Adolescent alcohol consumption: The drug link

The evidence is clear that in teenagers and young adults, drinking - especially heavy drinking - is often linked to smoking and the use of illegal drugs. But how should this link be understood? Do drinking and drug taking just happen to co-exist, or does the one cause the other. Here Jeremy S Gluck, Research Director of Adolescent Assessment Services (AAS), analyses the results of an AAS survey to throw light on these questions.

Causal links between one form of behaviour and another are always hard to establish. Normally this is due to myriads of additional overlapping factors or confounding variables. However, the link between adolescent alcohol use and other substance use appears clear: research has shown that there is little illegal drug use without preceding or concurrent alcohol use (i.e. Sutherland and Willner, 1998).

In this article I will present data gathered during 1999 and 2000 from 32,652 11-16 year olds from all over the UK. These data were collected by Adolescent Assessment Services (AAS), an independent research organisation working closely with Local Education Authorities and Health Departments to establish levels of and reasons behind substance use in young people. Firstly, current drinking, smoking and drug use levels will be presented and these behaviours will then be linked.

Alcohol Use
Using a specifically designed self-report questionnaire, AAS asked children about their drinking habits and found that 16.6 % of 11-16 year olds claimed to drink alcohol on at least a weekly basis. Table 1 shows these data by age and gender. Of those children who claimed any alcohol use at all, 38.5 % said they only drank yearly, 34.2 % said they drank monthly, 20.6 % claimed weekly use, 4.9 % said they drank on at least two to three occasions a week and 1.8 % said they drank daily.

Children were also asked about incidents of drunkenness in the year preceding the survey. Out of all the children surveyed, 40.6 % claimed to have been drunk on at least one occasion. Details of occurrences of drunkenness by this sub-group of children can be found in Table 2.

	Table 2 - Incidents of drunkenness (all figures are percentages of children claiming to have been drunk)
Age	11	12	13	14	15	16
1-2 times	61.3	57.9	49.8	41.3	36.8	36.5
3-5 times	20.7	17.9	24.3	26.6	23.0	22.0
6-10 times	6.8	10.9	11.4	12.3	14.4	15.0
11-20 times	4.3	4.8	6.5	8.9	9.6	8.8
20+ times	6.8	8.5	8.0	10.9	16.2	17.8

Drug Use
Children were also asked about their illegal drug use and 3.3 % claimed to use drugs at least weekly. Drug use by age and gender can be found in Table 3. Typically, more boys than girls claim illegal drug use.

	Table 3 - Weekly or greater drug use by age and gender
Age	11	12	13	14	15	16
Males	1.2	1.9	2.7	5.9	8.4	8.8
Females	0.5	0.9	2.4	4.5	6.9	6.6
Mean	0.8%	1.4%	2.5%	5.2%	7.6%	7.7%

Cigarette Smoking
Respondents were also asked about their regular smoking habits which were defined as any smoking which took place on a daily basis. The percentage of children smoking regularly can be found in Table 4. In line with other research of this type, it was found that considerably more girls than boys claimed to smoke.

	Table 4 - Proportions of children reporting daily smoking
Age	11	12	13	14	15	16
Males	4.7	6.3	9.5	14.7	18.0	20.9
Females	4.8	6.2	15.1	20.5	29.1	28.2
Mean	4.8%	6.3%	12.4%	17.7%	23.9%	24.7%

Alcohol and Drugs
AAS then looked at the relationship between alcohol and drugs and, as in the earlier study by Sutherland and Willner, found that a close relationship exists between use of alcohol and use of illegal drugs. The basic fact which emerged from the analyses was that 1.3 % of non-drinkers said they used drugs compared to 14.1 % of drinkers. However, the relationship went deeper than this and we found that the more often a child drank the more likely they were to use illegal drugs. Table 5 shows this relationship in detail.

	Table 5 - Occasions of alcohol drinking and drug use Occasions of Drinking
	Yearly	Monthly	Weekly	Weekly +	Daily
Males	1.5	2.6	11.7	15.5	31.8
Females	0.3	2.9	11.9	21.5	29.3
Mean	0.9%	2.7%	11.8%	18.2%	31.0%

A similar relationship was found between drunkenness and drug use. 0.7 % of children who said they had never been drunk in the preceding year claimed drug use compared with 7.3 % of children who said they had been drunk on at least one occasion. As with incidents of drinking, the more often an adolescent had been drunk, the more likely it was that they would also claim drug use. Table 6 shows this relationship in detail.

	Table 6 - Occasions of drunkenness and drug use Occasions of Drunkenness
	Yearly	Monthly	Weekly	Weekly +	Daily
Males	3.3	5.8	8.2	13.3	25.3
Females	2.8	5.2	8.1	11.7	25.3
Mean	3.0%	5.5%	8.2%	12.5%	25.3%

It is interesting to note that, unlike simple use which is mediated by age whereby substance use increases with age, no such effect was noted here. For instance, 14 % of 12 year olds who drank said they used drugs compared with 12.3 % of 16 year old drinkers.

Alcohol and Smoking
Finally, we looked at the relationship between adolescent drinking and smoking and the strength of the association between drinking and smoking was startling. 7.6 % of non-drinkers smoked compared with 39.8 % of regular drinkers. Table 7 shows that the more often a child drinks the more likely it is that they will be a smoker too. In particular it is notable that 65 % of girls who claimed to drink on a daily basis also claimed to smoke. As with the relationship between alcohol and drugs, no age effect was noted. Although, as we have seen, smoking increases with age, when alcohol was factored in, smoking was stable across the age range (33.9 % of 11 year old drinkers smoked compared with 34.2 % of 16 year old drinkers).

	Table 7 - Occasions of alcohol drinking and smoking Occasions of Drinking
	Yearly	Monthly	Weekly	Weekly +	Daily
Males	5.4	12.0	27.0	33.2	49.4
Females	6.6	22.2	47.5	63.7	65.0
Mean	6.0%	17.2%	36.9%	47.0%	54.3%

Of those children who said they had never been drunk 3.8 % said they were smokers, this compared to 26 % of children who said they had been drunk on at least one occasion in the year before the survey was carried out. As with the data reported earlier, it can also be seen in Table 8 that a clear relationship exists between occurrences of drunkenness and smoking: The more often a child is drunk, the higher the incidence in smoking. Again, this is particularly so in girls.

	Table 8 - Occasions of drunkenness and smoking Occasions of Drunkenness
	Yearly	Monthly	Weekly	Weekly +	Daily
Males	11.1	15.9	26.3	31.6	44.1
Females	19.4	31.7	45.1	55.9	62.6
Mean	15.2%	23.9%	36.0%	43.2%	52.7%

Discussion
It can be seen from these data that there is a strong association between alcohol, adolescent smoking and illegal drug use. However, I am not suggesting that alcohol drinking necessarily causes drug use. These data simply report on an association between the variables and it would not be scientifically or statistically correct to assume causality from this type of information. This is particularly the case as the information only relates to three specific variables whereas we know that dozens of others exist and act on individuals and that these variables will all play their part in all their substance using habits. Having said that, the association between alcohol and other substance use is extremely robust and too strong to discount. If the caveat of association rather than causality is accepted why is this association so pronounced?

Firstly, we live in a culture of substance use and use of alcohol in particular is normal in our society. Well over 90 % of adults drink alcohol on a regular basis and this use is reflected in increased drinking by our children. All the time children are bombarded with images of adults drinking alcohol either in the media or in their own homes, therefore the idea of ingesting a foreign substance is not alien to them. Children who are used to drinking are therefore less likely to refuse if offered a different drug simply because it is not unusual for them to be in the presence of consistent psychotropic drug (alcohol) use.

However, the fact that we have found almost no drug use without preceding alcohol use is indicative that there is ground for serious concern as regards adolescent alcohol abuse leading to drug use. Another reason for the association between alcohol and drug use is the disinhibiting effect of alcohol. Imagine a child who has drunk to excess: Is that child more or less likely to accept, say, any Ecstasy tablet than a sober child? The answer appears clear.

AAS asserts that this is a more complex and intractable problem that might at first be realised, and that currently the approaches to dealing with adolescent substance abuse are, at best, only marginally successful. The danger in underestimating the gravity of the situation is that the temptation to ascribe such trends purely to recognised, accepted factors can result in a perception of the problem that obscures the more deep-lying social causes.

Our data therefore suggests that if you can reduce adolescent alcohol use, you can subsequently reduce other types of adolescent substance use. In addition, it is reasonable to conclude that as the use of alcohol can lead to less inhibited behaviour other behaviours such as premature and risky sexual behaviour may be reduced if adolescent alcohol use is decreased. On this latter point, and in light of the fact that one person is diagnosed as having the HIV virus in the UK every three hours, it is clear that the benefits of reduced adolescent alcohol use could have important results.

The complacency about the centrality to our society of routine alcohol use, and the general reluctance to really address the causal links between adolescent alcohol use and adolescent drug use and sexual behaviour, shows that data such as we have collected is of great concern.

Until and unless we can honestly address the causal factors and link between alcohol and drug use, especially in children, we cannot expect to see a significant reduction in usage figures. Perhaps one reason that the causal link is not properly conveyed is that, simply, the distinction made to adolescents between alcohol and drugs is too facile. Alcohol use, for all its evident perils, is made to seem fundamentally inevitable and acceptable as of legal age, from which a young adolescent might well infer that drinking under legal age is more a matter of inclination than anything more.

Drugs, on the other hand, are presented as fundamentally unacceptable, and their criminal status emphasised. Therefore, the causal link between alcohol and drugs is obscured and even broken by making alcohol a conditional positive, but drugs an unconditional negative. This breaking of the causal link in educating adolescents in the hazards of abuse has its own hazards, including the fact that unless the gravity of alcohol abuse is conveyed as being unconditionally equal to that of drug use, young people might infer that alcohol use has little connection to drug use; this disassociation could certainly lead to a "comfort zone" around alcohol use where it is felt that drug use is rather divorced from the former, and therefore that alcohol use and abuse is less consequential.

It is important to note at this point that it is not the assertion of AAS that alcohol has in any way to be criminalised to deter its abuse by adolescents, but rather that education in substance use must reflect current research and clearly present the links established by work such as this.

AAS is endeavouring to broaden and deepen the scope and methodology of its research and provision of data to public and private bodies concerned with public health in order that this problem, which represents a critical dilemma for our society, can better be dealt with and ameliorated at the causal level. Therefore, in addition to baseline information, AAS is now in the process of gathering data related to the causes of alcohol and other substance abuse including information on expectations, attitudes, social correlates and personality variables.

Once the causal link between alcohol and drug use in adolescents can be formally established, more incisive education about it can begin, with potential reduction in present levels being a real possibility.

Can we afford any longer to obscure the link between alcohol and other types of drug abuse by children?

References

Sutherland, I & Willner, P. (1998) Patterns of substance use among English adolescents, Addiction, 93, 8, 1199 - 1208.