- Email: [email protected]
Trends in alcohol use and binge drinking, 1985–1999
Trends in Alcohol Use and Binge Drinking, 1985–1999 Results of a Multi-State Survey Mary K. Serdula, MD, MPH, Robert D. Brewer, MD, MSPH, Cathleen Gillespie, MS, Clark H. Denny, PhD, Ali Mokdad, PhD Background: Alcohol abuse is a major public health problem in the United States. Binge drinking and drinking among youth are of special concern. The purpose of this study is to examine trends in alcohol use and binge drinking and correlates of the behaviors with a focus on drinking among persons 18 to 20 years of age. Methods:
Data are from telephone interviews of 449,110 adults aged ⱖ18 years residing in the 19 states that participated in the Behavioral Risk Factor Surveillance System (BRFSS) from 1985 to 1999. The percentages reporting current alcohol use and binge use (ⱖ5 drinks per occasion) were calculated by year, age, gender, race, and level of education. Data were analyzed in 2003.
Results:
From 1985 to 1999, the prevalence of current alcohol use dropped 7.3%, and binge drinking dropped 3.3%. Among all age groups, most of the decline occurred before 1990. The greatest decline in both current (12.6%) and binge use (7.3%) occurred in the 18- to 20-year-old group. Between 1997 and 1999, however, respondents in this age group reported increases in these behaviors. Throughout the survey period, the proportion of current users who binge changed very little and remained highest among persons aged 18 –20 years (52.1%).
Conclusions: Alcohol use leveled off in the 1990s, but may be increasing, especially among persons 18 –20 years of age. Those who drink are about as likely to report binge drinking as were drinkers 15 years ago. (Am J Prev Med 2004;26(4):294 –298) © 2004 American Journal of Preventive Medicine
Introduction
A
lcohol abuse and alcoholism continue to be major public health problems in the United States. Binge drinking is a particularly dangerous activity that is associated with many health risk behaviors and adverse outcomes, including alcoholimpaired driving and unprotected sexual activity.1 In one study, for example, persons who reported binge drinking were 30 times as likely to report alcoholimpaired driving as were those who reported they did not binge drink.2 Binge drinking is common in the United States and may be increasing. A recent report indicates that between 1993 and 2001, the annual
From the Chronic Disease Nutrition Branch, Division of Nutrition and Physical Activity (Serdula, Gillespie), Centers for Disease Control and Prevention; the Division of Adult and Community Health (Brewer, Denny); and the National Center for Chronic Disease Prevention and Health Promotion and the National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia Address correspondence and reprint requests to: Mary Serdula, MD, MPH, Chronic Disease Prevention Branch, Division of Nutrition, Centers for Disease Control, 1600 Clifton Road, NE, Mailstop K26, Atlanta GA 30333. E-mail: [email protected].
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number of binge-drinking episodes in adults increased from 1.2 billion to 1.5 billion per year.3 Drinking among underage youth is of special concern because of the higher risk of alcohol abuse, motor vehicle crashes, and other alcohol-related health outcomes. To reduce these risks, state and local governments as well as various institutions (e.g., colleges and universities) have enacted policies to control drinking behavior, particularly among youth. Although some states had grandfather clauses that delayed the effective date of enforcement, all 50 states had enacted a minimum drinking age of 21 years by 1988.4 In addition, many states have enacted stricter laws against alcoholimpaired driving, including lower per se blood alcohol limits and administrative license revocation, both of which have been shown to be effective in reducing deaths from alcohol-related motor vehicle crashes.5 Local governments and colleges and universities have also enacted a variety of regulations, including restrictions on alcohol sales and possession. However, these regulations, and their enforcement, can vary substantially.6 In this study, data from the Behavioral Risk Factor Surveillance System from 1985 to 1999 were used to estimate trends in current alcohol use and binge drink-
Am J Prev Med 2004;26(4) © 2004 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/04/$–see front matter doi:10.1016/j.amepre.2003.12.017
ing (ⱖ5 drinks per occasion), with a focus on drinking among people 18 to 20 years of age. In addition, trends were examined in the proportion of current drinkers who report binge drinking.
Methods In 2003, data were analyzed from the 19 states that participated in the Behavioral Risk Factor Surveillance System from 1985 to 1999 (Arizona, Florida, Georgia, Idaho, Illinois, Indiana, Kentucky, Minnesota, Montana, New York, North Carolina, North Dakota, Ohio, Rhode Island, South Carolina, Tennessee, Utah, West Virginia, and Wisconsin). Data are collected by state health departments in collaboration with the Centers for Disease Control and Prevention. Every month throughout the year, participating states use random-digit dialing methods to select independent probability samples of non-institutionalized, civilian adults aged ⱖ18 years. Data from each state are weighted to reflect both the respondent’s probability of selection and the age- and gender-specific or race-, age-, and gender-specific population.7 A detailed description of the system is available elsewhere.8 The median upper-bound response rate (completed interviews divided by the sum of completed interviews, terminated interviews, and refusals) during the 1985–1999 study period was 84%. Questions on alcohol use were asked in all years except 1994, 1996, and 1998. Respondents were asked first about alcohol consumption in the previous month, then about their pattern of alcohol use, including binge drinking. During the survey period, the wording for the questions on alcohol consumption changed somewhat. From 1985 through 1988, respondents were asked the following: “Have you had any beer, wine or liquor in the past month, that is, since [date 1 month before the interview date]?” From 1989 through 1992, respondents were asked about “any beer, wine, wine coolers, cocktails, or liquor.” From 1993 on, respondents were asked: “During the past month, have you had at least 1 drink of any alcoholic beverage, such as beer, wine, wine coolers, or liquor?” Similar changes were made to the question on binge drinking. From 1985 to 1988, the question was as follows: “Considering all types of alcoholic beverages, that is, beer, wine, and liquor, as drinks, how many times during the past month did you have 5 or more drinks on an occasion?” From 1989 through 1992, two additional beverage-specific examples, wine coolers and cocktails, were included. Finally, from 1993 on, respondents were asked, “considering all types of alcoholic beverages, how many times during the past month did you have ⱖ5 drinks on an occasion?” Current drinkers were defined as those who reported drinking any alcohol in the previous month, and binge drinkers were those who reported consuming ⱖ5 drinks on at least one occasion in the previous month. Trends in alcohol in the 19 study states that participated in the Behavioral Risk Factor Surveillance System from 1985 to 1999 were compared with trends in the 26 additional states that participated from 1990 forward. This comparison allowed assessment of whether trends in alcohol consumption were different in the 19 study states relative to these other 26 states. To exclude the possibility that demographic changes accounted for the vari-
ation in alcohol consumption, age-, gender-, and race-standardized rates were computed. Although the standardized rates were slightly lower than the unadjusted rates, similar patterns of alcohol consumption were observed over time. Therefore, only the unadjusted estimates were reported. SUDAAN was used in all analyses (Research Triangle Institute, Research Triangle Park NC, 1997). Because of the large sample size, statistical significance was set at p⬍0.01.
Results Of the 461,003 persons who completed BRFSS interviews in 1985–1999, the excluded totaled 11,893, including those missing sociodemographic data (n⫽2461) and those who did not answer questions on alcohol intake (n⫽9570). Some persons were excluded for more than one cause. The final sample size was 449,110. For analyses of binge drinking, an additional 2046 persons were excluded due to missing data on this variable. For the entire survey period, 47.4% of the respondents were men. Respondents were predominantly white (81.9%); 29.7% were aged ⱖ 55 years, and 22.5% were college graduates. From 1985 to 1999, the prevalence of current alcohol use dropped from 54.9% to 47.6%, a decline of 7.3 percentage points. This prevalence declined significantly across most age, gender, race/ethnicity, and educational categories (Table 1). The decline in prevalence was inversely associated with age, with the greatest declines (in percentage points) observed among those aged 18 –20 years (12.6%) and among those with some college education (12.3%). Within the 18- to 20-year age group, women experienced a greater decline (17.5%) than did men (9.3%). However, because of the large standard errors, the change in the prevalence was not significantly different between any of the age groups. Among all age groups, the prevalence of current alcohol use declined during the last half of the 1980s, leveled off during most of the 1990s, and increased or remained the same between 1997 and 1999. The most notable decline in alcohol use during the last half of the 1980s was among 18- to 20-year-olds (16.5 percentage points). Conversely, respondents in this age group had the largest increase in current alcohol use between 1997 and 1999 (7.3 percentage points). During all survey years, the prevalence of current alcohol use increased with education and was higher in men than women and in those aged 21–25 years, compared with other age groups. With the exception of one survey year (1987), prevalence was higher in nonHispanic whites than other racial ethnic groups. From 1985 to 1999, the prevalence of binge drinking dropped from 16.9% to 13.6%, respectively (Table 1). The greatest declines (in percentage points) were observed among persons aged 18 –20 years (7.3%), those with some college education (6.1%), and males Am J Prev Med 2004;26(4)
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Table 1. Prevalence (%) of current alcohol use and binge drinkinga; Behavioral Risk Factor Surveillance System, 1985–1999 Current alcohol use
Parameter Total Gender Male Female Age group, years 18–20 21–25 26–34 35–54 55⫹ Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Other Education ⬍High school High school Some college College graduate
Binge drinking
1985 nⴝ 21,969
1991 nⴝ 36,051
1999 nⴝ 58,197
1991 nⴝ 35,910
1999 nⴝ 57,976
Change 1985–1999
54.9 (0.6)
44.4 (0.4)
47.6 (0.4)
ⴚ7.3 (0.7)* 16.9 (0.4)
11.7 (0.3)
13.6 (0.3)
ⴚ3.3 (0.5)*
63.7 (0.8) 47.0 (0.7)
52.9 (0.6) 36.7 (0.5)
56.3 (0.6) 39.8 (0.4)
ⴚ7.4 (1.0)* 26.3 (0.8) ⴚ7.2 (0.9)* 8.6 (0.4)
18.2 (0.5) 5.8 (0.3)
21.4 (0.5) 6.6 (0.2)
ⴚ4.9 (0.9)* ⴚ2.0 (0.5)*
59.1 (2.2) 70.3 (1.4) 64.8 (1.0) 55.9 (0.9) 39.5 (1.0)
40.0 (1.9) 56.0 (1.4) 54.1 (0.9) 46.2 (0.7) 32.4 (0.7)
46.5 (2.1) 60.4 (1.3) 54.3 (0.8) 50.9 (0.6) 36.3 (0.6)
ⴚ12.6 (3.0)* ⴚ9.9 (1.9)* ⴚ10.5 (1.3)* ⴚ5.0 (1.1)* ⫺3.1 (1.1)
31.4 (2.3) 33.6 (1.6) 22.7 (0.9) 14.2 (0.7) 5.0 (0.5)
19.1 (1.8) 23.8 (1.2) 18.0 (0.7) 9.9 (0.4) 3.6 (0.3)
24.1 (1.9) 30.3 (1.3) 19.6 (0.7) 13.4 (0.4) 4.1 (0.3)
⫺7.3 (3.0) ⫺3.3 (2.0) ⫺3.1 (1.1) ⫺0.8 (0.8) ⫺0.9 (0.6)
56.0 (0.6) 47.7 (1.8) 51.3 (2.8) 51.6 (4.4)
46.4 (0.5) 33.7 (1.3) 38.5 (1.9) 39.6 (3.2)
50.0 (0.4) 36.8 (1.1) 39.6 (1.5) 45.7 (2.5)
ⴚ6.0 (0.7)* ⴚ10.9 (2.1)* ⴚ11.7 (3.2)* ⫺5.9 (5.0)
17.6 (0.5) 10.3 (1.1) 18.3 (2.2) 17.7 (3.5)
12.3 (0.3) 7.2 (0.7) 11.3 (1.1) 9.3 (1.7)
14.4 (0.3) 8.1 (0.6) 13.6 (1.1) 12.4 (1.7)
ⴚ3.2 (0.6)* ⫺2.1 (1.3) ⫺4.7 (2.5) ⫺5.4 (3.9)
34.0 (1.1) 52.5 (0.9) 63.4 (1.0) 70.8 (1.1)
24.9 (0.9) 40.0 (0.7) 51.5 (0.8) 57.6 (0.8)
25.9 (0.9) 43.3 (0.6) 51.2 (0.7) 60.9 (0.7)
ⴚ8.1 (1.5)* ⴚ9.2 (1.1)* ⴚ12.3 (1.2)* ⴚ9.8 (1.3)*
10.3 (0.8) 17.7 (0.7) 21.5 (1.0) 17.0 (0.9)
7.2 (0.5) 11.5 (0.4) 15.4 (0.6) 10.8 (0.5)
9.5 (0.6) 13.5 (0.5) 15.5 (0.5) 14.0 (0.5)
⫺0.8 (1.0) ⴚ4.2 (0.9)* ⴚ6.1 (1.1)* ⫺3.0 (1.0)
Change 1985–1999
1985 nⴝ 21,821
Current alcohol use is defined as ⱖ1 drinks in the past month and binge drinking is defined as ⱖ5 drinks on at least one occasion in the past month. *Significant t test for change (p ⬍ 0.01).
a
(4.9%). Of the remaining population subgroups examined, most showed small or statistically nonsignificant declines. Among those aged 18 –20 years, males and females experienced a similar decline (6.7% and 9.6%, respectively). However, because of large standard errors, the change in the prevalence was not significantly different between any of the age groups. During the last half of the 1980s, prevalence of binge drinking declined across all age groups; the largest declines (in percentage points) were observed among those aged 18 –20 (12.3%) and 21–25 years (6.2%). However, respondents in both age groups reported substantial increases in binge drinking rates from 1997 to 1999 (8.3 percentage points for those aged 18 –20 years, 7.6 percentage points for those aged 21–25 years). During all survey years, the prevalence of binge drinking was higher in men than women, those 21–25 years compared with other age groups, nonblacks compared with blacks, and high school graduates compared with nongraduates. Despite the overall declines in current alcohol use and binge drinking, there was little change in the proportion of binge drinking among current drinkers from 1985 through 1997. However, from 1997 to 1999, this proportion increased for all age groups, with the largest increases occurring among those 18 –20 years (41.0% to 52.1%) and 21–25 years (40.5% to 50.3%). Throughout the survey period, the ratio of binge drinkers to current drinkers was inversely related to age, with the highest ratios consistently observed 296
among youth and young adults (aged 18 –20 years and 21–25 years). Prevalence estimates for current drinking and binge drinking were consistently lower in the 19 study states relative to the other 26 states that participated in the system from 1990 to 1999. However, similar to the 19 study states, there was very little change in the rates of current drinking and binge drinking in these 26 states during the 1990s. From 1990 to 1999, the prevalence of current alcohol use in these 26 states went from 50.1% to 54.5%, and the prevalence of binge drinking went from 16.5% to 15.3%. Furthermore, from 1990 to 1999, the proportion of binge drinking among current drinkers was very similar. In the 19 states, these proportions were 30.2% and 28.8%, respectively. In the 26 states, these proportions were 33.3% and 28.3%, respectively.
Discussion In the 19 states that participated in the Behavioral Risk Factor Surveillance System from 1985 to 1999, the prevalence of current alcohol use and binge drinking declined during the last half of the 1980s and leveled off during the first half of the 1990s. Overall, declines occurred in all age groups, but the greatest decline for both current alcohol use and binge drinking was observed among 18- to 20-year-olds. Unfortunately, from 1997 to 1999, the 18- to 25-year-old age group experienced a substantial increase in both current alcohol use and binge alcohol use. Whether this recent increase
American Journal of Preventive Medicine, Volume 26, Number 4
represents a trend will need to be explored in future years and confirmed by other surveys. Furthermore, despite overall declines in current and binge alcohol use, the proportion of current users who binged changed very little from 1985 through 1999, with the highest proportions consistently observed among youth (18 –20 years) and young adults (21–25 years). Although the BRFSS does not collect information on state alcohol policies, it could be speculated that these declines were likely due, at least in part, to increasing the minimum drinking age to 21 years in all states by 1988 and enacting “zero tolerance” laws, which lower the legal blood alcohol concentration for underage drivers. Even so, after 1990, alcohol consumption remained common among 18- to 20-year-olds, with 47% reporting current use and 24% binge use in the past month in 1999. These results were generally consistent with findings from national surveys. The National Household Survey on Drug Abuse, an annual survey of persons aged 12 years and older, showed a decline of 11 percentage points in the prevalence of alcohol use in the past month, from 63% in 1979 to 52% in 1998, with most of the decline occurring before 1988, after which there was no significant change.9 In this same survey, pastmonth binge drinking declined from 20% in 1985 to 16% in 1998, but again with no significant change after 1988.9,10 The National Alcohol Survey, a household survey of adults 18 years and older, showed a decline of 4 percentage points in drinking during the past year, from 69% in 1984 to 65% in both 1990 and 1995, whereas past-year binge drinking declined modestly from 30% in 1984, to 29% in 1990, and to 28% in 1995.11 The Monitoring the Future Survey, an annual national survey of adolescents and young adults, showed that the prevalence of past-month alcohol consumption in the 19 –20-year group declined from 73% in 1985 to 61% in 1992, after which consumption remained level.12 The 2-week prevalence of binge drinking declined from 41% in 1985 to 32% in 1995, and then rose to 35% in 2000. The Harvard School of Public Health College Alcohol Study showed a decline in the prevalence of pastyear alcohol consumption among college students from 85% in 1993 to 81% in 1999.13 Although the 2-week prevalence of any binge drinking (ⱖ5 drinks in a row for men, ⱖ4 drinks in a row for women) remained the same (44%), frequent binge drinking (ⱖ 3 times in a 2-week period) increased from 19.8% to 22.7%.13 In contrast to national survey data, apparent per capita alcohol consumption derived from sales data declined substantially during both the 1980s and the first half of the 1990s and then showed small annual increases during 1996, 1997, and 1998 (0.9%, 0.5%, 0.4% increase, respectively).14,15
Although the authors were unable to specifically assess the reason for the apparent increase in both current and binge drinking in the late 1990s, this was most likely due to a combination of environmental factors, including increased alcohol beverage marketing, as well as decreases in the real-dollar cost of alcoholic beverages— caused, at least in part, by declines in inflation-adjusted alcohol excise taxes in most states since the late 1960s. Alcohol use is also known to be influenced by a variety of other factors, including religious beliefs and country of origin. However, it is unclear what role, if any, state-level changes in these demographic characteristics might have had on the prevalence of current and binge alcohol use during our study period. Results from the 19 states in the current study could not be generalized to all 50 states. Compared with the other 26 states that participated in the system from 1990 through 1999, the prevalence estimates for current drinking and binge drinking were consistently lower in the 19 study states. However, similar to the case in the other 26 states, there was little change in the rates of current drinking and binge drinking during the first half of the 1990s. There was also essentially no change in the proportion of binge drinking among current drinkers in these two groups of states. This suggests that the trends observed from 1985 through 1999 in these 19 states from 1985 were probably not significantly influenced by differences in state characteristics. The current study had several other limitations. First, estimates of alcohol use were based on self-reports, which are known to underestimate actual consumption; compared with sales data, for example, self-reported intakes are consistently lower.16 Second, binge drinking was defined as ⱖ5 drinks per occasion for both genders. Although this definition is in general use, it may underestimate binge drinking for women because of their lower body weight and differences in the way women metabolize alcohol.17 Third, the format of the alcohol questions changed in 1989 and again in 1993. However, most of these changes were relatively minor, and only small changes were seen in the prevalence of current and binge alcohol before and after the questionnaire changed. For example, in 1988 and 1989, the prevalence of current alcohol use was 51.1% and 47.7%, respectively; the prevalence of binge alcohol use was 14.8% and 13.5%, and the proportion of binge drinking among current drinkers was 29.2% and 28.4%. In 1992 and 1993, the prevalence of current alcohol use was 45.6% and 48.5%, respectively; the prevalence of binge alcohol use was 12.4% and 13.1%, and the proportion of binge drinking among drinkers was 27.2% and 27.1%. In addition, as discussed above, the pattern of change observed— declining use during the last half of the 1980s and leveling off during the first half of the 1990s—is consistent with those reported in Am J Prev Med 2004;26(4)
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national surveys.9 –12 Fourth, the Behavioral Risk Factor Surveillance System does not include those living in households without telephones or include persons living in various public and private institutions, such as college students living in fraternities or sororities, who may have a higher prevalence of binge drinking.13 There are a variety of strategies to reduce underage and binge drinking, including environmental, policy, pricing, and clinical interventions, that have been shown to work. Effective environmental and policy interventions include strict enforcement of the age-21 minimum for drinking and zero-tolerance laws for underage youth. Additionally, communities and retail alcohol outlets can work together to implement strategies to reduce high-risk or binge drinking, including server training.18 A recent study found that communities can achieve significant reductions in binge drinking and alcohol-related outcomes (e.g., alcohol-related motor vehicle crashes) by implementing comprehensive programs that combine one or more of these intervention strategies.19 In addition, given the price elasticity of demand for alcohol products, raising taxes on alcoholic beverages has been shown to reduce the amount of alcohol consumed per drinking occasion. A recent review of the effect of price on alcohol consumption indicates that tax increases may be a particularly promising strategy for reducing alcohol abuse and alcohol-related health effects among youth and young adults.20 Finally, health professionals should routinely screen patients for alcohol problems, providing those who “screen positive” with brief counseling or referring them to a specialized treatment program, depending on the severity of their problem.21 A recent study found that counseling adolescents on alcohol and drug abstinence and screening adults for problem drinking were among the most valuable clinical preventive services.22 Through this combination of interventions, the prevalence of underage drinking and binge drinking may be further reduced, along with the many public health problems associated with them. We acknowledge the state BRFSS coordinators whose cooperation made this work possible.
References 1. National Institute on Alcohol Abuse and Alcoholism. 10th special report to the U.S. Congress on alcohol and health: highlights from current research. Washington DC: National Institutes of Health, 2000. (NIH Publication No. 00-1583.).
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2. Liu S, Siegel P, Brewer RD, et al. The prevalence of alcohol-impaired driving: results from a national survey of self-reported health behaviors. JAMA 1997;277:122–5. 3. Naimi TS, Brewer RD, Mokdad A, et al. Binge drinking among U.S. adults. JAMA 2003;289:70 –5. 4. Centers for Disease Control and Prevention. Update: Alcohol-related traffic crashes and fatalities among youth and young adults—United States, 1982–1984. MMWR Morb Mortal Wkly Rep 1995;44:869 –74. 5. Centers for Disease Control and Prevention. Motor vehicle occupant injury: strategies for increasing use of child safety seats increasing use of safety belts, and reducing alcohol-impaired driving. A report on recommendations of the Task Force on Community Preventive Services. MMWR 2001;50(No. RR-7):1–13. 6. Wagenaar AC, Wolfson M. Deterring sales and provision of alcohol to minors: a study of enforcement in 295 counties in four states. Public Health Rep 1995;110:419 –27. 7. Powell-Griner E, Anderson JE, Murphy W. State- and sex-specific prevalence of selected characteristics—Behavioral Risk Factor Surveillance System, 1994 and 1995. MMWR CDC Surveill Summ 1997;46:1–31.7. 8. Holtzman D. The Behavioral Risk Factor Surveillance System. In: Blumenthal D, DiClemente R, ed. Community-based health research: Issues and methods. New York: Springer Publishers, 2003; 115–131. 9. Office of Applied Studies Substance Abuse and Mental Health Administration. Summary of findings from the 1998 National Household Survey on Drug Abuse. Rockville, MD: Substance Abuse and Mental Health Administration, August 1999. (National Household Survey on Drug Abuse Series H-10). 10. Office of Applied Studies, Substance Abuse and Mental Health Administration. Summary of findings from the 2000 National Household Survey on Drug Abuse. Rockville, MD: Substance Abuse and Mental Health Administration, September 2001. (National Household Survey on Drug Abuse Series H-13). 11. Greenfield TK, Midanik LT, Rogers JD. A 10-year national trend study of alcohol consumption, 1984 –1995: Is the period of declining drinking over? Am J Public Health 2000;90:47–52. 12. Johnston LD, O’Malley PM, Bachman JG. Monitoring the Future national survey results on drug use, 1975–2000. Vol. 2: College students and young adults 19 – 40. Bethesda MD: National Institute on Drug Abuse, 2001. (NIH publication no.01-4925). 13. Wechsler H, Lee JE, Kuo M, et al. College binge drinking in the 1990’s: a continuing problem, results of the Harvard School of Public Health 1999 College Alcohol Study. J Am Coll Health 2000;48:199 –210. 14. Williams GD, Stinson FS, Sanchez LL, et al. Surveillance Report 47: apparent per capita alcohol consumption: national, state and regional trends, 1977–96. Bethesda, MD: U.S. Dept of Health and Human Services, Public Health Service, National Institute on Alcohol Abuse and Alcoholism, December 1998. 15. Nephew TM, Williams GD, Stinson FS, et al. Surveillance Report 55: apparent per capita alcohol consumption: national, state and regional trends, 1977–98. Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institute on Alcohol Abuse and Alcoholism, December 2001. 16. Midanik L. The validity of self-reported alcohol consumption and alcohol problems: a literature review. Br J Addict 1982;77:357–82. 17. Wechsler H, Dowdall GW, Davenport A, et al. A gender-specific measure of binge drinking among college students. Am J Public Health 1995;85:982–5. 18. McKnight AJ, Streff FM. The effect of enforcement upon service of alcohol to intoxicated patrons of bars and restaurants. Accid Anal Prev 1994;26: 79 –88. 19. Holder HD, Gruenewald PJ, Ponicki WR, et al. Effect on community-based interventions on high-risk drinking and alcohol-related injuries. JAMA 2000;284:2341–7. 20. Chaloupka FJ, Grossman M, Saffer H. The effects of price on alcohol consumption. 2001. In press. 21. Brewer RD, Sleet D. Alcohol and injuries: time for action (editorial). Arch Fam Med 1995;4:499 –501. 22. Coffield AB, Maciosek MV, McGinnis JM, et al. Priorities among recommended clinical preventive services. Am J Prev Med 2001;21:1–9.
American Journal of Preventive Medicine, Volume 26, Number 4
Data are from telephone interviews of 449,110 adults aged ⱖ18 years residing in the 19 states that participated in the Behavioral Risk Factor Surveillance System (BRFSS) from 1985 to 1999. The percentages reporting current alcohol use and binge use (ⱖ5 drinks per occasion) were calculated by year, age, gender, race, and level of education. Data were analyzed in 2003.
Results:
From 1985 to 1999, the prevalence of current alcohol use dropped 7.3%, and binge drinking dropped 3.3%. Among all age groups, most of the decline occurred before 1990. The greatest decline in both current (12.6%) and binge use (7.3%) occurred in the 18- to 20-year-old group. Between 1997 and 1999, however, respondents in this age group reported increases in these behaviors. Throughout the survey period, the proportion of current users who binge changed very little and remained highest among persons aged 18 –20 years (52.1%).
Conclusions: Alcohol use leveled off in the 1990s, but may be increasing, especially among persons 18 –20 years of age. Those who drink are about as likely to report binge drinking as were drinkers 15 years ago. (Am J Prev Med 2004;26(4):294 –298) © 2004 American Journal of Preventive Medicine
Introduction
A
lcohol abuse and alcoholism continue to be major public health problems in the United States. Binge drinking is a particularly dangerous activity that is associated with many health risk behaviors and adverse outcomes, including alcoholimpaired driving and unprotected sexual activity.1 In one study, for example, persons who reported binge drinking were 30 times as likely to report alcoholimpaired driving as were those who reported they did not binge drink.2 Binge drinking is common in the United States and may be increasing. A recent report indicates that between 1993 and 2001, the annual
From the Chronic Disease Nutrition Branch, Division of Nutrition and Physical Activity (Serdula, Gillespie), Centers for Disease Control and Prevention; the Division of Adult and Community Health (Brewer, Denny); and the National Center for Chronic Disease Prevention and Health Promotion and the National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia Address correspondence and reprint requests to: Mary Serdula, MD, MPH, Chronic Disease Prevention Branch, Division of Nutrition, Centers for Disease Control, 1600 Clifton Road, NE, Mailstop K26, Atlanta GA 30333. E-mail: [email protected].
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number of binge-drinking episodes in adults increased from 1.2 billion to 1.5 billion per year.3 Drinking among underage youth is of special concern because of the higher risk of alcohol abuse, motor vehicle crashes, and other alcohol-related health outcomes. To reduce these risks, state and local governments as well as various institutions (e.g., colleges and universities) have enacted policies to control drinking behavior, particularly among youth. Although some states had grandfather clauses that delayed the effective date of enforcement, all 50 states had enacted a minimum drinking age of 21 years by 1988.4 In addition, many states have enacted stricter laws against alcoholimpaired driving, including lower per se blood alcohol limits and administrative license revocation, both of which have been shown to be effective in reducing deaths from alcohol-related motor vehicle crashes.5 Local governments and colleges and universities have also enacted a variety of regulations, including restrictions on alcohol sales and possession. However, these regulations, and their enforcement, can vary substantially.6 In this study, data from the Behavioral Risk Factor Surveillance System from 1985 to 1999 were used to estimate trends in current alcohol use and binge drink-
Am J Prev Med 2004;26(4) © 2004 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/04/$–see front matter doi:10.1016/j.amepre.2003.12.017
ing (ⱖ5 drinks per occasion), with a focus on drinking among people 18 to 20 years of age. In addition, trends were examined in the proportion of current drinkers who report binge drinking.
Methods In 2003, data were analyzed from the 19 states that participated in the Behavioral Risk Factor Surveillance System from 1985 to 1999 (Arizona, Florida, Georgia, Idaho, Illinois, Indiana, Kentucky, Minnesota, Montana, New York, North Carolina, North Dakota, Ohio, Rhode Island, South Carolina, Tennessee, Utah, West Virginia, and Wisconsin). Data are collected by state health departments in collaboration with the Centers for Disease Control and Prevention. Every month throughout the year, participating states use random-digit dialing methods to select independent probability samples of non-institutionalized, civilian adults aged ⱖ18 years. Data from each state are weighted to reflect both the respondent’s probability of selection and the age- and gender-specific or race-, age-, and gender-specific population.7 A detailed description of the system is available elsewhere.8 The median upper-bound response rate (completed interviews divided by the sum of completed interviews, terminated interviews, and refusals) during the 1985–1999 study period was 84%. Questions on alcohol use were asked in all years except 1994, 1996, and 1998. Respondents were asked first about alcohol consumption in the previous month, then about their pattern of alcohol use, including binge drinking. During the survey period, the wording for the questions on alcohol consumption changed somewhat. From 1985 through 1988, respondents were asked the following: “Have you had any beer, wine or liquor in the past month, that is, since [date 1 month before the interview date]?” From 1989 through 1992, respondents were asked about “any beer, wine, wine coolers, cocktails, or liquor.” From 1993 on, respondents were asked: “During the past month, have you had at least 1 drink of any alcoholic beverage, such as beer, wine, wine coolers, or liquor?” Similar changes were made to the question on binge drinking. From 1985 to 1988, the question was as follows: “Considering all types of alcoholic beverages, that is, beer, wine, and liquor, as drinks, how many times during the past month did you have 5 or more drinks on an occasion?” From 1989 through 1992, two additional beverage-specific examples, wine coolers and cocktails, were included. Finally, from 1993 on, respondents were asked, “considering all types of alcoholic beverages, how many times during the past month did you have ⱖ5 drinks on an occasion?” Current drinkers were defined as those who reported drinking any alcohol in the previous month, and binge drinkers were those who reported consuming ⱖ5 drinks on at least one occasion in the previous month. Trends in alcohol in the 19 study states that participated in the Behavioral Risk Factor Surveillance System from 1985 to 1999 were compared with trends in the 26 additional states that participated from 1990 forward. This comparison allowed assessment of whether trends in alcohol consumption were different in the 19 study states relative to these other 26 states. To exclude the possibility that demographic changes accounted for the vari-
ation in alcohol consumption, age-, gender-, and race-standardized rates were computed. Although the standardized rates were slightly lower than the unadjusted rates, similar patterns of alcohol consumption were observed over time. Therefore, only the unadjusted estimates were reported. SUDAAN was used in all analyses (Research Triangle Institute, Research Triangle Park NC, 1997). Because of the large sample size, statistical significance was set at p⬍0.01.
Results Of the 461,003 persons who completed BRFSS interviews in 1985–1999, the excluded totaled 11,893, including those missing sociodemographic data (n⫽2461) and those who did not answer questions on alcohol intake (n⫽9570). Some persons were excluded for more than one cause. The final sample size was 449,110. For analyses of binge drinking, an additional 2046 persons were excluded due to missing data on this variable. For the entire survey period, 47.4% of the respondents were men. Respondents were predominantly white (81.9%); 29.7% were aged ⱖ 55 years, and 22.5% were college graduates. From 1985 to 1999, the prevalence of current alcohol use dropped from 54.9% to 47.6%, a decline of 7.3 percentage points. This prevalence declined significantly across most age, gender, race/ethnicity, and educational categories (Table 1). The decline in prevalence was inversely associated with age, with the greatest declines (in percentage points) observed among those aged 18 –20 years (12.6%) and among those with some college education (12.3%). Within the 18- to 20-year age group, women experienced a greater decline (17.5%) than did men (9.3%). However, because of the large standard errors, the change in the prevalence was not significantly different between any of the age groups. Among all age groups, the prevalence of current alcohol use declined during the last half of the 1980s, leveled off during most of the 1990s, and increased or remained the same between 1997 and 1999. The most notable decline in alcohol use during the last half of the 1980s was among 18- to 20-year-olds (16.5 percentage points). Conversely, respondents in this age group had the largest increase in current alcohol use between 1997 and 1999 (7.3 percentage points). During all survey years, the prevalence of current alcohol use increased with education and was higher in men than women and in those aged 21–25 years, compared with other age groups. With the exception of one survey year (1987), prevalence was higher in nonHispanic whites than other racial ethnic groups. From 1985 to 1999, the prevalence of binge drinking dropped from 16.9% to 13.6%, respectively (Table 1). The greatest declines (in percentage points) were observed among persons aged 18 –20 years (7.3%), those with some college education (6.1%), and males Am J Prev Med 2004;26(4)
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Table 1. Prevalence (%) of current alcohol use and binge drinkinga; Behavioral Risk Factor Surveillance System, 1985–1999 Current alcohol use
Parameter Total Gender Male Female Age group, years 18–20 21–25 26–34 35–54 55⫹ Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Other Education ⬍High school High school Some college College graduate
Binge drinking
1985 nⴝ 21,969
1991 nⴝ 36,051
1999 nⴝ 58,197
1991 nⴝ 35,910
1999 nⴝ 57,976
Change 1985–1999
54.9 (0.6)
44.4 (0.4)
47.6 (0.4)
ⴚ7.3 (0.7)* 16.9 (0.4)
11.7 (0.3)
13.6 (0.3)
ⴚ3.3 (0.5)*
63.7 (0.8) 47.0 (0.7)
52.9 (0.6) 36.7 (0.5)
56.3 (0.6) 39.8 (0.4)
ⴚ7.4 (1.0)* 26.3 (0.8) ⴚ7.2 (0.9)* 8.6 (0.4)
18.2 (0.5) 5.8 (0.3)
21.4 (0.5) 6.6 (0.2)
ⴚ4.9 (0.9)* ⴚ2.0 (0.5)*
59.1 (2.2) 70.3 (1.4) 64.8 (1.0) 55.9 (0.9) 39.5 (1.0)
40.0 (1.9) 56.0 (1.4) 54.1 (0.9) 46.2 (0.7) 32.4 (0.7)
46.5 (2.1) 60.4 (1.3) 54.3 (0.8) 50.9 (0.6) 36.3 (0.6)
ⴚ12.6 (3.0)* ⴚ9.9 (1.9)* ⴚ10.5 (1.3)* ⴚ5.0 (1.1)* ⫺3.1 (1.1)
31.4 (2.3) 33.6 (1.6) 22.7 (0.9) 14.2 (0.7) 5.0 (0.5)
19.1 (1.8) 23.8 (1.2) 18.0 (0.7) 9.9 (0.4) 3.6 (0.3)
24.1 (1.9) 30.3 (1.3) 19.6 (0.7) 13.4 (0.4) 4.1 (0.3)
⫺7.3 (3.0) ⫺3.3 (2.0) ⫺3.1 (1.1) ⫺0.8 (0.8) ⫺0.9 (0.6)
56.0 (0.6) 47.7 (1.8) 51.3 (2.8) 51.6 (4.4)
46.4 (0.5) 33.7 (1.3) 38.5 (1.9) 39.6 (3.2)
50.0 (0.4) 36.8 (1.1) 39.6 (1.5) 45.7 (2.5)
ⴚ6.0 (0.7)* ⴚ10.9 (2.1)* ⴚ11.7 (3.2)* ⫺5.9 (5.0)
17.6 (0.5) 10.3 (1.1) 18.3 (2.2) 17.7 (3.5)
12.3 (0.3) 7.2 (0.7) 11.3 (1.1) 9.3 (1.7)
14.4 (0.3) 8.1 (0.6) 13.6 (1.1) 12.4 (1.7)
ⴚ3.2 (0.6)* ⫺2.1 (1.3) ⫺4.7 (2.5) ⫺5.4 (3.9)
34.0 (1.1) 52.5 (0.9) 63.4 (1.0) 70.8 (1.1)
24.9 (0.9) 40.0 (0.7) 51.5 (0.8) 57.6 (0.8)
25.9 (0.9) 43.3 (0.6) 51.2 (0.7) 60.9 (0.7)
ⴚ8.1 (1.5)* ⴚ9.2 (1.1)* ⴚ12.3 (1.2)* ⴚ9.8 (1.3)*
10.3 (0.8) 17.7 (0.7) 21.5 (1.0) 17.0 (0.9)
7.2 (0.5) 11.5 (0.4) 15.4 (0.6) 10.8 (0.5)
9.5 (0.6) 13.5 (0.5) 15.5 (0.5) 14.0 (0.5)
⫺0.8 (1.0) ⴚ4.2 (0.9)* ⴚ6.1 (1.1)* ⫺3.0 (1.0)
Change 1985–1999
1985 nⴝ 21,821
Current alcohol use is defined as ⱖ1 drinks in the past month and binge drinking is defined as ⱖ5 drinks on at least one occasion in the past month. *Significant t test for change (p ⬍ 0.01).
a
(4.9%). Of the remaining population subgroups examined, most showed small or statistically nonsignificant declines. Among those aged 18 –20 years, males and females experienced a similar decline (6.7% and 9.6%, respectively). However, because of large standard errors, the change in the prevalence was not significantly different between any of the age groups. During the last half of the 1980s, prevalence of binge drinking declined across all age groups; the largest declines (in percentage points) were observed among those aged 18 –20 (12.3%) and 21–25 years (6.2%). However, respondents in both age groups reported substantial increases in binge drinking rates from 1997 to 1999 (8.3 percentage points for those aged 18 –20 years, 7.6 percentage points for those aged 21–25 years). During all survey years, the prevalence of binge drinking was higher in men than women, those 21–25 years compared with other age groups, nonblacks compared with blacks, and high school graduates compared with nongraduates. Despite the overall declines in current alcohol use and binge drinking, there was little change in the proportion of binge drinking among current drinkers from 1985 through 1997. However, from 1997 to 1999, this proportion increased for all age groups, with the largest increases occurring among those 18 –20 years (41.0% to 52.1%) and 21–25 years (40.5% to 50.3%). Throughout the survey period, the ratio of binge drinkers to current drinkers was inversely related to age, with the highest ratios consistently observed 296
among youth and young adults (aged 18 –20 years and 21–25 years). Prevalence estimates for current drinking and binge drinking were consistently lower in the 19 study states relative to the other 26 states that participated in the system from 1990 to 1999. However, similar to the 19 study states, there was very little change in the rates of current drinking and binge drinking in these 26 states during the 1990s. From 1990 to 1999, the prevalence of current alcohol use in these 26 states went from 50.1% to 54.5%, and the prevalence of binge drinking went from 16.5% to 15.3%. Furthermore, from 1990 to 1999, the proportion of binge drinking among current drinkers was very similar. In the 19 states, these proportions were 30.2% and 28.8%, respectively. In the 26 states, these proportions were 33.3% and 28.3%, respectively.
Discussion In the 19 states that participated in the Behavioral Risk Factor Surveillance System from 1985 to 1999, the prevalence of current alcohol use and binge drinking declined during the last half of the 1980s and leveled off during the first half of the 1990s. Overall, declines occurred in all age groups, but the greatest decline for both current alcohol use and binge drinking was observed among 18- to 20-year-olds. Unfortunately, from 1997 to 1999, the 18- to 25-year-old age group experienced a substantial increase in both current alcohol use and binge alcohol use. Whether this recent increase
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represents a trend will need to be explored in future years and confirmed by other surveys. Furthermore, despite overall declines in current and binge alcohol use, the proportion of current users who binged changed very little from 1985 through 1999, with the highest proportions consistently observed among youth (18 –20 years) and young adults (21–25 years). Although the BRFSS does not collect information on state alcohol policies, it could be speculated that these declines were likely due, at least in part, to increasing the minimum drinking age to 21 years in all states by 1988 and enacting “zero tolerance” laws, which lower the legal blood alcohol concentration for underage drivers. Even so, after 1990, alcohol consumption remained common among 18- to 20-year-olds, with 47% reporting current use and 24% binge use in the past month in 1999. These results were generally consistent with findings from national surveys. The National Household Survey on Drug Abuse, an annual survey of persons aged 12 years and older, showed a decline of 11 percentage points in the prevalence of alcohol use in the past month, from 63% in 1979 to 52% in 1998, with most of the decline occurring before 1988, after which there was no significant change.9 In this same survey, pastmonth binge drinking declined from 20% in 1985 to 16% in 1998, but again with no significant change after 1988.9,10 The National Alcohol Survey, a household survey of adults 18 years and older, showed a decline of 4 percentage points in drinking during the past year, from 69% in 1984 to 65% in both 1990 and 1995, whereas past-year binge drinking declined modestly from 30% in 1984, to 29% in 1990, and to 28% in 1995.11 The Monitoring the Future Survey, an annual national survey of adolescents and young adults, showed that the prevalence of past-month alcohol consumption in the 19 –20-year group declined from 73% in 1985 to 61% in 1992, after which consumption remained level.12 The 2-week prevalence of binge drinking declined from 41% in 1985 to 32% in 1995, and then rose to 35% in 2000. The Harvard School of Public Health College Alcohol Study showed a decline in the prevalence of pastyear alcohol consumption among college students from 85% in 1993 to 81% in 1999.13 Although the 2-week prevalence of any binge drinking (ⱖ5 drinks in a row for men, ⱖ4 drinks in a row for women) remained the same (44%), frequent binge drinking (ⱖ 3 times in a 2-week period) increased from 19.8% to 22.7%.13 In contrast to national survey data, apparent per capita alcohol consumption derived from sales data declined substantially during both the 1980s and the first half of the 1990s and then showed small annual increases during 1996, 1997, and 1998 (0.9%, 0.5%, 0.4% increase, respectively).14,15
Although the authors were unable to specifically assess the reason for the apparent increase in both current and binge drinking in the late 1990s, this was most likely due to a combination of environmental factors, including increased alcohol beverage marketing, as well as decreases in the real-dollar cost of alcoholic beverages— caused, at least in part, by declines in inflation-adjusted alcohol excise taxes in most states since the late 1960s. Alcohol use is also known to be influenced by a variety of other factors, including religious beliefs and country of origin. However, it is unclear what role, if any, state-level changes in these demographic characteristics might have had on the prevalence of current and binge alcohol use during our study period. Results from the 19 states in the current study could not be generalized to all 50 states. Compared with the other 26 states that participated in the system from 1990 through 1999, the prevalence estimates for current drinking and binge drinking were consistently lower in the 19 study states. However, similar to the case in the other 26 states, there was little change in the rates of current drinking and binge drinking during the first half of the 1990s. There was also essentially no change in the proportion of binge drinking among current drinkers in these two groups of states. This suggests that the trends observed from 1985 through 1999 in these 19 states from 1985 were probably not significantly influenced by differences in state characteristics. The current study had several other limitations. First, estimates of alcohol use were based on self-reports, which are known to underestimate actual consumption; compared with sales data, for example, self-reported intakes are consistently lower.16 Second, binge drinking was defined as ⱖ5 drinks per occasion for both genders. Although this definition is in general use, it may underestimate binge drinking for women because of their lower body weight and differences in the way women metabolize alcohol.17 Third, the format of the alcohol questions changed in 1989 and again in 1993. However, most of these changes were relatively minor, and only small changes were seen in the prevalence of current and binge alcohol before and after the questionnaire changed. For example, in 1988 and 1989, the prevalence of current alcohol use was 51.1% and 47.7%, respectively; the prevalence of binge alcohol use was 14.8% and 13.5%, and the proportion of binge drinking among current drinkers was 29.2% and 28.4%. In 1992 and 1993, the prevalence of current alcohol use was 45.6% and 48.5%, respectively; the prevalence of binge alcohol use was 12.4% and 13.1%, and the proportion of binge drinking among drinkers was 27.2% and 27.1%. In addition, as discussed above, the pattern of change observed— declining use during the last half of the 1980s and leveling off during the first half of the 1990s—is consistent with those reported in Am J Prev Med 2004;26(4)
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national surveys.9 –12 Fourth, the Behavioral Risk Factor Surveillance System does not include those living in households without telephones or include persons living in various public and private institutions, such as college students living in fraternities or sororities, who may have a higher prevalence of binge drinking.13 There are a variety of strategies to reduce underage and binge drinking, including environmental, policy, pricing, and clinical interventions, that have been shown to work. Effective environmental and policy interventions include strict enforcement of the age-21 minimum for drinking and zero-tolerance laws for underage youth. Additionally, communities and retail alcohol outlets can work together to implement strategies to reduce high-risk or binge drinking, including server training.18 A recent study found that communities can achieve significant reductions in binge drinking and alcohol-related outcomes (e.g., alcohol-related motor vehicle crashes) by implementing comprehensive programs that combine one or more of these intervention strategies.19 In addition, given the price elasticity of demand for alcohol products, raising taxes on alcoholic beverages has been shown to reduce the amount of alcohol consumed per drinking occasion. A recent review of the effect of price on alcohol consumption indicates that tax increases may be a particularly promising strategy for reducing alcohol abuse and alcohol-related health effects among youth and young adults.20 Finally, health professionals should routinely screen patients for alcohol problems, providing those who “screen positive” with brief counseling or referring them to a specialized treatment program, depending on the severity of their problem.21 A recent study found that counseling adolescents on alcohol and drug abstinence and screening adults for problem drinking were among the most valuable clinical preventive services.22 Through this combination of interventions, the prevalence of underage drinking and binge drinking may be further reduced, along with the many public health problems associated with them. We acknowledge the state BRFSS coordinators whose cooperation made this work possible.
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