Intemperate society
New Scientist, 21 August 2004
ALISON MOTLUK
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