Background
Binge drinking (i.e., 4/5 or more standard glasses of alcohol for women/men at one occasion) is a growing problem in Europe. A survey showed 24% of all 15–24 year old Europeans reported binge drinking at least once a week [
1]. In the Netherlands the frequency of adolescent binge drinking is among the highest in Europe [
2,
3]. A recent study showed that 59% of all 16 year old and 71% of all 17–18 year old Dutch adolescents have had at least one binge drinking occasion in the past 30 days [
4]. The Netherlands is one of few countries in the world that have a legal purchasing age of 16 years for low strength alcoholic beverages like beer and wine [
5]. This implies that regulations concerning alcohol purchases in this underage group are absent and that it is the responsibility of parents and adolescents to regulate their alcohol consumptions. In this respect, Dutch adolescents and parents face a unique situation, in which families have to deal with the alcohol use of adolescents in a permissive environment, where underage adolescents are legally allowed to buy alcohol and it is also accepted that adolescents drink at a relatively young age. These adolescents often still live at home in contrast to, for example, the US where the legal drinking age is much higher and more adolescents already live on their own when they enter the legal drinking age. Not much research has focused on this specific target group yet, so adequate knowledge about determinants of alcohol use is lacking. It is important to investigate in more detail what determines alcohol consumption and, more interestingly, binge drinking in this specific group and what the role of parents is, in order to give recommendations for possible interventions to reduce alcohol use in these adolescents.
It is important to reduce alcohol use in adolescents, because it is associated with a variety of negative consequences, like, getting into fights, experiencing dating violence, having forced intercourse, having considered or attempted suicide, and using other (illicit) drugs [
6,
7]. In addition, binge drinking also negatively effects school performance [
6], impairs learning and memory, and can result in permanent brain damage and cognitive deficits [
8]. In order to fight these consequences we need to know what the determinants of alcohol use in this age group are.
Studies and reviews about determinants of alcohol use and binge drinking during adolescence and young adulthood identified several factors that influence alcohol consumption. Firstly, several studies addressed personal factors. One study examined the predictive value of constructs of the theory of planned behavior [
9] in fifth to eighth grade students and found intention to drink alcohol accounted for 26% of the variance in alcohol use, while attitudes, subjective norms and perceived control explained 76% of the variance of intention to drink [
10]. Another study using an extended version of the theory of planned behavior showed that in undergraduate students attitudes and anticipated regret were strong predictors explaining 58% of variance in intention not to binge drink and that past behavior significantly predicted actual binge drinking behavior, explaining 32% of the variance [
11]. A more recent study suggests that beliefs of undergraduate students predicted intentions to binge drink in the evening and actual drinking behavior [
12]. Those beliefs were that friends approve binge drinking, lack of money would make it difficult to binge drink, getting drunk is enjoyable, sports teams approved binge drinking, and that celebrating, drinking patterns, and environment make it easier to binge drink. These beliefs strongly overlap with so called drinking motives based on the motivational model of alcohol use [
13]. In a review about drinking motives of 10 to 25 year old adolescents, the social drinking motive, which is drinking together with other people in order to get socially rewarded, was found to be related to moderate alcohol use. Enhancement drinking motives, which is drinking to enhance a positive mood, were related with heavy drinking, and coping motives, which means drinking to deal with negative emotions, with alcohol-related problems [
14]. Finally, adolescents who score high on a sensation seeking and impulsivity scale also tend to engage in problem drinking more often than adolescents that score low [
15]. An increase in sensation seeking and risk-taking propensity was predictive of greater odds of alcohol use [
16]. It is interesting to find out what personal factors play a role in 16 to 18 year old adolescents that are allowed to drink alcohol to see whether the factors are comparable or perhaps that additional factors play a role.
Secondly, studies examining peer influences on binge drinking revealed that the presence of friends increased the likelihood that a certain event would become a heavy drinking event by 2.4 times [
17]. Perceived friends’ drinking behavior and the friends’ normative standards were the strongest predictor of alcohol use for female adolescents [
18]. There is some evidence that not just peer influence leads to similar drinking patterns in adolescents, but also peer selection [
19], which is selecting similar others as friends. However, the results concerning peer selection are mixed: in young adolescents (13 to 14 years) peer influences play a dominant role, but with increasing age peer selection becomes more important [
20]. Other studies have found that both processes are important and stable over time [
21], but also that peer influences are more essential than peer selection [
22]. Furthermore, there is evidence that the influence of drinking friends on regular alcohol consumption of adolescents increases when adolescents grow older [
23]. Assuming that peers do have a big influence on adolescent drinking, it is interesting to know how Dutch adolescents perceive this influence.
Finally, parental influences have been subject of study in order to explain binge drinking. One study found that adolescents with substance using peers were at greater risk of using alcohol only when their parents reported problems with alcohol. When parents did not have problems with alcohol use, adolescents with substance using peers were less at risk of using alcohol [
24]. Furthermore, several other studies emphasize that certain parenting practices (i.e., specific and goal directed behaviors parents perform to socialize their children) positively influence alcohol consumption of adolescents. Parental monitoring, whether or not parents control and monitor the activities and whereabouts of their offspring, and parental disapproval of heavy drinking was associated with less heavy alcohol consumption in adolescents [
25]. Similarly, having strict rules concerning alcohol consumption seems to prevent adolescents from starting heavy alcohol consumption [
26]. Stricter alcohol rules are associated with less alcohol consumption and binge drinking in adolescents [
27]. Studies about communication between parents and children about alcohol intake have shown beneficial effects on alcohol consumption [
28] as well as non-effective or even detrimental effects [
29]. A systematic review [
30] of parenting factors associated with reduced adolescent alcohol use further found that parental modeling, limiting the alcohol availability to the child, the parent–child relationship quality, parental involvement and general communication were associated with delayed alcohol initiation and reduced levels of later drinking by adolescents.
However, these reviews and studies have only focused on younger adolescents aged 9 to 16 years [
10,
16,
24,
26,
31] or older than 18 years [
15,
17,
32], or adolescents with a broad range of age (10 to 25 years) [
14]. Also, these studies used a variety of alcohol measures that often lack a clear definition, like heavy alcohol use, problem drinking, excessive use or heavy episodic drinking. To our knowledge, there has not been any research on determinants of binge drinking in the age group from 16 to 18 years in countries with a legal drinking or purchasing age of 16, such as the Netherlands. We therefore chose to conduct focus group interviews with the target group. Focus group interviews allow detecting information when little is known about a certain topic in a specific target group [
33]. Additionally, influences of parents for this particular age group are also less explored. One may argue that their influence is declining for this age group [
23], yet, since most of the 16–18 year olds are still living with their parents [
34] it is relevant to know whether parents still perceive a parenting role concerning binge drinking.
In this paper, we combined focus group interviews conducted with 16 to 18 year old adolescents with focus group interviews with parents of adolescents from this age group. This allowed us to get a broad and detailed picture what determinants of alcohol use in this age group might be relevant and how alcohol use is managed in Dutch families. Further, we investigated differences and similarities in viewpoints of adolescents and parents, to provide useful insight into possible leads for further research and interventions.
Discussion
The current study reveals more insight into the opinion about and the handling of alcohol use within families in the Netherlands, where underage children are legally allowed to purchase and consume low strength alcoholic beverages. The unique feature of this study is that we talked to adolescents as well as parents about factors that influence binge drinking, so we could get a broad picture about what determines binge drinking in a permissive environment.
The majority of the adolescents we talked to identified themselves as a binge drinker, which is representative for the Dutch population as a whole [
4]. Almost all adolescents indicated that the amount of alcohol that is defined as binge drinking (4/5 glasses of alcohol) is low. Interestingly, sports seemed to have positive as well as negative influences on drinking behavior. Non binge-drinking adolescents indicated that individual sports, like swimming or cycling, especially when at a high level, makes them refrain from drinking alcohol, whereas team sports like hockey or soccer seemed to be supportive for binge drinking events, as indicated by binge drinkers. A recent review of high school and college athletes concluded that athletes reported higher levels of alcohol consumption than did non-athletes [
36]. However, there are several studies that found sports to be protective for early alcohol debut [
37] and alcohol consumption [
38], and has even shown to be protective against alcohol consumption when adolescents have substance using peers [
39]. One study focused on sport-type differences in alcohol use among college athletes and found that swimming and diving athletes reported significantly higher levels of alcohol consumption than other sport types (Baseball/Softball, Basketball/Volleyball, Soccer, Track/Cross country) [
40]. This is contrary to the results found in this study, where teams sport seems to be more encouraging alcohol consumption than individual sports. There might perhaps be a change of influence of sport teams. It could be that in late adolescence being a member of a sport team exposes adolescents more to other adolescents who are in an experimenting phase and thus encourage each other to drink together as a team, whereas when adolescents grow older and enter college a feeling of shared responsibility for the success of the team might work as an inhibitor to drink big amounts of alcohol. Another possible contributor to the higher alcohol consumption in team sports might be sponsorship of the teams by the alcohol industry. A study of New Zealand sport teams showed a positive association between alcohol industry sponsorship and AUDIT (Alcohol Use Disorder Identification Test) scores, indicating more hazardous drinking in people who are engaging in sports that are sponsored by the alcohol industry [
41]. Sponsorship of sports through the alcohol industry is very common in the Netherlands (
http://www.alcoholreclame.nl/alcoholreclame/alcoholreclamebeleid_in_nederland/achtergrond.html). However, we did not check in this study if the adolescents from our sample were subject to alcohol industry sponsorship.
Further, adolescents mentioned that their desire to belong to a group, and the expectation to become more relaxed were important drinking motives. This is in line with the results of a review on drinking motives [
14], where social motives (to obtain social rewards) and enhancement motives (drinking to enhance a good mood or well-being) were associated with moderate and heavy drinking in young people, respectively. The review also showed that conformity motives (drinking to avoid social rejection) are hardly mentioned by adolescents; in the current study adolescents also stated to feel no peer pressure. Nevertheless, influence of friends on drinking behavior seems to be evident as it has been reported in many studies (e.g. [
18,
20,
42]). From the literature and our study it seems that adolescents are subject to peer influences but are not explicitly aware of it. In the review of drinking motives adolescents’ ages varied between 10 and 25 years and most of the studies in this review were conducted in countries with a legal drinking age of 18 or higher. It is interesting to see that these motives seem to be the same in a more permissive society.
Environmental cues that would most likely lead to a binge drinking event, like being at a party or in a bar on weekend days together with friends, were also identified as the most difficult situations when trying not to drink. This indicates that alcohol consumption in social situations is widely accepted by Dutch adolescents. Furthermore, adolescents reported feeling pressure to drink alcohol when it is available. Further influences of peers explicitly mentioned were the size of the group and familiarity with the group. The bigger the group and the more familiar the members of the group were, the more alcohol they drank. This is in line with previous research [
43]. It seems important that interventions to reduce alcohol intake in adolescents should focus on this difficult situations, strengthen their efficacy to drink in a low risk manner when much alcohol is available and provide adolescents with advice how to handle peer pressure.
Also, parental attitude towards alcohol was perceived as positive by almost all adolescents, as long as they do not get drunk and throw up. Parents themselves indicated that they regard drinking by their children to be acceptable but within appropriate limits. This confirms the adolescents’ perspective; however, those limits were defined by parents to be two glasses of alcohol every two weeks. The attitude towards binge drinking among their children was negative in almost all parents. Apparently, the views of parents and adolescents are not totally in line with each other. In an intervention to reduce alcohol use among adolescents it should be stressed that parents clearly communicate their expectations and definitions of appropriate drinking towards their children, in order to avoid misinterpretations of acceptable limits.
Research has shown that it is not only the perceived approval of alcohol consumption of peers or the approval of drinking of parents that determine alcohol consumption in adolescents but the disparity between these two [
44]. The bigger the perceived gap between parental approval and peer approval, the more adolescents tended to drink. Reducing this gap may be a valuable component in an attempt to reduce alcohol consumption. Correction of the perceived norm of peer drinking [
45‐
47] on the one hand and encouraging parents to stay involved and communicate with their children to choose friends with similar attitudes towards drinking could be possibilities to reduce the gap [
44]. Interventions that encouraged parents to talk with their children about alcohol before they left for college showed that those students had less positive perceptions regarding drinking activities and showed less drinking and drunkenness [
28]. Furthermore, those students also perceived their peers to have similar perceptions regarding drinking [
28]. These studies indicate that parents still have considerable influence on their childrens’ drinking behavior even when they are about to leave home. When adolescents still live at home, as is the case with our target group [
34], this influence should be even easier to achieve.
Further, parents were quite aware of a number of negative effects of binge drinking on the health of their children, but despite their ideas about appropriate limits and knowledge about the consequences, most parents did not set clear rules concerning alcohol use and going out. Instead, parents rather talked to their children in, an understanding, non-accusatory fashion. This again is in line with the adolescents’ reports that their parents stopped handling clear rules concerning alcohol consumption and going out when they turned 16. Parents should be encouraged to keep setting appropriate rules concerning alcohol use, as these have been proven to be effective in reducing alcohol intake among adolescents [
26,
27]. Also, some adolescents indicated that this would have effect on their drinking behavior, so this may be a successful strategy in at least some adolescents.
Most parents had alcohol available at home and often thought it was more safe if adolescents drank alcohol at home in their presence than outside with peers. Yet, this perception may be incorrect as one study has shown that adult-supervised settings for alcohol use, in line with harm-minimization policies are associated with higher levels of harmful alcohol consequences compared to zero-tolerance policies that favor abstinence of alcohol [
48]. Often parents were convinced that their children had to learn how to drink, and that prohibiting the use of alcohol, or just allowing a certain amount of alcohol, would have no effect on the alcohol use of the child. Three factors mainly contributed to these stances: that parents experienced a lack of controllability of their child’s alcohol intake, due to the easy availability of alcohol in grocery stores; the fact that parents could not be around their children 24/7; and the legal purchasing age of 16. Some parents indicated that they had difficulties with these policies because they weaken their position as a parent. Parents explicitly stated that as soon as their children turn 16 they do not have any control about how much their child is drinking and where the child is drinking. This generally accepted, yet wrong, assumption that parents’ influence on adolescent drinking disappears when they leave home for college has been mentioned earlier [
49].
Even though some parents mentioned strategies they could use to decrease the amount of alcohol their child drank, there were also a couple of parents who thought that the responsibility to reduce the problem of binge drinking lies with the legal authorities and not with themselves. This may possibly be a side effect of the permissive rule setting from the Dutch government. Hence, interventions for Dutch parents should also focus on strengthening parents’ feelings of responsibility and self-efficacy to control the alcohol intake of their child. Another possibility would be to plead to increase the legal purchasing age from 16 to 18 years. This would at least have three advantages. First, it would probably increase the feeling of control and responsibility in parents. Second, it would give a clear signal to the adolescents that underage drinking is not (no longer) acceptable and third, make it more difficult for under-age adolescents to get hold of and consume alcohol. Of course, there is a difference between the introduction of law and observing the law, as in our sample many adolescents reported drinking before the age of 16, but increasing the age limit might possibly also increase the age of first alcohol consumption. Grocery stores and bars may be more triggered to check the ID of adolescents that do not look adult and parents could also become more sensible towards providing their adolescents with alcohol when they are under 18.
The results of these focus group interviews need to be quantified using questionnaires. This would lead to more insight into which of the factors named in this qualitative research are important and changeable [
50] and could give further indications on what kind of interventions to reduce binge drinking in this age group need to be developed. It is known that parents still have considerable influence on the child’s alcohol intake [
25‐
28], and that combining parents and children in an intervention is indeed more successful than delivering separate interventions to either the child or the parent [
51]. It therefore seems of upmost importance that parents are also included in these interventions to maximize the effect. Concerning the parents, we can conclude that many parents, at least from our sample, are not fully aware of the negative consequences of alcohol use, and they lack self-efficacy to control and reduce alcohol intake in their children. It also seems useful to reconsider the policies concerning the legal purchasing age and availability of alcohol to strengthen the position of parents and make availability of alcohol more difficult.
Limitations and strengths
A limitation of focus group interviews in general is that you most likely engage with people who are motivated to talk about a certain problem. This could have particularly played a role in the interviews with parents. Parents were hard to reach and response rates were low. Despite this, we managed to get a good insight into alcohol use in Dutch families, because despite their awareness of the problem and their motivation to talk to us, these parents acted as do many parents who see no problem: i.e. not setting rules and experiencing helplessness. Furthermore, we had to use one-on-one interviews with some parents, because for them it was not possible to join a focus group (e.g., because of the distance or time constraints). A disadvantage of this method is that you miss discussion with other parents in the group, but a big advantage is that you can get more in-depth insights in comparison with focus group interviews. Finally, we relied on self-reports of adolescents and parents, which can be prone to subjective bias, and due to a lack of insight information from self-report data can be missing.
The major strength of this study is that we combined focus group interviews from adolescents and parents, which creates a broader view on the problem and possible solutions to reduce binge drinking in adolescents.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AJ contributed to the development of the semi-structured questionnaire; conducting the interviews, transcribing the audiotapes; coding the transcripts; analysing and interpreting the data; and writing the manuscript. RC contributed to the development of the semi-structured questionnaire; conducting the interviews; coding the transcripts; interpreting the data; and drafting and revising the paper. LM contributed to the development of the semi-structured interview; interpreting the data; and drafting and revising the paper. HdV contributed to the developed the semi-structured questionnaire; interpreting the data; and revising the paper. All authors read and approved the final manuscript.