Tina Lam, Ph.D. For original editorial click here.
Globally, alcohol is the leading risk factor for death and disability in the population aged 15–49 years, accounting for almost 10% of deaths . Worldwide per capita consumption is projected to increase , and two thirds of the alcohol industry’s revenue is accounted for by drinking above government guidelines . Youth alcohol use is of particular concern because of teenage overrepresentation in acute harms such as alcohol-related emergency department presentations  and as earlier initiation and heavier consumption during adolescence increase the likelihood of chronic harms such as compromised brain development , alcohol dependence, diminished study or work capacity , and dose-dependent conditions such as cancer .
Although adolescent abstinence is becoming more common in high-income countries, one third of U.S. 12th graders  and half of 16- to 17-year-old Australian school students still used alcohol in the past month . Most governments regulate alcohol , and it is important to examine which approaches are more efficacious in preventing harms. In this issue of the Journal of Adolescent Health, Epstein et al.  sought to compare the impact of alcohol policies in the U.S. and Australia, specifically as they relate to young people under the legal drinking/purchase age.
During the era of U.S. Prohibition, Australia adopted a conceptual alternative that sought to reduce the harms of alcohol primarily through controlling access to alcohol, rather than prohibiting alcohol outright . Currently, the U.S. has what can be described as a “zero-tolerance” public health approach to alcohol use among youth, which relies more punitive measures such as school suspensions and police involvement to deter alcohol use before the legal minimum drinking age of 21 years. In contrast, since 2009, in Australia, has adopted a “harm minimization” approach that encourages the gradual introduction of “responsible drinking” to teenagers within the context of families . Australia does not have a legal minimum drinking age per se. Instead, the minimum age to purchase alcohol is 18 years, and “secondary supply” laws allow for parents (but not other unauthorized parties without consent) to provide alcohol to children within homes .
The Epstein et al. study was conducted in Washington State (the U.S.) and Victoria (Australia) using matched survey instruments and methods. Their samples were representative of seventh-grade school students (aged 13 years), and remarkably, 88% were followed up with at age 25 years. The main finding was that within both state’s cohorts, earlier alcohol use was consistently associated with higher alcohol problems at age 25 years. The alcohol-related permissiveness of school and parents did not moderate this relationship between early alcohol use and later problems. In comparing the cohorts, as those in the U.S. sample initiated drinking at a later age, a smaller proportion demonstrated alcohol problems in their 20s. The authors conclude that Australia’s harm reduction policy was not supported as a means of reducing adult alcohol problems and goes on to describe how various countries are moving toward increasing the minimum legal drinking/purchase age.
An important question remains: To what extent can these effects be attributed to Australia’s cultural history and lower purchase age, rather than specifically to a harm reduction philosophy? It can be difficult to disentangle the protective effects of a higher drinking age  from the way in which alcohol use is negotiated at younger ages (zero tolerance vs. gradual initiation). The more permissive school attitudes in Australia could be attributed both to a harm reduction philosophy and/or to the simple fact that, unlike in the U.S., many Australian Year 12 school students are of legal purchase age.
In addition to providing a clear-cut point at which alcohol use is appropriate, the zero-tolerance approach may also include harsher enforcement of the drinking age. Epstein et al. found that a more punitive school attitude (expulsion for drinking on school grounds) predicted higher likelihood of adult problems in Washington State. In contrast, other countries, such as Iceland, have attributed their dramatic reductions in youth drunkenness
to a conscious rejection of punitive measures, focusing instead on supportive practices such as the provision of alternative social activities and more active parenting . Together, these examples suggest that reliance on punitive measures may be less effective than proactive and supportive strategies.
Aside from varying minimum ages and enforcement methods, the central question remains as to whether the minimum age should be abruptly or gradually approached. Australia has, in a way, already chosen a stance with their National Health and Medical Research Council draft alcohol guidelines, released in December 2019 . The Health and Medical Research Council guidelines regarding alcohol consumption by youth aged <18 years have clearly become stricter over the past two decades. The 2001 guidelines stated that for those aged <18 years “to become responsible adult drinkers, a gradual supervised introduction to alcohol is recommended.” The 2009 guidelines attested “not drinking alcohol is the safest option” but conceded that 15- to 17-year-olds are more likely to drink than younger age groups and offered specific advice, including “to delay the initiation for as long as possible.” The draft guidelines due to be finalized in late 2020 recommend all young people aged <18 years “should not drink alcohol” 
So, the most current Australian guidelines provide a clear message that the age of initiation should not be aged <18 years and take a step away from possible interpretations of previous guidelines that underage alcohol consumption is inevitable or even desirable. The responsibility for choosing an exact age of initiation could also be perceived as shifting from individual households to expert consensus. The new guidelines note that
the bulk of the scientific evidence on harmful adolescent alcohol use includes participants aged 19 years . This suggests that if legislative changes were to be made on the basis of scientific evidence, there are grounds for the legal purchase age in Australia to be raised .
The study by Epstein et al. is a valuable demonstration that many of our approaches to mitigating health risks were officially embedded before the availability of evidence on their public health outcomes. As researchers and policy makers continue to identify best practices via cross-national comparisons and develop global alcohol control frameworks , it is also important to be reminded that the political feasibility and efficacy of various strategies must be examined within the context of a region’s underlying sociocultural and historical views or values around alcohol.
The author would like to thank Dr Rowan Ogeil for his valuable comments on this editorial.
There is no funding associated with this publication.
Tina Lam, Ph.D.
Monash Addiction Research Centre
 GBD 2016 Alcohol Collaborators. Alcohol use and burden for 195 countries and territories, 1990e2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2018;392:1015e35.
 World Health Organisation. Global status report on alcohol and health 2018. Switzerland: World Health Organisation; 2018.
 Bhattacharya A, Angus C, Pryce R, et al. How dependent is the alcohol industry on heavy drinking in England? Addiction 2018;113:2225e32.
 Lensvelt E, Gilmore W, Gordon E, et al. Trends in estimated alcohol-related emergency department presentations in Australia 2005-06 to 2011-12. Perth, Australia: National Drug Research Institute, Curtin University; 2015.
 Squeglia LM, Gray KM. Alcohol and drug use and the developing brain. Curr Psychiatry Rep 2016;18:46.
 Marshall EJ. Adolescent alcohol use: Risks and consequences. Alcohol Alcohol 2014;49:160e4.
 Liu Y, Nguyen N, Colditz GA. Links between alcohol consumption and breast cancer: A look at the evidence. Womens Health (Lond) 2015;11:65e77.
 Miech RA, Johnston LD, O’Malley PM, et al. Monitoring the future national survey results on drug use: 1975-2018: Secondary school students. Ann Arbor: Institute for Social Research, The University of Michigan; 2018.
 Guerin N, White V. ASSAD 2017 statistics & trends: Australian secondary students’ use of tobacco, alcohol, over-the-counter drugs, and illicit substances. Melbourne, Australia: Cancer Council Victoria; 2018.
 Epstein M, Bailey JA, Furlong M, Catalano RF, Toumbourou JW. Does adolescent alcohol harm minimization policy exposure reduce adult alcohol problems? A cross-national comparison. J Adolesc Health 2020;66:713e8.
 Room R. Alcohol and harm reduction, then and now. Crit Public Health 2004;14:329e44.
 National Health and Medical Research Council. Australian alcohol guidelines: Health risks and benefits. Canberra, Australia: National Health and Medical Research Council, Australian Government; 2001.
 Lam T, Ogeil RP, Fischer J, et al. Alcohol supply as a favour for a friend: Scenarios of alcohol supply to younger friends and siblings. Health Promot J Austr 2020;31:112e20.
 Gatley JM, Sanches M, Benny C, et al. The impact of drinking age laws on perpetration of sexual assault crimes in Canada, 2009e2013. J Adolesc Health 2017;61.
 Kristjansson AL, Sigfusdottir ID, Thorlindsson T, et al. Population trends in smoking, alcohol use and primary prevention variables among adolescents in Iceland, 1997e2014. Addiction 2016;111:645e52.
 National Health and Medical Research Council. Draft Australian guidelines to reduce health risks from drinking alcohol. Canberra, Australia: National Health and Medical Research Council; 2019.
 Toumbourou JW, Kypri K, Jones SC, Hickie IB. Should the legal age for alcohol purchase be raised to 21? Med J Aust 2014;200:568e70.