Diagnosing and dealing with the 'new British disease'

John McAlaney and John McMahon on psychology's role in defining and tackling binge drinking

If media reports are to be believed, binge drinking is an increasingly popular pastime of the British public – particularly amongst teenagers and young adults. But how prevalent is it? Figures from the General Household Survey of 2003 suggest that approximately 35 per cent of males and 28 per cent of females aged between 16 and 24 binge drink at least once a week. The corresponding rates for the entire adult population are lower but not negligible, at 20 per cent and 10 per cent for males and females respectively (Office of National Statistics, 2005). Former Prime Minister Tony Blair once went so far to say that binge drinking risks becoming the ‘new British disease’ (Hetherington & Bowers, 2005).

If media reports are to be believed, binge drinking is an increasingly popular pastime of the British public – particularly amongst teenagers and young adults. But how prevalent is it? Figures from the General Household Survey of 2003 suggest that approximately 35 per cent of males and 28 per cent of females aged between 16 and 24 binge drink at least once a week. The corresponding rates for the entire adult population are lower but not negligible, at 20 per cent and 10 per cent for males and females respectively (Office of National Statistics, 2005). Former Prime Minister Tony Blair once went so far to say that binge drinking risks becoming the ‘new British disease’ (Hetherington & Bowers, 2005). This comment has been met with some scepticism, with several researchers questioning if it is anything new, an especially British problem or in fact a ‘disease’ (e.g. Plant & Plant, 2006). Despite the somewhat alarmist reporting, there is growing evidence that a binge-drinking pattern of consumption can be harmful, over and above the total amount of alcohol consumed. In addition to the often-cited problems of crime and increased risk of accidents, recent research has also noted long-term neuropsychological problems, such as abnormal brain development (Monti et al., 2005) and cognitive impairment (Hartley et al., 2004).

Any organisation which has a large number of people – be it an educational establishment or a workplace – is likely to include a sizeable number of ‘binge drinkers’ in its ranks. If these individuals are indeed at a greater risk of a range of health and social problems, this could have larger-scale implications on issues such as productivity or academic achievement. Understanding the behaviour, the effects it has and how it can be changed are therefore important goals to several different types of psychologist, particularly health, social, occupational and academic.

There are, however, some challenges in researching binge-drinking behaviour, not least reaching a consensus over what the criteria for it should be.

What is a ‘binge’?
The most common definitions of binge drinking tend to be couched in terms of the quantity of alcohol consumed. In the USA the most widely used criteria to date is the 5+ measure, which defines binge drinking as consuming five or more alcoholic drinks in one session (Gmel et al., 2003). The definition has entered popular use and has been used in numerous research publications, in addition to being endorsed by organisations such as the National Institute of Alcohol and Alcohol Abuse in the USA. This definition is strongly opposed by some alcohol researchers, such as DeJong (2003). Arguing that it is a largely arbitrary cut-off point, he noted that the estimated blood alcohol concentrations of 37 per cent of ‘binge drinkers’ studied using the 5+ measure did not exceed the 0.08 per cent (the legal drink driving limit in the UK and many states of the USA).

In the UK a slightly different approach has often been taken, particularly in government-based research. This takes account of the type and strength of alcohol consumed, based on the number of units.

A typical pint of premium lager will contain about 2.8 alcohol units, whereas a bottle of wine will contain about 9 units. Criteria for binge drinking in the UK are set at eight or more units of alcohol for a man, and six or more units for a woman. However, we have noted that this definition has often been applied inconsistently (McAlaney & McMahon, 2006), undermining the validity of current UK binge drinking figures. The unit-based approach also suffers the main critique as the number of drinks method – it does not take into account factors such as duration of drinking session and therefore cannot reliably predict blood alcohol level and intoxication.

Such is the overall controversy over the phrase ‘binge drinking’ that one of the leading journals in the field, the Journal of Studies on Alcohol and Drugs, will not accept articles that use the phrase in this way. An alternative term which is occasionally used in the literature is ‘heavy episodic drinking’. This term captures the key point that we are talking about non-continuous or sporadic consumption of large amounts of alcohol in a short time. However the phrase ‘binge drinking’ has become so entrenched in academia, the media and the public mindset that an attempt at re-labelling might be futile and possibly counterproductive. The problem is perhaps more how the concept is operationalised and measured, an issue which will not be resolved by calling it by another name.

Several researchers have also suggested that measures of binge drinking should acknowledge the individual’s feelings of drunkenness. This view is based on research showing that how drunk an individual feels is often a more accurate predictor of health and social outcomes than the actual amount of alcohol consumed (Midanik, 1999).

It is important that these issues are addressed. Not only does a lack of consensus hinder research progress but, as we shall discuss, it may also indirectly contribute to rates of binge drinking.

Binge drinking interventions in the UK

A range of approaches have been suggested to reduce binge drinking and the consequent harm in the UK, such as changes to taxation, changes to alcohol licensing legislation and the use of safety glass to reduce injuries in fights (for a review see Plant & Plant, 2006). Amongst these varied responses have been public health interventions, such as the recent ‘Alcohol: Know Your Limits’ campaign from the NHS and the Home Office (www.knowyourlimits.gov.uk).

These campaigns are an example of the growing movement away from educating people about units of alcohol and safe levels of consumption, towards challenging attitudes and behaviour (Measham, 2006). Campaigns based solely on presenting information about alcohol units and health problems have not been found to be effective (Foxcroft et al., 2003). The newer range of campaigns take a different approach by attempting to alter the underlying processes which cause a person to binge drink in the first place; and such campaigns are increasingly based on psychological research (although much of it has been on alcohol consumption in general rather than binge drinking specifically).

It could be argued that alcohol expectancy research has been particularly influential in the design of some of the newer binge-drinking campaigns. Alcohol expectancies are what we think will happen when we drink alcohol. Positive expectancies, such as an expectation that intoxication will lead to tension reduction or increased attractiveness, will encourage alcohol consumption (despite being erroneous). Negative expectancies on the other hand, such as that intoxication will result in a hangover, discourage alcohol consumption.

The ‘Know Your Limits’ campaign uses these ideas on its website, which allows people to simulate a night out in a pub. For instance, one of the scenarios depicts a man on a night out with his friends. As more alcohol is consumed the man becomes increasingly confident, to the point where he approaches a young woman who he believes finds him attractive. Unfortunately in his drunken state he has misread the situation and is slapped, rejected and thrown out of the pub only to then be beaten up by a gang of youths outside. The scenario challenges positive expectancies about drinking alcohol, such as ‘It makes me better at talking to woman’ and ‘It is fun’. Similarly, negative expectancies, such as ‘I get into fights’ and ‘I feel ashamed of myself’, are reinforced.

These new-style binge-drinking campaigns are innovative, and it is a positive step that interventions designed specifically for binge drinking are being introduced. However, the evidence for the efficacy of campaigns based on alcohol expectancy is mixed. For example, Kraus et al. (1994) achieved a significant change in the expectancies of schoolchildren following an expectancy challenge programme similar to the one above. This was evident at a four-week follow-up, but similar work with a three-year follow-up (Corvo & Persse, 1998) noted that significant change was not maintained in the longer term.

Other research suggests that expectancy challenge is only really effective in those with the heaviest alcohol consumption (Dunn et al., 2000), perhaps those who drink sufficiently heavily to have an actual alcohol problem. As Weitzman and Nelson (2004) comment in discussing the ‘prevention paradox’, while it is important that the heaviest cases of binge drinking are addressed, such individuals make up the minority of the population. There are far more ‘low-level’ binge drinkers, so the bulk of binge-drinking-related harm actually originates from them.

Normative beliefs
Another cognitive process underlying binge-drinking behaviour has been gaining research interest. Normative beliefs refer to what an individual believes to be the normal, prevailing behaviours or attitude within a group. It has long been established that these beliefs are important determinants of an individual’s behaviour.

Some recent and interesting research from the American college system has suggested that these perceptions are almost invariably incorrect, with individuals typically overestimating how common and acceptable binge drinking is (Bosari & Carey, 2001). Although the strength of this misperception varies from one group to another, the volume of evidence for these misperceptions is impressive. Research on normative misperceptions has become the basis of a binge-drinking intervention that is frequently conducted in the United States, known amongst other names as a ‘social norms intervention’.

The premise of this approach is straightforward – that individuals binge drink because they are driven to match an overestimated perception of how normal it is to do so. Correcting this misperception should therefore lessen the individual’s drive to binge drink, which in turn results in a reduction of the binge-drinking behaviour. Unlike public binge drinking intervention campaigns in the UK, which are still in their infancy, this intervention has become an established approach in the USA and has evolved specifically to tackle binge drinking. Since its introduction in the mid 1990s its popularity has risen markedly, having been successfully applied to numerous college campuses and being named ‘Idea of the Year’ in 2001 by New York Times Magazine (Frauenfelder, 2001).

There are several variations on this approach. Global social norms interventions operate by firstly measuring rates of alcohol consumption in a population and then presenting that information back to the population. The assumption is that for the majority of the student body these ‘average’ figures will be much lower than individuals expect them to be, thus correcting the individual’s over-inflated normative perception. Another form of the approach is personalised social norms marketing, which provides individuals with personal feedback on how their individual alcohol consumption compares with the average for the group.

An example of this is a study by Neighbors et al. (2004) in which college students were assigned to either a personalised normative feedback treatment or a no treatment control group. After answering questions by computer on their own alcohol consumption and their perceptions of alcohol use in other students, participants in the treatment group were presented with onscreen personalised normative feedback. As with the majority of normative feedback interventions, this information was fairly brief and simple, reiterating to the participant how much they drank, how much they thought others drank and then revealing what the actual averages of drinking behaviour in the college were. This resulted in significant reductions of binge-drinking behaviour, an effect which was maintained at three- and six-month follow-up. This study also demonstrates the potential of using internet-based approaches – this could allow for easily accessed and instant personalised normative feedback, as discussed recently by Raskin-White (2006).

The efficacy of the social norm approaches has been strongly defended in the literature, with articles reporting a failure to find a normative misperception or change in behaviour following a normative intervention often being met with swift rebuttals. But there are valid concerns about normative misperceptions and the associated interventions, particularly if they are ever to be applied to a setting outside the American college system.

Firstly, such interventions are based on the assumption that a misperception exists. Whilst the overwhelming majority of studies have found such a misperception, these studies have almost exclusively been conducted in American college students (Perkins et al., 2005). Secondly it has been noted that the degree of misperception increases with social distance from the group. For instance, it would be expected that someone’s misperception about their friends’ binge drinking would be much smaller than their misperception about the more abstract and distant group of other students at their university. In comparison to the US, however, it is possible that students in the UK do not perceive their peers to be as socially distant.

Due to the differences in the legal age of drinking for example (21 in the US and 18 in the UK) the majority of UK students can drink openly and legally in bars whereas the majority of US students cannot. By having more opportunity to observe their peers drinking behaviour at first hand UK students may conceptualise other students’ drinking more concretely than their US counterparts.

Since the degree of misperception of a behaviour increases as the individual’s first hand knowledge of the referent group decreases, it is possible that UK students would have lesser degrees of misperception. And since social norms interventions operate on this misperception the efficacy of the interventions could therefore also be less when conducted in a UK setting.

However, the application of social norms interventions does appear to be a promising method of reducing binge-drinking behaviour. Preliminary research by ourselves with a student sample suggests that such misperceptions may indeed be found beyond the American college halls, with the students overestimating rates of binge drinking within the university to a degree consistent with the American studies (McAlaney & McMahon, 2007). Further planned research will more fully investigate these processes.

This research raises a few further questions about how we discuss binge drinking, and the effects this discussion has. Those who exceed the 8/6 units limit infrequently are included alongside those who do so frequently; neither of whom may have necessarily become intoxicated from their ‘binge’ sessions. Arguably, therefore, there are many people included in the binge-drinking figures of the UK who most researchers would agree are not ‘binge drinkers’ in the way the term is intended. Such figures and associated media reports may themselves be contributing towards a misperception as to how normal the behaviour is. Even in the most heavily binge-drinking group in the population – males aged 16 to 24 – regular binge drinking is not the majority behaviour. It is important to keep the scale of the issue in perspective and to avoid making it seem more prevalent than it actually is.

Conclusion and directions for the future
If concern about binge-drinking rates in the UK is to be translated into action, there are several issues which must be considered. We need to reach a consensus on how the behaviour should be defined, if in fact a simple but accurate classification system is even possible. We also need to clarify the health and social outcomes associated with a binge drinking pattern of consumption.

Most importantly however, in terms of behaviour change, is to begin to use interventions which are evidence-based. Media campaigns about binge drinking may look engaging, but this does not necessarily translate into long-term behaviour change. They may even indirectly contribute to the perception in certain groups (e.g. young adults) that binge drinking is the norm, fuelling normative misperceptions. It would be of interest to further explore the potential use of applying social norms interventions to UK settings, given their apparent successes in the USA. Until such further research is available we must be cautious about rhetoric that presents binge drinking as an established, major issue in British society, and about health campaigns that claim to be able to tackle it.   
- John McAlaney is a postgraduate student at the University of Paisley. E-mail: [email protected].

- Dr John McMahon is a senior lecturer at the University of Paisley. E-mail: [email protected].

Know Your Limits website: www.knowyourlimits.gov.uk
Portman Group funded alcohol advice site: www.drinkaware.co.uk
College Student Drinking Prevention project (USA): www.collegedrinkingprevention.gov 

Discuss and debate
 Should we attempt to eradicate binge drinking behaviour entirely or accept that occasional heavy drinking can aide in social facilitation, group integration and tension reduction?

Do alcohol campaigns portraying young adults as binge drinkers inadvertently risk fuelling the behaviour in that group?

Are the current 8/6 alcohol units criteria used to define binge drinking in the UK helpful to the public or do they oversimplify the issue?
Have your say on these or other issues this article raises. E-mail ‘Letters’ on [email protected] or members can contribute to our forum via www.psychforum.org.uk.


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