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.
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