Published online September 1, 2004
PEDIATRICS Vol. 114 No. 3 September 2004, pp. 714-719 (doi:10.1542/peds.2003-0864-L)
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Continuity of Binge and Harmful Drinking From Late Adolescence to Early Adulthood

Carolyn A. McCarty, PhD*,{ddagger},§, Beth E. Ebel, MD, MPH*,{ddagger}, Michelle M. Garrison, MPH*,{ddagger}, David L. DiGiuseppe, MSc{ddagger}, Dimitri A. Christakis, MD, MPH*,{ddagger} and Frederick P. Rivara, MD, MPH*,{ddagger},||

* Departments of Pediatrics
§ Psychology
|| Epidemiology
{ddagger} Child Health Institute, University of Washington, Seattle, Washington


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Objective. To test the hypothesis that late adolescent drinking behavior (ages 17–20) is associated with harmful and binge drinking in early adulthood (ages 30–31).

Methods. We used the National Longitudinal Survey of Youth (NLSY), a nationally representative longitudinal data set. We used harmful and binge drinking at ages 17 to 20 to predict harmful and binge drinking at ages 30 to 31, stratifying for gender and controlling for confounders.

Results. Data were available on harmful drinking at both the adolescent and the early adult age period for 3790 individuals and on binge drinking for 2387 individuals. Harmful drinking during adolescence was significantly associated with harmful drinking at ages 30 to 31 for men only. Among male adolescents, 14% of harmful drinkers continued harmful drinking at ages 30 to 31, compared with 4% of nonharmful drinkers who became harmful drinkers. In Poisson regression models, binge drinking during adolescence was associated with binge drinking at ages 30 to 31 for both men and women, generating relative risks of 2.3 (95% confidence interval: 1.8–3.0) and 3.0 (95% confidence interval: 2.4–4.8), respectively. Half of binge-drinking male adolescents and one third of binge-drinking female adolescents engaged in binge drinking into early adulthood, compared with 19% for non–binge-drinking male adolescents and 8% of non–binge-drinking female adolescents.

Conclusions. Problem drinking during adolescence is associated with problem drinking in early adulthood. Efforts to prevent and treat adolescent problem drinking could have an impact on the progression of alcohol-related disease.

Key Words: harmful drinking • binge drinking • alcohol use • prevention • adolescence

Abbreviations: NLSY79, National Longitudinal Survey of Youth 1979 • RR, relative risk • CI, confidence interval

Alcohol disorders are among the 3 most common psychiatric disorders, with estimates from the National Comorbidity Study suggesting a 14% lifetime prevalence of alcohol dependence and a 9.4% prevalence of alcohol abuse without dependence.1 The roots of harmful drinking frequently begin before youths reach the legal drinking age of 21. Alcohol use typically begins during adolescence, with median age of first alcohol use at 15.2 Many youths develop an early pattern of binge drinking, usually defined as drinking >5 or 6 drinks on 1 occasion.3 In a recent study, 31% of 12th graders and 40% of college students reported at least 1 episode of binge drinking during the previous 2 weeks.4 The use of alcohol typically accelerates in the late teens, peaks in the early 20s, and decreases in the late 20s, with a higher peak in consumption level for men than women.5,6 Nineteen to 20 is the median age of onset for alcohol-use disorders.7,8

Problem drinking during adolescence is concerning not only because of the immediate consequences (eg, motor vehicle crashes, contribution to other intentional and unintentional injury, risky sexual behavior, comorbid substance use, academic problems) but also because early drinking may lead to long-term alcohol problems.9 Early drinking has been associated with employment problems, other substance use, and criminal and violent behavior in young adulthood.10 Only 13% of young adolescents who abuse alcohol stop by age 17,11 and adolescent binge drinking is one of the strongest predictors of bingeing through the college years.12 Younger age at initiation of alcohol use and younger age at first intoxication are strong predictors of later alcohol abuse and are associated with higher risk of alcohol-related injuries.2,13,14 More than 40% of those who start drinking at age 14 or younger develop alcohol dependence, compared with 10% of those who begin drinking at age 20 or older.15 Harmful drinking during the college years has potential long-term ramifications, as it has been associated with alcohol-use disorders up to 10 years later.16

Alcohol research studies that begin in adolescence and follow participants through young adulthood hold promise toward understanding how alcohol problems develop over time.17 The most dramatic changes in drinking patterns consistently occur during young adulthood, with the emergence of greater stability in drinking levels and a concomitant decrease in alcohol problems for those older than 30 years.18 Thus, in assessing the long-term risks of adolescent drinking behavior, it is important to follow individuals into their early 30s.

Most studies have examined continuity in alcohol use over time by examining either quantity of alcohol use or binge drinking but have not examined both.19,20 We specifically wanted to test the extent to which harmful amounts of alcohol use and binge drinking among adolescents under the legal drinking age are associated with harmful and binge drinking later in adulthood. We hypothesized that there would be continuity in both harmful alcohol use and binge drinking from before age 21 into young adulthood. Using longitudinal data from a nationally representative sample, we calculated the relationship between harmful drinking and binge status at ages 17 to 20 with young adult drinking patterns at ages 30 to 31.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Data Source
Data for this study were drawn from the National Longitudinal Survey of Youth 1979 (NLSY79). The NLSY79, sponsored by the US Department of Labor, is a nationally representative sample of almost 12 700 individuals who were aged 14 to 22 years in 1979 and have been interviewed annually or biennially since.21 Blacks and Latinos were oversampled to provide statistical power for subgroup analyses, and population weights are used to draw valid national inferences. Data from the NLSY79 were accessed using the Center for Human Resource Research Database Investigator Software (The Ohio State University, Columbus, OH).

Our sample consisted of 2 nested analytic subsamples (Fig 1). The larger of the 2 contained information for 3790 respondents to the NLSY79 who had at least 1 survey measurement of harmful drinking status (explained in more detail below) between ages 17 and 20 years, at least 1 survey measurement of harmful drinking status between ages 30 and 31 years, and complete information on the covariates included in the models (explained below). The second subsample was a subset of the first, composed of 2387 individuals, representing respondents with at least 1 survey measurement of binge drinking status (defined below) between the ages 17 and 20 years, at least 1 survey measurement of binge drinking status between the ages of 30 and 31 years, and complete information on the covariates included in the models. The requirement of complete covariate data resulted in loss of ~3% of the data. For the determination of population estimates of drinking patterns over time, we required complete data only for drinking status (binge vs nonbinge, harmful vs nonharmful) during adolescence and drinking status during adulthood. Analyses were conducted separately for male and female individuals because of the gender differences that exist in alcohol use and alcohol disorders.


Figure 1
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  		Fig 1. Flowchart of study samples and exclusions. The eligible sample consisted of 4130 individuals who were interviewed at appropriate ages when drinking was assessed.

 
Drinking Variables
The definition of harmful drinking was >4 standard drinks per day for men and >2 standard drinks per day for women, based on respondents' reports of drinking in the past month. This categorization is based on collapsing the "heavy" and "harmful" drinking categories used by English and Holman22 and Ridolfo and Stevenson23 and is analogous to categories recommended by the World Health Organization.24 Binge drinking was defined as 6 or more drinks on at least 1 occasion in the last month for both men and women, consistent with NLSY protocol.25 For any respondent with >1 survey measurement during a given age period, the maximum reported drinking level was used as the measurement value for that period.

Covariates
Model covariates were chosen a priori on the basis of being clinically meaningful predictors of drinking behavior. Model covariates included race/ethnicity (Hispanic, black, Asian, Native American, white, or other), marijuana use, cigarette use, marital status (single vs married), and current enrollment in college (yes vs no). Marijuana and cigarette use was assessed in 1984, when respondents ranged in age from 19 to 23. Marital status of the respondent and current enrollment in college were based on the interview year for each respondent when they were closest to but still under the age of 21.

Modeling
The analysis consisted of calculating the weighted percentages of adolescents in each category of drinking status who became harmful or binge drinkers as adults (ages 30–31). We then developed 2 multivariate Poisson regression models, generating relative risks (RRs) with 95% confidence intervals (CIs). The first related binge-drinking status at ages 30 to 31 to binge drinking status at ages 17 to 20, controlling for the covariates; the second related harmful drinking status at ages 30 to 31 to harmful drinking status at ages 17 to 20, also adjusting for the covariates. Regressions incorporated the 1994 sampling weights for the respondents. All analyses were performed using Intercooled Stata 7.0 (Stata Corp, College Station, TX).


   RESULTS
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 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The eligible NLSY individual who were administered drinking questions at the appropriate ages represent 14 127 266 youths in 1974, whereas our harmful subsample represents 13 361 332 youths and our binge sample represents 8 460 454 youths. Approximately 50% of the youths were male, and 61% were white. The majority had used marijuana, and more than one third had smoked cigarettes. Approximately one quarter had an alcoholic parent, and one third were in college before age 21 (Table 1).


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  		TABLE 1. Demographic Characteristics of Sample Cohorts

 
Table 2 shows the proportion of harmful drinkers among male and female individuals. Twelve percent of male and 9% of female individuals reported harmful drinking in the assessment at ages 17 to 20. This decreased to 5% for men and 7% for women at ages 30 to 31 years. When comparing proportions of "harmful drinking" between genders, it is important to keep in mind that thresholds differed for male and female individuals. A large proportion of the harmful drinkers at ages 17 to 20 were also harmful drinkers at ages 30 to 31 (~14% male and female individuals; Table 3). By contrast, only 4% of male and 6% of female individuals who were nonharmful drinkers at ages 17 to 20 went on to become harmful drinkers at ages 30 to 31.


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  		TABLE 2. Prevalence of Harmful and Binge Drinking at Two Age Periods

 

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  		TABLE 3. Drinking Patterns From Adolescence (17–20 Years) Into Adulthood (30–31 Years), With 95% CIs

 
Male individuals were more likely than female individuals to have binge drinking at both age periods. Compared with the proportion of harmful drinkers, a much larger percentage of individuals qualified as binge drinkers (73% of male and 48% of female individuals at ages 18–20). The prevalence of binge drinking at ages 30 to 31 decreased compared with ages 17 to 20 (42% for male and 20% for female individuals). Fifty percent of male individuals who were binge drinkers at ages 17 to 20 were also binge drinkers at ages 30 to 31 (33% for females). Among individuals who were not binge drinkers at ages 17 to 20, 20% of male and 8% of female individuals became binge drinkers at ages 30 to 31.

We ran both multivariate models in the full sample to test for effect modification by gender. We found evidence for a significant difference between male and female individuals in the continuity of binge drinking (P < .001) but not harmful drinking (P = .95). In the multivariate models, harmful drinking at ages 17 to 20 was associated with an increased RR of harmful drinking at ages 30 to 31 for male individuals (2.71; 95% CI: 1.63–4.48) but did not reach significance for female individuals (1.43; 95% CI: 0.83–2.46; Table 4). Binge drinking at ages 17 to 20 increased the RR of binge drinking at ages 30 to 31 for both male (2.34; 95% CI: 1.81–3.04) and female individuals (3.38; 95% CI: 2.38–4.78). Marijuana use in adolescence was a predictor of harmful drinking in adulthood across genders and predicted binge drinking in adulthood for male individuals only. Cigarette use increased the risk of harmful and binge drinking for female individuals only, whereas being enrolled in college decreased the risk of binge and harmful drinking for male individuals only.


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  		TABLE 4. Multivariate Analysis of Risk for Harmful and Binge Drinking in Adulthood (30–31 Years): RRs (95% CI)

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
We found that problem drinking in adolescence predicted problem drinking in adulthood, particularly for binge drinking. For male individuals, drinking harmful quantities of alcohol during adolescence was a significant risk factor for harmful drinking during young adulthood. This was not the case for female individuals, although use of other substances (specifically marijuana and cigarettes) during adolescence was significant for the development of harmful drinking in adulthood. Binge drinking during adolescence was associated with binge drinking during young adulthood across both genders. These relationships held while controlling for potential confounding variables such as early cigarette use and college enrollment.

Most previous studies have had short follow-up, examining continuity only between adolescent and college-age drinking or college-age and young adulthood drinking. Bennett et al9 conducted one of the longer-term studies of alcohol use, following 3 cohorts of youths for 7 years. They found that most young adults displayed continuity in their drinking patterns over time, whether they were low, moderate, or problem users; however, those who matured out of problem drinking mostly did so during young adulthood (ages 21–28).

Harmful drinking and binge drinking both have important adverse effects on adolescents, including increasing their risk of injury, sexually transmitted disease, and dating violence.26–28 Approximately 65 000 deaths per year are attributed to alcohol.29 Harmful drinking increases the risk of chronic health conditions such as liver disease, heart disease, and cancer, and binge drinking increases the risk of motor vehicle crashes and other injuries.23 Both harmful and binge drinking are associated with increased risk of suicide and adverse psychosocial consequences.30

This study has some limitations that must be considered. The level of drinking that qualifies as "harmful" is not standardized in the literature on alcohol use, and using a fixed cutoff has some disadvantages. We chose a definition of harmful drinking to be consistent with previous work, but this definition does not necessarily endorse 4 drinks per day for men and 2 drinks per day for women as safe. Our definition of binge drinking (6 or more drinks on 1 occasion) is slightly more conservative than that used in other national surveys (typically 5 or more drinks on 1 occasion; some surveys use 4 or more for women). Other important limitations to consider in interpreting these findings include possible bias from loss to follow-up and the possibility that other confounding factors could underlie the continuity in drinking (eg, psychosocial risk). The data are based on self-report of drinking in the previous 30 days, which may not be indicative of drinking patterns throughout the year; however, self-report in general has been found to be reliable and is used in other surveys such as the Behavioral Risk Factor Survey. Finally, there may have been some misinterpretation of the Indian American or Native American self-categorization on the NLSY, as more respondents reported this ethnicity compared with 1979 Census estimates.31

Our study has important implications for adolescent medicine providers, mental health professionals, and others who serve adolescent health. The identification of problematic drinking behavior during adolescence is important not only because of the many short-term risks of injury and death associated with harmful drinking23,32 but also so that appropriate interventions can be delivered before those drinking habits become ingrained. Drinking >6 drinks at 1 sitting or drinking harmful levels of alcohol are not behaviors that youths necessarily outgrow. Other studies suggest that there is much less transitioning out of problem drinking after age 309,18; thus, we speculate that adolescents who binge drink and male individuals who drink >4 drinks per day on average may be at risk for lifelong problems. Pediatricians and adolescent medical providers need to communicate the potential long-term risks of adolescent binge and harmful drinking to their patients and parents, as many people assume that heavy drinking behavior can be normative and benign in adolescence. Second, they can refer those who are in need to interventions that have garnered empirical support, such as motivational interviewing and personal feedback,33 and can advocate for tax increases on alcohol and multimedia campaigns that seem to be effective interventions.34–36 Efforts to prevent and treat adolescent problem drinking are likely to have an impact on adult drinking patterns and therefore may have immediate as well as longstanding effects on public health.


   ACKNOWLEDGMENTS
 
This study was funded by a grant from the Robert Wood Johnson Foundation. The views expressed are those of the authors and do not necessarily represent those of the Robert Wood Johnson Foundation.


   FOOTNOTES
 
Accepted Apr 26, 2004.

Reprint requests to (C.A.M.) Child Health Institute, University of Washington, 6200 NE 74th St, Suite 210, Seattle, WA 98115-8160. E-mail: cmccarty{at}u.washington.edu


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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics



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