Introduction
Binge drinking, five or more drinks on an occasion for men and four or more for women, marks risky alcohol use. However, this dichotomous variable removes information about higher, more dangerous consumption. This paper examines predictors, consequences, and changes over a decade in drinking one to two times, two to three times, and three or more times standard gender-specific binge thresholds, labeled Levels I, II, and III.
Methods
In 2001–2002 and 2012–2013, respectively, 42,748 and 36,083 U.S. respondents aged ≥18 years were interviewed in person in cross-sectional waves of the National Epidemiologic Survey on Alcohol and Related Conditions (response rates, 81% and 61%). Respondents were asked their past-year maximum drink consumption per day, categorized as Levels I, II, or III. Predictors and whether Levels II and III were associated with more negative consequences were analyzed in 2012–2013 data.
Results
In 2001–2002, 23% of adults reported past-year binge drinking, with 15% peaking at Level I, 5% at Level II, and 3% at Level III. In 2012–2013, those percentages increased significantly to 33% binging, and 20%, 8%, and 5% binging at Levels I, II, and III, respectively. After adjusting for alcohol use disorder, the strongest predictor of Level I, II, and III binging, Level III versus I and non-binge drinkers had higher odds of past-year driving after drinking and, after drinking, experiencing physical fights, injuries, emergency department visits, arrests/detentions, and other legal problems.
Conclusions
Level II and III—relative to Level I—binging is associated with more negative alcohol consequences and may be increasing nationally. Research needs to explore prevention and counseling interventions.
Introduction
Alcohol remains the most commonly used intoxicant in the U.S. The 2012–2013 National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) indicates that, among 73% of adults aged ≥18 years who drank in the past year, 46% binged
1
(four or more drinks for women and five or more for men over 2 hours) at least once. Binging often produces blood alcohol concentrations (BACs) ≥0.08%, the legal definition of intoxication for individuals aged ≥21 years operating a motor vehicle.- Dawson D.A.
- Hingson R.W.
- Grant B.F.
Epidemiology of alcohol use, abuse and dependence.
in: Tsuang M. Tohen M. Jones P. Textbook in Psychiatric Epidemiology. 3rd ed. John Wiley & Sons,
Chichester, United Kingdom2011: 361-379https://doi.org/10.1002/9780470976739.ch21
2
Binge prevalence is a useful population index of dangerous alcohol consumption, but being dichotomous removes information regarding heavier, more dangerous drinking and assigns identical risk to all bingers regardless of how far they exceed the threshold.
3
, 4
A study5
of more than 10,000 college students found 49% of men and 30% of women drank two or more times the binge threshold (i.e., eight or more drinks for women and ten or more for men) in the previous 2 weeks. A national survey 30 years ago linked consuming five or more or eight or more drinks on an occasion with higher drinking problem scores.6
An analysis of the 2004–2005 NESARC suggests past-year consumption of ten or more versus five or more drinks per occasion was associated with driving after drinking too much (16% vs 8%) and placing oneself in risky situations after drinking (45% vs 30%).7
Another limitation of a single binge threshold is that overall binging prevalence could decline, while the prevalence of higher drinking levels stabilizes or increases. The Monitoring the Future (MTF) study, which tracks high school substance use nationally, found 10.5% of 12th graders consumed ten or more drinks and 5.6% consumed ≥15 drinks at least once in the past 2 weeks. From 2005 to 2011, the percentage who binged at five to nine and ten to 14 drinks declined but not the percentage consuming ≥15 drinks.
8
Binging three times the threshold (≥12 drinks for women or ≥15 drinks for men) is dangerous. A 135-pound female or a 160-pound male consuming these amounts over 4 hours on an empty stomach would reach BACs ≥0.30%. Even after a full meal, BACs would exceed 0.20% for men and 0.30% for women.
9
The odds of blackouts, failing to remember what transpired while drinking, are 50/50 at 0.22% BAC.10
One report11
found BACs averaged 0.36% among 693 people who died from alcohol poisoning. These potentially life-threatening consequences underscore the importance of characterizing the U.S. prevalence and frequency of binging at levels exceeding the threshold.Initial comparisons of the NESARC I and III surveys
12
, 13
indicated past-year drinking of five or more and ten or more drinks on an occasion increased from 31.0% and 11.5%, respectively, in 2001–2002 to 39.6% and 15.5% in 2012–2013.This paper analyzes binge drinking in the U.S. with a finer lens by examining drinking below the gender-specific binge thresholds and then one to two, two to three, and three or more times the thresholds, categorized, respectively, as Levels I, II, and III. For women, the levels correspond to one to three, four to seven, eight to 11, and ≥12 drinks on an occasion; for men, one to four, five to nine, ten to 14, and ≥15. Used in previous studies,
5
these levels capture BACs ranging from mild to potentially deadly intoxication. This study explores predictors of peak binge level prevalence and whether it changed from NESARC I−III. Consistent with problem behavior theory14
and prior research,6
the authors hypothesize that higher peak binge levels predict more negative alcohol-related consequences. Because previous reports suggest higher peak bingers binge more frequently5
and correlate with alcohol use disorder (AUD),15
the authors hypothesize that Level I, II, and III binging will be associated with AUD and that, after adjusting for meeting AUD criteria, Level II and III compared with Level I binging and non-binge drinking will predict experiencing more negative alcohol-related consequences.Methods
Two independent, cross-sectional, nationally representative surveys sponsored by the National Institute on Alcohol Abuse and Alcoholism of U.S. adults provided data: NESARC I (2001–2002; n=43,093; response rate, 81.0%)
16
and NESARC III (2012–2013; n=36,309; response rate, 61.1%).17
The Census Bureau (NESARC I) and Westat, Inc. (NESARC III) conducted fieldwork. Informed consent forms provided respondents written information about survey content, data uses, voluntary participation, and response confidentiality. Both research protocols received full ethical review and approval.The surveys’ identical eligibility criteria were U.S. adults aged ≥18 years living in households and non-institutional group quarters. Both surveys oversampled blacks and Hispanics; NESARC I oversampled adults aged 18–24 years and NESARC III Asians/Pacific Islanders. NESARC III permitted two respondents in minority households with four or more eligible respondents. NESARC I interviewed college students in on-campus residences, NESARC III in primary off-campus residences.
NESARC’s trained interviewers conducted in-home interviews. NESARC III but not I offered financial participation incentives.
16
, 17
Measures
Both surveys asked respondents who drank: (1) During the last year, what was the largest number of drinks that you drank in a single day? (2) About how often during the last year did you drink (this largest number of drinks) in a single day? and (3) About how old were you when you first started drinking, not counting tastes or sips of alcohol?
The NESARC III also asked respondents the age they first drank enough to feel intoxicated (your speech was slurred, you felt unsteady on your feet, or you had blurred vision). Both surveys asked respondents if, in the last year, they: (1) drove a motor vehicle while drinking; (2) drove a motor vehicle after drinking too much; (3) had a motor vehicle accident under alcohol’s influence; and after drinking; (4) drove a motor vehicle and injured themselves or someone else in an accident; (5) got into physical fights; (6) accidentally injured themselves or someone else other than in a motor vehicle accident, like a bad fall or cut; and (7) got arrested/detained or had other legal problems.
Survey questions gauged past-year AUD at severe (six or more symptoms), moderate (four to five), or mild (two to three) levels and whether that year respondents went anywhere or saw someone for drinking-related reasons—a physician, counselor, Alcoholics Anonymous, or other community agency, including family social services, alcohol or drug detoxification centers, inpatient hospital wards, community mental health centers, halfway houses, crisis centers, religious counselors (e.g., priests or rabbis), psychologists, or other professionals. Respondents were specifically asked about alcohol-related hospitalizations and emergency department (ED) visits.
Finally, NESARC explored respondent demographics, past-year health status, depression symptoms, job loss, moves, number of children, and lifetime drug and smoking history.
Statistical Analysis
Statistical analyses were performed using SUDAAN, version 11.0 in 2015–2016 accounting for complex survey design to ensure accurate estimation. Chi-square analyses examined binge level changes from NESARC I−III for the entire samples and demographic and other subgroups. NESARC I−III data were also pooled in a multinomial logistic regression model adjusting for selected demographics and a wave indicator to see if binging at each level increased significantly from NESARC I−III.
Cross-tabulation and chi-square (an analogy of Pearson’s chi-square) analyzed significance of binge drinking differences in various demographic and substance use groups (Appendix Table 1, available online). Multinominal logistic regression with proportional-odds cumulative logit analyses identified independent, significant predictors of Level I, II, and III binging relative to non-binge drinking. Table 1 compares NESARC I and III on covariates and binge variables adjusted for in the regression analyses. The covariates were found either in previous research
18
, 19
, 20
, 21
, 22
, 23
, 24
, 25
, 26
, - Chen C.M.
- Slater M.E.
- Castle I.-J.P.
- Grant B.F.
Alcohol use and alcohol use disorders in the United States: main findings from the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III).
U.S. Alcohol Epidemiologic Data Reference Manual. Volume 10. National Institute on Alcohol Abuse and Alcoholism,
Bethesda, MD2016
27
or this study’s bivariate analyses to predict binge drinking. A similar regression examined predictors of meeting past-year AUD criteria, including the same covariates and binge drinking as predictors of meeting AUD criteria. Non-significant variables were dropped from the final model. ORs and 95% CIs were calculated. Wald F-tests assessed statistical significance.Table 1Comparison of NESARC I and III on the Distribution of Covariates Used in the Study
| Covariates | NESARC I, % (SE) (n=42,748) | NESARC III, % (SE) (n=36,083) | p-value of χ2 test |
|---|---|---|---|
| Age | <0.0001 | ||
| 18−20 years | 5.9 (0.18) | 5.1 (0.2) | |
| 21−25 years | 9.0 (0.18) | 9.6 (0.30) | |
| 26−30 years | 9.0 (0.25) | 8.8 (0.24) | |
| 31−35 years | 9.6 (0.18) | 8.3 (0.22) | |
| 36−40 years | 10.8 (0.19) | 8.4 (0.18) | |
| 41−50 years | 20.2 (0.27) | 18.2 (0.3) | |
| 51−60 years | 15.1 (0.2) | 18.0 (0.32) | |
| ≥61 years | 20.5 (0.38) | 23.6 (0.57) | |
| Sex | 0.7365 | ||
| Male | 47.9 (0.31) | 48.1 (0.4) | |
| Female | 52.1 (0.31) | 51.9 (0.4) | |
| Race/ethnicity | 0.076 | ||
| Black | 11.1 (0.71) | 11.8 (1.16) | |
| Native American | 2.1 (0.18) | 1.6 (0.15) | |
| Asian | 4.4 (0.55) | 5.7 (0.77) | |
| Hispanic | 11.6 (1.28) | 14.7 (1.43) | |
| White | 70.9 (1.68) | 66.2 (2.34) | |
| Marital status | <0.0001 | ||
| Never married | 17.5 (0.23) | 19.7 (0.39) | |
| Divorced/widowed/separated | 20.9 (0.49) | 22.5 (0.74) | |
| Married | 61.6 (0.49) | 57.8 (0.71) | |
| Employment status | <0.0001 | ||
| Unemployed | 7.5 (0.21) | 12.5 (0.44) | |
| Retired/homemaker | 22.8 (0.35) | 22.3 (0.51) | |
| Employed | 65.0 (0.44) | 58.5 (0.66) | |
| Student | 3.2 (0.17) | 1.5 (0.08) | |
| Other | 4.8 (0.28) | 1.9 (0.09) | |
| College enrollment | <0.0001 | ||
| Yes | 10 (0.23) | 14.2 (0.41) | |
| No | 90 (0.23) | 85.8 (0.41) | |
| Highest education | <0.0001 | ||
| <High school | 15.7 (0.52) | 13.0 (0.61) | |
| High school | 29.3 (0.62) | 25.8 (0.72) | |
| College | 43.3 (0.55) | 47 (0.64) | |
| Graduate degree | 11.7 (0.37) | 14.2 (0.61) | |
| Family income | <0.0001 | ||
| <$20,000 | 23.6 (0.52) | 22.8 (0.74) | |
| $20,000−49,999 | 36.3 (0.47) | 32.6 (0.58) | |
| $50,000−99,999 | 28.4 (0.43) | 27.1 (0.49) | |
| $100,000−149,999 | 7.6 (0.35) | 10.3 (0.46) | |
| $150,000−199,999 | 2.1 (0.14) | 3.8 (0.28) | |
| ≥$200,000 | 1.9 (0.14) | 3.4 (0.32) | |
| Health status | <0.0001 | ||
| Excellent | 30.5 (0.55) | 21.8 (0.58) | |
| Good/fair | 65 (0.5) | 74.1 (0.48) | |
| Poor | 4.4 (0.17) | 4.1 (0.24) | |
| Past-year felt depressed | 0.1416 | ||
| Most/all of the time | 6.2 (0.17) | 6.2 (0.23) | |
| Some/few times | 40.9 (0.42) | 42.2 (0.47) | |
| Never | 52.9 (0.44) | 51.6 (0.49) | |
| Past-year moved | <0.0001 | ||
| Yes | 16.5 (0.39) | 22.6 (0.5) | |
| No | 83.5 (0.39) | 77.4 (0.50) | |
| Past-year lost job | 0.1913 | ||
| Yes | 6.4 (0.18) | 6.7 (0.17) | |
| No | 93.6 (0.18) | 93.3 (0.17) | |
| Number of children | <0.0001 | ||
| 1 | 16.3 (0.26) | 14.8 (0.31) | |
| 2 | 14.3 (0.23) | 12.4 (0.27) | |
| 3 | 5.7 (0.18) | 5.2 (0.17) | |
| ≥4 | 2.6 (0.13) | 2.6 (0.12) | |
| 0 | 61.2 (0.49) | 65 (0.56) | |
| Lifetime smoking | 0.6516 | ||
| Current/past year | 27.7 (0.61) | 27.2 (0.8) | |
| Former | 19.2 (0.37) | 18.7 (0.47) | |
| Never | 53.1 (0.78) | 54.2 (1.03) | |
| Lifetime drug use | |||
| Current/past year | 6.2 (0.20) | 13.3 (0.46) | <0.0001 |
| Former | 16.6 (0.43) | 23.2 (0.58) | |
| Never | 77.2 (0.54) | 63.6 (0.83) | |
| Age first used drugs | <0.0001 | ||
| ≤13 years | 2.1 (0.11) | 4.6 (0.19) | |
| 14−17 years | 9.8 (0.30) | 15.9 (0.46) | |
| 18−20 years | 6.2 (0.2) | 9.2 (0.29) | |
| 21−25 years | 2.5 (0.11) | 3.7 (0.13) | |
| 26−30 years | 0.8 (0.05) | 1.2 (0.07) | |
| ≥31 years | 1.2 (0.07) | 2.2 (0.13) | |
| Never | 77.3 (0.54) | 63.4 (0.83) | |
| Age of first drink | <0.0001 | ||
| ≤13 years | 3.8 (0.13) | 5.5 (0.18) | |
| 14−17 years | 23.7 (0.45) | 29.2 (0.61) | |
| 18−20 years | 30.3 (0.43) | 29.4 (0.44) | |
| 21−25 years | 18.6 (0.39) | 19.2 (0.33) | |
| 26−30 years | 3.0 (0.1) | 2.8 (0.13) | |
| ≥31 years | 2.9 (0.11) | 2.7 (0.13) | |
| Never | 17.6 (0.69) | 11.2 (0.61) | |
| Binge level | <0.0001 | ||
| Level III | 3.2 (0.15) | 4.9 (0.23) | |
| Level II | 5.3 (0.17) | 7.7 (0.23) | |
| Level I | 15.1 (0.34) | 20.0 (0.48) | |
| Drink no binge | 41.6 (0.55) | 39.9 (0.52) | |
| Abstain | 34.8 (0.71) | 27.5 (0.85) | |
| Frequency of peak binge drinking level | <0.0001 | ||
| Daily | 2.3 (0.09) | 1.3 (0.07) | |
| 1−4/week | 8.7 (0.20) | 9.0 (0.26) | |
| 1−3/month | 13.4 (0.26) | 14.0 (0.29) | |
| 1−11/year | 40.7 (0.59) | 48.3 (0.89) | |
| Abstain | 34.9 (0.71) | 27.4 (0.85) |
Note: Age first drunk was not asked in NESARC I. Boldface indicates statistical significance (p<0.05).
NESARC, National Epidemiologic Survey of Alcohol and Related Conditions.
Cross-tabulation with chi-square analysis also tested whether Level I, II, and III bingers were significantly more likely than abstainers and non-binge drinkers to receive counseling, visit an ED, be hospitalized for alcohol-related reasons, drive after any drinking and drinking too much, and, after drinking, be a driver in traffic crash, be in physical fights, get injured in traffic crashes or other ways, and be arrested/detained or have other legal problems.
Logistic regression analyses with complete case analysis examined whether, compared with non-binge drinkers, Level I, II, and III bingers experienced increased likelihoods of these outcomes, adjusting for meeting AUD criteria and select regression covariates. Strongest predictors were identified by comparing log-likelihood value of models in which predictors were entered. These analyses were repeated without AUD criteria as a covariate. Pairwise comparison was performed in each model with Bonferroni adjustment to control for overall Type 1 error.
Results
Table 1 compares NESARC I and III on analysis covariates. In NESARC I, in the past year, 35% abstained and 23% binged once or more: 15% at Level I, 5% at Level II, and 3% at Level III. In NESARC III, 28% abstained and 33% binged (20%, 8%, and 5% at Levels I, II, and III; all increases significant, p<0.001). In NESARC I, 15% of Level I and II and 18% of Level III bingers drank those amounts at least weekly, and 36%, 37%, and 35% monthly or more. NESARC III binge frequency declined slightly, with 12% of Level I and 16% of Levels II and III bingers consuming these amounts weekly, and 31%, 34%, and 35%, respectively, monthly or more (all differences, p<0.01).
No single demographic group accounted for most of binge Level I, II, and III increases from NESARC I-III. In some subgroups, changes were not significant. Increases were significant in all age groups except those aged 18–20 years. Both sexes, each racial/ethnic group, employed/unemployed, married, single, separated, and divorced people, those with and without children, college students, all income groups, smokers, nonsmokers, and drug and non-drug users all experienced significant increases (Appendix Tables 2A−C, available online). Multinomial logistic regression analyses adjusting for these characteristics indicated binging increased significantly from NESARC I-III (OR=1.5, 95% CI=1.43, 1.67; Wald F, p<0.0001).
Appendix Table 1 (available online) provides characteristics of NESARC III respondents significantly (p<0.001) associated with past-year binge levels.
Covariates identified in the Statistical Analysis section were entered into a logistic regression analysis with Level I, II, and III binging as the dependent variable. People aged 21–25 years, men, high school educated or less, childless, with earlier ages of first alcohol intoxication and drug use, past-year smoking and drug use, and, most strongly, AUD experiences all significantly, independently predicted higher-level binges. Blacks, Asians, graduate school educated, and homemakers or retired individuals were less likely to binge at these levels (Table 2).
Table 2Significant Predictors of Drinking at Levels I, II, and III among NESARC III Drinkers
a
(n=25,110)Outcome binge level is a four-level ordinal variable. Multinomial Logistic Regression with Proportional-Odds Cumulative Logit Model is fitted controlling for variables listed in the table plus non-significant variables, including college enrollment, family income, health status, past-year felt depressed, past-year moved, past-year lost job, lifetime drug use, and age of first drink.
| Predictors | AOR (95% CI) | p-value |
|---|---|---|
| Age | <0.0001 | |
| 18–20 years | 0.7 (0.5, 0.8) | |
| 21–25 years | 1.0 (1.0, 1.0) | |
| 26–30 years | 0.9 (0.8,1.1) | |
| 31–35 years | 0.8 (0.7, 0.9) | |
| 36–40 years | 0.7 (0.6, 0.8) | |
| 41–50 years | 0.6 (0.5, 0.7) | |
| 51–60 years | 0.3 (0.3, 0.4) | |
| ≥61 years | 0.2 (0.3, 0.3) | |
| Sex | <0.0001 | |
| Male | 1.4 (1.3, 1.5) | |
| Female | 1.0 (1.0, 1.0) | |
| Race/ethnicity | <0.0001 | |
| Black | 0.6 (0.5, 0.6) | |
| Native American | 1.2 (0.9, 1.5) | |
| Asian | 0.7 (0.6, 0.8) | |
| Hispanic | 1.2 (1.1, 1.4) | |
| White | 1.0 (1.0, 1.0) | |
| Marital status | 0.0025 | |
| Never married | 1.1 (0.95, 1.2) | |
| Divorced/widowed/separated | 1.1 (1.01, 1.3) | |
| Married | 1.0 (1.0, 1.0) | |
| Employment status | 0.0009 | |
| Unemployed | 0.9 (0.8, 1.0) | |
| Retired/homemaker | 0.8 (0.8, 0.9) | |
| Employed | 1.0 (1.0, 1.0) | |
| Student | 1.1 (0.9, 1.3) | |
| Other | 0.9 (0.7, 1.1) | |
| Highest education | <0.0001 | |
| <High school | 1.4 (1.3, 1.6) | |
| High school | 1.1 (1.1, 1.2) | |
| College | 1.0 (1.0, 1.0) | |
| Graduate degree | 0.8 (0.7, 0.9) | |
| Number of children | 0.0004 | |
| 1 | 0.8 (0.8, 0.9) | |
| 2 | 0.9 (0.8, 0.9) | |
| 3 | 0.8 (0.7, 0.96) | |
| ≥4 | 0.8 (0.6, 1.04) | |
| 0 | 1 (1.0, 1.0) | |
| Lifetime smoking | <0.0001 | |
| Current/past year | 1.8 (1.6, 1.9) | |
| Former | 1.1 (1.03, 1.3) | |
| Never | 1 (1.0, 1.0) | |
| Age first used drugs | <0.0001 | |
| ≤13 years | 1.4 (1.2, 1.7) | |
| 14–17 years | 1.3 (1.2, 1.6) | |
| 18–20 years | 1.3 (1.2, 1.5) | |
| 21–25 years | 1.2 (1.04, 1.5) | |
| 26–30 years | 1.1 (0.8, 1.4) | |
| ≥31 years | 0.9 (0.7, 1.3) | |
| Never | 1 (1.0, 1.0) | |
| Age first drunk | <0.0001 | |
| ≤13 years | 5.9 (4.7, 7.5) | |
| 14–17 years | 7.3 (6.4, 8.3) | |
| 18–20 years | 6.2 (5.4, 7.1) | |
| 21–25 years | 4.8 (4.2, 5.5) | |
| 26–30 years | 4.5 (3.6, 5.6) | |
| ≥31 years | 4.9 (3.9, 6.1) | |
| Never | 1 (1.0, 1.0) | |
| Past-year DSM-V AUD c Pairwise comparisons also shows that the odds of higher binge level significantly differ between all levels of AUD, p<0.05.AUD, alcohol use disorder; NESARC, National Epidemiologic Survey of Alcohol and Related Conditions. AUD, alcohol use disorder; NESARC, National Epidemiological Survey of Alcohol and Related Conditions. | <0.0001 | |
| Severe (≥6 symptoms) | 17.8 (15.2, 20.8) | |
| Moderate (4–5 symptoms) | 10 (8.5, 11.1) | |
| Mild (2–3 symptoms) | 6 (5.4, 6.6) | |
| No AUD | 1 (1.0, 1.0) |
Note: Boldface indicates statistical significance (p<0.05).
a Outcome binge level is a four-level ordinal variable. Multinomial Logistic Regression with Proportional-Odds Cumulative Logit Model is fitted controlling for variables listed in the table plus non-significant variables, including college enrollment, family income, health status, past-year felt depressed, past-year moved, past-year lost job, lifetime drug use, and age of first drink.
b Based on Wald F-tests, all predictors are significant at p<0.01.
c Pairwise comparisons also shows that the odds of higher binge level significantly differ between all levels of AUD, p<0.05.AUD, alcohol use disorder; NESARC, National Epidemiologic Survey of Alcohol and Related Conditions.AUD, alcohol use disorder; NESARC, National Epidemiological Survey of Alcohol and Related Conditions.
Logistic regression analyses adjusting for variables outlined in the Statistical Analysis section indicated the strongest predictor of meeting past-year AUD criteria was binging (Level III: OR=52.5, 95% CI=43.7, 63.2; Level II: OR=20.4, 95% CI=17.6, 23.6; Level I: OR=6.9, 95% CI=6.0, 8.0; non-binge drinkers: OR=1.0, 95% CI=1.0, 1.0) (Appendix Table 3, available online, lists all significant predictors). In turn, the strongest independent predictor of receiving alcohol-related counseling, ED visits, or hospitalizations was meeting AUD criteria (Table 3). Overall, 19% of drinkers met past-year AUD criteria. More (45%) reported one or more past-year binge episode. Among past-year bingers, 38% met past-year AUD criteria (24% at Level I, 51% Level II, and 74% Level III). Binging Levels I, II, and III each independently predicted past-year, alcohol-related ED visits (Table 3). Further, Level III and II versus Level I bingers significantly more often reported alcohol-related ED visits.
Table 3Seeking Counseling, ED Visits, and Being Hospitalized for an Alcohol-Related Problem Predicted by Binge Levels I, II, III and DSM-V AUD Level
a
Covariates used in modeling are age, sex, race/ethnicity, marital status, employment status, college enrollment, highest education, family income, health status, past-year felt depressed, past-year moved, past-year lost job, number of children, lifetime smoking, lifetime drug use, age first used drug, age first drink, age first drunk, binge level, past-year DSM-V alcohol use disorder, and frequency of peak binge drinking level.
| Binge/AUD levels | Alcohol counseling, OR (95% CI) (n=25,482) | p-value for pairwise comparison | ED visit, OR (95% CI) (n=25,545) | p-value for pairwise comparison | Hospitalization, OR (95% CI) (n=25,463) | p-value for pairwise comparison |
|---|---|---|---|---|---|---|
| Past-year DSM-V alcohol use disorder | ||||||
| Severe (≥6 symptoms) | 18.5 (13.2,25.9) | — | 36.6 (9.5, 140.6) | — | 27.9 (8.4, 92.6) | — |
| Moderate (4−5 symptoms) | 4.7 (3.2, 6.9) | — | 2.8 (0.5, 15.1) | — | 4.3 (1.1, 17.0) | — |
| Mild (2−3 symptoms) | 3.1 (2.1, 4.6) | — | 2.2 (0.4, 11.2) | — | 1.6 (0.4, 7.3) | — |
| No AUD | 1.0 (1.0, 1.0) | — | 1.0 (1.0, 1.0) | — | 1.0 (1.0, 1.0) | — |
| Binge | ||||||
| Level III | — | — | 9.9 (1.6, 61.7) | — | — | — |
| Level II | — | — | 13.1 (2.1, 82.5) | — | — | — |
| Level I | — | — | 5.1 (1.0, 26.9) | — | — | — |
| No binge | — | — | 1.0 (1.0, 1.0) | — | — | — |
| Past-year DSM-V alcohol use disorder | ||||||
| Severe vs moderate | 3.9 (2.8, 5.5) | <0.0001 | 13.1 (4.0, 43) | 0.0001 | 6.5 (2.5, 17.7) | 0.0002 |
| Severe vs mild | 6.0 (4.2, 8.5) | <0.0001 | 16.6 (6.1, 47) | <0.0001 | 17.4 (5.5, 55.2) | <0.0001 |
| Moderate vs mild | 1.5 (1.03, 2.2) | 0.0413 | 1.3 (0.3, 5.6) | 0.9016 | 2.7 (0.6, 11.7) | 0.1990 |
| Binge | ||||||
| Level III vs II | — | — | 0.8 (0.4, 1.5) | 0.7800 | — | — |
| Level III vs I | — | — | 1.9 (1.03, 5.0) | 0.0342 | — | — |
| Level II vs I | — | — | 2.6 (1.03, 6.4) | 0.0143 | — | — |
Note: Boldface indicates statistical significance (p<0.05).
a Covariates used in modeling are age, sex, race/ethnicity, marital status, employment status, college enrollment, highest education, family income, health status, past-year felt depressed, past-year moved, past-year lost job, number of children, lifetime smoking, lifetime drug use, age first used drug, age first drink, age first drunk, binge level, past-year DSM-V alcohol use disorder, and frequency of peak binge drinking level.
b Three outcome variables are dichotomous. Separate logistic regression models were fit for the three outcome measures respectively.
c Corresponding predictor is not statistically significant at p=0.05, comparison between levels were not performed, and the covariate was dropped from the final model.AUD, alcohol use disorder; ED, emergency department.
Given the strong correlation between AUD and Levels I, II, and III binging, when repeat regressions removed AUD as a covariate, compared with non-binge drinking, Levels I, II, and III binging most strongly, independently predicted past-year alcohol counseling (Level III: OR=7.4, 95% CI=4.7, 11.5; Level II: OR=4.0, 95% CI=2.6, 6.2; and Level I: OR=2.1, 95% CI=1.4, 3.1), ED visits (Level III: OR=93.1, 95% CI=23.4, 371.5; Level II: OR=70.2, 95% CI=18.2, 271.0; and Level I: OR=13.1, 95% CI=3.1, 55.0), or hospitalizations (Level III: OR=7.6, 95% CI=2.2, 25.8; Level II: OR=2.1, 95% CI=0.5, 8.1; Level I: OR=1.5, 95% CI=0.4, 5.5).
Table 4 displays drinking consequences significantly associated with Level I, II, and III binging and AUD after adjusting for all selected characteristics. Adjusting for AUD, Level I, II, and III binging compared with non-binge drinking all predicted higher odds of each consequence except driving under the influence accidents. Odds of having alcohol-related consequences increased with AUD severity. Further, Level III versus I bingers significantly more often drove after any drinking and drinking too much and, after drinking, were in physical fights, injured, arrested/detained, or had a legal problem. Level II versus I bingers were also significantly more likely to drive after drinking and drinking too much. In repeat regressions without AUD as a covariate, Level III binging, followed in order by Level II and I binging, most strongly predicted driving while drinking, driving under the influence accidents after drinking too much, and experiencing physical fights, injuries, arrests/detentions, and other legal problems after drinking (Appendix Table 4, available online, lists the results of this regression).
Table 4Six Adverse Consequences Predicted by Binge Levels I, II, III and DSM-V AUD Level
a
Covariates used in modeling are age, sex, race/ethnicity, marital status, employment status, college enrollment, highest education, family income, health status, past-year felt depressed, past-year moved, past-year lost job, number of children, lifetime smoking, lifetime drug use, age first used drug, age first drink, age first drunk, binge level, past-year DSM-V AUD, and frequency of peak binge drinking level.
| Adverse consequences | Drive after drinking (n=25,213) | Drive after drinking too much (n=25,147) | Driver in traffic crash (n=25,456) | In physical fight (n=25,447) | Injured (n=25,469) | Arrested or legal problem (n=25,459) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | |
| Past-year DSM-V AUD | ||||||||||||
| Severe (≥6 symptoms) | 23.2 (18.8, 28.9) | — | 24.8 (18.2, 32.4) | — | 31.1 (18.1, 53.3) | — | 60.7 (35.5, 103.8) | — | 29.6 (19.4, 45.3) | — | 18.2 (8.7, 38.1) | — |
| Moderate (4-5 symptoms) | 13.1 (10.4, 16.5) | — | 14.0 (10.5, 18.6) | — | 12.6 (6.9, 22.9) | — | 23.4 (13.7, 40.0) | — | 8.2 (4.9, 13.8) | — | 5.0 (2.4, 10.8) | — |
| Mild (2-3 symptoms) | 7.7 (6.4, 9.2) | — | 6.8 (5.2, 8.8) | — | 6.7 (4.0, 11.2) | — | 11.4 (6.7, 19.4) | — | 5.3 (3.2, 8.8) | — | 3.4 (1.4, 7.9) | — |
| No AUD | 1.0 (1.0, 1.0) | — | 1.0 (1.0, 1.0) | — | 1.0 (1.0, 1.0) | — | 1.0 (1.0, 1.0) | — | 1.0 (1.0, 1.0) | — | 1.0 (1.0, 1.0) | — |
| Binge level | ||||||||||||
| III | 3.6 (2.8, 4.7) | — | 5.2 (3.3, 8.1) | — | — | — | 2.9 (1.7, 5.0) | — | 7.0 (3.2, 15.3) | — | 6.1 (2.4, 15.9) | — |
| II | 3.4 (2.7, 4.3) | — | 5.0 (3.2, 7.7) | — | — | — | 1.9 (1.1, 3.3) | — | 4.3 (2.0, 9.2) | — | 3.6 (1.3, 10.2) | — |
| I | 2.7 (2.2, 3.5) | — | 4.0 (2.7, 5.8) | — | — | — | 1.8 (1.1, 2.9) | — | 3.8 (1.8, 7.9) | — | 3.1 (1.2, 8.0) | — |
| No binge | 1.0 (1.0, 1.0) | — | 1.0 (1.0, 1.0) | — | — | — | 1.0 (1.0, 1.0) | — | 1.0 (1.0, 1.0) | — | 1.0 (1.0, 1.0) | — |
| Past-year DSM-V AUD | ||||||||||||
| Severe vs moderate | 1.8 (1.4, 2.2) | <0.0001 | 1.8 (1.4, 2.2) | <0.0001 | 2.5 (1.6, 3.8) | 0.0001 | 2.6 (2.0, 3.3) | <0.0001 | 3.6 (2.6, 4.9) | <0.0001 | 3.6 (2.3, 5.6) | <0.0001 |
| Severe vs mild | 3.0 (2.5, 3.7) | <0.0001 | 3.6 (2.9, 4.4) | <0.0001 | 4.6 (3.0, 7.3) | <0.0001 | 5.3 (3.8, 7.4) | <0.0001 | 5.6 (4.0, 7.8) | <0.0001 | 5.3 (3.3, 8.7) | <0.0001 |
| Moderate vs mild | 1.7 (1.4, 2.1) | <0.0001 | 2.1 (1.7, 2.5) | <0.0001 | 1.9 (1.2, 3.2) | 0.0203 | 2.1 (1.5, 2.9) | <0.0001 | 1.5 (1.05, 2.3) | 0.0246 | 1.5 (0.8, 2.6) | 0.2259 |
| Binge level | ||||||||||||
| III vs II | 1.1 (0.9, 1.3) | 0.5172 | 1.0 (0.8, 1.3) | 0.7437 | — | — | 1.5 (1.1, 2.1) | 0.0047 | 1.6 (1.2, 2.2) | 0.0019 | 1.7 (1.1, 2.6) | 0.0012 |
| III vs I | 1.3 (1.1, 1.6) | 0.0308 | 1.3 (1.01, 1.7) | 0.0407 | — | — | 1.6 (1.6, 1.1) | 0.0045 | 1.8 (1.3, 2.5) | 0.0002 | 1.9 (1.3, 3.0) | <0.0001 |
| II vs I | 1.2 (1.1, 1.4) | 0.0451 | 1.2 (1.02, 1.6) | 0.0409 | — | — | 1.0 (0.7, 1.4) | 0.7987 | 1.1 (0.8, 1.6) | 0.4666 | 1.2 (0.7, 2.2) | 0.5593 |
Note: Boldface indicates statistical significance (p<0.05).
a Covariates used in modeling are age, sex, race/ethnicity, marital status, employment status, college enrollment, highest education, family income, health status, past-year felt depressed, past-year moved, past-year lost job, number of children, lifetime smoking, lifetime drug use, age first used drug, age first drink, age first drunk, binge level, past-year DSM-V AUD, and frequency of peak binge drinking level.
b Six outcome variables are dichotomous. Separate logistic regression models were fit for the six outcome measures, respectively.
c For pairwise comparison.
d Corresponding predictor is not statistically significant at p=0.05, comparison between levels were not performed, and the covariate was dropped from the final model.
e Simultaneously significant at p=0.05 with Bonferroni adjustment.AUD, alcohol use disorder.
Numerous other significant covariates predicted negative consequences after drinking, but their ORs were uniformly lower than odds predicted by Level I, II, and III binging (data available upon request).
Discussion
High-intensity binge drinking is prevalent in the U.S. In 2012–2013, 33% of those aged ≥18 years binged (20% peaking at Level I, 8% Level II, and 5% Level III). Approximately 12% who binged at Level I and 16% at Levels II and III drank at those levels at least weekly and approximately one third monthly or more. Consistent with other reports, Level I, II, and III binging was particularly common among young adults. MTF data
28
suggest 13% of college students consumed ten or more drinks in a row at least once in the prior 2 weeks and 5% consumed ≥15 drinks. Similarly, among non-college respondents, 12% had ten or more and 5% had ≥15. Another study18
reported 12.4% of adults aged 25–26 years consumed ten or more drinks once in the past 2 weeks.Level I, II, and III binging increased significantly from NESARC I-III, though binge frequency declined slightly. These increases were significant in most demographic subgroups, except those aged 18–20 years (below the legal drinking age). Previous studies of high school students, college students, and other young adults either found no changes or past-decade declines in high peak consumption levels.
28
, 29
MTF data from 2005–2010 and 2011–2015 suggest declines in young men’s past 2-week consumption of ten or more (23.8% to 18.3%) and ≥15 (10% to 7.8%) drinks. No significant changes were noted for women (6.8% to 6.9% for ten or more and 1.7% to 1.7% for ≥15). By contrast, NESARC I−III comparisons suggests an increase in past-year ten or more drinking for men aged 18–29 years from 33.9% to 38% and eight or more drinking for women from 14.7% to 22.1%.12
Possible differences in the patterns observed in MTF and NESARC resulted from MTF asking about high peak drinking in the previous 2 weeks, whereas NESARC asked about the past year. The increases in past-year Level I, II, and III binging among people aged ≥18 years in NESARC is consistent with U.S. per capita consumption increases over the past 15 years,30
and recent national increases in alcohol-related ED admissions.31
- Mullins P.M.
- Mazer-Amirshahi M.
- Pines J.M.
Alcohol-related visits to U.S. emergency departments, 2001–2011.
Alcohol Alcohol. 2016; https://doi.org/10.1093/alcalc/agw074
Binging at levels beyond the threshold raises concern because it increases risk of blackouts, overdoses, and other serious consequences. Also, high peak bingers more often consume drugs, which combined with alcohol, further heighten risk.
32
Level III bingers were more likely than Level I bingers to drive after drinking too much, and, after drinking, experience physical fights, injuries, arrests/detentions, and other legal problems. Level II versus I bingers were more likely to drive after any drinking and drinking too much.Level I, II, and III binging heightened the likelihood of meeting AUD criteria. Meeting AUD criteria most strongly predicted past-year alcohol-related counseling, ED visits, or hospitalizations. Level I, II, and III binging further predicted alcohol-related ED visits (Levels II and III versus Level I significantly more). Alcohol screening and brief counseling interventions for adult primary care are recommended.
33
, 34
, 35
Meeting AUD criteria triggers clinician willingness to treat or recommend alcohol treatment. However, many more drinkers binge than meet AUD criteria. Because, independent of meeting AUD criteria, Level I, II, and III binging predicts many behaviors placing individuals at risk of harming themselves or others, healthcare providers should consider questions about peak drinking levels when deciding whether further assessment or interventions are warranted.Consistent with the prevention paradox,
36
though higher percentages of Level III bingers experienced negative alcohol-related consequences, many more drinkers binged at Levels I and II. Consequently, Level I and II bingers experienced more occurrences of each explored negative alcohol-related consequence than Level III bingers. For example, 12% of Level III bingers experienced past-year injuries after drinking, compared with 5% and 2% of Level II and I bingers. However, 269 Level I and II bingers were injured compared to 221 Level III bingers. Level I and II bingers also accounted for more counseling episodes, ED visits, and hospitalizations than Level III bingers. Nonetheless, Level II and III bingers combined accounted for more negative consequences and counseling episodes than more numerous Level I bingers (data available upon request).Limitations
Reliance on self-report is a major limitation of this study. Some may be reluctant to report peak binging levels, and drinking-induced blackouts could reduce recall. Second, the survey did not ask whether alcohol-related consequences (e.g., traffic injuries) occurred on peak drinking days or the frequency of these consequences. Future studies should do so. Third, given the large sample size, often ORs close to 1 were significant but not very meaningful. Fourth, small data collection changes occurred between NESARC I and III, and NESARC III response rates were lower. NESARC III but not NESARC I college students were interviewed at home, possibly reducing reported binging at the three levels.
Despite survey design and data collection method differences, both samples are nationally representative. Some of the differences between the samples reflect population change. Post-survey weighting adjustment partially compensated for different non-response rates. However, differential non-response between the two surveys in some population and drinking level subgroups could have affected results. Finally, this analysis focused on national, cross-sectional surveys and acute consequences. Longitudinal studies of predictors and acute and chronic disease consequences of higher level binging are needed.
Conclusions
Findings suggest Level I, II, and III binging is prevalent and perhaps increasing. Level III versus I binging was significantly associated with more adverse health and social consequences, like alcohol-related ED visits, AUD, and, after drinking, experiencing fights, injuries, traffic crashes, arrests/detentions, and other legal problems. Level II versus I binging was associated with alcohol-related ED visits and driving after any drinking and drinking too much. Focusing simply on overall binge drinking prevalence obscures important information about higher, more dangerous Level II and III versus level I binging. There is a clear need to identify interventions to reduce such high-intensity drinking and related harms. Research is needed to determine whether questions about peak consumption levels are valuable in screening instruments and assess gender-specific risk factors for engaging in, and suffering consequences from, drinking at high peak levels.
Acknowledgments
The research presented in this paper is that of the authors and does not reflect the official policy of the National Institute on Alcohol Abuse and Alcoholism. Dr. Ralph Hingson is responsible for the design and conduct of the research; data analysis and interpretation; the drafting of the abstract, paper, and figures; and the coordination of the completion of the article. Dr. Wenxing Zha is responsible for drafting the methods section of the article, conduct of the statistical analyses, and interpretation of the results. Dr. Aaron White is responsible for aspects of the design of the research, the conception of some of the statistical analyses, the drafting of sections of the article, and overall editing of the article. Drs. Timothy Heeren, Boston University School of Public Health, and I-Jen Castle, CSR, Incorporated, offered useful recommendations during our revisions.
No financial disclosures were reported by the authors of this paper.
Appendix A. Supplementary material
Supplementary material
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