproblematic in one culturemay not be thought of as problematicin another culture.• Overall historical, cultural, economic,and social circumstances that affectmany areas related to alcohol consumption.For instance, if drinkinghabits are similar in two countriesbut people in one of those countriesare significantly less likely to own acar, then the frequency of drunkdriving and the proportion of alcoholrelateddeaths among all traffic fatalitieswill differ greatly between thetwo countries.• Alcohol control measures and theirenforcement. For instance, increasesin the legal drinking age and effectiveenforcement of the new age limitwill lead to lower alcohol consumptionlevels and fewer alcoholrelatedproblems among young adults andadolescents.The relationships between alcoholconsumption and alcoholrelated problems,as well as the factors that influencethese relationships, apply to both adultand adolescent drinking. When tryingto compare adolescent or young adultalcohol consumption across countriesor cultures, however, researchers mustkeep in mind that the definitions of thesetwo developmental stages can varyaccording to the cultural and historicalbackground of the society under investigation.Broadly defined, adolescenceand young adulthood include the periodof transition from childhood to adulthood.It is the time when a personacquires the skills needed to cope withthe emotional, physical, social, andeconomic separation from parents.Ideally, it also is the time when a personpaves the way for establishing his or herown family, raising children, and participatingin social and work life as wellas leisure time activities as an independentindividual. Because these developmentsmay occur at different ages in differentcultures, it is difficult to define adolescenceand young adulthood in terms ofexact ages. For practical purposes, in mostWestern industrialized societies, adolescenceis defined as ages 14 through 18and young adulthood as ages 19 through25 (Ahlström 2000). In some studies,even 29yearolds have been consideredyoung adults (Rehm et al. 2001).After a brief review of alcohol consumptionpatterns in the entire population(which to a certain extent alsoreflect consumption patterns by youngerpeople), this article provides an internationalperspective on alcohol consumptionamong adolescents and youngadults and examines gender differences,abstinence rates, the amount and frequencyof drinking, as well as drinkingto intoxication. This discussion considersnot only the actual drinking patternsbut also the drinking contexts (i.e., thetime and place of drinking and thenature of the drinking occasion). It isimportant to keep in mind, however,that the information on drinking patternsusually comes from survey studies, whichcan differ greatly in how different aspectsof drinking patterns are defined andmeasured (Simpura and Karlsson 2001).Furthermore, most of the availableresearch data were obtained in thedeveloped countries, which may limitthe generalizability of these researchfindings to adolescent and young adultdrinking in other areas of the world.<strong>International</strong> Comparisonsof Adult AlcoholConsumption PatternsDrinking alcohol is a social behaviorin the sense that it is something youngpeople learn and practice with othermembers of their culture (Edwards etal. 1994). Drinking patterns amongadolescents and young adults in anycountry or culture consequently arerelated in many ways to the drinkingpatterns of the entire population (Room2004). Therefore, a global review ofper capita alcohol consumption andgeneral drinking patterns also gives afirst rough description of the differencesin the amounts and patterns of adolescentand young adult drinking in differentparts of the world. Adolescent andyoung adult drinking behaviors mayshow some systematic deviation fromadult drinking behaviors in a givenculture, however, because of differencesin living conditions between adolescents/young adults and the adult populationand because of the influences of internationalyouth culture and mass media.One source of information on alcoholconsumption and its consequences invarious areas of the world is the WorldHealth Organization (WHO). For surveyingpurposes (e.g., to estimate theglobal burden of disease), WHO hasdivided the world into 15 geographicalareas based on adult and infant mortality.WHO also has used these areasto estimate the levels of alcohol consumptionand proportions of drinkersaround the globe. 1 However, countrieswithin these 15 areas are not alwaysuniform with regard to alcohol consumptionand drinking habits. Forexample, Iceland and Norway, with atotal alcohol consumption of about 7liters per person age 15 and older,belong to the area “Europe A,” wherethe average alcohol consumption is 13liters (i.e., almost twice that in Icelandor Norway). Despite these kinds ofproblems, the WHO data help to broadlycharacterize the levels and trends inalcohol consumption and drinking patternsin different parts of the world.General Trends in Total AlcoholConsumptionRehm and colleagues (2003) conductedan international comparison of averagealcohol consumption in people age 15and older around the world using theWHO data. These analyses found thefollowing:• Average alcohol consumption washighest in Europe, the Americas,and established market economies suchas Australia, Japan, and New Zealand,although there were exceptions (e.g.,the Muslim countries of the former1 These data are derived primarily from populationweightedaverages of country estimates, but in manycases the figures include a substantial element of extrapolationand expert judgment (Babor et al. 2003).Vol. 28, No. 4, 2004/2005 259

Soviet Union and Yugoslavia andthe least developed countries inSouth and Central America).• Average alcohol consumption generallywas lower in Africa and Asia.• Alcohol consumption was particularlylow in the Muslim countries inthe eastern Mediterranean regionand on the Indian subcontinent.Other studies have examined changesin per capita or per adult alcohol consumptionsince the mid1970s (Baboret al. 2003) and have found that:• Alcohol consumption appears tohave declined in many countries withpreviously high alcohol consumption,particularly in the traditionalwineproducing and winedrinkingcountries of Europe (i.e., France,Italy, Portugal, and Spain) but alsoin the wineproducing countries ofSouth America.• In many other established marketeconomies, such as Canada and theUnited States, a smaller but still significantdecrease in total alcoholconsumption has occurred over thesame period.• In most countries of the Americas andAfrica and in the eastern Mediterraneancountries, alcohol consumption hasbeen constant or slightly decreasingduring recent decades.• Alcohol consumption appears tohave increased the most in Asiancountries.• Some developed countries (e.g.,Denmark, Finland, Ireland, andJapan) have countered the trendtoward decreasing alcohol consumption;in fact, consumption therehas increased.Proportions of DrinkersThe proportion of people who drinkany alcohol varies greatly among differentcountries. In general, the highestproportion of drinkers is found inEurope, Australia, and New Zealand,where 80 to 90 percent of all adultsare drinkers (Rehm et al. 2003). In theWestern Pacific, 80 to 90 percent ofall men are drinkers. In the Americas,about twothirds of adults are drinkers.For instance, the share of drinkers is 73percent in Canada and 65 percent inthe United States (Babor et al. 2003).In African countries, around half ofthe men and onethird of the womendrink alcohol. In the rest of the world,only a minority of adults are drinkers.In all countries, men are more likelyto drink alcohol than are women. Thedifferences between men and women inthe proportion of drinkers are particularlymarked in China and SoutheastAsia. Women are especially likely to beabstainers in the Indian subcontinentand Indonesia as well as in the MiddleEast (Rehm et al. 2003).Differences in Drinking PatternsMany studies (primarily based on surveydata) have analyzed drinking patternsaround the world. These studies consistentlyhave found significant differencesin drinking patterns between men andwomen, between younger and olderpeople, and often among ethnic or religiousgroups. For example, Ahlströmand colleagues (2001a) found that, onaverage, men drink significantly morethan women do. In many countries, menaccount for 70 to 80 percent or moreof the total alcohol consumption, andin some developing countries, men’sshare of overall alcohol consumption iseven greater. For instance, survey datafrom China indicate that men consumeabout 95 percent of all alcohol (Baboret al. 2003).Alcohol consumption also is unevenlydistributed among the drinking populationin any country—that is, in allsocieties, most of the alcohol is consumedby a relatively small proportionof drinkers. For example, in the UnitedStates, the top 20 percent of drinkersconsume almost 90 percent of all alcohol(Greenfield and Rogers 1999). And inChina, the top 12.5 percent of thedrinkers (corresponding to 7.5 percentof the population) have been estimatedto account for 60 percent of total alcoholconsumption (Wei et al. 1999).In general, the proportion of drinkerswho account for most of the alcoholconsumption probably is smaller incountries with low per capita alcoholconsumption—that is, in these countriesalcohol consumption is more concentrated(Edwards et al. 1994).Intoxication and HarmfulDrinkingCountries also vary in how often peopledrink to intoxication, how intoxicatedpeople get, and how people behavewhile intoxicated. Generally, men aremore likely than women to consumelarge quantities of alcoholic beveragesor drink to intoxication (Babor et al.2003). Also, the proportion of heavydrinkers and the frequency of heavydrinkingoccasions are higher amongmen than among women. Consequently,patterns of harmful drinking 2 are morecommon in men than in women. Someevidence suggests that this phenomenonmay be even more pronounced in developingcountries (Room et al. 2002).According to WHO’s data on theglobal burden of disease, people in theformer socialist countries of EasternEurope, in Middle and South America,and in parts of Africa exhibit the mostdetrimental drinking patterns. Forexample, in these countries, drinkingto intoxication is a characteristic mediatorbetween alcohol consumption andalcoholrelated morbidity, mortality,and social harms. Conversely, drinkingpatterns appear to be least detrimentalin Western Europe, as represented bythe patterns found in the wineproducingcountries of southern Europe, wherepeople primarily consume wine withmeals and do not drink to intoxication(Rehm et al. 2003).2 Harmful drinking refers to any drinking pattern wheredrinking causes immediate harm to the drinker or others,including physical harm (e.g., resulting from alcoholrelatedunintended injuries and car crashes), social harm (e.g.,arguments with family members or others), economicharm (e.g., lost property), or legal harm (e.g., convictionfor drunk driving).260Alcohol Research & Health

<strong>International</strong> <strong>Perspectives</strong>Drinking Patterns ofAdolescents and YoungAdultsThe drinking patterns of people in variousage groups are difficult to compareinternationally because population surveysconducted in different countriesoften use different age groupings andvarying measures of alcohol consumptionlevels. Furthermore, most surveysthat compare drinking in various agegroups have been conducted in theestablished market economies of Europeand North America, and their findingsdo not always apply to other regions ofthe world. Nevertheless, two commonfindings have emerged from these studies(Babor et al. 2003): (1) abstinenceis more prevalent in older age groupsthan among young adults, and (2)intoxication is more frequent amongyoung adults than older people.One survey that has provided basicinformation on adolescents’ alcoholconsumption in various European countriesis the European School SurveyProject on Alcohol and Other Drugs(ESPAD) (Hibell et al. 2004). Thismultinational study of drinking habitsand drug use among 15 to 16yearoldEuropean students was first conductedin 1995, and a second survey followedin 1999. For the most recent data collection,conducted in 2003, studentsfrom 35 European countries filled outanonymous selfadministered inschoolquestionnaires. Sample sizes, which weredesigned to be nationally representative,ranged from 555 in Greenland toalmost 6,000 in Poland. The findingsof this and other relevant surveys aresummarized in the following sections.Age at Onset of Drinking andPrevalence of AbstinenceBoth the longterm and shorttermhealth effects of alcohol consumptiondepend at least in part on the age whenthe person begins to consume alcohol.For example, results from a U.S. surveyindicate that compared with those whobegin drinking at a later age, respondentswho begin drinking in their teenageyears are more likely during late adolescenceand adulthood to experiencealcoholrelated unintentional injuries(e.g., motor vehicle crashes, falls, burns,and drownings) and to be involved infights after drinking (Hingson et al.2000). Furthermore, early onset of regularalcohol consumption is a significantpredictor of lifetime alcoholrelatedproblems, at least in some Westerncountries (Chou and Pickering 1992;Grant and Dawson 1997; Kraus et al.2000; Pulkkinen et al. 2003). However,it is not clear whether starting to drinkat an early age actually causes alcoholrelatedproblems and alcohol use disordersor whether it simply indicates anexisting vulnerability to alcohol usedisorders (Dawson 2000).In the United States, the average ageof firsttime use of alcohol is about 13years. In contrast, in a survey conductedin 23 European countries in the late1990s, more than half of 11yearoldsreported having tasted alcohol (Jernigan2001). Still, at the beginning of adolescence,the abstinence rate in all Europeancountries is high compared with theadult abstinence rate.In the ESPAD study, the highest abstinencerate among European youths, 36percent, was found in Iceland (table 1).In the other Nordic alcoholmonopolycountries Finland, Norway, and Sweden(i.e., former spiritconsuming countries 3 ),about 20 percent of the 15 to 16yearoldstudents had not consumed anyalcoholic beverages during the previous12 months. Also, in some of the southernEuropean winepreferring countries,many of which are characterizedas having the highest alcohol consumptionin Europe, abstinence rates amongyouth were high (e.g., 26 percent inPortugal, 25 percent in Spain, and20 percent in France) (see table 1).Conversely, the abstinence rate inGreece—also a winepreferring country—was only 9 percent. Equally low or evenlower abstinence rates also were foundin beerpreferring countries such asAustria, the Czech Republic, Denmark,Germany, and the United Kingdom(Hibell et al. 2004). All of these abstinencerates are substantially lower thanin the United States, where 41 percentof students reported not having consumedany alcoholic beverages duringthe last 12 months (Johnston et al. 2004).Between adolescence and the onsetof adulthood, abstinence rates decreasedin most countries, and were about thesame for people at age 25 as for middleagedadults. Moreover, in many countries,differences in abstinence ratesbetween males and females were smallerat age 15 than at age 25 (see Hibell etal. 2004; Rehm et al. 2001). In fact,among 15 to 16yearold students,females in many countries showed lowerabstinence rates than males (table 1).Lifetime Frequency of DrinkingThe frequency of alcohol consumptionamong adolescents is still relatively low.In almost all ESPAD countries and inthe United States, less than half of 15to 16yearold students were consideredfrequent drinkers—that is, theyhad consumed alcohol on 40 or moreoccasions during their lifetime (seetable 2) (Hibell et al. 2004). The onlycountry where 50 percent of adolescentsreported such a frequency of alcoholconsumption (i.e., were frequent drinkers)was Denmark. Otherwise, the countrieswith the highest proportion of frequentdrinkers were Austria, the Czech Republic,the Netherlands, Ireland, and theUnited Kingdom. The lowest proportionsof frequent drinkers were found inGreenland, Iceland, Norway, Portugal,and Turkey. In most countries, moreboys than girls reported a lifetimeprevalence of drinking at least 40 times.Drinking to IntoxicationIn many cultures, drinking to intoxicationis particularly characteristic of adolescentsand young adults, and youngmales are more likely to drink to intoxicationthan young females (Currie etal. 2004; Hibell et al. 2004; Kuntscheet al. 2004).According to the ESPAD study, it isnot uncommon for students to drink3 Although some decades ago there seemed to be relativelyclear distinctions among European countries with respect tothe beverages of preference—that is, northern Europeancountries were classified as spiritconsuming, AngloSaxonand Central European countries were considered beerconsuming,and southern European countries were consideredwineconsuming—drinking patterns in many countrieshave changed, and these distinctions have been blurring inrecent decades.Vol. 28, No. 4, 2004/2005 261

to intoxication, although the prevalenceof drunkenness varies considerablyacross the countries (see table 2). Thus,in the Nordic and Baltic countries aswell as in Austria, the Czech Republic,Ireland, and the United Kingdom,nearly 20 percent or more of studentsreported having been drunk at least 20times in their lives, compared withabout 5 percent or less of students inmost southern European countries andin Belgium and the Netherlands (Hibellet al. 2004). In other central Europeanand in eastern European countries as wellas in the United States, the proportionsof students who reported having beendrunk at least 20 times were intermediate.Frequency and Amount of DrinkingThe ESPAD study also compared thenumber of drinking occasions and theamounts consumed per occasion byadolescents in the different countries.These analyses found that in the wineproducingcountries (i.e., France, Greece,Italy, and Portugal), adolescents’ alcoholconsumption can be characterized asfairly frequent but modest (Ahlström etal. 2001b). In the Nordic countries (i.e.,Finland, Iceland, Norway, and Sweden),in contrast, alcohol consumption canbe characterized as seldom but to intoxication.In the beerpreferring nationsof Denmark, Ireland, and the UnitedKingdom, the students drink frequentlyand to intoxication (see the figure).However, this is not the case in all beerpreferringcountries (e.g., Germany, theCzech Republic, and Belgium), demonstratingthat drinking habits are notproperties of alcoholic beverages andthat certain kinds of beverages may beused in different ways. Nevertheless,the prevailing drinking patterns exhibitsome relationship with the preferredalcoholic beverages.Time of Alcohol ConsumptionOne way to describe drinking patternsis to investigate how alcohol consumptionis integrated into everyday activities(e.g., consumption with meals) (AhlströmLaakso 1976). In many wineproducingcountries, drinking is an integral partof meals. For instance, Italian adults262rarely drink between meals. In contrast,in countries such as the United Kingdom,the United States, and the Nordiccountries, most people drink at timesother than meals.The drinking patterns of adolescentsand young adults in the various countriesmirror those of the adults. Thus, theprevalence of intoxication (which typicallyresults from alcohol consumptionoutside of meals) was much lower amongadolescents in wineproducing Europeancountries than among adolescents inAngloSaxon and Nordic countries(Currie et al. 2004; Hibell et al. 2004).In recent years, however, people inMediterranean countries, especiallyyoung people, have begun to consumewine at times other than meals (NahoumGrappe 1995), and adolescents inthese countries have begun to drinkto intoxication more frequently. TheseTable 1 Abstinence Rates Among European and American 15 and 16YearOldsDuring the Last 12 Months*Country All Students (%) Males (%) Females (%)Austria 7 8 6BelgiumBulgariaCroatia141418131315151421CyprusCzech RepublicDenmark21551654Estonia 13 14 11Faroe Islands 24 24 24Finland 20 22 19France 20 18 22GermanyGreece7977710Greenland 27 32 23HungaryIceland163616381635Ireland 12 14 10Isle of Man 6 8 4ItalyLatvia181315142012Lithuania 6 6 6Malta 10 9 11Netherlands 15 14 15NorwayPoland241526122117PortugalRomania262024162823Russia (Moscow)Slovak RepublicSloveniaSpainSweden141017252318101526232655119192423Switzerland 12 12 13TurkeyUkraine651660177215United KingdomUnited States9411043839*Data on European adolescents was taken from the 2003 European School Project on Alcohol and OtherDrugs (ESPAD).SOURCE: Hibell et al. 2004.Alcohol Research & Health

<strong>International</strong> <strong>Perspectives</strong>observations suggest that moderate,controlled drinking in the wineproducingcountries is being replaced by a moreirregular pattern of drinking leading toinebriation (Grosso 2004). Moreover,drunken behavior has become morefrequent on festive occasions. Thus, thedrinking behavior of adolescents fromwineproducing countries is beginningto resemble the behavior of adolescentsfrom countries such as Denmark,Finland, and the United Kingdom.Consequences of DrinkingMost alcoholrelated problems thataffect young people do not result fromchronic heavy drinking but from occasionalheavy drinking and intoxication.Only a minority of young adults—most of them men—drink heavily on aregular basis, thereby increasing theirrisk of encountering health problemstypically associated with chronic alcoholconsumption (e.g., liver disease). However,even young people (including themajority of young women) who generallyTable 2 Prevalence of Various Indicators of Drinking Behavior Among European and American 15 and 16YearOlds*Lifetime AlcoholBingeConsumption Intoxication DrinkingPercent who had Percent who had Percent who had Percent who hadconsumed alcohol been intoxicated been intoxicated consumed at least 5at least 40 times at least 20 times at least 3 times in drinks in a row at least 3Country in their lives in their lives the past 30 days times in the past 30 daysAustria 48 21 17 NA**Belgium 36 7 8 22Bulgaria 27 10 10 21Croatia 27 9 8 15Cyprus 21 2 1 10Czech Republic 46 18 13 18Denmark 50 36 26 24Estonia 32 26 17 20Faroe Islands 32 24 18 19Finland 20 26 16 15France 22 3 3 9Germany 37 12 10 28Greece 35 3 3 11Greenland 13 21 19 19Hungary 21 11 9 8Iceland 14 16 10 11Ireland 39 30 26 32Isle of Man 45 29 23 27Italy 24 5 7 13Latvia 26 14 8 22Lithuania 38 21 12 13Malta 33 4 5 25Netherlands 45 6 7 28Norway 15 14 12 24Poland 27 10 10 11Portugal 14 3 3 16Romania 18 3 3 11Russia 39 15 11 17Slovak Republic 34 14 11 15Slovenia 25 15 12 22Sweden 17 17 9 25Switzerland 27 10 9 15Turkey 7 1 1 5Ukraine 22 18 16 22United Kingdom 43 27 23 27United States 12 7 7 9*Data on European adolescents was taken from the 2003 European School Project on Alcohol and Other Drugs (ESPAD).**NA = no data availableSource: Hibell et al. 2004.Vol. 28, No. 4, 2004/2005 263

drink in moderation may occasionallydrink heavily, thereby increasing theirrisk for certain adverse effects. Forexample, alcohol interferes with cognitive,perceptual, and motor skills andtherefore can contribute to unintentionalinjuries and deaths, particularlyafter heavy alcohol consumption. Infact, in many societies, alcoholrelatedfatalities are particularly common amongyoung adults and contribute substantiallyto alcoholrelated mortality (Ahlström2002). This particularly high mortalityrate is attributable in part to the drinkingpatterns of young adults (i.e.,drinking heavily or to intoxication) andin part to their lack of experience withand tolerance for alcohol, which maymake them more likely, for example,to be involved in alcoholrelated trafficcrashes than more experienced drinkers(Ahlström 2002).In the established market economiesof Europe, the proportion of alcoholrelateddeaths is higher among youngmen than among young women. Among15 to 29yearolds, 12.8 percent of alldeaths among males and 8.3 percent ofall deaths among females have beenestimated to be attributable to alcohol,indicating that alcoholrelated deathsaccount for a considerable amount ofmortality in young Europeans (Rehmet al. 2001). Traffic crashes are the maincause of alcoholrelated deaths for bothgenders, followed by selfinflicted injuries;alcoholrelated chronic diseases are notcommon causes of death in this agegroup. Both the average volume ofalcohol consumption and patterns ofdrinking influence the rate of alcoholrelateddeaths.Young adults are susceptible notonly to alcoholrelated health problems(i.e., deaths and injuries) but also toalcoholrelated social problems. In fact,for any given level of drinking, youngadults report more social problemsthan do middleaged adults. Thesealcoholrelated social problems includeproblems with family, friends, and atwork; financial difficulties; legal problems,such as property damage, publicdisturbance, violence, or sexual assault;and other risktaking behavior. Theprobability of young people sufferingsuch social consequences increases withtheir level of drinking.Factors AffectingDrinking by Adolescentsand Young AdultsIn general, a person’s drinking behavioris affected by two groups of factors(Quigley and Marlatt 1996; also seeJackson et al. 2005):• Internal factors, such as gender,personality factors, and biologicaltraits (e.g., certain geneticpredispositions).• External factors, such as socialnorms and the physical availabilityand prices of alcoholic beverages.30Percent who had been drunk atleast 3 times in the last 30 days2520151050Denmark IrelandUnited KingdomEstoniaAustriaFinlandCzech RepublicNorway LithuaniaIceland PolandGermany Sweden HungarySwitzerlandBelgiumUSA ItalyNetherlandsMaltaTurkey Portugal, Cyprus Greece France0 5 10 15 20 25 30Percent who had consumed an alcoholic beverageat least 10 times in the last 30 daysFrequency of drinking and of getting drunk during the last 30 days among European and American 15 and 16yearolds, 2003.Data on European adolescents were taken from the 2003 European School Project on Alcohol and Other Drugs (ESPAD).SOURCE: Hibell et al. 2004.264Alcohol Research & Health

<strong>International</strong> <strong>Perspectives</strong>(For more information on geneticfactors that influence drinking behavior,see the article by Rose in this issue. Fordiscussion of social and other environmentalfactors that influence alcoholconsumption by young adults, see thearticles by White and Wagenaar andcolleagues.)Gender DifferencesGender and age are important factorsaffecting drinking behavior. In almostevery society, young adult males drinkmore often than young adult females.During adolescence, drinking patternsare less differentiated by gender, and atthe onset of young adulthood, femalesmay even drink more frequently thanmales, partly because females typicallymature earlier than males and partlybecause they do not yet have familybonds and responsibilities. Once theyreach and pass through young adulthood,however, young women tend toconsume less alcohol, drink less frequently,and get drunk less often thanyoung men (Ahlström et al. 2001a).The ESPAD study as well as someother analyses have demonstrated thatmany countries now show a convergenceof boys’ and girls’ drinking patternsthat blurs the distinction betweenthe genders (Currie et al. 2004; Hibellet al. 2000, 2004; Johnston et al. 2000).For example, although consumptionof beer and spirits still is more frequentamong boys than girls in most ESPADcountries, prevalence rates for consumptionof spirits are equal or almostequal between the sexes in nearly half ofthe countries. Likewise, the frequencyof intoxication is similar for both gendersin many ESPAD countries (Hibellet al. 2004). The convergence of drinkingpatterns is especially obvious in theNordic countries, Ireland, the UnitedKingdom, and the United States. Inthe eastern and southern Europeancountries, however, large gender differencesstill exist.Social Norms and Other Social FactorsSocial norms about when, how often,and at what level drinking is consideredacceptable vary among different countriesor even among population subgroupswithin a country, and they may changeover time. Other social factors, such asthe context of the drinking occasion,also can influence people’s drinkingbehavior. In a Dutch study investigatingthe factors contributing to young adults’heavy drinking in public during weekends,social norms condoning alcoholconsumption and drinking occasionscharacterized by socializing were identifiedas the most important factors (Oostveenet al. 1996). Modeling was the thirdmost influential variable, but direct socialpressure had only minimal influence.Thus, it appears that for youngadults, drinking not only is a matter ofpersonal experimentation but also canreflect a desire to fit in with peers andothers (Ahlström 2000). Consistentwith this hypothesis, evidence suggeststhat the most reliable predictor of adolescents’drinking behavior is the drinkingbehavior of their friends, followedby the drinking behavior of their siblings.Other family factors—such asparent–child relationships, communication,and parenting practices—alsosignificantly influence the drinkingbehavior of adolescents (Ahlström 2002).Considerable evidence suggests thatdrinking patterns for all adults alsodepend on education, social class,occupation, employment status, placeof residence, race or ethnicity, and religion.However, few studies have investigatedthe influence of these factors onyoung adults. One comparative studyconducted in nine European countriesexamined the influence of marriage,parenthood, and employment ondrinking behavior. These transitionstend to occur during early adulthoodand demand the adoption of new socialroles. The study found that parenthoodwas profoundly and consistently associatedwith women’s drinking patterns—that is, women who had children, particularlyyoung mothers, consumed lessalcohol than did women without children(Ahlström et al. 2001a). In the UnitedStates, religion also is an importantfactor affecting the age and onset ofdrinking. The importance of religion isfurther highlighted by the low alcoholconsumption levels and high rates ofabstinence in Muslim countries.The influence of any social factorcan differ profoundly among variouscountries. For example, in some countriesa person’s place of residence (e.g.,a rural or urban area) has been shownto influence what type of beverage heor she primarily consumes. In wineproducingcountries wine consumptionis usually more popular in rural areas,but in the Nordic countries wine is consumedprimarily in urban areas. This isexplained for the most part by the factthat in wineproducing countries wineis a traditional drink with meals, whereasin the Nordic countries wine drinkingis associated with modern living styles(Simpura and Karlsson 2001).Alcohol Availability and PricingMost countries have a minimum legaldrinking age (MLDA) for purchasing,selling, or consuming alcoholic beverages.In most European countries, theMLDA is 18 years or less (see table 3).Several other countries—such as theUnited States, Egypt, Indonesia,Micronesia, Palau, Samoa, and theSolomon Islands—do not allow peopleto purchase, sell, or consume alcoholicbeverages before the age of 21 (Jernigan2001; WHO 2004). In many countries,the MLDA is the same for all alcoholicbeverages, but in countries that havedifferent age limits for different beveragetypes, the age limits usually are lower forbeer and wine than for distilled beverages(Österberg and Karlsson 2002). Inmost countries, MLDAs are the samefor offpremise and onpremise sales.Alcohol taxation and high alcoholprices as well as strict regulation ofphysical alcohol availability (i.e., saleof alcoholic beverages only in limitedlocations or at certain times) are powerfulpolicy tools for controlling alcoholconsumption (Babor et al. 2003).Although such measures affect the entirepopulation, some studies have foundthat high alcohol prices particularlyaffect adolescents and young adults, whoin many societies have fewer economicresources than older adults (Williams etal. 2005).Evidence also suggests that the amountof money available to people influencesthe frequency of drinking. For example,Vol. 28, No. 4, 2004/2005 265

Rahkonen and Ahlström (1989) analyzedtrends in drinking habits amongFinnish adolescents between 1973 and1987. They found that drinking frequencydecreased at the beginning ofthe 1980s but then began to increaseby 1983. This rise was explained byincreased alcohol availability and by anincrease in money available to adolescentsfor their leisure time activities. Similarresults were obtained in a later studyamong Finnish students (Lintonen etal. 2000).To assess the effectiveness of measuresrestricting alcohol availability in limitingalcohol consumption by adolescents,Grossman and colleagues (1995) comparedthe effects of alcohol pricingpolicies and changes in MLDA. Theseinvestigators demonstrated that bothtypes of measures impacted alcohol useand mortality from alcoholrelated motorvehicle crashes, although higher taxeson alcohol were more effective at reducingadolescent drinking than implementationof a uniform MLDA of 21.Summary and DiscussionAlcohol consumption is a social behavior,something people learn from andpractice with other members of theirculture (family, peers, etc.). Consequently,the drinking behavior of adolescentsand young adults in any country orculture is related to the drinking behaviorof the whole population. <strong>International</strong>studies have demonstrated that adultdrinking patterns vary greatly amongdifferent countries and cultures overtime and between different populationgroups within a given country. Speakingvery generally, the frequency and amountof alcohol consumption are highest inEurope, North America, and other countrieswith established market economies;lower in Africa and Asia; and particularlyTable 3 Minimum Legal Drinking Ages (MLDAs) for OffPremise and OnPremise Sales of Various Types of Alcoholic Beveragesin European CountriesOffPremiseOnPremiseCountry Beer Wine Spirits Beer Wine SpiritsAustria 16 16 18 16 16 18Belgium —* — 18 16 16 18Bulgaria 18 18 18 18 18 18Cyprus NA** NA NA NA NA NACzech Republic 18 18 18 18 18 18Denmark 16 16 16 18 18 18Estonia 18 18 18 18 18 18Finland 18 18 20 18 18 18France 16 16 16 16 16 16Germany 16 16 18 16 16 18Greece — — 18 — — 18Hungary 18 18 18 18 18 18Iceland 20 20 20 20 20 20Ireland 18 18 18 18 18 18Italy 16 16 16 16 16 16Latvia 18 18 18 18 18 18Lithuania 18 18 18 18 18 18Luxembourg — — — 18 18 18Malta 16 16 16 — — —Netherlands 16 16 18 16 16 18Norway 18 18 20 18 18 20Poland 18 18 18 18 18 18Portugal 16 16 16 16 16 16Romania 18 18 18 18 18 18Slovak Republic 18 18 18 18 18 18Slovenia 15 15 15 15 15 15Spain 16 16 16 16 16 16Sweden 18 20 20 18 18 18Switzerland 16 16 18 16 16 18Turkey 18 18 18 18 18 18United Kingdom 18 18 18 16 16 18*— = no legal age limit**NA = no data availableSOURCE: WHO 2004.266Alcohol Research & Health

<strong>International</strong> <strong>Perspectives</strong>low in the Muslim countries of the easternMediterranean region and the Indiansubcontinent. In recent decades, alcoholconsumption has decreased especially insouthern Europe and increased in Asia.Despite its similarities to adult drinking,alcohol consumption by adolescentsand young adults has some specialcharacteristics because the way of lifeand living conditions of 14- to 25-yearoldsin any culture differ somewhatfrom those of older adults. For example,the mass media (particularly the advertisingindustry), the Internet, and internationalyouth cultures also affect thedrinking patterns of adolescents andyoung adults (Unger et al. 2003; Carrolland Donovan 2002).One difference between adolescent/young adult drinking patterns and adultdrinking patterns concerns gender differences.In almost all cultures, menabstain less frequently than women anddrink more frequently and in greaterquantities than women. Among adolescentsand young adults, especially at theonset of adolescence, however, thesegender differences are less prominent ordo not exist at all. Moreover, in manycultures, drinking to intoxication ismore characteristic of adolescent andyoung adult drinking than of drinkingby older adults. Finally, most of thealcohol-related problems that affectadolescents result from periodic heavydrinking and intoxication rather thanfrom chronic alcohol consumption,because relatively few adolescents drinkheavily on a regular basis. In contrast,older adults more frequently experiencethe adverse health effects (e.g., liver disease)that result from long-term alcoholconsumption.Because most of the informationresearchers have acquired about the drinkingpatterns of adolescents and youngadults is based on data obtained inEuropean and North American countries,global comparisons of drinking patternsare difficult to make. In addition, lessinformation is available on young adultsthan on adolescents, who, throughschool-based surveys, can be accessedmore easily. To address these limitationsand to allow for truly global and reliablecomparisons of drinking patterns inadolescents and young adults, futurestudies should focus more on regionsoutside North America and Europe. Suchanalyses also could reveal characteristicpatterns in the factors affecting adolescentand young adult drinking behavior.Finally, studies following participantsover time (i.e., longitudinal studies) areneeded to better evaluate the findingsof one-time cross-sectional studies.The generalizability of existing researchon the effects of alcohol pricing onadolescent and young adult drinkingis limited because most of these studieshave been conducted in the UnitedStates. Recent price decreases in Europe,especially in the Nordic countries,however, will provide researchers withan opportunity to study whether changesin price particularly affect alcohol consumptionby adolescents and youngadults in other countries as well. ■ReferencesAHLSTRÖM, S.K. The young adult. In: Cooper,D.B., ed. Alcohol Use. Abingdon, England:Radcliffe Medical Press, 2000. pp. 39–50.AHLSTRÖM, S.K. Family practices and use of legaland illegal drugs among adolescents: A review.Nordic Studies on Alcohol and Drugs, EnglishSupplement 19:76–82, 2002.AHLSTRÖM, S.K.; BLOOMFIELD, K.; AND KNIBBE,R. Gender differences in drinking patterns in nineEuropean countries: Descriptive findings. SubstanceAbuse 22:69–85, 2001a. PMID: 12466670AHLSTRÖM, S.K.; METSO, L.; AND TUOVINEN, E.L.Ungdomars bruk av rusmedel i Europa 1995 och1999. Nordisk Alkohol & Narkotikatidskrift 18:283–295, 2001b.AHLSTRÖM-LAAKSO, S. European drinking habits:A review of research and some suggestions for conceptual integration of findings. In: Everett, M.V.;Waddell, J.O.; and Heath, D.B.; eds. Cross-CulturalApproaches to the Study of Alcohol: An InterdisciplinaryPerspective. Chicago: Aldine, 1976. pp. 119–132.BABOR, T.; CAETANO, R.; CASSWELL, S.; ET AL.Alcohol: No Ordinary Commodity. Research andPublic Policy. Oxford, England: Oxford UniversityPress, 2003.BRUUN, K.; EDWARDS, G.; LUMIO, M.; ET AL. AlcoholControl Policies in Public Health Perspective. Forssa,Finland: Finnish Foundation for Alcohol Studies, 1975.CARROLL, T.E., AND DONOVAN, R.J. Alcohol marketingon the internet: New challenges for harmreduction. Drug and Alcohol Review 21:83–91, 2002.PMID: 12189009CHOU, S.P., AND PICKERING, R.P. Early onset ofdrinking as a risk factor for lifetime alcohol-relatedproblems. British Journal of Addiction 87:1199–1204,1992. PMID: 1511233CURRIE, C.; ROBERTS, C.; MORGAN, A.; ET AL.; EDS.Young People’s Health in Context. Health Behaviourin School-Aged Children (HBSC) Study: <strong>International</strong>Report From the 2001/2002 Survey. Health Policyfor Children and Adolescents, No. 4. Geneva:World Health Organization, WHO Regional Officefor Europe, 2004.DAWSON, D.A. The link between family historyand early onset alcoholism: Earlier initiation ofdrinking or more rapid development of dependence?Journal of Studies on Alcohol 61:637–646, 2000.PMID: 11022800EDWARDS, G.; ANDERSON, P.; BABOR, T.F.; ET AL.Alcohol Policy and the Public Good. New York:Oxford University Press, 1994.GRANT, B.F., AND DAWSON, D.A. Age at onset ofalcohol use and its association with DSM–IV alcoholabuse and dependence: Results from theNational Longitudinal Alcohol EpidemiologicSurvey. Journal of Substance Abuse 9:103–110, 1997.PMID: 9494942GREENFIELD, T.K., AND ROGERS, J.D. Who drinksmost of the alcohol in the U.S.? The policy implications.Journal of Studies on Alcohol 60:78–89, 1999.PMID: 10096312GROSSMAN, M.; CHALOUPKA, F.J.; SAFFER, H.; ANDLAIXUTHAI, A. Effects of alcohol price on youth: Asummary of economic research. In: Boyd, G.M.;Howard, J.; and Zucker, R.A.; eds. AlcoholProblems Among Adolescents: Current Directions inPrevention Research. Hillsdale, NJ: LawrenceErlbaum Associates, 1995. pp. 225–242.GROSSO, L. “Current Trends of Drug Use in Italy.”Paper presented at the 16 th ELISAD Annual Meeting,Florence, Italy, October 21–23, 2004.HIBELL, B.; ANDERSSON, B.; AHLSTRÖM, S.; ET AL.The 1999 ESPAD Report: Alcohol and Other DrugUse Among Students in 30 European Countries.Stockholm: Swedish Council for Information onAlcohol and Other Drugs, 2000.HIBELL, B.; ANDERSSON, B.; BJARNASSON B.; ET AL.The 2003 ESPAD Report: Alcohol and Other DrugUse Among Students in 35 European Countries.Stockholm: Swedish Council for Information onAlcohol and Other Drugs, 2004.HINGSON, R.W.; HEEREN, T.; JAMANKA, A.; ANDHOWLAND, J. Age of drinking onset and unintentionalinjury involvement after drinking. JAMA:Journal of the American Medical Association 284:1527–1533, 2000. PMID: 11000646JACKSON, K.M.; SHER, K.J.; AND PARK, A. Drinkingamong college students: Consumption and consequences.In: Galanter, M., ed. Recent Developmentsin Alcoholism, Vol. 17: Alcohol Problems in Adolescentsand Young Adults. Epidemiology, Neurobiology,Prevention, Treatment. New York: Springer, 2005.pp. 85–117. PMID: 15789861Vol. 28, No. 4, 2004/2005 267

JERNIGAN, D.H. Global Status Report: Alcohol andYoung People. Geneva: World Health Organization,2001.JOHNSTON, L.D.; O’MALLEY, P.M.; AND BACHMAN,J.G. Monitoring the Future National Survey Results onAdolescent Drug Use: Overview of Key Findings, 1999.Bethesda, MD: National Institute on Drug Abuse,2000.JOHNSTON, L.D.; O’MALLEY, P.M.; BACHMAN,J.G.; AND SCHULENBERG, J.E. Monitoring the FutureNational Survey Results on Drug Use, 1975–2003,Volume I : Secondary School Students. NIH Pub.No. 04–5507. Bethesda, MD: National Instituteon Drug Abuse, 2004.KRAUS, L.; BLOOMFIELD, K.; AUGUSTIN, R.; ANDREESE, A. Prevalence of alcohol use and the associationbetween onset of use and alcohol-related problemsin a general population sample in Germany. Addiction95:1389–1401, 2000. PMID: 11048357KUNTSCHE, E.; REHM, J.; AND GMEL, G. Characteristicsof binge drinkers in Europe. Social Science & Medicine59:113–127, 2004. PMID: 15087148LINTONEN, T.P.; RIMPELÄ, M.K.; VIKAT, A.; ANDRIMELÄ, A.H. The effect of societal changes ondrunkenness in early adolescence. Health EducationResearch 15:261–269, 2000. PMID: 10977374NAHOUM-GRAPPE, V. France. In: Heath, D.B., ed.<strong>International</strong> Handbook on Alcohol and Culture.Westport, CT: Greenwood Press, 1995. pp. 75–87.OOSTVEEN, T.; KNIBBE, R.; AND DE VRIES, H.Social influences on young adults’ alcohol consumptionnorms, modeling, pressure, socializing, andconformity. Addictive Behaviour 21:187–197, 1996.PMID: 8730520ÖSTERBERG, E., AND KARLSSON, T., EDS. AlcoholPolicies in EU Member States and Norway: A Collectionof Country Reports. Helsinki: National Research andDevelopment Centre for Welfare and Health(STAKES), 2002.PULKKINNEN, L.; FYRSTEN, S.; KINNUNNEN, U.; ETAL. Erään ikäluokan selviämistarina. Jyväskylä:Jyväskylän Yliopistoon Psykologian LaitoksenJulkaisuja, 2003.QUIGLEY, L.A., AND MARLATT, G.A. Drinkingamong young adults: Prevalence, patterns, and consequences.Alcohol Health & Research World 20(3):187–192, 1996.RAHKONEN, O., AND AHLSTRÖM, S.K. Trends indrinking habits among Finnish youth from 1973 to1987. British Journal of Addiction 84:1075–1083,1989. PMID: 2790271REHM, J.; GMEL, G.; ROOM, R.; AND ULRICH, F.Average volume of alcohol consumption, drinkingpatterns and related burden of mortality in youngpeople in established market economies of Europe.European Addiction Research 7:148–151, 2001.PMID: 11509845REHM, J.; REHN, N.; MONTEIRO, M.; ET AL. Theglobal distribution of average volume of alcoholconsumption and patterns of drinking. EuropeanAddiction Research 9:147–156, 2003. PMID:12970583ROOM, R. Drinking and coming of age in a crossculturalperspective. In: National Research Counciland Institute of Medicine. Bonnie, R.J., andO’Connell, M.E., eds. Reducing Underage Drinking:A Collective Responsibility. Washington, DC:National Academies Press, 2004. pp. 678–698.ROOM, R.; JERNIGAN, D.; CARLINI-MARLATT, B.;ET AL. Alcohol in Developing Societies: A Public HealthApproach. Helsinki: Finnish Foundation for AlcoholStudies, 2002.SIMPURA, J., AND KARLSSON, T. Trends in DrinkingPatterns in Fifteen European Countries, 1950 to 2000:A Collection of Country Reports. Helsinki: STAKES,2001.UNGER, J.B.; SCHUSTER, D.; ZOGG, J.; ET AL.Alcohol advertising exposure and adolescent alcoholuse: A comparison of exposure measures. AddictionResearch and Theory 11:177–193, 2003.WEI, H.; DERSON, Y.; SHUIYUAN, X.; ET AL. Alcoholconsumption and alcohol-related problems. Chineseexperience from six area samples, 1994. Addiction94:1467–1476, 1999. PMID: 10790899WILLIAMS, J.; CHALOUPKA, F.J.; AND WECHSLER,H. Are there differential effects of price and policyon college students’ drinking intensity? ContemporaryEconomic Policy 23:78–90, 2005.World Health Organization (WHO). Global StatusReport: Alcohol Policy. Geneva: WHO, 2004.268Alcohol Research & Health

International Perspectives on Adolescent and YoungAdult Drinking

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