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Excessive alcohol consumption, including binge and underage drinking, is the third leading preventable cause of death in the United States, and binge drinking, defined for women as consuming 4 or more alcoholic drinks on an occasion and for men as consuming 5 or more drinks on an occasion, accounts for more than half of the 79,000 annual deaths due to excessive drinking (1,2). Binge drinking is a common form of excessive alcohol use in the United States (1). According to 2009 Behavioral Risk Factor Surveillance System (BRFSS) data, an estimated 15.2% of adults (20.7% of men and 10.0% of women) are binge drinkers (2). Among some population groups, such as people aged 18 to 34 years, the prevalence of binge drinking is even higher (2,3). The frequency (4) (ie, number of binge drinking episodes within a defined time period) and intensity (4) (ie, number of drinks consumed per episode) of binge drinking are 2 measures used to examine the adverse health effects for this risk behavior (5). Several studies have demonstrated that risk of alcohol-related illness and death increases with the intensity of binge drinking (6-8).

Several studies have examined the association between health-related quality of life (HRQOL) and alcohol use (9,10) and the association between binge drinking and certain risk behaviors (eg, alcohol-impaired driving and violence) (11,12). In 2004, 1 study (13) reported that frequent binge drinking was associated with significantly worse HRQOL and mental distress, including stress, depression, and emotional problems. However, the relationship between the intensity of binge drinking per episode and HRQOL has not been examined. The primary objective of this study was to examine the association between HRQOL and the intensity of binge drinking among US adult binge drinkers. A secondary objective was to compare sex differences in HRQOL by sociodemographic characteristics and the intensity of binge drinking.

We used 2008-2010 BRFSS data and multivariate linear regression models to assess the relationship between binge drinking intensity and HRQOL.

The median largest number of drinks consumed was 5 (range, 4-14 drinks) for female binge drinkers and 6 (range, 5-29 drinks) for male binge drinkers. Among women, the median intensity of binge drinking was similar among sociodemographic groups. However, among men, the median intensity of binge drinking was higher among men aged 18 to 44 (7 drinks) than among men aged 45 or older (6 drinks), among men who never married (8 drinks) than among men who were married (6 drinks), and among men who were homemaker/students (8 drinks) than among men who were retired or employed (6 drinks).

Overall, female binge drinkers reported more unhealthy days (2.8 physically unhealthy days and 5.1 mentally unhealthy days) than male binge drinkers (2.5 physically unhealthy days and 3.6 mentally unhealthy days) (Table 1). The mean number of mentally unhealthy days among women and men aged 18 to 44 was significantly higher than the mean number for those aged 45 or older, whereas the mean number of physically unhealthy days among men and women aged 45 or older was significantly higher than the mean number for the younger age group. Men and women who were previously married had a significantly higher mean number of physically and mentally unhealthy days than men and women who were married or never married.

Female binge drinkers who consumed 7 or more drinks on any occasion reported significantly more unhealthy days (3.2 physical and 6.9 mental) compared with those who were binge drinking at a lower intensity (Table 1). Similarly, male binge drinkers who consumed 8 or more drinks on any occasion reported significantly more mentally unhealthy days (4.3 d) compared with those who were binge drinking at a lower intensity.

After adjustment for potential confounding factors (age, race/ethnicity, education, marital status, income, and employment), female binge drinkers who consumed 7 or more drinks had more mentally unhealthy days compared with female binge drinkers who consumed 4 drinks, and male binge drinkers who consumed 8 or more drinks had more mentally unhealthy days compared with male binge drinkers who consumed 5 drinks (Table 2).

In general, among all age groups for both sexes, the mean number of physically unhealthy days was associated with binge drinking intensity (Figure 1). The mean number of physically unhealthy days among both sexes aged 45 older was higher than for those aged 18 to 44. In general, among all age groups for both sexes, the mean number of mentally unhealthy days was associated with binge drinking intensity (Figure 2). The mean number of mentally unhealthy days among female binge drinkers was significantly higher than the mean number for male binge drinkers. We found no significant interactions between age and intensity of binge drinking in any of the linear regression models.

Although several studies have examined either sex-specific or alcohol-specific effects for HRQOL (13,19-21), this is the first study to examine the association between binge drinking intensity and HRQOL by sex. Adults who had high-intensity levels of binge drinking were more likely to report poor HRQOL than adults who had lower-intensity levels of binge drinking. This pattern was found for 2 measures of HRQOL — physically and mentally unhealthy days.

Among female binge drinkers, the highest-intensity binge drinkers had 37% more mentally unhealthy days than the lowest-intensity binge drinkers. This estimate of 1 or 2 additional unhealthy days per month is considered a meaningful difference in HRQOL (22).

We also found age effects for physically unhealthy days for both sexes; those aged 45 or older had significantly more physically unhealthy days than those aged 18 to 44. Age effects are likely due in part to the development of chronic conditions that increasingly affect health and well-being across the life span (23,24). The frequency and intensity of alcohol consumption are both important indicators for measuring and assessing the effect of binge drinking (5). A previous study found that poor HRQOL was associated with frequent binge drinking (13). Our study demonstrated that poor HRQOL (physically and mentally unhealthy days) was associated with the intensity of binge drinking among adults who reported binge drinking.

This study has several limitations. First, BRFSS is a landline telephone survey; therefore, people with cellular telephones only or no landline telephones are excluded, which may result in sampling bias. Studies show that an increasing proportion of young adults aged 18 to 34 use cellular telephones exclusively (25) and that the prevalence of binge drinking is approximately one-third higher among cellular telephone users than landline respondents to the BRFSS (2). Second, BRFSS data are self-reported and may be subject to recall and social desirability biases (26). A recent study based on state alcohol sales found that BRFSS identifies only 22% to 32% of presumed alcohol consumption (27). Third, this study is cross-sectional; therefore, any cause and effect between poor HRQOL and level of binge drinking intensity cannot be inferred. Fourth, a previous study (13) demonstrated that the frequency of binge drinking was associated with HRQOL, whereas our study investigated the relationship between the intensity of binge drinking and HRQOL. Further studies are needed to explore the effects of both frequency and intensity of binge drinking on HRQOL to better understand sex-specific effects.

This study also has several strengths. First, to our knowledge, it is the first study to assess the relationship between intensity of binge drinking and physical and mental health components of HRQOL. Second, the large sample of binge drinkers and the BRFSS sampling design suggest that these associations would be similar to those for all noninstitutionalized adult binge drinkers in the United States.

The results of this study support the recommendations of the US Preventive Services Task Force (28) to implement screening and counseling for alcohol misuse, including binge drinking, among adults by physicians and other health care providers. Such screening and counseling can highlight the negative consequences of binge drinking on current physical and mental health. In addition, these results support the use of binge drinking intensity as a measure that could be monitored when implementing and evaluating evidence-based population-level intervention strategies, such as increasing alcohol excise taxes (29) and limiting the density of alcohol sales outlets (30) to reduce drinking intensity and improve HRQOL.