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Underage Drinking

Philippe De Witte
Mack C. Mitchell Jr.


Philippe De Witte et Mack C. Mitchell Jr.

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1This report is based on a collaborative project on underage drinking in Europe and North America sponsored by ERAB: The European Foundation for Alcohol Research (ERAB) in partnership with the ABMRF/The Foundation for Alcohol Research (ABMRF)

2Underage drinking is a serious public health problem through many parts of the world. While there is a decline in drinking among youth both in North America and Europe, a significant percentage of youth engages in risky behaviour by repeated episodic heavy drinking on both sides of the Atlantic.

3Substantial evidence indicates that the initiation of risky drinking is higher during adolescence than at other times in life (Zeigler et al., 2005). Risky drinking is often part of an overall profile of high-risk behaviours in adolescents, but the availability and role of alcohol consumption in society demands a thorough understanding of underage drinking.

4Underage drinking could have different definitions across cultures and countries that have different minimum age of legal purchase, so this report focuses on the second decade of life; between the ages of 10 and 20, with an emphasis on drinking by adolescents through age 16. The second decade is a time of physical maturation and continuing development of the brain. Recognizing that different regions develop at different times may help to understand some of the impact of alcohol consumption during the second decade of life.

5Emotions and motivation are thought to originate in the midbrain, whereas the frontal region of the brain exerts executive function and limitation of impulsive behaviour. Understanding that the midbrain regions develop earlier and faster than the frontal regions helps explain why adolescents may experience more dramatic emotional responses following ingestion of alcohol yet not have sufficient ability to limit impulsivity. As a consequence of having inadequately developed executive functions adolescents are very vulnerable to the feeling of invincibility when drinking alcoholic beverages. This combination represents a dangerous mixture.

6The potential harm to brain development is one of the greatest concerns about underage drinking. Both animal and human studies have shown that heavy drinking can cause cognitive deficits, which further impair decision making, problem solving, planning, attention, and learning (Crews, He, & Hodge, 2007). Thus, early heavy drinking can interfere with school performance and create other behavioural difficulties for youth.

7Repeated episodes of binge drinking damage areas of the midbrain (e.g., the hippocampus) that encode memory processes (Guerri & Pascual, 2010; Medina & Tapert, 2012). Moreover, specific cell types within the brain, such as the microglia, can be activated by repeated heavy drinking, producing pro-inflammatory cytokines that persist for long periods of time after repeated consumption (Crews, Zou, & Qin, 2011). In other words, chronic heavy drinking during the second decade of life can induce immunological disturbances that first appear later in adulthood.

8Heavy drinking by youth can result in a wide range of costly health and social consequences, including fatal and nonfatal accidents, all types of interpersonal violence, risky sexual behaviour, academic problems, and alcohol poisoning (U.S. Department of Health and Human Services, 2011).

9In 2007, the U.S. Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking (U.S. Department of Health and Human Services, 2007), heralded the start of a more focused examination of the relationship between alcohol use and adolescence describing strategies to reduce and to prevent harmful drinking. Considerable work since then provides a deeper understanding of the problem. The complexity and importance of underage drinking prompted ERAB and ABMRF to initiate a review of the extent of underage drinking across Europe and North America and our current understanding of factors that increase the risk of this behaviour. This review compares similarities and differences in underage drinking between the two continents, including the prevalence and patterns of underage drinking and the risk and protective factors. The focus is primarily on modifiable risk factors since these factors represent potential targets for prevention. The report also examines effective evidence-based psychosocial approaches to prevent underage drinking and the harm that is often associated with the behaviour.

10Unfortunately, the problem is complex and a single solution or policy to prevent underage drinking does not exist. Nevertheless, a number of strategies are effective in some circumstances and warrant further study in different populations. Preventing risky drinking requires understanding of the important influence of family and peers. As young people develop independence and freedom from their parents, they learn behaviours related to drinking and other aspects of life from both family and peers (see Chapter 2). Genetic traits like impulsivity, anxiety, sensation seeking and emotional dysregulation can also influence harmful drinking (see Chapter 2). The expression of genetic traits and early learning is further influenced by the cultural and environmental milieu.

11Social networking and digital media have developed rapidly over the last 5 years. However, they remain a largely unexplored domain both for exacerbating and alleviating problems related to alcohol use in underage youth. The lack of publications in this area limits the extent of evaluation of both the benefits and risks for underage drinking. The recommendations take into account the need to expand the knowledge base in this key area as well as identifying other gaps in the research and avenues that need to be explored.

12Although public policies have the potential to modify adolescent drinking behaviours, consideration of most of those efforts is beyond the scope of this review. Much of the previous work regarding effectiveness of public policies on harm associated with alcohol consumption has examined the impact on the population as a whole (for example see Anderson, Braddick, Reynolds, & Gual, 2012; Babor et al., 2010). An exception is the growing body of knowledge regarding the vulnerability of the developing brain in adolescents to harmful effects of alcohol. This issue may have relevance for public policy regarding the age of purchase or consumption of alcoholic beverages. Future work in this area should examine the impact of public policies on adolescents, who may be “at-risk” for harm associated with heavy drinking.

13The first chapter, written by Franca Beccaria and Helene White, reviews epidemiological data on underage drinking in European countries and the United States and Canada. This chapter takes into account data from the 2011 European School Survey Project on Alcohol and Other Drugs (ESPAD; Hibell et al., 2012), Health Behaviour Survey of Children (HBSC; Currie et al., 2012), Monitoring the Future Survey (MTF; Johnston, O’Malley, Bachman, & Schulenberg, 2012) and Cross Canada Report on Student Alcohol and Drugs Use (Young et al., 2011). It is clear that underage drinking is widespread throughout Europe and North America. Not only do many adolescents drink, but when they drink they consume large quantities in a short period of time, a pattern of drinking that can cause serious problems.

14The second chapter, written by Reinout Wiers, Kim Fromme, Antti Latvala and Sherry Stewart, analyzes risk and protective factors for underage drinking. Some risk and protective factors are common to all cultures. These include biological and temperamental traits that predispose an individual to drink or not to drink and to experience greater reinforcement from drinking. On the other hand, other risk and protective factors are culturally-determined, such as expectancies about alcohol and parental influence. It is expected that the former types are consistent across countries, whereas the latter may differ.

15The third chapter, written by Sherry Stewart, Patricia Conrod, Antti Latvala, Reinout Wiers and Helene White, explores the reported evidence on preventive interventions in North America and Europe and explores what initiatives are effective in discouraging underage drinking and reducing related harms in different circumstances / cultures.

16The overall goal of this project was to develop a set of recommendations that could be used to address the problem of underage drinking in Europe, the United States and Canada. The final chapter presents a set of recommendations, recognizing that a single solution to this problem cannot be identified, given the different cultural backgrounds. However, the potential benefits of the exchange of knowledge and the examination of effective practices is enormous. Gaps in the literature and suggestions for future research are included. These recommendations share two common goals:

  • To delay the age of onset of drinking;
  • To prevent heavy episodic drinking and intoxication in underage drinkers.

17Accomplishing these goals will likely reduce the harm associated with underage drinking. Combining several interventions may improve overall effectiveness in comparison to using single interventions in isolation.



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Ph.D., Professor
Chairman of ERAB: the European Foundation for Alcohol Research
Biologie du Comportement
Université Catholique de Louvain
Croix du Sud 1 – box L7.04.03
BE – 1348 Louvain-la-Neuve, Belgium

M.D., Professor and Vice-Chairman of Internal Medicine
President of the ABMRF / The Foundation for Alcohol Research
U.T. Southwestern Medical School
5323 Harry Hines Blvd
USA – Dallas, TX

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