SPREADING OUT OR CONCENTRATING WEEKLY CONSUMPTION: ALCOHOL PROBLEMS AND OTHER CONSEQUENCES WITHIN A UK POPULATION SAMPLE

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1 Alcohol & Alcoholism Vol. 40, No. 5, pp , 2005 Advance Access publication 6 June 2005 doi: /alcalc/agh169 SPREADING OUT OR CONCENTRATING WEEKLY CONSUMPTION: ALCOHOL PROBLEMS AND OTHER CONSEQUENCES WITHIN A UK POPULATION SAMPLE PATRICK MILLER*, MOIRA PLANT and MARTIN PLANT Alcohol and Health Research Trust, Centre for Research in Public Health and Primary Care Development, University of the West of England, Glenside Campus, Blackberry Hill, Stapleton, Bristol BS16 1DD, UK (Received 20 September 2004; first review notified 7 November 2004; accepted in revised form 16 December 2004; advance access publication 6 June 2005) Abstract Aims: To consider the consequences, within a UK population sample, of consuming a given amount of alcohol weekly in one or two sessions as against spreading it out over several sessions. Methods: A new analysis of data from the UK components of the GENACIS survey of adults aged 18, was carried out. Results: At low levels of weekly alcohol consumption those subjects whose usual drinking frequency was several times per week ( spreaders ), if anything, reported more alcohol problems than those who consumed alcohol only once or twice per week ( bingers ). As weekly consumption increased above ~11 units per week bingers began to experience more problems than spreaders. At the highest levels of consumption bingers reported more positive experiences from drinking than did spreaders. Subjects >54 years showed lower levels of weekly alcohol consumption than other subjects, and relationships between problems, drinking level, and drinking pattern were less in evidence. Females drank less alcohol and experienced fewer alcohol-related problems than did their male counterparts. However, at high-consumption levels, female bingers experienced fewer problems than male bingers. Conclusions: For most but not all the variables studied, both drinking level and drinking pattern are important determinants of problems experienced. Binge drinking for people who drink more than ~11 units per week is an obvious target for harm minimization. INTRODUCTION The term binge drinking (sometimes called bout drinking ) has been used in two distinct ways. The first relates to a prolonged drinking spree during which the drinker gives up other activities and drinks for 2 or 3 days. Kessel and Walton (1965) described this phenomenon in these words: There are people who for three or six months, and sometimes longer, drink only socially, if at all. They then suddenly drink excessively for days on end, drinking all the time, neglecting all their responsibilities at work or to their families. (p. 90) The second meaning of the term binge relates to a single drinking session intended to or actually leading to intoxication. This session need not be prolonged but is assumed to be at least potentially risky. The latter use of the expression binge drinking has been very wide in the recent popular discussion about heavy and problematic alcoholic consumption in the UK and the US, and in the current research literature (e.g. Kuntsche et al., 2004). In the US, Weschler et al. (1994) used the term binge to describe the consumption of five drinks in a row by male students and four drinks in a row by female students. Several commentators have noted that there is no particular reason why four or five US drinks need be a special cut-off point for either alcohol consumption or its consequences (e.g. Heath, 2003). An interim analytical recent report by the UK Prime Minister s Strategy Unit (2003) defined a binge as drinking over twice the UK recommended daily guidelines for lowrisk drinking in 1 day. This is equivalent to six or more units for females and eight or more units for males. A unit is *Author to whom correspondence should be addressed at: Alcohol and Health Research Trust, Centre for Research in Public Health and Primary Care Development, University of the West of England, Glenside Campus, Blackberry Hill, Stapleton, Bristol BS16 1DD, UK. pm011g5446@blueyonder.co.uk equivalent to 1 cl or 7.9 g of alcohol. This is approximately equivalent to a single bar room measure of spirits, half a pint of normal strength beer, lager or cider, or to a small glass of wine (A half-pint of beer = 28.4 centilitres and beer is typically ~4% by volume. A small glass of wine contains ~12.5 centilitres. At 8% alcohol by volume this is exactly 1 unit). It should be noted that national standard drinks or units vary. A US standard drink is equal to 1.6 UK units (Stockwell and Single, 1997). The Strategy Unit noted (p. 11): binge drinking is a debated term. Since alcohol will affect people in different ways, there is no fixed relationship between the amount drunk and its consequences. So although many people understand bingeing to mean deliberately drinking to excess, or drinking to get drunk, not everyone drinking over 6/8 units in a single day will fit into this category. Similarly, many people who are drinking to get drunk will drink far in excess of the 6/8 unit-based definition. Drinking to the point of intoxication and beyond is certainly not new. In fact drunkenness has been recognized as a major social problem in many cultures for thousands of years. This fact has been documented and discussed by a vast literature (e.g. Heath, 1995; Pittman and Raskin White, 1991). Drinking to the point of intoxication is widespread, especially in North-west Europe. This has recently been illustrated by the findings of the European School Survey Project on Alcohol and other Drugs (ESPAD) (Hibell et al., 1997, 2001, 2004). These studies involved the application of a standardized questionnaire in surveys of drinking among representative samples of 15- and 16-year-old school students in Europe. ESPAD showed very clearly that there were massive differences in patterns of self-reported drinking habits and related consequences among European teenagers. Both the 1995 and 1999 surveys, indicated that heavy drinking, intoxication, and adverse effects (individual, sexual, relationship, and delinquency) were most common in North-west Europe, i.e. UK, Denmark, Finland, Greenland, Ireland, and Russia 461 The Author Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved

2 462 P. MILLER et al. (this only involved a survey in Moscow). In contrast, heavy drinking and its associated adverse effects were lowest among teenagers in Cyprus, France, Greece, Hungary, Italy, the Former Yugoslav Republic of Macedonia (FYROM), and Portugal. The ESPAD research team have defined a binge as the consumption of five or more drinks in a row. This may not seem to be a large amount of alcohol. Even so, it should be noted that this study relates to people aged only 15 and 16 years. The UK Strategy Unit, applying the 6/8 units per day definition to the 2001 General Household Survey of Britain (England, Wales, and Scotland, N = ), concluded that adult drinkers in Britain, or 15% of all adults, are classified as binge drinkers. The Strategy Unit further concluded (p. 20) that those aged years were most likely to be binge drinkers: only a quarter of women of this age and around one in six men report never drinking more than 6/8 units per day. For some people, this type of drinking behaviour continues to middle age, with around one in three men and one in five women drinking twice the recommended daily benchmarks at least once a week between the ages of 45 and 64. Although, some of the recent popular media coverage of binge drinking in the UK has implied that this is a new phenomenon, it is not. Even so, as noted by Plant et al. (2002) periodic heavy drinking is currently commonplace and has recently increased markedly in young women. The negative consequences of binge drinking, however defined, are widespread and obvious. The main thrust of this study is to compare the consequences for people who drink a given amount of alcohol in one or two sessions during the week with the consequences for those who drink the same amount of alcohol but spread it out over several drinking sessions during the week. The given amount of alcohol could be varied from a very low to a very high level. It was expected that, at low levels of weekly alcohol consumption, bingeing and spreading would both show little association with problems due to alcohol. At higher levels of weekly consumption bingeing would be worse than spreading. Throughout the paper drinking level refers to the amount of alcohol consumed within the past week. Drinking pattern concerns the extent to which drinking is spread out over that period or concentrated into fewer sessions (binges). METHODS The GENACIS (UK) Survey of 2027 people aged 18 in England, Scotland, and Wales was carried out in late 2000 as part of Gender, Alcohol and Culture: an International Study (GENACIS). Details of the objectives and the methodology of this survey have been described by Plant et al. (2002). In brief, the study involved a quota sample of adults 18 selected from 267 representative sampling points from England, Wales, and Scotland. The sample was designed to be representative of the population in terms of gender, age, and socio-economic status. The data were collected by trained interviewers who conducted most of the interviews in the respondents homes and the rest in survey offices. Respondents who preferred to do so were permitted to self-complete the entire interview rather than answer orally. These procedures resulted in data from 1052 women and 975 men. Measures Demographic data collected included age, gender, and social status. Drinking level was ascertained from a diary measuring the total units of alcohol consumed during the previous week. Drinking pattern was measured by a self-report question on the usual frequency of drinking during the past year. A 22-item scale of problems due to alcohol over the past 12 months had also been constructed. For the purposes of this paper this scale was divided as follows (items were originally scored no, yes, once or twice, yes, three or more times, but are here scored as present or absent): Relationship problems Harmful effect on marriage, intimate relationships. Harmful effect on relationships with other family members. Harmful effect on friendships or social life. Partner threatened to leave or actually left. Lost a friendship. Usual activities Harmful effect on work, studies, or employment. Harmful effect on housework or chores. Harmful effect on finances. Had an illness stopping usual activities for a week or more. Lost or nearly lost a job. Accidents, law and fights Had trouble with the law about drinking and driving. Accident where somebody hurt. Got into a fight. Health problems Harmful effect on physical health. Immediate problems So much drink that hard to speak clearly or walk steadily. Headache or nausea. Guilt or remorse. Unable to remember what happened the night before. Failed to do normally expected tasks. Needed a first drink in the morning. Not able to stop drinking once started. Tried to cut down drinking. There were two other dependent measures, the first being an 8-point scale of people who might have advised the subject to cut down drinking during the past year, one point being registered for each person who had so advised. The second was a 12-point scale of positive experiences that the subject might have enjoyed from drinking. The items were: Easier to relax. Easier to be open with other people. Easier to get through social situations. Feel more confident. Enjoy yourself more. Easier to talk to present partner about feelings or problems. Reduces work-related stress. Reduces stress at home. Helps through difficult situations. Less inhibited about sex. Sexual activity is more pleasurable. Feel more sexually attractive.

3 SPREADING OUT OR CONCENTRATING WEEKLY CONSUMPTION OF ALCOHOL 463 These items were originally set on 3-point scales characterized by usually true, sometimes true, and never true but were dichotomized in this analysis. there are many statistical tests the 0.01 level of significance is adopted throughout. Analysis Non-drinkers and those who drank alcohol less than once per week were excluded. This left a total sample of 477 women and 622 men. This sample was divided into age groups 18 24, 25 54, and 55+, to correspond roughly to life stage. The youngest group might be expected to be single and relatively uncommitted, the middle group rearing families and the oldest group tending to retire and, for women, to be post-menopause. Within each of these samples, and finally on the total sample, multiple regressions were run on the problem variables, positive experiences and influences to cut down as described above. Social status (manual, non-manual), gender, and age were entered first into the regressions in order to hold them constant. They were followed in order by drinking level (units consumed in the previous week as a continuous variable), drinking pattern (several times weekly, 3 4 times weekly, and once or twice weekly), and then the two-way interactions one at a time. Log transformations were used in linear regressions for positive experiences, immediate problems and total problems. For all the other variables the data were first dichotomized and binary logistic regressions were run. As Table 1. All subjects RESULTS Tables 1 4 illustrate the mean values for all the variables broken down by drinking pattern and drinking level. For simplicity, pattern is shown in just two categories and level is shown in two categories for the smaller samples and in three categories for the total sample (where there are greater numbers). The pattern variable may be seen as reflecting drinks per session. Thus somebody who drinks, for example, 14 units per week and spreads these several times per week is likely to be drinking ~2 5 units per session. Someone who drinks 14 units once or twice per week would be drinking 7 14 units per session. Drinking level and drinking pattern When all subjects are considered together (Table 1) it is clear that one of the most pervasive influences is drinking level. The higher the units consumed in the previous week the greater the reported problems during the previous year and the more likely it is that somebody has tried to influence the subject to Units consumed in the previous week (B) Pattern (A) Total Significance levels Positive Several times/week 3.41 (n = 252) b 3.84 (n = 147) 3.45 (n = 134) 3.54 A B*** experiences a Once or twice/week 3.51 (n = 427) 3.90 (n = 79) 5.05 (n = 39) 3.68 Total Influenced to Several times/week A** cut down c Once or twice/week B*** Total Relationship Several times/week A** problems c Once or twice/week B*** Total Usual Several times/week activities c Once or twice/week B*** Total A B** Accidents, Several times/week law, and Once or twice/week B*** fights c Total A B*** Health Several times/week problems c Once or twice/week B*** Total A B** Immediate Several times/week A** problems a Once or twice/week B*** Total A B** Total Several times/week A** problems a Once or twice/week B*** Total A B** Mean values of positive experiences, influences to cut down, and problems owing to alcohol consumption during the prior 12 months according to pattern and level of consumption. a Statistical analysis involved linear multiple regression for the log-transformed variable. See text. b n varies slightly throughout the table owing to missing responses. c Although means are shown in the table, statistical analysis was performed on presence/absence of the variable using binary logistic regression.

4 464 P. MILLER et al. Table 2. Subjects aged Units consumed in the previous week (B) Pattern (A) Total Significance levels Positive Several times/week 4.24 (n = 17) b 4.73 (n = 41) 4.59 experiences a Once or twice/week 3.89 (n = 45) 5.50 (n = 32) 4.56 Total Influenced to Several times/week cut down c Once or twice/week Total B** Relationship Several times/week problems c Once or twice/week B*** Total Usual activities c Several times/week Once or twice/week B*** Total A B** Accidents, law, and Several times/week fights c Once or twice/week B** Total Health problems c Several times/week Once or twice/week B*** Total Immediate problems a Several times/week Once or twice/week B*** Total Total problems a Several times/week Once or twice/week B*** Total A B*** Mean values of positive experiences, influences to cut down, and problems owing to alcohol consumption during the prior 12 months according to pattern and level of consumption. a Statistical analysis involved linear multiple regression for the log-transformed variable. See text. b n varies slightly throughout the table owing to missing responses. c Although means are shown in the table, statistical analysis was performed on presence/absence of the variable using binary logistic regression. cut down. The pattern of drinking shows significant effects on its own for two of the variables. Here, slightly surprisingly, those who spread their drinking out are more likely than those who binge to have been asked to cut down and to have had relationship problems. There are also several interaction effects (shown in the tables as A B ). Where these occur, it invariably means that as weekly alcohol consumption increases, problem levels increase more sharply for those who binge than for those who spread their drinking out. Thus, for 0 14 units consumed in the previous week, problems reported by bingers are less than those reported by spreaders while for 29+ units in the previous week they are greater. Figure 1 demonstrates this effect for total problems. Total problem levels are about equal for spreaders and bingers at ~11 units of consumption per week. Thereafter, for given levels of alcohol consumption bingers experience more problems than spreaders. For positive experiences the only significant effect is the interaction. Bingers at high levels of consumption show the highest levels of positive experiences. The influence of age Tables 2, 3, and 4 set out the level and pattern results for groups of people at different life stages. Both alcohol consumption and problem levels decline with increasing age. For the youngest group 54.1% drank 15+ units in the previous week, for the middle-aged it was 38.5% and for the older subjects 25.6%. Average total problem levels experienced in the past year were 5.46, 2.61, and 0.77, respectively. Within each of the three samples the results are broadly similar to those for the total sample although not always reaching the same levels of significance owing to smaller numbers. However, when testing the total sample three significant interactions between age and level of alcohol consumption were found. These concerned relationship problems (P = 0.045), immediate problems (P = 0.016), and total problems (P = 0.004). In each case, for older people, the association between drinking level and problems is less marked than it is for younger people. For example (Table 2), average levels of total problems in younger people are 3.65 for those consuming 0 14 units and 7.00 for those consuming 15+, a difference of For the middle-aged the corresponding difference is 2.42 and for older people it is No interactions were seen between age and pattern of drinking. Gender and social class differences The women in the sample drank fewer units in the previous week than the men (Table 5, χ 2 = 105.1, P < 0.001) and had a slightly lower usual drinking frequency (χ 2 = 5.31, P = 0.021).

5 SPREADING OUT OR CONCENTRATING WEEKLY CONSUMPTION OF ALCOHOL 465 Table 3. Subjects aged Units consumed in the previous week (B) Pattern (A) Total Significance levels Positive Several times/week 4.02 (n = 132) b 3.66 (n = 173) 3.82 experiences a Once or twice/week 3.77 (n = 270) 3.97 (n = 79) 3.82 Total Influenced to Several times/week A** cut down c Once or twice/week B*** Total Relationship Several times/week A*** problems c Once or twice/week B*** Total Usual activities c Several times/week Once or twice/week B*** Total Accidents, law Several times/week and fights c Once or twice/week B*** Total A B*** Health problems c Several times/week Once or twice/week B*** Total Immediate problems a Several times/week A** Once or twice/week B*** Total A B** Total problems a Several times/week A*** Once or twice/week B*** Total A B*** Mean values of positive experiences, influences to cut down, and problems owing to alcohol consumption during the prior 12 months according to pattern and level of consumption. a Statistical analysis involved linear multiple regression for the log-transformed variable. See text. b n varies slightly throughout the table owing to missing responses. c Although means are shown in the table, statistical analysis was performed on presence/absence of the variable using binary logistic regression. Overall, they suffered fewer problems ascribed to drinking during the past year than did the men. Significant gender level and gender pattern interactions are apparent for the immediate and the total problems due to drinking. The men who binge heavily (high consumption, once or twice per week) suffer a greater increase in problem level than the women who binge heavily. Women were significantly less likely than men to be influenced to cut down, and suffered fewer problems in relation to usual activities, health, accidents, law, and fighting. No other significant gender level or gender pattern interactions were found. No significant age gender interactions were found. Social class when taken on its own in the whole sample does show a significant relationship with total problems, with subjects in the manual group having more problems. However, this effect disappears when age and gender are taken into account. Throughout the analyses, only one significant relationship was found once age and gender were taken into account. Within the middle-aged group, working-class subjects perceived more positive experiences from drinking than did middle-class subjects (P < 0.01). No significant interaction effects on problems involving social class with gender, pattern, or level were discovered. DISCUSSION First, it should be emphasized that GENACIS was not specifically designed to be a detailed study of binge drinking. The methods of analysis used here were somewhat unconventional. No fixed definition of binge drinking was employed. Rather, the aim was to measure each subject s level of weekly consumption and then the extent to which they spread this out over the week. Non-drinkers and those who said they drank alcohol less than once a week were excluded from the analysis. As in all population surveys of alcohol consumption the measures used in this study have their drawbacks [see Dawson (1998) for a full review of this area]. Frequency of drinking was ascertained by a single question on typical frequency during the past year. This could be an underreport (Redman et al., 1987; O Callaghan and Callan, 1992). The quantity consumed was measured by the retrospective diary of drinking in the previous week. For some subjects this would not have been a typical week. However, several studies (e.g. Redman et al., 1987; O Hare, 1991; O Callaghan and Callan, 1992; Poikolainen et al., 2002) have shown a close correlation between results using the retrospective diary and the quantity frequency method and also that the diary method

6 466 P. MILLER et al. Table 4. Subjects aged 55 and over Units consumed in the previous week (B) Pattern (A) Total Significance levels Positive Several times/week 2.49 (n = 103) b 2.96 (n = 67) 2.67 experiences a Once or twice/week 2.72 (n = 112) 2.14 (n = 7) 2.69 Total Influenced to Several times/week cut down c Once or twice/week B** Total Relationship Several times/week problems c Once or twice/week Total Usual Several times/week activities c Once or twice/week B** Total Accidents, law Several times/week and fights c Once or twice/week Total Health Several times/week problems c Once or twice/week Total Immediate Several times/week problems a Once or twice/week B*** Total A B** Total problems a Several times/week Once or twice/week B*** Total Mean values of positive experiences, influences to cut down, and problems due to alcohol consumption during the prior 12 months according to pattern and level of consumption. a Statistical analysis involved linear multiple regression for the log-transformed variable. See text. b n varies slightly throughout the table owing to missing responses. c Although means are shown in the table, statistical analysis was performed on presence/absence of the variable using binary logistic regression. seems better at detecting heavy drinkers. Assuming that the inevitable misclassifications are distributed randomly, measurement problems would probably not bias the results in the present study but might have the effect of reducing the differences discovered. Turning to the substance of the results, drinking level rather than drinking pattern appears to bear the strongest relationships to problems of all kinds experienced by drinkers. Unsurprisingly, the higher the drinking level the more the problems. Drinking pattern shows fewer direct relationships. However, there are several interesting interaction effects between level and pattern. At low drinking levels those who drink frequently (3 4 times per week or more) record higher levels of problems owing to alcohol. When drinking level is greater than ~11 units per week the expected crossover effect is observed (Fig. 1), with those who drink less frequently (only once or twice per week) experiencing the highest levels of problems. Similar interactions are apparent for all except relationship problems and influence to cut down, in both of which there is only a main effect of pattern showing that, at all drinking levels, those who drink more frequently are more likely to have problems or to be asked to cut down. This may well have implications for guidelines to sensible drinking. It should not be concluded that heavy drinkers could avoid problems by spreading out their alcohol intake into more Means Total alcohol problems Usual frequency Units of alcohol last week several times/week once or twice/week Fig. 1. Alcohol problems according to units consumed in the previous week and usual frequency of drinking.

7 SPREADING OUT OR CONCENTRATING WEEKLY CONSUMPTION OF ALCOHOL 467 Table 5. Gender differences, drinking pattern, and drinking level for immediate and total problems owing to alcohol in the past year Units consumed in the previous week (C) Gender (A) Pattern (B) Total Significance Immediate Men Several times/week 1.35 (n = 117) 2.26 (n = 103) 3.41 (n = 109) 2.32 A*** problems Once or twice/week 1.28 (n = 196) 2.94 (n = 62) 4.00 (n = 35) 1.95 B** Total C*** Women Several times/week 1.38 (n = 143) 2.38 (n = 45) 4.14 (n = 28) 1.94 A B** Once or twice/week 1.06 (n = 234) 1.94 (n = 17) 3.50 (n = 4) 1.16 A C** Total B C*** Total Men Several times/week A*** problems Once or twice/week B** Total C*** Women Several times/week A B** Once or twice/week A C** Total B C*** frequent sessions. While heavy drinking spreaders did indeed have a significantly lower level of problems the effect is a small one. At 36+ units per week both groups show an average problem level greater than five (Fig. 1). The likely problem level rises in an approximately linear manner with alcohol intake and there is an increased likelihood for all the types of problems studied here. The commonest type is immediate problems, mostly hangover, and it is this type that is mainly seen at lower levels of alcohol consumption. From the results here it might be suggested that someone who wishes to experience little more than a few immediate problems should confine their weekly intake to below ~15 units. For positive experiences there are again interaction effects. Those who drink less frequently and at high levels are the most likely to claim to have positive experiences related to their drinking. Thus it appears that the enjoyment gained by binge drinkers in the more conventional sense outweighs their experience of greater problems a result which is in accord with that of Mäkela and Mustonen (2000). For older people (55+ years) all the relationships seen are less marked, although the figures tend in the same direction as for younger people. Alcohol consumption levels have declined and there are fewer problems. Although, significant interactions could not always be demonstrated these effects seemed to be independent of the type of problem considered, whether it be chronic or more immediate. Some of the decline in level is likely to have been owing to the early demise or the reform of very heavy drinkers in former years. The gender differences seen are unsurprising. Overall, at lower levels of drinking, women have a slightly lower drinking frequency and fewer problems than men. At higher consumption levels and lower drinking frequencies problems owing to alcohol do indeed increase for women. However, the range of problems suffered seems not as great as that for men. Women were less likely to get into fights, suffer accidents, have health problems, or to have problems relating to their usual activities such as housework chores. The evidence described above serves to re-emphasize that both the positive and negative consequences associated with drinking are influenced by alcohol consumption level and the pattern of drinking. There are also a host of national and cultural factors. Some of the latter have been reviewed by Grant and Litvak (1998). Many of the characteristics of these drinking cultures have been evident for centuries, even thousands of years. The intoxicating effects of alcohol are conspicuously a key to its widespread popularity. The main implication of binge drinking in modern society is that it is more widespread in some settings than elsewhere and that, as this study shows, it is particularly potent in increasing the problems associated with alcohol consumption. Binge drinking, particularly among men, is linked with acute problems such as public disorder, crime, accidents, and injuries. Practical and effective harm minimization responses are available. Some of these have been reviewed by Plant et al. (1997). Acknowledgements The authors are indebted to the University of the West of England, Bristol, UK for supporting this review. The Alcohol & Health Research Trust is an independent charity (# SC027580). The work of the research team has been funded by many agencies. These include government departments, research councils, charities, the beverage alcohol industry, the European Union, and the World Health Organization. The UK part of GENACIS is supported by the Amsterdam Group and the Alcohol Education and Research Council (AERC). The UK part of ESPAD 1999 was supported by the Alcohol Education and Research Council, the Department of Health Belfast, the Health Development Agency, the Wates Foundation, an anonymous charity, the PF charitable Trust, the North British Distillery Company Limited, the William Grant & Sons Charitable Trust, and the Drapers Fund. Editor s statement The authors of this work have declared funding by the alcohol beverage industry and by an alcohol beverage industry social policy organization. The paper has been independently refereed, and screened for impartiality, as far as feasible, by the Chief Editor. REFERENCES Dawson, D. (1998) Measuring alcohol consumption: limitations and prospects for improvement. Addiction 93, Grant, M. and Litvak, J., eds (1998) Drinking Patterns and Their Consequences. Taylor and Francis, Washington, DC. Heath, D., ed. (1995) International Handbook on Alcohol and Culture. Green wood Press, Westport, Conn. Heath, D. (2003) Binge drinking. Keynote presentation at Workshop on Binge Drinking, National Institute of Health/National Institute on Alcohol Abuse and Alcoholism, Washington, DC.

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