Binge Drinking --- United States, 2009

Dafna Kanny, PhD

Yong Liu, MS

Robert D. Brewer, MD

National Center for Chronic Disease Prevention and Health Promotion, CDC

Corresponding author: Dafna Kanny, PhD, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, 4770 Buford Highway, NE, MS K-67, Atlanta, GA 30341. Telephone: 770-488-5411; Fax: 770-488-5965; E-mail: dkk3@cdc.gov.

Excessive alcohol use is the third leading preventable cause of death in the United States (1) and was responsible for approximately 79,000 deaths and 2.3 million years of potential life lost (YPLL) in the United States each year during 2001--2005.* Binge drinking, defined as consuming four or more alcoholic drinks on one or more occasion for women and five or more drinks on one or more occasion for men, was responsible for more than half of these deaths and for two thirds of YPLL (2). More than half of alcohol consumed by adults in the United States is in the form of binge drinks (3). Healthy People 2010 (HP2010) (objective no. 26-11c) called for reducing the prevalence of binge drinking among adults (4). An overarching national health goal is to eliminate health disparities among different segments of the population.

To assess binge drinking by sex, age group, race/ethnicity, education level, income level, and disability status at the individual level, as well as geographic disparities in binge drinking at the state level, CDC analyzed data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) on binge drinking prevalence, frequency (i.e., the average number of binge drinking episodes), and intensity (i.e., the average largest number of drinks consumed by binge drinkers).

BRFSS is a state-based, random-digit--dialed telephone survey of the noninstitutionalized U.S. civilian population aged ≥18 years that is conducted monthly in all states and selected territories. BRFSS includes data regarding leading health conditions and health risk behaviors, including binge drinking. For this report, responses to questions regarding the prevalence, frequency, and largest number of drinks consumed by binge drinkers (a measure of the intensity of binge drinking) were analyzed, beginning with the question, "Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [X = 5 for men; X = 4 for women] or more drinks on an occasion?" Respondents then were asked, "During the past 30 days, what is the largest number of drinks you had on any occasion?" Responses to this question were assessed for binge drinkers only. After exclusion of persons who reported "don't know/not sure" or "refused" and those with missing information and respondents from the U.S territories, data from 408,845 respondents in the 50 states and the District of Columbia (DC) were used for analysis. Response rates for each state were calculated by using the Council of American Survey and Research Organizations (CASRO) guidelines. Response rates ranged from 37.9% (Oregon) to 66.9% (Nebraska) (median: 52.5%), and cooperation rates ranged from 55.5% (California) to 88.0% (Kentucky) (median: 75.0%).†

Binge drinking prevalence was calculated by dividing the total number of respondents who reported at least one binge drinking episode during the preceding 30 days by the total number of BRFSS respondents in all 50 states and DC. Frequency of binge drinking (i.e., the number of binge drinking episodes) was calculated by averaging the number of episodes reported by all binge drinkers during the preceding 30 days. Intensity of binge drinking was calculated by averaging the largest number of drinks consumed by binge drinkers during the past 30 days. All data were weighted to produce population-based estimates according to age-, race-, and sex-specific state population counts and to the respondent's probability of selection. Data were age- and sex-adjusted to the 2000 U.S. census standard population to provide estimates for race/ethnicity, education level, annual household income level, disability status, and state poverty level. Sexual orientation and racial/ethnic subgroups (e.g., the wide variation in the Hispanic population) were not assessed because this information is not collected in BRFSS. Two-tailed t-tests were used to determine differences between subgroups. Differences between prevalence estimates were considered statistically significant if the t-test p value was <0.05.

In 2009, the overall prevalence of binge drinking among adults in the 50 states and DC was 15.2% (Table 1). Binge drinking prevalence among men (20.8%) was two times higher than among women (10.0%). Men who reported binge drinking also reported a higher average number of binge drinking episodes during the preceding 30 days (4.6) than women (3.1) and the average largest number of drinks consumed (8.5 versus 5.7, respectively). Binge drinking prevalence decreased with increasing age, from 25.6% among respondents aged 18--24 years to 3.8% among respondents aged ≥65 years. However, binge drinkers aged ≥65 years reported the highest average number of binge drinking episodes during the preceding 30 days (5.4). The average largest number of drinks consumed by binge drinkers decreased with increasing age, from 9.1 among adults aged 18--24 years to 5.5 among those aged ≥65 years.

The age- and sex-adjusted prevalence of binge drinking among non-Hispanic whites (17.5%) was similar to the prevalence among American Indians/Alaska Natives (AI/ANs) (15.4%), but significantly higher (p<0.0001) than the prevalence for Hispanics (14.4%), non-Hispanic blacks (10.4%), and Asians/Native Hawaiians/Pacific Islanders (7.8%) (Table 2). Overall, the average number of binge drinking episodes was similar across racial/ethnic groups. However, the average largest number of drinks consumed by binge drinkers (8.4) was reported by AI/ANs.

Respondents who did not graduate from high school reported the lowest binge drinking prevalence (12.5%). However, non-high school graduates who reported binge drinking had the highest average frequency of binge drinking episodes (4.9) and the average largest number of drinks consumed (7.8). In contrast, binge drinking prevalence increased with income level and was highest among respondents with annual household incomes ≥$50,000 (18.5%). However, binge drinkers with household incomes ≥$50,000 reported a significantly lower average number of binge drinking episodes (3.6) and a lower average largest number of drinks consumed (6.5) than those with household incomes <$50,000. Respondents with disabilities had a significantly lower prevalence of binge drinking (14.3%) but a higher average frequency of binge drinking episodes (4.6) and average largest number of drinks consumed (7.2), compared with those without disabilities (Table 2). During 1993--2009, the greatest increase (p<0.0001) in the prevalence of binge drinking occurred among non-Hispanic whites (from 14.8% to 17.5%), college graduates (from 13.5% to 17.4%), and respondents with annual household incomes ≥$50,000 (from 13.4% to 18.5%). Binge drinking prevalence also was significantly higher (p<0.0001) in wealthier states (i.e., those with the lowest proportion of their population living below the federal poverty level) than in poorer states (17.6% and 13.9%, respectively) (Table 3).

Binge drinking is a risk factor for multiple adverse health and social outcomes, including unintentional injuries (e.g., motor-vehicle crashes), violence, suicide, hypertension, acute myocardial infarction, sexually transmitted diseases, unintended pregnancy, fetal alcohol syndrome, and sudden infant death syndrome (5). This report indicates that binge drinking is common among U.S. adults, especially among whites, males, persons aged 18--34 years, and those with household incomes ≥$50,000. These sociodemographic characteristics are in contrast with characteristics for other health risks (e.g., smoking and obesity), for which prevalence tends to be higher among racial/ethnic minorities and persons with lower education and income (6).

The findings in this report also highlight the need for assessing both the frequency and intensity of binge drinking among binge drinkers and the prevalence of binge drinking among the general population. These additional measures are important because the risk for adverse outcomes (e.g., alcoholic liver disease or traffic fatalities) increases with the frequency of binge drinking and with the amount consumed per binge drinking episode (7). Furthermore, reductions in the frequency and intensity of binge drinking might be expected to occur before reductions in binge drinking prevalence (7,8); thus, these measures serve as key indicators of progress toward achieving overall reductions in binge drinking.

One possible reason why binge drinking is more prevalent among whites and persons at higher income levels is that, unlike smoking, binge drinking has not been recognized widely as a health risk or subjected to intense prevention efforts (3). The differences in binge drinking among population groups also probably reflects cultural factors (9) and differences in state and local laws (10) that affect the price, availability, and marketing of alcoholic beverages.

The findings in this report are subject to at least four limitations. First, BRFSS data are self-reported; alcohol consumption generally, and excessive drinking in particular, are underreported in surveys because of recall bias and social desirability bias (11). A recent study reported that the BRFSS identifies only 22%--32% of presumed alcohol consumption in states on the basis of alcohol sales (12). Second, response rates for BRFSS were low, which increased the risk for response bias. Third, BRFSS does not collect information from persons living in institutional settings (e.g., on college campuses), and so data might not be representative of those populations. Fourth, BRFSS is conducted primarily by using landline telephones, and previous studies have indicated that an increasing proportion of youths and young adults aged 18--34 years use cellular phones exclusively and that the prevalence of binge drinking is approximately one third higher among cell phone users than among landline respondents to BRFSS (13). Therefore, binge drinking among persons in this age group is even more likely to be underestimated than in other age groups in BRFSS.

These findings support the need to implement such evidence-based population-level strategies to prevent binge drinking as those recommended by the Guide to Community Preventive Services (14): increasing alcohol excise taxes, regulating alcohol outlet density, and maintaining and enforcing age 21 years as the minimum legal drinking age. For example, a 10% increase in the price of alcoholic beverages as a result of an increase in alcohol excise taxes would be expected to reduce total alcohol consumption by 7%, and enhanced enforcement of the age 21 minimum legal drinking age could reduce retail sales to minors by 42%. Screening and counseling for alcohol misuse among adults, including binge drinking, also should be implemented as recommended by the U.S. Preventive Services Task Force (15). The frequency and intensity of binge drinking also should be monitored routinely to guide development and evaluation of culturally appropriate binge drinking prevention and intervention strategies for groups at greater risk.

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