Minimum legal drinking age—still an underrated alcohol control policy

In their latest review of alcohol control policies, Babor and colleagues1Babor TF Casswell S Graham K et al.Alcohol: no ordinary commodity—research and public policy.3rd edn. Oxford University Press, Oxford2023Google Scholar classify laws that involve increases to the minimum legal drinking age (MLDA) as best practice with a high degree of clear and consistent evidence. The prime example for implementing such laws was the US increase in MLDA from age 18 years to age 21 years, which was associated with reduced night-time traffic fatalities, lower suicide mortality, and decreased arrest rates for various crimes.2Carpenter C Dobkin C The minimum legal drinking age and public health.J Econ Perspect. 2011; 25: 133-156Crossref PubMed Scopus (93) Google Scholar Similar results in other, mostly high-income countries corroborated the effects of increasing the MLDA. The research evidence on longer-term consequences is scarce3Norberg KE Bierut LJ Grucza RA Long-term effects of minimum drinking age laws on past-year alcohol and drug use disorders.Alcohol Clin Exp Res. 2009; 33: 2180-2190Crossref PubMed Scopus (53) Google Scholar, 4Plunk AD Krauss MJ Syed-Mohammed H et al.The impact of the minimum legal drinking age on alcohol-related chronic disease mortality.Alcohol Clin Exp Res. 2016; 40: 1761-1768Crossref PubMed Scopus (10) Google Scholar and non-conclusive, and the few studies available are plagued with insufficient controls. The register-based cohort study by Juha Luukkonen and colleagues5Luukkonen J Tarkiainen L Martikainen P Remes H Minimum legal drinking age and alcohol-attributable morbidity and mortality by age 63 years: a register-based cohort study based on alcohol reform.Lancet Public Health. 2023; 8: e339-e346Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar in this issue of The Lancet Public Health adds substantially to our knowledge base on the effects of MLDA. The Article is based on a study measuring the opposite effect to that of the studies of increases in MLDA—ie, lowering the MLDA from 21 years to 18 years in Finland in 1969. Luukkonen and colleagues5Luukkonen J Tarkiainen L Martikainen P Remes H Minimum legal drinking age and alcohol-attributable morbidity and mortality by age 63 years: a register-based cohort study based on alcohol reform.Lancet Public Health. 2023; 8: e339-e346Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar conducted a survival analysis to compare the associated mortality and morbidity of the cohorts affected by the change. Their key result indicated that, for both men and women, the probability of alcohol-attributable morbidity and mortality was lower in cohorts who had an MLDA of 21 years than in those who had an MLDA of 18 years. Several additional analyses increase our confidence in their results. These analyses compared 1-year cohorts for several years before and after the change in MLDA, thus allowing the authors to show incremental changes in people who were fully exposed to the old law and those who were exposed to the new law only at age 20, 19, or 18 years and younger. Such an approach helps to exclude secular trends in increased alcohol-attributable mortality and morbidity, as both indicators increased after introducing MLDA but did not increase further afterwards. However, as in all ecological studies, not all confounders could be excluded: first, there are some indications that alcohol-attributable mortality and morbidity started to increase in women in some cohorts before the change in MLDA. Second, there was another weakening in alcohol control measures implemented at the same time, which allowed retail stores to sell medium-strength beer and allowed to establish state-monopoly stores and bars in rural municipalities.5Luukkonen J Tarkiainen L Martikainen P Remes H Minimum legal drinking age and alcohol-attributable morbidity and mortality by age 63 years: a register-based cohort study based on alcohol reform.Lancet Public Health. 2023; 8: e339-e346Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Thus, the reduction in the MLDA was implemented in a climate of loosening alcohol control policies in general and it seems hard to attribute outcomes to any policy in particular. These limitations are typical for studies on the effectiveness of alcohol control policies, which tend to be implemented in clusters (eg, the most recent changes in several countries in eastern European countries).6Berdzuli N Ferreira-Borges C Gual A Rehm J Alcohol control policy in Europe: overview and exemplary countries.Int J Environ Res Public Health. 2020; 178162 Crossref PubMed Scopus (8) Google Scholar, 7Neufeld M Bunova A Gornyi B et al.Russia's national concept to reduce alcohol abuse and alcohol-dependence in the population 2010–2020: which policy targets have been achieved?.Int J Environ Res Public Health. 2020; 178270 Crossref Scopus (16) Google Scholar As such, implementations might have synergistic effects on outcomes—both negative or positive effects on the basis of whether alcohol control is weakened or strengthened by several measures—making the evaluation of single policies much more difficult, particularly when measuring long-term effects. The difficulty increases when the policies are mainly intended to affect the drinking culture in a country, such as a ban on marketing and advertisement or a change in the MLDA.8Rehm J Lange S Gobiņa I et al.Classifying alcohol control policies enacted between 2000 and 2020 in Poland and the Baltic countries to model potential impact.Addiction. 2023; 118: 449-458Crossref PubMed Scopus (3) Google Scholar As a result, very few long-term evaluations on such policies have been done. For example, although a ban on marketing has been labelled a best buy for reducing alcohol-attributable harm by WHO,9WHOTackling NCDs: “best buys” and other recommended interventions for the prevention and control of noncommunicable diseases.https://apps.who.int/iris/handle/10665/259232Date accessed: February 26, 2023Google Scholar there are very few empirical studies that measure its effect on consumption or harm.1Babor TF Casswell S Graham K et al.Alcohol: no ordinary commodity—research and public policy.3rd edn. Oxford University Press, Oxford2023Google Scholar The Article by Luukkonen and colleagues5Luukkonen J Tarkiainen L Martikainen P Remes H Minimum legal drinking age and alcohol-attributable morbidity and mortality by age 63 years: a register-based cohort study based on alcohol reform.Lancet Public Health. 2023; 8: e339-e346Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar offers a methodology that can help us overcome the knowledge gap about the effects of policies trying to influence drinking culture in the long term. This methodology allows researchers to carefully examine the mortality of different cohorts who have been affected by the policy in a crucial period of their life course and compare them with cohorts of the same age for whom this is not the case. Adolescence and young adulthood are crucial periods and we would expect that a ban on marketing should make a difference for this group, which would result in reduced alcohol-attributable morbidity and mortality in the long run. Although still an ecological methodology, it allows researchers to rule out potentially confounding effects. If additional controls are added (eg, by using neighbouring countries without policy change as controls),10Rehm J Tran A Gobiņa I et al.Do alcohol control policies have the predicted effects on consumption? An analysis of the Baltic countries and Poland 2000–2020.Drug Alcohol Depend. 2022; 241109682 Crossref PubMed Scopus (3) Google Scholar confidence in the results can become even stronger. We can only hope that the example of Luukkonen and colleagues5Luukkonen J Tarkiainen L Martikainen P Remes H Minimum legal drinking age and alcohol-attributable morbidity and mortality by age 63 years: a register-based cohort study based on alcohol reform.Lancet Public Health. 2023; 8: e339-e346Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar will result in similar empirical research in other areas that have been dominated by arguments based on plausibility and ideology. I declare no competing interests. Minimum legal drinking age and alcohol-attributable morbidity and mortality by age 63 years: a register-based cohort study based on alcohol reformEarlier cohorts had consistently lower alcohol-attributable mortality and morbidity; however, other simultaneous increases in alcohol availability probably contributed to increased alcohol-related harm among the younger cohorts. Overall, differences between cohorts born only a few years apart highlight late adolescence as a crucial period for the establishment of lifelong patterns of alcohol use and suggest that higher MLDA could be protective for health beyond young adulthood. Full-Text PDF Open Access

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