Strong Public Health interest in preventing under-age alcohol use

The WHO Global Alcohol Strategy outlines no less than 10 areas for action and intervention to prevent and reduce alcohol harm. Among those are the Three Best Buys in alcohol policy (regulating availability, affordability and marketing). Area 3 deals with “Community Action”. For this area the following policy option and intervention is recommended:

Mobilizing communities to prevent the selling of alcohol to, and consumption of alcohol by, under-age and to develop and support alcohol-free environments, especially for youth and other at-risk groups.”

Scientific evidence shows that early onset of alcohol use has long-lasting negative consequences.

Research by Grant and Dawson (via NIAA) shows:

People who reported starting to [use alcohol] before the age of 15 were four times more likely to also report meeting the criteria for alcohol dependence at some point in their lives.”

The earlier young people start to use alcohol, the worse the alcohol-related consequences:

  • Alcohol dependence
  • Traffic crashes
  • Physical violence after alcohol consumption
  • Other unintentional injuries after alcohol intake (e.g. drowning, falls)
  • Potential damage to still-developing adolescent brain
  • Lower chances of success in school

The bottom line is that society has a strong public health and social welfare interest in preventing under-age alcohol use.

Social, Public Health, Economic Harm

Alcohol use by minors is a social and public health problem

In the United States, alcohol use contributes to more than 4,300 deaths among people below the age of 21, each year.

More than 90% of the alcohol consumed by those under the age of 21 is consumed by binge alcohol users. Alcohol use by minors is also strongly linked with:

  • Death from alcohol poisoning,
  • Unintentional injuries, such as car crashes,  falls, burns, and drowning,
  • Suicide and violence, such as fighting and sexual assault,
  • Changes in brain development,
  • School performance problems, such as higher absenteeism and poor or failing grades,
  • Alcohol dependence later in life,
  • Other risk behaviors such as smoking, abuse of other drugs, and risky sexual behaviors.

The 2015 Youth Risk Behavior Surveillance System found that among high school students in the United States, 33% consumed alcohol and 18% binge used alcohol during the past 30 days.

In 2015, the US Monitoring the Future Survey reported that 10% of 8th graders and 35% of 12th graders used alcohol during the past 30 days, and 5% of 8th graders and 17% of 12th graders binge consumed alcohol during the past 2 weeks.

Based on data from 2006 to 2010, the CDC estimates that, on average, alcohol is a factor in the deaths of 4,358 young people under age 21 each year. This includes:

  • 1,580 deaths from motor vehicle crashes
  • 1,269 from homicides
  • 245 from alcohol poisoning, falls, burns, and drowning
  • 492 from suicides.

Underage youth who consume alcohol are more likely to carry out or be the victim of a physical or sexual assault after alcohol intake compared to their peers who do not consume alcohol.

Alcohol use by minors is an economic problem

Underage alcohol use cost the U.S. economy $24 billion in 2010.

There were about 189,000 emergency department visits by people under the age of 21 for injuries and other conditions linked to alcohol in 2010 – burdening the healthcare system with massive costs.

Alcohol-impaired driving

Drinking by those below the age of 21 is strongly associated with alcohol-impaired driving.

For example, the 2015 Youth Risk Behavior Survey in the US, found that among high school students, during the past 30 days

  • 8% drove after consuming alcohol.
  • 20% rode with a driver who had been using alcohol.

Source: NIAA fact sheet

MLPA Worldwide

WHO’s Global Status Report on Alcohol, 2014, establishes:

Minimum legal purchase age (MLPA) limits are effective in reducing alcohol consumption among youth, and older age limits are more likely to effectively deter youth [alcohol use] than younger age limits.

Age restrictions can apply to the consumption of alcohol on-premise or off-premise.”

A 2012 overview shows that more countries have on-premise than off-premise MLPA regulations.

  • 15 countries reported having no on-premise age limits pertaining to beer sales and consumption
  • 16 countries had no age limit for wine and spirits
  • 21 countries had no off-premise age restrictions for any beverage types

Among the countries that have legal purchase ages for alcohol, the ages range from 10 years to 25 years, but the most common age limit is 18 years:

  • 115 countries have an on- or off-premise legal purchase age for at least one beverage set at 18 years
  • 15 countries set the MLPA at 16 years
  • 7 countries set the MLPA at 20 years
  • 14 countries set the minimum age limit at 21 years.

Minimum age limits for on-premise sales of beer, wine and spirits, by number of reporting countries, 2012
(n = 166 reporting countries)
Source: WHO Global Status Report Alcohol, 2014

Policy Effectiveness

Almost all countries have some form of legal restrictions on the age at which young people are allowed to purchase or possess alcohol. These restrictions very considerably.

Evidence shows that changes in minimum legal purchasing laws can have substantial effects on youth alcohol use and related harms.

Example #1: New Zealand

New Zealand reduced the MLPA from age 20 to age 18 in 1999.

Comparing four years before and after the change, alcohol-involved traffic crashes among 20 to 24 year-olds (comparison group) grew substantially:

  • 14% increase among 15 to 17 year-old males
  • 24% increase among 15 to 17 year-old females
  • 12% increase among 18 and 19 year-old males
  • 51% increase among 18 and 19 year-old females.

Example #2: United States

Minimum Legal Drinking Age (MLDA) laws specify the legal age when an individual can purchase or publicly consume alcoholic beverages. The MLDA in the United States is 21 years.

Prior to the enactment of the National Minimum Drinking Age Act of 1984, the legal age when alcohol could be purchased varied from state to state.

Evidence shows that the implementation of the uniform MLDA of 21 in the US reduced the overall prevalence of driving under the influence of alcohol. Additional studies have shown that changes in the minimum legal age are related to alcohol-related injury admissions to hospitals, injury fatalities and overall mortality.

The age 21 MLDA saves lives and improves health

The higher legal age had positive impact on lives saved, on reduction in alcohol use among adolescents, on better academic performance and on other alcohol-related problems.

  1. According to the CDC, states that increased the legal age to 21 saw a 16% median decline in motor vehicle crashes.
  2. After all states adopted an age 21 MLDA, alcohol use during the previous month among persons aged 18 to 20 years declined from 59% in 1985 to 40% in 1991.
  3. Alcohol use among people aged 21 to 25 also declined significantly when states adopted the age 21 MLDA, from 70% in 1985 to 56% in 1991.
  4. Students in states that had a MLDA of 18 had a 13 times greater chance of dropping out of high school compared to states with an MLDA of 21.
  5. There is also evidence that the age 21 MLDA protects alcohol users from developing addiction to alcohol and other drugs, adverse birth outcomes, and suicide and homicide.

Source: Alcohol No Ordinary Commodity, 2nd edition, 2010

Myth Busting

Myth: Extreme alcohol use is worse in the United States


The alcohol industry perpetuates the myth that young Europeans are introduced to alcohol in a cultural context that reduces heavy and harmful alcohol use. Since the minimum legal purchase age in the United States is 21 – much higher than in most European countries – young people would miss out on the opportunity to “learn” to consuming alcohol responsibly.

The believe is therefore, that American adolescents consume alcohol more frequently, binge consume more, and experience more alcohol-related problems in comparison to their European peers.

Myth as argument for policy change

This ill-informed belief and perception is employed as argument to lowering the minimum legal purchase age in the United States.

What the evidence says

Alcohol-related harm among US adolescents is lower compared to European peers.

  1. A greater percentage of young Europeans report alcohol use in the past 30 days.
  2. A majority of European countries have higher intoxication rates among young people than do youth from the United States.
  3. For a majority of these European countries, a greater percentage of youth report having been intoxicated before the age of 13.

The European School Survey Project on Alcohol and Other Drugs (ESPAD) provides European data on youth substance use and related harm.

The percentage of 15- and 16-year-old students in the United States who report alcohol consumption in the 30 days prior to the survey was 22%. That is less than half the average proportion in European countries, where the number is 48%.

Only Iceland had a lower prevalence of alcohol use in minors (9%) than the U.S.

The percentage of students who said they had five or more drinks on one or more occasions in the last month was 35%, on average, in Europe. The U.S. sample had 11%, clearly showing that binge alcohol use is a bigger problem across Europe than across the US.

Source: “EYES ON AGES. A research on alcohol age limit policies in European Member States. Legislation, enforcement and research”, 2013