866 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / NOVEMBER 2008
Three-Year Changes in Adult Risk Drinking Behavior in
Relation to the Course of Alcohol-Use Disorders*
DEBORAH A. DAWSON, PH.D.,† FREDERICK S. STINSON, PH.D., S. PATRICIA CHOU, PH.D.,
AND BRIDGET F. GRANT, PH.D., PH.D.
Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse
and Alcoholism, National Institutes of Health, 5635 Fishers Lane, Room 3071, MSC 9304, Bethesda, Maryland 20892-9304
ABSTRACT. Objective: This study examines the associations between
the course of alcohol-use disorder (AUD) and changes in average daily
volume of ethanol intake, frequency of risk drinking, and maximum
quantity of drinks consumed per day over a 3-year follow-up interval in
a sample of U.S. adults. Method: Data were taken from a longitudinal
study of a nationally representative sample of U.S. adults, who were 18
years of age and older (mean age = 46.4) when initially interviewed in
2001-2002 and successfully reinterviewed approximately 3 years later
(n = 22,245 baseline drinkers). The time reference period for the drink-
ing measures was the 12 months preceding the interview. Changes in
consumption refl ect differences between Wave 1 and Wave 2 measures
for individuals with nonmissing values at both Waves (n = 22,003 for
volume of intake, 22,132 for frequency of risk drinking and 21,942 for
maximum quantity of drinks). Results: There were positive changes
in all consumption measures associated with developing an AUD and
negative changes associated with remission of an AUD, even among
individuals who continued to drink. Increases and decreases associated
with onset and offset of dependence exceeded those associated with on-
set/offset of abuse only, and the decreases associated with full remission
from dependence exceeded those associated with partial remission. There
were few changes in consumption among individuals whose AUD status
did not change. Interactions of AUD transitions with other factors indi-
cate that development of an AUD is associated with a greater increase
in consumption among men, possibly refl ecting their greater total body
water and lower blood alcohol concentration in response to a given dose
of ethanol, and among individuals with high baseline levels of consump-
tion. Conclusions: Changes in consumption associated with onset and
offset of AUD are substantial enough to have important implications for
the risk of associated physical and psychological harm. (J. Stud. Alcohol
Drugs 69: 866-877, 2008)
with most focusing on the heavy drinking trajectories from
adolescence to early adulthood (Chassin et al., 2002; Hill
et al., 2000; Oesterle et al., 2004; Schulenberg et al., 1996;
Tucker et al., 2003; Windle et al., 2005). Within the devel-
opmental framework of this rich literature, numerous factors
have discriminated among different drinking trajectories.
Virtually all studies have found male gender to be associated
with higher baseline levels of heavy drinking and trajectories
more indicative of increasing or continued heavy drinking.
Other factors associated with change in drinking behavior
over time have included baseline levels of alcohol and other
UMEROUS STUDIES HAVE EXAMINED changes
in volume and pattern of drinking over the life course,
substance use (Auerbach and Collins, 2006; Chassin et al.,
2002; Hill et al., 2000; Sher and Rutledge, 2007; Windle
et al., 2005); family history of alcoholism (Chassin et al.,
2002, 2004; Jackson et al., 2001; Timberlake et al., 2007);
borderline personality disorder (PD) and/or behavioral un-
dercontrol and impulsivity (Rohde et al., 2001; Rutledge and
Sher, 2001); externalizing behavior, delinquency, conduct
disorder, and antisocial PD (Bucholz et al., 2000; Chassin et
al., 2002; Hill et al., 2000; Jackson and Sher, 2005; Tucker
et al., 2003); and early initiation of drinking (Casswell et al.,
2002; Goudriaan et al., 2007; Windle et al., 2005).
Far fewer longitudinal studies have examined changes
in drinking patterns past the early adult years. The decline
in heavy drinking with age that has been reported consis-
tently in cross-sectional studies implies a decline in heavy
drinking with age, but cross-sectional data run the risk of
confounding age, period, and cohort effects. However, us-
ing age-period-cohort models to distinguish these effects,
Kerr et al. (2004) concluded that beer and distilled sprits
consumption (although not wine consumption) did decline
signifi cantly with age. Similarly, in another study of a large,
nationally representative U.S. sample of adults followed up
four times over a 22-year period, the proportions of men and
women classifi ed as heavy drinkers (usual consumption of
5+/4+ drinks per drinking occasion, respectively) declined
steadily with increasing age, independent of period effects.
the National Institutes of Health, National Institute on Alcohol Abuse and
Alcoholism. The study on which this article is based, the National Epide-
miologic Survey on Alcohol and Related Conditions, is sponsored by the
National Institute on Alcohol Abuse and Alcoholism, National Institutes of
Health, U.S. Department of Health and Human Services, with supplemental
support from the National Institute on Drug Abuse. The views and opinions
expressed in this article are those of the authors and should not be construed
to represent the views of any of the sponsoring organizations, agencies, or
the U.S. government.
or via email at: firstname.lastname@example.org.
Received: November 21, 2007. Revision: May 21, 2008.
*This research was supported, in part, by the Intramural Program of
†Correspondence may be sent to Deborah A. Dawson at the above address
DAWSON ET AL. 867
The gender differential also narrowed with advancing age.
Other factors associated with a higher prevalence of heavy
drinking across the span of ages included not being married,
smoking, lower income, and lower education (Karlamangla
et al., 2006). The education fi nding supports other longitu-
dinal studies tracking individuals beyond the college years
that have found that lower levels of heavy drinking in their
late 20s and 30s by those who attended college (Lanza and
Collins, 2006; Muthén and Muthén, 2000).
Consistent with the general age-related decline in heavy
drinking reported in the studies above, a study based on
retrospective lifetime drinking histories from small samples
of non-Hispanic white, black, and Mexican-American men
found that all three groups reported the highest levels of
mean quantity, overall frequency, and total weekly volume
of consumption during a drinking stage that occurred in their
late teens to early 20s (Neff and Dassori, 1998). However,
a large study of adult primary care patients interviewed at
two points 5 years apart did not fi nd a signifi cant associa-
tion of age with shifts from lighter (≥1 drinks per day) to
heavier (≥3 drinks per day) drinking after controlling for
other signifi cant correlates of change. Rather, it found that
individuals at risk of shifting to heavier drinking were dis-
proportionately men, black, current or former smokers, and
those who reported mood or anxiety problems (Midanik et
al., 1990). Moreover, a meta-analysis of longitudinal data
for adult samples conducted as part of the Collaborative
Alcohol-Related Longitudinal Project determined that after
age 30 the age-related decline in drinking frequency was no
longer statistically signifi cant (Johnstone et al., 1996). Other
studies from this project found that changes in quantity, fre-
quency, and volume of consumption were positively related
to baseline values of those measures and were decreased
among individuals who were married or got married over the
follow-up interval (Leino et al., 1995).
Longitudinal studies of treatment and quasi-treatment
samples have shown long-term decreases in consumption
in association with recovery from an alcohol-use disorder
(AUD), with the extent or trajectory of decrease demon-
strating considerable instability over time and varying as a
function of baseline characteristics and treatment experience
(e.g., Delucchi et al., 2004; Maisto et al., 2002; Matzger et
al., 2004; Moos and Moos, 2005; Shaw et al., 1997; Skog
and Duckert, 1993). There are, however, virtually no general
population studies charting changes in consumption as a
function of the natural course of AUD. Based on retrospec-
tive data from two Canadian populations, Sobell et al. (1996)
reported that the current consumption levels of nonabstinent,
resolved problem drinkers were within sampling range of
levels for social drinkers, implying a decrease in relation
to remission of AUD, but they did not report on the actual
extent to which the resolved problem drinkers’ consumption
levels had declined. Similarly, Dawson (1996) reported that
individuals with prior alcohol dependence who had returned
to drinking without an AUD had far lower volumes of etha-
nol intake and frequencies of risk drinking and intoxication
than individuals with a current AUD, but these differences
could refl ect lower consumption levels to begin with for
those who recovered as well as differences exclusively at-
tributable to the change in AUD status. Also virtually absent
in the literature are studies that document changes in con-
sumption associated with the development of alcohol abuse
The scant literature on changes in consumption related
to course of AUD is unfortunate, because decreases in con-
sumption corresponding to recovery from AUD have been re-
lated to improved quality of life in treatment samples (Finney
and Moos, 1992; Kraemer et al., 2002), and increased con-
sumption levels have been correlated with increased risks
of psychological, physical, social, and legal harm in both
cross-sectional and longitudinal studies (Dawson et al., 2008;
Murray et al., 2002; Perreira and Sloan, 2002; Pletcher et al.,
2005). Thus consumption changes associated with onset and
offset of AUD are of considerable public health importance.
Moreover, the magnitude of these changes cannot be inferred
from the more extensive body of research in which con-
sumption as an independent variable has been used to predict
AUD transitions as outcomes (e.g., Caetano et al., 1997;
Dawson and Archer, 1993; Dawson et al., 2008; Grant and
Harford, 1990; Woerle et al., 2007). In addition, changes in
consumption associated with AUD transitions may enhance
understanding of the etiology of AUD and help to address
the debate as to the utility of the distinction between abuse
and dependence and their hierarchy in the current Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edi-
tion (DSM-IV) criteria (American Psychiatric Association,
The present study was designed to fi ll this gap in the lit-
erature. Using data from a longitudinal sample of U.S. adults
interviewed at two points approximately 3 years apart, it
classifi es individuals into 12 categories refl ecting transitions
in DSM-IV AUD status over the follow-up interval. It then
compares changes over the follow-up interval across these
12 categories for three commonly used measures of heavy
or risk drinking: average daily volume (ADV) of ethanol
intake, frequency of risk drinking, and maximum drinks
consumed in a single day. These comparisons are based on
models that adjust for baseline consumption levels, sociode-
mographic characteristics, and psychopathology as well as
family history of alcoholism and age at fi rst drink. On the
basis of the extant literature and the DSM-IV articulation of
alcohol abuse as secondary to and thus presumably milder
than alcohol dependence, we anticipate that (1) development
of an AUD will be associated with increases in all measures
of consumption; (2) remission of AUD will be associated
with decreases in consumption, even among individuals who
continued to drink; (3) increases in consumption associated
with developing dependence will be larger than those asso-
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