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© 2004 American Public Health Association
RESEARCH AND PRACTICE |
David E. Nelson is with the Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Ga. Timothy S. Naimi, Robert D. Brewer, and Julie Bolen are with the Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion. Henry E. Wells is with Research Triangle Institute, Atlanta, Ga.
Correspondence: Requests for reprints should be sent to David E. Nelson, MD, MPH, Centers for Disease Control and Prevention, 4770 Buford Hwy, NE, Mail Stop K-50, Atlanta, GA 30341 (e-mail: den2{at}cdc.gov).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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Objectives. We estimated adult binge drinking prevalence in US metropolitan areas.
Methods. We analyzed 1997 and 1999 Behavioral Risk Factor Surveillance System data for 120 metropolitan areas in 48 states and the District of Columbia.
Results. The prevalence of binge drinking varied substantially across metropolitan areas, from 4.1% in Chattanooga, Tenn, to 23.9% in San Antonio, Tex, (median = 14.5%). Seventeen of the 20 metropolitan areas with the highest estimates were located in the upper Midwest, Texas, and Nevada. In 13 of these areas, at least one third of persons aged 18 to 34 years were binge drinkers. There were significant intrastate differences for binge drinking among metropolitan areas in New York, Tennessee, and Utah.
Conclusions. Metropolitan-area estimates can be used to guide local efforts to reduce binge drinking.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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Alcohol use results in approximately 100 000 deaths each year in the United States, which makes it the third leading cause of preventable death in the country.1 Binge drinking is an especially hazardous pattern of alcohol consumption that causes a substantial proportion of alcohol-related deaths.2–5 Adverse effects of binge drinking include intentional injuries (e.g., interpersonal violence and suicide), unintentional injuries (e.g., motor vehicle crashes and drownings), fetal alcohol syndrome/effect, and unintended pregnancy.6–8
Binge drinking most commonly occurs among males, younger persons, and persons residing in urban or suburban areas,9,10 and the occurrence is generally higher in the Midwest, the Northeast, and the West.9–11 Recent studies have shown that binge drinking and its related health consequences have increased in the past few years,12–14 as binge drinking increased in 19 states while it declined in only 3 states from 1991 through 1999.13
Although national and state-based surveys obtain data on alcohol measures on a regular basis, there are only limited data about binge drinking at the local level. Independent surveys of adults in Los Angeles, Calif,15,16 and Harlem, NY,17 obtained selected data on alcohol use, and a few states have used the Behavioral Risk Factor Surveillance System (BRFSS) to generate health district or city estimates.18–21 The lack of local data is unfortunate. Local data can empower communities to address public health issues, to track progress toward Healthy People 2010 alcohol-related goals,22,23 and to improve planning and evaluation efforts to prevent alcohol abuse. However, because conducting surveys is time-consuming and expensive, most local health departments lack the resources to collect or analyze survey data.
We used reweighted BRFSS data24 to examine current alcohol use and binge drinking in 120 US metropolitan areas. The purposes of our study were to (1) estimate the prevalence of binge drinking in metropolitan areas, (2) determine if there were differences between metropolitan and statewide estimates of binge drinking, (3) assess intrastate differences in binge drinking for states with data from 2 or more metropolitan areas, (4) estimate the proportion of current drinkers who were binge drinkers by metropolitan area, and (5) identify the demographic subgroups within metropolitan areas that have the highest overall binge-drinking estimates and are at greatest risk for experiencing adverse effects from this type of alcohol use.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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Data were obtained from the BRFSS, a state-based system of adult health surveys coordinated by the Centers for Disease Control and Prevention.11,25 Health risk factor and preventive health services data were obtained through telephone surveys of randomly selected adults aged 18 years and older. Data were collected annually for some measures and biennially for others; questions on alcohol use were included in odd-numbered-year surveys during the 1990s.25 Current drinking was defined as consuming 1 or more alcoholic beverages in the past month; binge drinking was defined as consuming 5 or more alcoholic beverages on at least 1 occasion in the past month, which was determined by the question, "Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?"
We analyzed data from 1997 and 1999, the most recent years with available metropolitan-level data on binge drinking. The overall sample size was 133 048 in 1997 and 159 921 in 1999; median state sample sizes were 2340 in 1997 (range = 1505 to 4923) and 2939 in 1999 (range = 1248 to 7543). Median state response rates, on the basis of persons actually reached by telephone, were 76.8% in 1997 and 68.4% in 1999, with individual state response rates ranging from 44.5% to 95.1%.
Self-reported county of residence was used to classify respondents as residents of metropolitan areas in accordance with standard census definitions.26 Response rates by metropolitan area were unavailable, as all rates were calculated by state. Metropolitan-level estimates are composed of groups of counties, oftentimes encompassing counties in more than one state. Metropolitan-level data were not merged with state data because the state data were weighted to state populations and metropolitan-level data were weighted to county populations. See Table 1
for metropolitan city designations.
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All analyses were conducted with SAS27 and SUDAAN28 software. To increase sample sizes and to improve the precision of estimates, we pooled 1997 and 1999 data and limited analyses to the 120 metropolitan areas with 400 or more respondents for both alcohol measures; sample sizes ranged from 404 to 6682. We used intercensal estimates to reweight data by the age, gender, and racial/ethnic distributions for each metropolitan area. Missing or unknown data were excluded from all calculations. Data were not age standardized, because we wanted to provide actual binge-drinking estimates for each area.
Metropolitan-level data were available from metropolitan areas in 48 states and the District of Columbia (data not available for Alaska and New Hampshire, where there were no metropolitan areas with sufficient sample sizes). To provide additional context, we pooled state estimates of binge drinking from 1997 and 1999. State estimates were based on data from all state respondents, including those living within metropolitan areas.
We grouped metropolitan areas by census region (Northeast, Midwest, South, and West) and by state, and we calculated regional and national median and range values. To determine the relationship between estimates of current drinking and binge drinking, we calculated the proportion of current drinkers who were binge drinkers for each metropolitan area. For the 20 metropolitan areas with the highest levels of binge drinking, we conducted analyses of binge-drinking estimates stratified by age (18–34 years and 
35 years), gender, race/ethnicity (White, Black, Hispanic, other), education level (
high school, > high school), and income (< $25 000, $25 000–$49 999, and $50,000). To improve precision, these analyses were conducted only for subpopulations with at least 50 respondents.
We used 2-sample t tests29 to assess whether differences between statewide and metropolitan estimates and differences between intrastate metropolitan-area estimates were statistically significant. For the 20 areas with the highest levels of binge drinking, we also used 2-sample t tests to examine differences in estimates by demographic groups within each metropolitan area. Because of the large number of comparisons, differences were considered statistically significant only when 99% confidence intervals (CI) for differences excluded the null value.
We used logistic regression analyses to examine the independent association of binge drinking with age, gender, education, or race/ethnicity (on the basis of odds ratios [OR] and 95% CI) for the 20 areas with the highest levels of binge drinking. Income was not included in these models because of collinearity with education.
We mapped binge-drinking estimates with ArcGIS 8.2 software (Environmental Research Systems, Inc, Redlands, Calif) for all 120 metropolitan areas, as well as by state, to better understand regional patterns.30 Cutpoints for metropolitan and state estimates were based on quartile ranges.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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Considerable variability was found in overall binge-drinking estimates by metropolitan area. The median metropolitan estimate was 14.5%, which ranged from 4.4% in Chattanooga Tenn, to 23.9% in San Antonio, Tex (Table 1
). Estimates were generally highest in the Midwest, intermediate in the West and the Northeast, and lowest in the South (Table 1 and Figure 1). However, substantial variation in binge drinking was found in all 4 regions that ranged from a 2-fold difference in the Northeast to a 5-fold difference in the South.
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State binge-drinking estimates ranged from 7.4% in Tennessee to 25.2% in Wisconsin (median = 14.8%) (Figure 2
) and were significantly different from metropolitan estimates in Montana, Tennessee, and Utah (data not shown). Three of 40 states—New York, Tennessee, and Utah—had statistically significant intrastate differences in binge drinking among metropolitan areas.
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Nationally, the proportion of current drinkers who were binge drinkers was 26.7%, which ranged from 16.9% in Chattanooga, Tenn, to 42.2% in Grand Forks, ND–Minn; regional median estimates ranged from a low of 23.6% in the Northeast to a high of 30.4% in the Midwest (data not shown). The geographic pattern for this measure was generally similar to the overall pattern for binge-drinking prevalence. However, Provo–Orem, Utah; Salt Lake City, Utah; and Johnson City–Kingsport–Bristol, Tenn–Va were in the lowest quartile for binge drinking and were in the highest quartile for the proportion of current drinkers who also were binge drinkers.
The 20 metropolitan areas with the highest binge-drinking estimates are shown in Table 2 and Figure 2. Twelve areas were in 7 states in the upper Midwest (Iowa, Michigan, Minnesota, Nebraska, North Dakota, South Dakota, and Wisconsin), 3 were in Texas, and 2 were in Nevada. Not surprisingly, there was a strong correlation between high statewide estimates and metropolitan areas with the highest levels of binge drinking.
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Binge drinking was significantly more common among persons aged 18 to 34 years than among those aged 35 years and older in 18 of the 20 metropolitan areas with the highest binge-drinking estimates. Among persons aged 18 to 34 years, estimates ranged from 28.8% in Fargo–Moorhead, Minn–ND, to 44.2% in Springfield, Mass (Table 2
); in 13 areas, at least one third of persons in this age group were binge drinkers. Among adults aged 35 years and older, binge-drinking estimates ranged from 9.5% in Springfield, Mass, to 18.3% in San Antonio, Tex. Men were statistically more likely to report binge drinking than were women in 18 of the 20 metropolitan areas with the highest overall estimates (Table 2). More than one third of men were binge drinkers in San Antonio, Tex; Milwaukee–Waukesha, Wis; and Grand Forks, ND–Minn. Comparisons of binge drinking by race/ethnicity were limited, because sample sizes were sufficient in only 4 metropolitan areas for Blacks and in only 7 areas for Hispanics. We found no significant differences in the prevalence of binge drinking by race/ethnicity in these areas (data not shown). Similarly, analyses of binge-drinking prevalence by education level for all 20 areas with the highest estimates revealed no significant differences (data not shown). With the exception of Burlington, Vt, where binge drinking was higher among persons who had income levels below $25 000 compared with those who had incomes above $50 000, there were no other significant differences in binge drinking by income level (data not shown).
Logistic regression models confirmed the strong association between age and gender with binge drinking for nearly all metropolitan areas (Table 3), with a median OR for persons aged 18 to 34 years of 3.76 (range = 1.80–8.21) relative to persons aged 35 years and older and with a median OR for men of 3.72 (range = 2.50–8.11) relative to women. Significantly higher odds ratios for binge drinking among younger adults were found in Springfield, Mass, and Spokane, Wash, compared with Austin–San Marcos, Tex. There were no significant differences in OR between metropolitan areas for binge drinking among men.
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In San Antonio, Tex; Sioux Falls, SD; Davenport–Moline–Rock Island, Iowa–Ill; and Spokane, Wash, there was some evidence that lower levels of education were associated with binge drinking, although 95% CIs were close to 1.00 in each area. No association was found between levels of education and binge drinking in the remaining areas. Logistic models confirmed the absence of an independent association between race/ethnicity and binge drinking in areas with 50 or more Black or Hispanic respondents (data not shown), because a significant difference was found only among blacks in Las Vegas, Nev (OR = 1.78; 95% CI = 1.03, 3.08).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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To our knowledge, this is the first study that comprehensively reports binge-drinking estimates for US metropolitan areas. We found that binge drinking was especially common in metropolitan areas located in the upper Midwest, Texas, and Nevada. The proportion of current drinkers who reported binge drinking exceeded 30% in many US metropolitan areas. Analyses of areas with the highest binge-drinking estimates showed that at least one third of persons aged 18 to 34 years in 13 metropolitan areas were binge drinkers, as were more than one third of men in San Antonio, Tex; Grand Forks, ND–Minn; and Milwaukee–Waukesha, Wis. In the 20 areas with the highest binge-drinking estimates, we found that age and gender were strongly and independently associated with binge drinking.
Our results indicate that metropolitan binge-drinking estimates vary across regions, within regions, and within individual states. Although there were few differences when we compared metropolitan estimates with their corresponding state estimates, our ability to detect such differences was limited, because state estimates were based on information provided by all respondents within states, which included persons within metropolitan areas. Future studies are needed that compare metropolitan and nonmetropolitan binge-drinking estimates within states.
Our results were consistent with nationally representative adult data from the National Household Survey on Drug Abuse (NHSDA), which demonstrated higher binge-drinking estimates among young adults, men, and residents in the upper Midwest, as well as the general lack of differences by educational level.9,10 In contrast to our findings, NHSDA data demonstrated that adult binge-drinking estimates were higher for Whites and Hispanics than for Blacks. Although we did not find similar racial/ethnic differences, we used only a limited number of metropolitan areas for such comparisons. Our metropolitan estimates for binge drinking were generally similar to previous BRFSS-developed estimates for metropolitan areas in Wisconsin, Idaho, and Massachusetts.18–21
There are several possible explanations for the substantial variation in binge drinking across metropolitan areas. Because binge drinking among adults varies inversely with age,6,9,10 metropolitan areas with younger populations are likely to have higher estimates. For example, several metropolitan areas with high binge-drinking estimates, such as Grand Forks, ND–Minn; Austin–San Marcos, Tex; Lincoln, Neb; and Burlington, Vt, have major state universities. However, the OR for binge drinking in Austin–San Marcos, Tex, was the lowest among all 20 areas in the 18- to 34-year age group, which suggests that factors besides age distribution may account for higher estimates in this metropolitan area.
Other factors also influence local alcohol estimates. Sociocultural norms, such as religious beliefs, are likely to be influential.6 For example, alcohol use is proscribed for Mormons, and many members of Southern Baptist churches abstain from alcohol. This may help to explain low binge-drinking estimates for metropolitan areas in Utah and in certain parts of the South. Country of origin, level of acculturation, alcohol availability, price, alcohol outlet density, and type and extent of alcohol-related legislation and level of enforcement (e.g., beverage service practices, drinking and driving laws) also may contribute to local variation of binge-drinking estimates.
Previous research suggests that there may be a distinct drinking culture, especially among males, in parts of the United States, where abstention rates are high and where alcohol is less widely available (so-called "dry" areas, e.g., parts of the South and the Rocky Mountain States) such that the proportion of current drinkers who binge drink in these areas may still be quite high.6,31,32 We found some evidence of this, especially in Tennessee and Utah metropolitan areas, but even so, the proportion of alcohol users who binge drink was typically highest in areas with the highest prevalence of current alcohol use.
Overall, the BRFSS provides an efficient way to perform alcohol-related surveillance at the metropolitan level, and the local variation found in our study demonstrates the importance of conducting local analyses on an ongoing basis. The BRFSS uses a standardized methodology, relies on an existing infrastructure, and requires no new data collection, which results in cost savings for local health departments. Furthermore, BRFSS data on alcohol consumption, including binge drinking, has been collected annually (rather than in odd years only) since 2001. The increasing focus on binge drinking as an important public health problem, coupled with the growing demand for state and local surveillance data, underscores the need to further develop the BRFSS as a vital component of the public health infrastructure in the United States.
Our study has several limitations. The results probably underestimate the extent of binge drinking6,33,34 with social desirability35 and possibly with noncoverage (younger persons are less likely to have household telephones36,37 and are more likely to drink alcohol9,10), which may have had some effect on our estimates.35 Survey interview mode effects can affect estimates, although a study that compared BRFSS binge-drinking estimates with household survey estimates in Michigan found little difference.38 Estimates for women may be conservative, because others have used "4 alcoholic beverages or more on 1 occasion in the past month" to define binge drinking for women.2
Differences by metropolitan area may be the result of variations in demographics other than age, race/ethnicity, and education, such as employment and social class. Furthermore, our estimates were for entire metropolitan areas, but binge drinking is likely to vary within individual areas as well (e.g., central cities vs suburbs). We were unable to assess response rates by metropolitan area, as all rates were calculated by state. Typical of other telephone surveys in the late 1990s, response rates declined over the study period, and the effect of this decline on our estimates is unknown.39,40 Because we pooled data, we could not examine trends between 1997 and 1999; nevertheless, in spite of pooling, the number of respondents was small for certain areas and subpopulations, which reduced the precision of some estimates.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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The adoption of public health measures is needed to address the problem of binge drinking. Effective measures include increasing alcohol excise taxes, enforcing the minimum drinking age, and developing comprehensive community-based programs that include education, enforcement, and community mobilization.41,42 In addition, clinicians should screen all adult and adolescent patients for alcohol abuse in accordance with recommendations by the US Preventive Services Task Force.43 Screening and brief intervention strategies for alcohol abuse, including binge drinking, are effective and can reduce costs in primary care settings.44,45 Through this combination of interventions, binge drinking and its attendant health and social consequences can be prevented.
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Acknowledgments |
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We thank the state Behavioral Risk Factor Surveillance System coordinators for their assistance with data collection. We also thank Paul Mowery, MS, and Glenn Laird, PhD, for their input on statistical analyses and Jim Holt for preparing the maps (Figures 1
and 2).
Human Participant Protection
No protocol or institutional review board approval was needed for this study, because data were collected anonymously (no individual identifiers) from a public health surveillance system in which adults voluntarily consented to telephone interviews.
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Footnotes |
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Contributors
D. E. Nelson, T. S. Naimi, R. D. Brewer, and J. Bolen conceived and designed the study, interpretated the data, and wrote the article. H. E. Wells conducted the data analyses.
Accepted for publication May 13, 2003.
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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