Alcohol use and associated alcohol-related harm (ARH) are a prevalent and important public health problem, with alcohol representing about 4% of the global burden of disease. A discussion of ARH secondary to alcohol consumption necessitates a consideration of the amount of alcohol consumed and the drinking pattern. This study examined the association between alcohol drinking patterns and self-reported ARH. Pearson chi-square test
Alcohol use and associated alcohol-related harm (ARH) are among the most prevalent and important public health problems plaguing this generation [
Recommendations on maximum daily alcohol intake vary both between and within countries [
The main focus in surveys of ARH has historically been on characteristics and behavior of respondents, combined with sample designs in which one respondent is chosen per household to minimize cross contamination. Little attention has often been paid to social interactions (i.e., an individual’s drinking behavior that is considered as problematic and a reaction by someone other than the drinker) and contexts. There is however little agreement about methods of measuring drinking-related social harm in population surveys in spite of the growing consensus about how to measure patterns and amounts of drinking [
Potentially influential predictors of progression to alcohol-related harm besides alcohol consumption include socioeconomic position (SEP) [
There is an increasing shift in paradigm from mean alcohol consumption as a significant determinant of ARH at the individual and population level to drinking patterns [
The following hypotheses were examined.
This study therefore aimed to (i) describe the prevalence of two alcohol drinking patterns and self-reported ARH in the study sample; (ii) examine whether alcohol drinking patterns increased the risk of self-reported ARH; (iii) examine whether drinks per occasion will be more predictive of ARH; and (iv) assess the correlates of ARH among respondents.
Data was obtained from the National Comorbidity Survey Replication (NCS-R) conducted between February 2001 and April 2003. The NCS-R is a cross-sectional nationally representative sample of English-speaking adults aged ≥18 years in the noninstitutionalized civilian population of the 48 coterminous states in the US. Interviews were conducted face to face in the homes of respondents. Detailed descriptions of the methodology, weighting, and sampling procedures used in the NCS-R have been previously provided elsewhere [
Approval for these recruitment and consent procedures were obtained from the Human Subjects Committees of Harvard Medical School and the University of Michigan. The response rate was 70.9%.
Alcohol-related harm: five measures of ARH in the preceding 12 months were assessed: (1) drinking problem causing family/friend argues/problems; (2) drinking ever interfered with work/school/job/home; (3) family worries or complains about alcohol use; (4) alcohol use causing problems/argue with others; and (5) alcohol interfered with responsibilities. The analysis of ARH is kept at the item level (rather than exploring results with a score composed of all or some of the items), because in the National Comorbidity Survey Replication (NCS-R) alcohol-related harm (social harm) is measured as single items.
Alcohol drinking patterns examined include (1) frequency of drinking at least 1 drink in the past 12 months in the past year (daily, 3-4 days per week, 1-2 days per week, 1–3 days per month, less than once a month, and did not drink in past 12 months); and (2) number of drinks per day each time you drank (≤2 drinks per occasion, 2–4 drinks, and ≥5 drinks or binge drinking).
The following predictors were identified
Pearson chi-square test (
The most common types of alcohol-related harm were “family worries or complains about alcohol use” (12%), “drinking problem causing family/friend argues/problems” (7%), and “drinking interfered with work/school/job/home” (5%). The least common at 1% were “alcohol use causing problems with others” (1%) and “alcohol interfered with responsibilities,” respectively. The differences in the distribution of all the measures of ARH and alcohol drinking patterns among respondents were statistically significant for the overall sample and across respondents’ age and ethnicity. Individuals who did not drink (i.e., abstainers) more frequently reported almost all the measures of ARH compared to those who drank daily; this proportion was however not higher than that of light consumers (referred to in this study as those who drank less than once/month and 1–3 days/month). In contrast, individuals who drank the least amount of alcohol per occasion (i.e., ≤2 drinks/occasion) reported a higher prevalence of ARH compared to light consumers (referred to in this study as those who drank 2–4 drinks/occasion). Males were more frequently associated with several measures of ARH (family worried or complains about alcohol use; alcohol use caused problems with others; and alcohol interfered with responsibilities). The prevalence of all the measures of ARH was significantly higher amongst individuals aged 49 years or younger and non-Hispanic blacks. Individuals with higher education (≥16 years) reported the least prevalence of ARH (family worries or complains about alcohol use) (Table
Frequency of alcohol-related harm by alcohol drinking patterns and sociodemographic characteristics of respondents.
Family worries or complains about alcohol use | Alcohol use causing problems with others | Alcohol interfered with responsibilities | Drinking ever interfered with work/school/job/home | Drinking problem causing family/friend argues/problems | ||||||
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No | Yes | No | Yes | No | Yes | No | Yes | No | Yes | |
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Frequency of drinking |
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Daily | 320 (16) | 478 (6) | 17 (12) | 461 (6) | 20 (15) | 441 (6) | 154 (16) | 202 (18) | 219 (18) | 137 (15) |
3-4 days/week | 284 (14) | 560 (7) | 26 (18) | 534 (6) | 20 (15) | 514 (6) | 144 (15) | 182 (16) | 183 (15) | 142 (16) |
1-2 day/week | 350 (18) | 1461 (18) | 30 (21) | 1432 (18) | 23 (17) | 1409 (18) | 157 (16) | 238 (21) | 223 (18) | 173 (20) |
1–3 days/month | 257 (13) | 1709 (21) | 24 (16) | 1686 (21) | 19 (14) | 1667 (21) | 123 (12) | 145 (13) | 136 (11) | 133 (15) |
Less than once/month | 327 (17) | 2692 (32) | 24 (16) | 2669 (33) | 33 (25) | 2636 (33) | 160 (16) | 162 (14) | 169 (14) | 152 (17) |
Did not drink (abstainers) | 431 (22) | 1306 (16) | 25 (17) | 1280 (16) | 17 (12) | 1263 (16) | 248 (25) | 199 (18) | 300 (24) | 146 (17) |
Total |
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Drinks per occasion |
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2570 (61) | 423 (35) | 36 (38) | 2535 (62) | 30 (37) | 2505 (63) | 167 (29) | 289 (38) | 218 (29) | 238 (41) |
2–4 drinks/occasion | 1000 (24) | 329 (28) | 32 (34) | 969 (24) | 29 (36) | 940 (23) | 162 (29) | 223 (30) | 210 (28) | 174 (30) |
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609 (15) | 439 (37) | 27 (28) | 582 (14) | 22 (27) | 560 (14) | 238 (42) | 244 (32) | 318 (43) | 166 (29) |
Total |
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Sex |
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Male | 6980 (40) | 1491 (64) | 6864 (40) | 117 (68) | 6766 (39) | 100 (63) | 731 (65) | 634 (64) | 562 (63) | 804 (65) |
Female | 10513 (60) | 831 (36) | 10458 (60) | 55 (32) | 10397 (61) | 60 (37) | 400 (35) | 354 (36) | 324 (37) | 428 (35) |
Total |
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Age (group) |
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6157 (35) | 780 (34) | 6086 (35) | 71 (41) | 6002 (35) | 84 (53) | 396 (35) | 362 (36) | 354 (40) | 404 (33) |
35–49 years | 5443 (31) | 923 (40) | 5386 (31) | 57 (33) | 5332 (31) | 55 (34) | 429 (38) | 400 (41) | 316 (35) | 512 (41) |
50–64 years | 3463 (20) | 469 (20) | 3430 (20) | 33 (19) | 3415 (20) | 15 (9) | 217 (19) | 186 (19) | 149 (17) | 254 (21) |
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2430 (14) | 150 (6) | 2420 (14) | 11 (7) | 2414 (14) | 6 (4) | 89 (8) | 40 (4) | 67 (8) | 62 (5) |
Total |
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Education (years) |
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0–11 | 3388 (19) | 621 (27) | 3343 (19) | 45 (26) | 3318 (19) | 25 (16) | 300 (26) | 266 (27) | 226 (26) | 340 (28) |
12 | 5136 (29) | 719 (31) | 5085 (29) | 49 (28) | 5047 (29) | 39 (24) | 333 (29) | 295 (30) | 261 (29) | 367 (30) |
13–15 | 4620 (26) | 627 (27) | 4574 (26) | 46 (27) | 4523 (27) | 51 (32) | 313 (29) | 273 (28) | 238 (27) | 349 (28) |
≥16 | 4349 (26) | 355 (15) | 4320 (26) | 32 (19) | 4275 (25) | 45 (28) | 185 (16) | 154 (15) | 161 (18) | 176 (14) |
Total |
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Income |
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4830 (28) | 756 (33) | 4781 (28) | 48 (28) | 4735 (28) | 46 (29) | 374 (33) | 290 (29) | 274 (31) | 390 (32) |
$20,000–29,999 | 2692 (15) | 325 (14) | 2659 (15) | 30 (17) | 2644 (15) | 19 (12) | 145 (13) | 136 (14) | 124 (14) | 157 (13) |
$30,000–49,999 | 3738 (21) | 492 (21) | 3703 (21) | 37 (22) | 3665 (21) | 36 (22) | 229 (20) | 218 (22) | 198 (22) | 251 (20) |
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6233 (36) | 749 (32) | 6179 (36) | 57 (33) | 6119 (36) | 59 (37) | 383 (34) | 344 (35) | 290 (33) | 434 (35) |
Total |
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Ethnicity |
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Non-Hispanic black | 6519 (37) | 1043 (45) | 6441 (37) | 81 (47) | 6361 (37) | 79 (49) | 456 (40) | 423 (43) | 343 (39) | 535 (44) |
Hispanic/others | 5374 (31) | 697 (30) | 5338 (31) | 35 (20) | 5307 (31) | 32 (20) | 375 (33) | 269 (27) | 296 (33) | 347 (28) |
Non-Hispanic white | 5600 (32) | 582 (25) | 5543 (32) | 56 (33) | 5495 (32) | 49 (31) | 300 (27) | 296 (30) | 247 (28) | 350 (28) |
Total |
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The association between frequency of drinking and ARH is presented in Table
Crude association between sociodemographic characteristics and alcohol-related harm.
Family worries or complains about alcohol use | Alcohol use causing problems with others | Alcohol interfered with responsibilities | Drinking ever interfered with work/school/job/home | Drinking problem causing family/friend argues/problems | |
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OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | |
Sex | |||||
Male | 2.70 (2.47–2.96) | 3.24 (2.35–4.47) | 2.56 (1.86–3.53) | 0.98 (0.82–1.17) | 1.08 (0.90–1.30) |
Female | 1 | 1 | 1 | ||
Age (group) | |||||
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2.05 (1.71–2.46) | 2.57 (1.36–4.85) | 5.63 (2.46–12.91) | 2.03 (1.36–3.03) | 1.23 (0.85–1.79) |
35–49 years | 2.75 (2.30–3.29) | 2.33 (1.22–4.45) | 4.15 (1.78–9.65) | 2.07 (1.39–3.09) | 1.75 (1.21–2.54) |
50–64 years | 2.19 (1.18–2.66) | 2.12 (1.07–4.20) | 1.77 (0.68–4.56) | 1.91 (1.25–2.91) | 1.84 (1.23–2.75) |
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1 | 1 | 1 | 1 | 1 |
Education (years) | |||||
0–11 | 2.24 (1.96–2.58) | 1.82 (1.15–2.87) | 0.72 (0.44–1.17) | 1.06 (0.81–1.39) | 1.38 (1.05–1.81) |
12 | 1.71 (1.50–1.96) | 1.30 (0.83–2.03) | 0.73 (0.48–1.13) | 1.06 (0.82–1.39) | 1.29 (0.99–1.68) |
13–15 | 1.66 (1.45–1.91) | 1.36 (0.86–2.14) | 1.07 (0.72–1.60) | 1.05 (0.80–1.37) | 1.34 (1.02–1.76) |
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1 | 1 | 1 | 1 | 1 |
Income | |||||
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1.37 (1.22–1.53) | 1.12 (0.75–1.68) | 1.05 (0.70–1.55) | 0.86 (0.70–1.07) | 0.95 (0.77–1.18) |
$20,000–29,999 | 1.17 (1.01–1.35) | 1.39 (0.86–2.24) | 0.77 (0.44–1.37) | 1.05 (0.80–1.39) | 0.85 (0.64–1.13) |
$30,000–49,999 | 1.19 (1.04–1.35) | 1.16 (0.75–1.80) | 1.12 (0.73–1.71) | 1.06 (0.84–1.34) | 0.85 (0.67–1.08) |
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1 | ||||
Ethnicity | |||||
Non-Hispanic black | 0.81 (0.73–090) | 0.52 (0.35–0.78) | 0.49 (0.32–0.73) | 0.77 (0.63–0.95) | 0.75 (0.61–0.92) |
Hispanic/others | 0.65 (0.58–0.72) | 0.80 (0.57–1.13) | 0.72 (0.50–1.03) | 1.06 (0.86–1.31) | 0.91 (0.73–1.12) |
Non-Hispanic white | 1 | 1 | 1 | 1 | 1 |
Physical health rating | |||||
Good | 1.34 (1.16–1.54) | 1.02 (0.62–1.67) | 1.45 (0.92–2.29) | 1.24 (0.94–1.64) | 1.22 (0.92–1.61) |
Fair/poor | 2.02 (1.75–2.33) | 1.60 (0.98–2.62) | 0.97 (0.53–1.76) | 1.05 (0.79–1.39) | 1.06 (0.80–1.40) |
Very good/excellent | 1 | 1 | 1 | 1 | 1 |
Mental health rating | |||||
Good | 1.59 (1.39–1.82) | 1.26 (0.77–2.06) | 1.01 (0.61–1.67) | 1.01 (0.77–1.32) | 1.08 (0.82–1.41) |
Fair/poor | 2.63 (2.24–3.08) | 2.56 (1.51–4.36) | 1.60 (0.87–2.94) | 0.97 (0.72–1.32) | 1.25 (0.92–1.70) |
Very good/excellent | 1 | 1 | 1 | 1 | 1 |
Smoke | |||||
Yes | 1.51 (1.19–1.92) | 1.70 (0.66–4.37) | 1.39 (0.52–3.68) | 0.77 (0.50–1.17) | 0.77 (0.50–1.18) |
No | 1 | 1 | 1 | 1 | 1 |
In Table
Association between alcohol consumption measured as number of drinks per occasion and alcohol-related harm.
Family worries or complains about alcohol use | Alcohol use causing problems with others | Alcohol interfered with responsibilities | Drinking ever interfered with work/school/job/home | Drinking problem causing family/friend argues/problems | |
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OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | |
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Drinks per occasion | |||||
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1 | 1 | 1 | 1 | 1 |
2–4 drinks/occasion | 1.99 (1.70–2.35) | 2.32 (1.44–3.76) | 2.58 (1.54–4.31) | 1.26 (0.95–1.66) | 1.32 (1.00–1.73) |
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4.38 (3.73–5.14) | 3.27 (1.97–5.42) | 3.28 (1.88–5.73) | 1.69 (1.30–2.19) | 2.09 (1.61–2.72) |
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Drinks per occasion | |||||
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1 | 1 | 1 | 1 | 1 |
2–4 drinks/occasion | 1.40 (0.98–2.00) | 1.88 (1.02–3.46) | 1.98 (1.19–3.29) | 1.17 (0.90–1.53) | 1.26 (0.97–1.63) |
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3.33 (2.10–5.30) | 2.43 (1.16–5.08) | 2.64 (1.41–4.96) | 1.61 (1.21–2.13) | 2.17 (1.62–2.90) |
Sex | — | — | — | ||
Male | 1.79 (1.39–2.79) | 2.22 (1.17–4.22) | 1.59 (0.99–2.58) | ||
Female | 1 | 1 | 1 | ||
Age (group) | |||||
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1.70 (0.85–3.40) | 5.96 (0.79–45.04) |
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35–49 years |
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3.42 (0.44–26.70) |
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50–64 years | 1.84 (0.92–3.69) | 4.54 (0.57–36.35) | 1.16 (0.92–3.02) |
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1 | 1 | 1 | 1 | 1 |
Education (years) | — | — | |||
0–11 | 1.02 (0.55–1.86) | 1.73 (0.71–4.24) |
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12 | 0.68 (0.38–1.21) | 1.11 (0.48–2.60) | 1.21 (0.86–1.71) | ||
13–15 | 0.82 (0.44–1.51) | 1.16 (0.49–2.72) | 1.35 (0.96–1.89) | ||
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1 | 1 | 1 | ||
Income | — | — | — | ||
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1.57 (0.91–2.69) | 0.92 (0.42–1.99) | |||
$20,000–29,999 |
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1.16 (0.48–2.80) | |||
$30,000–49,999 |
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1.33 (0.65–2.73) | |||
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1 | 1 | |||
Ethnicity | |||||
Non-Hispanic black | 0.58 (0.22–1.54) |
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Hispanic/others | 1.29 (0.55–3.04) | 0.59 (0.26–1.30) |
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1.09 (0.83–1.43) | 0.93 (0.70–1.23) |
Non-Hispanic white | 1 | 1 | 1 | 1 | 1 |
Physical health rating | — | — | — | — | |
Good | 1.31 (0.89–1.94) | ||||
Fair/poor | 1.46 (0.92–2.31) | ||||
Very good/excellent | 1 | ||||
Mental health rating | — | — | — | ||
Good |
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1.39 (0.74–2.61) | |||
Fair/poor |
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Very good/excellent | 1 | 1 | |||
Smoke | — | — | — | — | |
Yes | 1.17 (0.80–1.73) | ||||
No | 1 |
In the multivariate analyses, male drinkers had significantly higher odds of ARH compared to female drinkers when alcohol consumption was measured either as frequency of drinking or as drinks per occasion. Younger individuals were generally at higher odds of ARH compared to those aged ≥65 years; the strongest odds ratio (ORs) was found among individuals aged ≤34 years and frequency of drinking (
Sensitivity analyses with daily drinking amounts and frequency both included with the other covariates resulted in the association between the drinking patterns and two measures of ARH (drinking ever interfered with work/school/job/home and drinking problem causing family/friend argues/problems) and the relation between drinks per occasion and the ARH “measure alcohol interfered with responsibilities” becoming statistically nonsignificant. There was a positive association between the frequency of drinking category “daily” and three ARH measures (“family worries or complains about alcohol use,” “alcohol use causing problems with others,” and “alcohol interfered with responsibilities”) compared to their counterparts who did not drink; all other categories of frequency of drinking were negatively associated with these three ARH measures. Respondents in the drinks per occasion category “≥5 drinks/occasion” had an almost threefold higher risk of having “family worries or complains about alcohol use” compared to those who drank ≤2 drinks/occasion.
This study examined the prevalence of ARH and the association between alcohol use patterns self-reported ARH and yielded 4 key findings. First, prevalence of ARH ranged between 1% (“alcohol use causing problems with others” and “alcohol interfered with responsibilities”) and 12% (“family worries or complains about alcohol use” and that abstainers and those with the least amount of drinking per occasion exhibited higher prevalence of alcohol-related harm than light consumers, irrespective of the alcohol drinking pattern). The prevalence of ARH found in the present study is within the range of those reported in the US (5.3%) [
Second, alcohol drinking patterns were associated with increased risks of self-reported ARH; this association was largely dose-dependent, corroborating findings from previous studies indicating that positive relations between overall intake established and patterns of drinking, especially irregular heavy drinking [
Third, binge or “risky” drinking was strongly predictive of ARH than other categories of drinks per occasion or frequency of drinking. This finding is consistent with those from other studies among a sample of US adults [
Other noteworthy findings include male drinkers being more likely than female drinkers to report ARH when alcohol consumption was measured either as frequency of drinking or as drinks per occasion. Similar findings have been reported in India [
Non-Hispanic blacks and Hispanic/other ethnic groups were generally more less likely to report ARH associated with both drinking patterns compared to non-Hispanic whites, with the exception of “alcohol interfered with responsibilities” in relation to frequency of drinking which non-Hispanic blacks were more likely to report than non-Hispanic whites. These mixed findings may be linked with social and cultural factors such as ethnic groups’ norms and attitudes regarding alcohol use and biological factors [
Finally, we found higher odds of ARH among those who reported good and fair/poor physical and mental health compared to those who reported very good/excellent physical health, which is consistent with findings from a California study [
By including frequency of drinking and drinks per occasion with the other covariates in the sensitivity analysis accounting for the distribution of those who drink frequently among those who consume much alcohol per occasion, and vice versa, the odds of “family worries or complains about alcohol use” increase almost threefold when the amount of alcohol consumed was ≥5 drinks/occasion. This finding provides added support for our earlier finding that binge or “risky” drinking was strongly predictive of ARH than other categories of drinks per occasion or frequency of drinking.
Among the limitations of this study are that all ARHs are based on self-report and thereby subject to recall error with the risk of underestimation of true levels of drinking. The association between drinking patterns and social harm relies on the subjective causal relationship of the reported ARH to alcohol; however, the cross-sectional design precludes inferences as to causality and longitudinal studies are needed to confirm the present findings and examine mechanisms underlying the predictors of the outcomes. We did not provide information on the severity or frequency of ARH since we only used binary variables to assess ARH; this may underestimate the share of the burden of total harm that could potentially be attributed to heavy drinkers/frequent binge drinkers. We emphasize that possible information bias of exposure could lead to nondifferential misclassification since it does not depend on the outcome; this could potentially result in underestimation of the association of interest [
The strategic approaches to tackling ARH differ markedly across countries. This study provides evidence to support important tasks needed to prevent ARH and suggests that comprehensive alcohol prevention strategies within countries should also include making strong commitments is public health prevention strategies aimed at the entire population of drinkers; this may be more effective for most alcohol-related problems and preferred to strategies aimed only at the smaller subgroup of high-risk drinkers in the population. However, efforts should also be made to reach high consumers.
This study provides evidence that alcohol drinking patterns were associated with increased risks of self-reported ARH and that drinks per occasion especially binge or “risky” drinking was strongly predictive of ARH than other categories of drinks per occasion or frequency of drinking. Males had significantly higher likelihood of ARH in relation to frequency of drinking and drinks per occasion. There is a need for comprehensive public health alcohol prevention strategies at the entire population of drinkers, including efforts aimed at the smaller subgroup of high-risk drinkers.
The authors declare that they have no conflict of interests.
Diddy Antai, Gerald Lopez, Justina Antai, and David Anthony contributed equally to this work.