Intemperate society

New Scientist, 21 August 2004

DAVE really had to pee. He was at the train station, facing a 90-minute journey home, and couldn't rustle up the coins he needed to get through the turnstile to the loo. When he tried to vault over, he tripped and snapped his wrist - a fact he only became aware of in the middle of the night, as the analgesic effects of several beers began to recede.

Then there's Libby. You'd think she'd have learned her lesson after falling face first onto concrete off the shoulders of a very tall friend. But just a few years later she was maimed by drink again, this time while table-dancing at the Munich Oktoberfest, where she slipped and accidentally cut off the tip of her thumb with a broken beer stein. Eve lost a front tooth, Rick lost his memory, Andrei lost control of one hand for several months. William routinely lost his temper; Kenji routinely lost his dinner. Jimmy almost lost his brother after he hurled him through a second-storey window in a drunken rage.

What all these people have in common (apart from, er-hem, all being drawn from amongst my friends, colleagues and family, though their names have been changed) is that they had been drinking heavily - bingeing, to be precise, though most of them would smart on hearing the term. The fact that I can quickly summon half-a-dozen personal examples is testimony to how common the practice is. And binge drinking is now grabbing the attention of researchers, politicians and public health officials the world over.

Binge drinking is nothing new. "Drinking to the point of impairment is as old as alcohol," says Timothy Naimi at the Centers for Disease Control and Prevention in Atlanta, Georgia. But for some reason it is rapidly on the rise, up 35 per cent in the US between 1995 and 2001, according to a study by Naimi and his colleagues. And as anyone who has picked up a newspaper or watched TV recently knows, attitudes toward this kind of drinking are changing fast, too.

In the past, "problem drinkers" basically meant alcoholics - people who are addicted to alcohol. Lads down the pub or students wasted in dorms were just having a bit of fun. Public spending in the US still reflects that thinking: most government funds earmarked for alcohol-related problems go to treat alcoholism, but only 3 to 4 per cent of the adult population is actually alcoholic, says Naimi. "There's a growing realisation," he says, "that the lion's share of alcohol-related problems stem from those who drink excessively, but who aren't alcoholic per se." It is now clear that what is important about alcohol is not just how much you drink, but how you drink it.

Most people don't consider themselves binge drinkers - even those who are. According to Naimi, about half of all binge-drinking episodes occur among otherwise moderate drinkers. Clearly, obnoxious lager louts are not the only transgressors. In fact, even the notion that predominantly wine-drinking nations like France and Spain are keeping consumption under control is a myth, says Jurgen Rehm of the Centre for Addiction and Mental Health in Toronto. In his opinion, almost without exception, people everywhere regularly drink too much too quickly. "Binge drinking is the style of drinking for most of the world," he says.

Earlier this year, the US National Institute on Alcohol Abuse and Alcoholism (NIAAA) finally agreed on a formal definition for the behaviour. For study purposes at least, a "binge" is a pattern of drinking that brings blood alcohol concentration to 0.08 per cent or above. That is, for every 100 millilitres of blood in your body, there's at least 80 milligrams of the hard stuff sloshing around in there with it. Though individual responses to booze vary enormously, that amount of alcohol would make most people feel noticeably drunk.

So how much would that translate into at the bar? The NIAAA reckons that "typical" males reach this level after socking back five or more standard drinks in two hours, while "typical" females get there after four or more standard drinks. And that's not difficult, as a standard drink is very much on the small side: a diminutive glass of wine, one bottle of American beer or an Australian schooner, about two-thirds of a British pint, or a mere splash from a Russian's standard vodka glass.

Bingeing is different from other drinking patterns. It bears little resemblance to, say, savouring the fine bouquet of a favourite wine. It's only a very distant cousin to that time-honoured practice of unwinding after a hard day's work. It is even distinct from a "bender" which, according to the NIAAA, involves two or more days of sustained heavy drinking. Nor is it addiction. Binge drinking is basically fast, excessive boozing. Some people slide into the habit unawares, but for many, especially college kids and sports fans, it's a very goal-oriented ritual where the aim is simply to get soused. Put simply, it's "drinking to get drunk".

The numbers - and there are lots of them - are sobering. Among 21 to 25-year-olds in the US, for instance, about 32 per cent reported regular bouts of intense drinking in 2001, according to Naimi's survey (The Journal of the American Medical Association, vol 289, p 70). Henry Wechsler at the Harvard School of Public Health in Boston says the figure's even higher for university students - about 44 per cent of them binge at least once in a typical two-week period. Naimi's team estimates that across the US population, there are some 1.5 billion binge-drinking episodes each year.

In the UK too, it is now widely acknowledged that binge drinking is getting out of hand. In June this year, the Home Secretary, David Blunkett, warned his Cabinet colleagues that a "summer of violence" lay ahead. The comment followed a week of alcohol-fuelled violence in England and the Algarve during the Euro 2004 football competition in Portugal. British government officials have recently been blaming binge drinking for an increase in "thuggery", and have been muttering about new temperance laws to ban drunken yobs from pubs if they are convicted of three drink-related offences over a 12-month period.

The UK charity Alcohol Concern estimates that binge drinking (which they define as 80 millilitres of alcohol in a single session for men and 6o for women) accounts for 40 per cent of all drinking occasions among men and 22 per cent among women - and for women the figure is rising. About a third of young people aged 16 to 24 binge at least once a week, they say.

Australia, too, has problems. Tim Stockwell, director of the National Drug Research Institute at Curtin University of Technology in Perth, has estimated that about 51 per cent of all alcohol drunk in Australia is consumed in binges (Medical Journal of Australia, vol 176, p 91). It is worth noting that Stockwell defined a binge as more than 60 grams of alcohol in a day for men or 40 grams in a day for women, which is lower than the US definition. In Russia, intensive drinking is practically the only kind there is.

Binge drinking has consequences that fall, broadly speaking, under the rubric of either public safety or public health. In terms of safety, drinkers imperil both themselves and others. In 2002, for instance, almost 15,000 Americans died on the roads as the result of binge drinking. Binge drinkers, notes Naimi, are 14 times as likely to drive while impaired as people who do not engage in the behaviour.

The impacts of binge drinking are probably best known from studies of its American hotbed: universities. Wechsler says that when compared to institutions where the majority of people do not overindulge, universities where more than half the student body routinely binge drink are twice as likely to have brawls, sexual assaults, noise and vandalism. Frequent binge drinkers, who were defined by Wechsler as students who got sloshed three or more times in a two-week period, were 17 times as likely to miss a class, 10 times as likely to vandalise property, and eight times as likely to get hurt or injured as their more sensible fellow students. "Heavy episodic drinking is the most significant health issue facing college kids," says Wechsler, "both the drinkers and the people around them."

Get drunk for less

In the UK, the issue seems to be less a problem of centres of higher learning than of centres of cities. With cut-throat competition between bars offering happy hours and special promotions, drinkers are finding it increasingly easy to get blotto fast. Bingers can become so unruly that ordinary folk are afraid to go out. According to a report by the Prime Minister's strategy unit, 70 per cent of people think alcohol has created problems of public disorder and violence near where they live. Almost half of all victims of violence report that perpetrators were under the influence.

And on top of the social ills and injuries directly related to booze, binge drinkers are seriously compromising their health. Everyone has heard that alcohol is good for the heart, but few are aware that too much alcohol can harm it. "Any of the positive effects from moderate drinking - which are, by the way, vastly overstated - are gone with binge drinking," says Naimi. Work by Martin McKee at the London School of Hygiene and Tropical Medicine, for instance, found that binge drinking did not produce the known cardioprotective effects associated with moderate drinking - even if the bingers drank the same amount or less overall than the moderate drinkers. Bingeing was linked to increased risk of thrombosis, high blood pressure and sudden cardiac death.

Calling Time, a report published in March by the UK's Academy of Medical Sciences, draws attention to the fact that per capita consumption of alcohol in the UK has doubled since the late 1950s, while in countries like France and Italy it has more than halved. The AMS points out that in the UK, overall consumption is tightly linked to binge drinking: when one goes up, so does the other. The increase is reflected in rising death rates from chronic liver disease, the primary cause of which is too much drink. In the 30 years between 1970 and 2000, death by cirrhosis for people aged 25 to 44 rose an astonishing 900 per cent, from about 80 cases a year to more than 700.

A newly released study has found that binge drinking may be behind a lot of the damage, especially in women. Saverio Stranges at the State University of New York in Buffalo asked 2943 people aged between 35 and 80 for details about their drinking habits. He also tested for markers of liver disease. "Our findings suggest that how and when drinkers consume alcohol may be as important to a healthy liver as the amount consumed," he says. Women who drank only on weekends, even if they drank less overall than other women, had higher levels of markers for liver disease, he found (Alcoholism: Clinical and Experimental Research, vol 28, p 949).

Copious amounts of wine

The first clues that patterns of drinking were as important as the quantities drunk came from Mediterranean countries, where people drink wine copiously, but spread consumption out over the week and tended to drink with meals. They actually fared better in terms of coronary heart disease than non-drinkers. For years people insisted that it was just that wine was healthier than other tipples, and the search was on for the magic ingredient. But more recently, studies comparing the boozing habits of Czechs, who drink beer the way a lot of people drink wine - daily, and often with meals - and Russians, who drink less overall but tend to drink it in foodless bouts, confirm that it is pattern, not alcohol type, that is important. "We have not paid enough attention to binge drinking," says Rehm. In most studies on alcohol, data on intake for single occasions was not even collected. "There's been this dogma that it's overall volume of alcohol that is important," he says. "This is where science has failed."

What we do know is that males the world over are the primary bingers, and younger males tend to be the worst. There are a few exceptions - nordic women, for example, keep pace with their men. We also know that the earlier a person starts to drink, the more likely they are to become a binge drinker and that if someone starts bingeing early, they are more likely to continue bingeing later in life. Worst of all, kids who start bingeing before the age of 15 are more likely to become alcohol-dependent. And this is not just bad genes: animal studies have found that even a creature not genetically predisposed to alcohol addiction can acquire a serious dependence on the stuff if it binges enough while young.

There are also alarming hints that high doses of alcohol are more injurious to young brains than to more mature ones. Sandra Brown and Susan Tapert at the University of California in San Diego have found that adolescents with a history of heavy drinking have problems with verbal and spatial memory. Brain scans reveal that their brain activity during certain tasks is quite different from that of carefully matched controls. Fifteen and 16-year-old former binge drinkers activate their brains in a more diffuse and intense way. A few years later, says Brown, the activation dwindles and is much less than what's seen in controls.

"One hypothesis is that initially the brain tries to compensate for the effects of alcohol," says Brown, "but in time, it is impaired to the extent that it can no longer do so." The big concern is that alcohol is disrupting the normal course of neurological development.

It is difficult to fathom what drives people to drink to utter excess. Group dynamics, stress, anger, opportunity - they probably all play a role. But there's no mystery about how to curb this kind of boozing. In Alcohol - No Ordinary Commodity, a book part-funded by the World Health Organization, a group of leading alcohol researchers headed by Thomas Babor, director of the Alcohol Resource Center at the University of Connecticut in Farmington, argue that we know which policies are likely to be most successful. Now all that's needed is to put them into practice. The authors rate 32 policy options according to effectiveness, applicability across countries, strength of the research and cost in terms of time, resources and money. Top of the pile, they conclude, are increasing the price of booze and limiting its availability.

Almost everywhere in the world, it is notable that the real price of alcohol, which takes inflation into account, has fallen dramatically in the past few decades. In the UK today, alcohol costs roughly half in real terms what it did in the 1970s (see Graph). Similarly, between 1975 and 1990, the real price of beer in the US fell by 20 per cent, wine by 28 per cent and spirits by 32 per cent, according to calculations by Frank Chaloupka, an economist at the University of Illinois in Chicago.

True, most other consumer goods have gone down in price over that time too. But governments everywhere have shown a serious reluctance to keep taxes on alcohol in line with inflation, let alone use them to temper soaring rates of drinking. In 1990, US federal excise taxes were raised on beer and wine for the first and only time since 1951.

Chaloupka has been studying the effect of price on alcohol for some years, comparing alcohol prices in different US states and seeing whether drinking patterns correlate with them. A central principle in economics is that as the price of a product goes up, demand for it will go down. And that is essentially what they have found for alcohol. Even better, raising the price of alcohol, they have shown, also reduces alcohol-related dangers such as car accidents, liver disease, violence and crime.

What's more, younger kids with less money are the most sensitive to price hikes. "A key finding is that increases in prices are effective in reducing not just drinking," says Chaloupka, "but binge drinking, especially in kids." That's especially good news because younger drinkers tend to be more influenced by group behaviour. So Chaloupka expects there are not just the pure effects of getting an individual consumer to buy less, but spillover effects too: if your buddies can't buy more beer, you may not bother either.

Other real world experiments are turning up some of the same results. In 1999, for instance, Switzerland opened up its import market for distilled spirits to comply with the World Trade Organization. Lower taxes plus more competition meant the price of spirits decreased by 30 to 50 per cent. Rehm and his colleagues surveyed 4007 people about their consumption and purchase of spirits both three months before the prices dropped and 28 months after. On average, respondents drank over a third more (Alcoholism: Clinical and Experimental Research, vol 27, p 720).

Oddly, when Tony Blair's strategists published their final document, Alcohol Harm Reduction Strategy for England, in April, they ruled out using price to influence alcohol consumption. They acknowledge a "clear association between price, availability and consumption", but argue that demand for alcohol is too complicated to try to manipulate in this way. In fact, the strategy eschews all the top 10 recommendations made by Babor and his team, which in addition to raising alcohol taxes, include restricting the hours or days of sale, lowering the blood alcohol limits for driving and restricting the density of retail outlets. Yet all these binge-promoting factors are actually set to get worse: the UK has the highest legal limit for drivers' blood alcohol in Europe. "What it offers is a recipe for ineffectiveness at the national level," says Robin Room, director of the Centre for Social Research on Alcohol and Drugs at Stockholm University in Sweden and co-author of No Ordinary Commodity. "There is almost total correspondence between the measures proposed in the strategy's recommendations and the measures ranked in the listing as 'ineffective'. They are all there in the strategy: school education, voluntary advertising codes, even a half-hearted discussion of alternative entertainment for youth," he writes in a forthcoming issue of Addiction.

To be fair, raising the price of booze and closing down or nationalising liquor stores are not the savviest decisions a politician can make. And that's the problem. We the electorate like our tipple just a bit too much. But that's no reason for despair: people can change. In Samuel Pepys's day, ale was served with breakfast; now it's not. In my dad's day, driving home drunk was OK; now it's not. Slow, perhaps. But progress it appears to be.

The binge effect

What five drinks in 2 hours does to your body

Time since start of binge: 15 mins
Drinks consumed: 1
Blood alcohol level: approximately 10 mg/ml

Effects: you may feel like you're relaxing, but you're actually winding up - low doses of alcohol increase neural activity. You have that comfortable feeling

Time since start of binge: 35 mins
Drinks consumed: 2
Blood alcohol level: approximately 50 mg/ml blood

Effects: still pumped. Your brain's reward circuitry is now all lit up. You're chatty and uninhibited

Time since start of binge: 60 mins
Drinks consumed: 3
Blood alcohol level: approximately 70 mg/ml blood

Effects: now you may be genuinely feeling more relaxed - your brain waves are showing more of the slow "alpha" type. A part of your brain responsible for remembering things, the hippocampus, is slowing down, as is the thalamus, charged with filtering sensory information. You're feeling woozy

Time since start of binge: 90 mins
Drinks consumed: 4
Blood alcohol level: approximately 80 mg/ml blood

Effects: you're feeling a little sedated and a lot clumsy. Blood flow to your cerebellum, the part of the brain that handles motor control, and to your occipital lobe, which handles vision, has slowed right down Face it, you're quite drunk

Time since start of binge: 120 mins
Drinks consumed: 5
Blood alcohol level: way too much

Effects: you're too far gone to realise there's really no good reason to drink this much this quickly. You've even blown your chance of a good night's sleep (alcohol suppresses REM) and you're up for a bad headache as your body starts metabolising the booze