OBJECTIVES. Underage drinking contributes to the 3 leading causes of death (unintentional injury, homicide, and suicide) among persons aged 12 to 20 years. Most adverse health effects from underage drinking stem from acute intoxication resulting from binge drinking. Although binge drinking, typically defined as consuming ≥5 drinks on an occasion, is a common pattern of alcohol consumption among youth, few population-based studies have focused specifically on the characteristics of underage binge drinkers and their associated health risk behaviors.
METHODS. We analyzed data on current drinking, binge drinking, and other health risk behaviors from the 2003 National Youth Risk Behavior Survey. Prevalence estimates and 95% confidence intervals were calculated by using SAS and SUDAAN statistical software. Logistic regression was used to examine the associations between different patterns of alcohol consumption and health risk behaviors.
RESULTS. Overall, 44.9% of high school students reported drinking alcohol during the past 30 days (28.8% binge drank and 16.1% drank alcohol but did not binge drink). Although girls reported more current drinking with no binge drinking, binge-drinking rates were similar among boys and girls. Binge-drinking rates increased with age and school grade. Students who binge drank were more likely than both nondrinkers and current drinkers who did not binge to report poor school performance and involvement in other health risk behaviors such as riding with a driver who had been drinking, being currently sexually active, smoking cigarettes or cigars, being a victim of dating violence, attempting suicide, and using illicit drugs. A strong dose-response relationship was found between the frequency of binge drinking and the prevalence of other health risk behaviors.
CONCLUSIONS. Binge drinking is the most common pattern of alcohol consumption among high school youth who drink alcohol and is strongly associated with a wide range of other health risk behaviors. Effective intervention strategies (eg, enforcement of the minimum legal drinking age, screening and brief intervention, and increasing alcohol taxes) should be implemented to prevent underage alcohol consumption and adverse health and social consequences resulting from this behavior.
Underage drinking is widely recognized as a leading public health and social problem in the United States1 and is associated with the 3 leading causes of death among youth (unintentional injury, homicide, and suicide).2 A number of studies have shown the harmful health and social consequences of underage drinking, such as neglecting responsibilities, getting into fights or arguments, missing school, driving after drinking, engaging in suicidal behavior, and engaging in risky sexual behavior.3–5 Underage drinking is also associated with carrying weapons, using illicit drugs, and having unprotected sexual activity.6–8 Some long-term effects of alcohol use during adolescence include increased risk of alcohol dependence, learning impairments, and memory impairments.9
Binge drinking, typically defined as drinking ≥5 drinks on an occasion,10 is a common pattern of alcohol consumption among adolescents who drink and accounts for 90% of the alcohol consumed by 12- to 17-year-old youth.11 However, few studies have specifically assessed the characteristics of underage binge drinkers and the relationship between binge drinking and other health risk behaviors. This association is important for understanding alcohol use among youth and for planning prevention strategies. This study evaluated the characteristics of high school students who drink; the drinking patterns among these students; and the association between binge drinking and other health risk behaviors, such as drinking and driving, risky sexual behavior, tobacco use, interpersonal violence, suicide, and other drug use.
The Youth Risk Behavior Survey (YRBS), developed by the Centers for Disease Control and Prevention, is a school-based survey that monitors 6 categories of priority health risk behaviors: behaviors that lead to unintentional injury and violence; tobacco use; alcohol and other drug use; sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases, including human immunodeficiency virus infection; unhealthy dietary behaviors; and physical inactivity.12 In 2003, the YRBS was administered to a nationally representative sample of private and public school students in grades 9 through 12 by using a 3-stage cluster sample design. Survey participation was anonymous and voluntary. Local parental permission procedures were followed at each school. Students recorded their responses directly on a self-administered, computer-scannable questionnaire with 97 items. The YRBS sampling strategies and the psychometric properties of the questionnaire have been described in more detail elsewhere.12–14
A weighting factor was applied to each student record to adjust for nonresponse and for varying probabilities of selection, including those resulting from oversampling of black and Hispanic students. Thus, the YRBS data are representative of all public and private high school students in grades 9 through 12 in all 50 states and the District of Columbia. In 2003, the school response rate was 81%, the student response rate was 83%, and the overall response rate was 67%. The resulting sample size was 15240 completed questionnaires of which 15214 were usable after quality control.12,13
Risk Behavior Variables
Drinking behavior was measured by the following questions from the YRBS questionnaire: “During the past 30 days, on how many days did you have at least 1 drink of alcohol?” and “During the past 30 days, on how many days did you have ≥5 drinks of alcohol in a row, that is, within a couple of hours?” Respondents were categorized as nondrinkers (ie, no drinking during the past 30 days), current drinkers (ie, consuming ≥1 drink during the past 30 days) who did not binge drink (ie, consuming ≥5 drinks in a row during the past 30 days), or current drinkers who binge drank.
The other reported health risk behaviors we studied included the following: driving a car or other vehicle when you had been drinking alcohol during the past 30 days; riding in a car or other vehicle driven by someone who had been drinking alcohol during the past 30 days; having sexual intercourse with ≥1 person during the past 3 months (currently sexually active); no condom use during last sexual intercourse among sexually active students; drinking or using drugs before last sexual intercourse among sexually active students; ever having been or having gotten someone else pregnant; smoking cigarettes or cigars on ≥1 day during the past 30 days (current cigarette or cigar use); using chewing tobacco, snuff, or dip on ≥1 day during the past 30 days (current smokeless tobacco use); being in a physical fight during the past 12 months; “seriously” considering to attempt suicide during the past 12 months; “actually” attempting suicide ≥1 time during the past 12 months; using marijuana ≥1 time during the past 30 days (current marijuana use); using any form of cocaine ≥1 time during the past 30 days (current cocaine use); and sniffing glue, breathing aerosol spray, or inhaling paints ≥1 time during the past 30 days (current inhalant use). We also examined being physically hurt on purpose by boyfriend or girlfriend during the past 12 months; ever being physically forced to have sexual intercourse; and self-description of grades in school during the past 12 months.
There were 1100 respondents who were excluded from this analysis because of missing responses on the current drinking question (n = 592), the binge-drinking question (n = 31), or both questions (n = 477). Those excluded represent ∼7% of the total survey respondents. Prevalence estimates with 95% confidence intervals (CIs) were calculated by using SAS (SAS Institute Inc, Cary, NC) and SUDAAN (Research Triangle Institute, Research Triangle Park, NC) statistical software. Overlapping CIs were used to assess statistical significance. To examine the relationship between drinking status and health risk behaviors, logistic regression was used to calculate adjusted odds ratios (AORs) with 95% CI, adjusting for binge-drinking days as a continuous variable, age as a continuous variable, gender, and race/ethnicity.
In 2003, 44.9% (or 7.4 million) of high school students reported drinking alcohol (16.1% reported current drinking with no binge drinking, and 28.8% reported current drinking with binge drinking, representing ∼4.7 million and 2.6 million students, respectively; Table 1). Girls reported more current drinking with no binge drinking than boys (17.8% vs 14.3%, respectively). Although black students had the highest prevalence of nondrinking of any racial/ethnic group, they had the highest prevalence of current drinking with no binge drinking (21.9%) compared with white students (14.6%), Hispanic students (16.4%), and students of other races (American Indian, Alaskan Native, Asian, Native Hawaiian, Pacific Islander and multi-racial) (16.0%). The prevalence of current drinking without binge drinking did not vary by age or school grade.
The prevalence of current drinking with binge drinking was similar among boys and girls (29.5% and 27.9%, respectively) (Table 1). However, binge-drinking prevalence increased with increasing age (17.8% among 12- to 14-year-olds vs 38.7% among students aged 18 years and older) and grade level (20.2% among 9th graders vs 37.8% among 12th graders). Black students (15.5%) reported less binge drinking than white students (32.5%), Hispanic students (29.2%), and students of other races (22.7%).
Among current drinkers, 67.4% of boys and 61.1% of girls reported binge drinking (Table 2). Overall, boy drinkers aged 18 years and older reported the highest rate of binge drinking (74.0%). Of the students aged 15 years and older, in the 11th grade, of white race, and of black race, the boy current drinkers reported more binge drinking than the girl current drinkers. Black students who reported current drinking had the lowest rates of binge drinking for both boys and girls (48.7% and 34.7%, respectively) compared with students of other race/ethnicities. Current drinkers who were white, boys, and in the 12th grade had the highest rate of binge drinking (75.5%; data not shown).
Among binge drinkers, approximately two thirds (68.7% or 3.2 million) of the students reported doing so on >1 day during the past 30 days, with boys binge drinking more frequently than girls (Fig 1). The prevalence of binge drinking ≥2 days was 73.3% (or 1.8 million) for boys and 63.7% (or 1.4 million) for girls; for ≥6 days, 28.2% (700000) and 18.3% (400000), respectively; and for ≥10 days, 13.6% (340000) and 6.8% (150000), respectively. This finding was observed across all grade levels (data not shown).
Other health risk behaviors were more common among both current drinkers who did not binge drink and those who did binge drink than among nondrinkers (Table 3). Compared with nondrinkers, current drinkers who did not binge drink were more likely to ride with a driver who had been drinking, be currently sexually active, drink or use drugs before last sexual intercourse, to have ever been or gotten someone pregnant, smoke cigarettes or cigars, use smokeless tobacco, be involved in a physical fight, experience dating violence, have forced intercourse, consider or attempt suicide, and use marijuana, cocaine, and inhalants (AOR range: 1.6–5.9). Current drinkers who did binge drink were even more likely to engage in these same health risk behaviors than nondrinkers (AOR range: 1.9–63.2). Binge drinkers were more likely to engage in health risk behaviors than current drinkers who did not binge (Fig 2) such that the AORs for the binge drinkers was 1.3 to 10.7 times the AORs for the current drinkers who did not binge (data not shown).
Logistic regression analysis revealed a strong and statistically significant (P < .05) dose-response relationship between the frequency of binge-drinking days among current drinkers and the prevalence of these risk behaviors (Table 4). The prevalence of these risk behaviors ranged from 1.5% to 36.8% among current drinkers who did not binge drink (0 days), 6.1% to 48.6% among those who binge drank only 1 day, and 27.0% to 85.0% among those who binge drank ≥10 days. Students who binge drank ≥10 days had prevalence estimates of engaging in these risk behaviors that were 1.5 to 24.7 times as high as the estimates of the students who binge drank only 1 day.
School performance (ie, the self-reported grades in school) was inversely associated with the prevalence of binge drinking (Fig 3). For example, the proportion of students with “mostly A's” who reported binge drinking was 19.7%, whereas the proportion of students with “mostly D's or F's” who reported binge drinking was 49.3%. However, the proportion of current drinkers who did not binge drink did not vary with school performance.
The objectives of this population-based study were to assess the prevalence and frequency of current drinking and binge drinking among high school students and to assess the association between the patterns of alcohol consumption and other health risk behaviors. Our findings demonstrate that almost half of high school students reported that they drank alcohol during the 30 days preceding the survey. Even more alarming, we found that among the students who drank, >60% reported binge drinking (drinking ≥5 drinks of alcohol in a row), and approximately two thirds of binge drinkers reported binge drinking on >1 day during the 30 days preceding the survey. Nondrinkers had the lowest rates of health risk behaviors compared with both current and binge drinkers. Compared with students who drank alcohol but did not binge drink, binge drinkers were more likely to engage in health risk behaviors and to have poor school performance.
Similar to our findings, other studies have shown that underage drinking is associated with other health risk behaviors, such as not wearing a helmet while cycling, engaging in sexual activity at an early age and with multiple partners, and using illicit drugs.3 It is important to realize that those students who engage in these other risk behaviors are more susceptible to adverse health outcomes, such as head injury from not wearing helmets, death resulting from lack of seatbelt use or fighting with weapons, or being infected with sexually transmitted diseases because of promiscuity and lack of protection. Windle et al15 found that girls in 8th grade who drank heavily (≥5 drinks in a row at least once during the past 2 weeks) were twice as likely to report attempting suicide than girls in 8th grade who did not drink. In another study of risk behavior among high school students in South Carolina, any alcohol consumption was significantly associated with physical fighting among white girls and carrying a weapon for all students except white girls; whereas binge drinking was associated with fighting among all boys and with carrying a weapon among white males and black girls.16
The high rates of current and binge drinking among young girls are of concern. Although binge-drinking rates were similar between boys and girls, girls aged 12 to 14 years were more likely to report binge drinking than their boy counterparts. This finding is similar to that shown in the 2004 Monitoring the Future study, where girls in the 8th grade had a higher binge-drinking rate than boys in the 8th grade.17 This gender difference contrasts with the drinking patterns observed among adults, where the prevalence of binge drinking is ∼3 times higher among men than women.18 If these rates among high school students persist into adulthood,19,20 we could see dramatic increases in binge drinking among adult women in the future. These findings are especially troubling because girls are more vulnerable to binge-drinking–related reproductive health outcomes, such as unintended pregnancy,21,22 sexually transmitted disease-related infertility,23,24 and alcohol-exposed pregnancies that could result in birth defects, such as fetal alcohol syndrome and fetal alcohol spectrum disorders.25,26 Indeed, an increase in binge drinking among adult women has already been noted in recent years.27
This study is unique because it examined the relationship between multiple health risk behaviors and alcohol consumption, as well as compared both binge drinkers and non-binge drinkers with nondrinkers. Because this was a cross-sectional study, however, a temporal relationship cannot be established between alcohol consumption and the risk behaviors studied. Furthermore, some of the associations found between alcohol consumption and risk behaviors may have been because of confounding factors that were not measured, such as parental alcohol abuse, emotional neglect, and other psychosocial factors that would affect multiple behaviors, including alcohol consumption. However, a number of non cross-sectional studies have demonstrated alcohol use and/or binge drinking to be associated with health risk behaviors, such as dating violence, unprotected sexual intercourse, and suicidal behavior.28–30
This study has several limitations. First, all prevalence estimates were obtained by self-reports. Studies have questioned the accuracy of self-reports and shown that among adults, self-reports of alcohol consumption are underestimates.31–34 If this were the case it would suggest that our prevalence estimates of current and binge drinking are conservative. This limitation also could mean that some of the increased risk associated with current drinking may actually be associated with binge drinking that was misclassified resulting from the respondent underreporting of binge-drinking occasions because recall was inaccurate. However, we do not know to what extent this may apply for anonymous, school-based surveys. Studies have shown these surveys typically have higher rates of self-reported alcohol use compared with other survey protocols (eg, household surveys) where youth may perceived a great risk of being identified.35 Second, because the YRBS is only administered to students in regular public or private high schools, these data do not represent alcohol use among youth who attended alternative schools or did not attend school. However, it is important to note that the vast majority of youth aged 12 to 18 years attend regular public or private schools36 and that those who do not attend these schools may have even higher rates of alcohol use.37
In addition, it is important to recognize that the prevalence of binge drinking among girls underestimates their risks of alcohol-related harms relative to boys based on the definition currently used in the YRBS (ie, using 5 drinks in a row for both boys and girls). From a physiologic perspective, girls typically weigh less than boys and have less alcohol dehydrogenase (the enzyme responsible for metabolizing ethanol) per unit of body mass than boys. Therefore, girls are more vulnerable than boys to the effects of alcohol consumption.38 For this reason, the new definition of binge drinking adopted by the National Institutes of Alcohol Abuse and Alcoholism recommends using a threshold of ≥4 drinks to define binge drinking among girls.39
The implementation of the National Minimum Legal Drinking Age Act and the zero-tolerance laws have had an important impact on reducing alcohol-related motor vehicle crash deaths among adolescents and young adults.40–44 Since that time, few environmental interventions to reduce underage drinking have been implemented on a wide scale, and other factors have hindered efforts to reduce underage drinking and its consequences. Specifically, most states lack adequate funding and community support to enforce retailer compliance with underage drinking laws,45 a high proportion of buy attempts by underage youth are successful,46,47 and >90% of high school seniors report that alcohol is easy to obtain.48 In addition, most alcohol advertising, particularly for beer and distilled spirits, is placed in media venues where audiences are disproportionately younger than the minimum legal drinking age.49,50
The ongoing problem of alcohol consumption among youth was addressed recently by the Institute of Medicine (IOM) of the National Academy of Sciences in a report entitled Reducing Underage Drinking: A Collective Responsibility.1 In its report, IOM “reached the fundamental conclusion that underage drinking cannot be successfully addressed by focusing on youth alone” and noted that “efforts to reduce underage drinking, therefore, need to focus on adults and must engage the society at large.” Given this, we recommend the adoption of effective environmental interventions to reduce both youth drinking and excessive drinking in the general population.51 These interventions, which were also given special emphasis in the IOM report, include adequate enforcement of the minimum legal drinking age, increased alcohol excise taxes, reduced exposure of underaged youth to alcohol advertising and marketing, the implementation of comprehensive community-based programs to prevent excessive drinking, adoption of evidence-based education interventions that incorporate elements known to be effective and that are part of a comprehensive community program, the development of a national media campaign to reduce risky drinking among adults and youth, and improved surveillance for youth alcohol consumption. Current funding for the prevention of alcohol consumption among youth is a fraction of what is spent on the prevention of illegal drug use and tobacco use,1 despite the fact that alcohol use among youth is more widespread than either tobacco or illegal drug use and kills many more youth than illegal drugs.52 Adequate funding and community participation for the implementation of these strategies are necessary to effectively prevent underage drinking.
From the clinical point of view, pediatricians and family practice physicians should be aware that most of their high school-aged patients drink alcohol and usually do so to the point of intoxication. Clinicians should also be aware of recent evidence demonstrating that alcohol consumption by youth has some negative effects on the liver, bone, growth, and brain development of the adolescent53 and increases the risk of subsequent adult drinking problems.20,54,55 Some studies have shown that screening and brief intervention in medical settings may be helpful for youth who screen positive for alcohol problems.56 The American Academy of Pediatrics encourages clinicians to ask adolescents about their alcohol use, refer those adolescents with suspected drinking problems or other psychosocial problems for age-appropriate treatment, include guidance for substance abuse prevention in routine and episodic office visits, and encourage parental and community efforts to prevent underage drinking.6,57
- Accepted September 14, 2006.
- Address correspondence to Jacqueline W. Miller, MD, Centers for Disease Control and Prevention, 4770 Buford Hwy, NE, Mailstop K-55, Atlanta, GA 30341. E-mail:
The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
The authors have indicated they have no financial relationships relevant to this article to disclose.
- ↵Bonnie RJ, O'Connell ME, eds. National Research Council and Institute of Medicine. Reducing Underage Drinking: A Collective Responsibility. Washington, DC: National Academies Press; 2004
- ↵Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system. Available at: www.cdc.gov/ncipc/wisqars. Accessed July 26, 2005
- ↵Hingson R, Kenkel D. Social, health, and economic consequences of underage drinking. In: National Research Council and Institute of Medicine, ed. Reducing Underage Drinking: A Collective Responsibility. Washington, DC: National Academies Press; 2004. Background papers [CD-ROM]
- ↵American Academy of Pediatrics, Committee on Substance Abuse. Alcohol use and abuse: a pediatric concern. Pediatrics.2001;108 :185– 189
- National Institute on Alcohol Abuse and Alcoholism. Alcohol Epidemiologic Data Directory. Washington, DC: US Department of Health and Human Services; 2003
- ↵Brown SA, Tapert SF. Health consequences of adolescent alcohol involvement. In: National Research Council and Institute of Medicine, ed. Reducing Underage Drinking: A Collective Responsibility. Washington, DC: National Academies Press; 2004. Background papers [CD-ROM]
- ↵Pacific Institute for Research and Evaluation. Drinking in America: Myths, Realities, and Prevention Policy. Calverton, MD: Pacific Institute for Research and Evaluation; 2002
- ↵Grunbaum J, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance: United States, 2003 [published corrections appear in MMWR Morb Mortal Wkly Rep. 2004;53:536 and MMWR Morb Mortal Wkly Rep. 2005;54:608]. MMWR Surveill Summ.2004;53(2) :1– 96
- ↵Brener ND, Kann L, Kinchen SA, et al. Methodology of the Youth Risk Behavior Surveillance System. MMWR Recomm Rep.2004;53 (RR-12):1–13
- ↵Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the future national survey results on drug use, 1975–2004. In: Volume 1: Secondary School Students. Bethesda, MD: National Institute on Drug Abuse; 2005. NIH publication 05–5727
- ↵McCarty CA, Ebel BE, Garrison MM, DiGiuseppe DL, Christakis DA, Rivara FP. Continuity of binge and harmful drinking from late adolescence to early adulthood. Pediatrics.2004;114 :714– 719
- ↵Jacobson JL, Jacobson SW. Prenatal alcohol exposure and neurobehavioral development: where is the threshold? Alcohol Health Res World.1994;18 :30– 36
- Fergusson DM, Lynskey MT. Alcohol misuse and adolescent sexual behaviors and risk taking. Pediatrics.1996;98 :91– 96
- Feunekes GIJ, van't Veer P, van Staveren WA, Kok FJ. Alcohol intake assessment: the sober facts. Am J Epidemiol.1999;150 :105– 112
- ↵Gast J, Caravella T, Sarvela PD, McDermott RJ. Validation of the CDC's YRBSS alcohol questions. Health Values.1995;18 :39– 43
- ↵US Census Bureau. School enrollment: 2000. Available at: www.census.gov/prod/2003pubs/c2kbr-26.pdf. Accessed May 25, 2005
- ↵The Century Council. Blood alcohol educator. Available at: www.b4udrink.org/index.cfm. Accessed March 17, 2005
- ↵National Institute on Alcohol Abuse and Alcoholism. NIAAA council approves definition of binge drinking. NIAAA Newsletter.2004;3 :3
- ↵Wagenaar AC, Toomey TL. Effects of minimum drinking age laws: review and analyses of the literature from 1960 to 2000. J Stud Alcohol.2002;14 :206– 225
- National Highway Traffic Safety Administration. Youth fatal crash and alcohol facts, 1997. Traffic Tech No. 195. Available at: www.nhtsa.dot.gov/people/injury/traffic_tech/1999/tt195.html. Accessed February 2, 2005
- ↵Johnston LD, O'Malley PM, Bachman JG. Monitoring the Future National Results on Adolescent Drug Use: Uverview of Key Findings, 2002. Rockville, MD: National Institute on Drug Abuse; 2003. NIH publication 03–5374
- ↵Babor TF, Caetano R, Casswell S, et al. Alcohol: No Ordinary Commodity—Research and Public policy. New York, NY: Oxford University Press; 2003
- ↵National Institute on Alcohol Abuse and Alcoholism. Underage Drinking: A Major Public Health Challenge. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism; 2003. Alcohol Alert 59
- ↵National Institute on Alcohol Abuse and Alcoholism. The effects of alcohol on physiological processes and biological development. Alcohol Res Health.2003;28 :125– 131
- ↵Kuling, JW; American Academy of Pediatrics, Committee on Substance Abuse. Tobacco, alcohol, and other drugs: the role of the pediatrician in prevention, identification, and management of substance abuse. Pediatrics.2005;115 :816– 821
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