Binge drinking

New Year's Eve is traditionally a time when many drink excessive amounts of alcohol. This picture is from a 1912 postcard mailed in the United States.

Binge drinking is the modern definition of drinking alcoholic beverages with the primary intention of becoming intoxicated by heavy consumption of alcohol over a short period of time.[1] It is a kind of purposeful drinking style that is popular in several countries worldwide, and overlaps somewhat with social drinking since it is often done in groups. The exact degree of intoxication, however, varies between and within various cultures that engage in this practice. A binge on alcohol can occur over hours or last up to several days.[2] Due to the long-term effects of alcohol misuse, binge drinking is considered to be a major public health issue.[3]

Binge drinking is associated with a profound social harm, economic costs as well as increased disease burden. Binge drinking is more common in males, during adolescence and young adulthood. Most binge drinkers are not familiar with the risks associated with binge drinking. Heavy regular binge drinking is associated with adverse effects on neurologic, cardiac, gastrointestinal, hematologic, immune, psychiatric and musculoskeletal organ systems.[4][5] Up to one third of adolescents binge drink, with six percent reaching the threshold of having an alcohol related substance use disorder.[6] Approximately one in twenty five women binge drink during pregnancy, which can lead to fetal alcohol syndrome and fetal alcohol spectrum disorders.[7] Binge drinking during adolescence is associated with traffic accidents and other types of accident, violent behavior as well as suicide. The more often a child or adolescent binge drinks and the younger they are the more likely that they will develop an alcohol use disorder including alcoholism. A large number of adolescents who binge drink also consume other psychotropic substances.[8]

Contents

Definition

Binge drinking is defined as episodic excessive drinking.[8] There is currently no world wide consensus on how many drinks constitute a "binge",[2] but in the USA, the term is often taken to mean consuming five or more standard drinks (male), or four or more drinks (female), in about two hours for a typical adult.[9][10] In the United Kingdom, binge drinking is defined as drinking more than twice the daily limit, that is, drinking eight units or more for men or six units or more for women.[11]

Other, less common definitions are based on blood alcohol concentration (BAC). For example, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recently redefined the term "binge drinking" as any time one reaches a peak BAC of 0.08% or higher as opposed to some (arguably) arbitrary number of drinks in an evening.[12] One study showed that university students often have numerous different definitions of "binge drinking" depending on their drinking habits, with drinkers having significantly higher definitions than nondrinkers.[13] Whatever the numerical definition used, heavy drinking or rapid consumption over a short period of time with the intention of becoming intoxicated is often implied when the term is used colloquially, since one can remain relatively sober if the four or five drinks are spread out widely over the course of a long evening.[14]

In the United States, sometimes the term "extreme drinking" or "industrial-strength bingeing" is used to describe a more severe form of (single-evening) binge drinking; it is often defined as ten or more standard American drinks on a single occasion (sometimes as eight drinks for women).[15][16] If done over 2 to 3 hours, a typical adult would have a peak BAC of at least 0.20%.

Health effects

Background

Acute intoxication, such as binge drinking, and alcoholism are known potent risk factors for suicide.[17] Binge drinking is commonly associated with damaged and lost friendships, accidents, law-breaking (especially vandalism and violence), arguments, neglect of obligations, and other acts that are later regretted. Binge drinking is also associated with an increased risk of unplanned sex, unprotected sex, unplanned pregnancies, and an increased risk of HIV infection. 10 percent of women and 19 percent of men have reported being assaulted as a result of alcohol. Males who drink more than 35 units of alcohol per week report being physically hurt as a result of alcohol, and 15 percent report physically hurting others as a result of their drinking. Almost 16 percent of binge drinkers report being taken advantage of sexually, and 8 percent report taking advantage of another person sexually as a result of alcohol within a 1 year period. Binge drinking can cause adverse effects on the body including effects on blood homeostasis and its circadian variation, cardiac rhythm, ischaemic heart disease, blood pressure, white blood cell activity, female reproductive hormone levels as well as adverse effects on the fetus. There is also evidence from animal studies that binge drinking causes brain damage.[18] Binge drinking has been associated with lower abdominal pain in women.[19] Ketoacidosis can occur in individuals who chronically abuse alcohol and have a recent history of binge drinking.[20]

Adolescence and young adulthood

The high levels of binge drinking among young people and the adverse consequences which includes increased risk of alcoholism as an adult and liver disease make binge drinking a major public health issue.[3] Recent research has found that young college binge drinkers who drink 4/5+ drinks on more than 3 occasions in the past 2 weeks are statistically 19 times more likely to develop alcoholism than non-binge drinkers, though the direction of causality remains unclear.[21] Heavy and regular binge drinking during adolescence is associated with an increased risk of alcoholism. Approximately 40 percent of alcoholics report heavy drinking during adolescence.[22] Repeated episodes of excessive drinking, especially at an early age, are thought to cause a profound increase in the risk of developing an alcohol-related disorder (ICD-10, harmful use/dependence syndrome). Other risk factors which influence the development of alcohol abuse or alcoholism include, social and genetic factors. Several researchers have found that starting drinking before the age of 15 is associated with a fourfold increased risk for developing alcoholism compared to people who delay drinking until age 20 or later. It has been estimated by some that if the age at which people started drinking could be delayed to age 20, there would be a 50 percent reduction in the number of cases of alcohol use disorder.[8] However, it is unclear whether this is a causal relationship, or a function of confounding familial (and other) factors associated with both age at first drink and propensity for alcoholism.[23]

The main cause of death among adolescents as a result of binge drinking is road traffic accidents; a third of all fatal road traffic accidents among 15- to 20-year-olds are associated with drinking alcohol. Riding a bicycle without a helmet is more common in adolescents who are binge drinkers and additionally adolescents who binge drink more commonly drink drive or are the passenger of a drink driver. It has been found that 50 percent of all head injuries in adolescents in the USA is associated with alcohol consumption. Violence and suicide is the third most common cause of death associated with binge drinking among adolescents. The suicide risk in adolescents is more than 4 times higher among binge drinkers than non-binge drinking adolescents.[8]

Earlier sexual activity, increased changing of sexual partners, higher rate of unwanted (teenage) pregnancy, higher rate of sexually transmitted diseases, infertility, alcohol-related damage to the fetus is associated with binge drinking. Female binge drinkers are three times more likely to be victims of sexual assault; 50 percent of adolescent girls reporting sexual assault were under the influence of alcohol or another psychotropic substance at the time.[8]

Adolescents who regularly binge drank for several years show a smaller hippocampus brain region, particularly those who began drinking in early adolescence. Heavy binge drinking is associated with neurocognitive deficits of frontal lobe processing and impaired working memory as well as delayed auditory and verbal memory deficits. Animal studies suggest that the neurodegenerative effects of alcohol abuse during adolescence can be permanent,[8] though whether such outcomes carry over to humans remains unclear.

Central nervous system

Heavy binge drinkers tend to have delayed auditory and verbal memory and deficits in executive planning function and episodic memory, which are similar to deficits seen in Korsakoff's syndrome. Impairments in spatial working memory and pattern recognition tasks also have been found in heavy binge drinkers. Impulse control is also impaired in binge drinkers, especially female binge drinkers. Additionally immediate and delayed recall of verbal and visual information are impaired; conversly, semantic organizational ability is better in binge drinkers compared to non-binge drinkers. Studies in adolescents have shown that regular binge drinking may cause long-lasting cognitive impairments, though the threshold needed to produce significant effects remains unclear. Cognitive impairments in adults is also unclear as one study found no association with binge drinking and cognitive impairments.[21]

Binge drinking is also thought to cause impulsivity due to altered functioning of prefrontal–subcortical and orbitofrontal circuits. Binge drinking and alcoholics who have undergone multiple detoxifications is associated with an inability to interpret facial expressions properly; this is believed to be due to kindling of the amygdala with resultant distortion of neurotransmission. Adolescents, females and young adults are most sensitive to the neuropsychological effects of binge drinking. Adolescence, particularly early adolescence, is a developmental stage which is particularly vulnerable to the neurotoxic and neurocognitive adverse effects of binge drinking due to it being a time of significant brain development.[11]

Repeated acute intoxication followed by acute withdrawal is associated with profound behavioural changes and neurobiological alterations in several brain regions. Much of the documented evidence of kindling due to multiple detoxifications regards increased seizure frequency. Increased fear and anxiety and cognitive impairments are also associated with alcohol withdrawal kindling due to binge drinking or alcoholics with multiple alcohol withdrawal experiences. Impairments induced by binge drinking or multiple detoxifications of alcoholic individuals causes a loss of behavioural inhibition of the prefrontal cortex; the prefrontal cortex is mediated by subcortical systems such as the amygdala. This loss of behavioural control due to brain impairment predisposes an individual to alcoholism and increase the risk of an abstaining alcoholic relapsing and additionally this impairment may result in a long-term adverse effects on emotional behaviour. Impaired associative learning may make behavioural therapies involving conditioning approaches for alcoholics less effective.[11]

Binge drinkers and alcoholics with multiple detoxifications have impairments in executive control tasks sensitive to dysfunction of prefrontal cortex. Animal studies show that repeated withdrawals are associated with an inability to learn new information. The mechanims of neurotoxicity and kindling of neurotransmission systems is due to alcohol's acute effects on GABAergic enhancement and NMDA suppression, leading to CNS depression leading to a partial acute tolerance to these effects, followed by a rebound effect, during acute withdrawal due to the partial tolerance that developed. The acute withdrawal/rebound causes the neurotransmission systems to go into a hyper-excitability state; if this hyper-excitability state occurs multiple times, kindling and possible neurotoxicity can occur. There is some evidence that excitotoxicity may also result as a result of repeated withdrawals. Similar to people who have been detoxified multiple times from alcohol, binge drinkers show a higher rate of emotional disturbance.[11]

Binge drinking regimes are associated with causing an imbalance between inhibitory and excitatory amino acids and changes in monoamines release in the central nervous system, which increases neurotoxicity and may result in cogitive impairments, psychological problems and in long-term heavy binge drinkers may cause irreversible brain damage in both adolescents and adults.[24][25]

While several rat studies indicate that alcohol is more toxic during adolescence than adulthood, some researchers believe that it remains unclear whether this is also the case in humans. Though heavy binge drinking adolescent humans show impaired brain activity during memory tests and underdeveloped brain structures compared to adolescents who did not binge drink, they argue that these findings are similar to adult alcoholics who did not abuse alcohol during adolescence.[26] Extrapolation from animal studies to humans is notoriously difficult,[27] and a review by the group Choose Responsibility concluded that alcohol's long-term damage to cognitive processes was the same regardless of whether heavy drinking commenced during adolescence or later.[26]

Pregnancy

Binge drinking is a more important factor rather than average alcohol intake, with regard to the severity of alcohol induced damage to the fetus. Alcohol has definite long-term adverse effects on the fetus, in particular impaired attentional skills and may lead to psychiatric disorders when the child grows up.[28] Approximately one in five nonpregnant women binge drink and one in twenty five pregnant women binge drink.[7] Binge drinking during pregnancy is associated with fetal alcohol syndrome, alcohol-related birth defects as well as alcohol-related neurodevelopmental disorders. These effected children pregnancy can suffer mental retardation and problems with learning, memory, attention, problem solving and problems with mental health and social interactions. Deformaties in facial features, skeletal and body organs as well as a smaller head circumference are also sometimes present in these children.[29][30] Studies in sheep indicate that fetal neurotoxicity induced by alcohol may be due to acidaemia and hypercapnia.[31] Binge drinking three or more times during pregnancy has been associated with an increased risk of stillbirth.[24]

Sudden death

Binge drinking is also associated with strokes and sudden death.[32] Binge drinking increases the risk of stroke by 10 times.[1] In countries where binge drinking is commonplace, rates of sudden death at the weekend in young adults and middle aged people increase significantly.[33] The withdrawal phase after an episode of binge drinking is particularly associated with ischaemic stroke as well as subarachnoid haemorrhage and intracerebral haemorrhage in younger men. In individuals who have an underlying cardiac disorder a binge on alcohol increases the risk of silent myocardial ischaemia as well as angina.[34] Binge drinking has negative effects on metabolism, lipid profile, blood coagulation and fibrinolysis, blood pressure and vascular tone and is associated with embolic stroke and acute myocardial infarction. Due to these risks experts believe that it is extremely important to warn people of the risks of binge drinking.[35] Binge drinking by people who would otherwise be considered to be light drinkers is associated with an increased risk of cardiovascular problems and mortality.[36] Binge drinking increases cardiovascular toxicity due to its adverse effects on the electrical conduction system of the heart and the process of atherothrombosis.[37]

Urinary system

The bladder may rupture if overfilled and not emptied, however urination can alleviate this problem. This can occur in the case of binge drinkers who have consumed very large quantities, but are not aware, due to stupor, of the need to urinate. This condition is very rare in women, but does occur. Symptoms include localized pain and uraemia (poisoning due to reabsorbed waste). The recovery rate is high, with most fatalities due to septic blood poisoning. A person is more likely to urinate while passed out before the bladder ruptures, as alcohol relaxes the muscles that normally control their bladder.[38]

Acute hazards

The most common risk of consuming massive quantities of alcohol in a short period of time is a dangerously high blood alcohol level. The result is called alcohol poisoning (overdose), which can be fatal. Choking on (or inhalation of) vomit is also a potential cause of death, as are injuries from falls, fights, motor vehicle and bicycle accidents.

Cause

In adults, binge drinking is more common in people who have never been married, score a grade B or less in education, and is also higher in adults who have little interest in religion.[21] Culture as well as peer pressure play an important role in driving binge drinking.[4]

The reasons for binge drinking by children and adolescents include;[8]

Other causes include feeling more grown up and fitting in with peers and to increase the chance of sexual encounters. Some also drink to alleviate stress or anxiety.[8]

Risk factors for binge drinking among adolescents include; low socioeconomic status, large amount of disposable (pocket) money, sensation/novelty seeking, low self-control, delinquency and having delinquent friends. Other risk factors include using alcohol as a coping strategy for emotional problems (more common in adolescent girls); excessive drinking among peers, poor relationship with parents, alcohol abuse by parents, genetic conditions combined with a background of negative environmental factors increase the harmful use of alcohol.[8] Additionally the risk taking behavior associated with adolescence promotes binge drinking.[39]

Pathophysiology

Impairments in impulse control in binge drinkers, which is more prominent in female binge drinkers, is due to dysfunction of the frontal lobe. The findings in humans have been largely concordant with animal studies. Such animal studies find that heavy and regular binge drinking causes neurodegeneration in corticolimbic brain regions areas which are involved in learning and spatial memory, such as the olfactory bulb, piriform cortex, perirhinal cortex, entorhinal cortex, and the hippocampal dentate gyrus. A study in rats found that a heavy 2 day drinking binge caused extensive neurodegeneration in the entorhinal cortex with resultant learning deficits. While brain damage from binge drinking is known to occur as a result of binge drinking patterns, it is unclear how long drinking sessions last and how regular binge drinking is done to cause brain damage in humans. One study found that humans who drank at least 100 drinks (male) or 80 drinks (female) per month (concentrated to 21 occasions or less per month) throughout a 3 year period had impaired decision making skills compared to non-binge drinkers. In the same study, an MRI brain scan found that levels of N-acetylaspartate (NAA) which is a metabolite biomarker for neural integrity was lower in binge drinkers and additionally found that brain metabolism was abnormal and found loss of white brain matter in the frontal lobe and higher parietal gray matter NAA. There was a correlation between binge drinking and poor executive functioning and working memory; frontal NAA loss was associated with impaired executive functioning and processing speed in neuro-performance tests. Repeated acute withdrawal from alcohol which occurs in heavy binge drinkers has been shown in several studies to be associated with cognitive deficits as a result of neural kindling; neural kindling due to repeated withdrawals is believed to be the mechanism of cognitive damage in both binge drinkers and alcoholics. Neural kindling may explain the advancing pathogenesis and progressively deteriorating course of alcoholism and explain continued alcohol abuse as due to avoidance of distressing acute withdrawal symptoms which get worse with each withdrawal. Multiple withdrawals from alcohol is associated with impaired long-term nonverbal memory impairment in adolescents and to poor memory in adult alcoholics. Adult alcoholics who experienced two or more withdrawals showed more frontal lobe impairments than alcoholics who had a history of one or no prior alcohol withdrawals. The findings of kindling in alcoholism is consistent with the mechanism of brain damage due to binge drinking and subsequent withdrawal.[21]

Blackouts, a form of amnesia which occurs in binge drinkers may be due to suppressed hippocampus function with rebound NMDA (glutamate) activity combined with excessive glucocorticoid release induced by the stress of repeated intoxication followed by acute withdrawal/abstinence is the proposed mechanism of neural kindling leading to neurotoxicity of structures involved in learning and memory within the brain of binge drinkers.[21] Frontal lobe processing may become impaired as a result of binge drinking with resultant neurocognitive deficits and impaired working memory.[21]

Alcohol suppresses brain function during intoxication; but upon withdrawal rebound effects occur in the glutamate/NMDA system and with excess glutamate activity glucocorticoid release; due to the repeated intoxication, followed by acute withdrawal a neurotoxic effect develops which damages the central nervous system, leading to persisting impairments in verbal and nonverbal cognitive abilities as well as impairment of spatial orientation. Due to developmental processes occurring during adolescence including myelinization and restructuring of the synapses, adolescents are thought to be more vulnerable to the neurotoxic effects of alcohol.[8]

Age and genetic factors influence the risk of developing alcohol related neurotoxicity.[39] Adolescence, especially early adolescence (i.e. before age 15), is a critical and delicate developmental stage for specialised neuronal and synaptic systems mature. This critical developmental stage is where life long adult traits e.g., talents, reasoning and complex skills mature; however alcohol and in particular binge drinking may disrupt and interfere with this developmental process. Adolescence is also a period of development characterised by a high level of novel seeking, thrill seeking and risk taking behaviour and thus alcohol and other drug experimentation and abuse is common.[40] An adolescent rat study found that a relatively short exposure to high levels of alcohol resulted long-lasting changes in functional brain activity with corresponding abnormalities in EEG brain waves which persisted into adulthood, including persisting disturbances in sleep EEG with a reduction in slow wave sleep. These EEG findings are similar to premature aging. According to one review of the literature, if the developmental stage of adolescence is similar to the developmental stage of the fetus with regard to sensitivity to the neurotoxic effects of alcohol, and if long-lasting or permanent damage to the brain occurs similar to what animal studies suggest, then this represents a major public health issue due to the high levels of alcohol use by adolescents.[41]

Brain damage

Binge drinking may induce brain damage due to the repeated cycle of acute intoxication followed by an acute abstinence withdrawal state.[42] Based on animal studies, regular binge drinking in the long-term is thought to be more likely to result in brain damage than chronic (daily) alcoholism. The reason for this is due to the 4 to 5-fold increase in glutamate release which is released during the acute withdrawal state in between binges. In contrast during withdrawal from chronic alcoholism only a 2 to 3 fold increase in glutamate release occurs. The high levels of glutamate release causes a chain reaction in other neurotransmitter systems. The reason that chronic sustained alcoholism is thought by some researchers to be less brain damaging than binge drinking is because tolerance develops to the effects of alcohol and unlike binge drinking repeated periods of acute withdrawal does not occur,[24][25] but there are also many alcoholics who typically drink in binges followed by periods of no drinking.[43] Excessive glutamate release is a known major cause of neuronal cell death. Glutamate causes neurotoxicity due to excitotoxicity and oxidative glutamate toxicity. Evidence from animal studies suggests that some people may be more genetically sensitive to the neurotoxic and brain damage associated with binge drinking regimes. Binge drinking activates microglial cells which leads to the release of inflammatory cytokines and mediators such as tumour necrosis factor, and nitric oxide causing neuroinflamation leading to neuronal destruction.[24][25]

The problems of alcoholism are well known, such as memory disorders, liver disease, high blood pressure, muscle weakness, heart problems, anaemia, low immune function, disorders of the digestive system and pancreatic problems as well as depression, unemployment and family problems including child abuse. Recently attention has been increasingly focused on binge drinking by adolescents and young adults due to neurochemical changes and brain damage which unlike with alcoholism can occur after a relatively short period of time; the damage is particularly evident in the corticolimbic region. This brain damage increases the risk of mood and cognitive abilities, increases the risk of dementia and additionally binge drinkers have an increased risk of developing chronic alcoholism.[24]

Diagnosis

For the purpose of identifying an alcohol use disorder when assessing binge drinking, using a time frame of the past 6 months eliminates false negatives. For example it has been found that using a narrow 2 week window for assessment of binge drinking habits leads to 30 percent of heavy regular binge drinkers wrongly being classed as not having an alcohol use disorder.[21] However, the same researchers also note that recall bias is somewhat enhanced when longer timeframes are used.[21]

Prevention

Binge drinking is considered harmful, regardless of a person's age, and there have been calls for healthcare professionals to give increased attention to their patients drinking habits, especially binge drinking.[44] Some researchers believe that raising the legal drinking age and screening brief interventions by healthcare providers are the most effective means of reducing morbidity and mortality rates associated with binge drinking.[45] Programs in the United States have thought of numerous ways to help prevent binge drinking. The Centers for Disease Control and Prevention suggests increasing the cost of alcohol or the excise taxes, restricting the number of stores who may obtain a license to sell liquor (reducing "outlet density"), and implementing stricter law enforcement of underage drinking laws.[12] There are also a number of individual counseling approaches, such as motivational interviewing and cognitive behavioral approaches, that have been shown to reduce drinking among heavy drinking college students.[46] In August 2008, a group of college presidents calling itself the Amethyst Initiative asserted that lowering the legal drinking age to 18 (presumably) was one way to curb the "culture of dangerous binge drinking" among college students.[47] This arguably counterintuitive idea is currently the subject of controversy. Proponents[48][49] argue that the 21 law forces drinking underground and makes it more dangerous than it has to be, while opponents[50] argue that lowering the age may only make the situation worse.

Treatment

Due to the risks especially in adolescents, of cognitive impairments and possible irreversible brain damage associated with binge drinking, urgent action has been recommended.[24] There is some evidence that interventions by employers such as, health and life-style checks, psychosocial skills training and peer referral, can reduce the level of binge drinking.[51] In the USA brief motivational interventions have shown some benefit in reducing future binge drinking.[8]

Adolescents who misuse alcohol can benefit from interventions aimed at risk reduction. For more severe cases a psychotherapeutic intervention involving parents or guardians is recommended.[52] An effective strategy of intervention for adolescents whose binge drinking leads to admission to hospital, e.g. for alcohol poisoning or injury, is manualised brief interventions at the hospital in one to four counselling sessions each lasting 30 to 60 minutes conducted by trained staff. Evaluation of personal pattern of drinking and associated risks and an emphasis on personal responsibility in a non-condescending mannor is recommended during the intervention; discussing and informing/educating the adolescent of possible negative short and long-term consequences of drinking is recommended. The setting of goals and rules to achieve those goals is also recommended during intervention with problem binge drinking adolescents.[8]

Increasing public information and awareness regarding the risks of binge drinking, conducting interviews in emergency departments of young people suspected of harmful drinking patterns and trying to persuade them to accept individual counseling in youth addiction counseling services are effective strategies for reducing the harm of binge drinking. Encouraging recreational training activities such as adventerous training activities such as climbing or driving can be an alternative "natural buzzes" to alcohol misuse. Additionally the provision of educational content about the risks of binge drinking and a risk assessment are benefitial during intervention with young binge drinkers and a referral in the case of an alcohol use disorder for specialised help.[8]

Epidemiology

Binge drinking is more common in men than it is in women. Among students in the USA approximately 50 percent of men and 39 percent of women binge drink. Racial differences exist among binge drinking with Hispanics followed by white people having the highest level of binge drinking. Individuals of African descent have a lower level of binge drinking followed by those of Asian descent. In the case of Asians their low level of binge drinking may be due to the presence of the aldehyde dehydrogenase gene (ALDH2, Chromosome 12) that results in poor metabolism of alcohol which leads to severe adverse effects such as facial flushing.[21] Men are more likely to binge drink (up to 81 percent of alcohol binges are done by men) than women and men are also more likely to develop alcohol dependence than women. People who are homozygous for the ALDH2 gene are less likely to binge drink due to severe adverse effects which occur even with moderate amounts of alcohol consumption, and this gene is common in Asian men.[21]

Australia

In 2004-2005, statistics from the National Health Survey[53] show that among the general population over 18; 88% of males and 60% of females engaged in binge drinking at least once in the past year, with 12% and 4%, respectively, doing so at least once a week. Among 18-24 year olds, 49% of males and 21% of females did so at least once a week. At the time, the definition for "binge drinking" corresponded to 7 or more standard Australian drinks per occasion for males and 5 or more for females, roughly equivalent to (but slightly less than) the 5/4 (standard American) drinks definition.[54]

In March 2008, the Australian government earmarked AUD$ 53 million towards a campaign against binge drinking, citing two studies done in the past eight years which showed that binge drinking in Australia was at what Prime Minister Kevin Rudd called "epidemic levels".[55] On June 15, the Australian Medical Association released new guidelines defining binge drinking as four standard Australian drinks a night.[56]

The last survey of drinking habits by the Australian Bureau of Statistics found there was an increase in drinking outside the home. In 1999, 34 percent of spending on alcoholic drinks took place on licensed premises. By 2004 this figure had risen to 38 percent. This figure is expected to fall in 2008 in Australia because of stricter licensing laws, smoking bans in pubs and the extra premium people have to pay for buying alcohol in a bar.[57]

Canada

Canadian binge drinking rates are comparable to the United States, and resemble most the geographically similar states that border on it. For example, 29% of 15-19 year olds (35% male, 22% female) and 37% of 20-24 year olds (47% male, 17.9% female) report having 5 or more drinks on one occasion, 12 or more times a year in 2000-01.[58]

In university, binge drinking is especially common during the first week of orientation, commonly known as "frosh week." The first ever known study comparing the drinking patterns of Canadian and American college students under age 25 (in 1998 and 1999, respectively) found that although Canadian students were more likely to drink, American students drank more heavily overall.[59] "Heavy alcohol use" was defined as usually having 5/4 drinks or more on the days that the person drinks in the past 30 days (American) or 2–3 months (Canadian). Among past year drinkers, 41% and 35% of American and Canadian students, respectively, reported participated in this behavior. Among the total sample, it was 33% and 30%, respectively. Differences included the lack of a gender gap in Canada compared with America, as well some as age-related differences. Canadians exceeded Americans in reported heavy alcohol use until age 19 (especially among the 1% percentage of students under 18), at which point Americans overtook and then began to exceed Canadians, especially among 21-22 year olds. After age 23, there was no longer much of a difference.[59] In Canada, the legal drinking age is 18 or 19, depending on the province.

A relatively popular drinking game among the Canadian skateboarders and heavy metal culture is "wizard sticks", in which drinkers tape a stack of their empty beer cans to the can from which they are currently drinking. The name comes from the fact that when the stack gets tall enough, it resembles a wizard's staff.[60]

Continental Europe

The drinking age in most countries is either 14 or 18, though in many countries national or regional regulations ban the consumption and/or the sale of alcoholic drinks stronger than beer or wine to those less than 18 years of age. Licensees may sometimes choose to provide beverages such as diluted wine or beer mixed with lemonade (shandy or Lager Top) with a meal to encourage responsible consumption of alcohol. It is generally perceived that binge drinking is most prevalent in the Vodka Belt (most of Northern and some of Eastern Europe) and least common in the southern part of the continent, in Italy, France, and the Mediterranean (the Wine Belt).[61] Using a "5-drink, 30-days" (5 standard drinks in a row during the last 30 days) definition, Denmark leads European binge drinking, with 60% of 15-16 year olds reporting participating in this behavior (and 61% reporting intoxication), and Turkey is the lowest in Europe at 15%.[62] However, there currently appears to be at least some convergence of drinking patterns and styles between the northern and southern countries, with the south beginning to drink more like the north more so than the other way around.

Malta

A notable exception to the lower rates of binge drinking in Southern Europe is the Mediterranean island of Malta, which has adopted the British culture of binge drinking, and where teenagers, often still in their early teens, are able to buy alcohol and drink it in the streets of the main club district, Paceville, due to a lack of police enforcement of the legal drinking age of 17.[63] In fact, statistics show that alcohol consumption in Malta exceeds that in the UK (but binge drinking is slightly lower and intoxication is significantly lower),[62] and report that Malta ranks 5th in the world in common binge drinking.[64] Maltese 15-16 year olds report binge drinking at a rate of 50%, using a 5-drink, 30-day definition, but only 20% report intoxication in the past 30 days.[62]

Spain

Since the mid 1990s the botellón has been growing in popularity among young people. Botellón, which literally means "big bottle" in Spanish, is a drinking party or gathering that involves consuming alcohol, usually spirits (often mixed with soft drinks), in a public or semi-public place (beaches, parks, streets, etc.). This can be considered a case of binge drinking since most people that attend it consume three to five drinks in less than five hours. Among 15-16 year olds, 23% report being intoxicated in the past 30 days.[62]

New Zealand

Concerns over binge drinking by teenagers has led to a review of liquor advertising being announced by the New Zealand government in January 2006. The review considered regulation of sport sponsorship by liquor companies, which at present is commonplace. Previously the drinking age in New Zealand was 20, then dropped to 18 in 1999.[65] In direct conjunction with the age-lowering, the Police were found to strictly enforce the on-license (bar, restaurant) code for underage-drinking, less so for the off-licences (liquor stores, supermarkets). As a result, young people ages 15–17 (ironically) found it significantly harder to get into (or be served at) bars and restaurants than it was before with a poorly enforced (though higher) drinking age of 20. This asymmetric enforcement led to a period of many of New Zealand's youth getting strangers to purchase high alcohol content beverages for them (e.g. cheap vodka or rum) at liquor stores.[66] A propensity to consume an entire bottle of spirits developed and led to an instant increase in the amount of youths under 18 being admitted to A&E hospitals. The price of alcohol at supermarkets and liquor stores had also gone down.[67] Alcohol remains cheap, and sweet, spirit-based ready to drink beverages (similar to alcopops) remain popular among young people.[68]

An example of this binge drinking mentality, often seen amongst university students, is the popularity of drinking games such as Edward Wineyhands and Scrumpy Hands, similar to the American drinking game Edward Fortyhands. A recent study showed that 37% of undergraduates binged at least once in the past week.[69] The New Zealand health service classifies Binge Drinking as anytime a person consumes 5 or more standard drinks in a sitting.

Russia

Binge drinking in Russia ("Zapoy" ("Запой") in Russian), often takes the form of two or more days of continuous drunkenness. Sometimes it can even last up to a week. One study found that among men ages 25–54, about 10% had at least one episode of zapoy in the past year, which can be taken as a sign that one has a drinking problem.[70] Almost half of working-age men in Russia who die are killed by alcohol abuse, reducing Russia's male life expectancy significantly.[71][72][73] Vodka is the preferred alcoholic beverage, and Russia is notably considered part of the Vodka Belt. However, using a 5-day, past 30 days definition, only 38% of Russian 15-16 year olds have binged and 27% became intoxicated, a percentage that is on par with other European countries, and even lower than some.[62]

Singapore

According to the National Health Survey 2004 conducted by the Health Promotion Board Singapore, binge drinking is defined as consumption of five or more alcoholic drinks over a short period of time.

The survey results showed that the frequency of binge drinking was 15.6% in males, 11.9% higher than that for females (3.7%). The largest proportion of males and females who binge drink fall within the 18 – 29 age group.

In 2007, Asia Pacific Breweries Singapore (APBS) spearheaded Get Your Sexy Back (GYSB), Singapore’s first youth-for-youth initiative to promote responsible and moderate drinking among young adults. The programme seeks to widen awareness and educate individuals about responsible drinking behaviour by raising the social currency of moderation. The programme engages youths in events and activities that are close to their lifestyles, focusing on four major platforms – Music, Fashion, Sports and Friends to spread the message of responsible drinking.

United Kingdom

In the UK, some areas of the media are spending a great deal of time reporting on what they see as a social ill that is becoming more prevalent as time passes. In 2003, the cost of binge drinking was estimated as £20 billion a year.[74] In response, the government has introduced measures to deter disorderly behavior and sales of alcohol to people under 18, with special provisions in place during the holiday season. In January 2005, it was reported that one million admissions to UK emergency department units each year are alcohol-related; in many cities, Friday and Saturday nights are by far the busiest periods for ambulance services.

The culture of drinking in the UK is markedly different from that of some other European nations. In mainland Europe, alcohol tends to be consumed more slowly over the course of an evening, often accompanied by a restaurant meal. In Scandinavia, occasional, heavy drinking sessions are the norm. In the UK (as well as Ireland), by contrast, alcohol is generally consumed rapidly, leading much more readily to drunkenness. In this way the British combine Northern European volumes of consumption with frequency resembling that of Southern Europe. This "drinking urgency" may have been inspired by traditional pre-midnight pub closing hours in the UK, whereas bars in continental Europe would typically remain open for the entire night. This may have stemmed from the Defence of the Realm Act 1914, emergency legislation dating back to the first world war regulating pub opening times with the intention of getting workers out of the pub and into the munitions factories. Consequently, it was criticised for being draconian and denying the working classes their pleasures. This is one of the reasons for introducing the Licensing Act 2003 which came into effect in England and Wales in 2005, and which allows 24 hour licensing (although not all bars have taken advantage of the change). Some observers, however, believed it would exacerbate the problem.[75] As of 2008, results have been mixed and inconsistent across the country.[76] However, among young people (under 25), binge drinking (and drinking in general) in England appears to have declined since the late 1990s according to the National Health Service.[77][78]

While being drunk (outside of a student context) in mainland Europe is widely viewed as being socially unacceptable[79], in the UK the reverse is true in many social circles. Particularly amongst young adults, there is often a certain degree of peer pressure to get drunk during a night out.[80] This culture is increasingly becoming viewed by politicians and the media as a serious problem that ought to be tackled, partly due to health reasons, but mostly due to its association with violence and anti-social behaviour.[81]

Using a 5-drink, 30-days definition, British 15-16 year olds binge drink at a rate of 54%, the fourth highest in Europe, and 46% report intoxication in the past 30 days.[62]

The British TV channel Granada produces a program called Booze Britain, which documents the binge drinking culture by following groups of young adults.

The severity of promiscuity and abortion incidents among teenage girls in the UK is related to binge drinking.[82]

United States

Despite having a legal drinking age of 21, binge drinking in the United States remains very prevalent among high school and college students. Using the popular 5/4 definition of "binge drinking", one study found that, in 1999, 44% of American college students (51% male, 40% female) engaged in this practice at least once in the past two weeks.[83] One can also look at the prevalence of "extreme drinking" as well. A more recent study of US first-semester college freshmen in 2003 found that, while 41% of males and 34% of females "binged" (using the 5/4 threshold) at least once in the past two weeks, 20% of males and 8% of females drank 10/8 or more drinks (double the 5/4 threshold) at least once in the same period, and 8% of males and 2% of females drank at least 15/12 drinks (triple the threshold).[84] A main concern of binge drinking on college campuses is how the negative consequences of binge drinking affect the students. A study done by the Harvard School of Public Health reported that students who engage in binge drinking experience numerous problems such as: missing class, engaging in unplanned or unsafe sexual activity, being victims of sexual assault, unintentional injuries, and physical ailments.[85] In 2008 the U.S Surgeon General estimated that around 5,000 Americans aged under 21 die each year from alcohol-related injuries involving underage drinking.[86] Rates of binge drinking in women have been increased; high risk drinking puts these women at increased risk of the negative long-term effects of alcohol.[87]

The population of people who binge drink mainly comprises young adults aged 18–29, although it is by no means rare among older adults. For example, in 2007 (using a 5-drinks definition per occasion for both genders), 42% of 18-25 year olds "binged" at least once a month, while 20% of 16-17 year olds and 19% of those over age 35 did so.[88] The peak age is 21. Prevalence varies widely by region, with the highest rates being in the North Central states.[89] The annual Monitoring the Future survey found that, in 2007, 10% of 8th graders, 22% of 10th graders, and 26% of 12th graders report having had five or more drinks at least once in the past two weeks.[90] The same survey also found that alcohol was considered somewhat easier to obtain than cigarettes for 8th and 10th graders, even though the minimum age to purchase alcohol is 21 in all 50 states, while for cigarettes it is 18 (and often poorly enforced in most states).

Social and culture

Binge drinking costs the UK economy approximately £20 billion a year; 17 million working days are estimated to be lost due to hangovers and drink-related illness each year. The cost of binge drinking to employers is estimated to be £6.4 billion and the cost per year of alcohol harm is estimated to cost the National Health Service £2.7 billion.[24] Urgent action has been recommended to understand the binge drinking culture and its aetiology and pathogenesis and urgent action has been called for to educate people with regard to the dangers of binge drinking.[24]

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