- MTF —
- Monitoring the Future
- SES —
- socioeconomic status
Alcohol use during adolescence carries an increased risk of negative psychosocial and health outcomes. Adolescents who drink heavily have a higher likelihood of unprotected sex, physical altercations, poor school or work performance, and problems with parents.1 Earlier age of initiation is also a strong predictor of heavy alcohol consumption by adulthood and potential progression to an alcohol use disorder.2
Fortunately, since its peak in the late 1990s, the prevalence of binge drinking (defined as ≥5 drinks in the past 2 weeks) has declined to historic lows of 3.4%, 9.7%, and 15.5% among eighth, 10th, and 12th graders, respectively, according to Monitoring the Future (MTF) data.3 Despite this critical public health occurrence, the underlying reasons for this change are unclear. In this month’s issue of Pediatrics, Jang et al4 explore this decline, using 1991–2015 MTF data to delineate age, period, and cohort effects on frequent heavy drinking. Frequent heavy drinking was defined as ≥2 occasions of ≥5 drinks in a row during the past 2 weeks.
“Age effects” describe the familiar phenomenon whereby adolescents become more likely to drink heavily as they get older. “Period effects” are secular trends in drinking that affect youth of all ages living during a particular time that may be caused by policies or norms during that time. Finally, “cohort effects” describe changes in drinking patterns intrinsic to youth born around the same time. As an example, most clinicians are familiar with the idea that “millennials” are a group of youth unique from other generations before them and may have different substance use behaviors.
Consistent with national trends, Jang et al4 found an overall decrease in heavy frequent drinking patterns since the 1990s, with the greatest decline among adolescents born between 1985 and 1990. The overall decline was driven by both period and cohort effects. Critically, they noted a slower decline among blacks than whites since 2007, indicating an important disparity in the overall improving national statistics. Furthermore, the authors observed that male and female prevalence rates of binge drinking are converging. That is, although male adolescents have had historically higher heavy drinking rates than female adolescents, the rate decline is greater for male than for female adolescents, such that they are approaching female adolescents’ lower rate. However, the authors also observed that the rates of heavy drinking are diverging according to socioeconomic status (SES). In other words, youth from low-SES backgrounds have had a slower decline in heavy drinking rates relative to youth from high-SES backgrounds.
The authors’ work suggests that the decline in frequent heavy drinking is not uniform, with female adolescents, black youth, and youth from low-SES backgrounds experiencing a less steep decline. Because of a known telescoping effect, women may be more likely to experience an accelerated progression from onset of first use to an alcohol use disorder, with potentially more psychological, medical, behavioral, and social problems than men.5 Although women have historically had a lower prevalence of substance use disorders, the public health sector has been observing this convergence with great concern.6 The results of this study were consistent with previous literature citing lower rates of alcohol use in black adolescents7 but differentiated from past research on SES8 highlighting that lower-SES adolescents have had a slower decline in the rate of frequent heavy drinking when compared with those of higher SES.
A primary strength of the study is the use of large-scale, nationally representative data. Nonetheless, it is important to note (as the authors do) that MTF data do not include students absent from school and thus cannot account for those who miss the school-based data collection process because of poor attendance amid ongoing substance use.9 Additionally, the same drinking cutoff of ≥5 drinks was applied to boys and girls. This cutoff may actually indicate more adverse outcomes in the population of girls screening positive in the study, and miss those consuming ≥4 drinks who still meet criteria for binge drinking as defined by the National Institute on Alcohol Abuse and Alcoholism.10 Additional studies are needed to understand whether the slower declines in binge drinking observed among female and black adolescents are simply a leveling-off phenomenon as binge drinking rates approach historically low levels.
Pediatric primary care providers have an opportunity to screen all adolescents for alcohol use as part of routine annual care and to provide brief prevention and early intervention strategies.11 A computer-facilitated approach to screening and brief advice has been shown efficacious for reducing alcohol use among a New England sample of 12- to 18-year-olds arriving for routine care,12 which is freely available for download for iPad from the Apple App Store (Juno Health).
Amid the public health success of declining binge drinking prevalence among US adolescents, this study by Jang et al4 helps clinicians, public health researchers, and policymakers understand that period and birth cohort effects are important contributors. Given the complexities underlying national trends in drinking, this study should prompt researchers to explore the meaning behind gender, race, and SES differences across historical time. Despite the reassuring decline in frequent heavy drinking, it is critical that ongoing efforts address differences in declining rates to avoid exacerbating disparities.
- Accepted March 21, 2017.
- Address correspondence to Justine Wittenauer Welsh, MD, Emory Adolescent Substance Abuse Treatment Services, Emory University School of Medicine, 12 Executive Park Dr NE, Atlanta, GA 30329. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2016-4023.
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- Copyright © 2017 by the American Academy of Pediatrics