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Binge Drinking: The Five/Four Measure


In December 1994, the Harvard School of Public Health College Alcohol Study (CAS) published the first of its reports on binge drinking by American college students (Wechsler et al., 1994). Binge drinking was selected as the main measure of alcohol use in this study because of its implications for accompanying risks for health and safety. It was defined as the consumption of five or more drinks in a row for men and four or more for women at least once during the 2 weeks preceding the survey. A five-drink measure is not new. In their 1969 report on American drinking, Cahalan et al. proposed five or more drinks in a sitting as a meaningful threshold for evaluating the social harm associated with drinking. The University of Michigan's Monitoring the Future project, which began as a prospective sequential cohort study of the health behavior of high school seniors, has been using the five-drink measure since 1975 (Johnston et al., 1996). In fact, more than a decade ago, in an article on the Monitoring the Future data, O'Malley et al. (1984) tentatively referred to this level of consumption as "binge" drinking. The gender distinction was added by the CAS to take into account differences in the proportions of men and women experiencing alcohol-related problems at various drinking levels. The five/four drink measure may reflect gender differences in rates of alcohol metabolism.

Since the publication of the CAS findings, the concept of binge drinking as defined by the five/four measure has gained widespread public exposure. A search of over 250 newspapers in the Lexis/Nexus news database found that, after the release of the CAS results, there was more than an 11-fold increase in mentions of college and/or university binge drinking in the American and international English-language print lay media, increasing from 10 in November 1994 to 115 the next month. The totals for 1991 and 1992 were 41 and 78, respectively. The year total for 1994 (240) was five and a half times greater than that for 1993 (43). In 1995, the number increased again to 336. and in 1996 it was 298. (Our thanks to Deanna Byck for conducting this search).

Concurrent with increased use of this concept of binge drinking, some objections have been voiced regarding the definition of this measure. This issue was first raised when the Journal of Studies on Alcohol accepted an article on second-hand effects of binge drinking but only on the condition that we change the term binge drinking to heavy episodic drinking (Wechsler et al., 1995). We reluctantly complied and indicated in a footnote that the term was changed at the request of the journal. The JSA action was based on past usage of the term binge by some clinicians to describe the prolonged drinking bouts of alcoholics. Such periods of continuous drinking can last for weeks and certainly for longer periods than the time needed to consume five drinks (When is a binge, 1996). But clinicians did not invent the term binge, and their definition of an alcoholic binge is not the only, nor the most commonly used, one. In other contexts, binge carries no requirement that the behavior be carried out over such a long period of time. In DSM-IV, the term has applications beyond alcohol abuse (American Psychiatric Association, 1994). In the classification of eating disorders, episodes of excessive eating, which typically last less than 2 hours, are labeled binges. Dictionaries generally define binge as a "drunken celebration" or "excessive indulgence," synonymous with "orgy" and "splurge," with no duration prerequisite.

Semantics aside, the more fundamental concern should be whether the five/four-drink benchmark truly represents a threshold for alcohol-related social consequences. Working with data from a sample of over 20,000 current drinkers in the United States, Midanik et al. (1996) found that the risk of driving after drinking, alcohol-related employment problems and ICD-10 alcohol dependence was significantly higher for people who reported consuming five or more drinks in a row at least once in the previous year compared to people who did not report having five or more drinks in a row. The risk of driving after drinking, alcohol-related job problems and ICD-10 alcohol dependence rose most sharply for those persons who reported having five or more drinks in a row at the lower end of the frequency range from once in the previous year to about once per week and then leveled off for those consuming five or more drinks in a row any more frequently.

Midanik et al.'s findings provide evidence that the five-drink measure is a meaningful threshold in terms of the risk of social consequences of drinking patterns. Midanik and several other researchers whose comments appear in the same issue as her article stress the importance of choosing a measure of alcohol consumption that is appropriate for the consequences of interest (Makela, 1996; Midanik et al., 1996; Rehm and Bondy, 1996; Room, 1996). Consumption measured in volume is associated with chronic illness, and medical epidemiologists often find it informative to quantify alcohol consumption in this way. In the context of social consequences, volume, as a summary measure, masks the more critical relationship between drinking patterns and social harm. In fact, there does not appear to be a clear threshold in the risk of social consequences when volume is used as the consumption measure. Variation in drinking patterns is far more illuminating when one is considering outcomes such as drunk driving and job problems than is the average volume of alcohol consumption. Using data from the Centers for Disease Control Behavioral Risk Factor Surveillance System. Duncan (1997) found that DWI rates were significantly related to rates of binge drinking but not to chronic drinking (i.e., total volume consumed).

From another perspective, a letter to the editor published in 1995 in the Journal of the American Medical Association in response to the Wechsler et al. (1994) article stated that the use of the five/four measure "problematized" drinking behavior that is common on college campuses. "There is little gained," the authors wrote, "(and perhaps more lost) with college students when normative behavior (44%) is labeled, viewed, or treated as pathological or when the phenomenon of college student drinking is compared with alcohol-dependent persons who binge involuntarily" (Dimeff et al., 1995). These comments ignore our important finding that, though it may be normative at many colleges, binge drinking has a significant negative impact on health and safety on America's campuses. We found the five/four measure of binge drinking to be significantly associated with greatly increased risk of alcohol-related social consequences (Wechsler et al., 1994). Students who binge drank one to two times (infrequent binge drinkers) or more than two times (frequent binge drinkers) in the last year had five times and ten times greater odds, respectively, of driving after drinking when compared to students who consumed alcohol in the past year but did not binge drink (nonbinge drinkers). Infrequent and frequent binge drinkers had five times and 25 times greater odds, respectively, of experiencing five or more different alcohol-related problems since the start of the academic year when compared to nonbinge drinkers. Nearly half (47%) of frequent binge drinkers experienced five or more alcohol-related problems, whereas only 3% of nonbinge drinkers did. In fact, 92% of the students who reported five or more alcohol-related problems in the previous year were identified by the five/four measure as binge drinkers.

Another objection to the five/four drink measure is that, because it is sufficiently low to include 44% of students, it will have the unintended effect of validating those who are inclined to drink heavily. Students will be led to think the argument goes that "Everybody else is doing it, so it must be OK." The flaw in this argument is that students already believe binge drinking is normative. Administrators conducting a survey of their students at a private northeastern university found that most do not view consuming up to nine drinks in a row to be problematic and that it is only when a person reaches for the tenth that he or she can be viewed as abnormal or deviant.

Making believe there is not much binge drinking at colleges by defining it out of existence will not make it go away. Recognizing that it is there and confronting it is the appropriate action. Let us not practice the same form of denial we attribute to people with alcohol problems.


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Harvard School of Public Health
Boston, Mass.

Wechsler H, Austin SB.

Original Publication:
Journal of Studies on Alcohol. 1998; 59: 122-123.