Students' Drinker Prototypes and Alcohol Use in a Naturalistic Setting

Background:  Perceptions about the type of people who drink, also referred to as drinker prototypes, may strengthen young people's motivation to engage in alcohol use. Previous research has shown that drinker prototypes are related to alcohol consumption in both adolescents and young adults. However, the evidence for the strength of these relationships remains inconclusive. One of the caveats in former studies is that all insights about prototype relations are based on self-reported data from youngsters themselves, mostly gathered in a class situation, which may contain bias due to memory distortions and self-presentation concerns.
Methods:  The present study examined the impact of drinker prototypes on young adults' drinking patterns by using a less obtrusive measure to assess alcohol consumption, i.e. ad lib drinking among friend groups in the naturalistic setting of a bar lab. Drinker prototypes, self-reported alcohol use in the past, and observed alcohol intake in the bar lab were assessed among 200 college students. Relations between participants' drinker prototypes and their self-reported and observed drinking behavior were examined by computing correlations and conducting multilevel analyses.
Results:  Drinker prototypes were related to both self-reported and observed alcohol use. However, the drinking patterns of friend group members had a strong impact on participants' individual drinking rates in the bar lab. After these group effects had been controlled for, only heavy drinker prototypes showed relations with observed alcohol intake in the bar lab.
Conclusions:  These findings further establish the value of drinker prototypes in predicting young adults' drinking behavior and suggest that people's motivation to drink alcohol in real-life drinking situations is related to their perceptions about heavy drinkers.     

Twenty-one-year trends and correlates of pressure to change drinking

Background: The vast majority of individuals with alcohol problems in the United States and elsewhere do not seek help. One policy response has been to encourage institutions such as criminal justice and social welfare systems to mandate treatment for individuals with alcohol problems (Addiction, 1997; 92 :1133). However, informal pressures to drink less from family and friends are far more common than institutional pressures mandating treatment (Addiction, 1996; 91 :643). The prevalence and correlates of these informal pressures have been minimally studied. Methods: This analysis used data from 5 Alcohol Research Group National Alcohol Surveys (NAS) collected at approximately 5‐year intervals over a 21‐year period (1984 to 2005, pooled N = 16,241) to describe the patterns of pressure that drinkers received during the past year from spouse, family, friends, physicians, police, and the workplace. Results: The overall trend of pressure combining all 6 sources across all 5 NAS data sets indicated a decline. Frequent heavy drinking and alcohol‐related harms also declined, and both were strong predictors of receiving pressure. Trends among different sources varied. In multivariate regression models, pressure from friends showed an increase. Pressure from spouse and family showed a relatively flat trajectory, with the exception of a spike in pressure from family in 1990. Conclusions: The trajectory of decreasing of pressure over time is most likely the result of decreases in heavy drinking and alcohol‐related harm. Pressure was generally targeted toward higher risk drinkers, such as heavy drinkers and those reporting alcohol‐related harm. However, demographic findings suggest that the social context of drinking might also be a determinant of receiving pressure. Additional studies should identify when pressure is associated with decreased drinking and increased help seeking.     

Alcohol intake in prairie voles is influenced by the drinking level of a peer

Background: Peer interactions can have important effects on alcohol‐drinking levels, in some cases increasing use, and in other cases preventing it. In a previous study, we have established the prairie vole as a model animal for the effects of social relationships on alcohol intake and have observed a correlation of alcohol intake between individual voles housed together as pairs. Here, we investigated this correlated drinking behavior, hypothesizing that 1 animal alters its alcohol intake to match the drinking of its partner. Methods: Adult prairie voles were tested for baseline drinking levels with continuous access to 10% alcohol and water for 4 days. In Experiment 1, high alcohol drinkers (>9 g/kg/d) were paired with low alcohol drinkers (<5 g/kg/d) of the same sex on either side of a mesh divider for 4 days with continuous access to the same 2‐bottle choice test. In Experiment 2, high drinkers were paired with high drinkers and low drinkers paired with low drinkers. In both experiments, animals were again separated following pairing, and drinking was retested in isolation. In Experiment 3, alcohol‐naïve animals were tested for saccharin consumption (0.05%) first in isolation and then in high saccharin drinkers paired with low saccharin drinkers, and then in another isolation period. Results: In Experiment 1, high drinkers paired with low drinkers significantly decreased their alcohol intake and preference from baseline drinking in isolation, and drinking levels remained significantly lower during isolation following pairing. Interestingly, there was variability between pairs in whether the high drinker decreased or the low drinker increased intake. In Experiment 2, high drinkers paired with high drinkers did not significantly change their intake level or preference, nor did low drinkers paired with low drinkers, and no changes occurred during the subsequent isolation. In Experiment 3, there was no change in saccharin intake or preference when high drinkers were paired with high drinkers or low paired with low, or in the subsequent isolation. Conclusions: Alcohol drinking of prairie voles can be altered under social conditions, such that 1 animal changes its alcohol intake to more closely match the intake of the other animal, helping to explain previous findings of correlated alcohol drinking. The effect does not extend to saccharin, a naturally rewarding sweet substance. This behavior can be used to model the peer pressure that can often affect alcohol intake in humans.     

Association of age at first drink with current alcohol drinking variables in a national general population sample

BACKGROUND: Age at first drink has been found to be associated with alcohol problems in adulthood, but little is known regarding the relationship of age at first drink and current alcohol intake variables. This study was designed to determine the relationship of age at first drink to traditional drinking variables as well as novel current drinking variables assessed for the first time in a national general population sample. METHOD: Data on age of first drink, pathological drinking (DSM-IV alcohol abuse or dependence) and alcohol intake on typical drinking occasions were collected on a national general population sample of 2631 subjects by means of computerized telephone interviewing. Variables assessed for the first time in a national survey included the duration of the typical drinking episode and the predicted peak blood alcohol levels achieved during those episodes. RESULTS: Data from 2276 subjects who reported an age at first drink were used in this study. Men and lifetime pathological drinkers reported an earlier age at first drink than did, respectively, women or lifetime nonpathological drinkers. There were significant regression coefficients between age at first drink and several current drinking measures. The largest coefficients were usually found within younger age groups. CONCLUSIONS: Age at first drink may be a useful predictive variable for some current drinking measures, including predicted peak blood alcohol levels as well as lifetime alcohol pathology. Further support was provided for the "convergence" hypothesis that the drinking habits of women have become more like those of men.     

The prevalence of alcohol use disorders among night-time weekend drivers

Aims The objective of this study was to establish the extent of alcohol use disorders (AUDs) among drivers at risk for alcohol‐related crashes. The prevalence of drivers with AUDs on US roads on weekend evenings when alcohol‐related crashes are most frequent is unknown. This study will inform laws and programs designed to reduce alcohol‐involved crashes. Design Interviews using a 15‐item AUD questionnaire with a stratified random sample of non‐commercial drivers at 60 primary sampling locations in the 48 contiguous states on Fridays and Saturdays between 10 p.m. and 3 a.m. from July to November 2007. Setting Off‐road locations into which a police officer directed a random selection of motorist passing the site. Participants A total of 4614 drivers of non‐commercial vehicles. Measurements AUDs, including heavy drinking, alcohol abuse, and alcohol dependence. Findings Of the participating drivers, 73.7% were current drinkers (reported drinking in the last year). Among those drinkers, 14% were classifiable either as dependent drinkers or as abusive drinkers based on self‐reports of drinking. Another 10% of the drivers were classified as heavy drinkers. Nearly half of the drivers in the survey who had blood alcohol concentrations (BACs) at or higher than the 0.08 g per deciliter legal limit fell into one of those three AUD categories. Conclusions Survey data suggest that the majority of high‐blood alcohol concentration drivers on US roads show no clinical signs of an alcohol use disorder, but they are categorized as heavy drinkers. This suggests that environmental programs directed at reducing heavy drinking and brief behavioral interventions aimed at reducing episodes of excessive consumption have promise for reducing alcohol‐related crashes.     

Young adult drinking behaviour: a comparison of diary and quantity-frequency measures

One hundred and twenty-two college students over a 2-week period completed a diary of their drinking habits and reasons for drinking, as well as a structured questionnaire about drinking attitudes and habits. Daily consumption based on the diary was compared with consumption based on a quantity-frequency measure within the questionnaire. There were no significant differences between estimates of consumption based on the two measures, and both measures were highly correlated. The questionnaire was more accurate in classifying drinkers and non-drinkers and led to better identification of those classified as hazardous and harmful drinkers. Sex differences in beliefs about drinking, as well as differences according to drinker classification, were found. Unsafe drinkers rated their drinking episodes as significantly more satisfying, comforting and exciting than other drinkers and were more likely to drink in order to get drunk and to relax. Their beliefs, attitudes and intentions also were more favourable towards the consumption of alcohol. Hotels or clubs were the most preferred locations for beer and spirits consumption while wine was consumed mainly at home. Most drinking took place within a mixed group or with close friends. Findings are discussed in terms of the relative advantages of both diary and quantity-frequency/questionnaire methods.     

A randomized controlled trial of an internet-based intervention for alcohol abusers

Objective   Misuse of alcohol imposes a major public health cost, yet few problem drinkers are willing to access in-person services for alcohol abuse. The development of brief, easily accessible ways to help problem drinkers who are unwilling or unable to seek traditional treatment services could therefore have significant public health benefit. The objective of this project is to conduct a randomized controlled evaluation of the internet-based Check Your Drinking (CYD) screener ( http://www.CheckYourDrinking.net ).
Method   Participants ( n  = 185) recruited through a general telephone population survey were assigned randomly to receive access to the CYD, or to a no-intervention control group.
Results   Follow-up rates were excellent (92%). Problem drinkers provided access to the CYD displayed a six to seven drinks reduction in their weekly alcohol consumption (a 30% reduction in typical weekly drinking) at both the 3- and 6-month follow-ups compared to a one drink per week reduction among control group respondents.
Conclusions   The CYD is one of a growing number of internet-based interventions with research evidence supporting its efficacy to reduce alcohol consumption. The internet could increase the range of help-seeking options available because it takes treatment to the problem drinker rather than making the problem drinker come to treatment.     

The Relationship Between Drinking and Heart Disease Morbidity in the United States: Results from the National Health Interview Survey

This study, based on data drawn from the responses of 18,323 males and 25,440 females to the 1988 National Health Interview Survey, a nationally representative, multistage probability sample of the United States, attempts to define more precisely the level of drinking at which the relationship between heart disease and alcohol consumption is a protective one. Its attempt at precision derives from (1) using drinking categories that represent various points within the range of moderate drinking (1–6 drinks) defined in the literature as protective; (2) adjusting for underreporting that commonly occurs in population surveys by using consumption at time of heaviest drinking; and (3) controlling for age, body mass, smoking, former drinker, and former smoker status, duration of drinking, and sociodemo-graphic factors. It also examines whether the relationship derived from these levels conforms to the U-shaped curve that demonstrates the protective effect of moderate drinking when abstainers are not used as the reference group. Relative to infrequent drinkers (less than 1 drink per day), men report more heart disease at the level of more than five drinks per day. However, black men also report more heart disease, relative to infrequent drinkers, at the greater than two drinks per day level; and women report more heart disease at the level of more than two drinks per day at the time of their heaviest drinking. Former drinkers of both genders, considered as an independent variable in the regression analysis, were more likely to report having heart disease. Abstainers, light drinkers, and infrequent drinkers were not significantly different in their reports of heart disease. Our results are consistent with studies that suggest protection from heart disease occurs only at lower levels of drinking.     

Developing a profile of alcohol consumption patterns of police officers in a large scale sample of an Australian police service

The current study aimed to examine the prevalence of alcohol use within a large sample (n = 4,193) of Australian police offers. Prevalence and at risk behaviour was measured through the use of a self-report survey containing the AUDIT and standard frequency and quantity questions. Results indicated that although police did not report drinking with high frequency when compared to the national statistics, they did drink in far greater quantities. Further, both males and females in the police sample reported high rates of binge drinking. The 18- to 25-year old age group reported the highest levels of frequency and quantity of alcohol consumed. Twenty-five percent of officers reported having drunk whilst on duty. An alarming proportion of the sample (30%) scored in the 'at risk of harmful consumption' category on the AUDIT while a further 3% scored in the 'alcohol dependant' category. Examination of demographic variables revealed that males, 18- to 35-year-olds, those divorced or separated, constables, operational personnel and officers who have served between 4 and 10 years were the groups most likely to fall in the risk category on the AUDIT. This was similar for the alcohol-dependant category except that males and females were equally likely to fall in this category. In conclusion, a significant number of police officers displayed at risk alcohol consumption behaviour; in comparison to earlier studies this proportion is not decreasing. Interventions and education programmes are needed within the police workplace, particularly in regard to the dangers of binge drinking for females and youth.     

Primary Health Care and the Addictions: where to start and where to go*

The development of community services for problem drinkers is briefly traced over the last 40 years. The numbers of drinkers in need of advice and treatment far exceeds the available resources. Family practice would be an ideal place in which to further primary care and prevention but lack of time, knowledge and motivation for probing into patients' drinking habits detract from the potential. A pilot study of opportunistic screening in general practice is described whereby a yellow label affixed to a patient's medical record card registers the average weekly alcohol intake. In a sample of 400 patients, 16% were high or intermediate risk drinkers. Each high risk drinker presented with a medical condition which could, in either aetiology or management, be related to high consumption. By discussing this, patients were often motivated to drink less or abstain. Various suggestions are made how better medical training and education could improve the diagnosis and treatment of drinking problems.     

Are Women at Greater Risk? An Examination of Alcohol‐Related Consequences and Gender

Men typically drink more than women; however, women achieve higher BACs (blood alcohol concentration) than men at equivalent consumption levels. This study investigated the unique effect of gender on individual alcohol problems by controlling both consumption and intoxication in a sample of 1,331 undergraduate drinkers. Gender independently influenced the risk of experiencing seven of nine negative consequences: (a) being female increased risk for tolerance, blacking out, passing out, drinking after promising not to, and getting injured; (b) being male increased risk for damaging property and going to school drunk. Gender patterns should be explored in a wider set of alcohol‐related problems.     

Injury and repeated injury - what is the link with acute consumption, binge drinking and chronic heavy alcohol use?

OBJECTIVES: First, to test whether current injury is more closely related to acute intake than to usual consumption patterns, and second, to test whether repeated injury is more closely related to general consumption patterns than to acute intake. METHODS: Screening of alcohol consumption of 7,872 patients enrolling between January 1, 2003 and June 30, 2004 in an emergency department (ED) in Lausanne, Switzerland. General consumption patterns were measured as usual volume (in drinks per week) and binge drinking (5+ drinks for men; 4+ drinks for women) at least once monthly. Acute intake was measured through number of drinks in the 24-hour period prior to attending the ED. Separate logistic regression models of current injury and repeated injury on alcohol consumption patterns were estimated. RESULTS: Acute intake and binge drinking dominated the association with current injury, while general consumption patterns were predictive of repeated alcohol-related injury. CONCLUSIONS: Acute intake is associated with current injury in a dose-response relationship and with binge drinking. Because acute intake can be found among moderate volume drinkers as well as among chronic heavy drinkers, for current injury usual volume adds little predictive value over the effects of acute intake. Repeated injuries occur more often among chronic heavy drinkers, and thus general consumption patterns are more closely associated with injury "recidivism" than with acute intake. A screening question assessing prior injury may be a useful tool in the ED for distinguishing between chronic heavy drinkers and usually moderate drinkers with heavy drinking episodes, and thus prove helpful when creating preventive efforts tailored to different types of drinker.     

Defining 'current drinkers' in national surveys: results of the 2000 National Alcohol Survey

Aims The purpose of this study is to determine which respondents of national surveys who report low ‘usual’ past year drinking frequency, are unsure of their drinking frequency or refuse to answer, are misclassified either as ‘current drinkers’ or as ‘ex‐drinkers.’ Design and setting The data are from the 2000 National Alcohol Survey, a national household telephone probability sample of adults in all 50 US States and Washington, DC (n = 7612). Participants A subsample of 1734 respondents who reported drinking ‘less than once a month but at least once a year’, ‘less than once a year’, ‘refused’ and ‘don’t knows’ were also asked if they had consumed a whole drink of any alcoholic beverage in the 12 months using dates to anchor the question. Measurements Five alcohol measures were used to compare groups who changed or did not change their drinking status based on the followup question: volume, mean number of days 5 +, social consequences, dependence symptoms and DSM‐IV. Findings The results indicate that only 4.6% of respondents (n = 349) changed their drinking status, and the percentages were equal in both directions. Women were more likely to change their drinking status and specifically become ex‐drinkers based on the follow‐up question. Respondents who became current drinkers drank significantly at a lower average volume than those who remained current drinkers. The prevalence rates based on the five alcohol measures were not affected by how ‘current drinker’ is defined. Conclusions Adding the follow‐up question is recommended for new alcohol surveys so that fewer respondents are misclassified.     

Correlates of alcohol abuse/dependence in early-onset alcohol-using women

Early-onset alcohol use is associated with increased vulnerability to subsequent alcohol abuse and dependence. However, not all early-onset alcohol users develop alcohol use disorders (AUDs). Using a sample of young women from the United States, we identify correlates that contribute to a greater likelihood of AUDs in early-onset alcohol users. Using interview and questionnaire data on participants of the Missouri Adolescent Female Twin Study (MOAFTS), we examine whether measures from domains including sociodemographic, pubertal development, religiosity, educational achievement, adverse life events, internalizing disorders, externalizing disorders, and family history and discipline were associated with development of AUDs in 1,158 women who had their first drink of alcohol prior to age 16. Early-onset drinkers were 3.6 times more likely to meet criteria for AUDs than later onset drinkers. While univariate analyses revealed that a host of correlates were associated with likelihood of AUDs in early-onset drinkers, multivariate analyses suggested that, even after accounting for a particularly early age of onset of drinking, those with a history of physical abuse, cotwin alcohol problems, conduct disorder, regular smoking, older peers, and peer substance use were considerably more likely to meet criteria for AUDs than early-onset drinkers without a lifetime history of these correlates. The progression from first drink to AUDs is complex, and while early age at first drink is a potent risk factor, other aspects of psychopathology, family history, conduct problems, and peer affiliations can exacerbate or alleviate the risk of AUDs in these young female drinkers.     

Revising the preventive paradox: the Swiss case

Aims. To examine Kreitman's preventive paradox of alcohol consumption and its revisions by Stockwell and colleagues and by Skog, with regard to alcohol‐related social harm in Switzerland, and to shed light on the reporting of alcohol‐related social harm in the low‐volume drinking, non‐bingeing subpopulation. The paper compares occurrence and severity of social harm in four subgroups defined by average consumption (volume) and binge drinking. Stage‐of‐change membership was used to further distinguish low‐risk drinkers who might have changed their drinking patterns from those who had not. Design, setting, and participants. Telephone interviews were conducted with 1256 current drinkers of a probabilistic two‐stage sample of the general population of Switzerland. Moderate and hazardous mean consumption (volume) was defined by means of a quantity‐frequency instrument. Daily average consumption of 20 g was set as the cut‐off point for women, and 30 g for men. Binge drinking was defined as taking four or more drinks on an occasion for women, and five or more for men. Structural equation modelling was used to construct a severity scale of six alcohol‐related consequences: work problems, accidents and problems with the police, with friends, with a partner or with the family. Explanatory factor analysis was used to assign drinkers to motivational stages of change. Findings. Moderate drinkers in terms of volume reported more problems than hazardous drinkers, which confirms Kreitman's view. Binge drinkers reported more problems than non‐binge drinkers, confirming the view of Stockwell and colleagues. Binge drinkers were more numerous in the moderate drinking group, which constituted the majority of drinkers, in accordance with Skog's view. Binge drinkers in the moderate‐volume and hazardous‐volume drinking groups did not differ significantly as to either severity or number of problems. Approximately 40% of moderate‐volume, non‐binge drinkers who reported alcohol‐related social harm had already changed their consumption pattern, which indicated that reported harm was related to an earlier drinking pattern. Conclusions. As Skog has pointed out, the second‐order preventive paradox of binge drinking reappeared, in that most binge drinkers were found to occur in the drinker group with low average consumption. Findings also indicate that, with respect to social harm, a preventive strategy aimed at the majority of the population, but on heavy‐drinking occasions rather than on mean consumption, may be valuable.     

Modification of the association of alcohol drinking with blood pressure by cigarette smoking

The purpose of this study was to investigate whether the association of alcohol drinking with blood pressure was modified by cigarette smoking. The subjects were healthy male workers aged 40-59 years and were divided into three different groups by average daily consumption of alcohol (non-drinkers; light drinkers, less than 30 g ethanol per day; heavy drinkers, 30 g or more ethanol per day) and cigarettes (non-smokers; light smokers, less than 20 cigarettes per day; heavy smokers, 20 cigarettes or more per day). The mean levels of both systolic and diastolic blood pressures were significantly lower in the light and heavy smoker groups than in the non-smoker group. In the light and heavy smoker groups, systolic blood pressure was higher in the light drinker subgroup than in the non-drinker subgroup, while there was no significant difference between systolic blood pressures in the non- and light drinker subgroups of non-smokers. In the non-, light and heavy smoker groups, systolic and diastolic blood pressures were significantly higher in the heavy drinker subgroup than in the non-drinker subgroup, and these differences tended to be greater in light and heavy smokers than in non-smokers. The above differences in the relationships of alcohol drinking with blood pressure in non-, light and heavy smokers were also observed when age and body mass index were adjusted and when alcohol intake-matched groups were used. These results suggest that the association of alcohol drinking with blood pressure is stronger in smokers than in non-smokers, independently of age, body mass index and alcohol intake.     

Alcohol and cancer in male Japanese physicians

Summary The relationship between alcohol and sitespecific cancers was investigated in a follow-up study of 5,139 male Japanese physicians. Information on drinking habits was obtained by mail questionnaire in 1965, and cancer deaths over 12.7 years were analyzed with drinking habits classified into five categories; nondrinker, ex-drinker, occasional drinker, and daily drinker whose intake of alcohol was equivalent to less than 2 or 2 and morego ofsake (1go sake27 ml alcohol). Both age and smoking habits were taken into account in the calculation of death rates based on man-years at risk. Logistic regression analysis was also performed on cummulative mortality data. Upper aerodigestive cancer was strongly associated with alcohol consumption, giving some confidence in the validity of the present study. Excluding ex-drinkers, the risk of stomach cancer and liver cancer was gradually increased from nondrinkers to daily drinkers with lower intake of alcohol, but no further increase was noted for daily drinkers with larger consumption. Logistic regression did not show any significant associations between drinking habits and these two cancers, but the number of deaths from liver cancer was still small. Not paticular patterns were observed for cancers of the large bowel and lung.Abbreviations used UAT upper alimentary tract - URT upper respiratory tract Supported partly by the Chiyoda Mutual Foundation, Tokyo     

Patterns of Drinking in a Small Development Town in Israel

The two central questions investigated in this study were the extent of alcohol consumption among the adult population in a small development town in Israel and the relationship between heavy drinking (daily drinking) and feelings of distress in four areas of life–economic, social, personal, and health. The findings indicated that the percentage of daily drinkers (8%) in [his population is higher than that found in a national survey of the adult urban Jewish population in Israel (2%). Two ‘deviant’ groups of drinkers were identified–daily drinkers and weekly drinkers (those who reported drinking 2-3 times per week). These two groups drink on non-ritual and non-ceremonial occasions. Daily drinkers frequently drink alone, drink several drinks at a time, and continue to drink without realizing how much. Daily drinkers tended to have strong feelings of powerlessness and a weak sense of coherence, and tended to be socially isolated. Drinking heavily is an infrequent response in the social context of the Israeli development town. No direct relationship was found between amount or kind of distress and extent of alcohol consumption. Those who do drink heavily, however, tend to be suffering from personal and social distress.     

Distribution of alcohol consumption and expenditures and the impact of improved measurement on coverage of alcohol sales in the 2000 National Alcohol Survey

BACKGROUND: To validate improved survey estimates of alcohol volume and new expenditures questions, these measures were aggregated and evaluated through comparison to sales data. Using the new measures, we examined their distributions by estimating the proportion of mean intake, heavy drinking days, and alcohol expenditures among drinkers grouped by volume. METHODS: The 2000 National Alcohol Survey is a random digit dialed telephone survey of the United States with 7,612 respondents including 323 who were recontacted for drink ethanol measurement. Among drinkers, we utilized improved drink ethanol content estimates and beverage-specific graduated frequency measures to assess alcohol consumption and past month beverage-specific spending reports to estimate expenditures. RESULTS: Coverage of alcohol sales by the new measures was estimated to be 52.3% for consumption and 59.3% for expenditures. Coverage was best for wine at 92.1% of sales, but improved most for spirits from 37.2% to 55.2%, when empirical drink ethanol content was applied. Distribution estimates showed that the top 10% of drinkers drank 55.3% of the total alcohol consumed, accounted for 61.6% of all 5+ and nearly 80% of all 12+ drinking days. Spirits consumption was the most concentrated with the top decile consuming 62.9% of the total for this beverage. This decile accounted for 33% of total expenditures, even though its mean expenditure per drink was considerably lower ($0.79) than the bottom 50% of drinkers ($4.75). CONCLUSIONS: The distributions of mean alcohol intake and heavy drinking days are highly concentrated in the U.S. population. Lower expenditures per drink by the heaviest drinkers suggest substantial downward quality substitution, drinking in cheaper contexts or other bargain pricing strategies. Empirical drink ethanol estimates improved survey coverage of sales particularly for spirits, but significant under-coverage remains, highlighting need for further self-report measurement improvement.