‘‘Culture of Drinking’’ and Individual Problems with Alcohol Use
Jennifer Ahern1,2,3, Sandro Galea2,3,4, Alan Hubbard5, Lorraine Midanik6, and S. Leonard Syme1
1Division of Epidemiology, University of California, Berkeley, School of Public Health, Berkeley, CA.
2Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI.
3Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY.
4Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY.
5Division of Biostatistics, University of California, Berkeley, School of Public Health, Berkeley, CA.
6University of California, Berkeley, School of Social Welfare, Berkeley, CA.
Received for publication September 20, 2007; accepted for publication January 9, 2008.
Binge drinking is a substantial and growing health problem. Community norms about drinking and drunkenness
may influence individual drinking problems. Using data from the New York Social Environment Study (n ¼ 4,000)
conducted in 2005, the authors examined the relation between aspects of the neighborhood drinking culture and
individual alcohol use. They applied methods to address social stratification and social selection, both of which are
challenges to interpreting neighborhood research. In adjusted models, permissive neighborhood drinking norms
were associated with moderate drinking (odds ratio (OR) ¼ 1.28, 95% confidence interval (CI): 1.05, 1.55) but
not binge drinking; however, social network and individual drinking norms accounted for this association. By
contrast, permissive neighborhood drunkenness norms were associated with more moderate drinking (OR ¼
1.20, 95% CI: 1.03, 1.39) and binge drinking (OR ¼ 1.92, 95% CI: 1.44, 2.56); the binge drinking association
remained after adjustment for social network and individual drunkenness norms (OR ¼ 1.58, 95% CI: 1.20, 2.08).
Drunkenness norms were more strongly associated with binge drinking for women than for men (pinteraction¼
0.006). Propensity distributions and adjustment for drinking history suggested that social stratification and social
selection, respectively, were not plausible explanations for the observed results. Analyses that consider social
and structural factors that shape harmful drinking may inform efforts targeting the problematic aspects of alcohol
alcohol drinking; alcoholic intoxication; culture; residence characteristics; sex
Abbreviations: CI, confidence interval; NIAAA, National Institute for Alcohol Abuse and Alcoholism; OR, odds ratio.
Excessive alcohol consumption is a substantial and grow-
ing health problem in the United States (1, 2). Alcohol use is
the third leading cause of mortality in the United States, and
over half of alcohol-related deaths are attributable to binge
drinking (1). Binge drinking is associated with many other
negative social and health consequences, such as violence,
child neglect, accidents, and reduced productivity (2). Al-
though it is more common among younger adults, binge
drinking has been rising across all age groups (2). There
have been recent calls for increased attention to this major
health problem (2–4).
A substantial body of research has identified risk factors
for binge drinking including young age, male gender, being
unmarried, lower education, lower income, and unemploy-
ment (5, 6). However, recently, interest has increased in
understanding the larger societal forces that shape individ-
ual behaviors such as binge drinking, since intervening on
these environmental characteristics may foster lasting and
Correspondence to Dr. Jennifer Ahern, University of California, Berkeley, School of Public Health, 101 Haviland Hall, Berkeley, CA 94720-7358
1041 Am J Epidemiol 2008;167:1041–1049
American Journal of Epidemiology
ª The Author 2008. Published by the Johns Hopkins Bloomberg School of Public Health.
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wide-reaching changes in behavior (7, 8). A small but grow-
ing body of research has examined aspects of the environ-
ment that may be associated with the risk of alcohol-related
problems. These include the availability of alcohol (9–14),
alcohol advertising (15, 16), policies related to alcohol
availability (14), and norms around drinking (17, 18).
Group norms may be particularly important in relation to
binge drinking, because theories suggest that there are
norms or aspects of the ‘‘culture of drinking’’ that separately
determine levels of any drinking, as distinct from levels of
binge (or other problem) drinking (19–22). Drinking norms
of a group are classified as either descriptive norms, defined
as the actual drinking behaviors of others within a group, or
injunctive norms, defined as the group approval or disap-
proval of drinking behaviors (18). Descriptive and injunc-
tive group norms provide each individual with information
on what behavior is acceptable or unacceptable in a partic-
ular social context (18). Group norms can be measured as
perceptions of group norms or objective group norms. There
is substantial research on perceived descriptive and injunc-
tive group norms in relation to binge drinking, conducted
mainly with young adults (18). In the college setting, the
individual perception that others in the peer network are
binge drinking and that they approve of binge drinking
has been associated with the same drinking behavior in in-
dividuals (18, 23, 24).
However, two important issues remain understudied to
date. First, we know little about the effects of group drinking
norms on people across different ages, because most extant
research has focused on the college setting; this is under-
standable given that the highest levels of binge drinking are
found in this population (2, 18). Yet, it is also important to
understand how group norms may affect the general popu-
lation, given a growing interest in intervening on drinking at
the community level (25) and a recent call by the National
Institute for Alcohol Abuse and Alcoholism (NIAAA) to
focus on alcohol use throughout the life span (26). Second,
we know far less about objective group drinking norms
and how they affect individual behavior than we do about
perceived group drinking norms. We are aware of only
one study that has examined objective group norms of
drinking in relation to drinking behavior (17). This work-
place-based analysis found that norms against drinking
were associated with lower levels of problematic drinking
behavior. However, this study did not adjust for each indi-
vidual’s norm and did not examine norms specific to heavy
drinking. We are not aware of any research that
has examined objective group norms of heavy drinking in
an adult population in association with individual drinking
In this analysis, we examine two distinct objective group
injunctive drinking norms, acceptability of drinking and ac-
ceptability of drunkenness (21, 22), in relation to drinking
patterns in urban neighborhoods. This research aims to con-
tribute to the literature by 1) providing a quantitative exam-
ination of aspects of the adult drinking culture in relation to
individual alcohol use patterns that is not available to date,
and 2) applying methods that address the problems of social
stratification and social selection that are challenges to in-
terpreting neighborhood research (27).
MATERIALS AND METHODS
The New York Social Environment Study is a multilevel
study designed to examine neighborhood-level exposures,
including economic, social, and structural characteristics of
communities, and substance use in New York City. This
study was conducted between June and December of
2005. We used random digit dialing methods to contact
and interview 4,000 New York City residents. One adult
aged 18 years or older was interviewed by telephone in each
household; the respondent was the person who either most
recently or would next celebrate his/her birthday (randomly
selected). Interviews were conducted in English or Spanish.
Respondents were offered $10 in compensation for their
participation. The study protocol was approved by the in-
stitutional review boards of the New York Academy of
Medicine, the University of Michigan, and the University
of California, Berkeley.
Respondents were interviewed with a structuredquestion-
naire that included questions on demographic and socioeco-
nomic characteristics, including age, race and ethnicity,
gender, marital status, place of birth, education, income,
employment, years lived in the current neighborhood, and
interview language. Drinking behavior was assessed by use
of the World Mental Health Comprehensive International
Diagnostic Interview alcohol module (28, 29) and the
NIAAA-recommended questions on binge drinking (30).
The Comprehensive International Diagnostic Interview al-
cohol measures that were used in the present analysis in-
clude drinking in the past 12 months and a retrospectively
recalled history of alcohol use, including age when first had
an alcoholic drink and age when first drank monthly. The
NIAAA binge drinking questions assessed the number of
occasions in the past 12 months when four (for women) or
period. This is drinking behavior that will raise the blood
alcohol content beyond 0.08 percent in most people, which
is considered legally drunk (30). For the analysis, drinking
was coded into three categories including abstinent in the
past 12 months (abstinent), drinking but not binge drinking
in the past 12 months (moderate drinking), and binge drink-
ing in the past 12 months (binge drinking). This approach
allows us to conduct an analysis that distinguishes between
exposures associated with the decision to drink at all from
those associated with problem drinking.
History of drinking, in conjunction with number of years
lived in the current neighborhood, was used to assess drink-
ing prior to residence in the current neighborhood. Respond-
ents were classified as those who never had a drink, those
who tried drinking but did not drink regularly, and those
who drank at least monthly prior to residence in the current
Respondents provided their residential address or nearest
cross-streets so that their locations could be geocoded and
linked to their neighborhoods of residence. Of the 4,000
respondents, 93.1 percent (n ¼ 3,725) were geocoded by
address (n ¼ 2,859) or cross-streets (n ¼ 866). For the
Am J Epidemiol 2008;167:1041–1049
1042Ahern et al.
remaining 275 respondents, we had insufficient address or
cross-street information or had only zip code information.
These participants were linked to the neighborhood that had
the largest percentage of overlap with their zip code (98.5
percent had more than 50 percent overlap between the zip
code and the neighborhood, and 68.7 percent had more than
75 percent overlap between the zip code and the neighbor-
hood). An indicator for linkage to the neighborhood by zip
code instead of by geocoding was considered in all analyses
as a potential confounder. The neighborhood units for this
analysis were the 59 community districts in New York City,
well-defined units, each headed by an administrative
community board, that as such have political and social
relevance for their residents. Community districts were ini-
tially defined by a resident consultative process organized
by the Office of City Planning to reflect residents’ own
descriptions of neighborhoods in the 1970s. Characteristics
of community districts have been shown to have a relation
with resident behavior and health (31–35).
Neighborhood drinking norms were measured by ques-
tions modified from the National Survey on Drug Use and
Health (36). Respondents were asked their opinion about
adults drinking alcoholic beverages and about adults getting
drunk at least once a week. For both questions, respondents
were given the options of ‘‘acceptable,’’ ‘‘unacceptable,’’
and ‘‘don’t care.’’ The neighborhood measures were the
proportions of residents who believed it was ‘‘unaccept-
able’’ for adultsto drink alcoholic beverages and ‘‘unaccept-
able’’ for adults to get drunk at least once a week in each
All analyses were weighted by the ratio of the persons in
the household to phone lines in the household to account for
the probability of selection for interview. In addition, all
analyses were replicated with additional weighting to adjust
the respondents to the joint age, race/ethnicity, and gender
distribution within each neighborhood as determined
from the 2000 US Census data. This was done to assess
the potential impact of nonresponse of particular population
groups and to examine whether nonresponse was a plausible
explanation for the analysis findings. Because none of the
results changed appreciably after this additional weighting,
analyses with only the selection probability weights are pre-
To assess the extent of social stratification, we examined
the probabilities or propensities for living in neighbor-
hoods with 1) high versus low drinking norms (median split)
and 2) high versus low drunkenness norms (median split),
modeled as a function of individual characteristics (37). In-
dividual characteristics in the propensity model included
history of drinking, individual drinking norm, age, race/
ethnicity, gender, marital status, place of birth, education,
income, employment, years lived in the neighborhood,
and survey language. Through this process, we were able
to examine whether there was overlap between the ‘‘types’’
of people, defined by covariate combinations, who lived in
permissive drinking norm neighborhoods and those who
lived in neighborhoods with strong norms against drinking.
If the people who actually lived in the two kinds of neigh-
borhoods had similar and predominantly overlapping distri-
butions of propensities, then we would know that there was
little social stratification in terms of the variables in the
propensity model. This would imply that people of all
‘‘types’’ lived in both permissive and strong norm neighbor-
hoods and that the analysis did not rely on extrapolation; for
example, if all White men aged 18–24 years lived in per-
missive drinking norm neighborhoods, extrapolation would
be required to assess the effect of strong norms against
drinking on this ‘‘type’’ of person.
To account for social selection, drinking prior to resi-
dence in the current neighborhood was controlled as a con-
founder in all analyses (38, 39); by controlling for history of
drinking, we ensured that the associations observed were not
due to the fact that drinkers were likely to move to certain
types of neighborhoods.
To model the three-category drinking outcome, two lo-
gistic regression models were used in each analysis, one
comparing moderate drinkers with abstainers and one com-
paring binge drinkers with abstainers. In a supplemental
analysis, we used logistic regression models to compare
binge drinkers with moderate drinkers and with all others
(abstainers and moderate drinkers), because abstainers alone
may not be the best comparison group for binge drinkers.
Generalized estimating equation logistic regression models
were used in all analyses to account for potential clustering
by neighborhood and to estimate population-averaged pa-
rameter estimates with robust standard errors (40–42).
Individual demographic and socioeconomic characteristics
that were conceptually considered confounders on the basis
of the literature were considered as confounders in the mul-
tivariable analysis. In addition, age, race/ethnicity, and gen-
der were considered potential effect modifiers on the basis of
previous findings (43); years lived in the neighborhood
and history of drinking were also considered, as they were
logical potential effect modifiers that had not been examined
in previous analyses. Missingness indicator variables were
included for all covariates where some respondents declined
Each neighborhood exposure was examined separately
in association with current drinking categories, adjusted
for demographic and socioeconomic confounders, and fi-
nally adjusted for friend and family drinking norms, as
well as individual drinking norm. All odds ratios presented
are for a 2-standard deviation change in the neighborhood
The survey respondents were demographically similar to
the overall population of New York City according to the
most recent census (table 1). Overall, 27.2 percent of re-
spondents were moderate drinkers, and 11.0 percent were
binge drinkers. The cooperation percentage was 54 percent,
representing the percentage of those contacted who agreed
to participate in the study ((completed þ screened out)/
(completed þ screened out þ refused)).
‘‘Culture of Drinking’’ and Problems with Alcohol Use 1043
Am J Epidemiol 2008;167:1041–1049
A descriptiveexamination of neighborhood norms around
drinking and drunkenness suggested that there were no out-
lying neighborhoods. The mean percentage believing it was
unacceptable for an adult to drink was 32 percent (range:
3–60 percent), and the mean percentage believing it was
unacceptable to get drunk weekly was 78 percent (range:
53–89 percent). Neighborhood drinking norms and norms
around getting drunk were positively correlated (correla-
tion: 0.48; p ¼ 0.06), suggesting that they are related, as
would be expected, but are sufficiently distinct to be con-
sidered measuring different constructs.
Examining the propensities for living in neighborhoods
with permissive versus restrictive drinking and drunkenness
norms, we found that there was little suggestion of social
stratification. People of all ‘‘types,’’ based on individual
covariates, lived in neighborhoods with different values of
the neighborhood exposures. In both cases, fewer than 0.5
percent of respondents had propensity values that were more
extreme (higher or lower) than the propensity values among
respondents living in neighborhoods with a different expo-
sure (tables and plots of the propensity values are available
from the corresponding author).
To adjust for confounders and account for clustering, the
relations between neighborhood norms and drinking pat-
terns were examined in generalized estimating equation lo-
gistic regression models. Twenty-one respondents did not
provide data on current drinking and were thus excluded
from all models. In the first series of models, we examined
the relation between neighborhood norms about drinking
and the drinking categories. In the unadjusted models, those
living in neighborhoods with weaker norms against drinking
had greater odds of moderate drinking (odds ratio (OR) ¼
2.66, 95 percent confidence interval (CI): 2.18, 3.25)
and binge drinking (OR ¼ 2.42, 95 percent CI: 1.54, 3.80)
compared with abstaining (table 2). After adjustment for
individual confounders including demographic and socio-
economic characteristics, the relations between norms about
drinking and the drinking categories were dramatically re-
duced, with greater odds of moderate drinking remaining
significant (OR ¼ 1.28, 95 percent CI: 1.05, 1.55) but no
remaining increase in the odds of binge drinking (OR ¼
1.12, 95 percent CI: 0.69, 1.82). In the final analysis, we
considered whether these associations were robust to further
adjustment for the norms of the closer social network and of
the individuals themselves; after this additional adjustment,
there were no remaining associations between neighbor-
hood drinking norms and either type of drinking (moderate
drinking OR ¼ 1.03, 95 percent CI: 0.86, 1.25; binge drink-
ing OR ¼ 0.98, 95 percent CI: 0.62, 1.54). To assess the
sensitivity of the analysis of binge drinking to the choice of
comparison group, final models were run with moderate
drinking as the comparison (OR ¼ 1.16, 95 percent CI:
0.80, 1.66) and with all others (moderate drinking and ab-
staining) as the comparison (OR ¼ 1.05, 95 percent CI:
0.71, 1.56), and no substantial differences were found.
In the second series of models, we examined the relations
between neighborhood norms about getting drunk regularly
and drinking patterns (table 3). In bivariable generalized
estimating equation logistic regression models, more per-
missive neighborhood norms about getting drunk were
Environment Study, 2005
Respondent characteristics, New York Social
New York Social
York, NY (%)
New York, NY
Other US location
Less than high school
Drinking before moved
Ever drank/tried drinking
1044Ahern et al.
Am J Epidemiol 2008;167:1041–1049
associated with greater odds of moderate drinking (OR ¼
1.66, 95 percent CI: 1.24, 2.22) and strongly associated with
greater odds of binge drinking (OR ¼ 2.74, 95 percent CI:
2.19, 3.42) compared with abstaining. After adjustment for
individual confounders, these associations were reduced but
remained significant; more permissive neighborhood norms
about getting drunk were associated with a greater odds of
moderate drinking (OR ¼ 1.20, 95 percent CI: 1.03, 1.39)
and binge drinking (OR ¼ 1.92, 95 percent CI: 1.44, 2.56)
compared with abstaining. After additional adjustment for
friend and family norms and for individual norms about
drunkenness, associations were further reduced but re-
mained significant in association with binge drinking (for
moderate drinking: OR ¼ 1.14, 95 percent CI: 0.99, 1.30;
for binge drinking: OR ¼ 1.58, 95 percent CI: 1.20, 2.08).
To assess the sensitivity of the analysis of binge drinking to
the choice of comparison group, final models were run with
moderate drinking as the comparison (OR ¼ 1.40, 95 per-
cent CI: 1.06, 1.85) and with all others (moderate drinking
and abstaining) as the comparison (OR ¼ 1.43, 95 percent
CI: 1.12, 1.84), and associations were somewhat weaker but
In the final model for binge drinking, we found an in-
teraction between gender and drunkenness norms in associ-
ation with binge drinking (p ¼ 0.006) such that norms
around drunkenness were more strongly associated with
binge drinking for women than for men. This interaction
is depicted in figure 1. None of the other hypothesized in-
teractions was found.
In a population-based multilevel study of urban resi-
dents, we found associations between neighborhood norms
about specific types of drinking and the corresponding
drinking behaviors. Neighborhoods with norms that were
permissive about drinking among adults had higher levels
of moderate drinking but no difference in levels of binge
drinking in adjusted models. This association was not ro-
bust to adjustment for the drinking norms of friends and
family and of each individual. In contrast, neighborhoods
with permissive norms about drunkenness had much higher
levels of binge drinking and somewhat higher levels of
moderate drinking. For binge drinking, this association
was robust to adjustment for friend and family norms
and for individual norms about the acceptability of getting
drunk. In the final model, neighborhood norms about
drunkenness were more strongly associated with binge
drinking for women than for men.
comparing moderate drinkers and binge drinkers with abstainers, New York Social Environment Study (n ¼ 3,979), 2005
Generalized estimating equation logistic regression models of neighborhood drinking norms and drinking pattern,
Model 1Model 2*
drinking norms§2.66 2.18, 3.252.421.54, 3.8 1.28 1.05, 1.551.120.69, 1.821.03 0.86, 1.250.980.62, 1.54
Drinking before moved
Never drank 1.001.00 1.001.00
drinking 0.81 0.57, 1.130.44 0.24, 0.810.710.5, 0.990.41 0.21, 0.81
Monthly drinker5.50 4.32, 7.02 6.39 3.93, 10.394.56 3.46, 6 5.483.25, 9.26
No opinion 1.00 1.00
Acceptable 1.30 1.01, 1.681.14 0.77, 1.68
Unacceptable0.68 0.47, 1 0.750.45, 1.23
Missing 0.68 0.36, 1.290.230.07, 0.76
No opinion1.00 1.00
Acceptable1.50 1.21, 1.861.471.06, 2.06
Unacceptable0.340.25, 0.460.28 0.17, 0.45
Missing 0.980.47, 2.070.30 0.08, 1.09
* Models additionally adjusted for age, race/ethnicity, sex, marital status, place of birth, education, income, employment, years lived in the neighborhood,
and survey language.
yModerate drinking analysis: n ¼ 3,541.
zBinge drinking analysis: n ¼ 2,854.
§ Odds ratios for a 2-standard deviation increase in permissiveness of drinking norms.
‘‘Culture of Drinking’’ and Problems with Alcohol Use1045
Am J Epidemiol 2008;167:1041–1049
Our analysis suggests that neighborhood norms about
drinking and neighborhood norms about drunkenness are
distinct aspects of the social environment that are associated
with different types of drinking behaviors in the communi-
ties studied, consistent with previous theories (21, 22). In
fact, the most robust and strongest association was between
norms about drunkenness and binge drinking, an association
that was independent of friend, family, and individual
norms. Even when an individual believed that it was accept-
able to get drunk regularly, if there were stronger norms
against drunkenness in the neighborhood, that individual
was less likely to binge drink.
We found that neighborhood drunkenness norms were
more strongly associated with binge drinkingamong women
than among men. Although this issue has not been examined
in many studies, two analyses of college students found that
perceptions of drinking among other students were more
strongly associated with alcohol consumption for women
than for men (44, 45). Research on gender differences in
drinking suggests that overall drinking and heavy drinking
pattern, comparing moderate drinkers and binge drinkers with abstainers, New York Social Environment Study (n ¼ 3,979), 2005
Generalized estimating equation logistic regression models of neighborhood norms around drunkenness and drinking
Model 1Model 2*
norms§ 1.661.24, 2.222.74 2.19, 3.42 1.201.03, 1.39 1.921.44, 2.561.14 0.99, 1.30 1.581.20, 2.08
Never drank1.001.00 1.001.00
drinking0.80 0.57, 1.120.43 0.23, 0.820.75 0.53, 1.05 0.440.24, 0.82
Monthly drinker 5.484.32, 6.966.40 3.90, 10.50 4.813.75, 6.19 5.903.50, 9.94
No opinion1.00 1.00
Acceptable1.651.32, 2.061.44 1.02, 2.02
Unacceptable 0.500.36, 0.70 0.660.41, 1.08
Missing0.68 0.38, 1.20 0.240.07, 0.84
No opinion 1.001.00
Acceptable 1.130.63, 2.041.04 0.64, 1.68
Unacceptable0.59 0.42, 0.820.28 0.20, 0.39
Missing 0.580.23, 1.460.05 0.01, 0.38
* Models additionally adjusted for age, race/ethnicity, sex, marital status, place of birth, education, income, employment, years lived in the
neighborhood, and survey language.
yModerate drinking analysis: n ¼ 3,541.
zBinge drinking analysis: n ¼ 2,854.
§ Odds ratios for a 2-standard deviation increase in permissiveness of drunkenness norms.
Weak normsMean drunkenness
Odds ratio for binge drinking (vs. abstaining)
New York Social Environment Study (n ¼ 3,979), 2005.
Odds ratios for the association between neighborhood
1046 Ahern et al.
Am J Epidemiol 2008;167:1041–1049
are more socially stigmatized for women than for men (46),
so it may be that, where there are norms against heavy
drinking generally, those norms are felt more strongly by
women or expressed more strongly towards women.
There are several limitations to this study. The coopera-
tion percentage was 54 percent, which is consistent with
recent telephone-based research (47). However, this raises
the question of whether the study sample is representative.
Participants were informed that they would be participating
in a ‘‘survey about the neighborhoods where New Yorkers
live and what people think about their neighborhoods,’’
and thus they were not likely to refuse on the basis of their
use or nonuse of alcohol. The findings were robust to addi-
tional weighting to adjust the respondents to the age, race/
ethnicity, and gender distribution within each neighborhood
as determined from the 2000 US Census data, suggesting
that nonresponse did not distort the study findings. However,
the participants may still differ from those in the City overall
in ways that we were unable to capture. Self-report is stan-
dard practice in alcohol research, and telephone interviews
are thought to elicit more accurate reports than in-person
interviews (48). However, there may be differences between
actual and reported alcohol use. The neighborhood drinking
and drunkenness norm variables were based on questions
originally designed to assess individual norms. These ques-
tions clearly assess injunctive norms, defined as approval or
disapproval of drinking behaviors (18), but they represent
only one of many ways these norms could have been as-
sessed. A recent review of perceived injunctive norms noted
the lack of consistency in how they are measured (18);
validation of items to assess group-level drinking norm
measures will be important for future work. Norms in
a neighborhood are naturally only one of many factors that
shape drinking behaviors. Structural aspects of neighbor-
hoods and legal restrictions on alcohol certainly have re-
ciprocal relations with neighborhood norms; for example,
changing availability of alcohol may alter norms and, con-
versely, changes in norms may affect availability of alcohol.
Teasing apart these complex interrelations would be a fruit-
ful topic for future longitudinal work. Recent discussions of
analyses that examine community characteristics and indi-
vidual outcomes have raised the problem of contagion
(27, 49). This problem arises when the prevalence of the
outcome (in this case, drinking or binge drinking) affects
the probability of the outcome for any individual (i.e., prev-
alence affects incidence). This dependence of the outcomes
between individuals means that parameter estimates from a
traditional analysis do not accurately reflect how much of
a change in outcome would be expected from a change in
exposure (50). A complementary analytical approach that
acteristics and health would be one that can account for these
that have been used to model infectious diseases (50, 51).
Among several strengths, this study includes a large
population-based sample. We assessed the extent of social
stratification by use of propensities and found that there was
virtually no social stratification in this analysis. We also
accounted for social selection by adjusting for history of
drinking prior to each person’s residence in his/her current
neighborhood. Social selection has been considered one of
the major barriers to determining whether the environment
has an influence on people, or whether people who have
worse health ‘‘drift’’ or select into worse types of environ-
ments (27, 52). Because we adjusted for history of drinking,
social selection is not a likely explanation for these findings.
Overall, we found that two distinct aspects of norms
around drinking in communities were associated with the
corresponding drinking behaviors. In particular, neighbor-
hood norms around drunkenness were strongly associated
with binge drinking independent of friend, family, and in-
dividual norms. This analysis and other analyses that con-
sider aspects of the social and structural environments that
may affect harmful drinking behaviors in particular may
provide insight for intervention strategies. If future analyses
of neighborhood drinking and drunkenness norms in other
settings support the results of this study, norm-changing
campaigns may be an important addition to community in-
terventions that target the problematic aspects of alcohol
consumption (25, 53, 54).
Funding for this work was provided in part by the
National Institute on Drug Abuse (R01 DA 017642, R01
Conflict of interest: none declared.
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