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1. Drug and Alcohol Dependence 132 (2013) 290–294
Contents lists available at SciVerse ScienceDirect
Drug and Alcohol Dependence
journal homepage: www.elsevier.com/locate/drugalcdep
Alcohol consumption among high-risk Thai youth after raising the legal
drinking age
Susan G. Shermana,∗
, Bangorn Srirojnb
, Shivani A. Patela
, Noya Galaia
, Kamolrawee Sintupatb
,
Rupali J. Limayea
, Sutassa Manowannab
, David D. Celentanoa
, A. Aramrattanab
a
Johns Hopkins Bloomberg School of Public Health, United States
b
Chiang Mai University, Thailand
a r t i c l e i n f o
Article history:
Received 24 October 2012
Received in revised form 9 February 2013
Accepted 17 February 2013
Available online 15 March 2013
Keywords:
Under-aged drinking
Methamphetamine users
Legal changes
Thai youth
a b s t r a c t
Objective: Methamphetamine and alcohol are the leading substances abused by Thai youth. In 2008 the
government passed laws that limited alcohol availability and increased the legal drinking age from 18 to
20. We assessed whether the law reduced drinking among methamphetamine-using 18–19 year olds in
Chiang Mai.
Method: The study compares drinking patterns among methamphetamine smokers aged 18–19 years
(n = 136) collected prior to the legal changes, to a comparable post-law sample (n = 142). Statistical tests
for differences between the pre- and post-law samples on problem drinking and recent drinking fre-
quency and drunkenness were conducted. Logistic regression modeled the relative odds of frequent
drunkenness, controlling for demographic characteristics.
Results: A high prevalence of problematic drinking was present in both samples, with no difference
detected. The post-law sample reported a significantly higher median days drunk/month (9 vs. 4,
p ≤ 0.01); in adjusted analysis, frequent drunkenness (>5.5 days/month) was more common in the post-
law compared to pre-law period in the presence of other variables (AOR: 2.2; 95%CI: 1.3, 3.9). Post-law
participants demonstrated a low level of knowledge about the law’s components.
Conclusions: The study suggests that the new laws did not reduce drinking among high-risk,
methamphetamine-smoking 18–19 year olds; rather, the post-law period was associated with increased
drinking levels. The data indicate that the law is not reaching high-risk under-aged youth who are at risk
of a number of deleterious outcomes as a result of their substance use.
© 2013 Published by Elsevier Ireland Ltd.
1. Introduction
As is the case throughout the world, alcohol is the most widely
abused substance among adolescents and young adults in Thailand.
Based on a national survey of school students, it is estimated that
one in four men and one in seven women consumed alcohol in
the past year, while roughly 10% of men and 4% of women reported
binge drinking in the past month (Assanangkornchai et al., 2009). In
a national household study, 18% and 7% of men and women, respec-
tively, aged 12–19 years report drinking in the past 12 months;
among these, 5% and 3% reported drinking daily (Assanangkornchai
et al., 2010). The public health burden of alcohol consumption in
Thailand is not minor; alcohol plays a role in 90% of road casualties
in Thailand, resulting in 37 lost lives per day (National Economic
and Social Development Board, 2005). In the general population,
∗ Corresponding author at: Johns Hopkins Bloomberg School of Public Health,
Epidemiology, 615 N. Wolfe Street, E6543, Baltimore, MD 21205, United States.
Tel.: +1 410 614 3518; fax: +1 410 955 1383.
E-mail address: ssherman@jhsph.edu (S.G. Sherman).
12.1% of all Disability-Adjusted Life Years (DALYs) among men
and 1.2% of DALYs among women are due to alcohol consumption
(Rehm et al., 2009).
Methamphetamine (MA) use is as common as alcohol use among
young men and women in the general population in some regions
of Thailand (Ruangkanchanasetr et al., 2005). MA is the most com-
monly used illegal substance in Thailand (Verachai et al., 2001;
Farrell et al., 2002), with the estimated number of MA users having
increased from 850,000 in 1999, to more than 2.5 million in 2002
(Thailand Narcotics Annual Report, 2003). The largest increase was
among males aged 12–24. MA smoking in Thailand has reached epi-
demic proportion among young Thais (Farrell et al., 2002; Melbye
et al., 2002; Sattah et al., 2002; Razak et al., 2003), and MA has been
shown to be independently associated with a number of delete-
rious sexual (i.e., inconsistent condom use, multiple sex partners)
and other risk behaviors such as fighting and motorcycle accidents;
Kipke et al., 1995; Molitor et al., 1998; McNall and Remafedi, 1999;
Nemoto et al., 2002).
Concurrent alcohol use among MA users is common and may
lead to greater harm for those engaging in both behaviors. A study
conducted among adolescents in Chiang Rai (n = 1725) found that
0376-8716/$ – see front matter © 2013 Published by Elsevier Ireland Ltd.
http://dx.doi.org/10.1016/j.drugalcdep.2013.02.023

2. S.G. Sherman et al. / Drug and Alcohol Dependence 132 (2013) 290–294 291
alcohol consumption in the past three months was associated with
a four-fold greater odds of MA use after controlling for other fac-
tors (Sattah et al., 2002); similarly, young people who consumed
alcohol were more likely to use illicit substances in a national sur-
vey of students (Assanangkornchai et al., 2009). In our previous
work among Chiang Mai youth aged 18–20 years with a history of
MA use and heavy alcohol consumption, we found alarmingly high
rates of sexually transmitted infections (24% positive for Chlamydia
and 6% positive for gonorrhea; Celentano et al., 2008), higher sub-
sequent depressive symptoms among current MA users (Sutcliffe
et al., 2009), and higher risk of incarceration for MA users who
consumed alcohol (Sherman et al., 2010).
Governments worldwide have imposed regulations in an effort
to reduce both the demand and negative outcomes associated with
alcohol consumption, particularly among youth (McCartt et al.,
2010, 2009). In Thailand, the rise in morbidity and mortality asso-
ciated with high rates of underage alcohol consumption prompted
the passage of new laws in February 2008 that govern both alco-
hol availability and increasing the legal drinking age from 18 to 20
years old. The laws ban certain alcohol advertisements, restricted
selling hours for alcohol, and prohibited alcohol sales as well as con-
sumption in educational, religious, and recreational venues as well
as government offices and public parks (Alcohol Beverage Control
Laws, 2008). The laws describe alcohol as a threat to “health and
family” which “affect the overall social and economic condition of
the country,” and aims to reduce these negative impacts by pro-
tecting children and youths against easy access to alcohol beverage
(Alcohol Beverage Control Laws, 2008, p. 13).
Structural and economic changes such as increasing the
legal drinking age, restricting alcohol availability, price increases
through taxation, reduction in alcohol advertising, and restrictions
on alcohol availability have successfully reduced youth alcohol
consumption (Kuo et al., 2003; Makowsky and Whitehead, 1991;
Treno et al., 2003). However, such interventions may not impact
high-risk youth, like MA users, in the same manner. The effect of
such broad structural interventions targeting alcohol consumption
among high-risk youth has not been previously examined in the
Southeast Asian setting. The current study compares drinking pat-
terns among 18–19 year old MA users prior to and after the legal
changes, by examining if the legal changes are associated with
reduction in problem drinking, frequency of drinking and frequency
of drunkenness among these high-risk youth. We also report addi-
tional alcohol related knowledge and behaviors among these youth
after the laws were enacted. Given the deleterious impact and
pervasiveness of both MA and alcohol use, we were interested in
exploring how the legal changes specifically impacted MA-using
youth.
2. Methods
2.1. Sample recruitment
The study population comprises samples recruited before
(referred to as “pre-law”) and after (referred to as “post-law”)
the implementation of the Alcohol Beverage Control laws in
February 2008. The pre-law sample was recruited as a part of ran-
domized behavioral trial examining the effect of peer-educator,
network-oriented intervention on HIV risk behaviors and sexually
transmitted infections, and has been described in detail previously
(Sherman et al., 2009). Between April 2005 and June 2006, pre-
law participants were recruited from bars, restaurants, nightclubs,
and karaoke clubs. Recruitment sites were informed by an exten-
sive 18-month formative, ethnographic research stage prior to the
development and implementation of the trial (German et al., 2006;
Sherman et al., 2008).
Index participants were eligible for the parent trial if they
were between the ages of 18 and 25 at screening, used metham-
phetamine at least three times and had sex at least three times
in the past three months, and were able to enroll at least one of
their sex or drug network members in the study within 45 days
of screening. Participants were excluded if they refused to have
blood drawn or provide urine, if they were enrolled in another pre-
vention study, or if they refused to provide locator information.
Of 1263 young adults screened, 1189 were eligible (94%) and 983
(78%) were enrolled (415 index participants and 568 members of
their drug and/or sexual networks aged 18–25 years). For the pre-
law comparison group in the current study, we used data from the
baseline pre-intervention visit from randomly selected 18 and 19
year old index participants (n = 136) who were matched on gender
with the post-law sample (n = 142).
The post-law sample was recruited between March and June
2010 through methods parallel to those used for the pre-law
recruitment. Twenty-seven pre-law study participants were con-
tacted to verify the usefulness of recruitment venues used in the
pre-law sample as well as to provide additional recruitment venues
for MA using youth. The inclusion criteria were the same as those
described above. Both studies were approved by the Institutional
Review Board (IRB) at Johns Hopkins Bloomberg School of Public
Health and the Human Experimentation Committee at the Research
Institute for Health Sciences, Chiang Mai University.
2.2. Data collection
Pre-law survey data were collected via an interviewer-
administered survey, which included questions on the participant’s
sociodemographic background, substance use and alcohol history,
sexual history, and involvement in the drug economy. Post-law
survey data were collected by interviewers on a personal dig-
ital assistant (PDA) and ascertained questions on participant’s
sociodemographic background, substance use and extensive alco-
hol history. Participants in both studies were compensated 200
baht ($5 USD) for completing the survey and providing a urine
sample.
2.3. Measures
The outcome of interest, alcohol consumption, was measured
by the total number of days in the past 30 days that the participant
reported drinking alcohol (frequency of drinking in the past month;
drinking days/month) and the total number of days in the past 30
days that the participant reported being drunk from alcohol (fre-
quency of drunkenness in the past month; drunken days/month).
Problems with alcohol were measured using the four-item Cut
down, Annoyed, Guilty, Eye-opener (CAGE) tool, using the standard
cutoff of two or greater (Ewing, 1984). MA use was measured as the
frequency (days) of MA use in the past month.
Socio-demographic characteristics of interest included age, reli-
gion, education level, student status, residence (living with family
versus elsewhere), and average monthly income over the past
three months were collected for both samples. For the post-law
sample only, we additionally asked about knowledge of the legal
restrictions, source of alcohol, preferred drinking locations, and
possession of a fake ID.
2.4. Statistical analysis
Sample socio-demographic composition is reported and the
pre- versus post-law samples are compared using chi-square tests
for categorical variables. Monthly income and frequency of MA
use were categorized into tertiles based on the combined sam-
ple. Median and interquartile range values (IQRs) are reported for

3. 292 S.G. Sherman et al. / Drug and Alcohol Dependence 132 (2013) 290–294
Table 1
Sample characteristics.
Pre-law n (%) n = 136 Post-law n (%) n = 142 p-Value*
Demographic characteristics
Male 108 (79.4) 113 (79.6) 0.97
18 years old 88 (64.7) 83 (58.5) 0.28
Buddhist 132(97.1) 134 (94.4) 0.27
Completed high school 14(10.29) 40 (28.2) <0.01
Currently studying 64(47.1) 54 (38.0) 0.13
Median monthly income, USD (IQR) 113(85–177) 123(85–142) 0.64**
Alcohol and MA behaviors
2+ CAGE score 101 (74.3) 114 (80.3) 0.23
Median drinking days/month (IQR) 17.5(8–24.5) 19 (12–25) 0.27**
Median drunk days/month (IQR) 4 (1–10) 9 (2–20) <0.01**
Past month MA use
0–3 days 63(46.3) 49(34.5) 0.13
4–10 days 41(30.2) 51(35.9)
>10 days 32(23.5) 42 (29.6)
*
p-Values are based on chi-square tests except where indicated by (**).
**
p-Values based on Wilcoxon rank-sum test.
Table 2
Relative odds of frequent drinking and drunkenness among 18–19 year olds with a history of MA use after raising the legal age for alcohol consumption from 18 to 20 years
(n = 278).
Frequent drinking (>18 days/month) Frequent drunkenness (>5.5 days/month)
Unadjusted Adjusted*
Unadjusted Adjusted**
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Post-law sample (ref = pre-law) 1.1 0.7 1.8 1.0 0.6 1.6 2.3 1.4 3.7 2.2 1.3 3.9
*
Adjusted for income, MA frequency, age, and high school completion.
**
Adjusted for above factors and for monthly frequency of drinking (in days).
continuous variables with skewed distributions; between-sample
differences are compared using nonparametric rank-sum tests.
Frequency of drinking and drunkenness were each
dichotomized by the median values of the combined sample.
“Frequent drinking” was defined as above-median number of
drinking days/month, while “Frequent drunkenness” was defined
as above-median number of drunken days/month. Unadjusted
and adjusted logistic regression was used to assess the effect of
the legal changes on frequent drinking and frequent drunkenness,
in separate models, controlling for age, high school completion,
residence, income tertiles, and tertiles of MA frequency. The
model for frequent drunkenness included frequent drinking as an
explanatory variable. Knowledge and practices related to alcohol
reported by the post-law sample are described.
All analyses were performed using SAS 9.2 software (SAS Insti-
tute Inc, Cary, North Carolina).
3. Results
Demographic and substance use characteristics are displayed
in Table 1. The pre- and post-law samples had an average age of
18.4 years old and the large majority of the sample was Buddhist.
The pre-law sample was significantly less likely to have completed
high school (10% vs. 28%, p < 0.01) compared to the post-law sample.
There were no significant differences between samples regarding
the median reported number of drinking days per month but the
post-law sample reported a significantly higher median days drunk
per month (9 vs. 4, p < 0.01). Liquor was the most common drink
consumed followed by beer in both samples, and both had high
rates of problematic drinking as indicated by the CAGE. MA use
was similar across both samples, with the majority reporting use
at least four days per month.
Table 2 shows the results of two multivariate models, exam-
ining correlates of frequent drinking and frequent drunkenness,
respectively. Controlling for age, completion of high school,
monthly income, and MA use frequency, frequent drinking (>18
days/month) was not associated with the change in the law. Con-
trolling for age, high school completion, monthly income, and MA
use frequency, and frequent drinking, frequent drunkenness (>5.5
days/month) was more common in the post-law period (AOR: 2.4;
95%CI: 1.3, 3.9).
Table 3 displays post-law participants’ knowledge of the law.
Participants correctly knew a median of six (60%) of ten alcohol
related restrictions that were asked [data not shown]. Most partic-
ipants (97%) believed that the legal drinking age was still 18 years.
Though underage, 68% reported their most frequent location for
drinking to be a public venue where alcohol was served; the major-
ity (93%) reported purchasing alcohol directly from the vendor (i.e.,
no middleman). Only 3% of participants reported having a fake ID
card.
4. Discussion
The current study found that restrictive federal drinking laws,
which included raising the legal drinking age from 18 to 20 years
old, did not decrease drinking levels among high-risk youth aged
18–19 years in Chiang Mai, Thailand. Comparing a sample of youth
recruited several years before to a sample recruited over one year
Table 3
Alcohol related knowledge and practices among the post-law sample (n = 142).
n (%)
Believe that the legal drinking age is still 18 138(97)
Most common drinking locations
Private locations (e.g., within home) 34(24)
Public venue, not alcohol-oriented (e.g., school, temple) 5 (4)
Public venue, alcohol-oriented (e.g., bar, club, alcohol stall) 96(68)
Most common alcohol source
Purchased by others 10(7)
Purchase directly from market (e.g., bar, grocery store) 132(93)
Owns fake ID 4 (3)

4. S.G. Sherman et al. / Drug and Alcohol Dependence 132 (2013) 290–294 293
after the legal changes, no reductions were reported in a high
number of drinking days per month. To the contrary, more than
twice as many drunk days per month were reported after the legal
change in our sample. Very few post-law participants knew that the
law changed the legal drinking age; only 4% of the sample report-
edly aware that the drinking age had increased. While both pre-
and post-law participants were identified at drinking venues, post-
law participants were legally underage for alcohol consumption
and purchase at the time of recruitment. Despite this, most (97%)
post-law participants reported not owning fake IDs. This indicates
the continuing ease of alcohol accessibility, despite current legal
restrictions prohibiting consumption and purchasing, among this
age group. In summary, the law seemed to have limited effect on
the drinking patterns and levels of problematic drinking among a
sample of high-risk youth. The study underscores the importance of
the manner in which laws are implemented, with the simultaneous
need to enhance knowledge of the legal changes and enforce the
restrictions at drinking venues. Participants reported low levels of
awareness of the legal changes, which could have been attributed
to an ineffectual implementation or lack of publicity around the
changes. Sustained high rates of drinking among the sample pop-
ulation could be attributed to these factors, in addition to a lack of
enforcement.
This study is based on a high-risk population. All participants
have a history of MA use, and over half of each pre- and post-
law samples reported MA use more than three times in the past
month. The vast majority of participant concurrently reported
alcohol-related problems, according to the four-item CAGE score.
Two-thirds of both samples reported a score of two or above on
the CAGE, indicative of problematic drinking. The combined MA
history and the CAGE score reflect that this population may be par-
ticularly at risk for harms associated with alcohol use. To the best of
our knowledge, there is no other study of the effect of heightened
legal restrictions for alcohol consumption and purchase among
such high-risk youth in Thailand.
Our findings may point to a secular change in the pattern of
alcohol consumption among high-risk youth. While frequency of
drinking was stable across both samples, the reported median of
nine days drunk in the past month by the post-law sample was
twice that of the pre-law sample. We observed the same pattern
among those aged 20 and older in the parent study (excluded from
present analysis; data not shown). The results potentially signal a
rise in excessive alcohol consumption, while overall frequency of
drinking remains unchanged.
The findings should be viewed in light of several limitations.
The pre-post study design prevents us from examining causal
effects of the legal changes on drinking behaviors, because we
are unable to measure and account for all the factors that may
confound observed associations between youth drinking behav-
iors and the legal changes. Our study population was relatively
small (n = 278). While there was a risk of sampling bias due to
recruitment time periods and locations, the variety of recruitment
venues and our study staff’s extensive research experience with the
current population mitigated this concern. Moreover, most back-
ground characteristics and the frequency of MA use, an important
characteristic of the compared samples, did not significantly change
over time. Given the inclusion criteria for both samples, the study’s
generalizability is limited to high-risk youth in Chiang Mai. Both
the pre- and post-law samples were restricted to sexually active
MA users because the pre-law sample was originally recruited for
a randomized trial aimed to reduce MA use and HIV risk behav-
iors (Sherman et al., 2009). Our participants reported drinking a
median of more than 15 days per month, relatively high compared
to other samples of similarly aged youth in the general population
(Ruangkanchanasetr et al., 2005). Additionally, data were collected
through two different self-report methods, paper survey and PDA,
which are both subject to social desirability and distinct forms of
data collections. In light of these limitations, the study provides
insights into the degree of harmful alcohol consumption among
risky youth subsequent to national legal changes targeting youth
drinking.
A number of factors influence the effectiveness of laws on the
books, primary of which is the nature of their implementation.
More robust quantitative research is needed in Thailand about the
effects of the law in a broader cross sample of under-aged youth.
Additionally, qualitative research could inform the nature of the
law’s implementation. In the US, research on the effects of legal
changes in drinking ages played a role in informing political debates
that resulted in raising the legal drinking age in numerous states
in the 1980s (Wagenaar, 1993). Most post-law participants (68%)
reported purchasing alcohol from grocery stores or at venues serv-
ing alcohol, while only 7% of these under-aged individuals reported
obtaining alcohol for consumption from others. Seemingly minimal
attention has been paid to the law’s implementation, based on both
low knowledge and ease of access that continues after the passage
of restrictions.
Among this high-risk population, the data indicate no changes
in drinking patterns except for increased frequent drunkenness,
reflecting the ineffectiveness of legal changes several years after
the law had been implemented. The new Thai drinking laws failed
to create an environment that reduced harmful alcohol consump-
tion among 18–19 year old patrons frequenting popular drinking
venues. Our study did not demonstrate reductions among high-risk
youth and underscores the lack of effectiveness of the law for its
intended consequences. Additional efforts are needed to abate the
prevalence of drinking and alcohol-related morbidities among Thai
youth who are high-risk for substance abuse.
Role of funding sources
This study was funded by the National Institute on Alcohol
Abuse and Alcoholism (NIAAA). The NIAAA had no role in executing
the study or this manuscript.
Contributors
S.G. Sherman, MPH, PhD: principal investigator of the project,
conceptualized the study and wrote the first draft of the
manuscript. S. Bangorn, MA: director of the project, and over-
saw participant recruitment and data collection and manuscript
review. SA Patel MPH conducted all analyses for the manuscript
and helped with the writing of the paper. K. Sintupat, BA: data
manager and translator. R. Limaye, MPH: instrument develop-
ment, analytic design and data interpretation. S. Manowanna, MA:
assisted in data collection and managemnt. D.D. Celentano, ScD:
co-investigator, design of the study and manuscript review. S.G.
Sherman, MPH, PhD: principal investigator of the project, designed
study, manuscript development and review. All authors con-
tributed to and have approved the final manuscript. A. Aramrattana,
MD, PhD: co-investigator, executed the protocol and manuscript
review.
Conflict of interest statement
No conflict declared.
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