1. Legal age limits for buying alcohol Peter Anderson MD, MPH, PhD Professor, Substance Use, Policy and Practice, Institute of Health and Society, Newcastle University, England Professor, Alcohol and Health, Faculty of Health, Medicine and Life Sciences, Maastricht University, Netherlands Amsterdam 30 May 2013

2. At the end of 2011, in the Netherlands, 20 14-15 year old ‘mystery’ shoppers each made 10 different purchase attempts with the instructions to go and buy beer (legal purchase age 16 years). Source: van Hoof & Gosselt 2013

3. All 14-15 year olds were able to buy alcohol, for 75% of the time at their first attempt, taking less than 10 minutes to do so. Source: van Hoof & Gosselt 2013

4. In this presentation, we will consider: 1.Adolescent drinking 2.Policy measures to reduce adolescent drinking 3.Legal age limits for buying alcohol

5. In this presentation, we will consider: 1.Adolescent drinking 2.Policy measures to reduce adolescent drinking 3.Legal age limits for buying alcohol

6. Adolescent drinking 1.ESPAD data

7. Source: Hibell et al 2012 Use of alcohol by 15-16 year olds during the past 30 days. ESPAD survey from 36 European countries. Averages for all countries in each of 5 time points, and for 18 countries with data across all 5 time points.

8. Source: Hibell et al 2012 % of 15-16 year olds reporting drinking 5+ drinks on at least one occasion during the past 30 days. ESPAD survey from 36 European countries. Averages for all countries in each of 5 time points, and for 14 countries with data across all 5 time points.

9. Adolescent drinking 1.ESPAD data 2.Brain structure

10. A systematic review identified 5 studies in the age range 14-21 years 7 studies in the age range 22-40 years that related brain structure to heavy drinking. Source: Welch et al 2013

11. There are both similarities and differences when comparing brain structural abnormalities in adolescents and young adults. Women of both groups exhibit prefrontal volume reduction, with prefrontal white matter reduction particularly pronounced in female adolescents. Adolescents of both genders exhibit lower hippocampal volume, whereas reduced corpus callosal area was only reported in young adults.

12. That any brain structural differences are more consistently found in the adolescents compared with young adults is surprising. The young adult group will have been drinking for longer and have consumed more alcohol, so if brain structural differences reflected a direct exposure-response effect, they would be greater in this group.

13. That the opposite is seen suggests that alcohol may be interacting with maturational processes specific to late adolescence.

14. White matter integrity (higher diffusivity, poorer integrity) in adolescents, mean age 18 years, followed-up for 18 months by number of days alcohol used over 18 months Source: Bava et al 2013

15. Adolescent drinking 1.ESPAD data 2.Brain structure 3.Consequences

16. Source: Livingstone & Room 2009 Alcohol use and problems amongst 29,445 Australians surveyed in 2004

17. Source: Livingstone & Room 2009

20. Adolescent drinking 1.ESPAD data 2.Brain structure 3.Consequences 4.Problematic drinking in later life

21. 1970 British cohort study of 17,000 people. Alcohol (g) consumed during previous week at ages 26, 30 and 34 years by whether light or heavy drinker at age 16 years. Source: Finlay & Flanagan 2013

22. OR for risk of harmful alcohol use at mean age 42 years by age at first drink amongst 22,000 US citizens Source: Dawson et al 2008

23. OR for risk of alcohol dependence at mean age 42 years by age at first drink amongst 22,000 US citizens Source: Dawson et al 2008

24. In this presentation, we will consider: 1.Adolescent drinking 2.Policy measures to reduce adolescent drinking 3.Legal age limits for buying alcohol

25. Policy measures to reduce adolescent drinking 1.Price

26. Source: Miller & Droste 2013 485 Australian university students recruited on Facebook - how much were they willing to pay for a drink

27. Policy measures to reduce adolescent drinking 1.Price 2.Advertising

28. The impact of alcohol marketing in digital media on subsequent youth alcohol consumption was studied amongst 6,651 students with a mean age of 14 years from Germany, Italy, the Netherlands and Poland in a longitudinal setting. Source: De Bruijn et al 2013

29. Nearly one third of students reported using a social media site which contained alcohol advertisements, and two thirds reported noticing alcohol advertisements on an internet page.

30. For every doubling of exposure to digital alcohol marketing at baseline, 14 months later, students were 20% more likely to have used alcohol during the previous 30 days.

31. In this presentation, we will consider: 1.Adolescent drinking 2.Policy measures to reduce adolescent drinking 3.Legal age limits for buying alcohol

32. Of 33 studies of minimum legal drinking age law (MLDA) and alcohol consumption, 11 (33%) found an inverse relationship; only 1 found the opposite. Of 79 analyses of MLDA and traffic crashes, 46 (58%) found a higher MLDA related to decreased traffic crashes; none found the opposite. Of 23 analyses of MLDA and other problems, 8 (35%) found a higher MLDA associated with reduced problems; none found the opposite. Source: Wagenaar & Toomey 2002

33. Compared drinking habits at median age 36 years of 39,240 US citizens born between 1949 and 1972, by whether or not citizens lived in states with minimum legal drinking age of <21 years or 21 years. Source: Plunk et al 2013

34. Odds ratios of minimum legal drinking age of <21 years versus 21 years on: Binge drinking > 1/month: 1.15 (1.04-1.28) Non-heavy drinking: 0.81 (0.71-0.94)

35. Of course, legal minimum age purchase laws will only work if enforced.

36. A longitudinal study was undertaken in two Dutch communities, comparing the impact of a control community with an intervention community with intensified inspections on alcohol retailers on the drinking of 1,327 13-15 year olds over a two-year period. Source: Schelleman-Offermans et al 2012

37. Hazard ratios of ease of purchase on: Initiation weekly drinking: 1.20 (1.12-1.30) Initiation drunkenness: 1.51 (1.20-1.89)

38. Hazard ratios of impact of intervention on: Initiation weekly drinking: 1.12 (1.05-1.20) Initiation drunkenness: 0.82 (0.72-0.95)

39. The problems for the inspectors in applying fines or withdrawing licences was lack of proof (could not verify age of adolescent) – Hence, the importance of mystery shoppers - to be discussed later today.

40. Conclusions: 1.Drinking in adolescence: i.Negatively impacts brain structure ii.Has more problems per gram of alcohol iii.Leads to more problems in later life

41. 2.Increasing the price of alcohol and banning all forms of commercial communications, including in social and digital media, will reduce adolescent drinking and its consequences.

42. 3.Introducing a minimum legal age of purchase for all beverages groups of at least 18 years will reduce adolescent drinking and its problems.

43. 4.Enforcement of legal age of purchase with threat of loss of license to retailer is needed and can reduce adolescent drinking and related problems.

44. 5.Adolescents can very easily buy alcohol: the use of mystery shoppers adds clarity to enforcement.

45. All 14-15 year olds were able to buy alcohol, for 75% of the time at their first attempt, taking less than 10 minutes to do so. Source: van Hoof & Gosselt 2013