Binge Drinking and Violence

Excessive consumption of alcohol was responsible for approximately 75 000 deaths and 2.3 million years of potential life lost (about 30 years of life lost per death) in the United States in 2001.^{1 - 2} Binge drinking, typically defined as the consumption of 5 or more alcoholic drinks on 1 occasion for a man or 4 or more drinks on a single occasion for a woman,³ accounted for more than half of these deaths and for approximately two thirds of the years of potential life lost.¹ Binge drinking is also associated with a wide range of serious health and social problems, including sexually transmitted disease, unintended pregnancy, sudden infant death syndrome, acute myocardial infarction, and motor vehicle crashes.^{4 - 5} The World Health Organization estimates that use of alcohol, including binge drinking, is responsible for 4% of the global burden of disease, only slightly less than the burden imposed individually by tobacco use and high blood pressure.⁶

Binge drinking is a common risk behavior in the United States throughout all life stages and is closely interwoven into the fabric of US society, affecting a variety of health outcomes. For example, self-reported data indicate that almost half of all US high school students are current drinkers and that approximately 60% of these underage drinkers engaged in binge drinking in the past month.⁷ Binge drinking is also a key risk behavior among US college students and college-aged youth, many of whom are younger than 21 years, with an estimated 44% of college students reporting that they had engaged in binge drinking in the past 2 weeks.⁸ Among US adults, the data are also cause for dismay: from the mid 1980s to 1999, about 29% of current drinkers reported having engaged in binge drinking in the past month.⁹ However, while the overall prevalence of binge drinking among current drinkers has remained relatively constant, binge-drinking episodes—ie, the frequency of binge drinking—has not. Between 1993 and 2001, the number of binge-drinking episodes among US adults increased 29%, from 1.2 billion to 1.5 billion, and yearly episodes per person increased by 17%, from 6.3 to 7.4.⁴ In fact, it is estimated that approximately 90% of the alcohol consumed by underage youth,¹⁰ and about 50% of the alcohol consumed by US adults,¹¹ is in the form of binge drinks.

While binge drinking is related to a wide range of health and social problems, its association with injuries is among the most robust and imminent. The proportion of injury deaths in the United States that are attributable to alcohol consumption ranges from approximately 20% to 100%, depending on the type of injury.² The risk of injury increases with the amount of alcohol consumed and is largely related to the acute (vs chronic) effects of alcohol consumption. Indeed, a recent case-crossover study (ie, a study in which the patient serves as his or her own control) reported a 9-fold increase in the odds of injury among patients who reported consuming 5 to 6 drinks during the 6-hour period prior to being injured and a 17-fold increase in the odds of injury among those who reported consuming 7 or more drinks during the same period.¹² Findings such as these underscore the observation made by Foege almost 20 years ago that alcohol is the “AIDS virus of injury control” because it “lowers the defenses and immunity to injury.”¹³

The strong connection between binge drinking and injuries is perhaps best characterized for motor vehicle crashes. Injury from such crashes is the leading cause of alcohol-attributable deaths in the United States.¹ In 2003 (the most recent year for which data are available), approximately 14 600 deaths resulted from a motor vehicle crash in which a driver or nonoccupant had a blood alcohol concentration of at least 0.08 g/dL,¹⁴ the legal blood alcohol limit for driving in most states. Indeed, the National Institute for Alcohol Abuse and Alcoholism uses this blood alcohol concentration as its physiological definition of binge drinking.³ In the United States, alcohol-impaired driving is far more common among binge drinkers. In a national study from 1993 through 2002, on average, 85% of the self-reported episodes of alcohol-impaired driving (159 million in 2002 alone) involved binge drinkers.¹⁵ Furthermore, the 29% relative increase in impaired driving episodes that occurred over this 9-year period directly parallels the increase in binge-drinking episodes that occurred from 1993 to 2001, supporting the association between these risk behaviors.

Research findings support a strong connection between binge drinking and violence. Alcohol consumption is common among perpetrators of violent crimes in the United States, including those arrested for homicide (range, 28%-86%), assault (range, 24%-37%), robbery (range, 7%-72%), and sexual offenses (range, 13%-60%).¹⁶ High school students who binge drink are more likely to be involved, injured, or to injure others in physical fights, even after controlling for other factors that might affect this outcome (eg, age, race, and sex).¹⁷ In addition, a recent international study of injured patients treated in emergency departments found that patients having a blood alcohol concentration of 0.08 g/dL were more than 3.2 times more likely to experience a violent injury than patients with unintentional injury and that there was a significant dose-response relationship between the amount of alcohol consumed and the risk of violent injury.¹⁸ These findings suggest that binge drinking may play an even larger role in violent injuries than in unintentional injuries, even though alcohol is known to be an important risk factor for unintentional injuries as well.

The fact that binge drinking is a strong and consistent risk factor for violent behavior among both youth and adults is probably due to a variety of factors, including the physiological and psychopharmacological consequences of consuming large quantities of alcohol, particularly within a short period (eg, disinhibition and psychological and cognitive impairment, which results in miscommunication, misinterpretation of social cues, attention deficits, and bad judgment); individual expectations regarding the effects of alcohol use; and various situational factors, including the setting and social context in which drinking occurs.¹⁹ Binge drinking is one of many behavioral risk factors that can act in combination with other individual, situational, and sociocultural factors to facilitate involvement in violent behavior, but unlike many of these other factors, binge drinking is preventable.

Several evidence-based strategies appear to be effective in preventing binge drinking and, in turn, violence.²⁰ For example, consumption of alcohol and related harms, including violence, are significantly affected by the price of alcoholic beverages.²¹ As a general rule, if the price goes up, consumption goes down. Of the policies that directly influence the price of alcoholic beverages, excise taxation is the most widely used.²¹ Sloan et al²² estimated that a 10% increase in the tax on beverages containing alcohol could reduce monthly episodes of binge drinking by 8%. Markowitz and Grossman²³ suggest that a 10% increase in the excise tax on beer may reduce the probability of any child abuse by 1.2% and of severe child abuse by 2.1%. Reducing access to alcohol, including enforcement of the minimum legal drinking age of 21 years, has also been found effective.²⁰ A recent study in New Hampshire found that enhanced enforcement of the state’s legal age for drinking in Concord, the state’s capital, reduced illegal sales to underage youth by 64% and was associated with an approximately 20% reduction in the prevalence of current drinking and binge drinking among students attending high school in the city.²⁴ In contrast, statistically nonsignificant declines were seen in the prevalence of current and binge drinking among high school students statewide (11% and 7%, respectively). Screening and brief counseling for alcohol problems is also effective in reducing excessive alcohol consumption²⁰ and has specifically been shown to reduce episodes of binge drinking by 40% among men and women.²⁵ The US Preventive Services Task Force strongly recommends screening and brief counseling for excessive drinking among adults.²⁶

In conclusion, binge drinking is a leading cause of preventable death and a ubiquitous although still underrecognized risk factor for a variety of health and social outcomes in the United States and throughout the world. The scientific link between binge drinking and injuries, including violence, is strong. Evidence-based prevention strategies, including increasing excise taxes on alcohol, restricting physical access to alcoholic beverages, and screening and brief intervention, are available but underused. Although there continue to be gaps in current knowledge regarding the link between alcohol and public health, enough is known to begin aggressively implementing these and other strategies to prevent binge drinking.