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1.  Do High Risk Urban Youth also have Older Friends? 
The purpose of this study was to explore how behavioral, intra-personal and socio-environmental factors were associated with the likelihood of having at least one older friend.
Participants included 3709 ethnically-diverse 8th grade students in the Project Northland Chicago intervention trial. Socio-demographic characteristics included gender, family composition, language spoken at home, race/ethnicity, and age. Behavioral factors included cigarette, alcohol, and marijuana use, depressed feelings, willingness to wear alcohol-branded merchandise, and violent and delinquent behavior. Intrapersonal factors included low refusal self efficacy and outcome expectations and expectancies. Socio-environmental factors included alcohol offers and access, normative estimates and expectations, and peer alcohol use. Having an older friend was defined as having at least one friend aged 16 or older (students’ mean age=14.2). Logistic mixed-effects regression models were used and controlled for gender, race/ethnicity, treatment status, and age.
Females and older eighth graders were significantly more likely to have at least one older friend. Students who scored higher on all of the behavioral, intra-personal and socio-environmental risk factors were significantly more likely to have at least one older friend. Significant gender interactions were found for several of the relationships.
Overall this study found multiple risk-related factors are associated with having older friends in eighth grade. Particularly important factors appear to be cigarette, marijuana and alcohol use, having friends who use alcohol, having increased alcohol offers, and being willing to wear or use alcohol-branded merchandise.
PMCID: PMC3079854  PMID: 21501805
Peers; Friends; Risk Behaviors; Risk Factors; Adolescence
2.  Association of parents' alcohol use and family interaction with the initiation of alcohol use by sixth graders: A preliminary study in Taiwan 
BMC Public Health  2009;9:172.
The family is the main environment where children are socialized and learn individual behavior. Although previous studies have examined predictors of preadolescent first alcohol use, few studies have analyzed factors associated with alcohol use in children in a country with low alcohol consumption. The aim of this study was to investigate the initiation of alcohol use by sixth graders and determine family factors associated with first alcohol use.
Data used in this study was collected as part of the Child and Adolescent Behaviors in Long-term Evolution (CABLE) project in 2002 (when study participants were in grade 5 and aged 10–11 years) and 2003 (when study participants were in grade 6 and aged 11–12 years). Data from a total of 1,183 participants was analyzed. Main study variables included children's alcohol use: (1) never user (never user in 2002 and 2003), or (2) first-time user (never user in 2002 but ever user in 2003); parents' alcohol use: (1) both parents ever users, (2) mother ever user and father never user, (3) father ever user and mother never user, (4) both parents never users; parental support; and family conflict. Correlates of first alcohol use were identified using logistic regression.
There were 183 students (15.5%) who became first-time users of alcohol in the sixth grade. Having parents who both used alcohol, less parental support, and more family conflict were significant predictors of sixth graders' first alcohol use. Family interaction and parents' drinking were equally important predictors of preteen's first use of alcohol.
Family factors influence children's initiation of alcohol use. It is important to educate parents about the effects of alcohol on children and to emphasize the importance of prevention.
PMCID: PMC2702380  PMID: 19497107
3.  Co-use of Alcohol and Tobacco Among Ninth-Graders in Louisiana 
Preventing Chronic Disease  2009;6(3):A85.
The co-use of alcohol and tobacco by adolescents is a public health problem that continues well into adulthood and results in negative behavioral, social, and health consequences. The purpose of this study was to examine the co-use of alcohol and tobacco among ninth-graders in south-central Louisiana.
We created a health habits survey to collect data from 4,750 ninth-grade students, mean age 15.4 years. Cross-sectional analysis used χ 2, 1-way analysis of variance, and logistic regression methods.
Almost 20% of students were co-users. Students who were white, performed poorly in school, did not expect to graduate high school, and had more discretionary money to spend were more likely to be co-users. Co-users had friends who got drunk weekly and were more likely to approve of alcohol use among friends than among adults. Significant differences in attitudes toward drinking and smoking were observed between co-users and nonusers. For adolescent drinkers, including girls, hard liquor was the preferred beverage.
These data for high school students are applicable for prevention strategies at a critical age when harmful health behaviors can mark the start of lifelong habits. Intervention efforts will be successful only if they account for multiple levels of influence.
PMCID: PMC2722390  PMID: 19527586
Journal of drug education  2010;40(3):265-280.
Alcoholic beverage consumption among high school students has shifted from beer to liquor. The current longitudinal study examined the effects of beverage-specific alcohol use on drinking behaviors among urban youth. Data included 731 adolescents who participated in Project Northland Chicago and reported consuming alcohol in 7th grade. Logistic regression tested the effects of beverage-specific use on consequences (e.g., alcohol use in the past month, week, heavy drinking, and ever drunkenness). Compared to wine users, adolescents who reported drinking hard liquor during their last drinking occasion had increased odds of alcohol use during the past month (OR = 1.44; 95% CI = 1.01–2.05), past week (OR = 3.37; 95% CI = 1.39–8.18), and ever drunkenness (OR = 1.56; 95% CI = 1.07–2.29). Use of hard liquor was associated with increased risk of alcohol-related consequences. Early selection of certain alcoholic beverages (e.g., hard liquor) may result in negative health outcomes and problematic alcohol use over time.
PMCID: PMC3721330  PMID: 21313986
5.  Relationships Between Alcohol-Related informal Social Control, Parental Monitoring and Adolescent Problem Behaviors Among Racially Diverse Urban Youth 
Journal of community health  2008;33(6):425-433.
The purpose of the present study is to investigate the relationships between alcohol-related informal social control and parental monitoring on alcohol use, behavior and intentions; violent behavior; and delinquent behavior in a racially diverse population of young urban adolescents. Baseline surveys were administered to 6th grade male and female students in 61 urban Chicago schools as part of Project Northland Chicago, a group randomized trial for the prevention/reduction of substance use. A subset of their parents (n=3034) was also surveyed regarding alcohol use, violence, and delinquency and related issues. Structural equation modeling was used to assess relationships between alcohol-related informal social control (as measured by parental perceptions of neighborhood action regarding youth drinking) and parental monitoring (as reported by parents), and three adolescent outcomes (alcohol use, behaviors and intentions; violent behavior; and delinquent behavior; as reported by teens). Associations between alcohol-related informal social control and parental monitoring were positive and significant (p<.001). Direct paths from parental monitoring to all three adolescent outcomes were negative and statistically significant (alcohol use, behaviors and intentions, p<.001; violent behavior, p<.001; and delinquent behavior, p<.001). Alcohol-related informal social control was not significantly associated with adolescent outcomes. Efforts to engage parents to be more active in monitoring adolescents’ activities may be related to lower levels of underage drinking, violence and delinquency among both female and male urban youth. Neighborhood norms and action against teenage drinking may be too distal to adolescent outcomes to be directly associated.
PMCID: PMC2603288  PMID: 18607698
Parental monitoring; Alcohol-related informal social control; Adolescent behaviors; Alcohol; Delinquency; Violence
6.  Alcohol Sales and Risk of Serious Assault 
PLoS Medicine  2008;5(5):e104.
Alcohol is a contributing cause of unintentional injuries, such as motor vehicle crashes. Prior research on the association between alcohol use and violent injury was limited to survey-based data, and the inclusion of cases from a single trauma centre, without adequate controls. Beyond these limitations was the inability of prior researchers to comprehensively capture most alcohol sales. In Ontario, most alcohol is sold through retail outlets run by the provincial government, and hospitals are financed under a provincial health care system. We assessed the risk of being hospitalized due to assault in association with retail alcohol sales across Ontario.
Methods and Findings
We performed a population-based case-crossover analysis of all persons aged 13 years and older hospitalized for assault in Ontario from 1 April 2002 to 1 December 2004. On the day prior to each assault case's hospitalization, the volume of alcohol sold at the store in closest proximity to the victim's home was compared to the volume of alcohol sold at the same store 7 d earlier. Conditional logistic regression analysis was used to determine the associated relative risk (RR) of assault per 1,000 l higher daily sales of alcohol. Of the 3,212 persons admitted to hospital for assault, nearly 25% were between the ages of 13 and 20 y, and 83% were male. A total of 1,150 assaults (36%) involved the use of a sharp or blunt weapon, and 1,532 (48%) arose during an unarmed brawl or fight. For every 1,000 l more of alcohol sold per store per day, the relative risk of being hospitalized for assault was 1.13 (95% confidence interval [CI] 1.02–1.26). The risk was accentuated for males (1.18, 95% CI 1.05–1.33), youth aged 13 to 20 y (1.21, 95% CI 0.99–1.46), and those in urban areas (1.19, 95% CI 1.06–1.35).
The risk of being a victim of serious assault increases with alcohol sales, especially among young urban men. Akin to reducing the risk of driving while impaired, consideration should be given to novel methods of preventing alcohol-related violence.
In a population-based case-crossover analysis, Joel Ray and colleagues find that the risk of being a victim of serious assault increases with retail alcohol sales, especially among young urban men.
Editors' Summary
Alcohol has been produced and consumed around the world since prehistoric times. In the Western world it is now the most commonly consumed psychoactive drug (a substance that changes mood, behavior, and thought processes). The World Health Organization reports that there are 76.3 million persons with alcohol use disorders worldwide. Alcohol consumption is an important factor in unintentional injuries, such as motor vehicle crashes, and in violent criminal behavior. In the United Kingdom, for example, a higher proportion of heavy drinkers than light drinkers cause violent criminal offenses. Other figures suggest that people (in particular, young men) have an increased risk of committing a criminally violent offense within 24 h of drinking alcohol. There is also some evidence that suggests that the victims as well as the perpetrators of assaults have often been drinking recently, possibly because alcohol impairs the victim's ability to judge potentially explosive situations.
Why Was This Study Done?
The researchers wanted to know more about the relationship between alcohol and intentional violence. The recognition of a clear link between driving when impaired by alcohol and motor vehicle crashes has led many countries to introduce public awareness programs that stigmatize drunk driving. If a clear link between alcohol consumption by the people involved in violent crime could also be established, similar programs might reduce alcohol-related assaults. The researchers tested the hypothesis that the risk of being hospitalized due to a violent assault increases when there are increased alcohol sales in the immediate vicinity of the victim's place of residence.
What Did the Researchers Do and Find?
The researchers did their study in Ontario, Canada for three reasons. First, Ontario is Canada's largest province. Second, the province keeps detailed computerized medical records, including records of people hospitalized from being violently assaulted. Third, most alcohol is sold in government-run shops, and the district has the infrastructure to allow daily alcohol sales to be tracked. The researchers identified more than 3,000 people over the age of 13 y who were hospitalized in the province because of a serious assault during a 32-mo period. They compared the volume of alcohol sold at the liquor store nearest to the victim's home the day before the assault with the volume sold at the same store a week earlier (this type of study is called a “case-crossover” study). For every extra 1,000 l of alcohol sold per store per day (a doubling of alcohol sales), the overall risk of being hospitalized for assault increased by 13%. The risk was highest in three subgroups of people: men (18% increased risk), youths aged 13 to 20 y (21% increased risk), and those living in urban areas (19% increased risk). At peak times of alcohol sales, the risk of assault was 41% higher than at times when alcohol sales were lowest.
What Do These Findings Mean?
These findings indicate that the risk of being seriously assaulted increases with the amount of alcohol sold locally the day before the assault and show that the individuals most at risk are young men living in urban areas. Because the study considers only serious assaults and alcohol sold in shops (i.e., not including alcohol sold in bars), it probably underestimates the association between alcohol and assault. It also does not indicate whether the victim or perpetrator of the assault (or both) had been drinking, and its findings may not apply to countries with different drinking habits. Nevertheless, these findings support the idea that the consumption of alcohol contributes to the occurrence of medical injuries from intentional violence. Increasing the price of alcohol or making alcohol harder to obtain might help to reduce the occurrence of alcohol-related assaults. The researchers suggest that a particularly effective approach may be to stigmatize alcohol-related brawling, analogous to the way that driving under the influence of alcohol has been made socially unacceptable.
Additional Information.
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Bennetts and Seabrook
The US National Institute on Alcohol Abuse and Alcoholism provides information on all aspects of alcohol abuse, including an article on alcohol use and violence among young adults
Alcohol-related assault is examined in the British Crime Survey
Alcohol Concern, the UK national agency on alcohol misuse, provides fact sheets on the health impacts of alcohol, young people's drinking, and alcohol and crime
The Canadian Centre for Addiction and Mental Health in Toronto provides information about alcohol addiction (in English and French)
PMCID: PMC2375945  PMID: 18479181
7.  Parents’ and children’s self report of parenting factors 
Health education journal  2010;69(1):31-42.
The purpose of this study was to determine if parents’ and children’s reports of parenting practices were correlated, if the reports were differentially associated with alcohol use, and which report had the strongest association with alcohol use.
Cross-sectional and longitudinal.
Public schools, Chicago, Illinois.
Participants included 1373 ethnically-diverse students and parents involved in an alcohol use prevention intervention. Surveys were conducted in sixth grade and eighth grade. Mixed-effects regression analyses were used to model relationships cross-sectionally and longitudinally.
Parents’ and children’s perceptions of parenting practices, while significantly correlated, were not strongly associated. Analyses within each parenting domain found parents’ report of parental monitoring and children’s reports of alcohol-specific communication, general communication, and relationship satisfaction were associated with alcohol use behaviors and intentions. After adjusting for all other parenting practices, parents’ report of parental monitoring and children’s report of alcohol-specific communication were most strongly related to alcohol use behaviors and intentions both cross-sectionally and longitudinally.
When comparing results across studies, it is important to identify whose report was used, parent or child, as the results may differ based on reporter. Studies with limited resources may consider using parents’ reports about parental monitoring and using children’s reports for alcohol-specific communication, general communication, and relationship satisfaction.
PMCID: PMC2885720  PMID: 20563227
Parenting; parent-child relationships; alcohol use; early adolescence
8.  Receptivity to alcohol marketing predicts initiation of alcohol use 
This longitudinal study examined the influence of alcohol advertising and promotions on the initiation of alcohol use. A measure of receptivity to alcohol marketing was developed from research about tobacco marketing. Recall and recognition of alcohol brand names were also examined.
Data were obtained from in-class surveys of 6th, 7th, and 8th graders at baseline and 12-month follow-up. Participants who were classified as never drinkers at baseline (n=1,080) comprised the analysis sample. Logistic regression models examined the association of advertising receptivity at baseline with any alcohol use and current drinking at follow-up, adjusting for multiple risk factors, including peer alcohol use, school performance, risk taking, and demographics.
At baseline, 29% of never drinkers either owned or wanted to use an alcohol branded promotional item (high receptivity), 12% students named the brand of their favorite alcohol ad (moderate receptivity) and 59% were not receptive to alcohol marketing. Approximately 29% of adolescents reported any alcohol use at follow-up; 13% reported drinking at least 1 or 2 days in the past month. Never drinkers who reported high receptivity to alcohol marketing at baseline were 77% more likely to initiate drinking by follow-up than those were not receptive. Smaller increases in the odds of alcohol use at follow-up were associated with better recall and recognition of alcohol brand names at baseline.
Alcohol advertising and promotions are associated with the uptake of drinking. Prevention programs may reduce adolescents’ receptivity to alcohol marketing by limiting their exposure to alcohol ads and promotions and by increasing their skepticism about the sponsors’ marketing tactics.
PMCID: PMC2175037  PMID: 18155027
9.  Current drinking and health-risk behaviors among male high school students in central Thailand 
BMC Public Health  2011;11:233.
Alcohol drinking is frequently related to behavioral problems, which lead to a number of negative consequences. This study was to evaluate the characteristics of male high school students who drink, the drinking patterns among them, and the associations between current drinking and other health risk behaviors which focused on personal safety, violence-related behaviors, suicide and sexual behaviors.
A cross-sectional study was conducted to explore current alcohol drinking and health-risk behaviors among male high school students in central Thailand. Five thousand one hundred and eighty four male students were classified into 2 groups according to drinking in the previous 30 days (yes = 631, no = 4,553). Data were collected by self-administered, anonymous questionnaire which consisted of 3 parts: socio-demographic factors, health-risk behaviors and alcohol drinking behavior during the past year from December 2007 to February 2008.
The results showed that the percent of current drinking was 12.17. Most of them were 15-17 years (50.21%). Socio-demographic factors such as age, educational level, residence, cohabitants, grade point average (GPA), having a part time job and having family members with alcohol/drug problems were significantly associated with alcohol drinking (p < 0.05). Multiple logistic regression analysis, after adjusting for socio-demographic factors, revealed that health-risk behavioral factors were associated with current alcohol consumption: often drove after drinking alcohol (OR = 3.10, 95% CI = 1.88-5.12), often carried a weapon (OR = 3.51, 95% CI = 2.27-5.42), often got into a physical fight without injury (OR = 3.06, 95% CI = 1.99-4.70), dating violence (OR = 2.58, 95% CI = 1.79-3.71), seriously thought about suicide (OR = 2.07, 95% CI = 1.38-3.11), made a suicide plan (OR = 2.10, 95% CI = 1.43-3.08), ever had sexual intercourse (OR = 5.62, 95% CI = 4.33-7.29), alcohol or drug use before last sexual intercourse (OR = 2.55, 95% CI = 1.44-4.53), and got someone pregnant (OR = 3.99, 95% CI = 1.73-9.25).
An increased risk of health-risk behaviors, including driving vehicles after drinking, violence-related behaviors, sad feelings and attempted suicide, and sexual behaviors was higher among drinking students that led to significant health problems. Effective intervention strategies (such as a campaign mentioning the adverse health effects and social consequences to the risk groups, and encouraging parental and community efforts to prevent drinking) among adolescents should be implemented to prevent underage drinking and adverse consequences.
PMCID: PMC3090349  PMID: 21492419
10.  Sequence of Alcohol Involvement from Early Onset to Young Adult Alcohol Abuse: Differential Predictors and Moderation by Family-Focused Preventive Intervention 
Addiction (Abingdon, England)  2012;107(12):2137-2148.
This study tests risk factors for four dimensions of alcohol use in the sequence from (a) early onset prior to age 13 to (b) adolescent alcohol use and (c) alcohol problems to (d) young adult alcohol abuse. It also examines whether family-focused preventive interventions buffer predictive relationships.
Data were from a randomized prevention trial extending from ages 11 to 21.
Families of sixth graders enrolled in 33 rural schools in the Midwestern United States were invited to participate.
Families (N = 667) were pretested and randomly assigned to a control group (n = 208) or to family interventions (n = 459). The average age of participating youth was 11.3 years when the study began (52% female). Measurements: Questionnaire data were collected on alcohol dimensions during adolescence (early onset, alcohol use, alcohol problems) and young adulthood (alcohol abuse), and on risk factors in early adolescence (male gender, impulsive behaviors, aggression-hostility, peer deviance, and parent problem drinking).
Impulsive behaviors predicted early onset, peer deviance predicted alcohol use, and parent problem drinking predicted alcohol problems (p < .05). Aggression-hostility and alcohol problems predicted alcohol abuse in the control group (p < .05), but not in the family interventions group (p > .05).
Different dimensions of alcohol use and problems from before age 13 to young adulthood are predicted by different risk factors. Family-focused preventive interventions can reduce the influence of some of these risk factors, including early adolescent aggression-hostility and late adolescent alcohol problems.
PMCID: PMC3477285  PMID: 22724619
alcohol use; alcohol abuse; prevention; family; risk factors; youth
11.  Thinking and Drinking: Alcohol-Related Cognitions across Stages of Adolescent Alcohol Involvement 
Psychology of Addictive Behaviors  2011;25(3):415-425.
Alcohol-related cognitions, particularly expectancies for drinking and non-drinking and motives for non-drinking, are involved in the initiation, maintenance, and cessation of alcohol use and are hypothesized to play key roles in adolescent decision making. This study explored (a) the relationships between alcohol use expectancies, non-drinking expectancies and non-drinking motives, (b) the roles of these cognitions across hypothesized developmental stages of adolescent alcohol use and (c) the relationships between these cognitions and recent or intended future changes in drinking behavior in a cross-sectional sample.
Surveys assessing alcohol use behaviors and attitudes were administered to 1648 high school students.
Heavier drinkers reported more positive alcohol use expectancies and fewer non-drinking motives than lighter drinkers or non-drinkers, however non-drinking expectancies only differed between non- and rare- drinkers and all subsequent drinking classes. Alcohol use expectancies, non-drinking expectancies and non-drinking motives differentiated students who recently initiated alcohol from those who had not, while non-drinking expectancies and non-drinking motives differentiated binge drinking students who had made recent efforts to reduce/stop their drinking from those who had not. Intentions to initiate or reduce drinking in the coming month were also associated with these alcohol-related cognitions.
Drinking and non-drinking expectancies, and motives for not drinking may play critical roles in decisions to alter alcohol-use behavior during adolescence. Future exploration of temporal relationships between changes in alcohol-related cognitions and behavioral decision making will be useful in the refinement of effective prevention and intervention strategies.
PMCID: PMC3372460  PMID: 21534645
alcohol expectancies; non-drinking expectancies; non-drinking motives; adolescent alcohol use; alcohol use transitions
12.  Early Adolescent Exposure to Alcohol Advertising and Its Relationship to Underage Drinking 
To determine whether early adolescents who are exposed to alcohol marketing are subsequently more likely to drink. Recent studies suggest that exposure to alcohol ads has a limited influence on drinking in mid-adolescence. Early adolescents may be more vulnerable to alcohol advertising effects.
Two in-school surveys of 1,786 South Dakota youth measured exposure to television beer advertisements, alcohol ads in magazines, in-store beer displays and beer concessions, radio-listening time, and ownership of beer promotional items during sixth grade, and drinking intentions and behavior at seventh grade. Multivariate regression equations predicted the two drinking outcomes using the advertising exposure variables and controlling for psychosocial factors and prior drinking.
After adjusting for covariates, the joint effect of exposure to advertising from all six sources at Grade 6 was strongly predictive of Grade 7 drinking and Grade 7 intentions to drink. Youth in the 75th percentile of alcohol marketing exposure had a predicted probability of drinking that was 50% greater than that of youth in the 25th percentile.
Although causal effects are uncertain, policy makers should consider limiting a variety of marketing practices that could contribute to drinking in early adolescence.
PMCID: PMC2845532  PMID: 17531759
advertising; alcohol marketing; children; drinking; television
13.  A Peer-drinking Group Motivational Intervention among Thai Male Undergraduate Students 
Excessive alcohol consumption, particularly among young males, is an important global health problem, in part because of the increased risks of intentional and non-intentional injuries, uses of illicit drug, crime, and psychiatric disorders. There are no data available to evaluate the extent to which interventions are effective in reducing hazardous/harmful alcohol consumption among young males in Thailand. We examined the efficacy of alcohol harm reduction strategies administered as a peer-drinking group motivational intervention (PD-GMI) among Thai male undergraduates.
We used a quasi-experimental study design that included two student groups assessed at baseline and at two time points post-intervention. Participants were students enrolled in two public universities and who reported alcohol consumption during the current academic year. Students in one university were assigned to an assessment-only study group (n=110); and students in the other university were assigned to a 2-hour PD-GMI (n=115). This intervention was designed to (1) increase the awareness of risks associated with hazardous/harmful alcohol consumption; (2) enhance students' motivation to change their drinking behaviors; and (3) encourage harm reduction strategies during episodes of alcohol consumption. Alcohol consumption and adverse consequences were assessed using the Alcohol Use Disorders Identification Test (AUDIT) and the Rutgers Alcohol Problem Index (RAPI).
Students receiving the intervention had significant reductions in mean AUDIT scores; 50.4% at baseline to 1-month and 61.2% at baseline to 3-month post-intervention. Their mean RAPI scores were also reduced; 42.0% at baseline to 1-month and 42.9% at baseline to 3-month post-intervention. Reductions in alcohol consumption and the prevalence of harmful alcohol consumption patterns were statistically significant among students in the intervention group versus those in the control group. The reductions remained after adjustments for baseline differences.
These results suggest the efficacy of the PD-GMI intervention for reducing alcohol consumption and adverse consequences among Thai male students.
PMCID: PMC3683575  PMID: 20347584
alcohol; harm reduction; group motivational intervention; students; Thailand
14.  Prevalence and Predictors of Adolescent Alcohol Use and Binge Drinking in the United States 
Because alcohol use typically is initiated during adolescence and young adulthood and may have long-term consequences, the Monitoring the Future (MTF) study annually assesses various measures of alcohol use among 8th-, 10th-, and 12th-grade students. These analyses have found that although alcohol use among these age groups overall has been declining since 1975, levels remain high. Thus, in 2011 about one-quarter of 8th graders, one-half of 10th graders, and almost two-thirds of 12th graders reported drinking alcohol in the month preceding the interview. Binge drinking (i.e., consumption of five or more drinks in a row) was also prevalent. Specific rates of drinking, binge drinking, and getting drunk varied among different student subgroups based on gender and race/ethnicity. The MTF study has also identified numerous factors that influence the risk of alcohol use among adolescents, including parents and peers, school and work, religiosity and community attachment, exercise and sports participation, externalizing behavior and other drug use, risk taking and sensation seeking, well-being, and drinking attitudes and reasons for alcohol use. Drinking during adolescence can have long-term effects on a person’s life trajectory. Therefore, these findings have broad implications for prevention and intervention efforts with this population.
PMCID: PMC3908711  PMID: 24881328
Underage drinking; binge drinking; adolescent; high school student; young adult; prevalence; predictors; causes of alcohol and other drug use; risk factors; school risk factors; environmental risk factors; family risk factors; peer risk factors; gender differences; racial/ethnic differences; Monitoring the Future (MTF) Study; United States
15.  Effects of the Communities That Care System on Cross-Sectional Profiles of Adolescent Substance Use and Delinquency 
Adolescent substance use and delinquency are major public health problems. Although community–based prevention strategies have been recommended to produce population-level reductions in rates of substance use and delinquency, few models show evidence of effectiveness.
To test the efficacy of a community–based prevention system, Communities That Care (CTC), in reducing community rates of problem behaviors, particularly effects on specific profiles of adolescent substance use and delinquency in eighth and tenth graders.
Twenty-four communities were randomized to CTC intervention or control groups. Data were collected from 14,099 eighth and tenth grade students in these communities using anonymous cross-sectional surveys in 2004 and 2010 and analyzed in 2012. Outcomes were four different profiles of self–reported substance use and delinquency in eighth grade and five profiles in tenth grade.
In the cross-sectional 2010 data, there was no intervention effect on the probability of experimenting with substances or of substance use coupled with delinquent activities for either grade. However, tenth graders in intervention communities were significantly less likely to be alcohol users than those in control communities (OR=0.69, CI=0.48, 1.00).
Cross–sectional population surveys showed evidence of CTC effects in reducing tenth grade alcohol users but not experimenters. A community-wide reduction in adolescent alcohol use is important because alcohol is the most commonly used illicit substance during adolescence, and early initiation of alcohol use has been associated with alcohol-related disorders in adulthood. Failure to find hypothesized effects on experimenters qualifies these results.
PMCID: PMC4106992  PMID: 24986217
16.  Influence of Grade-Level Drinking Norms on Individual Drinking Behavior 
To investigate which points of the middle-school drinking distribution are the most influential in the social contagion of drinking across the middle-school years, in order to identify potential social multipliers.
We measured drinking intentions and behaviors by gender, school, and grade among urban middle-school students who participated in Project Northland Chicago in a longitudinal cohort design.
Individual drinking behaviors were consistently influenced by extreme (80th percentile) drinking intentions and behaviors. This effect was mediated through normal or average levels of drinking, over time.
Interventions can target extreme drinkers as the influential persons in middle-school grades.
PMCID: PMC3707398  PMID: 22943103
social norms; drinking; middle school; gender; mediation
17.  A Population-Based Study on Alcohol and High-Risk Sexual Behaviors in Botswana 
PLoS Medicine  2006;3(10):e392.
In Botswana, an estimated 24% of adults ages 15–49 years are infected with HIV. While alcohol use is strongly associated with HIV infection in Africa, few population-based studies have characterized the association of alcohol use with specific high-risk sexual behaviors.
Methods and Findings
We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana using a stratified two-stage probability sample design. Multivariate logistic regression was used to assess correlates of heavy alcohol consumption (>14 drinks/week for women, and >21 drinks/week for men) as a dependent variable. We also assessed gender-specific associations between alcohol use as a primary independent variable (categorized as none, moderate, problem and heavy drinking) and several risky sex outcomes including: (a) having unprotected sex with a nonmonogamous partner; (b) having multiple sexual partners; and (c) paying for or selling sex in exchange for money or other resources. Criteria for heavy drinking were met by 31% of men and 17% of women. Adjusted correlates of heavy alcohol use included male gender, intergenerational relationships (age gap ≥10 y), higher education, and living with a sexual partner. Among men, heavy alcohol use was associated with higher odds of all risky sex outcomes examined, including unprotected sex (AOR = 3.48; 95% confidence interval [CI], 1.65 to 7.32), multiple partners (AOR = 3.08; 95% CI, 1.95 to 4.87), and paying for sex (AOR = 3.65; 95% CI, 2.58 to 12.37). Similarly, among women, heavy alcohol consumption was associated with higher odds of unprotected sex (AOR = 3.28; 95% CI, 1.71 to 6.28), multiple partners (AOR = 3.05; 95% CI, 1.83 to 5.07), and selling sex (AOR = 8.50; 95% CI, 3.41 to 21.18). A dose-response relationship was seen between alcohol use and risky sexual behaviors, with moderate drinkers at lower risk than both problem and heavy drinkers.
Alcohol use is associated with multiple risks for HIV transmission among both men and women. The findings of this study underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.
Alcohol use is associated with multiple risks for HIV transmission in men and women. The findings underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.
Editors' Summary
Human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS), is most commonly spread through unprotected sex with an infected partner. HIV enters the body through the lining of the sex organs, rectum, or mouth, and destroys immune system cells, leaving the infected person susceptible to other viruses and bacteria. Although HIV education and prevention campaigns emphasize the importance of safe sex in reducing HIV transmission, people continue to become infected by having unprotected sex (that is, not using a condom) with either a nonmonogamous partner or multiple sexual partners, or in situations where they are paying for or selling sex. Research in different populations suggested that heavy alcohol use is associated with risky sexual behaviors. This is because alcohol relaxes the brain and body, reduces inhibitions, and diminishes risk perception. Drinking alcohol may further increase the risk of becoming infected with HIV through its suppressive effects on the immune system.
Why Was This Study Done?
Alcohol abuse is widespread in sub-Saharan Africa where most HIV infections occur and has been associated with risky sexual behaviors. It may therefore be one of the most common, potentially modifiable HIV risk factors in this region. However, research to date has concentrated on the association between alcohol consumption and risky sex in people attending HIV-treatment clinics or recruited at beer halls, and these populations may not be representative of the general population of sub-Saharan Africa. In this study, the researchers have investigated the potential role of alcohol in perpetuating the HIV epidemic by undertaking a population-based study on alcohol use and high-risk sexual behaviors in Botswana. Nearly a quarter of adults are infected with HIV here, and alcohol abuse is also common, particularly in the townships.
What Did the Researchers Do and Find?
The researchers recruited a random cross-section of people from the five districts of Botswana with the highest number of HIV-infected individuals and interviewed all 1,268 participants using a questionnaire. This included general questions about the participants (for example, their age and marital status) and questions about alcohol use, sexual behavior, and knowledge of HIV. Overall, 31% of the men in the study and 17% of the women were heavy drinkers—more than 21 drinks/week for men, 14 for women; a drink is half a pint of beer or a glass of wine. Heavy alcohol use was associated with being male, being in an intergenerational relationship (at least 10 years age difference between partners; intergenerational sex facilitates the continued spread of HIV in sub-Saharan Africa), having had more education, and living with a sexual partner. Among men, those who drank heavily were three to four times more likely to have unprotected sex or multiple partners or to pay for sex than nondrinkers. Among women, there was a similar association between heavy drinking and having unprotected sex or multiple partners, and heavy drinkers were eight times as likely to sell sex as nondrinkers. For both men and women, the more they drank, the more likely they were to have risky sex. The study did not address behavior among same-sex partnerships.
What Do These Findings Mean?
This study indicates that heavy alcohol consumption is strongly and consistently associated with sexual risk behaviors in both men and women in Botswana. Because of the study design, it does not prove that heavy alcohol use is the cause of such behaviors but provides strong circumstantial evidence that this is the case. It is possible that these results may not apply to neighboring African countries—Botswana is unique in being relatively wealthy and in its government being strongly committed to tackling HIV. Nevertheless, taken together with the results of other studies, this research strongly argues for the need to deal with alcohol abuse within HIV prevention programs in sub-Saharan Africa. Strategies to do this could include education campaigns that target both alcohol use and HIV in schools and in social venues, including beer halls. But, stress the researchers, any strategy that is used must consider the cultural and social significance of alcohol use (in Botswana, alcohol use is a symbol of masculinity and high socioeconomic status) and must simultaneously tackle not only the overlap between alcohol use and risky sexual behavior but also the overlap between alcohol and other risk behaviors such as intergenerational sex.
Additional Information
Please access these Web sites via the online version of this summary at
US National Institute of Allergy and Infectious Diseases factsheet on HIV infection and AIDS
US Department of Health and Human Services information on AIDS
US Centers for Disease Control and Prevention information on HIV/AIDS
US National Institute on Alcohol Abuse and Alcoholism patient information on alcohol and HIV/AIDS]
Aidsmap, information on HIV and AIDS provided by the charity NAM,which includes some information on HIV infections and alcohol
AVERT information on HIV and AIDS in Botswana
PMCID: PMC1592342  PMID: 17032060
18.  Exposure to cigarette promotions and smoking uptake in adolescents: evidence of a dose-response relation 
Tobacco Control  2000;9(2):163-168.
OBJECTIVE—To assess whether a dose-response relation exists between the number of cigarette promotional items (CPIs) owned by an adolescent, and smoking behaviour.
DESIGN AND SETTING—Voluntary, self administered survey of 1265 sixth through to 12th grade students (ages 10-19 years), representing 79-95% of all students attending five rural New Hampshire and Vermont public (state funded) schools in October 1996. The association between the number of CPIs owned by students and smoking behaviour was examined using multivariate regression methods.
OUTCOME MEASURES—Adjusted odds of being a smoker (⩾ 100 cigarettes lifetime) and, among never and experimental smokers, adjusted cumulative odds of having higher levels on a smoking uptake index given the number of CPIs owned.
RESULTS—One third of students owned a CPI (n = 406). Among owners, 211 owned one, 82 owned two, 57 owned three, 24 owned four, 23 owned five, and 7 students owned six CPIs. The number of CPIs owned by students was not associated with grade in school but was significantly higher in males, those with poorer school performance, those who perceived high prevalence of peer smoking, and those with higher exposure to peer and family smoking. The more items a student owned, the greater the chances of being a smoker. For example, smoking prevalence was 11.2% for those not owning a CPI, 41.5% for those owning two, 58.5% for those owning four, and 71.4% for those owning six CPIs. The dose-response relation remained after controlling for confounding; compared with those who did not own a CPI, the likelihood of being a smoker was significantly higher for those who owned one CPI, with an adjusted odds ratio (OR) of 2.7 (95% confidence interval (CI) 1.7 to 4.1); OR was 3.4 (95% CI 1.9 to 5.9) for those owning two CPIs, and 8.4 (95% CI 5.0 to 14.2) for those owning three or more CPIs. After excluding smokers, there was a crude dose-response association between CPI ownership and higher rates of experimentation with cigarettes among sixth to ninth graders (ages 11-15 years) only (n = 543). After controlling for confounding influences, the dose-response relation remained, with the likelihood of being higher on the smoking uptake index rising with the number of CPIs owned: one CPI, adjusted cumulative OR 1.7 (95% CI 1.1 to 2.60); two CPIs, OR 2.5 (95% CI 1.2 to 5.1); and three or more CPIs, OR 4.8 (95% CI 1.9 to 12.2).
CONCLUSIONS—This study offers evidence of a dose-response relation between the number of CPIs owned by adolescents and higher likelihood of experimental and established smoking. The dose-response relation persists after controlling for confounding influences. These data provide further support of a causal relation between tobacco promotional campaigns and smoking behaviour among adolescents.

Keywords: adolescents; epidemiology; tobacco marketing
PMCID: PMC1748336  PMID: 10841852
19.  Work stress and alcohol consumption among adolescents: moderation by family and peer influences 
BMC Public Health  2014;14:1303.
Excessive alcohol use in adolescence can be detrimental to health and academic performance. Few studies consider the moderating effects of parental and peer influence within the context of adolescent work outside of the school environment. This study aims to examine work stress among adolescents and the association with alcohol use and drunkenness, in the context of parental and peer influences.
Grade 12 students who participated in Monitoring the Future surveys between 2005 and 2009 (n = 12,341) were included in this study. Independent variables included work stress (job satisfaction, perceived safety, and perceived safety of possessions), self-reported perceptions towards academics and influence from parents and peers. Frequency of alcohol use and drunkenness were measured for lifetime, last 30 days and 12 months. The moderating effects of academic aspiration, parental, and peer influence were assessed on the relationship between work stress and alcohol use.
Any work stress was positively associated with alcohol use over the past 12 months (odds ratio = 1.12, 95% confidence interval (CI) 1.02-1.23). Stratified analysis found that peer influence significantly moderated the relationship between work stress and alcohol use over the lifetime and past 12 months. Among adolescents with work stress, odds ratios of alcohol use over the lifetime was 0.83 (95% CI 0.71-0.97) for those with low negative peer influence and 1.09 (95% CI 0.97-1.22) for those with high negative peer influence.
Problematic drinking patterns were more apparent among high school students who experienced stress at work. Positive peer influence, however, may buffer the adverse effect of work stress on alcohol use.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-1303) contains supplementary material, which is available to authorized users.
PMCID: PMC4301940  PMID: 25523951
Adolescent employment; Alcohol use; Work stress
20.  Extreme Binge Drinking among 12th-Grade Students in the U.S.: Prevalence and Predictors 
JAMA pediatrics  2013;167(11):10.1001/jamapediatrics.2013.2392.
The prevalence of underage alcohol use has been studied extensively but binge drinking among youth in the U.S. is not yet well understood. In particular, adolescents may drink much larger amounts than the threshold (5 drinks) often used in definitions of binge drinking. Delineating various levels of binge drinking, including extreme levels, and understanding predictors of such extreme binge drinking among adolescents will benefit public health efforts.
To examine the prevalence and predictors of 5+ binge drinking and of 10+ and 15+ extreme binge drinking among 12th graders in the U.S.
A non-clinical nationally representative sample.
High school seniors in the annual Monitoring the Future study between 2005 and 2011.
The sample included 16,332 12th graders (modal age 18) in the U.S. Response rates were 79–85%.
Main Outcome Measures
Prevalence of consuming 5+, 10+, and 15+ drinks in a row in the past two weeks.
Between 2005 and 2011, 20.2% of high school seniors reported 5+ binge drinking, 10.5% reported 10+ extreme binge drinking, and 5.6% reported 15+ extreme binge drinking in the past 2 weeks. Rates of 5+ binge drinking and 10+ extreme binge drinking have declined since 2005, but rates of 15+ extreme binge drinking have not. Students with college-educated parents were more likely to consume 5+ drinks but less likely to consume 15+ drinks than students whose parents were not college educated. Students from more rural areas were more likely than students from large metropolitan areas to drink 15+ drinks. Socializing with substance-using peers, number of evenings out with friends, substance-related attitudes, and other substance use (cigarettes, marijuana) predicted all three levels of binge and extreme binge drinking.
Binge drinking at the traditionally defined 5+ drinking level was common among high school seniors representative of all 12th graders in the contiguous U.S. A significant segment of students also reported extreme binge drinking at levels two and three times higher. These data suggest the importance of assessing multiple levels of binge drinking behavior and their predictors among adolescents in order to target effective screening and intervention efforts.
PMCID: PMC3818300  PMID: 24042318
This paper describes adolescents’ exposure to alcohol advertising in stores and to alcohol-branded promotional items and their association with self-reported drinking.
A cross-sectional survey was administered in non-tracked required courses to sixth, seventh, and eighth graders (n = 2125) in three California middle schools. Logistic regressions compared the odds of ever (vs. never) drinking and current (vs. ever) drinking after controlling for psychosocial and other risk factors for adolescent alcohol use.
Two-thirds of middle school students reported at least weekly visits to liquor, convenience, or small grocery stores where alcohol advertising is widespread. Such exposure was associated with higher odds of ever drinking, but was not associated with current drinking. One-fifth of students reported owning at least one alcohol promotional item. These students were three times more likely to have ever tried drinking and 1.5 times more likely to report current drinking than students without such items.
This study provides clear evidence of an association of adolescent drinking with weekly exposure to alcohol advertising in stores and with ownership of alcohol promotional items. Given their potential influence on adolescent drinking behaviour, retail ads, and promotional items for alcohol deserve further study.
PMCID: PMC4238906  PMID: 17218364
22.  Alcohol consumption and binge drinking in adolescents: comparison of different migration backgrounds and rural vs. urban residence - a representative study 
BMC Public Health  2011;11:84.
Binge drinking is a constant problem behavior in adolescents across Europe. Epidemiological investigations have been reported. However, epidemiological data on alcohol consumption of adolescents with different migration backgrounds are rare. Furthermore representative data on rural-urban comparison concerning alcohol consumption and binge drinking are lacking. The aims of the study are the investigation of alcohol consumption patterns with respect to a) urban-rural differences and b) differences according to migration background.
In the years 2007/2008, a representative written survey of N = 44,610 students in the 9th. grade of different school types in Germany was carried out (net sample). The return rate of questionnaires was 88% regarding all students whose teachers respectively school directors had agreed to participate in the study. Weighting factors were specified and used to make up for regional and school-type specific differences in return rates. 27.4% of the adolescents surveyed have a migration background, whereby the Turkish culture is the largest group followed by adolescents who emigrated from former Soviet Union states. The sample includes seven large cities (over 500,000 inhabitants) (12.2%), independent smaller cities ("urban districts") (19.0%) and rural areas ("rural districts") (68.8%).
Life-time prevalence for alcohol consumption differs significantly between rural (93.7%) and urban areas (86.6% large cities; 89.1% smaller cities) with a higher prevalence in rural areas. The same accounts for 12-month prevalence for alcohol consumption. 57.3% of the rural, re-spectively 45.9% of the urban adolescents engaged in binge drinking in the 4 weeks prior to the survey. Students with migration background of the former Soviet Union showed mainly drinking behavior similar to that of German adolescents. Adolescents with Turkish roots had engaged in binge drinking in the last four weeks less frequently than adolescents of German descent (23.6% vs. 57.4%). However, in those adolescents who consumed alcohol in the last 4 weeks, binge drinking is very prominent across the cultural backgrounds.
Binge drinking is a common problem behavior in German adolescents. Obviously adolescents with rural residence have fewer alternatives for engaging in interesting leisure activities than adolescents living in cities. This might be one reason for the more problematic consumption patterns there. Common expectations concerning drinking behavior of adolescents of certain cultural backgrounds ('migrants with Russian background drink more'/'migrants from Arabic respectively Oriental-Islamic countries drink less') are only partly affirmed. Possibly, the degree of acculturation to the permissive German alcohol culture plays a role here.
PMCID: PMC3045949  PMID: 21299841
23.  Cigar, Cigarillo, and Little Cigar Use Among Current Cigarette-Smoking Adolescents 
Nicotine & Tobacco Research  2012;15(5):925-931.
Cigar, cigarillo, and little cigar (CCLC) use is prevalent among adolescents, particularly among those who smoke cigarettes.
Using data from a longitudinal study of smoking patterns among adolescents, we examined differences between CCLC users (ever and past 30 days) and nonusers (never and not in the past 30 days) among adolescents who smoked a cigarette in the last month (n = 486).
In our sample, 76.7% reported ever trying CCLC and 40.7% reported past month CCLC use. Bivariate analyses showed that CCLC users differed from nonusers in terms of demographics, other forms of tobacco use, other substance use, and mental health. Multivariate logistic regression analyses found that both ever and past 30-day CCLC use were strongly associated with being male and concurrent use of hookah. Ever CCLC use was also strongly associated with recent use of alcohol, and past 30-day CCLC use was strongly associated with antisocial behavior. After controlling for the number of days on which cigarettes were smoked in the past 30 days, past 30-day CCLC use was associated with most other forms of tobacco use, other substance use, and mental health, but not with number of cigarettes smoked in the past month and nicotine dependence.
Results suggest that CCLC use is high among adolescent cigarette users and is associated with a variety of negative correlates. Importantly, many of these relationships are not accounted for by the adolescent’s level of cigarette use. Further characterizing CCLC use will be important for developing more targeted and tailored interventions.
PMCID: PMC3621583  PMID: 23072873
24.  Physician Advice to Adolescents About Drinking and Other Health Behaviors 
Pediatrics  2013;131(2):249-257.
This report assessed the proportion of US 10th graders (average age, 16) who saw a physician in the past year and were asked and given advice about their drinking. We hypothesized that advice would vary by whether students were asked about drinking and their drinking, bingeing, and drunkenness frequency.
A nationally representative sample of 10th graders in 2010 (N = 2519) were asked their past 30-day frequency of drinking, bingeing, and intoxication and whether, during their last medical examination, their drinking was explored and they received advice about alcohol’s risks and reducing or stopping.
In the past month, 36% reported drinking, 28% reported bingeing, and 23% reported drunkenness (11%, 5%, and 7%, respectively, 6 or more times). In the past year, 82% saw a doctor. Of that group, 54% were asked about drinking, 40% were advised about related harms, and 17% were advised to reduce or stop. Proportions seeing a doctor and asked about drinking were similar across drinking patterns. Respondents asked about drinking were more often advised to reduce or stop. Frequent drinkers, bingers, and those drunk were more often advised to reduce or stop. Nonetheless, only 25% of them received that advice from physicians. In comparison, 36% of frequent smokers, 27% of frequent marijuana users, and 42% of frequent other drug users were advised to reduce or quit those behaviors.
Efforts are warranted to increase the proportion of physicians who follow professional guidelines to screen and counsel adolescents about unhealthy alcohol use and other behaviors that pose health risks.
PMCID: PMC4074674  PMID: 23359580
alcohol; advice; adolescence; physician practice patterns
25.  Peer selection and influence effects on adolescent alcohol use: a stochastic actor-based model 
BMC Pediatrics  2012;12:115.
Early adolescent alcohol use is a major public health challenge. Without clear guidance on the causal pathways between peers and alcohol use, adolescent alcohol interventions may be incomplete. The objective of this study is to disentangle selection and influence effects associated with the dynamic interplay of adolescent friendships and alcohol use.
The study analyzes data from Add Health, a longitudinal survey of seventh through eleventh grade U.S. students enrolled between 1995 and 1996. A stochastic actor-based model is used to model the co-evolution of alcohol use and friendship connections.
Selection effects play a significant role in the creation of peer clusters with similar alcohol use. Friendship nominations between two students who shared the same alcohol use frequency were 3.60 (95% CI: 2.01-9.62) times more likely than between otherwise identical students with differing alcohol use frequency. The model controlled for alternative pathways to friendship nomination including reciprocity, transitivity, and similarities in age, gender, and race/ethnicity. The simulation model did not support a significant friends’ influence effect on alcohol behavior.
The findings suggest that peer selection plays a major role in alcohol use behavior among adolescent friends. Our simulation results would lend themselves to adolescent alcohol abuse interventions that leverage adolescent social network characteristics.
PMCID: PMC3469361  PMID: 22867027

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