Full length articleExposure to alcohol outlets, alcohol access, and alcohol consumption among adolescents
Introduction
Two clear and incongruous observations motivate this paper. First, alcohol consumption is common among US adolescents. The 2017 National Survey on Drug Use and Health estimates that 7.4 million (20%) adolescents aged 12–20 consumed alcohol within the previous 30 days, and 4.5 million (12%) binged on 4 or more drinks for females and 5 or more drinks for males (Center for Behavioral Health Statistics and Quality, 2018). The high prevalence of this risk behavior persists despite a trend of decreasing consumption over the last quarter century (Esser et al., 2017). Second, alcohol consumption is illegal for US adolescents. Laws in all 50 States and the District of Columbia restrict purchases in retail outlets to persons aged ≥ 21 who have a valid identification (Babor et al., 2010). Given that alcohol use by adolescents is both common and illegal, a logical line of inquiry is to examine the sources through which adolescents access alcohol, with a view to identifying possible preventive interventions to reduce alcohol consumption. These are critical public health questions because approximately 4,300 adolescents die due to alcohol-related causes (National Center for Chronic Disease Prevention and Health Promotion, 2016) and 190,000 attend emergency rooms each year (Center for Behavioral Health Statistics and Quality, 2012).
Descriptive studies largely agree about the sources through which adolescents access alcohol. The 2018 Monitoring the Future study documented that 86% of 12th graders considered alcohol “fairly easy” or “very easy” to get (Johnston et al., 2019). Other studies document that those who actually access alcohol most commonly nominate peers as their primary sources (Gilligan et al., 2012; Schwartz et al., 1998; Wagenaar et al., 1996), and a smaller proportion indicate that they access alcohol from home with their parents’ permission (Gilligan et al., 2012; Hearst et al., 2007; Ward and Snow, 2011). Fewer still report accessing alcohol through retail sources (Harrison et al., 2000; Wagenaar et al., 1996), despite research finding that a considerable proportion of retail outlets are willing to sell to minors (Britt et al., 2006; Forster et al., 1994, 1995; Gosselt et al., 2012; Lynne-Landsman et al., 2016; Paschall et al., 2007; Preusser and Williams, 1992; Toomey et al., 2008). Importantly, access through peer, home, and retail sources differs according to adolescents’ demographic characteristics (Harrison et al., 2000; Hearst et al., 2007; Wagenaar et al., 1996). For example, younger adolescents are more likely than older adolescents to access alcohol through their parents (Hearst et al., 2007), females are more likely than males to access alcohol through peers, and racial and ethnic minorities are more likely than whites to buy alcohol at retail outlets (Harrison et al., 2000).
The sources through which adolescents’ access alcohol is related to their patterns of alcohol consumption. Dent et al. (2005) surveyed 11th grade students in Oregon and found individuals who accessed alcohol through peers aged under 21 reported more frequent alcohol consumption, binging, drunk driving, and riding in a vehicle with a drunk driver. Other studies find similar links between alcohol consumption and alcohol access through the home (Deutsch et al., 2017; Tobler et al., 2009) and through retail outlets such as bars (Casswell and Zhang, 1997). Possessing a fake ID is associated with increased alcohol consumption and related harms (Morleo et al., 2010), although it is not clear if this association is causal or if possessing a fake ID marks for other characteristics, such as risk taking (Stogner et al., 2016). Event-level studies find that perceived ease of access (Bersamin et al., 2016) and accessing alcohol through adults in the previous year are associated with increased alcohol intake, but drinking with a parent present is associated with lower single-session intake (Foley et al., 2004).
A complementary group of studies identifies that certain neighborhood conditions predict the sources through which adolescents access alcohol. Most notably, the concentration of retail alcohol outlets near adolescents’ homes seems to affect alcohol access (Reboussin et al., 2011). For example, Chen et al (2009) found that adolescents who live in ZIP codes with more alcohol outlets were more likely to access alcohol through home, through peers aged under 21, and though retail outlets (either directly or by asking a stranger), but not through peers aged 21 or older. Similarly, Treno et al (2008) found that greater concentrations of off-premise outlets around the home were associated with greater perceived ease of access and more frequent direct purchases through retail sources, but less frequent access through peers and other social sources. Importantly, retail outlets are more likely to sell alcohol to adolescents when there are more outlets nearby (Chen et al., 2009; Freisthler et al., 2003), possibly due to increased competition (Gruenewald, 2007).
In addition to predicting the sources through which adolescents access alcohol, neighborhood conditions are also directly related to the quantity and frequency of adolescents’ alcohol consumption. Specifically, adolescents who live in cities (Treno et al., 2003) and neighborhoods (Kypri et al., 2008; Reboussin et al., 2011; Scribner et al., 2008; Truong and Sturm, 2009) with more alcohol outlets consume more alcohol, and these associations are typically strongest for on-premise outlets (Sherk et al., 2018) near adolescents’ homes (Morrison et al., 2019). For example, in generalized structural equation models, Rowland et al. (2016) identified that exposure to alcohol outlets predicted increased alcohol consumption one year later among Australian adolescents. A possible explanation for these findings is that frequent exposure to alcohol outlets affects adolescents’ perceptions of normative behavior regarding alcohol consumption (Tobler et al., 2011). Alternatively, alcohol outlets tend to be located in disorganized neighborhoods (Gorman and Speer, 1997; Morrison et al., 2015; Theall et al., 2009), and the absence of social controls may contribute to deviant behavior, including greater alcohol consumption (Shaw and McKay, 1942).
Thus, previous studies identify that (i) the sources through which adolescents access alcohol is related to their alcohol consumption, (ii) neighborhood conditions, including alcohol outlet density, affect the sources through which adolescents access alcohol, and (iii) neighborhood conditions are associated with adolescents’ alcohol consumption. The aim of this study is to combine these perspectives and elucidate the paths through which neighborhood conditions, alcohol access, and alcohol consumption are interrelated for adolescents. We interpret our results in the context that alcohol access and consumption by adolescents is both common and illegal, and that harms related to alcohol consumption are an important public health problem.
Section snippets
Study setting
Healthy Communities for Teens is a cohort study of exposure to physical and social environmental conditions and risks for alcohol, tobacco and other drug use and problem behaviors among adolescents. Study participants were a convenience sample of 261 adolescents recruited from 10 cities in the San Francisco Bay Area. The cities were the closest to the Prevention Research Center (Berkeley, CA) from among a random sample of 50 California cities with populations between 50,000 and 500,000. The
Results
Complete data were available for 168 participants, whom we tracked using GPS for a mean of 598.7 h per person (SD = 113.1) during Wave 2 and who travelled a mean of 1,560.2 kilometers per person (SD = 734.2). Demographic characteristics were similar to the demographic profile of the San Francisco Bay Area; there were 66 (39.2%) males, 88 (52.4%) non-Hispanic Whites, 33 (19.6%) Hispanics, 21 (12.5%) Blacks and 11 (6.6%) Asians. In the Wave 3 annual survey, 45 (27.3%) participants reported
Discussion
Alcohol access and consumption are both illegal and common for adolescents aged under 21 years in the United States. Because alcohol consumption during adolescence is associated with increased problems during adolescence (such as injury, offending, regretted sex) (Bellis et al., 2009; National Center for Chronic Disease Prevention and Health Promotion, 2016; Center for Behavioral Health Statistics and Quality, 2012) and in later life (such as alcohol use disorders) (Grant, 1998; Wells et al.,
Conclusion
Alcohol consumption is both illegal and common for adolescents. This study and many others that have considered paths connecting neighborhood conditions, alcohol access, and alcohol consumption indicate that exposure to alcohol outlets contribute to greater alcohol access through peers, and that alcohol access through peers contributes to greater alcohol consumption. Environmental strategies that interrupt these paths may reduce adolescents’ alcohol consumption and benefit public health.
Contributors
CNM conceptualized the study, curated the data, developed the methodology, conducted the formal analyses, and wrote an original draft. HFB, BAM, SEW, WRP, and DJW conceptualized the study, assisted with methodology, and reviewed and edited the manuscript. HFB supervised the study. All authors have read and approved the final manuscript.
Declaration of Competing Interest
No conflict declared.
Acknowledgements
This study was funded by NICHS is the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD078415-01A1) and NIAAA is the National Institute on Alcohol Abuse and Alcoholism (K01AA026327-01A1).
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