Underage Drinking

Consequences of Underage Drinking

Excerpts from The Surgeon General’s Call to Action To Prevent and Reduce Underage Drinking

All text in this fact sheet is excerpted directly from The Surgeon General’s Call to Action To Prevent and Reduce Underage Drinking, a 2007 report from the Office of the Surgeon General.

The short- and long-term consequences that arise from underage alcohol consumption are astonishing in their range and magnitude, affecting adolescents, the people around them, and society as a whole. Adolescence is a time of life characterized by robust physical health and low incidence of disease, yet overall morbidity and mortality rates increase 200 percent between middle childhood and late adolescence/early adulthood (Surgeon General’s Call to Action, page 10).

This dramatic rise is attributable in large part to the increase in risk-taking, sensation-seeking, and erratic behavior that follows the onset of puberty and which contributes to violence, unintentional injuries, risky sexual behavior, homicide, and suicide1 (Call to Action, page 10).

Alcohol frequently plays a role in these adverse outcomes and the human tragedies they produce. Among the most prominent adverse consequences of underage alcohol use are those listed below.

Annually, about 5,000 people under age 21 die from alcohol-related injuries involving underage drinking. Approximately:

  • 1,900 (38 percent) of the 5,000 deaths involve motor vehicle crashes,
  • 1,600 (32 percent) result from homicides, and
  • 300 (6 percent) result from suicides2 (Call to Action, page 10).

Underage drinking:

  • Plays a significant role in risky sexual behavior, including unwanted, unintended, and unprotected sexual activity, and sex with multiple partners. Such behavior increases the risk for unplanned pregnancy and for contracting sexually transmitted diseases (STDs), including infection with HIV, the virus that causes AIDS3 (Call to Action, page 10).
  • Increases the risk of physical and sexual assault4 (Call to Action, page 10).
  • Is associated with academic failure5 (Call to Action, page 11).
  • Is associated with illicit drug use6 (Call to Action, page 11).
  • Is associated with tobacco use7 (Call to Action, page 11).
  • Can cause a range of physical consequences, from hangovers to death from alcohol poisoning (Call to Action, page 11).
  • Can cause alterations in the structure and function of the developing brain, which continues to mature into the mid- to late twenties, and may have consequences reaching far beyond adolescence8 (Call to Action, page 11).
  • Creates secondhand effects that can put others at risk. Loud and unruly behavior, property destruction, unintentional injuries, violence, and even death because of underage alcohol use afflict innocent parties. For example, about 45 percent of people who die in crashes involving a drinking driver under the age of 21 are people other than the driver.9Such secondhand effects often strike at random, making underage alcohol use truly everybody’s problem (Call to Action, page 11).
  • In conjunction with pregnancy, may result in fetal alcohol spectrum disorders, including fetal alcohol syndrome, which remains a leading cause of mental retardation10 (Call to Action, page 11).
  • Is a risk factor for heavy drinking later in life,11 and continued heavy use of alcohol leads to increased risk across the lifespan for acute consequences and for medical problems such as cancers of the oral cavity, larynx, pharynx, and esophagus; liver cirrhosis; pancreatitis; and hemorrhagic stroke12 (Call to Action, pages 10-11).

There Is a High Prevalence of Alcohol Use Disorders Among the Young.

Early alcohol consumption by some young people will result in an alcohol use disorder-that is, they will meet diagnostic criteria for either alcohol abuse or dependence. . . . Figure 2 shows that the highest prevalence of alcohol dependence is among people ages 18-20 (Call to Action, page 4).

In other words, the description these young people provide of their drinking behavior meets the criteria for alcohol dependence set forth in the most recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-DSM-IV and DSM-IV-TR13 (Call to Action, page 4).

Early Onset of Drinking Can Be a Marker for Future Problems, Including Alcohol Dependence and Other Substance Abuse.

Approximately 40 percent of individuals who report drinking before age 15 also describe their behavior and drinking at some point in their lives in ways consistent with a diagnosis for alcohol dependence. This is four times as many as among those who do not drink before age 21.14 (Call to Action, page 12).

The Negative Consequences of Alcohol Use on College Campuses Are Widespread.

Alcohol consumption by underage college students is commonplace, although it varies from campus to campus and from person to person. Indeed, many college students, as well as some parents and administrators, accept alcohol use as a normal part of student life. Studies consistently indicate that about 80 percent of college students drink alcohol, about 40 percent engage in binge drinking,15 and about 20 percent engage in frequent episodic heavy consumption, which is bingeing three or more times over the past 2 weeks.16 The negative consequences of alcohol use on college campuses are particularly serious and pervasive (Call to Action, pages 12-13). For example:

  • An estimated 1,700 college students between the ages of 18 and 24 die each year from alcohol-related unintentional injuries, including motor vehicle crashes17 (Call to Action, page 13).
  • Approximately 600,000 students are unintentionally injured while under the influence of alcohol18 (Call to Action, page 13).
  • Approximately 700,000 students are assaulted by other students who have been drinking19 (Call to Action, page 13).
  • About 100,000 students are victims of alcohol-related sexual assault or date rape20 (Call to Action, page 13).

Underage Military Personnel Engage in Alcohol Use That Results in Negative Consequences.

Problems among underage military drinkers include: serious consequences (15.8 percent); alcohol-related productivity loss (19.5 percent); and as indicated by AUDIT scores,21 hazardous drinking (25.7 percent), harmful drinking (4.6 percent), or possible dependence (5.5 percent)22 (Call to Action, page 13).

Children of Alcoholics Are Especially Vulnerable to Alcohol Use Disorders.

Children of alcoholics (COAs) are between 4 and 10 times more likely to become alcoholics than children from families with no alcoholic adults23 and therefore require special consideration when addressing underage drinking. COAs are at elevated risk for earlier onset of drinking24 and earlier progression into drinking problems25 (Call to Action, pages 13-14).


  1. R. E. Dahl, “Adolescent brain development: A period of vulnerabilities and opportunities,” (Keynote address) Annals of the New York Academy of Sciences 1021 (2004):1-22.
  2. Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control (NCIPC). WebBased Injury Statistics Query and Reporting System (WISQARS) 2004; R. Hingson and D. Kenkel, “Social health and economic consequences of underage drinking” in: Reducing Underage Drinking: A Collective Responsibility (Washington, DC: National Academies Press, 2004), 351-382.; D. T. Levy, T. R.. Miller, and K. C. Cox, Costs of Underage Drinking (Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, 1999); National Highway Traffic Safety Administration (NHTSA)., Traffic Safety Facts 2002: Alcohol, DOT Pub. No. HS-809-606 (Washington, DC: NHTSA, National Center for Statistics and Analysis, 2003); G. S. Smith, C. C. Branas, and T. R. Miller, “Fatal nontraffic injuries involving alcohol: A metaanalysis,” Annals of Emergency Medicine 33 (1999):659-668.
  3. M. L. Cooper and H. K. Orcutt, “Drinking and sexual experience on first dates among adolescents,” Journal of Abnormal Psychology 106 (1997):191-202; M. L. Cooper, R. S. Pierce, and R. F. Huselid, “Substance use and sexual risk taking among black adolescents and white adolescents,” Health Psychology 13 (1994):251-262.
  4. R. Hingson, T. Heeren, M. Winter, et al, “Magnitude of alcohol-related mortality and morbidity among U.S. college students age 18-24: Changes from 1998 to 2001,” Annual Review of Public Health 26 (2005):259-279.
  5. J. A. Grunbaum, L. Kann, L., S. Kinchen, et al, “Youth risk behavior surveillance-United States, 2003,” MMWR Surveillance Summaries: Morbidity and Mortality Weekly Report Summary 53(2):1-96, May 21, 2004. Errata in MMWR Morbidity and Mortality Weekly Report 53(24):536, June 25 2004; 54(24):608, June 24, 2005.
  6. Ibid.
  7. S. Shiffman and M. Balabanis, “Associations between alcohol and tobacco,” in Alcohol and Tobacco: From Basic Science to Clinical Practice, NIAAA Research Monograph No. 30, NIH Pub. No. 95-3931 (Washington, DC: U.S. Govt. Print. Off., 1995), 17-36.
  8. S. A. Brown, S. F. Tapert, E. Granholm, et al, “Neurocognitive functioning of adolescents: Effects of protracted alcohol use,” Alcoholism: Clinical and Experimental Research 24 (2000):164-171; F. T. Crews, C. J. Braun, B. Hoplight, et al, “Binge ethanol consumption causes differential brain damage in young adolescent rats compared with adult rats,” Alcoholism: Clinical and Experimental Research 24 (2000):1712-1723; M. D. De Bellis, D. B. Clark, S. R. Beers, et al “Hippocampal volume in adolescent-onset alcohol use disorders,” American Journal of Psychiatry 157 (2000):737-744; H. S. Swartzwelder, W. A. Wilson, and M. I. Tayyeb, “Age-dependent inhibition of long-term potentiation by ethanol in immature versus mature hippocampus,” Alcoholism: Clinical and Experimental Research 19 (1995):1480-1485; H. S. Swartzwelder, W. A. Wilson, and M. I. Tayyeb, “Differential sensitivity of NMDA receptor-mediated synaptic potentials to ethanol in immature versus mature hippocampus,” Alcoholism: Clinical and Experimental Research 19 (1995):320-323; S. F. Tapert and S. A. Brown, “Neuropsychological correlates of adolescent substance abuse: Four-year outcomes,” Journal of the International Neuropsychological Society 5 (1999):481-493; A. M. White and H. S. Swartzwelder, “Age-related effects of alcohol on memory and memory-related brain function in adolescents and adults,” in Recent Developments in Alcoholism, Vol. 17: Alcohol Problems in Adolescents and Young Adults: Epidemiology, Neurobiology, Prevention, Treatment, (New York: Springer, 2005), 161-176.
  9. U.S. Department of Transportation Fatality Analysis Reporting System 2004.
  10. K. L. Jones and D. W. Smith, “Recognition of the fetal alcohol syndrome in early infancy,” Lancet 2(7836):999-1001, 1973.
  11. J. D. Hawkins, J. W. Graham, E. Maguin, et al, “Exploring the effects of age of alcohol initiation and psychosocial risk factors on subsequent alcohol misuse,” Journal of Studies on Alcohol 58 (1997): 280-290; J. E. Schulenberg, K. N. Wadsworth, P. M. O’Malley, et al, “Adolescent risk factors for binge drinking during the transition to young adulthood: Variable- and pattern-centered approaches to change,” Developmental Psychology 32 (1996):659-674.
  12. Alcohol Research & Health, Alcohol and Disease Interactions Vol. 25, No. 4, 2001.
  13. American Psychiatric Association (APA), Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (Washington, DC: APA, 1994); American Psychiatric Association (APA), Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision(Washington, DC: APA, 2000).
  14. B. F. Grant and D. A. Dawson, “Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey,” Journal of Substance Abuse 9 (1997):103-110.
  15. In college studies, binge drinking is usually defined as “five or more drinks in a row for men and four or more drinks in a row for women” (National Institute on Alcohol Abuse and Alcoholism [NIAAA] National Advisory Council). The definition was refined by the NIAAA National Advisory Council in 2004 as follows: “A ‘binge’ is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gram percent or above. For the typical adult, this pattern corresponds to consuming 5 or more drinks (male), or 4 or more drinks (female), in about 2 hours.” It is a criminal offense in every State for an adult to drive a motor vehicle with a blood alcohol level of 0.08 gram percent or above.
  16. National Institute on Alcohol Abuse and Alcoholism (NIAAA), A Call to Action: Changing the Culture of Drinking at U.S. Colleges(Bethesda, MD: NIAAA, 2002).
  17. R. Hingson, T. Heeren, M. Winter, et al, “Magnitude of alcohol-related mortality and morbidity among U.S. college students age 18-24: Changes from 1998 to 2001,” Annual Review of Public Health 26 (2005):259-279.
  18. Ibid.
  19. Ibid.
  20. Ibid.
  21. The Alcohol Use Disorders Identification Test (AUDIT), which was developed by the World Health Organization, consists of 10 questions scored 0 to 4 that are summed to yield a total score ranging from 0 to 40. It is used to screen for excessive drinking and alcohol-related problems. Scores between 8 and 15 are indicative of hazardous drinking, scores between 16 and 19 suggest harmful drinking, and scores of 20 or above warrant further diagnostic evaluation for possible alcohol dependence.
  22. R. M. Bray, L. L. Hourani, K. L. R. Olmsted, et al, 2005 Department of Defense Survey of Health Related Behaviors Among Military Personnel (Research Triangle Park, NC: RTI International, 2006).
  23. M. Russell, “Prevalence of alcoholism among children of alcoholics,” in Children of Alcoholics: Critical Perspectives (New York: Guilford, 1990), 9-38.
  24. J. E. Donovan, “Adolescent alcohol initiation: A review of psychosocial risk factors,” Journal of Adolescent Health 35 (2004):529e7-529e18.
  25. B. F. Grant and D. A. Dawson, “Age at onset of drug use and its association with DSMIV drug abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey,” Journal of Substance Abuse 10 (1998):163-173.

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