Does the prevention paradox apply to various alcohol habits and problems among Swedish adolescents?

Background: The prevention paradox states that a majority of alcohol-related problems in a population come from moderate drinkers because they are more numerous than heavy drinkers, although the latter have a higher individual risk of adverse outcomes. We examined the extent to which the prevention paradox applies to the relationship between alcohol consumption, heavy episodic drinking (HED) and alcohol-related problems in adolescents; an area in which studies are lacking. Methods: A total of 7288 alcohol-consuming adolescents aged 13-17 years were examined. The proportions (%) of problems related to drinking measures [the upper 10% and bottom 90% of drinkers by annual alcohol intake, and those with frequent (monthly), less frequent, and no heavy drinking episodes] were calculated. Results: The bottom 90% of consumers by annual intake accounted for a large majority of the alcohol-related problems among boys and girls at all ages. The share of problems accounted for by monthly HEDs increased with age, from similar to 10% among those aged 13 years to > 50% among those aged 17 years. Attributable proportions for the top 10% alcohol consumers ranged between 22% and 37%. Conclusions: Our analyses suggest that the prevention paradox is valid for adolescent boys and girls aged epsilon 15 years and applies to a large range of alcohol-related problems of varying severity. Our results imply that not only that prevention directed at all adolescents is essential, but also that HED should be particularly noticed.