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Article Excerpt
ALCOHOL-USE DISORDERS (AUDs), such as alcohol abuse/harmful use or dependence, have long been considered an important issue in public health and medicine because of their high prevalence and their devastating effects on individuals, families, and society (Kessler et al., 1997; Rehm et al., 2003; Robins et al., 1991). Alcohol, on a global basis, is responsible for 4.0% of the total loss of disability-adjusted life years, with Latin America and the Caribbean region responsible for 9.7% of this estimate. Alcohol also causes more years of potential life lost through death and disability than tobacco and illegal drugs (World Health Organization [WHO], 2004) and is related to many major disease outcomes and social harms in most developing societies (Rehm et al., 2006).
AUDs constitute only a small part of all alcohol-related harms (Rehm et al., 2005). Heavy episodic drinking (HED), also considered a broader definition of binge drinking by some authors (Kuntsche et al., 2004), is defined as the consumption of five or more drinks in a row for men and four or more drinks in a row for women, at least once in the past 2 weeks (Wechsler et al., 1995, 2002). It also is typically defined as the consumption of five or more alcoholic drinks on one occasion for a man and four or more drinks on a single occasion for a woman (five-plus/four-plus drinking; National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2005) or as a pattern of alcohol consumption that places the drinker at increased risk for experiencing alcohol-related harms (Wechsler and Nelson, 2001).
The definition of HED takes into account the large and growing body of epidemiologic evidence that has consistently demonstrated that five-plus/four-plus drinking is associated with a wide range of adverse health and social outcomes, including physical injury, high-risk sexual behavior, unintended pregnancy, acute myocardial infarction, alcohol overdose, falls, violence, alcohol-impaired driving, psychosocial problems, antisocial behavior, and academic difficulties among both college students and the general population (Brewer and Swahn, 2005; Naimi et al., 2003; Perkins, 2002; Wechsler et al., 2003). Furthermore, HED increases both all-cause and cardiovascular mortality and has been linked to an increased risk for psychiatric disorders, cancer, and gastrointestinal disease (Corrao et al., 2004; Ramstedt, 2004; Rehm et al., 2003, 2006).
Although college drinking has brought HED to center stage in recent years, investigation of the utility of HED as a way of classifying drinkers has inspired research in a variety of populations. Self-reported data indicate that almost half of all U.S. high school students are current drinkers, and approximately 60% of these underage drinkers have engaged in HED in the past month (Grunbaum et al., 2004). Among U.S. adults, data are also of concern from the mid-1980s to 1999. About 29% of current drinkers reported having engaged in HED in the past month (Serdula et al., 2004). Between 1993 and 2001, the number of heavy drinking episodes among U.S. adults increased by 29%, from 1.2 billion to 1.5 billion, and annual episodes per person increased by 17%, from 6.3 to 7.4 (Naimi et al., 2003). Recently, heavy episodic alcohol consumption has been associated with poor self-rated health in a sample of U.S. adults (Okosun et al., 2005).
Some European and Scandinavian countries have extremely high percentages of heavy episodic drinkers, with definitions of this term varying from 4 or more to 10 or more among the countries (Bloomfield et al., 2002; Makela et al., 2001; Webb et al., 2005; Wilsnack et al., 2000). Wilsnack et al., studying gender differences in a pool of epidemiologic surveys, most of them in European countries, found that men had the highest rates, varying from 59.3% in the Czech Republic to 8.8% in Israel. Women's rates varied from 38.6% in Sweden to 3.0% in Israel. Webb et al., studying alcohol consumption in adults in Ukraine, found that, among heavy alcohol users (22%), 92% of the men and 52% of the women consumed at least 80 g of ethanol in a typical drinking day.
The correlates of HED, based on American studies, include being male, young, and unmarried; lower educational attainment; and smoking (Karlamangla et al., 2006; Naimi et al., 2003). In European studies, the correlates are similar (Kuntsche et al., 2004) except that in some countries male heavy episodic drinkers are more prevalent in middle age (i.e., age 35-54; Bobak et al., 1999; Mateos et al., 2002; Webb et al., 2005).
Most of the available evidence on patterns of alcohol use comes from research undertaken in developed countries, and little is known about developing countries, where the majority of the world's population resides (Riley and Marshall, 1999). In Brazil, the 2004 annual per capita consumption, including unrecorded consumption, was estimated at 8.32 L of pure alcohol per adult (WHO, 2004). Data from a national household survey about drug use in Brazil (N = 8,589; age bracket of 12-65 years old) showed that 68.7% of the respondents reported lifetime alcohol use, 11.2% reported alcohol dependence (17.1% of men and 5.7% of women), and 5.2% reported regular drinking (at least 3 or 4 days of alcohol intake per week; male: female ratio of 5:1; Carlini et al., 2002).
Several surveys in Brazil have measured some patterns of alcohol consumption that resemble the concept of HED, taking into account both the amount and the frequency of drinking (Table 1). The rates of past-month heavy alcohol use among students range from 6.7% in 27 state capitals (Galduroz et al., 2004) to 32.4% in private schools in Sao Paulo (Carlini-Marlatt et al., 2003). Rates of past-year heavy drinking among adults range from 7% in Salvador (northeastern area; Almeida-Filho et al., 2004) to 15.5% in Porto Alegre (southern area; Moreira et al., 1996). These percentages reflect differences in the definitions of heavy alcohol consumption, the regions surveyed, and the sampling methods employed.
The aims of the present study, with data from the Sao Paulo Catchment Area Study (Andrade et al., 2002), were to estimate the prevalence of HED among this population-based adult sample and to investigate the association of some sociodemographic determinants with this pattern of drinking. We also examined the extent to which these associations are different in the two genders.
Method
The Sao Paulo Catchment Area Study is a household survey conducted in the city of Sao Paulo, located in Southeastern Brazil. As the largest city in South America, Sao Paulo has 12 million inhabitants (Fundacao IBGE, 2004). The population for this study was drawn from two boroughs in the catchment area of the University of Sao Paulo's Medical Center, an area of 10.5 [km.sup.2] with 412 blocks and 28,169 households with 91,276 inhabitants, mainly from a middle or upper socioeconomic level.
The sample design of this survey has been described elsewhere (Andrade et al., 2002). In summary, we used an area probability design with age stratification and multiple respondents per household. Eligible respondents included noninstitutionalized adults ages 18 or older, with an oversampling of persons ages 18-24 years and 60 years or older--that is, all 18- to 24-year-olds and people older than age 60 living in the selected household were selected to be interviewed. Of the remaining individuals ages 25-59 years old living in the selected household, only one was chosen randomly for an interview based on Kish's selection table (Kish and Frankel, 1970). In this way, it was possible to have more than one person interviewed in each selected household. The analyses were conducted by using weights to adjust for the differential effects of oversampling. Based on these three age strata, 1,906 people were selected to participate. Of those, 442 individuals refused, resulting in a final sample of 1,464 subjects, with an individual response rate of 76.8%. For all respondents, face-to-face interviews were conducted between 1994 and 1995, after they...
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