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Alcohol Use in Adolescents

The Scope of the Problem and Strategies for Intervention

Thomas L. Schwenk, MD


In Brief: Alcohol use among adolescent athletes is fairly high, but the problem is complex. Young athletes may be more likely to abuse alcohol than their nonathlete peers and more likely to suffer behavioral and psychosocial consequences as a result of drinking. They are also more prone to binge drinking. Education and prevention strategies should focus on behavioral and psychosocial consequences because athletic performance typically does not suffer. A change in behavior is most likely to alert a physician to an alcohol problem, which is best addressed using a direct approach.

The problem of alcohol use among competitive athletes is complex, partly because of their high visibility. For years the media have regularly reported incidents involving college and professional athletes and their use of alcohol (1,2). Although some athletes, including former Minnesota Vikings lineman Carl Eller and Golden State Warriors' Chris Mullins, have demonstrated that treatment and rehabilitation can be successful, too often alcohol use among athletes ends in tragedy. In 192021, for example, a University of Kentucky football player and another college student were killed in a car accident when teammate Jason Watts was driving while legally drunk.

Unfortunately, the consequences of alcohol use also extend to younger, less visible athletes, particularly to high school athletes who abuse alcohol through chronic overuse or binge drinking (five or more drinks at one sitting for men and four or more for women). Many high school coaches have had an unfortunate amount of experience with team cohesion and athletic relationships divided by alcohol use, resulting, in my estimation, in less-than-optimal performance due to decreased collegiality and team commitment. Others have had to deal with tragedies such as automobile accidents and other alcohol-related injuries and deaths.

In a survey (3) of 215 high school athletic directors in North Carolina, 59% reported having personally encountered intoxicated student-athletes. They considered alcohol use to be a bigger problem among their players than the use of other drugs.

A review of alcohol use among high school and college athletes, as well as the clinical, physiologic, psychosocial, and behavioral effects in these groups, can provide help in assessing the efficacy of education and prevention efforts and provide to team physicians, coaches, and athletic directors practical strategies for dealing with individual athletes.

Prevalence and Patterns of Use

A literature search found only one study specifically on alcohol use among high school athletes; however, several over the past 15 years have looked at alcohol use among large groups of college athletes. (See "Alcohol and Athletes at a Glance: Patterns and Prevention," below.) Some findings in the studies of college athletes have important implications about alcohol use among high school athletes.

In one study (4) that did compare alcohol use among high school athletes with use among nonathletes, 1,713 students (541 athletes and 1,172 nonathletes) completed a 38-item questionnaire. Fifty percent of male athletes reported regular use of alcohol (not defined) compared with 41% of male nonathletes. No difference in alcohol use was reported between female athletes and female nonathletes (42%). Eight percent of male athletes compared with 11% of male nonathletes reported abstaining from alcohol, and 73% of male athletes compared with 58% of female athletes reported that becoming intoxicated was the goal of consuming alcohol.

A similar but smaller study (5) of 146 college students in Mississippi (71 athletes and 75 nonathletes) found no reported difference in alcohol use among athletes and nonathletes, although athletes were more likely to believe that alcohol is damaging. A significant finding, however, was that male athletes who reported frequent use of alcohol were more likely to start drinking at age 12 or younger than were female athletes.

Early age of initial use of alcohol was also a finding in a 120219 national survey (1) of alcohol and drug use among college athletes. In a replication of a 120215 study, 2,282 varsity athletes participating in any of five men's and five women's sports at 11 institutions completed a written questionnaire. Although alcohol use remained stable from 120215 to 120219, 80% to 90% of participants reported having used alcohol during the preceding 12 months. The percentage of those who had used it varied from sport to sport, with the highest use (96%) reported among male tennis players. More significantly, 22% of participants reported that they began using alcohol during junior high school or earlier, 63% began using it during high school, 12% during freshman year of college, and only 3% during sophomore year of college or later. Compared with historical controls such as the Monitoring the Future Study (6), alcohol use also appeared about the same for athletes and nonathletes.

These studies indicate that alcohol use among college athletes is at least as common as it is among nonathletes, despite acknowledgement by athletes that alcohol may be detrimental to their athletic performance, and that alcohol use starts early in the school careers of many athletes.

Associated Risk-Taking Behavior

Other studies have compared the risks of maladaptive lifestyle and health-risk behaviors, including alcohol and substance abuse, among college athletes and their nonathlete peers. Kokotailo et al (7) assessed differences between gender and athletic status for the following variables, determined by questionnaire responses of 1,046 students (271 athletes, 775 non-athletes): physical risk, mental health, alcohol and other drug use, and sexual behavior. They found that male athletes had a higher prevalence of risky behaviors than their male nonathlete counterparts. In contrast, female athletes had fewer risky behaviors than their female nonathlete counterparts. For example, male athletes were more likely to drive an automobile under the influence of alcohol and to ride with a driver who had been drinking than were male nonathletes or female athletes.

In a similar study (8) of lifestyles and health risks of collegiate athletes, 2,20211 students (2,22021 athletes, 683 nonathletes) at seven institutions completed confidential survey questionnaires assessing lifestyle and health-risk behaviors during the previous year. Athletes demonstrated significantly higher risk-taking behaviors than their nonathlete peers. For example, they were less likely to use seat belts, more likely to ride as a passenger with a driver under the influence, and more likely to binge drink. Fifty-eight percent of athletes compared with 42% of nonathletes reported binge drinking. The behavior was more common among male athletes than among female athletes, and more common among participants of contact sports than noncontact sports.

A survey (9) of 14,500 students at 116 universities found that 43% of students binged at least once in the preceding 2 weeks. Of the students who drank alcohol, 52% drank to get drunk.

In one of the most methodologically sound studies of binge drinking and tobacco and illicit drug use in college athletes, Wechsler et al (10) surveyed 17,592 students in 140 colleges, using a 20-page questionnaire that correlated alcohol use with level of involvement in athletic activities. Binge drinking was reported during the previous 2 weeks by 61% of men who were heavily involved in athletics, compared with 55% who were partly involved and 43% who were not involved at all. The corresponding data for women were 50% for those heavily involved in athletics compared with 36% for those with no involvement. Twenty-five percent of male athletes were drunk more than twice in the preceding month, compared with 17% of men uninvolved in athletics.

The strongest predictors of binge drinking among these college athletes were residence in a fraternity or sorority, a partying attitude toward school, use of marijuana or cigarettes, and high school binge drinking. In general, athletes smoked less but binged more frequently, indicating that athletes make a distinction between the known physiologic harm of smoking and the less appreciated behavioral, legal, academic, and psychosocial harm associated with binge drinking.

Finally, in a study (11) of 290 college athletes, participants reported the perception that other college students drank more than survey respondents did, when in fact the intake of other students was less than or equal to that of respondents.

Together these studies suggest that athletes as a group are more likely to exhibit risk-taking behavior, leading to a high risk of binge drinking, a lack of appreciation for the potential harm and consequences of their drinking, and a perception that others drink more than they do, which might serve to increase their own alcohol intake.

Clinical and Physiologic Effects of Alcohol

Studies of acute clinical and physiologic effects of alcohol are limited, particularly compared with the studies of long-term effects of excessive intake. Borg et al (12) investigated the effect of moderate alcohol consumption on the rating of perceived exertion (RPE). After consuming an alcohol dose corresponding to 1 g per kg of lean body mass, 10 fit men exercised at increasing intensities on a cycle ergometer. At the initial intensity of 50 W, alcohol induced an increase in heart rate of 8 to 10 beats per minute. At higher intensities, heart rate increases were insignificant. Alcohol ingestion did not significantly change blood pressure, blood lactate, or RPE.

Blomqvist et al (13) found similar results in a study of eight healthy men who consumed 150 mL (5 oz) of hard liquor over 20 minutes and exercised on a cycle ergometer. At submaximal intensities, the men had an increased VO2 and an increased heart rate that resulted in increased cardiac output compared with equal workloads before alcohol consumption. Respiratory function was the same before and after alcohol consumption, and there were no changes at maximal intensity.

The negative effects of alcohol use on myocardial function, cell death, blood clotting, skeletal muscle function, testosterone secretion, "holiday heart" syndrome (cardiac arrhythmias such as atrial fibrillation), diuresis, and dehydration are well described (14). These effects, however, may not be as relevant to athletes because they result from chronic abuse rather than the binge drinking more typical of athletes. The well-known decreases in balance, judgment, psychomotor response, and coordination associated with drinking may be more relevant to athletes if they drink close to the time of practice or competition but are less well understood for alcohol use at other times.

Behavioral and Psychosocial Consequences

Because the behavioral and psychosocial consequences of alcohol use extend beyond athletic performance, they are probably more important in prevention and educational programs than are clinical and physiologic effects. For example, in a case control study, Spaite et al (15) compared the severity of bicycle accidents among 29 emergency department patients who had detectable blood alcohol (BA) with 321 patients who did not. Seven percent of patients with BA were wearing helmets compared with 34% of patients with no BA. Mean injury severity, measured with a global standardized scale, was 10.3 for patients with BA and 3.3 for patients without. Severe injury occurred in 21% of patients with BA compared with 4% without, mean hospital length of stay was 3.5 days (1.4 days in an intensive care unit [ICU]) vs 0.5 days (0.1 in ICU), and the mean cost was $7,200 vs $1,200. These results exemplify alcohol use resulting in more serious injury during activities separate from athletic performance.

The behavioral and psychosocial harm associated with alcohol abuse among athletes was shown in a study (16) of 51,483 students in 125 colleges. Participants completed the Core Alcohol and Drug Survey, which included questions about involvement in athletics, ranging from noninvolvement to participant to team leadership position. Eighteen of 19 consequences of drinking were significantly more likely for athletes, including driving while drinking, hangovers, nausea and vomiting, impaired academic performance, fights and arguments, memory loss, and legal problems. Contrary to the notion that team leaders are more responsible, male team leaders consumed more alcohol, binged more often, and suffered more consequences than teammates.

Education and Prevention

A variety of prevention and education models have been suggested to address alcohol abuse in adolescents, athletes and nonathletes alike (17). No one model has significant empirical data to support its exclusive use. Alternative approaches might be effective for different athletes.

Models based on social learning theory support a team approach to education and prevention that involves friends and other individuals, families, small groups, and communities providing positive and negative reinforcement for avoiding the hazards of drinking. These models also support the use of peers in media ads.

Cognitive dissonance theory emphasizes eliminating incongruence between adolescents' attitudes and behavior regarding alcohol use. Models based on this theory suggest using oral or written "inoculations" to establish or strengthen beliefs and attitudes about resisting drinking, which may be in conflict with another, more desirable goal. This may involve making a public commitment or private contract with friends to abstain from drinking.

Behavioral intention theory suggests that attitudes and beliefs predict behavior and emphasizes the need to disconnect perceived social norms in alcohol use from individual behavior. This approach makes use of data noted above suggesting that inflated perceptions of alcohol consumption by others may lead to increases in personal intake.

The health behavior approach to education and prevention combines information on the physical, psychological, social, and personal risks of alcohol use into a single program.

Finally, of particular importance in reducing alcohol use among athletes is the need for programs to account for the concept of thrill-seeking, in which athletes need new and stimulating experiences that can border on the dangerous or excessive, apparently for an adrenaline release. Such behavior correlates with age and sex, with men under the age of 30 forming the largest group (17).

All of these theories have been incorporated in various ways into pilot educational programs designed to reduce alcohol use among adolescents. Most have shown some benefit compared with historical controls (17), although this approach to study design is methodologically weak. Some research (9) has suggested that success can depend as much as anything on the name and face recognition and credibility of the staff responsible for counseling and educating, as well as their visibility at practice, in the locker room, and at events.

There are, however, problems with preventive approaches taken to date. While prevention efforts educate athletes about the hazards of alcohol use, the message may be diluted or contradicted in other ways. For example, testing programs in NCAA Division I universities may focus more on drugs such as marijuana, even though most athletic trainers believe that alcohol is the most abused drug.

In addition, educational programs compete directly—and often unsuccessfully—with the association of sports and alcohol seen in advertising. A study by Slater et al (18) provides an example of the influence of sports imagery on alcohol advertising. A sample of 157 white male public school junior and senior high students viewed 72 television advertisements and 24 television excerpts that highlighted the use of beer or another product, with or without sports involvement. The students responded more positively to beer ads with sports content than without sports content, as well as to nonbeer ads with sports involvement. To think that the association between alcohol intake and sports is not influenced by alcohol advertising is naive.

At least one study (9) has taken a different approach to recommendations for education and prevention. The authors recommended creating a closer connection between binge drinking and its consequences by designing programs to give students responsibility for consequences such as cleaning up vomit, caring for drunken students, repairing damage from vandalism, and picking up litter. They also recommended that repeat offenders be expelled, that fraternity and sorority drinking behavior be controlled by directly addressing the known problems of alumni influence, that there be limits on alumni drinking behavior at sporting events, and that alcohol-industry promotions and advertising associated with sports be restricted.

Random or mandatory testing is probably not helpful but deserves further, more controlled study, with a focus on the nature of follow-up and how positive tests are handled.

Dealing With Alcohol Abuse

Athletes who are abusing alcohol generally come to the attention of team physicians, athletic trainers, or coaches because of their behavior rather than physiologic problems. Changes in appearance, attitude, or behavior during practice, as well as hostility, violence, legal problems, complaints from teammates or coaches, and social isolation from the team all may be indicators of alcohol abuse.

There is a well-accepted approach to intervention that is similar for all alcohol abusers, athletes or not. The person who confronts the athlete should explain the motivation for doing so, describe the problems that have been observed, share personal reactions to the observed problems, listen to the athlete's explanation (which will almost certainly include significant denial and rationalization), and explain the desired behaviors and the potential consequences of noncompliance, being specific about the official sanctions involved.

A simple way to assess the depth of an athlete's alcohol problem is to ask him or her to compare the importance of sports involvement to the importance of alcohol. If he or she expresses any hesitation about being able to give up alcohol, even temporarily, or if alcohol comes close to sport in importance, achieving positive behavior change will likely be a significant problem (2).

Renewing Prevention Efforts

Alcohol use by high school and college athletes receives little attention compared with the use of other illicit drugs and ergogenic agents. Given the nature and magnitude of the problem, it deserves close attention and intervention where possible by physicians, trainers, mental health specialists, coaches, and athletic directors.


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Alcohol and Athletes at a Glance

Patterns and Prevention

Below is a recap of points made in the text on the nature and magnitude of alcohol use among high school and college athletes and how best to approach the problem.

  • An increasing number of college athletes and nonathletes either binge drink or abstain, with fewer students reporting modest intake.
  • College athletes drink alcohol at least as frequently and as intensely as nonathletes, with the difference between male athletes and nonathletes greater than that between female athletes and nonathletes. Athletes in contact sports report greater alcohol use.
  • Drinking usually starts by high school, often in junior high.
  • The clinical and physiologic effects of alcohol are mostly related to chronic abuse, with minimal evidence of clinical or physiologic harm from intermittent use proximate to athletic performance. Most harm from alcohol use by athletes is behavioral, legal, academic, and social, all of which can lead to sports eligibility and participation problems. Therefore, education and prevention efforts should focus on academic, behavioral, legal, social, and sports-participation consequences of alcohol and avoid highlighting physiologic effects.
  • Athletes who drink do not necessarily experience more legal or behavioral consequences than other college students who drink, but athletes are often more visible, and their problems often lead to highly publicized consequences.
  • Educational and preventive interventions should be initiated and led by student-athletes and be sport specific. Athletic directors and coaches should provide the proper environment, enforcement, and sanctions. Random or mandatory testing is probably not helpful but deserves further study.
  • Multiple educational approaches to address alcohol may be necessary for various athletes because no preferred approach exists.

Dr Schwenk is professor and chair in the Department of Family Medicine at the University of Michigan Medical Center in Ann Arbor. Address correspondence to Thomas L. Schwenk, MD, Dept of Family Medicine, University of Michigan Medical Center, 1500 E Medical Center Dr, L2021 Women's Hospital, Box 0239, Ann Arbor, MI 48109.