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National Institute on Alcohol Abuse and Alcoholism
Division of Epidemiology and Prevention Research
Alcohol Epidemiologic Data System
SURVEILLANCE REPORT #74
TRENDS IN UNDERAGE DRINKING
IN THE UNITED STATES, 1991–2003
Gabriella Newes-Adeyi, Ph.D., M.P.H.1
Chiung M. Chen, M.A.1
Gerald D. Williams, D.Ed1
Vivian B. Faden, Ph.D. 2
1 CSR, Incorporated
Suite 1000
2107 Wilson Boulevard
Arlington, VA 22201
2 Division of Epidemiology and Prevention Research
National Institute on Alcohol Abuse and Alcoholism
5635 Fishers Lane, MSC 9304
Bethesda, MD 20892–9304
October 2005
U.S. Department of Health and Human Services
Public Health Service
National Institutes of Health
CSR, Incorporated, operates the Alcohol Epidemiologic Data System (AEDS) under Contract No. N01AA32007 for the Division of Epidemiology and Prevention Research, National Institute on Alcohol Abuse and Alcoholism
HIGHLIGHTS
This surveillance report, prepared by the Alcohol Epidemiologic Data System (AEDS), National Institute on Alcohol Abuse and Alcoholism (NIAAA), presents data on underage drinking for 1991–2003. This is the first of a series of reports to be published every two years on underage drinking and related attitudes and risk behaviors. Data for this series are compiled from three separate nationally-representative surveys, the National Survey on Drug Use and Health (NSDUH), the Monitoring the Future (MTF) survey, and the Youth Risk Behavior Survey (YRBS). The following are highlights of trends from 1991 through 2003.
Prevalence of use
Although there are marked differences in absolute values of estimates, and estimates show different patterns of increase and decrease over the time period evaluated, the trends across all three survey data sources show an overall decline in the prevalence of alcohol consumption in the past 30 days between 1991 and 2003. In 2003, 29.3 percent of youth ages 12–20 reported consuming alcohol in the past 30 days (NSDUH).
Drinking patterns
The mean age of onset for drinking alcohol has increased slightly from 13.8 years in 1991 to 14 years in 2003 (NSDUH). In addition, there is a gradual decline over the decade in the proportion of youth reporting initiating drinking at age 12 years or younger, although this trend may be leveling off (NSDUH, YRBS).
Over the course of the decade, males have maintained higher average frequency, quantity, and volume of consumption in the past 30 days than females. In 2003, youth ages 12 to 20 reported drinking on a mean of 5.8 days in the past 30 days. They consumed an average of 4.9 drinks on these days, corresponding to an average total of 35.4 drinks in the past 30 days (NSDUH).
Alcohol-related attitudes
Alcohol-related risk behaviors
INTRODUCTION
This surveillance report on underage drinking is one of a series of reports published to monitor trends in alcohol consumption and alcohol-related morbidity and mortality. These reports are prepared by the Alcohol Epidemiologic Data System (AEDS), Division of Epidemiology and Prevention Research, NIAAA, and are intended to be useful to researchers, planners, policymakers, and other professionals interested in alcohol abuse and its associated consequences. The data also are essential in assessing changes toward meeting the Nation’s health promotion and disease prevention goals to reduce underage drinking as stated in Healthy People 2010 (U.S. Department of Health and Human Services 2000). This is the first surveillance report on underage drinking developed by NIAAA. AEDS expects to issue follow-on reports on this topic every two years.
Rates of alcohol consumption among underage youth are a cause for concern (NRC 2003). In 2003, 29.3 percent of 12-20 year olds reported drinking alcohol in the past 30 days (NSDUH 2003). This is a decrease from the rate of 33.4 percent a decade earlier in 1991 (NHSDA 1991), although changes in survey methodology preclude a direct comparison of these two estimates. Alcohol consumption begins early, with a mean age of 14 (NSDUH 2003) and 28 percent of high school students reporting consuming their first drink of alcohol before age 13 (Grunbaum et al. 2004). By the 12th grade, 27.9 percent of adolescents report binge drinking (consuming 5 or more drinks in a row within the past 2 weeks) (MTF 2003).
Underage drinking is associated with a wide array of social, emotional, behavioral and health problems (Komro and Toomey 2002). O’Malley and colleagues (1998) found that, among 12th graders surveyed between 1994 and 1997, 18 percent (or close to a third of the 53 percent who had consumed alcohol on at least 10 occasions) had experienced three or more alcohol-related problems. For example, alcohol caused them to behave in ways they later regretted; it interfered with their ability to think clearly; or it caused them to drive unsafely. Youth who drink and drive are at increased risk of involvement in accidents, because of the duality of alcohol-related impairment and relative inexperience driving (OAS 2003). Underage drinking is associated with driving after consuming alcohol or riding with a peer who has consumed alcohol (Windle 2003). When youth consume alcohol, they are more likely to engage in risky sexual behaviors such as unprotected sexual intercourse, having multiple-partners, and being drunk or high during intercourse (Hingson et al. 1990; Ramisetty-Mikler et al. 2004; Strunin and Hingson 1992; Stueve and O’Donnell 2005), putting them at risk of such adverse consequences as sexual victimization (Champion et al. 2004), pregnancy (Slevin and Marvin 1987) and sexually transmitted infections (Shafer et al. 1993). Adolescents under the influence of alcohol or with a history of drinking alcohol are also more likely to engage in violence, such as physical fighting and assault (Blitstein et al. 2005; Kodjo et al. 2004; Swahn et al. 2004; Wells et al. 2004). Adolescent alcohol use disorder increases the risk for both suicide attempts and completion (Chatterji et al. 2004; Esposito-Smythers et al. 2004). Several studies have established a convincing link between youth alcohol use, particularly binge drinking, and illicit drug use (Greenblatt 2000; OAS 2002; O’Malley et al. 1998). Adolescent binge drinkers, for example, are 7 times more likely to report past-year illicit drug use than adolescent non-binge drinkers (OAS 2002). Binge drinking and alcohol use disorder during adolescence has recently been reported to cause life-long pathological changes in the brains of rats and neurocognitive disadvantages in humans (Brown and Tapert 2004; Monti et al. 2005).
Age at onset of drinking affects future drinking patterns and alcohol-related risk behaviors (Grant and Dawson 1997; Grant et al. 2001; Hingson et al. 2002; Stueve and O’Donnell, 2005; Warner and White 2003; Wells et al. 2004). For example, early age at onset is associated with binge drinking, getting drunk and high, and subjective reports of substance use interfering with life activities (Stueve and O’Donnell 2005), and alcohol abuse and dependence later in life (Grant and Dawson 1997; Grant et al. 2001; York et al. 2004). Hingson and colleagues (2002) found that onset age was associated with driving after drinking and being involved in drinking-related vehicle crashes.
DATA SOURCES
Data for this report are drawn from three sources, the National Survey on Drug Use and Health (NSDUH), the Monitoring the Future (MTF) survey, and the Youth Risk Behavior Survey (YRBS).
National Survey on Drug Use and Health
The NSDUH, formerly the National Household Survey on Drug Abuse, is conducted by the Substance Abuse and Mental Health Services Administration. The nationally representative survey was initiated in 1971 and administered annually from 1991. The survey is administered at the household level through in person interviews. Since 1999, computer-assisted interviewing methods have been used, including audio computer-assisted self-interviewing for selected survey components. In this same year, the survey sample was expanded to allow for computation of state-specific prevalence estimates. All respondents ages 12 through 20 years were selected for inclusion in the underage drinking surveillance report.
Monitoring the Future
The MTF survey is funded by the National Institute on Drug Abuse and conducted annually by the University of Michigan Institute for Social Research. Initiated in 1975 among 12th graders only, 8th and 10th graders were added in 1991, providing a nationally representative sample of secondary school students in those age groups. The survey is administered in school to a sample of students enrolled in public and private secondary schools. Since 1976, a random sample of 12th graders has been followed biannually through a self-administered mail back questionnaire. For this surveillance report, all respondents from the 8th, 10th, and 12th grade samples were included in the analyses.
Youth Risk Behavior Survey
The YRBS is conducted by the Centers for Disease Control and Prevention and administered every two years to students enrolled in public or private schools in grades 9 through 12. Initiated in 1991, the survey provides a nationally representative sample of youth enrolled in high school. All respondents from the biannual surveys were included in this surveillance report.
All three sources of data for this surveillance report are nationally representative repeated cross sectional surveys that provide data on youth alcohol consumption and related risk behaviors. As described above, there are also important differences among the three surveys, related to the ages of youth sampled, the timing of the survey, the setting of survey administration and consequent type of youth sampled and level of anonymity involved, and question wording. Specifications of the three surveys are summarized in the Appendix and briefly reviewed here.
Age groups
Whereas the NSDUH collects information on youth as young as 12 years old, the YRBS collects information from youth in grades 9 through 12 and the MTF skips grades, surveying youth in 8th, 10th, and 12th grades.
Periodicity
Both the NSDUH and the MTF are administered on an annual basis, whereas the YRBS collects data every 2 years.
Survey administration location
As school-based surveys, the MTF and YRBS collect data only on youth currently enrolled in school. Data from the NSDUH cover both youth enrolled in school and those not enrolled. Given the setting of the survey administration, there are different levels of anonymity. For example, youth are more likely to feel comfortable about revealing sensitive information, such as alcohol and other drug use, in the more anonymous school setting than in the home setting (Faden et al. 2004; Fendrich and Johnson 2001; Fowler and Stringfellow 2001; Sudman 2001). On the other hand, youth may also be responding to perceived peer influence in the school setting and may exaggerate their reported risk behaviors, although such effects are hard to assess (Fowler and Stringfellow 2001; Harrison 2001). Thus, whereas alcohol consumption rates may be under-reported in the NSDUH, they may be inflated in the MTF and YRBS data sets.
Question wording
The three surveys differ in the number and wording of questions on alcohol consumption and on related risk behaviors. The reference period for all surveys is generally the past 30 days. However, for binge drinking the MTF asks about drinking in the past two weeks whereas the other surveys ask about drinking in the past month. Age at onset is asked in the NSDUH and the YRBS, but grade at onset is asked in the MTF survey. All surveys ask about driving under the influence, but the MTF frames the question around whether the respondent has ever gotten a moving violation ticket or warning after drinking alcohol. The Appendix specifies the wording used in each survey for the indicators included in the report. Data tables and figures are not provided for all questions listed.
METHODS
This surveillance report tracks consumption and associated behaviors among youth ages 12 through 20 years old. This corresponds on the lower limit to the youngest age for which nationally representative data are available (from NSDUH), and, on the upper limit, to the last year before youth are legally allowed to drink alcohol. Findings are presented for 1991 through 2003, the latest year for which data are available for this report from all three data sources. For new indicators collected only in the past several years, all available data are reported (i.e., detailed data by race, data on selected alcohol-related risk behaviors).
Definitions
The report presents trend data on different categories of indicators for alcohol consumption and related risk behaviors, including prevalence of use, pattern of use, alcohol-related attitudes, and alcohol-related risk behaviors. Definitions of measures used are provided below, including descriptions of calculated measures:
Prevalence of use
Any drinking of alcohol in the past 30 days (more than just a sip or two from a drink)
Onset of use
Age at first use of alcohol
Initiating drinking at age 12 years or younger
Frequency of use
Number of drinking days in the past 30 days
Quantity of use
Number of drinks on drinking days in the past 30 days
Volume of use
Total number of drinks in the past 30 days, computed as frequency multiplied by average quantity in the past 30 days
Binge drinking
Any drinking of 5 or more drinks in a row in the past 30 days (for NSDUH and YRBS data) or in the past two weeks (for MTF data)
Frequency of drinking 5 or more drinks in a row in the past 30 days
Frequency of drinking 5 or more drinks in a row in the past 30 days, categorized as 0 days, 1–2 days, 3–4 days, and 5 or more days
Drunkenness
Frequency of being drunk or very high from drinking in the past 30 days
Alcohol-related attitudes
Disapproval of consuming one or two drinks nearly every day, categorized as don’t disapprove, disapprove, and strongly disapprove
Disapproval of consuming five or more drinks once or twice each weekend, categorized as don’t disapprove, disapprove, and strongly disapprove
Perception of risk of harm for those drinking one or two drinks nearly every day, categorized as no risk, slight risk, moderate risk, and great risk
Perception of risk of harm for those drinking five or more drinks once or twice each weekend, categorized as no risk, slight risk, moderate risk, and great risk
Alcohol-related risk behaviors
Driving after drinking alcohol in the past 30 days
Riding in a car driven by someone who had been drinking in the past 30 days
Drinking alcohol or using drugs before last sexual intercourse
Drinking on school property in the past 30 days
Drinking and activity with risk of physical danger in the past 12 months
Drinking and getting into legal trouble in the past 12 months
Problems with family or friends caused by drinking in the past 12 months
Analyses
This report examines a wide range of relevant data over multiple years and discusses observed changes without reference to more complicated statistical analyses of trends, such as those used by Faden and Fay (2004). For different analyses, data are presented by sex, race (non-Hispanic white and non-Hispanic black) and Hispanic origin, age or current school grade, and school enrollment status. More detailed data by race and Hispanic origin (non-Hispanic white, non-Hispanic black, Native American/ Alaska Native, Asian/Native Hawaiian Islander/Other Pacific Islander, Hispanic, more than one race) are presented in the tables for years 1999–2003. To increase the stability of estimates, prevalence estimates by age are presented in age groupings, specifically 12–14, 15–17, and 18–20. Trend data from the three data sources are compared in separate graphs for selected indicators. Because of the large age span of the NSDUH and its inclusion of youth enrolled and not enrolled in school, more detailed analyses by demographic characteristics are presented for the NSDUH only. We present results from primary data analysis for NSDUH and YRBS data, as publicly- available data on these surveys do not cover all the indicators, categories, and age groupings applicable to this report. Applicable estimates by grade are publically available for MTF data, and these are presented in tables in this report to facilitate comparison with publicly-available data. We present primary analysis results for MTF estimates across grade, as these aggregate estimates are not publicly-available. Some MTF indicators are available from only a subsample, as not all questions were included on all survey forms. We note in the MTF figures and tables when estimates are based on less than the full sample.
To ensure reliability of findings presented, all cases with outliers were censored. Specifically, cases with reported alcohol consumption of greater than 50 drinks per drinking day were truncated at 50 drinks on drinking days. Cases with missing values for an indicator of interest were excluded from analysis for that indicator. The stability of estimates (r) was assessed using the relative standard error (RSE), computed as RSE=100 x (SE(r)/r). Following the recom-mendations of the National Center for Health Statistics (Klein et al. 2002), estimates with RSE>17.5 percent were considered of low reliability and are marked in the tables with the symbol #.
Limitations
Due to differences in sample population (i.e., only school-enrolled youth vs. both enrolled and not enrolled youth) and survey administration (i.e., in school vs. in home), comparisons among the three data sources need to be made with caution. Although it is not appropriate to compare prevalence estimates across surveys within a single year, it is possible to compare trends across years. For example, there are marked differences in absolute values of past 30 day alcohol consumption prevalence among findings from the NSDUH, the MTF, and the YRBS, however, trend lines from all three surveys show a decrease in prevalence between 1991 and 2003.
Furthermore, the NSDUH also had a major change of design during this period. Close examination of the NSDUH trend for past 30 day consumption shows a steep decrease in rates between 1998 and 1999 followed by an increase from 1999 to 2003. It is not clear if this is a real increase or an artifact of the 1999 methodological changes. Further improvements in data collection quality control were institutionalized in 2002, which may have resulted in higher self-reported substance use by respondents (SAMHSA 2003). Caution needs to be taken in comparing estimates from before and after 1999, as well as from before and after 2002. The major change in survey methodology of 1999 is marked with shading in the graphs included in this report. Prevalence estimates from the NSDUH included in this report may differ slightly from those presented in reports issued by SAMHSA, as SAMHSA analysts use a restricted-use dataset for their analyses.
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Figure 1-1. Prevalence of drinking in the past 30 days, by sex, 1991–2003
Figure 1-2. NSDUH: Prevalence of drinking in the past 30 days among 12–20 year olds, by sex and race/Hispanic origin, 1991–2003
Figure 1-3. NSDUH: Prevalence of drinking in the past 30 days among 12–20 year olds, by enrollment status, 1991–2003
Figure 2-1. NSDUH and YRBS: Prevalence of initiating drinking at age 12 years or younger, by sex, 1991–2003
Figure 2-2. NSDUH: Mean age at first use of alcohol among 12–20 year olds, by sex and race/Hispanic origin, 1991–2003
Figure 2-3. NSDUH: Mean age at first use of alcohol among 12–20 year olds, by school enrollment status, 1991–2003
Figure 3-1. NSDUH: Mean frequency of drinking in the past 30 days among 12–20 year olds, by sex and race/Hispanic origin, 1991–2003
Figure 3-2. NSDUH: Mean frequency of drinking in the past 30 days among 12–20 year olds, by age, sex, and race/Hispanic origin, 2003
Figure 4-1. NSDUH: Mean quantity on drinking days in the past 30 days among 12–20 year olds, by sex and race/Hispanic origin, 1991–2003
Figure 4-2. NSDUH: Mean quantity on drinking days in the past 30 days among 12–20 year olds, by age, sex, and race/Hispanic origin, 2003
Figure 5-1. NSDUH: Average total number of drinks in the past 30 days among 12–20 year olds, by sex and race/Hispanic origin, 1991–2003
Figure 5-2. NSDUH: Average total number of drinks in the past 30 days among 12–20 year olds, by age, sex, and race/Hispanic origin, 2003
Figure 6-1. Prevalence of binge drinking, by sex, 1991–2003
Figure 6-2. NSDUH: Mean number of binge drinking days in the past 30 days among 12–20 year olds, by sex, and race/Hispanic origin, 1991–2003
Figure 6-3. NSDUH: Mean number of binge drinking days in the past 30 days among 12–20 year olds, by school enrollment status, 1991–2003
Figure 6-4. NSDUH: Frequency of binge drinking in the past 30 days among 12–20 year olds, by category (0 days, 1–2 days, 3–4 days, 5+ days), sex, and race/Hispanic origin, 1991–2003
Figure 7. MTF: Prevalence of having been drunk or very high from drinking alcoholic beverages in the past 30 days among 8th, 10th, and 12th graders, by sex, 1991–2003
Figure 8-1a. MTF: Percent distribution of disapproval towards taking one or two drinks nearly every day among 8th, 10th, and 12th graders, by sex, 1991–2003
Figure 8-1b. MTF: Percent distribution of disapproval towards having five or more drinks once or twice each weekend among 8th, 10th, and 12th graders, by sex, 1991–2003
Figure 8-2a. MTF: Percent distribution of perceived risk of harm by having one or two drinks nearly every day among 8th, 10th, and 12th graders, by sex, 1991–2003
Figure 8-2b. MTF: Percent distribution of perceived risk of harm by having five or more drinks once or twice each weekend among 8th, 10th, and 12th graders, by sex, 1991–2003
Figure 8-2c. NSDUH: Percent distribution of perceived risk of harm by having five or more drinks once or twice a week among 12–20 year olds, by sex, 1991–2003
Figure 9-1a. NSDUH: Prevalence of driving a vehicle while under the influence of alcohol in the past 12 months among 12–20 year olds, by sex and race/Hispanic origin, 1995–2003
Figure 9-1b. YRBS: Prevalence of driving after drinking alcohol in the past 30 days, by sex and race/Hispanic origin, 1991–2003
Figure 9-1c. YRBS: Prevalence of riding in a car driven by someone who had been drinking in the past 30 days, by sex and race/Hispanic origin, 1991–2003
Figure 9-2. YRBS: Prevalence of drinking alcohol or using drugs before last sexual intercourse, by sex, 1991–2003
Figure 9-3. YRBS: Prevalence of ever drinking on school property in the past 30 days, by sex, 1993–2003
Figure 9-4. NSDUH: Prevalence of drinking and activity with risk of physical danger in the past 12 months among 12–20 year olds, by sex, 2000–2003
Figure 9-5. NSDUH: Prevalence of drinking and getting into legal trouble in the past 12 months among 12–20 year olds, by sex, 2000–2003
Figure 9-6. NSDUH: Prevalence in the past 12 months of problems with family or friends caused by drinking among 12–20 year olds, by sex, 2000–2003
Table 1-1. NSDUH: Prevalence of drinking in the past 30 days, by age, sex, and race/Hispanic origin, among 12–20 year olds, United States, 1991–2003
Table 1-2. MTF: Prevalence of drinking in the past 30 days, by grade and sex, United States, 1991–2003
Table 1-3. YRBS: Prevalence of drinking in the past 30 days, by grade and sex, United States, 1991–2003
Table 2-1. NSDUH: Mean age at first use of alcohol, by age, sex, and race/Hispanic origin, among ever drinkers ages 12–20, United States, 1991–2003
Table 2-2. NSDUH: Prevalence of initiating drinking at age 12 years or younger, by sex, among ever drinkers ages 12–20, United States, 1991–2003
Table 2-3. YRBS: Prevalence of initiating drinking at age 12 years or younger, by sex, among ever drinkers, United States, 1991–2003
Table 3. NSDUH: Mean frequency of drinking in the past 30 days, by age, sex, and race/Hispanic origin, among current drinkers ages 12–20, United States, 1991–2003
Table 4. NSDUH: Mean quantity of drinking on drinking days in the past 30 days, by age, sex, and race/Hispanic origin, among current drinkers ages 12–20, United States, 1991–2003
Table 5. NSDUH: Average total number of drinks in the past 30 days, by age, sex, and race/Hispanic origin, among current drinkers ages 12–20, United States, 1991–2003
Table 6-1. NSDUH: Prevalence of binge drinking in the past 30 days, by age, sex, and race/Hispanic origin, among 12–20 year olds, United States, 1991–2003
Table 6-2. MTF: Prevalence of binge drinking in the past 2 weeks, by grade and sex, United States, 1991–2003
Table 6-3. YRBS: Prevalence of binge drinking in the past 30 days, by grade and sex, United States, 1991–2003
Table 6-4. NSDUH: Mean number of binge drinking days in the past 30 days, by age, sex, and race/Hispanic origin, among current drinkers ages 12–20, United States, 1991–2003
Table 7. MTF: Prevalence of having been drunk or very high from drinking alcoholic beverages in the past 30 days by grade and sex, United States, 1991–2003
Table 8. NSDUH: Prevalence of driving a vehicle while under the influence of alcohol in the past 12 months, by age, sex, and race/Hispanic origin, among 12–20 year olds, United States, 1995–2003
Appendix A. Differences Among Survey Data Sources
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