Longitudinal Effects of Age at Onset and First Drinking Situations on Problem Drinking#

SUBSTANCE USE & MISUSEVol. 38. No. 14. pp. 1983-2016, 2003

Longitudinal Effects of Age at Onset and FirstDrinking Situations on Problem Drinking^

Lynn A. Warner, M.S.W., Ph.D. '*and Helene R. White, Ph.D.^

'School of Social Work, and^Center of Alcohol Studies, Rutgers University,

New Brunswick. New Jersey. USA

ABSTRACT

The purpose of this study was to describe aspects of the first alcohol-usc experience, and examine the predictive relations among age offirst use, context of alcohol use initiation, and problem drinking withand without controls for psychosocial risk factors. Data were fromthe Rutgers Health and Human Deveiopnient Project, a five-wave,prospective study of substance-use behaviors in a community sample.Respondents, who were first interviewed at age 12 (1979-81) and

Â previous version of this article was presented as a poster al the ResearchSociety on Alcoholism Twenty-Fourth Anntia! Scientific Meeting (June 2001),Montreal. Canada.*Correspondence: Lynn A. Warner, M.S.W.. Ph.D., School of Social Work,Rutgers University, 536 George Street, New Brunswick, NJ 08901, USA; Fax:(732) 932-8181; E-mail: lywarner(flirci.rutgers,edu.

1983

DOI: 10.l08i/JA-120025t23 1082-6084 tPrint); 1532-2491 (Online)Copyright © 2003 by Marcel Dekker. Inc. ; www.dekker.com

1984 Warner and White

most recently at age ."0 or 31 (1999-2000) {N = i7ll reported ontheir first drinking expericnee. and on a range of known risk factorsfor alcohoi abuse. Most alcohol initialion occurred during a familygathering. Regardless of initiation context, youth who drank at anearly age were more likely than youth who initiated later to becomeproblem drinkers, although the risk was relatively greater for theyouth who first drank outside a family gathering, Ba.sed onmultivariate logistic regressions, feeling drunk al initiation was theonly onset-related variable significantly associated with problemdrinking; other significant risks factors included male gender,delinquency, and family history of alcoholism. Because mostinitiation occurs at a family gathering, alcoholism preventionresearch may benefit from examining the role that drinking infamily contexts eould play with regard to socializing young drinkersto less risky drinking behaviors in adulthood. In particular, furtherresearch focusing on the subjective effects experienced by youth whenthey first drink may be merited.

Key Words: Drinking initiation context; First aleohol use;Protective factors; Risk factors.

INTRODUCTION

Life course developmetit and developmental psychopathologytheories increit.singly emphasize the importance of both timing andcotitext of childhood and adolescent experiences for normal development(Boyce et a)., 1998; Cicchetti atid Rogosch. 1999). To the extent thatcommon experiences, such as first alcohol use. occur at ages that arenot normative and within contexts that reinforce negative alcohol-usebehaviors, maladaptive learning patterns are developed. As a result,unsuccessful transitions to adult roles and compromised physical andmental health are more likely outcomes. Researchers in the area ofsubstance use have increasingly recommended the application ofdevelopmental theories and methodologies to the study of substancemisuse (Cicchetti and Rogosch. 1999; Flay et al.. 1999; Petraitis et al..1995; Zucker, 1994). However, the evaluation of age at onset along witheontextual infltiences on the developtnent of problems related to alcoholuse has not occurred.

Several studies have demonstrated signiticant associations betweenage of first use and subsequent alcohol-related problems and disorder(DeWit et al.. 2000; Grant and Dawson. 1997; Guo et al.. 2000; Nelsonet al.. 1998). although there is debate in the literature about the strength

Longitudinal Effects on Problem Drinking 1985

of the association when other factors are controlled, and the extent towhich age at tirst use interacts with other predictors. In a birth cohort ofNew Zealand children, alcohol use before age 6 compared to after age 13increased the likelihood of having drinking problems at age 15, evencontrolHng for parental alcohol use and other risks (Fergusson et al.,1994). Additionally. Hawkins and colleagues found that early use ofaleohol almost entirely mediated other risk factors for alcohol misuse(Hawkins et al., 1997). On the other hand, a study that examined asmaller set of predictors found friends' drinking behavior was moreimportant than youth's own early drinking in predicting alcohol misuse(Griffin et al.. 2000). McGue and colleagues' results indicate that earlyage at first drink may be a reflection of underlying pathological behaviorthat causes alcoholism, rather than a direct cause itself (McGuc ct al..2001). Similarly, based on analyses of data provided by Norwegianyouth. Pedersen and Skrondal suggest that the role of age of onsetmay be overestimated whenever analyses do not account for commonrisk factors predicting both onset and consumption (Pedersen andSkrondal. 1998). Finally, results from the longitudinal Rutgers Healthand Human Development Project have shown that age at first use ofalcohol does not predict later intensity of alcohol use or alcohol problemswhen other substance use is included in the models (Labouvie et al..1997). Interpreting these results in the context of other studies of age atonset, Labouvie and White argue that age of onset may be a usefulindicator of risk when the period of observation is limited to adolescenceor young adulthood, but that over a longer period current behaviors andexperiences assume significant relationships with alcohol misuse while ageat onset recedes in importance (Labouvie and White, 2002). Thus,attention to developmental processes over a longer period of time mayprovide a more accurate understanding of the role of age at first use.

When context effects are studied, the outcome of interest is usuallycurrent substance use or drinking patterns, rather than the developmentof harmful substance-use behavior. Assessing contextual influences onlong-term, alcohol-use behaviors is further complicated by the differentlevels at which context can be measured, and the difficulty of adequatelymeasuring and analyzing ail dimensions within a single study. In a com-prehensive review of risk and protective factors for substance abuse.Hawkins., Catalano. and Miller identified studies that highlight proximal,or micro-level influences on youth's drinking, including peer, friend, andparent attitudes and drinking behaviors (Hawkins et al., 1992). Distalsocial influences include laws and norms, as well as effects that stemfrom economic deprivation and social disorganization at the neighbor-hood level. An increasing number of cross-sectional studies of alcohol


consumption in nations other than the United States underscore the widevariability in the role alcohol plays in social life, drinking patterns, andthe consequences of drinking that are considered to be problematic(Bennet et al.. 1998; Smart and Ogborne. 2000; Vega et al,. 2002).Furthermore, drinking patterns vary across cultural groups withincountries.

Although drinking behaviors and attitudes of persons who haveinfluence on youth's development have been studied, it is interesting tonote that we know very little about the contexts in which youths actuallydrink. A relatively small body of research has examined modeling effectswhen youth drink as part of religious observances within family settings,or as part of a cultural tradition. Bales was among the first to proposethat this type of early drinking, because it is minimal and invested with areligious purpose, is not likely to increase risk for alcoholism (Bales,1946). More recent research in this area has focused on religiosity andsuggests that it may serve as a protective factor for youth at risk ofdrinking at early ages (Heath et al., 1999; Kendler et al.. 1999; Masonand Windle, 2002), although it is not clear if drinking at family gatheringswas controlled in these studies. One study that directly examined youth'salcohol use at home found high probabilities of alcohol use for seventhgrade students who had been allowed to drink at home when they werefifth graders (Jackson et al.. 1999), However, data were not available toestimate the development or persistence of alcohol-related problems forthose children as they aged, or to understand the nature ofthe occasionswhen youth were allowed to drink.

The primary aim of this research is to examine the context in whichdrinking first occurs to better understand the nature of the relationshipbetween age at onset of alcohol use and subsequent problem drinking. Ofparticular interest is the possibility that drinking at relatively early ages inthe context of family gatherings may help distinguish early onset drinkerswhose use escalates into problems from those who never develop alcoholproblems, or mature out of them. For example, research has identifiedtwo main categories of adolescent drinkers: one whose drinking developsin ways that are not harmful, and another who are more prone to alcoholproblems because of a lack of control and impuisivity (Labouvie andWhite. 2002; Weber et al., 1989). Although the specific reasons thatalcohol problems develop may not be generalizable. the categorizationis a useful departure point for understanding why some youth who drinkdevelop problems and some don't. Pedersen and Skrondal have arguedthat it is important to differentiate between "normal" early onset and"problem prone" early onset (Pedersen and Skrondal, 1998). To theextent that drinking for the first time at a family gathering is


"normal." we would expect the family initiator to have lower risk forproblem drinking, other factors being equal. Therefore, this study will(a) characterize the first-use experience in terms of age of onset and onsetcontext (e.g., initiation at, vs. outside a family gathering); (b) identifyaspects of the first drinking experience that predict alcohol problems;and (c) examine whether effects of the first-use experience remain whenrisk factors from key domains are included in the analyses.

The domains of risk factors were seleeted because prior research hasestablished their significanl associations with alcohol-related problems ordisorder, and because of their substantive relationship with aspects ofthefirst-use experience and broader social context. Specifically, individual-level factors, such as degree of attachment to social institutions, inciudingreligion and school (Mason and Windle, 2001. 2002; Brown et al.. 2001,Hops et al.. 1999; Miller et al., 2000; Park et al., 2001), as well astendencies toward delinquency (White, 1997), sensation seeking (Bateset al., 1994; Comeau ct al., 2001; Donohew et al., 1999; Greene et al.,2000). or depression (Deykin et al., 1987; White, 1992; Tsehann, 1994)may be associated with youth's attitudes about or reasons for usingalcohol. Family history of alcoholism might infiuence expectationsabout the effect of alcohol (Brown. 1999; Wiers. 2000), or actual reactionsto it. Alcohol use among parents, siblings, and friends provide opportu-nities to drink and to model drinking behavior (Barnes et al.. 1997;Weinberg et al., 1994; White et al., 1991; Welte et a!., 1999; Woodet al., 2001). Finally, aspects ofthe parent-child relationship, particularlythose that suggest parents know and care about what their children aredoing, influence decisions to drink and to spend time with youth who do(Barnes and Farrell. 1992). It is also likely that opportunities to modeldrinking behavior and characteristics of the parent-child relationshipvary across families in which youth drink at family gatherings. Forexample, the long-term consequences of drinking within a family contextmay be harmful when the family is comprised of members whothemselves are prone to excessive alcohol consumption, whereas theremay be no or protective effects when it occurs in families without negativealcohol-use patterns.

METHOD

Satnple ^

Data are from the Rutgers Health and Human Development Project(HHDP), a five-wave, prospective study of substance-use behaviors in a


community sample that is most representative of white adolescents livingin a metropolitan, working- and middle-class environment (Pandina et al.,1984). Adolescents aged 12, 15. and 18 were recruited between 1979 and1981 from a random selection of telephone numbers in New Jersey. Theinitial recruitment was conducted by trained staff of the EagletonInstitute and the Eagleton Poll at Rutgers University to identify house-holds with an eligible adolescent. Eligibility criteria included birth year,absence of a language barrier, absence of serious physical and mentallimitations, and not being institutionalized at the time of initial contact.

After the initial anonymous telephone survey, field staff comprisedprimarily of college-educated male and female interviewers of mixedraces visited adolescents in their homes to recruit them and obtain theirand their parents' consent to participate in a longitudinal study abouthealth and human development. Because the project design called forthe sample to be evenly divided by gender and age. a quota samplingprocedure guided the initial recruitment phase. Overall. 46% of thoseasked to participate agreed to enroll in the study. Compared toyouth who refused, participants had higher levels of parental incomeand education.

At the time of initial data collection, the sample was comparable tothe population of the state with regard to religion (50% Catholic, 30%Protestant, 9% Jewish, and 11% an "other" or no religion), and medianfamily iticome (between $20,000 and $29,000). although a slightly higherproportion of persons in the sample were white (89yo), compared to thestate census (83%) (US Bureau of the Census. 1981). Patterns ofsubstance use were also comparable between the HHDP respondentsand same-age peers in nationally representative samples, living in thenortheastern part of the United States at that time (Johnston et al.,2000a. 2000b: Substance Abuse and Mental Health ServicesAdministration. 1996).

All participants were reinterviewed at three points over a 13-yearperiod (Time 2 and Time 3 interviews occurred at 3-year intervals,followed by a 7-year interval). The longitudinal retention rate betweenTime 1 and 4 was 91%. Only the youngest respondents were reinter-viewed after an additional 5-year interval (during 1999/2000), such thattheir ages at the five data collection points were 12. 15. 18, 25, and 30, or31 years old.

Because most of the youth who were 15 and 18 years old had firsttried alcohol before the time of their first interview, and the recall periodfor first use was comparatively shorter for the youth who were 12 yearsold at first interview, analyses were limited to the youngest participantswho provided data at all follow-up periods (374 out of 447). Analysis of

Longitudinal (Effects on Problem Drinking 1989

attrition effects is presented in the Results section. Because we aim tounderstand the risk of developing alcohol-related problems, we furtherrestricted the sample to those who reported ever drinking (H = 3 7 1 ) atTime I, 2, or 3. The respondents who began drinking between Times3 and 4 were not asked questions about first-use context.

Survey Protocol

At recruitment, parents and participants completed self-reportquestionnaires in their homes and mailed them back to the study team.Subsequently, arrangements were made for study participants to go tothe project site, the Center of Alcohol Studies at Rutgers University, for aday of data collection. Data collection for all follow-up surveys occurredat the project site as well, although some participants were interviewed intheir own homes. Not counting breaks, participants spent between fourand six hours on a single day completing self-report, intervieweradministered questionnaires, cognitive/behavioral tasks, and physicalhealth assessments at their own pace. The data in this study eome fromself-report questionnaires, which have been shown to be valid indicatorsof alcohol use in nonclinical samples (e.g.. Harrison et al., 1998; Rouseet al., 1985; Smith et al.. 1995). Trained interviewers supervised allaspects associated with data collection.

Measures

Alcohol Use-Related Problems

At each assessment, respondents completed a self-report inventory ofproblems experienced as a result of aleohol during the last 3 years (ever atTime I), We used this information to construct a proxy measure oflifetime DSM-IV alcohol abuse and dependence, based on 16 and 14items, respectively (American Psychiatric Association. 1994; Muthenet al.. 1993; Woody et al., 1993). Note that this measure includesproblems experienced over a 3-year period rather than a i-year periodas is used for actual DSM-IV diagnoses. Because the main aim of thecurrent research is not to understand variations over time in severity ofalcohol-use disorder, but to determine if initiation context is significantfor developing alcohol-related problems, we treat this measure as aclinically relevant threshold rather than a marker of disorder.Therefore, participants were categorized either as problem drinkers


(i.e.. met the proxy criteria for either abuse or dependence) and coded asI, otherwise coded 0.

Aspects of First Use

The HHDP respondents were asked the age at which they tried (morethan a few sips) beer. wine, and hard liquor for the first time, and the ageat which they first tried each type of alcohol outside a family gathering.Because respondents were asked about onset age at each of the first threedata collection points, there were some inconsistent reports of the onsetage from one interview occasion to another. In those cases we chose theage reported the first time the respondent indicated ever drinking. Fromthese responses we created a four-level variable indicating "'early use at afamily gathering." "early use outside a family gathering," "late use at afamily gathering", and "late use outside a family gathering." Based onthe onset age distribution (median = 10, mean = 10.7). a respondent is inthe "early use" category if the first drink occurred before the age of 11. Itis important to note that these analyses are based only on the youngestcohort respondents, who on average reported younger ages at onset thanthe older respondents, and also had smaller discrepancies in reportedonset ages (Golub et al., 2000),

Many respondents had two types of alcohol onset; the first time at afamily gathering and the first time outside a farnily gathering. Therefore,we created another variable that represented the difference in yearsbetween the ages reported for inside and outside family gathering initia-tion: of those who first drank at a family gathering, 56% drank outside afamily gathering within 5 years, while the other 44% did not drinkoutside a family gathering for 5 or more years.

Information about the first-use experience includes whether therespondent felt "high or drunk" at alcohol initiation (in the form of ayes/no question), and what the experience was like (very pleasant,pleasant, no effect, unpleasant, very unpleasant) trichotomized into"not pleasant" (the reference group), "no efiect." and "pleasant."

Risk Factors

The HHDP data set contains information on a range of factors thatresearch has shown to be associated with alcohol use outcomes (Petraitiset al.. 1995; Hawkins et al., 1992; for reviews). The definition andoperationalization of the variables that were used in the multivariatemodels are described in Table 1. Specific measures fall into four domains


of influence; family history, drinking among youth's friends and family(i.e., social influences), parental relationship, and intrapersonal. Due toconcerns th;it the power to detect significant relationships betweenpredictors and problem drinking would be limited in multivariatemodels, we used a two-step process to select risk factors. First, availablevariables from each ofthe four domains described above that have beenidentified in the literature as having strong associations with early alcohoiuse or alcohol use-related problems were evaluated one at a time in aseries of chi-square analyses for categorical variables and one-wayanalysis of variance (ANOVAs) for continuous variables. Variablessignificantly associated with alcohol use-related problems at p<0.05 atthe bivariate level were retained for the multivariate analyses. Variablesexcluded from the analysis at this step fell into the parental relationshipcategory (i.e., self reported likelihood of punishment if parents foutid outthe youth had tried alcohol, perceived parental warmth, perceivedparental hostility, parental permissiveness, and parental attachment),and the intrapersonal category (i.e., self-esteem, achievement orientation,impuisivity, and school attachment).

Except for family history of alcoholism, values for each variable weretaken from the first interview during which an age was recorded for firstuse of alcohol. The report of first use could have occurred at Time I, 2,or 3. Therefore, for each standardized scale used in the analysis, the tablereports the range of the reliability scores (Cronbach's alpha) over thethree data collection points.

Control Variables

All models control for gender (male coded 1. female coded 0),parental socioeconomic status measured by highest level of parentalacademic achievement, and religion. Even though previous studies havedemonstrated that there are substantial gender differences in age at onset,use pattenis. and risk fiictor constellations (Costello et ai.. 1999; Curranet al., 1999; Kandel et al., 1998; White and Huselid, 1997), separateanalyses were not run for males and females. Rather, gender was ana-lyzed for main and interaction effects. Power analyses showed that thenumber of observations in the male and female sub-samples was insuffi-cient to detect significant improvements in model fit based on the numberof variables planned for the analysis, a 0.05 probability of rejecting a truenull hypothesis, and various assumptions about the magnitude of thechange in R^. Power ranged from between 0,54 in the sub-samples to0.90 in the full sample (Hintze, 2000).


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Based on previous research (Amoateng and Bahr. 1986; Cochranet al.. 1988). religions were categorized into three groups; proscriptive(e.g.. Baptist. Jehovah's Witness), prescriptive (e.g.. Catholic. Jewish,Episcopalian, Presbyterian), and none (e.g., Atheist. Agnostic). Alcoholuse goes against the philosophy of the proscriptive religions (the referencegroup in analyses), plays a sacred role in the religious practices of some ofthe prescriptive religions, and may be unchecked among those without areligious affiliation. In contrast to religiosity, which is a scale reflectingthe importance of religion in one's day to day living., religion is treated asa status in these analyses.

Analyses

Basic descriptive statistics were generated to determine theproportion of respondents who reported first drinking at and outside afamily gathering and mean age at onset for the two groups, as well asfrequencies for other variables related to the alcohol onset experience thatare used in the multivariate analyses. Then, hierarchical logisticregression models were used to test the relationship between onset typeand problem drinking, controlling for other aspects of the first-useexperience. Hierarchical regressions were also used to analyze therelationship between first-use characteristics and problem drinking,controlling for other risk taclors. None of the correlations among thevariables in the multivariate models were correlated at 0.4 or above,indicating that multicollinearity did not bias the results.

RESULTS

Attrition Analysis

Comparisons hetween the 15% of the youngest respondents whowere lost to follow-up and those with complete data generally yieldednonsignificant dififerences on the variables used in the analyses. Of the 20onset-related and risk-factor variables, four differed significantly betweenfollow-up and dropout samples. Those who were retained were morelikely to be female (x^ = 4.67. ! df, ;7<0.05), more likely to identifywith a prescriptive religion (x"^8,O5, 1 df. p<0.0\), more likely tohave parents with a high level of academic attainment (x" —5.14, 1 df,p < 0.05). and reported higher levels of parental control (t = 2.2, p < 0.05).Overall, the data indicate that attrition effects were minimal.


Table 2. Characteristics of alcohol initiation among those who ever drank.

Family onsetOutside family onsetUnpleasantNo effectPleasantDid not feel drunkFelt drunkFive or more years to

outside family drinking*"Less than 5 years lo

outside family drinking

Number

27110043

177134126243119

152

Mean agefirst use(±SD)

8,6 ±2,614.2 ±3.19.8 ±3.89.3 ±3.2

IO.2±3.Ill.4±4.59.4 ±3.07.1 ±1.7

9,8 ±2.6

Early use(%)

81"18637262

SO'*71

98^

67

Problemdrinking (%)

364144404216^52

34"

47

,0001.V<0,05.''This measure is assessed only for those who reported first drinking at a familygathering.

Bivariate Associations Between Age at Onset, InitiationContext, and Problem Drinking

For the entire sample, the mean age at onset was 10.7 years.However, the majority (73%) of the sample reported a first drinkingexperience at a family gathering, with a much lower mean age at initia-tion (8.6 years). For nonfamily gathering initiates, the mean onset agewas 14.2 years (see Table 2).

Most (81%) ofthe family gathering initiates started drinking at anearly age (before 11 years), which is significantly higher than the 18% ofnonfamily gathering initiates who first drank before age II ( x ' ~ 122.14,1 df. /;< 0.0001). Context alone is not significantly associated with prob-lem drinking (x~ —0.75, I df, ns): and regardless of context, a significantlygreater proportion of early onset drinkers develop alcohol-relatedproblems than late onset drinkers (46.8% vs. 27.3%, x^= 13.54, 1 df,/j<O.OI) (not shown). If relatively fewer years (less than 5) comparedto more years (5 or more) elapse between family onset and the firsttime drinking occurs outside a family gathering, then the rate of problemdrinking is significantly higher (47% vs. 34%, x ' ^ 4 . 7 3 . 1 df. /?<0.05).Whether the first experience was pleasant is not significantly associatedwith problem drinking (x' = 0.26, 1 df, ns), but feeling drunk is (52% vs.16%. x" = 47,04, ldf,/.<0.0001).


• Firs) usa beforeaoe 11 OFIretusaain woktor •First

Figure J. Problem drinking by onset location ;ind early age at onset.

Figure 1 illustrates that when context and age at onset are evaluatedtogether, youth who initiated at an early age outside a family gatheringshow the highest rate of drinking problems. Their rate of problemdrinking is 78%, eompared to 28% for the late onset drinkers outsidea family gathering (x"^ 15.98. I df, / J < 0.0001). This proportion is alsosignificantly greater than the 44% of the youth who first drank beforeage 11 at a family gathering (x* = 7.49, I df. /j<0.01).

Muttivariate Associations Between Age at Onset, InitiationContext, and Problem Drinking

Table 3 presents the odds ratios and confidence intervals for hier-archical models testing the relationship between onset type, problemdrinking, and other aspects of the first drinking experience. The firstregression shows that compared to the group that is hypothesized tohave the lowest risk of alcohol use-related problems (i.e.. youth whoinitiate at older ages at a family gathering), early initiates who firstdrink at a family gathering, and early initiates who first drink outsidea family gathering are significantly more likely to develop problemsassociated with alcohol use (ORs=:2.86 and 8,32. respectively).

Lonj>itudinal Effects on Problem Drinking 1997

Tahle S. Summary of hierarchical regression anaiysis for onset type and othercharacteristics of first alcohol use predicting problem drinking, controlling forgender, socioeconomic status, and religion.

Control variablesMaleParental SESProscripiive religionPrescriptive religionNo religion

Onset typeEarly onset at a

family gatheringEarly onset outside

a family gatheringLate onset at a family

gatheringLate onset outside a

family gatheringLess than 5 years

between family andoutside family onset

First use charaeteristicsFirst alcohol experience

Not pleasurableNo effeetPleasurable

Fell drunk at first use

Model

OR

2.52 '1,02—

1,061,19

2,86''

8.32''

—

0.90

2.54''

Problem

I (TV = 368)

95% Ci

1,60-3.980,89-1.18

0,53-2.130.37-3.84

1.36-6.00

2.28-30.41

—

0.40-2,02

1.45-4.42

drinking

Mode! I

OR

2.54''1.09—

0,891.07

2.39'-"

5.75''

—

1.20

2.20''

—0.810.655.20"

I (<V=353)

95% CI

1.56-4.140.93-1.27

0.42-1.900.28-4.06

1.10-5,20

1.53-21.54

0.50-2.90

1,22-3.96

0.37-1,770.29-1.442.84-9,52

Note: 0,0001.

V<0,05.OR = Odds ratio.CI = Confidence interval.

Although the risk is higher when the context is outside a family gather-ing, the relatively wide confidence interval around that estimate suggeststhat this result may be unstable. When there is a relatively fastertransition from first drinking in a family context to drinking outside


(less than 5 years), the odds of problem drinking are significantlygreater than when 5 or more years elapse between drinking in thetwo context types (OR = 2.54; p<0.0\). When other variables relatedto first use are added to the model, the onset type variables are largelyunchanged. OP the two variables related to the subjective experiencewhen alcohol was first used, only the sensation of feeling drunk isrelated to problem drinking. Those who fell drunk are five timesmore likely to be problem drinkers than those who did not ( / J < 0 , 0 0 0 1 ) .

Because early initiation in both contexts was significantly associatedwith problem drinking, we tested whether the first-use characteristics heldwhen we operational ized onset type with two variables (early vs. lateonset and family vs. outside family). Consistent with the results inTable 3, early onset is significantly associated with three times the oddsof problem drinking compared to late onset, but initiating outside afamily gathering compared to at a family gathering is not significant(results not tabled). The other first use characteristics are relativelyunchanged.

Alcohol Use Initiation. Other Risk Factors,and Problem Drinking

Table 4 presents hierarchical regression results that delineate therelationship between first-use characteristics and problem drinkingwhen other risk factors are included in the analysis. For this model wepresent standardized and unstandardized estimates, and their associatedsignificance levels. For these analyses we entered age of onset as acontinuous variable and location of first-drinking experience as adichotomous variable (i.e., at a family gathering or outside) rather thancombine them as a single dummy variable in order to estimate theindependent effects of age of onset. The results show that feeling drunkis the only variable related to the first-use experience that significantlypredicts problem drinking when other risks are included. Furthermore, ofall the predictors it is most strongly related to the outcome (standardizedbeta is 0.38).

Of the risk factors that were significantly associated with problemdrinking in bivariate analyses, having a family history of alcoholism andhigher levels of delinquency significantly predict problem drinking in themultivariate regression. As in the previous analyses, gender is asignificant predictor; males compared to females are more likely tobecome problem drinkers.


Interaction terms combining feeling drunk at initiation, and each ofthe other significant predictors in Table 4 were created to evaluate anymoderating effects the risk factors may have on this first-use experience(results not tabled). Interactions between gender and the other significantpredictors were also tested. None ofthe interactions, entered in separatemodels, achieved significance at the 0.05 level.

DISCUSSION

The purpose of this study was to describe aspects ofthe first alcohol-use experience, and examine the predictive relations between age at onsetand context of alcohol-use initiation and problem drinking. In a U.S.community-based, longitudinal study, most youth reported that their firstuse of alcohol occurred at a family gathering, and the family gatheringinitiates reported the earliest ages of first use. When first alcohol use ageand context are evaluated jointly, early onset is a risk factor for problemdrinking regardless of context, although the risk is relatively greater whenearly first use occurs outside a family gathering compared to at a familygathering. Problem drinking is also more likely when iess than 5 yearselapse between initiation at a family gathering and the first time drinkingoccurs outside a family gathering. However, these relationships do nothold in models controlling for other risk factors. On the other hand, thereis a consistent effect whereby the risk for developing problems related toalcohol use is significantly higher when first use is accompanied by feelingdrunk.

The problem drinking measure was based on questions thatcorrespond to DSM-IV symptoms of abuse and dependence; becausethe symptoms were measured over a longer period of time than thestandard 1-year diagnostic window and did not necessarily capturepersistence of a problem at any given time, the measure does not reflecta diagnosis or changes in problem drinking behavior. Nevertheless, thepercentage of the sample that reported problem drinking comparesfavorably to the 35% prevalence of DSM-IV abuse or dependencereported in a household survey of adults (Hasin et al.. 1997).

Early Age at Onset and Onset Location

Mean age at onset is markedly different when it is estimated sepa-rately for family gathering and nonfamily gathering initiates. Among


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nonfamily gathering initiates, the mean age at onset is comparable tostudies that show the majority of most youth samples have tried alcoholby the mid-teens (Fetro et al.. 2001; Maes et a l . 1999; Martin et al.,1996). However, comparisons between mean ages at onset reportedhere and other studies arc somewhat limited because, in addition tosample design diflerences, most studies do not instruct respondents toreport ages for both lamily gathering and outside fiimily gathering first-drinking experiences. The recall process may be different when respon-dents attempt to make a distinction between the two types of onset. Forexample, it is possible that even though respondents were instructed toprovide the age at which they first drank more than a few sips ofalcohol,there may be differentia! recall ol'the amount consumed, such that futureresearch in this area should distinguish between age of first exposureto alcohol (a few sips) and age of first full drink.

The finding of modest support for lower risk of alcohol-relatedproblems among the early onset drinkers who initiate at a familygathering rather than outside is intriguing lo consider in light ofother studies that have found similar threshold effects, but do nothave information about location of the first drinking experience. Forexample, according to a general population study of psychiatric andsubstance-use disorders in Ontario, the respondents who first drankbetween ages II and 14 progressed more quickly to dependence thanthose who initiated after 14 (DeWit et al.. 2000). However, theyoungest drinkers, those who began before age 11, did not havethe same high risk. In a nationally representative U.S. sample.Grant found that the overall rate of alcohol dependence fluctuatedin the same way (Grant, 1998), and Chou and Pickering found thatpersons who started drinking before age 12 were less likely to developalcohol-related problems than those who began between \2 and 17(Chou and Pickering. 1992).

It is possible that results from these studies could be explained, atleast in part, by the context in which drinking first occurs, rather than theabsolute age at which it occurs. The significantly lower risk of drinkingproblems when outside family gathering drinking occurs several yearsafter initial drinking at a family gathering, found in bivariate analyses,and the model with first-use characteristics (without risk factors),supports this interpretation. That is. risk for developing alcoholuse-related problems appears to be greater for youth who first drink atan early age at a family gathering and then drink at an early age outsidea family gathering, rather than limiting their alcohoi use to familyfunctions until they are much older. Nevertheless, consistent with resultsfrom other analyses of HHDP data (Labouvie et al., 1997; Labouvie

Effects on Problem Drinking 2003

and White. 2002). we find that neither age at onset nor initiationcontext predicts problem drinking when models control for other riskfactors.

Other Aspects of Alcohol Initiation

In all models, feeling drunk at first use increased the odds of devel-oping alcohol-related problems, as did gender. Overall, feeling drunk atinitiation appears to be the most robust predictor, as it is significantlyrelated to problem drinking in each analysis, and always at/T<O.OOOI. Itis possible that this variable is capturing quantity ofalcohol consumed atinitiation, which would suggest that age at first use is oniy important tothe extent that enough alcohol was consumed to generate a physiologicalreaction. However, results from a longitudinal study of secondarystudents do not support this interpretation (Bailey. 1992). Althoughthat study was focused on progression from alcohol use to illicitsubstance use, rather than alcohol use to problem drinking, it is notablethat heavy, first-time use (i.e., three or more drinks) was not related to useof illicit substances, but progression to higher levels ofalcohol use over aperiod of time was.

Results from an early study that compared alcoholics in prison tocollege students (Ullnian. 1962) suggest an alternate explanation forthe strong effect of feeling drunk at initiation; when asked to describetheir first drinking experiences, significantly more alcoholics thancollege students reported getting drunk the first time they triedalcohol, indicating that risk for alcohol use-related problems maybe due to neurobiological differences in sensitivity to alcohol. Morerecently, a study on vulnerability to alcoholism found that behavioralresponse to alcohoi predicts early onset of alcoholism (Schuckit andSmith, 2001), In that study, however, a low rather than high level ofbehavioral response was associated with increased risk, the measureincluded physiological indicators rather than self reports alone, andresponse was measured around age 20 instead of the time alcohol wasactually first tried.

Finally, feeling drunk at initiation could be a manifestation ofgeneticpredisposition for alcohol-use disorder. Young users with a familyhistory of alcoholism might manifest or perceive an exaggerated reactionto alcohol, regardless of quantity consumed. In this study, bothfeeling drunk at initiation and having a family history of alcoholismindependently predicted problem drinking, although the interactionbetween them was not significant.


Other Risk Factors

The contribution of family history of alcoholism to younginitiates" likelihood of becoming problem drinkers is consistent withadoption and twin studies that eslimatc high rates of inheritedliability for alcoholism (Kendler et al.. 1994; McGue et al.. 1992;Merikangas. 1990). Debate continues, however, regarding the condi-tions under which the genetic risk is expressed, and whether the riskcan be expressed in multiple ways. Results from both twin (McGueet al., 2001) and community-based (Dawson. 2000) samples suggestthe familial effect on developing alcoholism may be due primarily toits relationship with early initialion. For this to be true, the mechan-ism through which family history of alcoholism leads to an early ageat first alcohol consumption is likely to include behavioral effectssuch as youth's modeling of parents' drinking (Johnson et al., 1997;White et al.. 2000), or genetic effects such as the transmission oftraits that would predict earlier onset oi' alcohol use. such as conductproblems and sensation-seeking behavior (Jang et al., 2000). We didnot test how these mechanisms affected early onset, but our findingsindicate that parental drinking behavior at the time that the youthstarts drinking is not a significanl predictor of later alcohol use-related problems. On the other hand, delinquency but not sensationseeking at the time period of initiation significantly predicts lateralcohol use-related problems even when other use context and riskfactors are controlled. These results, combined with other studies,suggest that a more complex set of modeling behaviors may beimportant to study when family history of alcoholism is present.

Study Limitations

Results of this study should be interpreted in the context of severallimitations. First, the results may be biased due to reliance on retrospec-tive reports of age at first alcohol use. However, by analyzing only thedata provided by the youngest HHDP participants, who are typicallyreporting on an experience that occurred within 1 to 3 years of theirage al interview, this potential bias may be minimal. A prospectivestudy that spans ages before and after initiation is needed to evaluatethis assumption. Second, because the sample primarily reflects suburban,middle class youth, the findings may not be generaiizable to youth withother backgrounds. Nevertheless, the relative homogeneity ofthe sample


render it well suited to be used as a first step in examining the longitudinaleffects of the first drinking situation, without potentially confoundingregional variation, for example, or uneven enforcement of under-agedrinking laws. Third, power to detect significant effects for interactionterms in the muitivariate models may be limited due to sample size.Consequently, the absence of a significant interaction among risk factors,such as family history of alcoholism and feeling drunk at first alcohoi useshould be interpreted cautiously.

Finally, the original study was not designed to answer questionsabout the association between alcohol initiation context and problemdrinking, per se. Therefore, measures about first drinking experiencesand contexts were limited. Nevertheless, the data were collected prospec-tively from a nonclinical sample spanning the time period fromadolescence to young adulthood with a fairly low attrition rate. Thus.this study is an important first step in understanding how outcomesrelated to alcohol use might be shaped by both age at which importantevents occur and the context in which these events occur.

Implications for Theory, Research,and Prevention of Alcoholism

To date, little research has focused both on the timing and context offirst alcohol use. and especially on the combined effects of both factors.Nevertheless, this emphasis appears to be warranted, both in termsof illuminating the assumptions behind developmental theories, and forprevention research. In this study, there is a suggestive finding that forsome youth who drink at very young ages, long-term drinking outcomesmay be differentially influenced by where first drinking occurs; youth whodrank at an early age were more likely than youth who initiated later tobecome problem drinkers, although the risk was relatively greater for theyouth who first drank outside a family gathering.

To the extent that family initiation is discovered to be as prevalent inother samples as it is in this one, it may be important for future researchon alcohol abuse etiologies to incorporate methods and measures thatcapture the full range of initiation experiences. For example, the measureof first drinking context available in the HHDP study eould be developedto include information about how much adult supervision was involvedwhen a family gathering was the setting for a youth's first experiencewith alcohol, and the nature of and participants in subsequent familygatherings during which youth drank. Use of alcohol for secular and


religious purposes would be important components of this research. Dataof this type may be particularly informative for prevention efforts thatcould be targeted to enhance the effects of learning to drink in a protectedenvironment.

Given the array of risk and protective factors that are believed to beassociated with alcoholism, and the difiiculty in predicting the severityof the outcome when risk factors cluster differentially, it may also beimportant to develop an understanding of how actual drinking behaviorwithin the family, and therefore opportunities for modeling, interactswith other dimensions of the childhood social context that have beenfound to predict alcohol use. If future longitudinal studies are designedto account for multiple levels of contextual influence and incorporatequalitative approaches to understand the dynamics among them, theprobable pathways that lead from first use to alcoholism may be betterunderstood. Additionally, if studies of alcohol use in other countries arefielded to include assessment of drinking experiences and contexts amongyouth, they may inform hypotheses about the causal mechanismsthrough which early drinking experiences predict later drinking behavior.These studies will be most instructive if attention is devoted to developinginstruments that are sensitive not only to cultural variability in the role ofalcohol in society, but to cultural variability in the expression of problemsrelated to alcohol use (Warner et al.. 2001).

For the most part, researchers have chosen to ignore drinking byyouth witliin family contexts. In the United States this indifference maypartially reflect ambivalence about the role alcohol plays in society, andthe extent to which drinking practices are criminalized (Heath, 1995).However, most people drink before they are legally allowed (Johnstonet al.. 2001). and at least in this study they are most likely to drink forthe first time at a family gathering. Therefore, it may be necessaryto question research assumptions about developmentally appropriatedrinking behavior. The results reported here suggest that uniformlylabeling early use of alcohol as deviant may obscure the relationshipbetween age and alcohol-use patterns.

ACKNOWLEDGMENTS

This research was funded by The Alcoholic Beverage MedicalResearch Foundation and the National Institute on Drug Abuse(DA/AA 03395), The authors thank Valerie Johnson for her commentson an earlier version of this article.


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RESUMEN

El proposito de este estudio es presentar los elementos relacionadoscon el consumo inicial del alcohol. A su vez. intentaremos identificar: (1)edad inicial de consumo: (2) area donde el consumo se da; (3) consumiralcohol dentro y fuera de los circulos sociales de desarrollo. Informaciondel Rutgers Health and Human Development Project referente al mues-treo estadistico de personas de 12 anos y posteriormente el mismomuestreo a la edad de 30-31. en el uso de sustancias alcoholicas retiejaque; (1) el consumo de alcohol se da frecuentemente en reuniones famil-iars; (2) personas que consumen alcohol a temprana edad tienden a serconsumidores mas dedicados que los que empiczan mas tarde. Sinembargo el riesgo es mayor para personas que se inician fuera del


contexto familiar. Basados en regresiones multilogisticas. sentirse ebrio alprincipio fue la unica variable que se reiaciona con problemasposteriores de tomadores serios. Otras variables de riesgo incluyen: elsexo. delicuencia, y historia familiar de alcoholismo. Teniendo encuenta que la cantidad de personas que se inician en e! consumo delalcohol toma lugar en reuniones familiars, estudio sobre la prevenciondel consumo de alcohol debe analizarse en ese contexto. En particular,estudios debendeponer atencion en los efectos de la primera experenciacon alcohol.

RESUME

L'objet de cette etude, etait d'ecrire. les aspects de la premiere experi-ence de consommation de boisson alcoolisee et d'examiner les relationsprevisibles parmi les facteurs tels que Page de la premiere experience, lecontexte d'utilisation d'alcool et le probleme de la boisson avec ou sanscontrole des facteurs de risque psychosociaux. Les donnees venaient duDepartement de la Sante de Rutgers et du Projet de DeveloppementHumain, une etude basee sur cinq etapes et basee sur les comportementsd'un echantillon de personnes consommant des substances alcoolisees.Les reponses des premieres personnes qui ent ete interviewees a Page de12 ans puis plus recemment aux ages de 30 et 31 ans (A'=:371), lesresultats refletant leurs premieres experiences abusive de boisson alcoo-lisees. se situant dans la lignee des facteurs a risque. La plupart desinitiations a Talcool se passent lors de reunions familialcs. Sans tenircompte du contexte initial, les jeunes qui boivent des leur plus jeuneage sont plus exposes a devenir alcooliques. que ceux qui commencenta boire plus tard dans leur vie. Par contre, le risque etait relativement plusimportant pour les jeunes qui buvaient en dehors des reunions familiales.Base sur une logique, variant de maniere multiples regressions, etre saouldes le debut etait Tunique variable en relation avec le probleme de laboisson; d'autres facteurs risques comme le sexe masculin, la delinquanceet I'histoire de Talcoolisme familiale. Etant donne que le debut de laconsommation d'alcool commence lors d'une reunion de famille, larecherche contre l'utilisation de Falcool pourrait porter ces fruits enexaminant le role de Ia famille en Ia consommation d'alcool en tenantcompte des risques que cela peut entrainier au niveau des jeunes. Celapourrait limiter les comportements alcooliques de ces jeunes qui devien-nent adultes. Precisement de plus amples recherches mettent leur devo-tion sur les effets secondaires produits sur des jeunes gens qui peuventboire pour la premiere fois.


THE AUTHORS

Lynn A. Warner, M.S.W., Ph.D.. is anassistant professor at the School ofSocial Work at Rutgers University.Her research focuses on the epidemiol-ogy of substance abuse and mentalhealth problems among youth, and theprevention and treatment implicationsfor youth who have both problems.

Helene R. White, Ph.D.. is aprofessor at the Center of AlcoholStudies and Sociology Department atRutgers University. She is currentlyengaged in longitudinal research onthe comorbidity of substance use,crime and mental health problems,and on the short- and long-term conse-quences of adolescent substance use.

Documents

Longitudinal Effects of Age at Onset and First Drinking Situations on Problem Drinking#