Lower drinking age? It’s a complex issue

The Amethyst Initiative, a collaborative effort of more than 120 U.S. college presidents to open debate on the minimum legal drinking age of 21, raises concerns that are shared by many Americans:

• How can adults supervise and help shape responsible alcohol use among our youth when we cannot legally be present when they use alcohol?

• Does making alcohol use by 18- to 21-year-olds illegal lead to secretive use in potentially harmful patterns, such as shots, drinking games and other binge drinking that may actually increase the risk of alcohol toxicity, injury or later alcohol disorders?

• Is it morally justifiable to withhold an adult privilege from persons to whom we entrust all other adult responsibilities, including voting, marriage and military service?

• What are the implications for the development of good citizenship and respect for the law when, to use alcohol in any context, young people must break the law?

These questions merit careful consideration and thoughtful answers. The impulse of those of us in the public health community to respond by citing data on increased drinking-related harm associated with a lower drinking age does not fully address them.

Supporting the current drinking age, however, is extensive and compelling data that indicate the 21-year-old drinking age saves lives and prevents injuries. A recent review of scientific evidence by the U.S. Centers for Disease Control concluded that lowering the drinking age to 18 would result in a 10 percent increase in traffic fatalities. The National Highway Traffic Safety Administration estimates that approximately 1,000 lives have been saved each year since all states adopted the 21-year-old drinking age.

In addition, there is clear evidence that a lower drinking age would result in increased use of alcohol by children in younger age groups. And because neurobiologic research indicates that the younger a person begins to use alcohol, the greater the risk of developing an alcohol use disorder, a lower drinking age is expected to increase the individual and societal burden of alcohol-related health conditions.

It is difficult to estimate the combined value of a likely reduction in secretive youth drinking, increased opportunity for adult supervision and the justice of a uniform age of majority anticipated with a lower drinking age and to weigh this against the 1,000 additional annual traffic fatalities and expected increase in adult alcohol disorders. But we must try. We cannot realistically evaluate the net effects of changing (or maintaining) the current drinking age unless both sides bring equal measures of science and moral and socio-cultural consideration to bear on their arguments.

It is reasonable to consider whether targeted regulatory or social changes might reduce the traffic fatalities or increased alcohol disorders expected with a lower drinking age.

Among strategies some have considered: creating a societal norm of zero tolerance for any alcohol use and driving; lowering legal blood alcohol levels for driving; markedly increasing enforcement of drinking and driving laws; requiring alcohol detector ignition-blocking systems in all cars; changing the driving age; increasing penalties for providing alcohol to under-aged persons, and/or creating graduated drinking laws that might, for example, permit persons 18 to 21 to be served limited alcohol with food in a restaurant or in a private home in the presence of a responsible adult over age 25.

A 2001 report of the U.S. National Highway Traffic Safety Administration supports the possibility that some interventions might reduce the harm expected with a lower drinking age. It noted that while uniform adoption of the 21-year-old drinking age by all states in 1988 contributed to reduced drinking and driving by youth (reflected in a dramatic 61 percent reduction of drinking drivers under age 21 involved in fatal crashes between 1982 and 1998) other factors clearly contributed as well.

Both Canada (which has 18- or 19-year-old drinking ages in all provinces) and those U.S. states that had always had a 21-year-old drinking age saw parallel declines in drinking-related traffic fatalities among youth during the same time period.

Worldwide problem

In considering change of the U.S. drinking age, however, it is important to be aware that concern over harmful youth alcohol use is not limited to the United States.

Recent surveys of the European School Project on Alcohol and Other Drugs and the U.S. Monitoring the Future project found that rates of binge drinking (five or more drinks in a row) are higher among youth in 34 of 35 European countries surveyed than in the United States, and self-reported intoxication by youth is higher in more than three-quarters of the European nations than in the United States.

In addition, most European nations report similar or higher rates of adult alcohol dependence than the United States.

In aggregate, the European data do not support conjectures, often offered by supporters of a lower drinking age, that youth drink more responsibly with fewer negative consequences of alcohol use in countries with lower drinking ages.

A World Health Organization report offers raising the minimum drinking age in other countries as a potential strategy to reduce harm. The report also identifies corporate marketing of alcohol to youth as likely the major force driving the global epidemic of unhealthy alcohol use by young people.

The college presidents have provided an important service in opening the debate. For too long public discussion of the drinking age, particularly arguments that favor lowering the drinking age, have seemed taboo among persons in a position to make a difference in harmful youth alcohol use. But bad ideas take root in darkness and usually fade away when exposed to light; we must explore all dimensions of the drinking age debate energetically and without bias.

While it is possible that the 21-year-old drinking age is one variable that contributes to a harmful alcohol culture among American youth, the forces driving the global epidemic of harmful youth drinking are far more complex and run far deeper than the age of majority for alcohol.

As we debate the drinking age, it is critical to the health and well-being of our young that we continue to apply evidence-based principles already known to reduce harmful youth drinking in our current national context. A simple solution to this complex problem is unfortunately not likely.

Seddon Savage is director of the Dartmouth Center on Addiction Recovery and Education, a collaborative effort of Dartmouth College and Dartmouth Medical School. She is immediate past president of the New Hampshire Medical Society.