Blackwell Science, LtdOxford, UKADDAddiction0965-2140 2004 Society for the Study of Addiction

99
Original Article
Alcohol disorders and adolescent alcohol consumption
Yvonne A. Bonomo
et al.

RESEARCH REPORT

Teenage drinking and the onset of alcohol dependence:

a cohort study over seven years
Yvonne A. Bonomo1, Glenn Bowes2, Carolyn Coffey1, John B. Carlin3 & George C. Patton1
1
Centre for Adolescent Health, Murdoch Childrens Research Institute and Department of Paediatrics, University of Melbourne,2 Department of Paediatrics,
University of Melbourne, Royal Childrens Hospital, Parkville, Melbourne and 3Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute
and Department of Paediatrics, University of Melbourne

Correspondence to:
Yvonne Bonomo
5462 Gertrude Street
Fitzroy 3065
Victoria
Australia
Tel: + 61 39814 8444
E-mail: ybonomo@bigpond.com
Submitted 28 November 2003;
initial review completed 9 January 2004;
final version accepted 6 May 2004

RESEARCH REPORT

ABSTRACT
Aim To determine whether adolescent alcohol use and/or other adolescent
health risk behaviour predisposes to alcohol dependence in young adulthood.
Design Seven-wave cohort study over 6 years.
Participant A community sample of almost two thousand individuals followed from ages 1415 to 2021 years.
Outcome measure Diagnostic and Statistical Manual volume IV (DSM-IV) alcohol dependence in participants aged 2021 years and drinking three or more
times a week.
Findings Approximately 90% of participants consumed alcohol by age
20 years, 4.7% fulfilling DSM-IV alcohol dependence criteria. Alcohol dependence in young adults was preceded by higher persisting teenage rates of frequent drinking [odds ratio (OR) 8.1, 95% confidence interval (CI) 4.2, 16],
binge drinking (OR 6.7, 95% CI 3.6, 12), alcohol-related injuries (OR 4.5 95%
CI 1.9, 11), intense drinking (OR 4.8, 95% CI 2.6, 8.7), high dose tobacco use
(OR 5.5, 95% CI 2.3, 13) and antisocial behaviour (OR 5.9, 95% CI 3.3, 11).
After adjustment for other teenage predictors frequent drinking (OR 3.1, 95%
CI 1.2, 7.7) and antisocial behaviour (OR 2.4, 95% CI 1.2, 5.1) held persisting
independent associations with later alcohol dependence. There were no prospective associations found with emotional disturbance in adolescence.
Conclusion Teenage drinking patterns and other health risk behaviours in
adolescence predicted alcohol dependence in adulthood. Prevention and early
intervention initiatives to reduce longer-term alcohol-related harm therefore
need to address the factors, including alcohol supply, that influence teenage
consumption and in particular high-risk drinking patterns.
KEYWORDS Adolescence, alcohol, alcohol abuse, alcohol dependence,
cannabis, depression, emotional problems, young adults.

INTRODUCTION
Alcohol now features prominently in the social interaction of teenagers in many countries. Among Australian
teenagers, approximately two-thirds report that they are
recent drinkers and around one-third drink weekly [1].
Figures for binge drinking vary between countries, from
15% of young Australians [1] to one-third of students in
2004 Society for the Study of Addiction

Denmark, Ireland, Poland and the United Kingdom [2].

The most common adverse consequences of such patterns of drinking in young people include the acute
physiological effects of excessive alcohol (blackouts,
hangovers, etc.) and behavioural effects (violence, unsafe
sexual intercourse) [3].
Also disturbing are the significant rates of alcohol
dependence found among young adults. Twelve-month

doi:10.1111/j.1360-0443.2004.00846.x

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Alcohol disorders and adolescent alcohol consumption

prevalence rates for alcohol disorders are similar across

western countries estimated to be at least 5% for males
and 2% for females [46] and, contrary to the popular
impression that alcohol disorders are most prevalent
among adults aged in their mid-40s, their prevalence is
highest among young adults. This raises questions
about the benign view of teenage drinking as a phase
that will abate with maturity. Insight into this issue is
hampered by the lack of studies of appropriate design.
Cross-sectional research does not capture the variability in alcohol consumption characteristic of adolescence. Retrospective longitudinal studies are limited by
bias in the recall of drinking patterns during teen years.
Prospective studies that have been conducted such as
the Swedish conscript study commenced their follow-up
only in late adolescence/early adulthood and defined
their outcome measure as a diagnosis of alcoholism
requiring admission to psychiatric care [7]. The results
cannot therefore be extrapolated readily to the current
social context where alcohol consumption by young
people is occurring earlier [8] and more heavily, resulting in symptoms of alcohol dependence that do not
reach clinical services until much later (if at all). This
study used a large community-based sample of adolescents followed prospectively to adulthood to examine
which teenage patterns of drinking (and other health
risk behaviour) predict the development of Diagnostic
and Statistical Manual volume IV (DSM-IV) alcohol
dependence.

METHODS
Procedure and sample
Between August 1992 and December 1998 a seven-wave
cohort study of adolescent health was conducted in Victoria, Australia. The cohort was defined using a two-stage
procedure. At stage 1, 45 schools from a stratified frame
of government, catholic and independent schools (total
number of students 60 905) were selected randomly. At
stage 2, a single intact class from each participating
school was selected at random to constitute the wave 1
sample. To augment the cohort sample size yet avoid
excessive burden on schools, recruitment to the study
was spread over two different school years: when the
wave 1 sample had moved into year 10, a second class
from each participating school was selected at random.
One school from the initial cross-sectional survey was
unavailable for study, leaving a total of 44 schools. At the
time of sampling, 98% of Victorian school students were
still recorded as present in the education system [9]. Participants were reviewed biannually during the teens
(waves 16) with final follow-up at age 20/21 years
(wave 7).
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Adolescent phase: waves 16

Written parental consent for participation was sought at
entry of the students into the study. The students completed measures at intervals of 6 months between year 9
and year 12 (six waves). Laptops were used to administer
the questionnaire [10]. Subjects unavailable for followup at school were interviewed by telephone. A total of
1943 adolescents (96% of the intended sample) participated at least once during waves 16 with a gender ratio
(males: 48.6%) similar to that in Victorian schools at the
time of sampling [9].

Missing data: waves 16

Seventy per cent of the cohort completed five waves of
data collection. As recruitment into the cohort was
staged over the first two waves, 54% of observations were
not present in the first wave of data collection. Proportions for missing observations in subsequent waves were
11%, 13%, 16%, 19% and 21% for waves 2, 3, 4, 5 and 6,
respectively. Multiple imputation was used to handle this,
enabling summary measures to be defined for each participant in each of five completed data sets. Final results
were obtained by combining analyses from the five
imputed data sets (see below). Imputation was performed
using a multivariate mixed effects model [11].

Young adult survey (wave 7, 1998)

The young adult survey was carried out by telephone
using computer-assisted interviews. Mean age of wave 7
participants was 20.7 years (SD 0.5); 46.0% were male
(Fig. 1).
A total of 1601 young adults (82% of all cohort participants) were interviewed between April and December
1998. Three hundred and forty-two participants were
not interviewed at wave 7; 152 refused, 59 were located
but unable to be contacted, 129 were lost to follow-up
and two had died from natural causes.

Outcome measure: alcohol dependence in

young adulthood
The young adult survey incorporated the Composite
International Diagnostic Interview (CIDI) to assess DSMIV alcohol dependence [1215] according to standard
DSM criteria. The CIDI is a structured diagnostic interview designed for use by non-clinical professionals and
has been demonstrated to be both reliable and cross-culturally valid [1215].
A pragmatic consideration in the conduct of a cohort
study is the maintenance of participant cooperation by
the minimization of avoidable responder fatigue. It was
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Yvonne A. Bonomo et al.

1st sample
N1=1037

2nd sample
N2=995

wave 1
n1=898
(87%)
late 1992

wave 2
n2=1728
(85%)
early 1993

Total intended sample = N1+N2 = 2032

Total achieved sample = 1943 (96%)

wav 3
n3=1699
(84%)
late 1993

wave 4
n4=1629
(80%)
early 1994

wave 5
n5=1576
(78%)
late 1994

wave 6
n6=1530
(75%)
early 1995

ADOLESCENT PHASE

wave 7

n7=1601
(79%)
1998
YOUNG
ADULT
SURVEY

Figure 1 Victorian Adolescent Health Cohort Study, 19921998

considered unlikely that a diagnosis of alcohol dependence was consistent with only occasional alcohol use,
given the DSM-IV description of substance dependence
as repeated (substance) self-administration. Consequently, the CIDI interview was administered only to
those participants who reported using alcohol at least
three times a week. Our outcome is therefore defined as
alcohol dependence in frequent alcohol users.

beer, mixed drinks, etc.) and amounts (e.g. glass, can,

etc.) consumed in the 7 days prior to the survey. Estimates of frequency of consumption and self-reported
alcohol dose were calculated from the responses,
enabling the following classifications: (1) frequent drinkers: defined as drinking on 3 or more days in previous
week; and (2) binge drinkers: defined as consuming 45 g
of ethanol or more (equivalent to 5 + standard drinks)
[16].

Background factors
Alcohol-related consequences
Demographic factors and parental alcohol and tobacco use
Demographic factors and parental alcohol and tobacco
use were included as indicators of socio-economic status
and of environmental exposure to substances, recognized
as risk factors for alcohol disorders. Demographic factors
included gender and country of birth. Participants were
also asked at each wave to report their parents marital
status (married, de facto, divorced, single or dead) and
their parents highest level of education (high school
not completed, high school completed, non-university
tertiary education, university education). Variables for
parental marital status classifying parental divorce or
separation by wave 6 and parental education were then
defined. Participant report of parental alcohol use was
categorized as none, drank most days or drank every
day. They were also asked whether their parents smoked
cigarettes never, occasionally, most days or every
day. Variables derived for parental alcohol and tobacco
use identified whether either parent drank or smoked
most days or every day.

Adolescent risk factors

Alcohol consumption
Alcohol consumption was assessed at each survey. Those
individuals who reported drinking alcohol were asked to
fill in a diary which recorded categories of alcohol (e.g.
2004 Society for the Study of Addiction

There were three broad categories of alcohol-related consequences examined among the adolescents:
1 Intense drinking. Two items in the adolescent phase
surveys asked about intense drinking. The first item
related to drinking to a significantly altered conscious
state. Respondents were asked whether they had ever
consumed so much alcohol that they could not
remember the next day about events the night before.
The second item asked the adolescents if they had ever
found themselves unable to stop drinking.
2 Alcohol-related accidents or injuries. The adolescents
were asked: In the last 6 months have you had an
injury because of drinking: never, once, more than
once? They were then asked In the last 6 months have
you had an accident because of drinking: never, once,
more than once?
3 Alcohol-related sexual risk-taking. There were three
items that related to sexual risk-taking under the influence of alcohol in the adolescent survey. Participants
were asked: In the last 6 months, have you ever had
any of the following problems because of drinking?
Having sex with someone and later regretting it? Having sex without using a contraceptive? Having sex with
out using a condom?
Where two or more adverse outcomes of drinking
were reported, they were classified as being recurrent and
assessed as potential risk factors for subsequent alcohol
dependence.
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Alcohol disorders and adolescent alcohol consumption

1523

Tobacco use

Ethics approval

Tobacco use was assessed at each survey. Those who

reported that they were smokers were asked to keep a 7day retrospective smoking diary, in which the individual
reported the number of cigarettes smoked on each day
during the last week. The following groups were categorized: (i) occasional smokingin previous month, but
less than 6 days in the previous week; (ii) daily smokingon 67 days of previous week; and (iii) high dose
smokingdaily, with an average of 10 + cigarettes per
day.

Ethics approval was obtained from the Royal Childrens

Hospital Ethics Committee.

Cannabis use
Cannabis use was assessed by asking the adolescents at
each wave whether they had used marijuana. Those who
had were asked to report how often they had used it in the
previous six months. At least weekly use was defined as
frequent cannabis use.

Data analysis
Data analysis was undertaken using Stata 7 [23] and followed the method of Rubin [24] for creating valid inferences under the assumptions of the imputation model,
combining over separate analyses performed on each of
the imputed datasets. Software for facilitating these analyses was written in Stata [25].
Univariate and multivariate logistic regression analyses were performed on the binary outcome of alcohol
dependence. The Wald test was used to assess first order
interactions. All confidence intervals are based on the
95% level. Two-tailed P-values are reported.

RESULTS
Antisocial behaviour
Alcohol dependence in young adulthood (wave 7)
Antisocial behavior was assessed at each wave based on
10 items from the Self-Report Early Delinquency Scale
covering property damage, interpersonal violence and
theft in previous 6 months [17].
Psychological distress
Depression and anxiety were assessed using the revised
Clinical Interview Schedule (CIS-R) [18,19], providing
data on the frequency and severity of 14 common psychiatric symptoms [20]. The total scores were dichotomized
at 11/12 reflecting a level appropriate for clinical intervention [18,21,22].
Peer alcohol use
Participants were asked how many of their friends drank
alcohol: none, some, most or dont know. A variable
was defined that classified participants who reported that
most of their friends drink alcohol.
Explanatory variables: waves 16
Measures of persistence at a defined level of intensity were
constructed: (i) the number of waves at which a condition
was reported was counted and classified into three levels:
zero, one wave (indicating experimentation), two to six
waves (indicating persisting exposure); and (ii) maximal
level of cigarette smoking reported during the six waves
was categorized into (none; less than daily; daily and less
than 10 cigarettes/day; daily and 10 or more cigarettes/
day).
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Of the 1601 wave 7 young adults, 1374 consumed alcohol in the previous year and 124 reported drinking at
least three times a week. Sixty-eight (55% of participants
drinking three or more times a week) fulfilled DSM-IV
alcohol dependence criteria. They were more likely to be
male (OR 3.7, 95% CI 2.1, 6.5), have divorced parents
(OR 1.7, 95% CI 1.0, 3.0) and to have at least one parent
who drank alcohol most days (OR 2.0, 95% CI 1.2, 3.2)
(Table 1). Ninety-six per cent (CI 93%, 98%) of these
adults had reported drinking during the adolescent phase
(waves 16).

Univariate associations between alcohol dependence in

frequent drinkers (wave 7) and adolescent exposures
(waves 16)
Frequent drinking and binge drinking in adolescent
waves 16 defined separate groups of individuals
(Table 2). Frequent drinkers in adulthood were assessed
for the frequency of adolescent factors and for crude associations with alcohol dependence (Table 3).

Persistence of drinking patterns and alcohol-related behaviour

Frequent drinking and binge drinking each showed
strong associations with alcohol dependence in young
adulthood. Recurrent reports increased odds for later
dependence at least sixfold (recurrent frequent drinking:
OR 8.1, 95% CI 4.2, 16; recurrent binge drinking: OR
6.7, 95% CI 3.6, 12). Alcohol dependence was also more
likely with persistent alcohol-related accidents and
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Yvonne A. Bonomo et al.

Table 1 Association of background factors with alcohol dependence at the age of 20 years (n = 1601): odds ratios (OR) from univariate
logistic regression models.
Alcohol dependence at age 20 years
Background factor

OR

95% CI

Male
Parental divorce/separation by wave 6
Parental education
Tertiary
Completed secondary
Incomplete secondary
One or both parents drinks most days
One or both parents smokes most days

735
284

3.7
1.7

2.1, 6.5
1.0, 3.0

576
510
515
568
991

1
1.7
1.4
2.0
1.6

0.94, 3.2
0.77, 2.7
1.2, 3.2
0.94, 2.8

Table 2 Alcohol use from wave 17 in 1601 wave 7 participants. Figures are percentages (standard errors).
Wave of survey

Mean age (years)

Non-drinker
No drinking last week
Drank 1 or 2 days last week
Max < 45 g/day
Max > 45 g/day
Drank 3 or more days last week
Max < 45 g/day
Max > 45 g/day

14.9
57.7 (2.00)
28.6 (1.84)

15.5
46.1 (1.28)
32.0 (1.20)

15.9
35.4 (1.27)
37.7 (1.34)

16.4
27.9 (1.17)
42.0 (1.33)

16.8
31.6 (1.31)
36.2 (1.37)

17.4
17.9 (0.99)
46.9 (1.26)

20.7
14.0 (0.87)
29.3 (1.14)

5.7 (0.66)
5.6 (0.73)

9.6 (0.75)
8.6 (0.78)

11.7 (0.81)
10.6 (0.87)

11.0 (0.88)
14.7 (0.90)

10.9 (0.83)
16.9 (0.98)

10.9 (0.80)
18.8 (1.02)

12.2 (0.82)
30.1 (1.15)

0.8 (0.30)
1.6 (0.39)

0.8 (0.24)
2.8 (0.45)

1.3 (0.32)
3.3 (0.47)

0.8 (0.25)
3.6 (0.57)

0.4 (0.16)
4.1 (0.55)

0.7 (0.22)
4.7 (0.55)

2.4 (0.39)
11.9 (0.81)

injuries (OR 4.5, 95% CI 1.9, 11) and with intense drinking (OR 4.8, 95% CI 2.6, 8.7) but not with alcoholrelated sexual risk taking.

Psychiatric morbidity
No evidence of association with psychiatric morbidity
was found.

Drinking peers
Adolescents who persistently reported that most friends
drank were eightfold more likely to be alcohol-dependent
later (OR 8.1, 95% CI 2.5, 26).

Cigarette smoking
High dose (10 + cigarettes) daily smoking in adolescence
had fivefold increased odds of alcohol dependence (OR
5.5, 95% CI 2.3, 13).

Cannabis use, antisocial behaviour

Both cannabis use and antisocial behaviour were associated prospectively with alcohol dependence in young
adulthood. The odds increased with increasing frequency
of antisocial behaviour (OR for report at one wave: 2.7,
95% CI 1.3, 5.6; OR for report at multiple waves: 5.9,
95% CI 3.3, 11).
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Independent associations between alcohol dependence in

frequent drinkers (wave 7) and adolescent exposures
(waves 16)
Multiple logistic regression was used to examine independent predictive associations between alcohol dependence
in young adulthood and adolescent measures and to
adjust for possible confounding (Table 4). An independent relationship between alcohol dependence in young
adulthood and frequent teenage drinking was demonstrated, the likelihood increasing with persistence of frequent drinking through adolescence (OR for frequent
drinking at one wave: 2.0, 95% CI 1.0, 4.3; OR for frequent drinking at multiple waves: 3.1, 95% CI 1.2, 7.7).
Adolescent antisocial behaviour was also associated
independently with alcohol dependence, with individuals
persistently reporting such behaviour being approximately 2.5 times more likely to be in the alcohol-dependent group in young adulthood (OR 2.4, 95% CI 1.2,
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Alcohol disorders and adolescent alcohol consumption

1525

Table 3 Estimated frequency of time varying adolescent measures and their association with alcohol dependence in frequent alcohol users
at age 20 years (n = 1601): odds ratios (OR) from univariate logistic regression models.

Estimated frequency

Alcohol dependence at
age 20 years

Adolescent measure: waves 16

Category

95% CI

OR

Frequent drinking

None
One wave
More than one wave
None
One wave
More than one wave
None
One wave
More than one wave
None
One wave
More than one wave
None
One wave
More than one wave
None
One wave
More than one wave
None
Occasional
Daily, < 10 cigs/day
Daily, > 10 cigs/day
None
One wave
More than one wave
None
One wave
More than one wave
None
One wave
More than one wave

1344
169
88
900
298
403
1460
88
53
1450
97
55
1247
204
150
413
220
969
632
606
207
157
1415
80
106
1244
188
169
857
245
499

1313, 1374
142, 196
68, 108
858, 942
263, 333
367, 439
1438, 1483
70, 106
38, 67
1425, 1474
77, 117
40, 69
1213, 1281
177, 231
125, 176
377, 449
184, 255
927, 1011
578, 686
552, 660
180, 233
133, 181
1389, 1440
61, 99
86, 127
1206, 1282
155, 221
144, 194
808, 905
202, 288
462, 537

1
4.4
8.1
1
3.0
6.7
1
2.0
4.5
1
1.5
0.88
1
2.1
4.8
1
2.3
8.1
1
2.4
3.9
5.5
1
4.3
2.7
1
2.7
5.9
1
1.2
0.91

Binge drinking

Alcohol-related injuries or accidents: 2

or more behaviours
Alcohol-related sexual risk-taking: 2 or
more behaviours
Intense drinking: 2 or more behaviours

Most friends drink alcohol

Maximal tobacco smoking

Weekly or more frequent cannabis use

Antisocial behaviour: 2 or more

behaviours
Psychiatric morbidity CIS > 11

95% CI

2.4, 8.4
4.2, 16
1.4, 6.7
3.6, 12
0.8, 5.1
1.9, 11
0.6, 3.8
0.2, 3.7
1.0, 4.2
2.6, 8.7
0.4, 12
2.5, 26
1.0, 5.8
1.6, 9.7
2.3, 13
1.7, 10.5
1.2, 6.1
1.3, 5.6
3.3, 11
0.6, 2.8
0.5, 1.6

CIS, Clinical Interview Schedule.

5.1). No first order interaction effects between gender

and any explanatory variable were found.

DISCUSSION
Our study demonstrates that the clearest predictor of
alcohol dependence in young adults was regular recreational alcohol use in the teens. Regular drinking clustered with a range of health risk behaviours including
binge drinking, injuries and accidents under the
influence of alcohol, smoking in high dose and cannabis
use.
Although alcohol dependence has been accepted traditionally as occurring in young adulthood [26,27], the
strong association between frequent teen drinking and
2004 Society for the Study of Addiction

alcohol dependence in adulthood may reflect an already

existent dependence syndrome in adolescence. Surveys
based on both general population and clinical samples
indicate that DSM alcohol disorders are evident at as
early as 1617 years of age [28]. While such data support
the concept that adolescents can experience alcohol
dependence the extrapolation to adolescents of DSM criteria developed for adults is problematic. The frequently
progressive nature of adult drinking problems and the
spectrum of chronic complications (such as liver, pancreatic and other gastrointestinal injury as well as neurological and cardiovascular injury) are observed far less
frequently in adolescents who abuse alcohol. DSM criteria for alcohol disorders also appear to have different
implications for adolescents compared to adults. For
instance, while tolerance is often considered to have high
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Yvonne A. Bonomo et al.

Table 4 Predictive association of adolescent measures with alcohol dependence in frequent alohol users at age 20 years (n = 1601), adjusted
for sex, parental divorce/separation and parental alcohol use: odds ratios (OR) from multivariate logistic regression models.
Alcohol dependence at age 20 years
Adolescent measure: waves 16

Category

OR

Frequent drinking

None
One wave
More than one wave
None
One wave
More than one wave
None
One wave
More than one wave
None
One wave
More than one wave
None
One wave
More than one wave
None
Occasional
Daily, < 10 cigs/day
Daily, > 10 cigs/day
None
One wave
More than one wave
None
One wave
More than one wave

1
2.0
3.1
1
1.5
1.4
1
0.59
0.82
1
1.0
1.8
1
1.6
3.2
1
1.5
1.5
1.6
1
1.4
0.48
1
1.3
2.4

Binge drinking

Alcohol-related injuries or accidents: 2 or more behaviours

Intense drinking: 2 or more behaviours

Most friends drink alcohol

Maximal tobacco smoking

Weekly or more frequent cannabis use

Antisocial behaviour: 2 or more behaviours

specificity in alcohol-dependent adults, it appears to have

low specificity among problem drinking adolescents in
treatment [29]. DSM criteria also do not account for
interruptions to adolescent psychosocial development in
recurrent adolescent alcohol abuse.
If the association is not measurement-related, then a
process of kindling may explain frequent teen drinking
progressing to dependence. Cycles of regular exposure
increase tolerance to alcohol, which drive escalating consumption [27,30,31]. For some, constitutional predisposition to heavy intake making it difficult to moderate
drinking may play a role. For example, individuals with a
family history of alcohol abuse have described feeling less
intoxicated at high blood alcohol levels [3234]. Studies
of genetics suggest at least some heritability of vulnerability to alcoholism [35,36]. More broadly, there are
significant social influences that influence heavy
consumption of alcohol by young people today. These
include peer models and normative expectations about
alcohol which, in large part, are driven by such developments as the production of sweet and colourful alcoholic
beverages with tantalizing names as well as intensive
marketing of alcohol to young people portraying alcohol
consumption as fun and sexy through both traditional
2004 Society for the Study of Addiction

95% CI

1.0, 4.3
1.2, 7.7
0.62, 3.6
0.61, 3.4
0.21, 1.7
0.27, 2.5
0.47, 2.1
0.82, 4.1
0.27, 9
0.94, 11
0.58, 3.8
0.55, 4.1
0.53, 4.7
0.51, 4.0
0.17, 1.4
0.58, 2.8
1.2, 5.1

and newer media (internet, SMS texts on mobile phones)

[37,38]. These social changes provide challenges in
defining what is the healthy norm for adolescent alcohol
consumption.
This study has a number of advantages, including
high participation rates and frequent prospective measures during the teens. Alcohol consumption and other
health risk behaviours in adolescence were recorded at 6monthly intervals, capturing some of the variability in
behaviour that is characteristic among adolescents. It
was also possible to examine adolescent patterns of drinking in detail. Apart from quantity and frequency of alcohol intake, adverse outcomes of adolescent problem
drinking were included in the analysis. The use of multiple imputation enabled bias introduced by missing data in
the course of the study to be addressed. This method is
valid under the assumption that the probability that a
participant is missing a wave can be predicted from data
observed at other waves (missing at random), and even
under some departure from this assumption is likely to
produce less biased results than complete-case analyses
[39]. Potential selection bias at the inception of the study
is likely to have been minimal because of high school
retention rates, and there was high ascertainment in the
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Alcohol disorders and adolescent alcohol consumption

study with 96% of the sampling frame having participated at least once.
As alcohol consumption among young people
increases, evidence is emerging for its potential longerterm impact. At present, there is marked ambivalence
within the community regarding teenage drinking and
what constitutes a safe level of alcohol consumption. The
traditional or conservative opinion is that young people
should not consume alcohol until at least age 18 years
because of continuing neurological, particularly cerebral, development [40,41]. The alternative view is that
alcohol consumption by teenagers is not only acceptable
but of little concern, because it is better than illicit drug
use and that periods of blackouts and other complications
of alcohol use among young people are merely part of the
rite of passage to adulthood [42]. This ambivalence
results in a failure to mount a robust defence against the
increasingly assertive marketing of alcohol products to
young people. In addition, prevention and early intervention initiatives to reduce longer-term alcohol-related
harm need to broaden their focus to include adolescents,
in particular uptake of alcohol with other substances and
high-risk drinking patterns.

References
1 Australian Institute of Health and Welfare (AIHW) (2002)
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