R E S E A R C H Open Access
Factors influencing risky single occasion
drinking in Canada and policy implications
, William Ian Andrew Bonner
, Jillian Code
, Keely McBride
, Mustafa Andkhoie
, Richa Tikoo
, Colleen Dell
, Michael Szafron
and Marwa Farag
Background: Misuse of alcohol, including single risky occasion drinking (RSOD) is associated with a number of health,
social and economic consequences. While research demonstrates that many factors contribute to individuals’drinking
practices, little is known about risk factors that contribute to RSOD in the Canadian population. The objectives of this
study are to examine the patterns of RSOD in Canada, to identify factors associated with RSOD, and to explore policy
Methods: The Canadian Community Health Survey (CCHS) 2009–2010 annual component was used to conduct all the
analyses in this paper. We used two models: (1) a binary logistic regression model, and (2) a multinomial logistic
regression model, to identify factors that were significantly associated with our dependent variables, RSOD engagement
and frequency of RSOD, respectively.
Results: Daily smokers were 6.20 times more likely to engage in frequent RSOD than those who never smoke.
Males were 4.69 times more likely to engage in risky RSOD. We also found significant associations between the frequency
of RSOD and Province/Territory of residence, income and education, marital status and perceived health status. Finally,
stress was associated with engaging in infrequent RSOD.
Conclusions: Our finding associating daily smoking with risk alcohol intake specifically suggests the possibility
of combining public health interventions for both. The study findings also indicate that education is a protective factor,
further supporting the role of education as a major determinant of health. The significant provincial variation we found
also point to the need to study this issue further and understand the links between provincial level policies and RSOD.
Keywords: Risky single occasion drinking RSOD in Canada, Health policy, Stress, Smoking, Alcohol, Education, Social
From a public health perspective, alcohol consumption
is a challenging issue to address. Controversy existed in
the research community whether low levels of alcohol
consumption have protective effects, and if these effects
outweigh known harms; however, there is a growing
consensus in the literature that the positive effects of
alcohol consumption have been overestimated in the
past [1–4]. Defining low-risk consumption has proved
methodologically difficult, resulting in a variety of guide-
lines for low-risk alcohol intake across countries .
Likewise, alcohol misuse represents a wide spectrum of
terms, from exceeding low-risk guidelines to alcohol de-
pendence. A glossary of terms used in this article is out-
lined in Table 1.
Despite variation in how different organizations define
and convey low-risk drinking, it is clear that the misuse
of alcohol, including risky single occasion drinking
(RSOD), is associated with a number of negative health,
social, and economic consequences [6, 7]. Direct health
implications associated with alcohol misuse include de-
pendency, liver cirrhosis, organ damage, diabetes, car-
diovascular disease, and various types of cancer [7, 8].
Furthermore, impaired judgement, impaired driving
(), injury, suicide, and risky sexual behaviour may be
prompted by high levels of alcohol consumption,
* Correspondence: firstname.lastname@example.org
School of Public Health, University of Saskatchewan, 104 Clinic Place,
Saskatoon, SK S7N 2Z4, Canada
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Rafferty et al. Archives of Public Health (2017) 75:22
suggesting there may be broader health and social reper-
cussions [7, 10]. In Canada, the most recent comprehen-
sive economic analysis of alcohol-related costs was
conducted in 2006 using data from 2002, and estimated
that a total of CAD 14.6 billion was spent that year on
direct and indirect costs [11, 12]. These costs are associ-
ated with healthcare, law enforcement, and productivity
losses [7, 12]. Direct healthcare costs alone accounted
for CAD 3.3 billion in spending in 2002 [7, 12]. More
recently in 2013, the costs of Fetal Alcohol Spectrum
Disorder (FASD) in Canada alone totalled approximately
CAD 1.8 billion dollars  In contrast, the societal and
healthcare costs of excessive alcohol use in the United
States have been estimated at USD 223.5 billion and
24.5 billion, respectively . Worldwide, alcohol abuse
accounted for approximately 3.3 million deaths and 139
million disability-adjusted life years (DALYS) due to
injury and morbidity . Inhabitants of the North
American region drank 8.4 l of pure alcohol per capita
in 2010, 35% higher than the world average (6.2L) and
second only to the European region (10.9 L). Among
current alcohol drinkers in the Americas, the prevalence
of heavy episodic drinking is 22%, again second only to
Europe (22.9%). In the United States, the prevalence of
monthly binge drinking defined in the article as 5+
drinks for men, 4+ for women in one occasion is
approximately 17% .
A substantial proportion of these alcohol-related
harms are associated with populations who exceeded
low-risk alcohol guidelines, which is determined by
quantity and/or frequency of alcohol use [7, 14, 17]. As
the frequency of RSOD increases, the likelihood of nega-
tive health and social consequences increases [7, 17]. In
addition, there is some evidence from the United States
which indicates that moderate drinkers contributed to
the majority of RSOD episodes ().
Research shows that a number of economic, cultural,
and historical factors contribute to individuals’drinking
practices [1, 19]. Data from the National Epidemiologic
Survey on Alcohol and Related Conditions (NESARC)
and the National Survey on Drug Use and Health
(NSDUH) demonstrated associations between early initi-
ation of drinking (before the age of 21), age of 20–29
years, enrollment in college, being male and an increased
engagement in RSOD, [1, 20]. However, it appears the
gender gap is decreasing among younger cohorts . In
general, the factors that impact alcohol consumption
have not been well explored within a Canadian context.
Of particular interest may be how location of residence
influences alcohol consumption in Canada, as provincial
and territorial (P/T) jurisdiction over alcohol policy has
created a patchwork of liquor regulations throughout
the country [19, 21]. Studying provincial variations in
alcohol consumption may provide insight into the
impact of public policy, along with other cultural and
socio-political differences, on RSOD. Furthermore, a
deeper understanding of the risk factors that contribute
to RSOD with respect to P/T may help guide relevant
and informed alcohol related policies for each P/T.
Although experts agree that alcohol consumption can
lead to negative health, social and economic conse-
quences, defining low-risk intake has proved challenging
for researchers and organizations [5, 12, 22]. Both vol-
ume and patterns of alcohol use can lead to separate
risks, and studies have varied in their assessment of risk,
with some focused on dose–response curves, while
others focused on alcohol-attributable fractions .
Grams of pure alcohol per standard drink varies widely
Table 1 Glossary of Terms Associated with Alcohol Consumption
Alcohol abuse Is a pattern of drinking that results in harm to one’s health, interpersonal relationships, or ability to work .
Alcohol dependency Dependency on alcohol, also known as alcohol addiction and alcoholism, is a chronic disease. The signs and
symptoms for alcohol dependence include a strong craving for alcohol, continued use despite repeated
physical, psychological, or interpersonal problems and the inability to limit drinking .
Binge drinking A pattern of alcohol consumption that brings the blood alcohol concentration level to 0.08% or more.
This pattern of drinking usually corresponds to 5 or more drinks on a single occasion for men or 4 or more
drinks on a single occasion for women, generally within about 2 h .
Excessive alcohol use Excessive drinking, or excessive alcohol use includes binge drinking, heavy drinking, any alcohol use by people
under the minimum legal drinking age, and any alcohol use by pregnant women .
Heavy drinking For men heavy drinking is typically defined as consuming 15 drinks or more per week. For women, heavy
drinking is typically defined as consuming 8 drinks or more per week .
Heavy episodic drinking Defined by the World Health Organization (WHO) as 60 or more grams of pure alcohol on at least one single
occasion at least monthly .
Risky drinking Women having more than 3 drinks or men having more than 4 drinks on any single occasion once per month
or more often .
Risky single occasion drinking
Having X number of standard drinks or more (X+) on one occasion. This definition may vary across countries
by number of drinks as well as grams of alcohol per drink . This article uses 5 or more drinks regardless of
sex to define RSOD, based on the CCHS classification, which is equivalent to consuming 70 g or more of pure
alcohol on one single occasion.
Rafferty et al. Archives of Public Health (2017) 75:22 Page 2 of 11
worldwide and portion sizes served often differ from the
standard drink . These debates added to the complex-
ity for P/T governments and non-profit organisations to
determine Canada’s Low Risk Alcohol Drinking Guide-
lines and communicate them to the public. In 2011, the
National Alcohol Strategy Working Group (NASWG)
recommended that, based on the available evidence, no
more than two drinks should be consumed on most days
for women (28 g of ethanol) and no more than three a day
for men (42 g of ethanol) [23–25]. Similarly, the guidelines
recommend that over the duration of a week, women
should consume less than 10 drinks and men less than 15
(140 and 210 g of pure alcohol, respectively) . The
CCSA defines risky drinking as “women having more than
3 drinks or for men more than 4 drinks on any single oc-
casion once per month or more often”. In contrast,
the Canadian guidelines surrounding the definition of
low-risk drinking are stricter compared to guidelines in
the United States. For women, the National Institute on
Abuse and Alcoholism (NIAA)  decrees that low-risk
drinking consists of no more than 3 drinks per day and 7
per week (42 and 98 g of pure alcohol, respectively),
whereas for men the guideline is 4 and 14 respectively (56
and 196 g of pure alcohol, respectively) . European
guidelines vary widely by country, and in response to this,
recent practice principles from the Joint Action Reducing
Alcohol Related Harm (RARHA) in Europe and the Cen-
ter for Addiction and Mental Health (CAMH) have
attempted to identify a standard definition of risk. They
indicate that a level of alcohol intake of 10 g or less per
day would result in an alcohol attributed death rate of
below 1 in 100, and provide this as a suggested maximum
for low risk drinking [27, 28]. This would equate with less
than one standard drink per day in Canada, where one
standard drink contains approximately 14 g of pure alco-
hol [24, 25].
The overall purpose of this study is to explore the past-
year prevalence of RSOD in Canada and the factors asso-
ciated with any RSOD and frequency of RSOD in Canada.
Understanding the underlying factors contributing to
RSOD in Canada will help guide the development of more
effective policy interventions to curtail high-risk con-
sumption. The two research questions developed were:
1) What factors determine the likelihood of individuals
engaging in any RSOD over the past 12 months?
2) What factors determine the likelihood of engaging
in frequent RSOD?
We defined infrequent RSOD as (past-year occurrence
of drinking 5+ drinks (70+ grams alcohol) once a month
or less) and frequent RSOD as (past-year occurrence of
drinking 5+ drinks (70+ grams alcohol) more than once
The Canadian Community Health Survey (CCHS)
2009–2010 annual component was used to conduct all
the analyses in this paper (). The sample size of this
survey was 124,188. The response rate for the outcome
variable of interest “How often in the past 12 months
have you had 5 or more drinks on one occasion?”was
74.3%. Since logistic regression modeling uses listwise
exclusion of missing values, the sample size of the re-
gression models and descriptive statistics was 68,440.
The sample was weighted using the survey weights pro-
vided by CCHS as instructed by Statistics Canada .
Descriptive statistics were conducted in SPSS Version
22.0 and regression modeling conducted using SAS 9.4
software. The alpha was set at 0.05.
The CCHS captured individual’s alcohol consumption
through the original question “How often in the past 12
months have you had 5 or more drinks on one occa-
sion?”R (18) . As this is the only measure for alcohol
consumption in the CCHS, we drew on the work of
Thomas  and defined occasional any RSOD conser-
vatively as having 5 or more drinks on one occasion in
the past 12 months, infrequent RSOD as having 5 or
more drinks on one occasion once or less than once a
month and frequent RSOD as having 5 or more drinks
on one occasion more than once a month . In
Canada, one standard drink contains approximately 14 g
of pure alcohol, therefore RSOD in this case would be
defined as having 70 g of alcohol in one sitting [24, 25].
Based on these definitions, we created two dependent
(1)RSOD which has two categories (binary outcome
variable). ‘Yes’if individual engaged in any RSOD in
the past 12 months and ‘no’if the individual did not
engage in RSOD in the past 12 months.
(2)Frequency of RSOD (multinomial outcome variable)
which has three categories:
i. No RSOD in the past 12 months
ii. Infrequent RSOD: Over the past year, engaging in
RSOD once a month or less
iii. Frequent RSOD: Over the past year, engaging in
RSOD more often than once a month
Based on the relevant literature, we were able to identify
independent variables likely associated with risky drink-
ing, including age, sex, marital status, education status,
income, employment, smoking status, self-perceived
health, and self-perceived life stress [7, 31, 32]. As
Thomas  identified, there is substantial provincial
variation in alcohol consumption across Canada, and so
Rafferty et al. Archives of Public Health (2017) 75:22 Page 3 of 11
we included the P/T variable as a geographic marker, as
well as an indication of alcohol price and other regula-
tory policies. This comparison is possible as price (e.g.,
taxation) and regulation of alcohol differ by P/T. The P/
T variable also stands to represent other historical,
socio-political and cultural factors that may be present
within jurisdictions. Age groups were categorized based
on Thomas et al. . Employment status was grouped
as “employed last week”and “unemployed last week”to
see the effect of employment status on RSOD, and was
categorized based on the CCHS question, “Are you an
employee or self-employed?”Total household income
was captured and analyzed in increments of CAD 20,000
from <20,000 to 80,000 or greater. Education status was
dichotomized to examine the significance of post-
secondary education on RSOD. The highest level of edu-
cation that is available from the CCHS survey data is
post-secondary so we could not break it down further.
Self-perceived life stress was assessed with the question
“thinking about the amount of stress in your life, would
you say that most days are: (not at all stressful, not very
stressful, a bit stressful, quite a bit stressful, or extremely
stressful)”and both responses quite stressful and ex-
tremely stressful were combined to increase the power
of the model. Please refer to Table 2 for a full descrip-
tion of the frequencies associated with each dependent
and independent variables.
We built two models: (1) a binary logistic regression
model, and (2) a multinomial logistic regression model, to
identify factors that were significantly associated with our
dependent variables, any RSOD in the past 12months and
frequency of RSOD in the past 12 months, respectively.
We set the reference categories based on the group least
likely to engage in RSOD according to the literature. We
checked for absence of multicollinearity between the inde-
pendent variables using Variance Inflation Factor (VIF)
and found no issue (VIF less than 1.5). Backwards elimin-
ation method was used for modeling and all the variables
were statistically significant.
After removing the cases with missing values for the
dependent and independent variables from our sample,
the sample size for both Model 1 and Model 2 was
68,440, equivalent to a complete response rate of 55.1%
from the original survey sample size of 124,188. The
estimated past-year prevalence of RSOD in the Canadian
population is 51.6%. Further breakdown shows that 48.4,
36.0, and 15.6% of Canadians engage in no RSOD, infre-
quent RSOD and frequent RSOD, respectively. Therefore,
among those who engage in RSOD, 70% do so
infrequently while 30% do so frequently. For a full descrip-
tion of the frequencies associated with each dependent
and independent variables, please refer to Table 2.
Binary logistic regression (Model 1)
Please refer to Table 3 for a complete list of odds ratios
and confidence intervals for each independent variable.
After controlling for the other nine independent vari-
ables, we found that holding everything else constant, as
an individual’s income level increased, the estimated
odds for engaging in RSOD in the past year increased.
In fact, the odds of the highest income group to indulge
in RSOD were 1.77 times the odds of those in the lowest
income group. The odds of males to engage in RSOD
were 2.61 times the odds of females. Being married was
significantly protective from engaging in RSOD, with the
odds of RSOD being 1.77 times more in the single/never
married category than in the married category. As indi-
viduals’self-perceived health improved, and with an in-
crease in smoking, an individual’s likelihood of engaging
in RSOD also increased. Those who smoked daily had
3.63 times the odds of engaging in RSOD, than those
who never smoked. The odds of RSOD among those
who were employed last week were 1.32 times the
odds of those who were unemployed last week. Indi-
viduals with less than post-secondary education had
1.09 times higher odds than individuals with post-
secondary education. Finally, individuals in the adoles-
cent (12–17) and young adult (18–24) age groups had
much greater odds of engaging in RSOD than those
aged 60 years or older.
There was provincial variation in the RSOD of resi-
dents from different Canadian P/T. New Brunswick
(NB), Nova Scotia (NS), Prince Edward Island (PEI),
Newfoundland and Labrador (NFLD) and Yukon/North
West Territories/Nunavut (YTN) had 1.64, 1.71, 1.80,
2.36 and 1.65 times the odds of engaging in RSOD than
residents from Ontario, respectively. Therefore, individ-
uals from the Maritime Provinces and Canadian north-
ern territories had the highest of odds of engaging in
RSOD compared to Ontario residents.
Multinomial logistic regression (Model 2)
The multinomial logistic regression model (Model 2)
shows the difference in the likelihood of those engaging in
infrequent and frequent RSOD compared to those who
ever engaged in any RSOD in the past 12 months. Many
of the findings in Model 2 are consistent with Model 1.
Similar to model 1, Individuals from Maritime provinces
and northern territories consistently had higher odds of
engaging in infrequent and frequent RSOD in the past
year than residents of Ontario. One notable difference is
that residents from Alberta, Quebec and Saskatchewan
were found to be statistically no different than residents
Rafferty et al. Archives of Public Health (2017) 75:22 Page 4 of 11
from Ontario when it comes to frequent RSOD, however
residents in the above listed provinces are 1.18, 1.20, and
1.25 times more likely, respectively, to engage in infre-
quent RSOD than the residents of Ontario.
In terms of age, both Model 1 and Model 2 consist-
ently show differences in the behavior of RSOD based
on age group. For example, young adults aged 18 to 24
are 8 times and 10 times more likely to engage in infre-
quent and frequent RSOD than adults 60 years of age
and older, respectively. Males dominantly engage in both
infrequent and frequent RSOD compared to females.
Consistent with the findings of model 1, being married
is a protective factor against both frequent and infre-
quent RSOD. In addition, current and past smoking had
a strong effect in engaging RSOD. For example, daily,
occasional and former smokers are 6.85, 6.5, and 3.2
times more likely to engage in frequent RSOD than
those who never smoke, respectively.
Perceived life stress is an interesting variable as it is
associated with infrequent RSOD but not frequent
RSOD. For example, people who perceive their life as
quite or extremely stressful are 1.22 times more likely to
engage in infrequent RSOD than those who perceive
their life as not stressful at all; however, there is no dif-
ference between those who perceive their circumstances
as quite stressful or extremely stressful versus non
stressful when it comes to frequent RSOD. Therefore,
stress is associated with infrequent RSOD but not fre-
quent RSOD. In terms of income, Model 1 and Model 2
Table 2 Distribution of the Canadian population according to
independent and dependent variables, based on the CCHS
cycle 2009/2010 (n= 68,440)
Variables Freq (%)
Past 12 month RSOD
Past 12 month RSOD frequency
British Columbia 12.8
New Brunswick 2.3
Newfoundland & Labrador 1.7
Nova Scotia 2.9
Yukon, Northwest Territories & Nunavut 0.3
12 to 17 years 2.9
18 to 24 years 10.7
25 to 39 years 28.1
40 to 59 years 42.3
60 years or older 16.0
Single or never married 24.0
Widowed, separated or divorced 10.3
Type of smoker
Always occasionally or occasionally 5.8
Never smoked 34.1
Total household income (CAD)
No or < $20,000 6.5
Table 2 Distribution of the Canadian population according to
independent and dependent variables, based on the CCHS
cycle 2009/2010 (n= 68,440) (Continued)
$80,000 or more 45.3
Perceived life stress
Not stressed 9.6
Not very stressed 21.1
Bit stressed 43.6
Quite/Extremely stressed 25.3
Unemployed last week 25.8
Employed last week 74.2
Less than post-secondary 14.1
Very good 39.9
Fair or poor 8.5
Rafferty et al. Archives of Public Health (2017) 75:22 Page 5 of 11
Table 3 Odds ratios of variables associated with past-year RSOD (model 1) and odds ratios of variables associated with frequency of
past-year RSOD (model 2) in Canada, based on the CCHS cycle 2009/2010
Model 1: logistic regression Model 2: multinomial regression model
RSOD vs No RSOD Infrequent RSOD vs No RSOD Frequent RSOD vs no RSOD
Variables OR CI RRR CI RRR CI
Province (Reference = Ontario)
Alberta 1.16* 1.04 1.29 1.18* 1.05 1.32 1.08 0.92 1.26
British Columbia 1.03 0.93 1.14 1.05 0.94 1.17 0.96 0.83 1.11
Manitoba 1.29* 1.11 1.49 1.27* 1.09 1.48 1.39* 1.13 1.72
New Brunswick 1.63* 1.43 1.86 1.59* 1.38 1.84 1.79* 1.49 2.14
Newfoundland & Labrador 2.39* 2.05 2.79 2.14* 1.82 2.53 3.05* 2.48 3.75
Nova Scotia 1.71* 1.49 1.97 1.68* 1.45 1.95 1.79* 1.47 2.18
PEI 1.81* 1.49 2.20 1.86* 1.51 2.28 1.65* 1.23 2.20
Quebec 1.14* 1.05 1.25 1.20* 1.09 1.31 0.95 0.85 1.08
Saskatchewan 1.25* 1.10 1.42 1.25* 1.10 1.43 1.20 0.99 1.46
Yukon, Northwest Territories & Nunavut 1.65* 1.41 1.94 1.50* 1.27 1.77 2.03* 1.63 2.53
Age (Reference = 60 years or older)
12 to 17 years 3.25* 2.74 3.85 3.42* 2.87 4.08 2.58* 2.14 3.56
18 to 24 years 8.09* 6.99 9.35 7.79* 6.70 9.05 9.62* 7.78 11.9
25 to 39 years 4.27* 3.87 4.71 4.25* 3.84 4.70 4.25* 3.57 5.06
40 to 59 years 2.03* 1.86 2.22 2.02* 1.84 2.22 2.16* 1.84 2.54
Sex (Reference = Female)
Male 2.60* 2.44 2.77 2.32* 2.17 2.47 4.69* 4.23 5.21
Marital status (Reference = Married)
Single or never married 1.71* 1.54 1.89 1.64* 1.47 1.82 2.12* 1.80 2.48
Common-law 1.51* 1.35 1.68 1.44* 1.28 1.61 1.93* 1.60 2.33
Widowed, separated or divorced 1.75* 1.60 1.91 1.59* 1.45 1.75 2.68* 2.35 3.07
Type of smoker (Reference = Never smoked)
Daily 3.56* 3.22 3.93 3.16* 2.85 3.50 6.20* 5.29 7.26
Always occasionally or occasionally 3.41* 2.93 3.96 2.96* 2.54 3.46 6.35* 5.16 7.82
Former 2.29* 2.12 2.46 2.18* 2.02 2..35 3.01* 2.63 3.46
Income (Reference = No or < $20,000)
$20,000–$39,999 1.04 0.90 1.21 1.09 0.93 1.28 0.96 0.79 1.25
$40,000–$59,999 1.13 0.97 1.32 1.15 0.98 1.35 1.10 0.90 1.36
$60,000–$79,999 1.38* 1.17 1.62 1.44* 1.21 1.71 1.28* 1.03 1.59
$80,000 or more 1.74* 1.49 2.03 1.79* 1.52 2.11 1.75* 1.42 2.16
Self-perceived life stress (Reference = Not stressed)
Not very stressed 1.11 0.99 1.24 1.14* 1.01 1.28 0.99 0.85 1.16
Bit stressed 1.07 0.96 1.20 1.11* 1.01 1.25 0.90 0.77 1.04
Quite stressed 1.14* 1.01 1.29 1.16* 1.02 1.31 1.03 0.87 1.21
Employment (Reference = Unemployed)
Employed 1.30* 1.20 1.41 1.31* 1.20 1.42 1.30* 1.14 1.49
Education (Reference = Post-secondary)
Less than post-secondary 1.08 0.99 1.18 1.08 0.98 1.18 1.15* 1.03 1.28
Self-perceived health (Reference = Fair or poor)
Rafferty et al. Archives of Public Health (2017) 75:22 Page 6 of 11
demonstrated similar directions of association wherein
the two highest income groups are more likely to engage
in RSOD than lowest income group holding everything
In terms of employment status, those who were
employed in last week are 1.31 and 1.30 times more likely
to engage in infrequent and frequent RSOD than those
who were unemployed last week, respectively. Education
is a protective factor for frequent RSOD but has no effect
on infrequent RSOD. Excellent perceived health increase
the likelihood of engaging in both infrequent and frequent
RSOD. For example, those who identify as being in excel-
lent health are 1.36 and 1.30 times more likely to engage
in infrequent and frequent RSOD than those who identify
as being in poor health, respectively.
This study is the first nation-wide study of factors, which
are associated with the likelihood of individuals engaging
in RSOD and frequency of engaging in RSOD in Canada.
Multiple factors associated with RSOD identified in our
models were consistent with the existing literature. Indi-
viduals who are male, unmarried or common-law, within
the 18–24 year age range, and smoke were found to be
more likely to engage in RSOD [1, 19, 31, 33] Other sig-
nificant findings with regards to engaging in RSOD in
the past year included: living in any province other than
Ontario or British Columbia, being under 60 years of
age, being widowed/separated/divorced, having a high
income, reporting being stressed, being employed, and
having a higher perceived health status. With regards to
frequent RSOD, our findings were similar with notable
differences identified for the P/T variable and the per-
ceived life stress variable.
Socioeconomic status (SES), as a composite measure
of an individual’s income, occupation, educational attain-
ment, and social position in relation to others, has been
generally linked to the risk of alcohol misuse including
RSOD particularly among persons in the lowest SES
strata [33–35]. Breaking down this measure into its prin-
cipal components: income, occupation, and educational
attainment, we find conflicting results between all three
variables across both statistical models.
Our findings relating to educational attainment are
consistent with the literature in which individuals with
higher educational attainment drink less at an occasion
than those with lower levels of educational attainment
[34, 35]. An alternative hypothesis for this relationship,
aside from SES, is higher educational attainment has
been linked to an increased uptake of healthy behaviors
including reduced smoking, increased physical exercise,
and more moderate alcohol consumption [36, 37]. This
further supports the role of education as a major deter-
minant of health.
Individuals in the highest income brackets surprisingly
had much higher odds of engaging in any RSOD, includ-
ing both infrequent and frequent RSOD, compared to
those in the lowest income bracket controlling for all
other factors including education. This finding differs
from the literature, as studies examining RSOD indicate
that individuals with lower incomes and SES engage in
drinking that exceeds low risk guidelines more often than
their counterparts with higher incomes [33, 35]. The cen-
ters for disease control and prevention  surveillance of
binge drinking (defined equivalently with RSOD in our
study as 5+ drinks on a single occasion) has demonstrated
that the prevalence of RSOD is highest among those with
a high household income, however the intensity and fre-
quency of RSOD is highest among those with the lowest
household income . Studies have also found that indi-
viduals with higher incomes tend to drink more often,
however whether these individuals reach the threshold of
RSOD is up for debate . In addition, research on the
relationship between alcohol use and wage earnings has
demonstrated that individuals who drink earn higher
wages than non-drinkers  however individuals who
drink excessively earn less, suggesting an inverse u-shape
relationship between alcohol use and wage earnings and
Currently there is limited Canadian literature on the re-
lationship between employment factors and alcohol intake
. In this study, after controlling for all other independ-
ent variables, we found that being employed in the last
week increased the odds of engaging in both infrequent
and frequent RSOD compared to those unemployed.
These findings, while inconsistent with the SES theory,
are consistent with the findings of Marchand et al. 
which found that hours worked per week were associated
with increased frequency of RSOD. Moreover, Brown et
al.  found unemployed individuals to be less likely to
engage in heavy alcohol consumption, which the authors
theorized could be due to a lack of funds or
Table 3 Odds ratios of variables associated with past-year RSOD (model 1) and odds ratios of variables associated with frequency of
past-year RSOD (model 2) in Canada, based on the CCHS cycle 2009/2010 (Continued)
Excellent 1.35* 1.18 1.54 1.36* 1.19 1.56 1.30* 1.04 1.63
Very good 1.34* 1.19 1.51 1.37* 1.21 1.56 1.21 0.98 1.48
Good 1.18* 1.05 1.33 1.21* 1.06 1.37 1.09 0.89 1.34
* denotes statistical significance at 0.05
Rafferty et al. Archives of Public Health (2017) 75:22 Page 7 of 11
underreporting by this population group. This association
between employment and RSOD may be further linked by
type of employment and occupational status, unavailable
in this dataset, and highlights an area for further explor-
ation within the Canadian context.
As for the link between self-perceived health status and
RSOD, we found in both models that as self-perceived
health status is associated with an increase in the odds of
infrequent and frequent RSOD. These findings differ from
the existing literature outlining that increased alcohol use
is correlated with lower self-perceived health scores .
However, studies have demonstrated that alcohol con-
sumption decision making may be influenced by under-
lying health concerns . It is possible that there may be
a clinically-induced relationship between illness, pharma-
ceutical interventions, and the consumption of alcohol.
This relationship was not explored in this study.
Interestingly, perceived stress increased the odds of in-
frequent RSOD but not frequent RSOD. Alcohol, as a
depressant, is generally viewed as a coping mechanism
for life stress and higher levels of stress in the form of
job insecurity is linked to high-risk alcohol consumption
. However, one would expect that this relationship
would extend into frequent RSOD.
We found that smokers, at any level, are much more
likely to engage in RSOD and frequent RSOD compared
to non-smokers. This relationship was much stronger at
predicting frequent RSOD, suggesting a strong link
between alcohol use and smoking. This finding is con-
sistent with the literature linking smoking with alcohol
abuse and other illicit drug use ([45, 46]).
As expected, marriage is associated with a protective
effect on the risk of RSOD. However, persons living in
common-law were more likely to engage in any RSOD
and frequent RSOD than married individuals. This is in-
teresting because common-law couples have enjoyed
similar tax benefits and legal status in Canada as married
couples due to high profile court cases Egan v. Canada
 and M. v. H. . Research on the differences
between common-law and married couples has demon-
strated that common-law couples are more likely to
separate than married couples , are more likely to
experience relationship strain , and enjoy fewer
economic benefits . The higher levels of instability in
common-law relationships and households may contrib-
ute to the increased odds of RSOD and frequent RSOD.
Finally, province of residence was associated with the
likelihood of engaging in RSOD. Persons living in Atlantic
Canada or in one of the three Territories were more likely
to engage in infrequent and frequent RSOD compared to
Ontario. In the literature, comparative data pertaining to
RSOD by province was not available; however, statistics
show higher rates of overall consumption in the Territor-
ies, British Columbia, Alberta, and Newfoundland and
Labrador . This P/T variation is likely due to a
myriad of factors including: alcohol policies and tax-
ation, cultural norms, historical factors, and the social
environment [19, 52, 53].
Although the legal age for purchase of alcohol in
Canadian P/T is 19 years except in Alberta, Manitoba and
Quebec, the regulatory system of alcohol sale is compli-
cated. The retail liquor sale is wholly private (AB), exclu-
sively controlled by Government (PEI, NB, NWT) or
mixed controlled by both private and public systems (NS,
QC, ON, SK, MB, BC, YT) . The system is further
complicated by permitting delisted products to be sold at
significantly less than minimum price (SK), establishing
special outlets for selling at discounted prices or allow-
ing private liquor stores selling less than minimum
price (BC) .
As for an association between P/T alcohol policies and
RSOD, our findings did not uncover a link between the
two variables. For instance, residents of Saskatchewan
and Alberta had similar results with relation to RSOD;
however these provinces employ very different alcohol
policies. Saskatchewan has a mixed government and pri-
vate sales structure whereby minimum prices are set in
government stores and prices are indexed to inflation;
whereas Alberta employs a free-market with regard to
alcohol sales with privatization, no minimum prices, and
no indexing to inflation . Although factors such as
price controls and tax policy have been shown to reduce
regular alcohol consumption and heavy drinking ,
the effects of these forms of policy were not evident in
our study. Therefore more direct research on this topic
is needed to determine the best methods for provincial
governments to control RSOD.
Our findings extend the existing literature by focusing
on the Canadian population, and demonstrate that age,
sex, education, income, employment, marital status, smok-
ing status, life stress, self-perceived health, and province of
residence are associated with RSOD and the frequency of
There are some limitations to our study. The CCHS sur-
vey provides secondary data, which can restrict the avail-
ability and clarity of indicators pertaining to RSOD. For
example, the provincial variable used in the research does
not allow for interpretation of the factors within the prov-
ince that may contribute to consumption (e.g., urban/
rural, ethnicity). Moreover, using the provincial variable as
a representation of the impact of alcohol policy proved
challenging, as there too many confounding factors to
draw a direct comparison. We could not explore the ef-
fects of different levels of post-secondary education using
the “education”variable in the CCHS survey data because
the variable had only one category for post-secondary
Rafferty et al. Archives of Public Health (2017) 75:22 Page 8 of 11
education. The missing data also represent a possible bias
in the results. We performed missing value analysis and
determined that not all the missing data were MCAR. We
attributed this to people who did not complete a large
portion of the survey (failed to answer questions relating
to both an independent and dependent variables).
At the same time, the range of definitions and terms
(e.g., problematic drinking, binge drinking, risky drink-
ing) used to define high risk alcohol consumption in
Canada can make it difficult to directly compare and
understand varying alcohol-specific research and policy.
For example, the definition of risky drinking as employed
by the CCHS survey may underrepresent the number of
individuals engaging in risky drinking compared to the
definition employed by the Canadian Centre for Substance
Abuse (CCSA) as 4+ drinks for men and 3+ drinks for
women, consumed on one occasion. Also, newer literature
suggests a low-risk cut point of 10 g of pure alcohol per
day, which is largely exceeded by what was captured by
the CCHS survey (equivalent to approximately 70 g of
pure alcohol). Finally, as reflected in the literature, the
prevalence of health compromising behaviors such as al-
cohol overconsumption are likely underestimated in self-
reported surveys, such as the CCHS .
Conclusion and policy implications
This paper examined RSOD and frequent RSOD within
the Canadian population. It was found that engaging in
RSOD was significantly influenced by a myriad of demo-
graphic, socioeconomic, and health status variables. More
research into the factors which we found to influence
RSOD is needed to determine ways to mediate RSOD at
all levels within the Canadian population as it is associated
with negative health and social implications [7, 8].
It is important for policy-makers and researchers to
start to consider the impact of people who participate in
both infrequent and frequent RSOD, as those who en-
gage in frequent RSOD are more likely to have serious
negative health consequences however those who engage
in infrequent RSOD remain at risk and represent a lar-
ger proportion of the Canadian population. As with
Geoffrey Rose’s prevention paradox , targeting higher
risk populations (frequent risky single occasion drinkers)
for prevention is effective but not as effective as a mass
prevention strategy in order to shift the whole popula-
tion’s distribution of RSOD downwards.
Attempts at reducing RSOD through traditional health
promotion efforts such as educational and media campaigns
have proven largely ineffective , however studies have
shown that changing perceptions about RSOD and cultural
norms can be effective . In addition research has shown
that alcohol consumption is price-sensitive  and heavier
drinkers may be more sensitive to price changes . There-
fore effective prevention strategies should include aspects of
changing perceptions, especially among youth and young
adults, about RSOD and cultural norms in conjunction with
changes to provincial alcohol policies and taxation.
Additionally, our finding associating smoking with RSOD
specifically suggests an opportunity to combine public
health prevention strategies for both substances. Policies
surrounding “cultural norms”with regards to RSOD, along
with effective alcohol price controls are likely to reduce the
prevalence and frequency of RSOD in Canada.
AB: Alberta; BC: British Columbia; CCHS: Canadian Community Health Survey;
MB: Manitoba; MCAR: Missing completely at random; NB: New Brunswick;
NL: Newfoundland and Labrador; NS: Nova Scotia; NT: Northwest Territories;
NU: Nunavut; ON: Ontario; P/T: Provinces/Territories; PE: Prince Edward Island;
QC: Quebec; RSOD: Risky single occasion drinking; SES: Socioeconomic
status; SK: Saskatchewan; YT: Yukon
This study was not funded by a grant.
Availability of data and materials
The databases analyzed during the current study are publicly available from
All authors participated in the preparation of the manuscript and approved
its final version for submission. JC, KM, SM and RT conducted the review of
the literature and assisted with the editing of the paper. ER and MA contributed
equally to conducting the statistical analyses. AB and ER took the lead role in
writing and interpretation of findings. CD was responsible for the critical review
of the manuscript because she is a content area expert. SM contributed
to revising the manuscript, included new literature, and participated in
writing the manuscript. MS supervised and led developing the statistical
methodology, analyses and the interpretations of the associated results.
MF supervised and contributed to the quantitative analysis, interpretation of the
findings as well as the writing of the paper.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
This study did not require ethics approval.
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
School of Public Health, University of Saskatchewan, 104 Clinic Place,
Saskatoon, SK S7N 2Z4, Canada.
Department of Sociology, University of
Saskatchewan, 1019 - 9 Campus Drive, Saskatoon, SK S7N 5A5, Canada.
Received: 2 January 2017 Accepted: 26 March 2017
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