QTc prolongation in adolescents with acute alcohol intoxication.

In adults, alcohol intoxication is associated with prolongation of the QT interval corrected for heart rate (QTc). The QTc is influenced by age and sex. Although alcohol intoxication is increasingly common in adolescents, there are no data on the prevalence of QTc prolongation in adolescents with alcohol intoxication. This study aimed to determine the prevalence of QTc prolongation in adolescents with alcohol intoxication and identify at-risk adolescents. In this observational study including adolescents aged 10-18 years, heart rate and QT interval were automatically assessed from an electrocardiogram (ECG) at alcohol intoxication using a validated algorithm. The QTc was calculated using both the Bazett formula (QTcB) and Fridericia formula (QTcF). If present, an ECG recorded within 1 year of the date of admission to the emergency department was obtained as a reference ECG. A total of 317 adolescents were included; 13.3% had a QTcB and 7.9% a QTcF longer than the sex- and age-specific 95th-percentile. None of the adolescents had a QTcB or QTcF > 500 ms, but 11.8% of the adolescents with a reference ECG had a QTcB prolongation of > 60 ms, while no adolescents had a QTcF prolongation of > 60 ms. QTc prolongation was mainly attributable to an increase in heart rate rather than QT prolongation, which underlies the differences between QTcB and QTcF. Male sex and hypokalaemia increased the likelihood of QTc prolongation.Conclusion: QTc prolongation was seen in approximately 10% of the adolescents presenting with alcohol intoxication, and although no ventricular arrhythmias were observed in this cohort, QTc prolongation increases the potential for malignant QT-related arrhythmias. Clinicians must be aware of the possibility of QTc prolongation during alcohol intoxication and make an effort to obtain an ECG at presentation, measure the QT interval, and give an adequate assessment of the findings. We advocate admitting adolescents with alcohol intoxication and QTc prolongation. During hospital admission, we recommend limiting exposure to QTc-prolonging medication, increasing potassium levels to a high-normal range (4.5-5.0 mmol/L) and obtaining a reference ECG at discharge.

The co-occurrence of mental disorders among Dutch adolescents admitted for acute alcohol intoxication.

Adolescents with substance use disorders are often diagnosed with co-occurring mental disorders. However, it is unknown if adolescent hospital admission for acute alcohol intoxication is also associated with co-occurring mental disorders. Therefore, the primary aim of this study is to estimate the prevalence of co-occurring mental disorders among Dutch adolescents admitted for acute alcohol intoxication. Secondly, this study aims to explore the cross-sectional relationship between the co-occurrence of mental disorders and patient characteristics, such as sex, age and blood alcohol concentration at admittance. Data were retrospectively collected from 726 adolescents admitted for acute alcohol intoxication. Overall, 245 (34%) of the 726 adolescents treated for acute alcohol intoxication were diagnosed with a co-occurring mental health disorder, such as attention-deficit hyperactivity disorder (13%) or autism spectrum disorder (2.1%). Attention-deficit hyperactivity disorder in particular seems to be more prevalent in the study population than in the general Dutch adolescent population.Conclusion: This study demonstrates that among adolescents admitted for acute alcohol intoxication, the prevalence of co-occurring mental disorders is a common and a relevant issue for treatment and prevention strategies. What is Known: • Alcohol consumption among adolescents has been associated with negative psychosocial effect. • Among adolescents admitted for acute alcohol intoxication, risk factors for psychological dysfunction appear to be inadequately assessed, documented and followed up. What is New: • The current study reports on the prevalence of co-occurring mental disorders among a substantial sample of adolescents admitted for acute alcohol intoxication. • Understanding the prevalence of co-occurring mental disorders is clinically relevant for the outpatient follow-up of adolescents admitted for acute alcohol intoxication.

The role of tobacco smoking and illicit drug use in adolescent acute alcohol intoxication.

BACKGROUND: This study aims to determine the prevalence of tobacco smoking and illicit drug use among Dutch adolescents admitted to hospital for acute alcohol intoxication treatment. Furthermore, socio-demographic predictors for smoking and illicit drug use in the sample population will be studied. The relationship between illicit drug use and specific characteristics of intoxication, such as blood alcohol concentration (BAC) and duration of reduced consciousness is also investigated. METHODS: The national Dutch Paediatric Surveillance Unit was used to prospectively register cases of acute alcohol intoxication from 2007 through 2017. Cases were included if they met the following inclusion criteria: BAC > 0.0 g/L, aged between 10 to 18 years old and requiring hospital treatment due to reduced consciousness. Questionnaires were sent to paediatricians to obtain clinical information. RESULTS: During the period 2007-2017, 5322 cases that met the inclusion criteria were reported. In this patient group, the prevalence of tobacco smoking was 22.2% (CI 21.0-23.5%), while the prevalence of illicit drug use was 11.8% (CI 10.9-12.7%). The predictors for smoking were the absence of alcohol-specific parental rule-setting, lower educational level, non-traditional family structure and positive drug screening. The predictors for illicit drug use were the absence of alcohol-specific parental rule-setting and smoking. Illicit drug use was also associated with a lower BAC at the time of admission. CONCLUSIONS: Assessing smoking and illicit drug use among adolescents admitted for acute alcohol intoxication is important in acute cases of intoxication, for outpatient follow-up and for the purposes of prevention. The relationship between simultaneous illicit drug use and a lower BAC is of relevance for paediatricians' attempts to diagnose acute intoxication. With respect to outpatient follow-up and preventive measures, it is important to be aware that adolescents' alcohol consumption, tobacco and illicit drug use are related and, ultimately, increase the odds of using other substances.

Age at First Alcohol Use as a Possible Risk Factor for Adolescent Acute Alcohol Intoxication Hospital Admission in the Netherlands.

BACKGROUND: The primary objective of this study is to determine whether age at first alcohol use is a determinant for adolescent acute alcohol intoxication characteristics, such as age at first acute alcohol intoxication and blood alcohol concentration (BAC) at hospital admission. Around the world, as in the Netherlands, a key aim of alcohol policy is to postpone the age at first alcohol use. This is based on cohort studies that indicate a relationship between a younger age at first alcohol use and subsequent adult alcohol use disorders. METHODS: This study was conducted using a cohort of data comprising individuals under 18 years of age. Data were collected between 2007 and 2017 by the Dutch Pediatric Surveillance System (NSCK) in order to monitor trends in admissions for acute alcohol intoxication. Multivariate linear regression analyses were used to determine the association between age at first alcohol use and acute alcohol intoxication characteristics, such as age at first acute alcohol intoxication and BAC at admission. RESULTS: This study indicates that among adolescents admitted for acute alcohol intoxication, adolescents who started drinking at ≤ 14 years of age are significantly more often female, lower educated, and raised in nontraditional family structures than adolescents who started drinking between 15 and 18 years of age. Multiple linear regression analyses indicated that age at first alcohol use, corrected for covariates, significantly predicted the age at acute alcohol intoxication and BAC at admission. The association between age at first alcohol use and age at intoxication was also found to be clinically relevant. CONCLUSIONS: Although causation cannot be implied based on the results of these analyses, the results of this study suggest that interventions delaying the age at first alcohol use could be successful in increasing the average age that adolescents are admitted to the hospital for acute alcohol intoxication.

The role of consumer age and financial profit in vendor compliance for underage alcohol sales.

Age limit restriction for risky products is widely implemented as an instrument to improve public health. To study reasons for vendor (non-)compliance this 2 (underage vs. adult consumer) × 2 (low vs. high profit) field experimental research was conducted. Trained mystery shoppers conducted 218 alcohol purchase attempts. ID checks and compliance were significantly higher when financial profit was low (74% ID checks; 67% compliance) compared with the high-profit conditions (26%; 18%). There were no significant differences between the adult and underage consumer conditions. The motivation to comply appears to be the crucial factor, and enforcement needs to be intensified.

Served straight up: Effects of verticality cues on taste evaluations and luxury perceptions.

Based on the embodied cognition framework and research addressing transfer effects between visual perception and taste, the point of departure for this study is the widespread association between vertical orientation and connotations related to luxury and (economic) power. Specifically, this study tests whether vertical orientation not only affects impressions of product luxury, but also influences actual taste evaluations, including perceptions of taste strength (intensity) and taste liking. Results confirm these predictions by showing that participants in a Dutch coffee house gave higher ratings on these constructs when they were exposed to an ad display depicting vertically-oriented rather than horizontally-oriented visual cues during a coffee sample test. Findings furthermore stress the influence of design cues as opposed to more traditional product claims. Implications for marketing and design practice are discussed.

The effectiveness of ID readers and remote age verification in enhancing compliance with the legal age limit for alcohol.

Currently, two different age verification systems (AVS) are implemented to enhance compliance with legal age limits for the sale of alcohol in the Netherlands. In this study, we tested the operational procedures and effectiveness of ID readers and remote age verification technology in supermarkets during the sale of alcohol. Following a trained alcohol purchase protocol, eight mystery shoppers (both underage and in the branch's reference age) conducted 132 alcohol purchase attempts in stores that were equipped with ID readers or remote age verification or were part of a control group. In stores equipped with an ID reader, 34% of the purchases were conducted without any mistakes (full compliance). In stores with remote age verification, full compliance was achieved in 87% of the cases. The control group reached 57% compliance, which is in line with the national average. Stores with ID readers perform worse than stores with remote age verification, and also worse than stores without any AVS. For both systems, in addition to effectiveness, public support and user friendliness need to be investigated. This study shows that remote age verification technology is a promising intervention that increases vendor compliance during the sales of age restricted products.

Gender, age, and educational level attribute to blood alcohol concentration in hospitalized intoxicated adolescents; a cohort study.

BACKGROUND: The prevalence of adolescents hospitalized with acute alcohol intoxication, mainly because of severe reduced consciousness, is increasing. However, the characteristics of these adolescents are mainly unidentified. In this clinical research, we aimed to identify factors that attribute to higher ethanol concentration, on which targeted alcohol health interventions can be designed. METHODS: Since 2007, alcohol intoxication among adolescents has been one of the leading topics of the Dutch Pediatric Surveillance System. In the current study, we have analyzed which demographic characteristics, general alcohol use behaviors, and clinical intoxication data were related to the blood alcohol concentration (BAC) levels at hospital admittance. We included all adolescents aged <18 years, admitted with BAC >0.0 g/l, and reduced consciousness during the years 2007, 2008, 2009, and 2010. RESULTS: A total of 2,023 adolescents with alcohol intoxication were reported, and 1,618 questionnaires were returned, of which 1,350 met our inclusion criteria. In univariate analysis, age, gender, educational level, place of alcohol purchase, place of alcohol consumption, age of first drink, and regular alcohol use during the weekend correlated with higher BAC. After multivariate analysis, older adolescents, boys, and higher educational level significantly attributed to higher BAC at admittance. CONCLUSIONS: In alcohol-intoxicated adolescents with reduced consciousness, gender, age, and also educational level correlate with BAC at admittance. Explanatory factors could be found in sensitivity to alcohol, but also in socioeconomic factors, which influence availability. Intervention strategies could be targeted more specific now for the subgroups found in this study to decrease the growing burden of adolescent alcohol intoxication, both on the societal level and on the clinical level.

One more beer? Serving alcohol to pseudo-intoxicated guests in bars.

BACKGROUND: Consuming large quantities of alcohol might result in negative consequences for both individual drinkers (alcohol dependency and addiction) and society (violence, traffic crashes). In order to decrease the prevalence of alcohol abuse, many countries have adopted regulations prohibiting the catering industry to serve alcohol to intoxicated guests. This article investigated compliance with these regulations in the Netherlands. METHODS: A study was conducted in which pseudo-intoxicated actors tried to order alcoholic drinks in 58 bars. A 2 × 2 design was used, based on (i) the number of actors involved (1 vs. 2) and (ii) the level of intoxication (moderately vs. very drunk). In contrast to earlier studies, research accomplices checked afterward whether the bartenders noticed that the actors appeared intoxicated. RESULTS: In 86% of the cases, the actors were able to buy alcohol, without comments or questions. In 10%, the actors were refused entrance by a bouncer. Only in 4%, the bartender refused to serve. In 81% of the cases, the bartenders remembered the actors: In 93% of those cases, they noticed that the actor appeared intoxicated. Only the "very drunk" script involving 2 actors led to refusals. CONCLUSIONS: The results show that compliance with the regulations regarding overserving to intoxicated guests is problematic in the Netherlands. Misinterpretations of the situation could be ruled out: Most bartenders noticed that the actors appeared intoxicated but served nonetheless.

Young poker faces: compliance with the legal age limit on multiple gambling products in the Netherlands.

Gambling is an activity that can be performed on-premise (slot machines in casinos, bars and restaurants) or off-premise (scratch cards and lottery tickets). Although the addictive potential may depend on the specific gambling product, early onset increases the likelihood for future pathological gambling. To delay the onset of gambling behavior and to reduce gambling-related problems, many countries have introduced age limits that should decrease the availability of gambling products to underage individuals. In this study we evaluated compliance to the legal age limit, making use of a mystery shopping method. We distinguished between (1) off-premise scratch cards (n = 51); (2) off-premise lottery tickets (n = 49); (3) on-premise slot machines in casinos (n = 88); and (4) on-premise slot machines in the catering industry (n = 100), and we focus on the factors, such as characteristics of the establishment, buyer, and vendor, that may account for possible differences. The 288 visits demonstrate that gambling products are highly available and accessible to under-aged customers; young customers are still able to gamble despite the legal regulations. The compliance rates fluctuate and appear to be related to the specific gambling product in question. Furthermore, age verification activities and certain outlet- and buyer characteristics, as well as characteristics associated with the purchase attempt, may influence compliance.

Improving shop floor compliance with age restrictions for alcohol sales: effectiveness of a feedback letter intervention.

PURPOSE: In this study, we investigated the effects and handling of an intervention to increase compliance with age limits regarding alcohol sales. The intervention tested in this field experiment was a feedback letter sent to alcohol outlets about their individual compliance results based on a mystery shopping study. METHOD: We measured compliance in 146 alcohol outlets (cafeterias, supermarkets, bars, liquor stores and youth centres) in one region in the Netherlands with 15-year-old mystery shoppers. About half (n=72) of the outlets received the intervention letter (the experimental group). After this intervention, we measured compliance again (n=138). Then we sent the same letter to the control group and interviewed all the outlets regarding their handling of the intervention (n=106). RESULTS: After the experimental group received the letter, compliance increased significantly (from 18.1% to 32.4%). In the control group, compliance did not change. Of the outlets interviewed, 81% stated that they had received the letter, and the action most commonly taken was to bring the letter to the attention of their staff. CONCLUSIONS: Positive feedback letters are more often copied and shared integrally with personnel, compared with negative letters. Compliance with respect to underage alcohol sales can be improved, although compliance levels remain low in the Netherlands.

Adolescent alcohol intoxication in Dutch hospital centers of pediatrics: characteristics and gender differences.

Gender differences in alcohol intoxication among adolescents are still largely unknown, whereas these differences have been studied in adults. To investigate possible differences, this study analyzed pediatric admissions for alcohol intoxication to the majority of Dutch hospitals between 2007 and 2009. Another aim was to explore key characteristics (e.g. blood alcohol concentration, duration of reduced consciousness, and age) and trends of alcohol intoxication among adolescents in the period 2007-2009. We analyzed data from the Dutch Pediatric Surveillance system, which monitors alcohol intoxication among children in pediatric departments of Dutch hospitals. Patients aged 11-17 years with reduced consciousness due to alcohol intoxication were included. The number of adolescents admitted with alcohol intoxication increased sharply from 2007 to 2009. The average age of the patients treated for alcohol intoxication increased from 15.3 years in 2007 and 15.4 years in 2008 to 15.7 years in 2009. The duration of reduced consciousness due to alcohol intoxication also increased over the 3-year period: from 2.2 to 3.1 h. Gender differences were observed regarding alcohol intoxication characteristics. Most strikingly, intoxicated girls were younger (15.3 vs. 15.7 years), had a lower blood alcohol concentration (1.79 vs. 1.94 g/l) and were hospitalized for shorter times than boys. No association was found between alcohol intoxication and other, possibly illicit drug use. The drinks most consumed prior to hospital admission were spirits and beer. Alcohol intoxication among adolescents is an emerging problem. Differences in intoxication characteristics between boys and girls were observed. These findings are important for future prevention and intervention strategies. In the Netherlands, special policlinics for children with alcohol intoxication have already been established.

How logical is safety? An institutional logics perspective on safety at work.

BACKGROUND: Occupational incidents and accidents are still commonplace in the contemporary workplace, despite increased understandings of safety. OBJECTIVE: This article aims to yield new insights into safety-related thinking, decisions and behaviours through the application of an institutional logics perspective. METHOD: Semi-structured interviews with twenty-two managers in a railroad construction and maintenance organisation were conducted, in which a variety of topics related to occupational safety and management were discussed. RESULTS: The results illustrate that an institutional logics perspective provides useful insights into the different logics of the market, profession, and corporation in the occupational safety context. Furthermore, the results demonstrate contradictory viewpoints, so-called complexity, between these three logics and subsequent management approaches. CONCLUSIONS: We demonstrate that viewing occupational safety through the lens of institutional logics leads to a better understanding of safety and reveals various rationales for safety attitudes and behaviours that otherwise may have been dismissed as irrational. Understanding and possessing the discourse of logics can help managers and safety professionals with analysis and prevention of accidents.

[Ten years of alcohol intoxication among young people in The Netherlands]. / 10 jaar alcoholintoxicaties bij jongeren.

OBJECTIVE: To provide insight into the number of adolescents admitted to hospital with alcohol intoxication in the period 2007-2016. DESIGN: Observational cross-sectional study. METHODS: We used data from the hospital admissions for alcohol intoxication among minors that had been reported to the Dutch Paediatric Surveillance System (NSCK). We also used data on minors who had been admitted to hospital for other alcohol-related reasons. RESULTS: In the period 2007-2016, 4,674 minors were admitted to a hospital in the Netherlands with alcohol intoxication. The number of minors admitted with alcohol intoxication increased annually from 2007 to 2011, after which it became reasonably stable, with a peak in 2015. The average age at which a minor was admitted increased (2007: 14.9 years; 2016: 15.5 years), and this also applied to the duration of loss of consciousness (2007: 2.24 hours; 2016: 3.12 hours). Parents of young people admitted with alcohol intoxication have become markedly stricter; 69% had given permission for consumption of alcohol in 2011; in 2016 that had decreased to 19%. CONCLUSION: Raising the minimum age for obtaining low-alcohol drinks, the creation of better awareness of the consequences of alcohol use and the opening of the Outpatient Adolescents and Alcohol Clinics seem to have had an effect. The average age of young people with alcohol intoxication has increased and parents have become stricter, but binge-drinking is still a serious problem. Further research is needed into characteristics and treatment of the group of young people who end up in hospital.

Determinants of safety outcomes and performance: A systematic literature review of research in four high-risk industries.

INTRODUCTION: In spite of increasing governmental and organizational efforts, organizations still struggle to improve the safety of their employees as evidenced by the yearly 2.3 million work-related deaths worldwide. Occupational safety research is scattered and inaccessible, especially for practitioners. Through systematically reviewing the safety literature, this study aims to provide a comprehensive overview of behavioral and circumstantial factors that endanger or support employee safety. METHOD: A broad search on occupational safety literature using four online bibliographical databases yielded 27.527 articles. Through a systematic reviewing process 176 online articles were identified that met the inclusion criteria (e.g., original peer-reviewed research; conducted in selected high-risk industries; published between 1980-2016). Variables and the nature of their interrelationships (i.e., positive, negative, or nonsignificant) were extracted, and then grouped and classified through a process of bottom-up coding. RESULTS: The results indicate that safety outcomes and performance prevail as dependent research areas, dependent on variables related to management & colleagues, work(place) characteristics & circumstances, employee demographics, climate & culture, and external factors. Consensus was found for five variables related to safety outcomes and seven variables related to performance, while there is debate about 31 other relationships. Last, 21 variables related to safety outcomes and performance appear understudied. CONCLUSIONS: The majority of safety research has focused on addressing negative safety outcomes and performance through variables related to others within the organization, the work(place) itself, employee demographics, and-to a lesser extent-climate & culture and external factors. PRACTICAL APPLICATIONS: This systematic literature review provides both scientists and safety practitioners an overview of the (under)studied behavioral and circumstantial factors related to occupational safety behavior. Scientists could use this overview to study gaps, and validate or falsify relationships. Safety practitioners could use the insights to evaluate organizational safety policies, and to further development of safety interventions.

Remote age verification to prevent underage alcohol sales. First results from Dutch liquor stores and the economic viability of national adoption.

OBJECTIVES: Alcohol consumption among minors is a popular topic in the public health debate, also in the Netherlands. Compliance with the legal age limits for selling alcohol proves to be rather low. Some Dutch liquor stores (outlets with an exclusive license to sell off-premise drinks with 15% alcohol or more) have recently adopted a remote age verification system. This paper discusses the first results of the use of the system. METHODS: We use data from 67 liquor stores that adopted Ageviewers, a remote age verification system, in 2011. A remote validator judges the customer's age using camera footage and asks for an ID if there is any doubt. The system then sends a signal to the cash register, which approves or rejects the alcohol purchase. RESULTS: From the 367346 purchase attempts in the database, 8374 were rejected or aborted for age-related reasons. This figure amounts to an average ratio of 1.12 underage alcohol purchase attempts per sales day in each participating liquor store. Scaling up to a national level, the figures suggest at least 1 million underage alcohol purchase attempts per year in Dutch liquor stores. DISCUSSION: Underage alcohol purchases can be prevented by the nationwide adoption of remote age verification. However, given the lax enforcement of the age limits by the government, adopting such a system on a voluntary basis is generally not in the economic interest of the liquor stores. Obligatory installation of the system in off-premise alcohol outlets may pass a social cost-benefit test if certain conditions are fulfilled.

Alcohol sales to underage buyers in the Netherlands in 2011 and 2013.

PURPOSE: Measuring vendors' compliance and possible change in compliance with the legal age limits on alcohol sales in 2011 and 2013. METHODS: In 2011 and 2013, representative mystery shopping studies were conducted. In total, 2,737 underage mystery shopping alcohol purchase attempts were conducted both in off-premise (supermarkets, liquor stores, and take away restaurants) and on-premise (bars and sports bars) outlets as well as from alcohol home delivery services. RESULTS: Average compliance increased significantly from 28.2% in 2011 to 46.5% in 2013, and asking proof of age (ID) also increased significantly from 43.9% in 2011 to 54.1% in 2013. CONCLUSIONS: Both asking proof of age and, ultimately, compliance with the legal age limits increased significantly. Nevertheless, still 53.5% of the adolescents could purchase alcohol themselves, which makes alcohol largely available through the various premises.

Druggists and pharmacists as gatekeepers: sales routines and compliance with sales protocols for over-the-counter naproxen 275 mg medicines in the Netherlands.

OBJECTIVES: Since for the sales of over-the-counter (OTC) medicines, prescribing physicians are not involved, and written instructions on/in the medicine boxes are inefficient, druggists and pharmacists are important gatekeepers in preventing customers' accidents. In this study we investigated the sales routines, and compliance with sales protocols, in order to evaluate that gatekeeper's function. METHODS: By means of the mystery shopping method, 228 pharmacies and drugstores in The Netherlands were visited and a naproxen 275mg medium-risk medicine was requested for a (fictitious) patient who was suffering from severe back pains. According to the sales protocols the vendors should never sell the requested medicine, because the mystery shoppers only gave an answer to one of the four mandatory sales protocol questions. Furthermore, the requested medicine is not the right or best choice for back pains. Four different scenarios were used in a 2×2 design (8-year-old patient vs. 25-year-old patient, and 1 box with 12 pills vs. 3 boxes with 12 pills). RESULTS: Of the drugstores and pharmacies only 16.7% complied with the sales protocols and did not sell the specific (or comparable) medicine, after asking all four mandatory questions (or already after one, two or three questions). Most vendors (83.3%) did not comply and sold the requested medicine, a comparable medicine, or even a more risky medicine after no question at all (or after asking some or even all four questions). Although both score low, pharmacists show better compliance (23.9%) than druggists (10.1%). CONCLUSIONS: When it comes to OTC medicines, druggists and pharmacists largely commit sloppy sales. The expected gatekeeping function of pharmacists and druggists is very limited, and customers might be in danger of inappropriate medicine selection, quantity and usage. We call for thorough evaluation of the over-the-counter system, improvement of the educational programs for medicine providers, and national campaigns to inform the public.

Underage alcohol sales--it only takes a minute: a new approach to underage alcohol availability.

OBJECTIVE: Because minors generally report higher accessibility than one would expect on the basis of the "compliance rates" established by researchers (the percentage of stores that comply with age limits for sales of age-restricted products such as alcoholic beverages), we propose a new method to better depict the availability of age-restricted products for minors as an alternative to the compliance approach, which in our view is too narrow. METHOD: Underage mystery shoppers were assigned to buy alcohol in a store of their preference, using any (legally allowed) purchase method. The time required to buy alcohol was the main outcome variable. As a benchmark, the time required to buy soft drinks was recorded. RESULTS: All underage mystery shoppers succeeded in buying alcohol, which means 100% availability. On average, buying alcohol took less than 10 minutes (including travel and shopping time), which was 2 minutes more than when purchasing soft drinks. CONCLUSIONS: Compliance at an outlet level can misrepresent the actual availability to minors. Both the proposed approach to availability and a new approach to age validation indicate that the general assumption that the traditional methods of age validation can effectively prevent the commercial availability of age-restricted products to minors should be seriously questioned.