Alcohol

"In 2021, a total of 54,258 people died of alcohol-induced causes in the United States (Tables 7, 9, and 24). This category includes deaths from dependent and nondependent use of alcohol, and deaths from accidental poisoning by alcohol. It excludes unintentional injuries, homicides, and other causes indirectly related to alcohol use, and deaths due to fetal alcohol syndrome. For a list of alcohol-induced causes, see Technical Notes.

"The age-adjusted death rate for alcohol-induced causes increased 9.9%, from 13.1 in 2020 to 14.4 in 2021 (Tables 6, 11, and 24). For males in 2021, the age-adjusted death rate for alcohol-induced causes was 2.5 times the rate for females. The rate increased 8.9% for males and 10.7% for females from 2020 to 2021 (Tables 11 and 24).

"Among race–ethnicity groups—Age-adjusted rates increased from 2020 to 2021 by 23.9% for the American Indian and Alaska Native population (30.6% for American Indian and Alaska Native males and 13.9% for American Indian and Alaska Native females), 15.5% for the Black population (10.7% for Black males and 21.8% for Black females), 7.9% for the Hispanic population (7.2% for Hispanic males), and 9.1% for the White population (7.9% for White males and 9.2% for White females) (Tables 11 and 24). The age-adjusted rate for alcohol-induced death did not change significantly from 2020 to 2021 for the Asian populations, Hispanic females, and Native Hawaiian or Other Pacific Islander populations."

"Among people aged 12 or older in 2023, 47.5 percent (or 134.7 million people) drank alcohol in the past month (Figures 7 and 8 and Table A.1B). The percentage was highest among adults aged 26 or older (51.9 percent or 116.1 million people), followed by young adults aged 18 to 25 (49.6 percent or 16.9 million people). The percentage was lowest among adolescents aged 12 to 17 (6.9 percent or 1.8 million people).

"By Race/Ethnicity

"Among people aged 12 or older in 2023, 52.3 percent of White people drank alcohol in the past month (Table B.4B). This percentage was higher than the percentages of people in other racial or ethnic groups. Multiracial (46.5 percent), Black (42.5 percent), or Hispanic people (41.2 percent) had a higher estimate of past month alcohol use compared with Asian (32.5 percent) or American Indian or Alaska Native people (30.0 percent). The estimate of current alcohol use could not be calculated with sufficient precision for Native Hawaiian or Other Pacific Islander people.¹⁵"

"Alcohol use accounted for 1.78 million (95% uncertainty interval [UI] 1.39–2.27) deaths in 2020 and was the leading risk factor for mortality among males aged 15–49 years (Bryazka D, unpublished). The relationship between moderate alcohol use and health is complex, as shown in multiple previous studies.^{1, 2, 3, 4, 5, 6} Alcohol consumption at any level is associated with health loss from several diseases, including liver cirrhosis, breast cancer, and tuberculosis, as well as injuries.^{7, 8, 9, 10} At the same time, some studies have found that consumption of small amounts of alcohol lowers the risk of cardiovascular diseases and type 2 diabetes.^{11, 12, 13} As a corollary, the amount of alcohol that minimises health loss is likely to depend on the distribution of underlying causes of disease burden in a given population. Since this distribution varies widely by geography, age, sex, and time, the level of alcohol consumption associated with the lowest risk to health would depend on the age structure and disease composition of that population.^{14, 15, 16}"

"Alcohol consumption is the third leading preventable cause of cancer in the United States, after tobacco and obesity.¹ 

In 2019, an estimated 96,730 cancer cases were related to alcohol consumption including 42,400 in men and 54,330 in women.¹ This translates to nearly 1 million preventable cancer cases over ten years in the U.S. The largest burden of alcohol-related cancer in the U.S. is for breast cancer in women with an estimated 44,180 cases in 2019, representing 16.4% of the approximately 270,000 total breast cancer cases for women.¹ Globally, 741,300 cancer cases were related to alcohol consumption in 2020; 185,100 of those cases were related to consumption of approximately two drinks daily or fewer (Figure 1).¹²"

"In 2023, 22% of high school students drank alcohol during the past 30 days. Female students were more likely than male students to currently drink alcohol. Asian and Black students were less likely than Hispanic, White, and Multiracial students to currently drink alcohol. LGBTQ+ students were more likely than cisgender and heterosexual students to currently drink alcohol."

"Globally, 1.03 billion (95% UI 0·851–1·19) males (35.1% [29.1–40.7] of the male population aged ≥15 years) and 312 million (199–432) females (10.5% [6.72–14.6] of the female population aged ≥15 years) consumed alcohol in amounts exceeding the NDE [Non-Drinker Equivalence] in 2020; the number and proportion of people consuming alcohol in excess of the NDE, along with the percentage change since 1990 in the proportion of people consuming alcohol in excess of the NDE, by age group, sex, and location is reported in table 1. Since 1990, the global proportion of drinkers consuming alcohol in excess of the NDE has not changed significantly. Although the proportion of the population consuming harmful amounts of alcohol stayed at the same level over the past three decades, the number of people consuming harmful amounts of alcohol increased from 983 million (718–1190) in 1990 to 1.34 billion (1.06–1.62) in 2020, driven by population growth. Overall, among individuals consuming harmful amounts of alcohol in 2020, 76.9% (73.0–81.3) were male."

"In the U.S., there are about 20,000 alcohol-related cancer deaths annually.1,2 This is greater than the number of alcohol-associated traffic crash fatalities (about 13,500 annually) in the U.S.a,13 Alcohol-related cancer deaths shorten the lives of those who die by an average of 15 years.14 Annually, a total of about 305,000 years of potential life are lost due to alcohol-related cancer deaths.14 Breast cancer accounts for the majority (~60%) of alcohol-related cancer deaths in women, whereas liver cancer (~33%) together with colorectal cancer (an additional ~21%) account for the majority of alcohol-related cancer deaths in men.2 About 83% of the estimated 20,000 U.S. alcohol-related cancer deaths per year occur at levels above the 2020-2025 U.S. Dietary Guidelines for Americans recommended limits of two drinks daily for men and one drink daily for women.2,15 Nonetheless, the remaining 17% of the estimated 20,000 U.S. alcohol-related cancer deaths per year occur at levels within those recommended limits.2"

"Despite clear evidence demonstrating the effect of alcohol consumption on cancer risk, there is a large gap in public understanding of the risk. In a 2019 survey, 45% of Americans recognized alcohol use as a risk factor for cancer compared to 91% of Americans who recognized the risk of radiation exposure, 89% for tobacco use, 81% for asbestos exposure, and 53% for obesity (Figure 2).b,4 Additionally, public awareness of alcohol consumption as a cancer risk factor has not substantially improved over nearly two decades,4 even as evidence documenting the link between alcohol consumption and cancer risk has increased."

"The proportion of clients in treatment for the three broad categories of substance abuse problems—both alcohol and drug abuse, drug abuse alone, and alcohol abuse alone—demonstrated some changes between 2011 and 2020.

"● The percentage of clients in treatment for both drug and alcohol abuse decreased from 44 percent in 2011 to 31 percent in 2020. (The number of clients in treatment for both drug and alcohol abuse decreased from 535,258 in 2011 to 333,526 in 2020 [Table 3.3].)

"● The percentage of clients in treatment for drug abuse alone increased from 38 percent in 2011 to 52 percent in 2020. (The number of clients in treatment for drug abuse alone increased from 464,406 in 2011 to 743,828 in 2019 and then decreased to 569,522 in 2020 [Table 3.3].)

"● The percentage of all clients in treatment for alcohol abuse alone decreased from 18 percent in 2009 to 13 percent in 2020. (The number of clients in treatment for alcohol abuse alone decreased from 221,632 in 2011 to 146,710 in 2020 [Table 3.3].)

"● The percentage of clients in treatment for diagnosed co-occurring mental and substance use disorders increased from 41 percent in 2011 to 49 percent in 2020. (The number of clients in treatment for diagnosed co-occurring mental and substance use disorders increased from 506,162 in 2011 to 702,914 in 2019, before falling to 531,105 in 2020 [Table 3.3].)"

"In this randomized clinical trial of psilocybin-assisted psychotherapy treatment for AUD [Alcohol Use Disorder], psilocybin treatment was associated with improved drinking outcomes during 32 weeks of double-blind observation. PHDD [Percentage of Heavy Drinking Days] among participants treated with psilocybin was 41% of that observed in the diphenhydramine-treated group. Exploratory analyses confirmed a between-group effect across a range of secondary drinking measures. Although this was, to our knowledge, the first controlled trial of psilocybin for AUD, these findings are consistent with a meta-analysis³⁹ of trials conducted in the 1960s evaluating LSD as a treatment for AUD.

"Adverse events associated with psilocybin administration were mostly mild and self-limiting, consistent with other recent trials evaluating the effects of psilocybin in various conditions.^1-8 However, it must be emphasized that these safety findings cannot be generalized to other contexts. The study implemented measures to ensure safety, including careful medical and psychiatric screening, therapy and monitoring provided by 2 well-trained therapists including a licensed psychiatrist, and the availability of medications to treat acute psychiatric reactions."

"Several limitations of the study warrant discussion. First, diphenhydramine was ineffective in maintaining the blind after drug administration, so biased expectancies could have influenced results. Control medications such as methylphenidate,⁴² niacin,² and low-dose psilocybin¹ likewise did not adequately maintain blinding in past psilocybin trials, so this issue remains a challenge for clinical research on psychedelics. Second, EtG samples, used to validate self-reported drinking outcomes, were available for only 53.8% of treated participants. Third, the study did not have adequate power to evaluate effects in subgroups, such as women, ethnic and racial minority groups, and individuals with psychiatric comorbidity, nor was it designed to identify causal mechanisms, optimal dosing, or predictors of treatment response. Fourth, the study population was lower in drinking intensity at screening than in most AUD medication trials, and results cannot be assumed to generalize to populations with more severe AUD. Fifth, the 2-group design does not permit evaluation of the effects of psychotherapy or the interaction between psychotherapy and medication. Sixth, the study does not provide information on the duration of the effects of psilocybin beyond the 32-week double-blind observation period, which is important given the often chronic, relapsing course of AUD. Further studies will be necessary to address these questions and many others concerning the use of psilocybin in the treatment of AUD."

"Withdrawal
"A continuum of symptoms and signs of central nervous system (including autonomic) hyperactivity may accompany cessation of alcohol intake.

"A mild alcohol withdrawal syndrome includes tremor, weakness, headache, sweating, hyperreflexia, and gastrointestinal symptoms. Tachycardia may be present and blood pressure can be slightly elevated. Symptoms usually begin within about 6 hours of cessation. Some patients have generalized tonic-clonic seizures (called alcohol-related seizure, or rum fits) but usually not > 2 in short succession. Seizures generally occur 6 to 48 hours after cessation of alcohol.

"Alcoholic hallucinosis (hallucinations without other impairment of consciousness) follows abrupt cessation from prolonged, excessive alcohol use, usually within 12 to 24 hours. Hallucinations are typically visual. Symptoms may also include auditory illusions and hallucinations that frequently are accusatory and threatening; patients are usually apprehensive and may be terrified by the hallucinations and by vivid, frightening dreams.

"Alcoholic hallucinosis may resemble schizophrenia, although thought is usually not disordered and the history is not typical of schizophrenia. Symptoms do not resemble the delirious state of an acute organic brain syndrome as much as does delirium tremens (DT) or other pathologic reactions associated with withdrawal. Consciousness remains clear, and the signs of autonomic lability that occur in DT are usually absent. When hallucinosis occurs, it usually precedes DT and is transient.

"Delirium tremens usually begins 48 to 72 hours after alcohol withdrawal; anxiety attacks, increasing confusion, poor sleep (with frightening dreams or nocturnal illusions), profuse sweating, and severe depression also occur. Fleeting hallucinations that arouse restlessness, fear, and even terror are common. Typical of the initial delirious, confused, and disoriented state is a return to a habitual activity; eg, patients frequently imagine that they are back at work and attempt to do some related activity.

"Autonomic lability, evidenced by diaphoresis and increased pulse rate and temperature, accompanies the delirium and progresses with it. Mild delirium is usually accompanied by marked diaphoresis, a pulse rate of 100 to 120 beats/minute, and a temperature of 37.2 to 37.8° C. Marked delirium, with gross disorientation and cognitive disruption, is accompanied by significant restlessness, a pulse of > 120 beats/minute, and a temperature of > 37.8° C; risk of death is high.

"During delirium tremens, patients are suggestible to many sensory stimuli, particularly to objects seen in dim light. Vestibular disturbances may cause them to believe that the floor is moving, the walls are falling, or the room is rotating. As the delirium progresses, resting tremor of the hand develops, sometimes extending to the head and trunk. Ataxia is marked; care must be taken to prevent self-injury. Symptoms vary among patients but are usually the same for a particular patient with each recurrence."

"In fully adjusted, prespecified models that accounted for effects of sampling, between-study variation, and potential confounding from former drinker bias and other study-level covariates, our meta-analysis of 107 studies found (1) no significant protective associations of occasional or low-volume drinking (moderate drinking) with all-cause mortality; and (2) an increased risk of all-cause mortality for drinkers who drank 25 g or more and a significantly increased risk when drinking 45 g or more per day.

"Several meta-analytic strategies were used to explore the role of abstainer reference group biases caused by drinker misclassification errors and also the potential confounding effects of other study-level quality covariates in studies.2 Drinker misclassification errors were common. Of 107 studies identified, 86 included former drinkers and/or occasional drinkers in the abstainer reference group, and only 21 were free of both these abstainer biases. The importance of controlling for former drinker bias/misclassification is highlighted once more in our results which are consistent with prior studies showing that former drinkers have significantly elevated mortality risks compared with lifetime abstainers.

"In addition to presenting our fully adjusted models, a strength of the study was the examination of the differences in relative risks according to unadjusted and partially adjusted models, including the effect of removing individual covariates from the fully adjusted model. We found evidence that abstainer biases and other study characteristics changed the shape of the risk relationship between mortality and rising alcohol consumption, and that most study-level controls increased the observed risks from alcohol, or attenuated protective associations at low levels of consumption such that they were no longer significant. The reduced RR estimates for occasional or moderate drinkers observed without adjustment may be due to the misclassification of former and occasional drinkers into the reference group, a possibility which is more likely to have occurred in studies of older cohorts which use current abstainers as the reference group. This study also demonstrates the degree to which observed associations between consumption and mortality are highly dependent on the modeling strategy used and the degree to which efforts are made to minimize confounding and other threats to validity.

"It also examined risk estimates when using occasional drinkers rather than lifetime abstainers as the reference group. The occasional drinker reference group avoids the issue of former drinker misclassification that can affect the abstainer reference group, and may reduce confounding to the extent that occasional drinkers are more like low-volume drinkers than are lifetime abstainers.2,8,132 In the unadjusted and partially adjusted analyses, using occasional drinkers as the reference group resulted in nonsignificant protective associations and lower point estimates for low-volume drinkers compared with significant protective associations and higher point estimates when using lifetime nondrinkers as the reference group. In the fully adjusted models, there were nonsignificant protective associations for low-volume drinkers whether using lifetime abstainers or occasional drinkers as the reference group, though this was only a RR of 0.97 for the latter.

"Across all studies, there were few differences in risk for studies when stratified by median age of enrollment above or below age 56 years in the fully adjusted analyses. However, in the subset of studies who enrolled participants aged 50 years or younger who were followed for at least 10 years, occasional drinkers and medium-volume drinkers had significantly increased risk of mortality and substantially higher risk estimates for high- and higher-volume consumption compared with results from all studies. This is consistent with our previous meta-analysis for CHD,9 in which younger cohorts followed up to older age did not show a significantly beneficial association of low-volume consumption, while older cohorts, with more opportunity for lifetime selection bias, showed marked, significant protective associations.

"Our study also found sex differences in the risk of all-cause mortality. A larger risk of all-cause mortality for women than men was observed when drinking 25 or more grams per day, including a significant increase in risk for medium-level consumption for women that was not observed for men. However, mortality risk for mean consumption up to 25 g per day were very similar for both sexes."

"From 2016–2017 to 2020–2021, the average annual number of U.S. deaths from excessive alcohol use increased by more than 40,000 (29%), from approximately 138,000 per year (2016–2017) to 178,000 per year (2020–2021). This increase translates to an average of approximately 488 deaths each day from excessive drinking during 2020–2021. From 2016–2017 to 2020–2021, the average annual number of deaths from excessive alcohol use increased by more than 25,000 among males and more than 15,000 among females; however, the percentage increase in the number of deaths during this time was larger for females (approximately 35% increase) than for males (approximately 27%). These findings are consistent with another recent study that found a larger increase in fully alcohol-attributable death rates among females compared with males (8).

"Increases in deaths from excessive alcohol use during the study period occurred among all age groups. A recent study found that one in eight total deaths among U.S. adults aged 20–64 years during 2015–2019 resulted from excessive alcohol use (9). Because of the increases in these deaths during 2020–2021, including among adults in the same age group, excessive alcohol use could account for an even higher proportion of total deaths during that 2-year period. In addition, data from Monitoring the Future, an ongoing study of the behaviors, attitudes, and values of U.S. residents from adolescence through adulthood, showed that the prevalence of binge drinking among adults aged 35–50 years was higher in 2022 than in any other year during the past decade§§§; this increase could contribute to future increases in alcohol-attributable deaths. In this study, fewer than one third of deaths from excessive alcohol use were from fully alcohol-attributable causes, highlighting the importance of also assessing partially alcohol-attributable causes to better understand the harms from excessive drinking, including binge drinking.

"The nearly 23% increase in the deaths from excessive alcohol use that occurred from 2018–2019 to 2020–2021 was approximately four times as high as the previous 5% increase that occurred from 2016–2017 to 2018–2019. Increases in the availability of alcohol in many states might have contributed to this disproportionate increase (10). During the peak of the COVID-19 pandemic in 2020–2021, policies were widely implemented to expand alcohol carryout and delivery to homes, and places that sold alcohol for off-premise consumption (e.g., liquor stores) were deemed as essential businesses in many states (and remained open during lockdowns).¶¶¶ General delays in seeking medical attention, including avoidance of emergency departments**** for alcohol-related conditions††††; stress, loneliness, and social isolation; and mental health conditions might also have contributed to the increase in deaths from excessive alcohol use during the COVID-19 pandemic."

"Among people aged 12 or older in 2022, 5.7 percent (or 16.1 million people) were heavy alcohol users in the past month (Figures 8 and 9 and Table A.1B). The percentage was highest among young adults aged 18 to 25 (7.6 percent or 2.6 million people), followed by adults aged 26 or older (6.0 percent or 13.4 million people). The percentage was lowest among adolescents aged 12 to 17 (0.2 percent or 63,000 people).

"By Race/Ethnicity

"Among people aged 12 or older in 2022, White people were more likely to be heavy alcohol users in the past month (6.6 percent) compared with Hispanic (5.1 percent), Black (4.2 percent), or Asian people (1.9 percent) (Figure 11 and Table B.4B). Asian people were less likely to be heavy alcohol users in the past month compared with people in other racial or ethnic groups. The estimate of current heavy alcohol use could not be calculated with sufficient precision for Native Hawaiian or Other Pacific Islander people.13"

"Alcohol-caused harms are spread across populations and can be experienced both by people who use alcohol and by those who do not. 

"In the case of people who use alcohol, recent evidence indicates that, for both health and social harms, there is a risk even at low consumption levels (19–22). For example, in the European Union (EU), alcohol consumption is estimated to be the cause of 17% of the seven alcohol-related cancer types. Light to moderate alcohol consumption (less than 20 g of pure alcohol per day) was associated with 13.3% of these cases, equivalent to nearly 23 000 new cancer cases in 2017 (19,23). Concerning social harms, the literature is more sparse, but even so, studies to date have shown that the heaviest 10% of drinkers by volume are responsible for less than half of alcohol-related problems such as alcohol-related work absenteeism (24) and alcohol-related quarrels and fights (25). Hence, the social harms associated with drinking are attributable, to different degrees, to both heavy and non-heavy (ordinary) drinkers (26). 

"Apart from those who use alcohol, other people, including children, families and communities, can experience alcohol-caused harms. While the decision to drink may often be a personal one, those affected by alcohol’s harm to others (AHTO) are generally not given a choice or option (27,28). In one Australian study conducted in 2021, approximately one third of all adults were harmed by the alcohol use of other people; women, younger people and heavier drinkers were at greater risk, and the source of the harm was more likely to be people they knew rather than strangers (29). The most recent European data (from 2021), covering 39 629 respondents from 32 European countries, demonstrate that AHTO disproportionately affects women and people with low incomes (30). Overall, AHTO makes up a substantial proportion of the alcohol-attributable burden of disease (31). 

"In broad terms, no amount of alcohol is risk-free. Research shows that the majority of drinkers face some level of risk of experiencing alcohol-related harm (19,26,32)."

"Since the early 1990s, binge drinking (defined as drinking at least 4 drinks in a row for women or at least 5 drinks in a row for men) has been a key indicator of risky drinking. 

"However, the binge threshold may not clearly distinguish drinking risk. A person who consumes five drinks over a few hours may or may not show signs of intoxication, depending on factors including body composition, food and water intake, and tolerance. In contrast, a person who consumes ten drinks over the same time period is at high risk for alcohol poisoning and other negative outcomes. 

"Therefore, researchers have recently begun examining the prevalence, correlates, and consequences of high-intensity drinking, which is defined as drinking 10 or more drinks in a row (or with sex-specific cutoffs of drinking at least 8 drinks for women or at least 10 drinks for men). 

"High-intensity drinking typically occurs in combination with other risky drinking patterns. On days when people engage in high-intensity drinking, not only do they consume a high number of drinks, but they also tend to drink for longer periods of time and at a faster pace than they do when drinking at moderate or binge levels. That is, they have more drinks in a shorter period of time, which leads to a higher estimated blood alcohol content (eBAC).¹"

"Among people aged 12 or older in 2022, 21.7 percent (or 61.2 million people) were binge drinkers in the past month (Figures 8 and 9 and Table A.1B). The percentage was highest among young adults aged 18 to 25 (29.5 percent or 10.3 million people), followed by adults aged 26 or older (22.6 percent or 50.1 million people). The percentage was  lowest among adolescents aged 12 to 17 (3.2 percent or 834,000 people).

"By Race/Ethnicity

"Among people aged 12 or older in 2022, Asian people (10.3 percent) were less likely to be binge drinkers in the past month compared with people in other racial or ethnic groups (Figure 10 and Table B.4B). The estimate of binge drinking in the past month could not be calculated with sufficient precision for Native Hawaiian or Other Pacific Islander people.13 Estimates of binge drinking in the past month did not differ significantly among people in the other racial or ethnic groups."

"In addition to asking about any alcohol use, NSDUH collected information on past month binge alcohol use and heavy alcohol use. Binge drinking for males was defined as drinking five or more drinks¹⁸ on the same occasion on at least 1 day in the past 30 days, which has remained unchanged from the threshold prior to 2015. Since 2015, binge alcohol use for females has been defined as drinking four or more drinks on the same occasion on at least 1 day in the past 30 days.¹⁹ This definition of binge alcohol use is consistent with federal definitions.²⁰ Heavy alcohol use was defined as binge drinking on 5 or more days in the past 30 days based on the thresholds described previously for males and females.

"Among the 139.7 million current alcohol users aged 12 or older in 2019, 65.8 million people (47.1 percent) were past month binge drinkers (Figure 6). Among past month binge drinkers, 16.0 million people (24.4 percent of current binge drinkers and 11.5 percent of current alcohol users) were past month heavy drinkers.²¹"

• "After annual increases of 7% or less between 2000 and 2018, the overall age-adjusted rate of alcohol-induced deaths increased 26%, from 10.4 per 100,000 in 2019 to 13.1 in 2020 (Figure 1).
   
• "Rates of alcohol-induced deaths for males were stable from 2000 to 2009, increased 30% from 2009 (11.3) to 2018 (14.7), and increased 26% from 2019 (15.2) to 2020 (19.2).
   
• "Rates of alcohol-induced deaths for females increased over the entire period, with the largest annual increase (27%) occurring between 2019 (5.9) and 2020 (7.5).
   
• "Differences in rates between males and females decreased over the study period, from 3.6 times higher for males than females in 2000 (11.4 and 3.2, respectively), to 2.6 times higher in 2020 (19.2 and 7.5, respectively)."

"• In 2019 56% of the world’s population aged 15+ abstained from drinking alcohol – the numbers of drinkers and abstainers in the world are relatively stable over time.

"• The level of alcohol consumption per capita among drinkers amounts on average to 27 grams of pure alcohol per day, which is associated with appreciably increased risks of numerous health conditions and associated mortality and disability.

"• In 2019, 17% of people aged 15+ years and 38% of current drinkers engaged in heavy episodic drinking or 'binge drinking' (consuming at least 60g of pure alcohol on one or more occasions in the last month), while continuous heavy drinking was highly prevalent (6.7%) among men. Trends in total alcohol per capita consumption (APC) differ between WHO regions with a substantial decrease in Europe and a marked increase in APC in South-East Asia since 2000. In all WHO regions gender differences in alcohol consumption are significant with no major changes over time globally.

"• In 2019 the prevalence of alcohol consumption among 15–19-year-olds was unacceptably high worldwide (22%) with very little gender differences and a tendency of increase from initially low levels in some regions.

"• Worldwide distilled alcoholic beverages are the leading category in recorded alcohol consumption followed by beer and wines.

"• Unrecorded alcohol consumption made up 21% of overall consumption worldwide, and, overall, the wealthier a country or region, the higher the level of consumption and the lower the proportion of unrecorded consumption. "

"• The global burden of disease and injuries caused by alcohol consumption can be quantified for 31 health conditions on the basis of the available scientific evidence for the role of alcohol use in their development, occurrence and outcomes.

"• Worldwide, 2.6 million deaths were attributable to alcohol consumption in 2019, representing 4.7% of all deaths in that year.

"• The alcohol-attributable disease burden is heaviest among males: 2 million alcohol-attributable deaths and 6.9% of all DALYs among males and 0.6 million deaths and 2.0% of all DALYs among females in 2019.

"• The highest levels of alcohol-attributable deaths per 100 000 persons are observed in the WHO African and European regions.

"• Globally, an estimated 400 million people, or 7% of the world’s population aged 15 years and older, live with alcohol use disorders, and an estimated 209 million (3.7% of the adult world population) live with alcohol dependence, with substantial differences in the numbers of people affected in different WHO regions.

"• There has been a decreasing trend in the prevalence of alcohol use disorders worldwide since 2010 driven by decreases in the regions of the Americas, Europe and the Western Pacific, while an increasing trend is observed in the African, Eastern Mediterranean and South-East Asia regions.

"• The burden of age-standardized mortality (death rates) and morbidity (DALY rates) from alcohol consumption per litre of alcohol consumed is highest in low-income countries, followed by lower-middle-income countries, and is lowest in high-income countries.

"• The health burden expressed in years of healthy life lost due to ill-health or disability from alcohol consumption per litre of alcohol consumed is highest in high-income countries due, in part, to the high prevalence of alcohol use disorders and high rates of ill-health and disability associated with alcohol-related unintentional injuries.

"• People of younger age are disproportionately affected by alcohol consumption with the highest proportion (13.0%) of alcohol-attributable deaths from all deaths in 2019 among persons of 20–39 years.

"• From 2010 to 2019, the number of deaths attributable to alcohol per 100 000 people decreased by 20.2% – greater than the overall decrease in total deaths worldwide for the same period of time (14.8%); similarly a decrease in the number of alcohol-attributable DALYs lost within the same period (18.3%) was larger than the observed decrease in all-cause DALYs lost (14.0%)."

"• Age-adjusted rates of alcohol-induced deaths among all persons aged 25 and over were stable from 2000 to 2006 at about 10.7 per 100,000, then increased 43% to 15.3 in 2018 (Figure 1).

"• For males aged 25 and over, rates were stable from 2000 to 2005, then increased 34% from 2005 through 2018, from 16.9 to 22.6.

"• For females aged 25 and over, rates increased 76% from 2000 through 2018, from 4.9 to 8.6.

"• For each year, rates of alcohol-induced deaths for males aged 25 and over were higher than for females."

"In 2014, alcohols, including ethanol and isopropyl alcohol, were involved in 15% of all drug overdose deaths and 17% of the drug overdose deaths that mentioned involvement of at least one specific drug. Table E shows the frequency of alcohol involvement among drug overdose deaths involving specific drugs.

"• Alcohol involvement was mentioned in 12%–22% of the drug overdose deaths involving fentanyl, heroin, hydrocodone, morphine, oxycodone, alprazolam, diazepam, or cocaine.

"• Alcohol involvement was mentioned in less than 10% of the drug overdose deaths involving methadone and methamphetamine."

• "In 2019 and 2020, alcoholic liver disease was the most frequent cause of alcohol-induced death, followed by mental and behavioral disorders due to use of alcohol (Figure 5).
   
• "From 2019 to 2020, the largest increases in rates were from alcohol-induced acute pancreatitis (50%), from 0.1 per 100,000 to 0.2, followed by mental and behavioral disorders due to use of alcohol (33%), from 3.0 to 4.0.
   
• "Deaths from alcoholic liver disease increased 23%, from 6.4 in 2019 to 7.9 in 2020, and deaths from accidental poisoning of alcohol increased 14%, from 0.7 in 2019 to 0.8 in 2020.
   
• "No change was seen in rates of death from alcoholic cardiomyopathy or from other alcohol-induced causes of death from 2019 to 2020."

"Globally, an estimated 741,300 (95% UI 558,500–951,200; PAF 4·1% [3·1–5·3]) of all new cases of cancer in 2020 were attributable to alcohol consumption. In males, there were 568,700 (76·7%; 95% UI 422,500–731,100; PAF 6·1% [4·6–7·9]) alcohol-attributable cancer cases, and in females there were 172,600 (23·3%; 135,900–220,100; 2·0% [1·6–2·5]) alcohol-attributable cancer cases (table). The global age-standardised incidence rate was 8·4 (95% UI 6·2–10·9) alcohol-attributable cancer cases per 100,000 people: 13·4 (10·0–17·4) cases per 100 000 males and 3·7 (2·7–5·0) cancer cases per 100,000 females.

"The cancers with the highest PAFs were cancers of the oesophagus (31·6% [95% UI 18·4–45·7]), pharynx (22·0% [9·0–37·8]), and lip and oral cavity (20·2% [12·1–32·3]), with considerable differences by sex; for example, 39·2% (22·7–55·6) of oesophageal cancers in males were attributable to alcohol, compared with 14·3% (9·0–23·5) in females. The cancer sites that contributed the most attributable cases were cancers of the oesophagus (189,700 cases [95% UI 110,900–274,600]), liver (154,700 cases [43,700–281,500]), and breast (98,300 cases [68,200–130,500]; table)."

"From 2006 through 2010, excessive alcohol consumption accounted for nearly 1 in 10 deaths and over 1 in 10 years of potential life lost among working-age adults in the United States. Furthermore, an average of 2 out of 3 AAD and 8 out of 10 alcohol-attributable YPLL involved working-age adults. Although AAD rates varied by state, the national annual average AAD rate of 27.9 deaths per 100,000 population was higher than the average annual death rate for 10 of the 15 leading causes of deaths from 2006 through 2010 (12). The majority of the average annual AAD involved males (71%); over half of AAD and two-thirds of YPLL resulted from acute causes of death, all of which were by definition attributable to binge drinking. About 5% of all average annual AAD and 10% of average annual YPLL involved those under age 21 years, most of which were due to acute conditions."

"This study found that about 9 of 10 adult excessive drinkers did not meet the diagnostic criteria for alcohol dependence. About 90% of the adults who drank excessively reported binge drinking, and the prevalence of alcohol dependence was similar among excessive drinkers and binge drinkers across most sociodemographic groups. The prevalence of alcohol dependence also increased with the frequency of binge drinking. However, even among those who reported binge drinking 10 or more times in the past month, more than two-thirds did not meet diagnostic criteria for alcohol dependence according to their responses to the survey.

"The prevalence of alcohol dependence among adult excessive drinkers and binge drinkers in this study was slightly higher than the prevalence reported in other studies using the same diagnostic criteria for the classification of alcohol dependence. A 2001 study of alcohol abuse and dependence among US adults using the National Household Survey on Drug Abuse (NHSDA) — the precursor to the NSDUH — found that the prevalence of alcohol dependence was 7.4% among men and 7.3% among women who reported binge drinking (13). The higher prevalence of alcohol dependence among binge drinkers in this study may be due to the different time period as well as differences in the survey methods, which make these estimates not directly comparable (14). The former NHSDA was redesigned in 1999, and other changes were made to the survey in 2002, which may have increased the sensitivity of the NSDUH for identifying people who are binge drinking and alcohol dependent.

"Differences in the prevalence of alcohol dependence between the current study and the 2002 study in New Mexico (10.7% among excessive drinkers and 8.1% among binge drinkers) (8) are probably due to differences in the survey methods used by the NSDUH and the BRFSS as well as differences in the populations studied (15).

"Consistent with previous studies, binge drinking was most common among men, those aged 18 to 24, non-Hispanics whites, those with some college education, and those with an annual family income $75,000 or more (16). In contrast, alcohol dependence was most common among American Indians or Alaskan Natives, those having less than a high school education, and those with an annual family income of less than $25,000. These findings may reflect the known impact of alcohol dependence on many areas in the drinker’s life, including their ability to work and their productivity in the workplace. Reduced workplace productivity is the single largest contributor to alcohol-attributable economic costs in the United States (1).

"The strong relationship between the prevalence of excessive drinking and binge drinking is also consistent with the findings of previous studies (17), as is the higher prevalence of alcohol dependence among binge drinkers relative to all current drinkers (8), and the positive relationship between the frequency of binge drinking and alcohol dependence (18). These findings emphasize the usefulness of screening for binge-level alcohol consumption to identify excessive drinking among adults, including those who are alcohol-dependent (19). The relatively low prevalence of alcohol dependence among people who drink excessively also suggests that most people who are screened for excessive drinking in clinical settings will probably not need to be referred for specialized treatment."

"The presence of alcohol in almost all of the polydrug-use repertoires and among all of the different populations addressed is one of the key findings of this ‘Selected issue’. Alcohol is almost always the first drug with strong psychoactive and mind-altering effects used by young people, and its widespread availability makes it the ever-present drug in substance combinations among young adults, particularly in recreational settings."

"Each year, OMACs [One-Month Alcohol Abstinence Campaigns] attract an increasing number of participants. For example, even if it still represents less than one percent of the Australian adult population in 2019, 44,000 people officially registered for Dry July [28], while they were 16,787 in 2016 and 9,532 in 2010 [34]. Regarding Dry January, 4,000 people participated in the 2014 campaign while they were 3.9 millions in 2020, that is, approximately 7.5% of the UK adult population [35, 36]. However, for ensuring the continued success of such campaigns, it is important to inform participants whether these programs meet harm reduction objectives. This review thus aimed to determine the profile of participants in the different national one-month abstinence campaigns, to estimate the rates and factors of success, and to explore the associated subjective benefits in participating in or completing the challenge.

"Based on the studies pertaining to Dry January, it seems that those taking part in the challenge were more likely to be heavier drinkers, more concerned about their health, and had higher levels of incomes and education. The latter aspects are consistent with those reported elsewhere: the concern for healthy behaviors is more developed among individuals with higher education and incomes [37, 38]. However, this relationship is probably mediated, at least partially, by the overall level of education received, including during school years, suggesting that sustained and universal health education programs could help to bridge this gap [39]. The finding that females were more attracted in participating in abstinence campaigns is possibly in line with the fact that females are in general more concerned about health-related behaviors [40]. However, being a male led to better chance of successfully complete the abstinence campaign, specifically for campaigns promoting restriction of alcohol use. These results may reflect cultural differences across gender, with respect to alcohol use and alcohol-related representations [41].

"Completing the one-month abstinence challenge was found to be associated with lower drinking patterns and better psychosocial functioning at baseline. Thus, it is interesting to note that those participating in the abstinence campaigns had more elevated drinking patterns compared to the non-participating alcohol users, whereas those achieving the challenge had lower drinking patterns compared to those who did not. Another important factor of success was the registration and active participation in social media communities. This is in line with the overall finding that interactive social media on the Internet can be a very effective tool to change health behaviors in the general population [42]. There may be some biases in this finding as participants who registered on social communities might be the most motivated ones, which could explain a better success in achieving the challenge. However, sharing the experience and the difficulties encountered during of a long time period of alcohol abstinence on a virtual community was designated as the most efficient strategy to successfully reach the abstinence goal during the online HSM program [7]. In this program, other strategies which were reported to be efficient to abstain from alcohol include the engagement in alcohol-free activities, the use of non-alcoholic beverages instead of alcohol, support from family and friends, and anticipation of social events [7]. On the contrary, anxiety, stress, negative emotions, social pressure to drink, loneliness, boredom, and no social support were reported as barriers to maintain alcohol abstinence [7]. Considering those dimensions as potential factors for success or failure in national one-month abstinence campaigns would be relevant in further studies.

"Many participants in OMACs reported subjective improvements in health, including improved sleep, weight loss, an increased “energy”. An important finding is that Dry January participants also reported to have tried to increase their physical activity and to improve their diet, which was also reported by Dry July participants during the mid-year health check. This may suggest that these campaigns are actually not merely alcohol-focused for many participants, and might consist for them to a health-focused month, in particular when it is the first month of the year immediately after the end of year celebrations. This finding might have important implications for the evolution of the communication around these prevention campaigns. Moreover, improvement in health after one-month alcohol abstinence was objectively demonstrated for several parameters in a study with drinkers drinking above national guidelines where one-month alcohol abstinence led to a decrease in blood pressure, decrease in circulating concentrations of cancer-related growth factors, decrease in insulin resistance and weight reduction compared to the non-abstinent group [43]."

"Alcohol is, by far, the most widely used drug among college students, with 60.8% of students reporting alcohol use in the past month (Substance Abuse & Mental Health Services Administration, 2012). In 2009, 61.5% of college students reported that they had been intoxicated at least once in the past year, with 42.4% reporting that they had been intoxicated in the past 30 days (Johnston, O'Malley, Bachman, & Schulenberg, 2010). Approximately 37 to 44% of college students reported that they binge drank at least once in the past two weeks to month (Hingson, Heeren, Winter, & Wechsler, 2005; Johnston et al., 2010; Wechsler et al., 2002).

"Alcohol use can lead to a wide range of problems (e.g., involvement in risky sexual situations, driving under the influence, hangovers, nausea and vomiting, and aggression). Due to the high levels of alcohol consumption and the contexts in which college students typically consume alcohol (e.g., parties where excessive drinking is the norm), along with no parental oversight and monitoring, this population may be particularly likely to experience alcohol-related problems (ARPs). Of college students who drank at least once per week during their first year of college, 80% experienced more than one ARP during their first year, and 34% reported that they had experienced six or more ARPs during that time (Mallett et al., 2011)."

"The potential use of ketamine for AUD was first suggested in 1972 (32, 33). Possible hypotheses for ketamine use in AUD include balancing cortical glutamate homeostasis and enhancing neuroplasticity which may facilitate learning and acquiring new skills, especially those that help individuals cope with drinking (29, 34). Acute alcohol exposure stimulates the GABA receptors and inhibits the NMDA-glutamate receptors. Chronic alcohol use decreases the concentration of GABA receptors and upregulates NMDA-glutamate receptors. This new balance of inhibitory and excitatory neurotransmitters requires continued regulation with alcohol. Abrupt cessation of alcohol use causes enhanced signaling of the glutamatergic system manifesting as fear, anxiety, and restlessness resulting in a syndrome of alcohol withdrawal. Additionally, the dysregulation of glutaminergic tone results in individuals experiencing alcohol craving. Ketamine mimics some of the mechanisms of action of alcohol through antagonism of the NMDA receptor which may reduce alcohol cravings. Ketamine additionally upregulates the mu and kappa-opioid receptor. The downstream effects are to enhance dopamine secretion which has been described as a mechanism to address depression. For individuals who have AUD, depression is a common comorbidity and may explain some of the potential effects of ketamine on alcohol use (35, 36). Like any substance use, alcohol use can change the neuronal plasticity and lead to formation of maladaptive memories that contribute to increased drug craving and seeking behavior. This neuronal plasticity is partly modulated by the NMDA-glutamate receptor (glutamatergic system) which can be potentially reversed by the inhibitory action on this receptor by ketamine (37, 38). Ketamine can also serve as a potential adjunct in the management of AWS. Ketamine may serve as an adjunct to benzodiazepines in AWS because it acts as an NMDA antagonist and may help to balance cortical glutamate homeostasis faster with decreased sedation time than with benzodiazepines alone (39)."

"Among residents of a COVID-19 isolation hotel shelter for people experiencing homelessness, we found that an emergency, provisional safe supply program (i.e., prescribing pharmaceutical-grade medications and beverage-grade alcohol) was associated with low rates of adverse events and high rates of successful completion of the 14-day isolation period. No shelter residents experienced an overdose during their stay. We identified medication dosage ranges that generally fell within those recommended in “risk mitigation” prescribing guidelines, which were urgently produced in response to evolving risks of COVID-19."

"There is increasing interest in the use of ketamine as an adjunct to treatment of AUD and management of AWS. There were three studies that showed the benefit of using ketamine as an adjunctive treatment to conventional first-line therapies in patients with severe AWS. Ketamine was added to the medication regimen when AWS was refractory to BZD or after clinical signs of delirium tremens (DT). IV ketamine was administered in variable doses ranging from 0.15 to 0.75 mg/kg/h. Ketamine therapy led to a decrease in BZD dose requirements, early resolution of AWS and DT, and decreased duration of ICU stay and intubation time. No AWS complications such as seizures, hallucinations, or delirium tremens were reported after initiation of ketamine (13). The administration of ketamine in AWS was generally safe without any serious adverse effects except oversedation noted in two participants among all the three studies (13, 14). Oversedation was managed by ketamine dose reduction and there was no reported use of any additional treatment modalities. This adverse effect could be explained by either due to the primary known effect of ketamine or due to sedation potentiation by BZD’s administration.

"Despite encouraging results after ketamine initiation in AWS, one of several potential confounders was the use of other medications such as phenobarbital and propofol. In all studies, ketamine was initiated late in AWS management depending on the BZD refractory status of AWS or development of DT. It is possible that the efficacy of ketamine may be greater if it were used as a first line or adjunct to BZD before large doses of BZD or other GABA agonists are used. These limitations make it difficult to determine the true efficacy and situation in which ketamine may be used in AWS.

"We also found seven studies that assessed the efficacy and safety of ketamine for AUD. While the study design, rigor, and target population varied across studies, all studies that examined alcohol outcomes showed greater alcohol abstinence rates in both short-term (21 days) and long-term (1 year) intervals compared to control conditions (43, 44, 46). Ketamine was administered in subanesthetic doses in variable frequency and routes. The highest dose administered was a single dose ketamine 2.5 mg/kg IM (43). Subsequent studies used lower doses – single ketamine 0.35 mg/kg IV infusion, ketamine 0.5 mg/kg IV once weekly for 4 weeks, single ketamine 0.71 mg/kg, three weekly ketamine 0.8 mg/kg IV infusions. Severe adverse effects like euphoria, tachycardia, hypertension, and low mood were reported in 6.3% (3/96) of participants in the Grabski et al. study and affected their normal activities of daily living. Two out of the three participants with severe adverse effects withdrew from the study due to medication intolerability. In addition to ketamine, most studies included adjunctive psychotherapy which may have contributed to outcomes, raising important questions about the frequency, timing, and type of psychotherapy that might help to optimally improve AUD-related outcomes.

"While ketamine did show an improvement in abstinence rates, the longevity of this effect was variable as there was return to alcohol consumption. However, all studies showed ketamine administration produced longer periods of abstinence and reduction in alcohol consumption and cravings, which suggests that ketamine impacts drinking outcomes beyond the direct pharmacologic effects. Furthermore, due to its anti-depressant properties, ketamine may be useful for managing depression that may arise during the abstinence periods."

"Among the 137.4 million current alcohol users aged 12 or older in 2022, 61.2 million people (or 44.5 percent) were past month binge drinkers (Figure 8). Among past month binge drinkers, 16.1 million people were past month heavy drinkers. The 16.1 million heavy drinkers represent 26.3 percent of current binge drinkers and 11.7 percent of current alcohol users.²⁰

"Any Alcohol Use

"Among people aged 12 or older in 2022, 48.7 percent (or 137.4 million people) drank alcohol in the past month (Figure 9 and Table A.1B). The percentage was highest among adults aged 26 or older (53.4 percent or 118.2 million people), followed by young adults aged 18 to 25 (50.2 percent or 17.5 million people). The percentage was lowest among adolescents aged 12 to 17 (6.8 percent or 1.8 million people).

"By Race/Ethnicity

"Among people aged 12 or older in 2022, 53.4 percent of White people drank alcohol in the past month (Table B.4B). This percentage was higher than the percentages of people in other racial or ethnic groups. Hispanic people had a higher estimate of past month alcohol use (43.6 percent) compared with Asian people (36.7 percent). The estimate of current alcohol use could not be calculated with sufficient precision for Native Hawaiian or Other Pacific Islander people.¹³"

"Social anxiety disorder (SAD) and alcohol use disorders (AUDs) are frequently comorbid (see Morris, Stewart, and Ham (2005), for a review). Approximately 13% of adults with past-year SAD met criteria for a comorbid AUD, and of adults with lifetime SAD, 48.2% met criteria for an AUD (Grant et al., 2005). This relationship appears to be due to a greater likelihood of having comorbid alcohol dependence (characterized by tolerance, withdrawal, or compulsive alcohol consumption (APA, 2000); OR = 2.26 to 2.7) rather than alcohol abuse (characterized by a pattern of negative consequences that result from alcohol use (APA, 2000); OR = 1.2 to 1.23; Buckner, Timpano, Zvolensky, Sachs-Ericsson, & Schmidt, 2008; Grant et al., 2005). Both retrospective and longitudinal studies have shown that when SAD and AUD co-occur, SAD typically precedes the onset of the AUD (Buckner, Schmidt, et al., 2008; Buckner, Timpano, et al., 2008; Buckner & Turner, 2009; Falk, Yi, & Hilton, 2008).

"Consistent with studies of adults, Kushner and Sher (1993) found that 43% of college freshmen with SAD met diagnostic criteria for an AUD while only 26% of college freshman without SAD met criteria for an AUD. Overall, however, research on the relationship between social anxiety and alcohol use among college students has revealed very mixed findings (see Morris et al. (2005), for a review). Some laboratory studies have demonstrated that socially anxious participants drink more in anticipation of both interaction (Higgins & Marlatt, 1975) and speech tasks (Kidorf & Lang, 1999), whereas others (e.g., Holroyd, 1978) have found that socially anxious students drink significantly less alcohol than non-socially anxious peers during informal laboratory-based “get togethers.” Survey studies of college students have either failed to find a relationship between social anxiety and alcohol consumption, or have found an inverse relationship between social anxiety and alcohol consumption (e.g., Buckner, Schmidt, & Eggleston, 2006; Gilles, Turk, & Fresco, 2006; Ham & Hope, 2006; Lewis et al., 2008). One possible reason for the lack of a positive relationship between social anxiety and alcohol use is that socially anxious students may avoid social situations and only use alcohol to cope with anxiety in social situations when they cannot be avoided (Norberg, Norton, & Olivier, 2009; Stewart, Morris, Mellings, & Komar, 2006).

"Despite the fact that many studies have found a negative relationship, or no relationship at all, between social anxiety and alcohol use, A.R. Schry, S.W. White / Addictive Behaviors 38 (2013) 2690–2706 2691many studies have found that social anxiety is positively associated with ARPs (e.g., Buckner, Ecker, & Proctor, 2011; Buckner & Heimberg, 2010; Buckner et al., 2006; Gilles et al., 2006; Norberg et al., 2009). A significant relationship between social anxiety and ARPs may be particularly important, because AUDs are defined by problems resulting from the use of alcohol rather than simply the quantity and frequency of use (Buckner et al., 2006). However, not all studies have found a significant relationship between social anxiety and ARPs (e.g., Ham, Zamboanga, Bacon, & Garcia, 2009; LaBrie, Pedersen, Neighbors, & Hummer, 2008)."

"The prescribing practices described in this evaluation – safe supply medications and managed alcohol, for unwitnessed consumption – are a recent development. While the relative safety of medications and alcohol dispensed for unwitnessed consumption has not been previously well-described in the literature, the practice is an extension of the evidence from witnessed consumption settings (Bonn et al., 2021; Brothers et al., 2022; Tyndall, 2020; Hales et al., 2020; Bonn et al., 2021). Witnessed injectable OAT (iOAT) with liquid hydromorphone or diacetylmorphine (Heroin) has a robust evidence-based and has been incorporated into Canadian clinical practice guidelines for opioid use disorder (Oviedo-Joekes et al., 2016; Fairbairn et al., 2019). Qualitative studies have evaluated the benefits of witnessed hydromorphone tablet consumption, which is more flexible and less resource-intensive than witnessed iOAT (Ivsins et al., 2021; Ivsins et al., 2020). A recent study from Ottawa, Canada, describes positive outcomes for people with severe opioid use disorder who are provided hydromorphone iOAT along with supported housing (Harris et al., 2021). Benefits of managed alcohol programs are also clearly established for people with severe alcohol use disorder, and particularly people who drink non-beverage alcohol (Stockwell et al., 2021; Stockwell et al., 2018; Crabtree et al., 2018). Some existing managed alcohol programs include once-daily alcohol dispensing and/or unwitnessed ingestion (Pauly et al., 2018)."

"Trends in Substance Use
"Past month alcohol use, binge alcohol use, and illicit drug use remained relatively stable among black adults between 2002 and 2008 (Figure1).^4,5

"Past Month Alcohol and Illicit Drug Use
"Combined 2004 to 2008 data indicate that, in the past month, 44.3 percent of black adults used alcohol, 21.7 percent reported binge alcohol use, and 9.5 percent used an illicit drug (Figure 2).

"Rates of past month alcohol use and binge alcohol use were lower among black adults than the national averages. The rate of past month illicit drug use among black adults, however, was higher than the national average.

"Substance Use among Young Adults (Aged 18 to 25)
"Rates of past month and binge alcohol use were considerably lower among young black adults than the national average of young adults (48.6 vs. 61.1 percent and 25.3 vs. 41.6 percent, respectively) (Figure 3).

"Past month illicit drug use among young black adults was slightly lower than the national average (18.7 vs. 19.7 percent).

"Substance Use among Older Adults (Aged 65 or Older)
"Older black adults had a rate of past month alcohol use that was considerably lower than the national average of older adults (20.3 vs. 38.3 percent) (Figure 4). Their rates of binge alcohol use and past month illicit drug use, however, did not differ significantly from the national averages.

"Substance Use among Women
"Compared with the national averages, adult black females had lower rates of past month alcohol use and binge alcohol use and a slightly higher rate of past month illicit drug use (Table 1). Patterns varied by age group.

"Among women aged 18 to 44 who were pregnant at the time of the survey interview, blacks had a higher rate of binge alcohol use than the national average (8.1 vs. 3.6 percent) (Figure 5). As for past month alcohol use and past month illicit drug use, the rates appear to have been higher than the national average of pregnant women, but the differences were not statistically significant.

"Substance Use among Men
"Compared with the national averages, adult black males had lower rates of past month alcohol use and binge alcohol use and a slightly higher rate of past month illicit drug use (Table 2). Patterns varied by age group."

"Alcohol and marijuana are the two most commonly used substances by teenagers to get high, and a question that is often asked is to what extent does change in one lead to a change in the other. If the substances co-vary negatively (an increase in one is accompanied by a decrease in the other) they are said to be substitutes; if they co-vary positively, they are said to be complements.

"Interestingly, the answer may differ by historical era. Before 2007 patterns of use for the two substances suggested they acted as complements. When marijuana use increased in the late 1970s, so too did alcohol use. Between 1979 and 1992 marijuana use declined and a parallel decline took place in annual, monthly, and daily alcohol use, as well as in binge drinking among 12th graders. As marijuana use increased again in the 1990s, alcohol use again increased with it, although not as sharply. In sum, before 2007 there was little evidence from MTF to support what we have termed “the displacement hypothesis,” which asserts that an increase in marijuana use will lead to a decline in alcohol use, or vice versa.8

"However, since 2007 a new trend has emerged that would be consistent with the “displacement” hypothesis. From 2007 through 2019 alcohol use declined markedly, reaching historic lows in the life of the study. Meanwhile, for most of this time period marijuana use has stayed steady or increased for all age groups. For the first time trends in alcohol and marijuana use are substantially diverging, suggesting that the historical relationship between these two drugs may have changed."

"Alcohol and tobacco consumption levels are by far those which cause the most serious extent of damage, either on the health or social level, or with regard to potential dependency."

"The data are quite consistent with the view that Prohibition at the state level inhibited alcohol consumption, and an attempt to explain correlated residuals by including omitted variables revealed that enforcement of Prohibitionist legislation had a significant inhibiting effect as well. Moreover, both hypotheses about the effects of alcohol and Prohibition are supported by the analysis. Despite the fact that alcohol consumption is a positive correlate of homicide (as expected), Prohibition and its enforcement increased the homicide rate."

"The lethal dose of alcohol divided by a typical recreational dose (safety ratio) is 10, which places it closer to heroin (6), and GHB (8) in terms of danger from overdose, than MDMA ('Ecstasy' – 16), and considerably more dangerous than LSD (1000) or cannabis (>1000)."

"Lifetime alcohol users aged 21 or older had a significantly higher rate of past year illicit drug use (13.7 percent) compared with lifetime nondrinkers (2.7 percent). In addition, lifetime alcohol users had significantly higher rates of past year use across all illicit drug categories, with the exception of inhalants (Table 1). Nonmedical use of pain relievers was the illicit drug used most often by lifetime nondrinkers, whereas lifetime alcohol users reported using marijuana most frequently."

"In 2002 and 2003, an estimated 88.2 percent of persons aged 21 or older (175.6 million) were lifetime alcohol users, whereas an estimated 11.8 percent (23.5 million) were lifetime nondrinkers. Over half of lifetime alcohol users (52.7 percent) had used one or more illicit drugs at some time in their life, compared to 8.0 percent of lifetime nondrinkers. Among persons who had used an illicit drug in their lifetime, the average age at first illicit drug use was 19 years for lifetime alcohol users, versus 23 years for lifetime nondrinkers."

"• As was the case in prior years, the level of alcohol use was associated with illicit drug use in 2013. Among the 16.5 million heavy drinkers aged 12 or older, 33.7 percent were current illicit drug users. Persons who were not current alcohol users were less likely to have used illicit drugs in the past month (4.3 percent) than those who reported current use of alcohol but no binge or heavy use (7.3 percent), binge use but no heavy use (18.5 percent), or heavy use of alcohol (33.7 percent).

"• Alcohol consumption levels also were associated with tobacco use in 2013. Among heavy alcohol users aged 12 or older, 53.1 percent smoked cigarettes in the past month compared with 16.2 percent of non-binge current drinkers and 15.5 percent of persons who did not drink alcohol in the past month. Smokeless tobacco use and cigar use also were more prevalent among heavy drinkers (12.1 and 15.4 percent, respectively) than among non-binge drinkers (2.0 and 3.9 percent) and persons who were not current alcohol users (2.0 and 1.8 percent)."

"Excessive alcohol use* accounted for an estimated average of 80,000 deaths and 2.3 million years of potential life lost (YPLL) in the United States each year during 2001–2005, and an estimated $223.5 billion in economic costs in 2006. Binge drinking accounted for more than half of those deaths, two thirds of the YPLL, and three quarters of the economic costs."

* Excessive alcohol use includes binge drinking (defined by CDC as consuming four or more drinks per occasion for women or five or more drinks per occasion for men), heavy drinking (defined as consuming more than one drink per day on average for women or more than two drinks per day on average for men), any alcohol consumption by pregnant women, and any alcohol consumption by youths aged less than 21 years.

"VIVITROL was approved in 2006 by the FDA as an extended-release formulation of naltrexone for the treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment. VIVITROL is administered by intramuscular (IM) injection once per month."

"The rate of past year alcohol use disorder among persons aged 12 to 20 was higher for American Indians or Alaska Natives (14.9 percent) than for whites (10.9 percent), blacks (4.6 percent), Hispanics (8.7 percent), and Asians (4.9 percent). One in eight Native Hawaiians or Other Pacific Islanders (12.7 percent) met the criteria for an alcohol use disorder."

"Combined data from 2002 to 2006 indicated that an annual average of 9.4 percent of persons aged 12 to 20 (3.5 million persons in that age range) met the diagnostic criteria for an alcohol use disorder (dependence or abuse) in the past year."

"On average, 6 people died every day from alcohol poisoning in the US from 2010 to 2012. Alcohol poisoning is caused by drinking large quantities of alcohol in a short period of time. Very high levels of alcohol in the body can shutdown critical areas of the brain that control breathing, heart rate, and body temperature, resulting in death. Alcohol poisoning deaths affect people of all ages but are most common among middle-aged adults and men."

"The central finding gleaned from the present study was that MML [Medical Marijuana Legalization] is not predictive of higher crime rates and may be related to reductions in rates of homicide and assault. Interestingly, robbery and burglary rates were unaffected by medicinal marijuana legislation, which runs counter to the claim that dispensaries and grow houses lead to an increase in victimization due to the opportunity structures linked to the amount of drugs and cash that are present. Although, this is in line with prior research suggesting that medical marijuana dispensaries may actually reduce crime in the immediate vicinity [8]."

"In sum, these findings run counter to arguments suggesting the legalization of marijuana for medical purposes poses a danger to public health in terms of exposure to violent crime and property crimes. To be sure, medical marijuana laws were not found to have a crime exacerbating effect on any of the seven crime types. On the contrary, our findings indicated that MML precedes a reduction in homicide and assault. While it is important to remain cautious when interpreting these findings as evidence that MML reduces crime, these results do fall in line with recent evidence [29] and they conform to the longstanding notion that marijuana legalization may lead to a reduction in alcohol use due to individuals substituting marijuana for alcohol [see generally 29, 30]. Given the relationship between alcohol and violent crime [31], it may turn out that substituting marijuana for alcohol leads to minor reductions in violent crimes that can be detected at the state level. That said, it also remains possible that these associations are statistical artifacts (recall that only the homicide effect holds up when a Bonferroni correction is made)."

"• Admissions for abuse of alcohol alone, with no secondary drug abuse, represented 21 percent of TEDS admissions aged 12 and older in 2012 [Table 1.1b].
"• The average age at admission among admissions for alcohol only was 41 years. The average age at admission for alcohol with secondary drug was 37 years [Table 2.1a]. Admission for alcohol only or with secondary drug was the most likely reason for admissions aged 30 and older [Table 2.1b].
"• Non-Hispanic Whites made up 66 percent of all alcohol-only admissions (approximately 46 percent were males and 21 percent were females) [Table 2.3a].
"• Eighty-seven percent of alcohol-only admissions reported that they first became intoxicated before age 21, the legal drinking age. Almost one-third (30 percent) first became intoxicated by age 14 [Table 2.5].
"• Among admissions referred to treatment by the criminal justice/DUI source, alcohol-only admissions were more likely than admissions for alcohol with secondary drug abuse to have been referred as a result of a DUI/DWI offense (28 vs. 16 percent) [Table 2.6].
"• Some 34 percent of alcohol-only admissions aged 16 and older were employed compared with 22 percent of all admissions that age [Table 2.8]."

"Alcohol is neurotoxic to brain development, leading to structural hippocampal changes in adolescence,¹⁶ and to reduced brain volume in middle age.¹⁷ Alcohol is a dependence-producing drug, similar to other substances under international control, through its reinforcing properties and neuro-adaptation in the brain.¹⁸ It is an immunosuppressant, increasing the risk of communicable diseases,¹⁹ including tuberculosis.²⁰ Alcoholic beverages are classified as carcinogenic by the International Agency for Research on Cancer, increasing the risk of cancers of the oral cavity and pharynx, oesophagus, stomach, colon, rectum, and breast in a linear dose-response relation,²¹ with acetaldehyde as a potential pathway.²² Alcohol has a biform relation with coronary heart disease. In low and apparently regular doses (as little as 10 g every other day), alcohol is cardioprotective,²³ although doubt remains about the effect of confounders.²⁴ At high doses, especially when consumed irregularly, it is cardiotoxic.²⁵

"After years of research, Ethyl Glucuronide (EtG) and Ethyl Sulfate (EtS) were found to be a direct metabolite of the alcohol (ethanol). EtG/EtS has emerged as the marker of choice for alcohol and due to the advances in technologies is now routinely available. Its presence in urine may be used to detect recent alcohol consumption, even after ethanol is no longer measurable using the older methods. The presence of EtG/EtS in urine is a definitive indicator that alcohol was ingested. Other types of alcohol, such a stearyl, acetyl and dodecanol, metabolizes differently and will not cause a positive result on an EtG/EtS test.

"The EtG/EtS test has become known as the “80 hour test” for detecting any amount of consumed ethyl alcohol. This is a misnomer. It is true that EtG can be detected in chronic drinkers for 80 hours or even up to 5 days but not from a person that only consumed 2 or 3 drinks. During the period of chronic use, the EtG level can exceed 100,000 ng/mL. A level of 1.25 million was found in one sample. Two primary factors to determine the window of detection is based on volume of alcohol consumed and the time between each drink. A person that consumes 3 drinks can only have a detectable level of EtG for approximately 20 to 24 hours. The level peaks at approximately 9 hours with an EtG level around 15,000 ng/mL.

"The presence of EtG and EtS in urine indicates that ethanol was ingested.

"EtG/EtS is stable in urine for more than 4 days at room temperature. Recent experiments indicate that heating urine to 100 degrees C actually increased the stability. Therefore, heat does not cause the breakdown of EtG/EtS. In addition, no artificial formation of EtG/EtS was found to occur following the prolonged storage of urine at room temperature fortified with 1% ethanol.

"EtG/EtS is a direct metabolite of alcohol (ethanol), and its detection in urine is highly specific, similar to testing for other drugs. The typical lab utilizes the most sophisticated, sensitive, and specific equipment and technology available, LC/MS/MS, to screen, confirm, and quantify EtG/EtS. This methodology provides
highly accurate results.

"EtG/EtS is only detected in urine when alcohol is consumed. This is important since it is possible to have alcohol in urine without drinking. Alcohol in urine without drinking is due to the production of ethanol in vitro. Ethanol in vitro is spontaneously produced in the bladder or the specimen container itself, due to fermentation of urine samples containing sugars (diabetes) and yeast or bacteria. Since the ethanol produced is not metabolized by the liver, EtG/EtS will not be produced and will therefore not be detected in a urine containing alcohol as a result of fermentation.

"Tests show that “incidental exposure” to the chronic use of food products (vanilla extract), hygiene products, mouthwash, or OTC medications (cough syrups) can produce EtG/EtS concentrations in excess of 100 ng/mL. However, if EtG is detected in excess of 250 ng/mL, then this is very strong evidence that beverage alcohol was consumed."

"The present study sought to test the validity of a commercially available uEtG test to detect past day drinking, past day binge drinking, past 3-day drinking, and past 3-day binge drinking in a sample of heavy drinkers. We found that while uEtG was reasonably able to detect past day alcohol use and past day binge drinking, detection of drinking and binge drinking in the past 3 days was poor. These findings were consistent with a recent study examining the utility of uEtG testing among women of childbearing age, which found poor sensitivity to detect light-to-moderate drinking beyond a 12-hour window (Graham et al., 2017). These preliminary results call into question the validity of commercially available urine EtG tests at the manufacturer recommended detection cutoffs as means of validating alcohol abstinence and binge drinking in clinical research. It is important to consider the sensitivity of detection window as the current uEtG was commercially sold to detect alcohol use in the past 80 h, yet was only accurate for detecting past 24 h’ alcohol use. As false positives are common with uEtG tests (Costantino et al., 2006; Wurst et al., 2015), researchers should be aware of the limitations of urinary EtG using the manufacturer recommended detection threshold of 500 ng/ml and should not rely on commercial uEtG alone as verification of past alcohol use, particularly when using conservative detection thresholds. Breath alcohol concentrations (BrAC) should be used in conjunction with physiological biomarkers and self-report in order to accurately capture recent alcohol intake."

"When an alcoholic beverage is consumed, approximately 20% of the alcohol is absorbed in the stomach and 80% is absorbed in the small intestine (Freudenrich, 2001). After absorption, alcohol enters the bloodstream and dissolves in the water of the blood where it is quickly distributed to body tissues. When alcohol reaches the brain, it affects the cerebral cortex first, followed by the limbic system (hippocampus and septal area), cerebellum, hypothalamus, pituitary gland, and lastly, the medulla, or brain stem. Some of these regions are similar to those affected by cannabis, but alcohol also affects sexual arousal/function and increases urinary output. When BAC is near toxic levels, lower order brain regions are affected, which is often followed by sleepiness, lack of consciousness, coma, or death."

"Antidepressants are most commonly in the form of selective serotonin uptake inhibitors (SSRIs), such as fluoxetine (Prozac®) and sertraline (Zoloft®). They can cause impairment, especially in circumstances where extremely high blood concentrations are measured or if they are taken outside of medical need or therapeutic treatment. There is also an additional risk of impairment associated with combined use with alcohol."

"Alcohol has a range of psychomotor and cognitive effects that increase accident risk on reaction times, cognitive processing, coordination, vigilance, vision and hearing, even at low blood alcohol levels. For these reasons alcohol consumption is normally closely regulated in relation to the operation of transport systems and other safety sensitive environments and activities.

"Adverse effects on vision have been found at blood alcohol concentrations of 30mg ethanol per 100ml blood, and the psychomotor skills required for driving have been found to show impairment from 40mg/100ml (in the UK the legal blood alcohol limit for drivers is 80mg/100ml). Raised risk of accident can also remain for some time after drinking, as skills and faculties do not necessarily return to normal immediately even once all alcohol has left the body. Drink-driving vehicles in general is a dangerous activity, as the number of alcohol-related serious injuries and deaths on Great Britain’s roads demonstrates. Since 2010, 4% – 5% of all reported road traffic accidents involved at least one driver over the drink drive limit have accounted for around. Between 13% – 16% of all deaths on GB roads over the same period did so too.¹

"Impairment of faculties can also have a dangerous effect on the control of aircraft. In a study of airline pilots who had to perform routine tasks in a simulator under three alcohol test conditions, it was found that:

"• before the ingestion of any alcohol, 10% of them could not perform all the operations correctly;

"• after reaching a blood alcohol concentration of 100mg/dl, 89% could not perform all the operations correctly;

"• and 14 hours later, after all the alcohol had left their systems, 68% still could not perform all the operations correctly.²"

"Alcohol thus ranks at the dangerous end of the toxicity spectrum. So despite the fact that about 75 percent of all adults in the United States enjoy an occasional drink, it must be remembered that alcohol is quite toxic. Indeed, if alcohol were a newly formulated beverage, its high toxicity and addiction potential would surely prevent it from being marketed as a food or drug."

"The findings in this report confirm those from the most recent National Roadside Survey, which in 2007 found that only a small percentage of adult drivers are alcohol-impaired. That survey showed that 2.2% of drivers on the road on Friday afternoon or Friday or Saturday night had a BAC of ?0.08 g/dL (12). Additionally, the findings in this report are consistent with alcohol-impaired driving fatality data. Men accounted for 81% of all alcohol-impaired driving episodes in 2010 and 82% of all alcohol-impaired drivers involved in fatal crashes in 2009 (1). Likewise, men aged 21–34 accounted for 32% of alcohol-impaired driving episodes and 35% of all alcohol-impaired drivers involved in fatal crashes (Tonja Lindsey, National Highway Traffic Safety Administration, personal communication, 2011)."

"Alcohol-impaired driving fatalities declined 20% from 13,491 to 10,839 from 2006 to 2009, the most recent year for which fatality data are available (7). However, the proportion of all motor vehicle fatalities that involve at least one alcohol-impaired driver has remained stable at about 33%, because non-alcohol-impaired driving fatalities have declined at the same rate as alcohol-impaired fatalities (7). This study indicated that alcohol-impaired driving rates remain disproportionally high among young men, binge drinkers, persons who do not always wear a seatbelt, and persons living in the Midwest."

"As with cannabis, alcohol use increased variability in lane position and headway (Casswell, 1979; Ramaekers et al., 2000; Smiley et al., 1981; Stein et al., 1983) but caused faster speeds (Casswell, 1977; Krueger & Vollrath, 2000; Peck et al., 1986; Smiley et al., 1987; Stein et al., 1983). Some studies also showed that alcohol use alone and in combination with cannabis affected visual search behavior (Lamers & Ramaekers, 2001; Moskowitz, Ziedman, & Sharma, 1976). Alcohol consumption combined with cannabis use also worsened driver performance relative to use of either substance alone. Lane position and headway variability were more exaggerated (Attwood et al., 1981; Ramaekers et al., 2000; Robbe, 1998) and speeds were faster (Peck et al., 1986).
"Both simulator and road studies showed that relative to alcohol use alone, participants who used cannabis alone or in combination with alcohol were more aware of their intoxication. Robbe (1998) found that participants who consumed 100 g/kg of cannabis rated their performance worse and the amount of effort required greater compared to those who consumed alcohol (0.05 BAC). Ramaekers et al. (2000) showed that cannabis use alone and in combination with alcohol consumption increased self-ratings of intoxication and decreased self-ratings of performance. Lamers and Ramaekers (2001) found that cannabis use alone (100 g/kg) and in combination with alcohol consumption resulted in lower ratings of alertness, greater perceptions of effort, and worse ratings of performance."

"During the 30 days before the survey, 24.1% of students nationwide had ridden one or more times in a car or other vehicle driven by someone who had been drinking alcohol (Table 5). The prevalence of having ridden with a driver who had been drinking alcohol was higher among white female (23.8%) than white male (20.5%) students. Overall, the prevalence of having ridden with a driver who had been drinking alcohol was higher among Hispanic (30.7%) than white (22.1%) and black (22.8%) students; higher among Hispanic female (30.7%) than white female (23.8%) and black female (23.2%) students; and higher among Hispanic male (30.7%) than white male (20.5%) and black male (22.5%) students."

"When compared to alcohol, cannabis is detected far less often in accident-involved drivers. Drummer et al. (2003) cited several studies and found that alcohol was detected in 12.5% to 79% of drivers involved in accidents. With regard to crash risk, a large study conducted by Borkenstein, Crowther, Shumate, Zeil and Zylman (1964) compared BAC in approximately 6,000 accident-involved drivers and 7,600 nonaccident controls. They determined the crash risk for each BAC by comparing the number of accident-involved drivers with detected levels of alcohol at each BAC to the number of nonaccident control drivers with the same BAC. They found that crash risk increased sharply as BAC increased. More specifically, at a BAC of 0.10, drivers were approximately five times more likely to be involved in an accident.
"Similar crash risk results were obtained when data for culpable drivers were evaluated. Drummer (1995) found that drivers with detected levels of alcohol were 7.6 times more likely to be culpable. Longo et al. (2000) showed that drivers who tested positive for alcohol were 8.0 times more culpable, and alcohol consumption in combination with cannabis use produced an odds ratio of 5.4. Similar results were also noted by Swann (2000) and Drummer et al. (2003)."

"The first discussion of a relationship between alcohol consumption and motor vehicle collisions to be published in an American scientific journal appeared as an editorial in the Quarterly Journal of Inebriation (1904). The editor had received a communication about 25 fatal crashes of automobile wagons in which 23 occupants died and 14 suffered injuries. Nineteen of the drivers had used alcohol within an hour of the crash. The author of the communication commented that driving automobile wagons was a more dangerous activity for drinkers than driving locomotives. Drinking by on-duty railroad employees had been prohibited since 1843 (Borkenstein, 1985)."

Law and Policies

"Since there are substantial commercial interests involved in promotion of alcohol’s manufacture, distribution, pricing, and sale,² the alcohol industry has become increasingly involved in the policy arena to protect its commercial interests, leading to a common claim among public health professionals that the industry is influential in setting the policy agenda, shaping the perspectives of legislators on policy issues, and determining the outcome of policy debates towards self-regulation.²"

"By all estimates, the Eighteenth Amendment was a costly blunder. Between 1920 and 1930, the federal government spent an average of twenty-one million dollars enforcing the Volstead Act.¹² [the National Prohibition Act - enabling legislation for the 18th Amendment] During the same period, the United States lost an estimated $1.25 billion in potential tax revenues annually.¹³ In spite of the resources consumed by Alcohol Prohibition, it affected only one segment of the nation. National Prohibition cut in half the consumption of spirits by the poor and working classes, but the “consumption of alcoholic beverages by the business, professional and salaried class [was] fully as great . . . as it was prior to prohibition.”¹⁴ While National Prohibition kept the poor dry, it made local organized crime groups wealthy enough to extend their control over entire cities.¹⁵ This success further reflected mainstream America’s implicit rejection of temperance morality. As Al Capone himself so pointedly remarked:"

"I make my money by supplying a public demand. If I break the law, my customers, who number hundreds of the best people in Chicago, are as guilty as I am. The only difference between us is that I sell and they buy. Everybody calls me a racketeer. I call myself a business man. When I sell liquor, it’s bootlegging. When my patrons serve it on a silver tray on Lake Shore Drive, it’s hospitality."

"• Among current drinkers, 39.6% reported binge drinking in the past month, with the Marine Corps reporting the highest prevalence of binge drinking (56.7%), and the Air Force reporting the lowest prevalence (28.1%).
"• When examining levels of drinking across all services, 9.9% were classified abstainers, 5.7% were former drinkers, and 84.5% were current drinkers; 58.6% of all personnel were classified as infrequent/light drinkers, 17.5% were moderate drinkers, and 8.4% were classified as heavy drinkers.
"• Heavy drinkers were more often in the Marine Corps (15.5%), had a high school education or less (12.6%), 21-25 years old (13.2%), unmarried (11.9%), and stationed OCONUS (9.9%).
"• In general, active duty personnel who were heavy drinkers, initiated alcohol use at earlier ages, or drank at work more often reported higher work-related productivity loss, serious consequences from drinking, began drinking at older ages, or did not drink at work.
"• Across all drinking levels, 11.3% of active duty personnel were classified as problem drinkers (AUDIT ≥), with 58.4% of heavy drinkers considered problem drinkers compared to 22.6% of moderate drinkers and 3.5% of infrequent/light drinkers."

"Frequent alcohol use is also considerably more prevalent among the non-college-bound. For example, daily drinking is reported by 4.8% of the non-college-bound 12th graders versus 1.5% of the college-bound. Binge drinking (five or more drinks in a row at least once during the preceding two weeks) has less of a relative difference: It is reported by 29% of the non-college-bound 12th graders versus 21% of the college-bound. There are also modest differences between the non-college-bound and college-bound 12th graders in lifetime (75% vs. 67%), annual (67% vs. 61%), and 30-day (45% vs. 38%) prevalence of alcohol use. In the lower grades, there are even larger differences in the various drinking measures between those who expect to go to college and those who do not (see Tables 4-5 through 4-8). As shown in earlier editions of Volume II in this monograph series, the college-bound eventually increase their binge drinking to a level exceeding that of the non-college-bound—an important reversal with age."

"Thirty-day prevalence of alcohol use is also negatively associated with SES [Socio-Economic Status] in 8th grade, but that association declines in upper grades and showing little difference by 12th grade. The prevalence of getting drunk in the prior 30 days is also negatively associated with SES in 8th grade, but becomes positively correlated with SES by 12th grade."

"Nationwide, 70.8% of students had had at least one drink of alcohol on at least 1 day during their life (i.e., ever drank alcohol) (Table 41). The prevalence of having ever drunk alcohol was higher among black female (66.1%) than black male (60.9%) students. Overall, the prevalence of having ever drunk alcohol was higher among white (71.7%) and Hispanic (73.2%) than black (63.5%) students; higher among Hispanic female (74.1%) than black female (66.1%) students; and higher among white male (72.3%) and Hispanic male (72.4%) than black male (60.9%) students."

"• Alcohol and nicotine in all of its forms (including smoking cigarettes, using smokeless tobacco, and vaping nicotine) are the two major licit drugs that are included in the MTF surveys, though even these are now legally prohibited for purchase by those under the age of 21, which is virtually all of our respondents. Alcohol use is more widespread than use of illicit drugs. Nearly three fifths of 12th grade students (59%) have at least tried alcohol, and about three out of ten (29%) are current drinkers – that is, they reported consuming some alcohol in the 30 days prior to the survey (Table 4-2). Even among 8th graders, a quarter (25%) reported any alcohol use in their lifetime, and one in 13 (7.9%) is a current (past 30-day) drinker.⁵

"• Of greater concern than just any use of alcohol is its use to the point of intoxication: In 2019 more than two out of five 12th graders (41%), one quarter of 10th graders (26%), and about one tenth of all 8th graders (10.1%) said they had been drunk at least once in their lifetime. The levels of self-reported drunkenness during the 30 days immediately preceding the survey are high: 17.5%, 8.8%, and 2.6%, respectively, for grades 12, 10, and 8.

"• Another measure of heavy drinking asks respondents to report on how many occasions during the last two weeks they had consumed five or more drinks in a row. In 2019 prevalence levels for this behavior, which we refer to as binge drinking, were 14.4%, 8.5%, and 3.8% in the 12th, 10th, and 8th grade, respectively.⁶

"• Extreme binge drinking, also known as high intensity drinking,7 refers to the consumption of 10 or more drinks in a row or 15 or more drinks in a row on a single occasion. One of the most concerning findings from the alcohol frequency results relate to this outcome. Table 4-4b shows that prevalence of having 5 or more drinks in a row in the prior two weeks – our standard measure of “binge drinking” – was 14.4% for 12th graders in 2019, but more than one third of them (5.3% of the total) said that they had 10 or more drinks in a row, and more than one fifth of them (3.2% of the total) reported 15 or more drinks in a row. Similarly, in 10th and 8th grades between 39% to 46% of youth who reported 5 or more drinks in a row in the prior two weeks reported 10 or more drinks in a row during the same period. (Questions about 15 or more drinks in a row were not asked of 8th and 10th graders.)"

"In 2006, more than one third (35.8 percent) of persons aged 12 to 20 who used alcohol in the past month also had used an illicit drug in the past month, and 16.0 percent of underage drinkers used an illicit drug within 2 hours of using alcohol on their last occasion of alcohol use.

"Marijuana was the illicit drug most used by underage drinkers, with nearly one third (30.0 percent) having used marijuana in the past month, and 15.0 percent having used marijuana within 2 hours of their last alcohol use."

"Among all underage current drinkers, 31.0 percent paid for the alcohol the last time they drank, including 9.3 percent who purchased the alcohol themselves and 21.6 percent who gave money to someone else to purchase it. Underage persons who paid for alcohol themselves consumed more drinks on their last drinking occasion (average of 5.9 drinks) than did those who did not pay for the alcohol themselves (average of 3.9 drinks).

"More than one in four underage drinkers (25.8 percent) indicated that on their last drinking occasion they were given alcohol for free by an unrelated person aged 21 or older. One in sixteen (6.4 percent) got the alcohol from a parent or guardian, 8.3 percent got it from another family member aged 21 or older, and 3.9 percent took it from their own home."

"• In 2012, 75.9 percent of youths aged 12 to 17 reported having seen or heard drug or alcohol prevention messages in the past year from sources outside of school, such as from posters or pamphlets, on the radio, or on television. This rate in 2012 was similar to the 75.1 percent reported in 2011, but was lower than the 83.2 percent reported in 2002 (Figure 6.6). In 2012, the prevalence of past month use of illicit drugs among those who reported having such exposure (9.4 percent) was not significantly different from the prevalence among those who reported having no such exposure (10.0 percent).

"• In 2012, 75.0 percent of youths aged 12 to 17 enrolled in school in the past year reported having seen or heard drug or alcohol prevention messages at school, which was similar to the 74.6 percent reported in 2011, but was lower than the 78.8 percent reported in 2002 (Figure 6.6). In 2012, the prevalence of past month use of illicit drugs or marijuana was lower among those who reported having such exposure in school (8.9 and 6.7 percent for illicit drugs and marijuana, respectively) than among youths who were enrolled in school but reported having no such exposure (12.3 and 9.7 percent)."

"We found that alcohol consumption up to moderate levels had no independent effects on weight or HC [head circumference] at birth, and there was no evidence of longer-term effects at 5 years. There was an apparent effect of binge drinking on birth weight, but this was due to confounding by cigarette use. Cigarette exposure, not binge drinking, adversely affected HC and birth weight."

"The lack of adverse outcomes due to consumption up to moderate levels is consistent with several previous studies of effects on either weight or HC in children ranging from birth to 24 months [9,12,24,30–42]. One study that measured children at birth and then again at 6 years also found no effects associated with measures of actual alcohol consumption, although reduced HC and length were associated with a measure of indications of problem drinking [24,51]. Of particular interest is a study that investigated a group who would be considered to be at high risk of adverse outcomes since it involved disadvantaged mothers with a history of alcohol abuse [31]. Although detrimental effects on weight, length, and HC appeared to be due to alcohol consumption, they were no longer significant once covariates such as maternal smoking and race were taken into account."