Initiation of and Escalation to High-Intensity Drinking in Young Adults

JAMA Pediatr. 2023;177(3):286-293. doi:10.1001/jamapediatrics.2022.5642

Key Points:

Question  When is high-intensity drinking (HID) (≥10 drinks in a row) initiated, who initiates earlier, and are earlier HID initiation of and speed of escalation to HID associated with young adult alcohol use in the US?

Findings  In this cohort study of 451 individuals, HID was initiated, on average, in late high school, and adolescents escalated from first drink to HID in 2 years. Family history of alcohol problems was associated with earlier HID initiation, and earlier HID initiation was associated with greater alcohol consumption, more frequent HID, and symptoms of alcohol use disorder at age 20 years.

Meaning  Early initiation of and quick escalation to HID may be markers for later negative outcomes among young adults and can inform screening and prevention.

Abstract

Importance  High-intensity drinking (HID) (≥10 drinks in a row) is associated with acute negative outcomes. Identifying factors associated with HID initiation in adolescence and how it is associated with young adulthood outcomes can inform screening and prevention.

Objective  To identify when individuals initiate HID and speed of escalation from first drink and first binge to first HID; characteristics associated with initiation and escalation; and whether these characteristics are associated with weekly alcohol consumption, HID frequency, and symptoms of alcohol use disorder at age 20 years.

Design, Setting, and Participants  This cohort study analyzed web-based survey data from respondents in the US who reported alcohol use in the past 30 days recruited from the 2018 12th grade Monitoring the Future study and surveyed again from February 14 through April 17, 2020, at modal age 20 years in the Young Adult Daily Life Study. Only respondents who reported HID by modal age 20 years were included in the analyses.

Exposures  Retrospective alcohol use initiation and self-reported alcohol use measures.

Main Outcomes and Measures  Key retrospective measures included year of initiation for alcohol, first binge (≥5 drinks), and HID (≥10 drinks). Measures at age 20 years included weekly alcohol consumption, HID frequency, and Alcohol Use Disorders Identification Test (AUDIT) scores. Covariates included biologic sex, race and ethnicity, parental college education, family history of alcohol problems, and college status. Descriptive statistics and multivariable regression models were used, and all analyses were weighted.

Results  Of the 451 participants with data eligible for analysis, 62.0% were male (38.0% female). On average, alcohol, binge, and HID were initiated during high school. Mean time of escalation from first drink to first HID was 1.9 (95% CI, 1.8-2.1) years and between first binge and first HID, 0.7 (95% CI, 0.6-0.8) years. Initiating HID by grade 11 (vs later) was associated with higher average weekly alcohol consumption (adjusted incidence rate ratio [aIRR], 1.40; 95% CI, 1.10-1.79]), HID frequency (aIRR, 2.01; 95% CI, 1.25-3.22]), and AUDIT score (adjusted odds ratio, 1.17; 95% CI, 1.02-1.34]) at age 20 years. Escalation from first binge to first HID in the same year (vs ≥1 year) was associated with higher HID frequency at age 20 years (aIRR, 1.66; 95% CI, 1.06-2.61).

Conclusions and Relevance  These findings suggest that understanding ages and patterns of HID initiation and escalation associated with particular risk may facilitate screening for adolescents and young adults.

Initiation of and Escalation to High-Intensity Drinking in Young Adults | Adolescent Medicine | JAMA Pediatrics | JAMA Network

Bangladesh Introduces New Alcohol Policy Measures, Including Alcohol Age Limit and Health Warnings
February 2022
  
Bangladesh has introduced new Alcohol Control Rules 2022 including a 21 year minimum age for alcohol purchasing and health warning labelling on alcohol products.
 The new rules address specific flaws in Bangladeshi alcohol laws and corrected several inconsistencies.
 The Ministry of Home Affairs in Bangladesh has introduced new Alcohol Control Rules 2022 to ensure discipline in the sale, marketing, import-export, storage, production, processing, and consumption of alcohol. The rules have been set to effectively implement the Narcotics Control Law 2018.
A breakdown of the new alcohol rules in Bangladesh
 Notable changes in the laws:

• Introduction of a minimum age of 21 years for alcohol sales. Previously Bangladesh did not have a legal minimum age for alcohol sales.
• License, permit, and renewal fees for alcohol have been increased.
• All alcoholic product bottles must carry a health warning label.
• Alcohol permit holders or license holders are not allowed to show alcohol products to other persons for commercial or other purposes to attract people.
• The rules have specified new opening and closure times of bars and liquor selling shops.

Other changes to the alcohol laws:

• Official permit needed for consumption and use of alcohol products.
• Sellers can sell a maximum of three units of alcohol to permitted holders at one time and a maximum of seven units for one month with some exceptions.
• Authorities can issue licenses to sell alcohol in an area if there are 100 local or foreign liquor permit holders.
• A pass is needed for carrying and transportation of alcohol products.
• Import-export, production, processing, supply, marketing, sale, purchase, storage, and containing alcohol would require licenses.
• Bars, off-trade shops, on-trade shops, and local liquor shops must be closed on Fridays, Muharram, Shab-e-Baraat, Eid-e-Miladunnabi, Shab-e-Kadar, Eid-ul-Fitr, Eid-ul-Adha and other government declared holidays.
• Conditions have been set for establishing bars in hotels, restaurants, and clubs – having at least 200 permit holder members, export processing zones, theme parks, and the government’s development projects – where foreign nationals reside.
• Foreign remittance earner duty-free shops can import alcohol.
• Restaurants, hotels, clubs, or bars can procure 40% of required alcohol from Bangladesh Parjatan Corporation by paying duty taxes at regular rates or through import. The other 60% is to be collected from local sources.
• Clubs having more than 200 permit holder members can import the highest 40% of foreign liquor. The remaining 60% is to be procured from local sources.

For complete article Bangladesh Introduces New Alcohol Policy Measures, Including Alcohol Age Limit and Health Warnings - Movendi International
 
Austria: Low Minimum Legal Age for Alcohol Consumption Hurts Youth
Posted on April 8, 2021 in 
 New research by a group of economists shows how the low legal minimum age for alcohol consumption in Austria is causing greater alcohol harm in young people. The 16 years legal age limit is contributing to widening health inequality in Austrian youth.
 The products and practices of the alcohol industry cause serious harm to children and youth, for example by affecting their development into healthy adults. The legal minimum age for alcohol purchase and consumption is supposed to protect children, adolescents and youth and prevent alcohol harm as much as possible. However, the low legal minimum age, such as the 16 years of age threshold in Austria, fails to protect young people adequately. It contributes substantially to socio-economic inequalities in children and youth caused by the products and practices of the alcohol industry.
 Europe has the world’s highest alcohol consumption rate. Teenage binge and heavy alcohol use is also high across the European region.
 New research by economists Alexander Ahammer, Stefan Bauernschuster, Martin Halla and Hannah Lachenmaier shows that this high level of harm is related to the low minimum legal age for alcohol use.
 The study was conducted among an Austrian sample of teenagers using three sources of data, the European School Survey Project on Alcohol and other Drugs (ESPAD), the Upper Austrian Regional Health Insurance Fund and a large field study in which minor test buyers tried to purchase alcohol in Upper Austrian shops.
  
Key results from the study
 Key results of the study reveal a reality of substantial alcohol harm among children and youth in Austria. As soon as Austrian’s reach 16 years of age,

• The amount of alcohol consumed in the previous week skyrockets by 90% – from 55 grams of alcohol per week to 105 grams. This amounts to an increase of about three 0.5l bottles of beer on average. The effects are particularly strong for boys and for children from socially disadvantaged families.
• The probability of having had 5 alcoholic beverages or more on at least one or two occasions (binge alcohol use) in the previous month increases by 10 percentage.
• The probability of being hospitalized with alcohol intoxication increases immediately by 42%.
• For teens who have a household history of alcohol problems, alcohol use behavior does not change at 16. The researchers say teens with a history often are using alcohol heavily from before 16 years of age which is why there is no notable jump.

  

  
Increasing inequality
 Children and youth from socially disadvantaged families consume even more alcohol once they reach the legal minimum age. Before the 16th birthday the probability of alcohol intoxication is similar among social class. But after turning 16 a clear gap arises in terms of alcohol use and harm among vulnerable children and youth. From the 16th to 21st birthday, hospital admissions for alcohol intoxication among young people from socially disadvantaged families rise higher than others.
What are the causes?
 The researchers note that the data confirm the prevailing motto: “If the legislator allows it, then it cannot be so bad”. After turning 16, Austrian children stop considering binge and heavy alcohol use as harmful.
 Alcohol is already easily and widely available for minors in Austria even before they reach the legal age limit.

• Out of 4,269 underage test purchase attempts, around 23% were successful.
• 84% of 15 year-olds perceive access to alcohol as ‘easy’ or ‘rather easy’ according to the ESPAD survey.

  In an environment where children and youth are already heavily exposed to alcohol, the low legal minimum age provides no protection from the products and practices of the alcohol industry.
 The researchers therefore discuss some normative effects of the legal age limit.

• Teens may feel obliged to not have alcohol before the legal age.
• Households might be more relaxed about giving children alcohol once they’ve reached the legal age limit.

   
What can be done?
Increasing the legal minimum age has been found to have very positive effects for the health and development of children and youth. When the United States (U.S.) increased their legal minimum age from 18 to 21, society saw a range of positive effects:

• 16% median decline in motor vehicle crashes,
• Reduction in alcohol use in the past month among 18 to 21 year olds from 59% in 1985 to 40% in 1991, and
• Alcohol use among people aged 21 to 25 declined significantly from 70% in 1985 to 56% in 1991.

  To better protect the most vulnerable children and youth in the absence of an age limit increase, the researchers suggest targeted measures for socio-economically disadvantaged children and youth as well as for kids with a household history of alcohol problems, since the alcohol harm they are exposed to is already high before they reach the legal age limit for alcohol use.

Sources
Universitat Passau: “Alcohol at 16 – Legal license to binge drink”
VOX EU CEPR: “Minimum legal drinking age and the social gradient in binge drinking“
  
This original Article used with permission MOVENDI https://movendi.ngo/news/2021/04/08/austria-low-minimum-legal-age-for-alcohol-consumption-hurts-youth/
 
Alcohol‐induced blackouts at age 20 predict the incidence, maintenance and severity of alcohol dependence at age 25: a prospective study in a sample of young Swiss men
First published: 06 May 2019   https://doi.org/10.1111/add.14647
 Abstract
Background and Aims: Alcohol‐induced blackout (AIB) is a common alcohol‐related adverse event occurring during teenage years. Although research provides evidence that AIB predicts acute negative consequences, less is known about the associations of AIB with chronic consequences, such as alcohol dependence (AD). This study estimated the associations between an experience of AIB at age 20 and the incidence, maintenance and severity of AD at age 25 among Swiss men.
Design: Prospective cohort study with 5.5 years separating baseline and follow‐up.
 Setting – Switzerland.
Participants – Swiss male drinkers (n = 5469, age 20 at baseline) drawn from the Cohort Study on Substance Use Risk Factors (C‐SURF).
Measurements: Self‐report questionnaires assessing AIB, AD, alcohol (drinking volume, binge drinking), cigarette and cannabis use, several risk factors (sensation‐seeking, family history of problematic alcohol use, age of first alcohol intoxication) and socio‐demographic variables.
Conclusions: Among Swiss men, alcohol‐induced blackout at age 20 predicts the development, maintenance and severity of alcohol dependence at age 25
For complete study https://onlinelibrary.wiley.com/doi/10.1111/add.14647
 
Trajectories of Alcohol Use Problems based on Early Adolescent Alcohol Use: Findings from a 35 Year Population Cohort Abstract
 
 Background: Early exposure to alcohol in adolescence is associated with a range of long term harms. Better understanding of trajectories of alcohol use from adolescence to early adulthood would help target prevention strategies to high risk groups.
 
 Methods: Christchurch (New Zealand) general population birth cohort (n = 1265). A latent trajectory model of alcohol use behaviour at age 14–16 was used to predict alcohol use outcomes at age 18–35, net of covariate factors known to be associated with substance use outcomes in this cohort.
 
 Results: Three classes of adolescent alcohol use were identified. These were: occasional alcohol users, emergent binge alcohol users and increasing heavy alcohol users.
 
 Conclusions: This analysis identifies three groups of adolescent alcohol users with differing patterns of use. Emergent binge alcohol users likely require public policy responses to alcohol use whereas increasing heavy alcohol users are potentially able to be identified individually on the basis of patterns of alcohol use and social variables. This group may benefit from psychosocial interventions and are unlikely to respond to a broad public health approach.
 
Read More
Heavy drinking in teens causes lasting changes in emotional center of brain
 
 Date: February 6, 2019   Source: University of Illinois at Chicago
 Summary: Lasting changes in the brain caused by drinking that starts in adolescence are the result of epigenetic changes that alter the expression of a protein crucial for the formation and maintenance of neural connections in the amygdala -- the part of the brain involved in emotion, fear and anxiety.
 
Read More
 
It’s time to Raise the Minimum Legal Drinking Age to 21
 
Professor John Toumbourou & Shane Varcoe
 18th June 2013
 
Professor John Toumbourou, Chair in Health Psychology, Deakin University
 
 Shane Varcoe – Executive Director , Dalgarno Institute
 
This report summarises the evidence for raising the Minimum Legal Drinking Age (MLDA) to 21 and describes the options for implementing such a change. The reasons for raising the MLDA are outlined and include: (1) rising rates of youth violent offending and alcohol related-harm; (2) scientific evidence that in the early twenties the brain is still developing and therefore vulnerable to damage through common patterns of youth alcohol use; (3) solutions such as taxation and regulation are not included in any major political party platform; and (4) support for this policy change has increased to 50.2% of Australians.

It’s time to raise the Minimum Legal Drinking Age to 21
Recognising the strong scientific evidence for social and health benefits, the document that follows has been prepared to clarify the scientific evidence and to encourage public discussion of the options for restricting rights to purchase and use alcohol until age 21.
 
The Dalgarno Institute
The Dalgarno Institute is a community based coalition of individuals, community groups, and associations that hold the common vision of making the world a better place for woman, families and children by reducing the adverse impact of alcohol and drug use. The Institute continues the 150 year tradition of the Australian Temperance movement that made important historical contributions to developing Australia’s public health and women’s rights movements. Australians are exposed to heavy investment from vested-interests that profit from marketing alcohol. The Institute is one of few public forums that continues to promote the scientific and social benefits of abstinence.
 
Proposal that the Minimum Legal Drinking Age be raised to 21
While rates of youth violent offending and alcohol related-harm continue to rise in all Australian States, solutions such as taxation and regulation are not included in any major political party platform. Given this situation and recognising the strong scientific evidence for social and health benefits (summarised below), the Dalgarno Institute calls on all Australian governments to amend relevant state liquor licensing regulations to restrict full rights to purchase and use alcohol until age 21 years. There are a range of policy options that are available to achieve a Minimum Legal Drinking Age (MLDA) of 21. As one option the Federal government could follow the example of the USA in 1986 and make Federal road funding conditional on States increasing the MLDA to age 21. Alternatively any State or Territory can act unilaterally to amend State Liquor Licensing regulations or to introduce one or more of the following restrictions from age 18 until age 21:

•  Restricting the amount and or the types of alcoholic products that can be purchased by youth as occurs in a number of Scandinavian countries
•  Extending the restrictions on secondary supply that many states have implemented (e.g., requiring that young people purchase their own alcohol to ensure they monitor their use)
•  Extending regulation and enforcement that occurs in many local government areas to restrict use in specific contexts such as in public spaces
•  Restrictions on heavy alcohol use measured by blood alcohol content
•  Limitations on rights to purchase and use alcohol conditional on prior alcohol offending

The present document has been prepared to clarify the scientific evidence and to encourage public discussion of the options for introducing a Minimum Legal Drinking Age (MLDA) of 21.
 
Scientific Evidence
Until the late 1960s the legal age for purchasing and using alcohol in licensed premises was 21 in all Australian states. Regulations were amended in the late 1960s and early 1970s within each state to lower the age for purchase and use down to age 18. A study evaluated the impact of these changes and found they were associated with an average 10% increase in road trauma for young people. 
 
 The Minimum Legal Drinking Age (MLDA) has been the subject of political controversy over the past four decades and there have been a number of states in different nations that have either lowered the MLDA (as did Australian states in the late 1960s and early 1970s) or increased it. The effect of variation in the MLDA has been widely studied. More than 70 studies have examined the impact on road injury and deaths and other outcomes of either increasing or decreasing the MLDA. Several studies in the 1970s found that motor vehicle crashes increased significantly among teens when the MLDA was lowered 2 Convinced of the evidence for public health benefits President Reagan supported legislation in 1986 that made Federal road funding conditional on US states introducing a standard age 21 MLDA. A review of 17 studies from the states that raised the MLDA to 21 estimated that underage crash involvements were reduced on average by 16%.2 The evidence indicates that a higher MLDA is effective in reducing youth alcohol consumption and in preventing alcohol-related deaths and injuries among youth. When the MLDA has been lowered, road crashes, injury and deaths have increased, and when the MLDA is increased rates have declined 3
 
 A common argument among opponents of a higher MLDA is that, because many minors still drink and purchase alcohol, the policy doesn't work. The evidence shows, however, that although many youth still consume alcohol, they drink less and experience fewer alcohol-related injuries and deaths.2,3 It is sometimes argued that increasing the MLDA in the USA has increased illicit drug use, but this is incorrect. Annual trends in national school surveys show that illicit drug use declined in the USA after the national implementation of the age 21 MLDA in the 1980s. In 1987, 56.6% of USA students in their final year of high school (year 12) reported they had previously used an illicit drug. Rates fell steadily in subsequent years reaching an historic low of 40.7% in 1992 and since then have risen slightly to 46.7% in 2009.4 Lifetime alcohol use was 92.2% for year 12 students in 1987 and fell steadily to an historic low of 69.4% in 2012. 4 A cross-national comparison found that rates of substance use (either alcohol or illicit drug use) were twice as high for Australian compared to US children in 2002, with much of this effect explained by the substantially higher rates of alcohol use in Australian children.5
 
 The benefits of increasing the MLDA to 21 are evident not just in road safety prior to age 21 but also in improved road safety after age 21 until age 25.2,3 Recent neuro-imaging studies show that the human brain is still developing through to the mid-20s. Episodes of heavy alcohol use that are common amongst young adults have detrimental implications for healthy brain development.6 Research shows that when the MLDA is increased to 21, people under age 21 drink less overall and continue to do so through their early twenties.3 Decreasing the MLDA below age 21 has also been shown to result in population increases in other alcohol-related harms including suicide 7 and youth crime.8
 
 With most research on the effects of MLDA laws having been conducted in the United States in the 1980s, it is sometimes argued that the introduction of alternative policies such as random breath testing for alcohol impaired drivers has made MLDA policies redundant. However, recent evidence on the adverse crash effects of lowering MLDA in New Zealand suggests that the policy impacts are independent of alternative road safety policies. In New Zealand the MLDA was lowered from 20 to 18 in 1999. An analysis found that alcohol-involved crash injury rates increased between 12% and 50% for cohorts in the 15 to 19 age groups after the MLDA was lowered.9 The effect of lowering the MLDA occurred despite the previous policy having been implemented with little or no enforcement. A range of studies show that the benefits of increasing the MLDA can be enhanced when strong enforcement is also implemented.
 The National Drug Strategy Household Survey found that Australian support for raising the MLDA to 21 is growing strongly from 40.7% in 2004 to 50.2% in 2010. It is often considered that young voters in the 18 to 20 age range would oppose raising the MLDA to 21, however, such opposition is unlikely to be universal. Many young people are aware that the potential benefits for their age group includes a reduction in alcohol-related violence and injury and increased road safety. The Dalgarno Institute encourages public debate as a means of clarifying that there is overwhelming scientific evidence and strong public support that favours raising the MLDA to 21.
 
References
 
1 Smith DI, & Burvill PW. (1986) Effect on traffic safety of lowering the drinking age in three Australian states. Journal of Drug Issues. 16, pp. 183–98.
 2 Shults RA, Elder RW, Sleet DA, Nichols JL, Alao MO, Carande-Kulis VG, Zaza S, Sosin DM, and Thompson RS. (2001) Reviews of evidence regarding interventions to reduce alcohol-impaired driving. American Journal of Preventative Medicine. 21(4 suppl 1): 66–88.
 3 Wagenaar AC. Minimum drinking age and alcohol availability to youth: Issues and research needs. In: Hilton ME, Bloss G, eds. Economics and the Prevention of Alcohol-Related Problems. National Institute on Alcohol Abuse and Alcoholism (NIAAA) Research Monograph No. 25, NIH Pub. No. 93-3513. Bethesda, MD: NIAAA; 1993:175-200.)
 4 Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2013). Monitoring the Future national survey results on drug use, 1975–2012: Volume I, Secondary school students (NIH Publication No. 10-7584). Bethesda, MD: National Institute on Drug Abuse.
 5 Toumbourou, J.W., Hemphill, S.A., McMorris, B.J., Catalano, R.F., & Patton, G.C. (2009) Alcohol use and related-harms in school students in the United States and Australia. Health Promotion International. 24(4), 373-82.
 6White AM, & Swartzwelder HS. (2004) Hippocampal function during adolescence: a unique target of ethanol effects. Annals of the New York Academy of Sciences, vol. 1021, pp. 206-20.
 7 Birckmayer J, Hemenway D. (1999) Minimum-age drinking laws and youth suicide, 1970–1990. American Journal of Public Health. 89, 1365–1368.
 8 Smith DI, Burvill PW. (1987) Effect on juvenile crime of lowering the drinking age in three Australian states. Br J Addict. 82:181–188.
 9 Kypri, K., Voas, R.B., Langley, J.D., Stephenson, S.C.R., Begg, D.J., Tippetts, A.S., & Davie, G.S. (2006) American Journal of Public Health. 96(1), 126 – 131.