full text

RESEARCH REPORT

2004 Society for the Study of Addiction doi:10.1111/j.1360-0443.2004.00846.x

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Blackwell Science, Ltd

Oxford, UK

ADDAddiction

0965-2140 2004 Society for the Study of Addiction

99Original Article

Alcohol disorders and adolescent alcohol consumptionYvonne A. Bonomo et al.

Correspondence to:

Yvonne Bonomo 5462 Gertrude Street Fitzroy 3065 Victoria Australia Tel:

+

61 39814 8444 E-mail: [email protected]

Submitted 28 November 2003; initial review completed 9 January 2004;

final version accepted 6 May 2004

RESEARCH REPORT

Teenage drinking and the onset of alcohol dependence: a cohort study over seven years

Yvonne A. Bonomo

1

, Glenn Bowes

2

, Carolyn Coffey

1

, John B. Carlin

3

& George C. Patton

1

1

Centre for Adolescent Health, Murdoch Childrens Research Institute and Department of Paediatrics, University of Melbourne,

2

Department of Paediatrics, University of Melbourne, Royal Childrens Hospital, Parkville, Melbourne and

3

Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute

and Department of Paediatrics, University of Melbourne

ABSTRACT

Aim

To determine whether adolescent alcohol use and/or other adolescenthealth risk behaviour predisposes to alcohol dependence in young adulthood.

Design

Seven-wave cohort study over 6 years.

Participant

A community sample of almost two thousand individuals fol-lowed from ages 1415 to 2021 years.

Outcome measure

Diagnostic and Statistical Manual

volume IV (DSM-IV) alco-hol dependence in participants aged 2021 years and drinking three or moretimes a week.

Findings

Approximately 90% of participants consumed alcohol by age20 years, 4.7% fulfilling DSM-IV alcohol dependence criteria. Alcohol depen-dence in young adults was preceded by higher persisting teenage rates of fre-quent drinking [odds ratio (OR) 8.1, 95% confidence interval (CI) 4.2, 16],binge drinking (OR 6.7, 95% CI 3.6, 12), alcohol-related injuries (OR 4.5 95%CI 1.9, 11), intense drinking (OR 4.8, 95% CI 2.6, 8.7), high dose tobacco use(OR 5.5, 95% CI 2.3, 13) and antisocial behaviour (OR 5.9, 95% CI 3.3, 11).After adjustment for other teenage predictors frequent drinking (OR 3.1, 95%CI 1.2, 7.7) and antisocial behaviour (OR 2.4, 95% CI 1.2, 5.1) held persistingindependent associations with later alcohol dependence. There were no pro-spective associations found with emotional disturbance in adolescence.

Conclusion

Teenage drinking patterns and other health risk behaviours inadolescence predicted alcohol dependence in adulthood. Prevention and earlyintervention initiatives to reduce longer-term alcohol-related harm thereforeneed to address the factors, including alcohol supply, that influence teenageconsumption and in particular high-risk drinking patterns.

KEYWORDS

Adolescence, alcohol, alcohol abuse, alcohol dependence,

cannabis, depression, emotional problems, young adults.

INTRODUCTION

Alcohol now features prominently in the social interac-tion of teenagers in many countries. Among Australianteenagers, approximately two-thirds report that they arerecent drinkers and around one-third drink weekly [1].Figures for binge drinking vary between countries, from15% of young Australians [1] to one-third of students in

Denmark, Ireland, Poland and the United Kingdom [2].The most common adverse consequences of such pat-terns of drinking in young people include the acutephysiological effects of excessive alcohol (blackouts,hangovers, etc.) and behavioural effects (violence, unsafesexual intercourse) [3].

Also disturbing are the significant rates of alcoholdependence found among young adults. Twelve-month

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prevalence rates for alcohol disorders are similar acrosswestern countries estimated to be at least 5% for malesand 2% for females [46] and, contrary to the popularimpression that alcohol disorders are most prevalentamong adults aged in their mid-40s, their prevalence ishighest among young adults. This raises questionsabout the benign view of teenage drinking as a phasethat will abate with maturity. Insight into this issue ishampered by the lack of studies of appropriate design.Cross-sectional research does not capture the variabil-ity in alcohol consumption characteristic of adoles-cence. Retrospective longitudinal studies are limited bybias in the recall of drinking patterns during teen years.Prospective studies that have been conducted such asthe Swedish conscript study commenced their follow-uponly in late adolescence/early adulthood and definedtheir outcome measure as a diagnosis of alcoholismrequiring admission to psychiatric care [7]. The resultscannot therefore be extrapolated readily to the currentsocial context where alcohol consumption by youngpeople is occurring earlier [8] and more heavily, result-ing in symptoms of alcohol dependence that do notreach clinical services until much later (if at all). Thisstudy used a large community-based sample of adoles-cents followed prospectively to adulthood to examinewhich teenage patterns of drinking (and other healthrisk behaviour) predict the development of

Diagnosticand Statistical Manual

volume IV (DSM-IV) alcoholdependence.

METHODS

Procedure and sample

Between August 1992 and December 1998 a seven-wavecohort study of adolescent health was conducted in Vic-toria, Australia. The cohort was defined using a two-stageprocedure. At stage 1, 45 schools from a stratified frameof government, catholic and independent schools (totalnumber of students 60 905) were selected randomly. Atstage 2, a single intact class from each participatingschool was selected at random to constitute the wave 1sample. To augment the cohort sample size yet avoidexcessive burden on schools, recruitment to the studywas spread over two different school years: when thewave 1 sample had moved into year 10, a second classfrom each participating school was selected at random.One school from the initial cross-sectional survey wasunavailable for study, leaving a total of 44 schools. At thetime of sampling, 98% of Victorian school students werestill recorded as present in the education system [9]. Par-ticipants were reviewed biannually during the teens(waves 16) with final follow-up at age 20/21 years(wave 7).

Adolescent phase: waves 16

Written parental consent for participation was sought atentry of the students into the study. The students com-pleted measures at intervals of 6 months between year 9and year 12 (six waves). Laptops were used to administerthe questionnaire [10]. Subjects unavailable for follow-up at school were interviewed by telephone. A total of1943 adolescents (96% of the intended sample) partici-pated at least once during waves 16 with a gender ratio(males: 48.6%) similar to that in Victorian schools at thetime of sampling [9].

Missing data: waves 16

Seventy per cent of the cohort completed five waves ofdata collection. As recruitment into the cohort wasstaged over the first two waves, 54% of observations werenot present in the first wave of data collection. Propor-tions for missing observations in subsequent waves were11%, 13%, 16%, 19% and 21% for waves 2, 3, 4, 5 and 6,respectively. Multiple imputation was used to handle this,enabling summary measures to be defined for each par-ticipant in each of five completed data sets. Final resultswere obtained by combining analyses from the fiveimputed data sets (see below). Imputation was performedusing a multivariate mixed effects model [11].

Young adult survey (wave 7, 1998)

The young adult survey was carried out by telephoneusing computer-assisted interviews. Mean age of wave 7participants was 20.7 years (SD 0.5); 46.0% were male(Fig. 1).

A total of 1601 young adults (82% of all cohort par-ticipants) were interviewed between April and December1998. Three hundred and forty-two participants werenot interviewed at wave 7; 152 refused, 59 were locatedbut unable to be contacted, 129 were lost to follow-upand two had died from natural causes.

Outcome measure: alcohol dependence in young adulthood

The young adult survey incorporated the CompositeInternational Diagnostic Interview (CIDI) to assess DSM-IV alcohol dependence [1215] according to standardDSM criteria. The CIDI is a structured diagnostic inter-view designed for use by non-clinical professionals andhas been demonstrated to be both reliable and cross-cul-turally valid [1215].

A pragmatic consideration in the conduct of a cohortstudy is the maintenance of participant cooperation bythe minimization of avoidable responder fatigue. It was


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considered unlikely that a diagnosis of alcohol depen-dence was consistent with only occasional alcohol use,given the DSM-IV description of substance dependenceas repeated (substance) self-administration. Conse-quently, the CIDI interview was administered only tothose participants who reported using alcohol at leastthree times a week. Our outcome is therefore defined asalcohol dependence in frequent alcohol users.

Background factors

Demographic factors and parental alcohol and tobacco use

Demographic factors and parental alcohol and tobaccouse were included as indicators of socio-economic statusand of environmental exposure to substances, recognizedas risk factors for alcohol disorders. Demographic factorsincluded gender and country of birth. Participants werealso asked at each wave to report their parents maritalstatus (married,

de facto

, divorced, single or dead) andtheir parents highest level of education (high schoolnot completed, high school completed, non-universitytertiary education, university education). Variables forparental marital status classifying parental divorce orseparation by wave 6 and parental education were thendefined. Participant report of parental alcohol use wascategorized as none, drank most days or drank everyday. They were also asked whether their parents smokedcigarettes never, occasionally, most days or everyday. Variables derived for parental alcohol and tobaccouse identified whether either parent drank or smokedmost days or every day.

Adolescent risk factors

Alcohol consumption

Alcohol consumption was assessed at each survey. Thoseindividuals who reported drinking alcohol were asked tofill in a diary which recorded categories of alcohol (e.g.

beer, mixed drinks, etc.) and amounts (e.g. glass, can,etc.) consumed in the 7 days prior to the survey. Esti-mates of frequency of consumption and self-reportedalcohol dose were calculated from the responses,enabling the following classifications: (1) frequent drink-ers: defined as drinking on 3 or more days in previousweek; and (2) binge drinkers: defined as consuming 45 gof ethanol or more (equivalent to 5

+

standard drinks)[16].

Alcohol-related consequences

There were three broad categories of alcohol-related con-sequences examined among the adolescents:

1

Intense drinking. Two items in the adolescent phasesurveys asked about intense drinking. The first itemrelated to drinking to a significantly altered consciousstate. Respondents were asked whether they had everconsumed so much alcohol that they could notremember the next day about events the night before.The second item asked the adolescents if they had everfound themselves unable to stop drinking.

2

Alcohol-related accidents or injuries. The adolescentswere asked: In the last 6 months have you had aninjury because of drinking: never, once, more thanonce? They were then asked In the last 6 months haveyou had an accident because of drinking: never, once,more than once?

3

Alcohol-related sexual risk-taking. There were threeitems that related to sexual risk-taking under the influ-ence of alcohol in the adolescent survey. Participantswere asked: In the last 6 months, have you ever hadany of the following problems because of drinking?Having sex with someone and later regretting it? Hav-ing sex without using a contraceptive? Having sex without using a condom?Where two or more adverse outcomes of drinking

were reported, they were classified as being recurrent andassessed as potential risk factors for subsequent alcoholdependence.

Figure 1

Victorian Adolescent Health Cohort Study, 19921998

1st sample 2nd sampleN1=1037 N2=995

wave 1 wave 2 wav 3 wave 4 wave 5 wave 6 wave 7n1=898 n2=1728 n3=1699 n4=1629 n5=1576 n6=1530 n7=1601(87%) (85%) (84%) (80%) (78%) (75%) (79%)

late 1992 early 1993 late 1993 early 1994 late 1994 early 1995 1998

Total intended sample = N1+N2 = 2032Total achieved sample = 1943 (96%)

ADOLESCENT PHASE YOUNGADULTSURVEY


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Tobacco use

Tobacco use was assessed at each survey. Those whoreported that they were smokers were asked to keep a 7-day retrospective smoking diary, in which the individualreported the number of cigarettes smoked on each dayduring the last week. The following groups were catego-rized: (i) occasional smokingin previous month, butless than 6 days in the previous week; (ii) daily smok-ingon 67 days of previous week; and (iii) high dosesmokingdaily, with an average of 10

+

cigarettes perday.

Cannabis use

Cannabis use was assessed by asking the adolescents ateach wave whether they had used marijuana. Those whohad were asked to report how often they had used it in theprevious six months. At least weekly use was defined asfrequent cannabis use.

Antisocial behaviour

Antisocial behavior was assessed at each wave based on10 items from the Self-Report Early Delinquency Scalecovering property damage, interpersonal violence andtheft in previous 6 months [17].

Psychological distress

Depression and anxiety were assessed using the revisedClinical Interview Schedule (CIS-R) [18,19], providingdata on the frequency and severity of 14 common psychi-atric symptoms [20]. The total scores were dichotomizedat 11/12 reflecting a level appropriate for clinical inter-vention [18,21,22].

Peer alcohol use

Participants were asked how many of their friends drankalcohol: none, some, most or dont know. A variablewas defined that classified participants who reported thatmost of their friends drink alcohol.

Explanatory variables: waves 16

Measures of persistence at a defined level of intensity wereconstructed: (i) the number of waves at which a conditionwas reported was counted and classified into three levels:zero, one wave (indicating experimentation), two to sixwaves (indicating persisting exposure); and (ii) maximallevel of cigarette smoking reported during the six waveswas categorized into (none; less than daily; daily and lessthan 10 cigarettes/day; daily and 10 or more cigarettes/day).

Ethics approval

Ethics approval was obtained from the Royal ChildrensHospital Ethics Committee.

Data analysis

Data analysis was undertaken using Stata 7 [23] and fol-lowed the method of Rubin [24] for creating valid infer-ences under the assumptions of the imputation model,combining over separate analyses performed on each ofthe imputed datasets. Software for facilitating these anal-yses was written in Stata [25].

Univariate and multivariate logistic regression analy-ses were performed on the binary outcome of alcoholdependence. The Wald test was used to assess first orderinteractions. All confidence intervals are based on the95% level. Two-tailed

P

-values are reported.

RESULTS

Alcohol dependence in young adulthood (wave 7)

Of the 1601 wave 7 young adults, 1374 consumed alco-hol in the previous year and 124 reported drinking atleast three times a week. Sixty-eight (55% of participantsdrinking three or more times a week) fulfilled DSM-IValcohol dependence criteria. They were more likely to bemale (OR 3.7, 95% CI 2.1, 6.5), have divorced parents(OR 1.7, 95% CI 1.0, 3.0) and to have at least one parentwho drank alcohol most days (OR 2.0, 95% CI 1.2, 3.2)(Table 1). Ninety-six per cent (CI 93%, 98%) of theseadults had reported drinking during the adolescent phase(waves 16).

Univariate associations between alcohol dependence in frequent drinkers (wave 7) and adolescent exposures (waves 16)

Frequent drinking and binge drinking in adolescentwaves 16 defined separate groups of individuals(Table 2). Frequent drinkers in adulthood were assessedfor the frequency of adolescent factors and for crude asso-ciations with alcohol dependence (Table 3).

Persistence of drinking patterns and alcohol-related behaviour

Frequent drinking and binge drinking each showedstrong associations with alcohol dependence in youngadulthood. Recurrent reports increased odds for laterdependence at least sixfold (recurrent frequent drinking:OR 8.1, 95% CI 4.2, 16; recurrent binge drinking: OR6.7, 95% CI 3.6, 12). Alcohol dependence was also morelikely with persistent alcohol-related accidents and


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injuries (OR 4.5, 95% CI 1.9, 11) and with intense drink-ing (OR 4.8, 95% CI 2.6, 8.7) but not with alcohol-related sexual risk taking.

Drinking peers

Adolescents who persistently reported that most friendsdrank were eightfold more likely to be alcohol-dependentlater (OR 8.1, 95% CI 2.5, 26).

Cigarette smoking

High dose (10

+

cigarettes) daily smoking in adolescencehad fivefold increased odds of alcohol dependence (OR5.5, 95% CI 2.3, 13).

Cannabis use, antisocial behaviour

Both cannabis use and antisocial behaviour were associ-ated prospectively with alcohol dependence in youngadulthood. The odds increased with increasing frequencyof antisocial behaviour (OR for report at one wave: 2.7,95% CI 1.3, 5.6; OR for report at multiple waves: 5.9,95% CI 3.3, 11).

Psychiatric morbidity

No evidence of association with psychiatric morbiditywas found.

Independent associations between alcohol dependence in frequent drinkers (wave 7) and adolescent exposures (waves 16)

Multiple logistic regression was used to examine indepen-dent predictive associations between alcohol dependencein young adulthood and adolescent measures and toadjust for possible confounding (Table 4). An indepen-dent relationship between alcohol dependence in youngadulthood and frequent teenage drinking was demon-strated, the likelihood increasing with persistence of fre-quent drinking through adolescence (OR for frequentdrinking at one wave: 2.0, 95% CI 1.0, 4.3; OR for fre-quent drinking at multiple waves: 3.1, 95% CI 1.2, 7.7).Adolescent antisocial behaviour was also associatedindependently with alcohol dependence, with individualspersistently reporting such behaviour being approxi-mately 2.5 times more likely to be in the alcohol-depen-dent group in young adulthood (OR 2.4, 95% CI 1.2,

Table 1

Association of background factors with alcohol dependence at the age of 20 years (

n

=

1601): odds ratios (OR) from univariatelogistic regression models.

Background factor

Alcohol dependence at age 20 years

n OR 95% CI

Male 735 3.7 2.1, 6.5Parental divorce/separation by wave 6 284 1.7 1.0, 3.0Parental education

Tertiary 576 1Completed secondary 510 1.7 0.94, 3.2Incomplete secondary 515 1.4 0.77, 2.7

One or both parents drinks most days 568 2.0 1.2, 3.2One or both parents smokes most days 991 1.6 0.94, 2.8

Table 2

Alcohol use from wave 17 in 1601 wave 7 participants. Figures are percentages (standard errors).

Wave of survey

1 2 3 4 5 6 7

Mean age (years) 14.9 15.5 15.9 16.4 16.8 17.4 20.7Non-drinker 57.7 (2.00) 46.1 (1.28) 35.4 (1.27) 27.9 (1.17) 31.6 (1.31) 17.9 (0.99) 14.0 (0.87)No drinking last week 28.6 (1.84) 32.0 (1.20) 37.7 (1.34) 42.0 (1.33) 36.2 (1.37) 46.9 (1.26) 29.3 (1.14)Drank 1 or 2 days last week

Max

45 g/day 5.6 (0.73) 8.6 (0.78) 10.6 (0.87) 14.7 (0.90) 16.9 (0.98) 18.8 (1.02) 30.1 (1.15)Drank 3 or more days last week

Max

45 g/day 1.6 (0.39) 2.8 (0.45) 3.3 (0.47) 3.6 (0.57) 4.1 (0.55) 4.7 (0.55) 11.9 (0.81)


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5.1). No first order interaction effects between genderand any explanatory variable were found.

DISCUSSION

Our study demonstrates that the clearest predictor ofalcohol dependence in young adults was regular recre-ational alcohol use in the teens. Regular drinking clus-tered with a range of health risk behaviours includingbinge drinking, injuries and accidents under theinfluence of alcohol, smoking in high dose and cannabisuse.

Although alcohol dependence has been accepted tra-ditionally as occurring in young adulthood [26,27], thestrong association between frequent teen drinking and

alcohol dependence in adulthood may reflect an alreadyexistent dependence syndrome in adolescence. Surveysbased on both general population and clinical samplesindicate that DSM alcohol disorders are evident at asearly as 1617 years of age [28]. While such data supportthe concept that adolescents can experience alcoholdependence the extrapolation to adolescents of DSM cri-teria developed for adults is problematic. The frequentlyprogressive nature of adult drinking problems and thespectrum of chronic complications (such as liver, pancre-atic and other gastrointestinal injury as well as neurolog-ical and cardiovascular injury) are observed far lessfrequently in adolescents who abuse alcohol. DSM crite-ria for alcohol disorders also appear to have differentimplications for adolescents compared to adults. Forinstance, while tolerance is often considered to have high

Table 3

Estimated frequency of time varying adolescent measures and their association with alcohol dependence in frequent alcohol usersat age 20 years (

n

=

1601): odds ratios (OR) from univariate logistic regression models.

Adolescent measure: waves 16 Category

Estimated frequencyAlcohol dependence at age 20 years

n 95% CI OR 95% CI

Frequent drinking None 1344 1313, 1374 1One wave 169 142, 196 4.4 2.4, 8.4More than one wave 88 68, 108 8.1 4.2, 16

Binge drinking None 900 858, 942 1One wave 298 263, 333 3.0 1.4, 6.7More than one wave 403 367, 439 6.7 3.6, 12

Alcohol-related injuries or accidents: 2 or more behaviours

None 1460 1438, 1483 1One wave 88 70, 106 2.0 0.8, 5.1More than one wave 53 38, 67 4.5 1.9, 11

Alcohol-related sexual risk-taking: 2 or more behaviours

None 1450 1425, 1474 1One wave 97 77, 117 1.5 0.6, 3.8More than one wave 55 40, 69 0.88 0.2, 3.7

Intense drinking: 2 or more behaviours None 1247 1213, 1281 1One wave 204 177, 231 2.1 1.0, 4.2More than one wave 150 125, 176 4.8 2.6, 8.7

Most friends drink alcohol None 413 377, 449 1One wave 220 184, 255 2.3 0.4, 12More than one wave 969 927, 1011 8.1 2.5, 26

Maximal tobacco smoking None 632 578, 686 1Occasional 606 552, 660 2.4 1.0, 5.8Daily,

10 cigs/day 157 133, 181 5.5 2.3, 13Weekly or more frequent cannabis use None 1415 1389, 1440 1

One wave 80 61, 99 4.3 1.7, 10.5More than one wave 106 86, 127 2.7 1.2, 6.1

Antisocial behaviour: 2 or more behaviours

None 1244 1206, 1282 1One wave 188 155, 221 2.7 1.3, 5.6More than one wave 169 144, 194 5.9 3.3, 11

Psychiatric morbidity CIS

>

11 None 857 808, 905 1One wave 245 202, 288 1.2 0.6, 2.8More than one wave 499 462, 537 0.91 0.5, 1.6

CIS, Clinical Interview Schedule.


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specificity in alcohol-dependent adults, it appears to havelow specificity among problem drinking adolescents intreatment [29]. DSM criteria also do not account forinterruptions to adolescent psychosocial development inrecurrent adolescent alcohol abuse.

If the association is not measurement-related, then aprocess of kindling may explain frequent teen drinkingprogressing to dependence. Cycles of regular exposureincrease tolerance to alcohol, which drive escalating con-sumption [27,30,31]. For some, constitutional predispo-sition to heavy intake making it difficult to moderatedrinking may play a role. For example, individuals with afamily history of alcohol abuse have described feeling lessintoxicated at high blood alcohol levels [3234]. Studiesof genetics suggest at least some heritability of vulnera-bility to alcoholism [35,36]. More broadly, there aresignificant social influences that influence heavyconsumption of alcohol by young people today. Theseinclude peer models and normative expectations aboutalcohol which, in large part, are driven by such develop-ments as the production of sweet and colourful alcoholicbeverages with tantalizing names as well as intensivemarketing of alcohol to young people portraying alcoholconsumption as fun and sexy through both traditional

and newer media (internet, SMS texts on mobile phones)[37,38]. These social changes provide challenges indefining what is the healthy norm for adolescent alcoholconsumption.

This study has a number of advantages, includinghigh participation rates and frequent prospective mea-sures during the teens. Alcohol consumption and otherhealth risk behaviours in adolescence were recorded at 6-monthly intervals, capturing some of the variability inbehaviour that is characteristic among adolescents. Itwas also possible to examine adolescent patterns of drink-ing in detail. Apart from quantity and frequency of alco-hol intake, adverse outcomes of adolescent problemdrinking were included in the analysis. The use of multi-ple imputation enabled bias introduced by missing data inthe course of the study to be addressed. This method isvalid under the assumption that the probability that aparticipant is missing a wave can be predicted from dataobserved at other waves (missing at random), and evenunder some departure from this assumption is likely toproduce less biased results than complete-case analyses[39]. Potential selection bias at the inception of the studyis likely to have been minimal because of high schoolretention rates, and there was high ascertainment in the

Table 4

Predictive association of adolescent measures with alcohol dependence in frequent alohol users at age 20 years (

n

=

1601), adjustedfor sex, parental divorce/separation and parental alcohol use: odds ratios (OR) from multivariate logistic regression models.

Adolescent measure: waves 16 Category

Alcohol dependence

at age 20 years

OR 95% CI

Frequent drinking None 1One wave 2.0 1.0, 4.3More than one wave 3.1 1.2, 7.7

Binge drinking None 1One wave 1.5 0.62, 3.6More than one wave 1.4 0.61, 3.4

Alcohol-related injuries or accidents: 2 or more behaviours None 1One wave 0.59 0.21, 1.7More than one wave 0.82 0.27, 2.5

Intense drinking: 2 or more behaviours None 1One wave 1.0 0.47, 2.1More than one wave 1.8 0.82, 4.1

Most friends drink alcohol None 1One wave 1.6 0.27, 9More than one wave 3.2 0.94, 11

Maximal tobacco smoking None 1Occasional 1.5 0.58, 3.8Daily,

10 cigs/day 1.6 0.53, 4.7Weekly or more frequent cannabis use None 1

One wave 1.4 0.51, 4.0More than one wave 0.48 0.17, 1.4

Antisocial behaviour: 2 or more behaviours None 1One wave 1.3 0.58, 2.8More than one wave 2.4 1.2, 5.1


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study with 96% of the sampling frame having partici-pated at least once.

As alcohol consumption among young peopleincreases, evidence is emerging for its potential longer-term impact. At present, there is marked ambivalencewithin the community regarding teenage drinking andwhat constitutes a safe level of alcohol consumption. Thetraditional or conservative opinion is that young peopleshould not consume alcohol until at least age 18 yearsbecause of continuing neurological, particularly cere-bral, development [40,41]. The alternative view is thatalcohol consumption by teenagers is not only acceptablebut of little concern, because it is better than illicit druguse and that periods of blackouts and other complicationsof alcohol use among young people are merely part of therite of passage to adulthood [42]. This ambivalenceresults in a failure to mount a robust defence against theincreasingly assertive marketing of alcohol products toyoung people. In addition, prevention and early interven-tion initiatives to reduce longer-term alcohol-relatedharm need to broaden their focus to include adolescents,in particular uptake of alcohol with other substances andhigh-risk drinking patterns.

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