Does Alcohol Misuse Differ by Gender and Veteran Status in Adults Ages 25 and Older?

Goodell HE, Van Noy AE, Zarker KM, Kotulek SR, Diver TE and Hartos JL*

Department of Physician Assistant Studies, University of North Texas Health Science Center, USA

*Corresponding Author:
Hartos JL
Department of Physician Assistant Studies
University of North Texas Health Science Center, USA
Tel: 817-735-2454
Fax: 817-735-2529
E-mail: [email protected]

Received date: November 13, 2017; Accepted date: January 30, 2018; Published date: February 6, 2018

Citation: Goodell HE, Van Noy AE, Zarker KM, Kotulek SR, Diver TE, et al. (2018) Does Alcohol Misuse Differ by Gender and Veteran Status in Adults ages 25 and Older? J Prev Med Vol.3 No.1:7..doi: 10.21767/2572-5483.100028

Copyright: © 2018 Goodell HE, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.

 
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Abstract

Purpose: Research shows conflicting findings for prevalence of alcohol use, binge drinking, and heavy drinking between veteran males and females, and as compared to civilians. The purpose of this study was to assess whether alcohol use, binge drinking, and heavy drinking differ by veteran and gender status in adults ages 25 and older in the general population.
Methods: This cross-sectional analysis used 2015 data from the Behavioral Risk Factor Surveillance System (BRFSS) for males and females ages 25 and older in Alaska, Maine, Montana, Oregon, and South Carolina. Separate multiple logistic regression analyses by state were used to assess patterns in relationships between alcohol outcomes and veteran and gender status while controlling for demographic factors, depression, and tobacco use.
Results: About half of male and female adults 25 and older reported alcohol use, and few reported binge drinking or heavy drinking. Across all states, both veteran and nonveteran males reported more alcohol use and binge drinking than female non-veterans. In addition, binge drinking and heavy drinking showed moderate to high relations to smoking in all 5 states.
Conclusion: The results of adjusted analyses indicated that in all five states, alcohol use and binge drinking differed significantly by veteran and gender status. In addition, binge drinking and heavy drinking were significantly related to smoking in all 5 states. For adults ages 25 years and older in a primary care setting, providers may expect a moderate prevalence of alcohol use, and low prevalences of binge drinking, heavy drinking, and smoking. Standard of care is to automatically screen for alcohol use and tobacco use in all patients. However, if signs of either alcohol misuse or smoking are present, especially among males, providers should consider screening for alcohol misuse.

Keywords

Prevalence of alcohol; Behavioral risk factor; Veteran and gender status; Depression; Tobacco use

Introduction

Excessive alcohol use leads to about 88,000 deaths in the United States each year, and shortens the life of those who die by almost 30 years. In addition, excessive drinking costs the United States $249 billion in 2010 [1]. Alcohol use disorders are one of the most common and expensive of all health conditions among US veterans [2].

Research has shown that alcohol misuse is related to demographic and health factors within United States military personnel and veterans. For example, military personnel who are married are less likely to have alcohol use disorders than those who are separated or divorced [3]. In addition, military personnel and veterans with less education and lower income levels are more likely to have alcohol use disorders [3,4]. Furthermore, in U.S. veteran males, non-Hispanic blacks have the highest incidence of alcohol use disorders, followed by Hispanics, then non-Hispanic whites with the lowest prevalence; however, in veteran women, Hispanics had the lowest prevalence of alcohol use disorders [5]. Other research shows that active duty personnel and veterans with mental health issues such as depression, anxiety, and PTSD, as well as those who use tobacco are at increased risk for alcohol misuse [4,6-10].

Veteran and gender status may also be related to alcohol misuse. For example, research shows that veteran and nonveteran female rates of alcohol use and misuse are similar [7]; however, other research indicates that veteran males may be less likely to report binge drinking but more likely to report heavy drinking than non-veteran males [8]. Additionally, research indicates that veteran males may be more likely than veteran females to report heavy drinking [9]; however, other research indicates that gender is not significantly related to prevalence of alcohol use [10].

In addition to the limited studies and conflicting findings, much of the research assessing alcohol use and misuse in U.S. veterans uses data from veteran services [5,7]. As such, prevalence for alcohol misuse between male and female veterans and between veterans and civilians in general populations may be unclear. This information would be useful for identifying at-risk groups not utilizing veteran services so that early interventions can be implemented. Therefore, the purpose of this study was to determine whether alcohol use, binge drinking, and heavy drinking differ by veteran and gender status in U.S. adults ages 25 and older in the general population.

Methods

Design

This cross-sectional analysis used data from the 2015 Behavioral Risk Factor Surveillance System (BRFSS) [11]. BRFSS is a system of health-related telephone surveys using random digit dialing techniques conducted by the CDC that collect state data about U.S. residents regarding their health-related risk behaviors, chronic health conditions, and use of preventive services. BRFSS collects data in all 50 states as well as the District of Columbia and three U.S. territories and completes more than 400,000 adult interviews each year.

Sample

The sample included veteran and non-veteran males and females ages 25 and older in Alaska (N=3451), Maine (N=8745), Montana (N=5742), Oregon (N=5059), and South Carolina (N=11005). These states were chosen because of their higher percentages of veterans and of reported binge and heavy drinking than other states [11]. This study was given exempt status by the Institutional Review Board at The University of North Texas Health Science Center.

Data

Alcohol outcomes included alcohol use, binge drinking, and heavy drinking. Alcohol use was measured as yes/no having had at least one drink of alcohol in the past 30 days. Binge drinking was measured as yes/no having had 5 or more drinks on one occasion for males and 4 or more drinks on one occasion for females in the past 30 days. Heavy drinking was measured as yes/no having had more than 14 drinks per week for males and more than 7 drinks per week for females in the past 30 days. The factor of interest, veteran and gender status was categorized as non-veteran female, veteran female, non-veteran male, or veteran male.

Control variables included age, education level, income level, marital status, race, depression, and tobacco use. Age was categorized as 25-34, 35-44, 45-54, 55-64, and 65 and older. Education level was dichotomized as “graduated college or technical school” or “did not graduate college or technical school.” Annual income level was categorized as “$0 to less than $25,000,” “$25,000 to less than $50,000,” or “$50,000 or more.”

Marital status was categorized as “married” or “not married.” Because the vast majority of participants were white, race was categorized as “white, non-Hispanic” versus “other.” Depression was measured as “ever” or “never” in response to the BRFSS question, “Have you ever been told that you have a depressive disorder, including depression, major depression, dysthymia, or minor depression?” Tobacco use was measured as “current smoker” versus “non-smoker.” Descriptive statistics and categories for all variables are shown in Table 1.

Variables Alaska N=3451 Maine N=8745 Montana N=5742 Oregon N=5059 South Carolina N=11005
N % N % N % N % N %
Alcohol use (Total) 3313 96 8447 97 5551 97 4768 94 10575 96
Yes 1790 54 4820 57 2976 54 2824 59 4674 44
No 1523 46 3627 43 2575 46 1944 41 5901 56
Binge Drinking (Total) 3267 95 8393 96 5494 96 4726 93 10470 95
Yes 497 15 925 11 728 13 584 12 1072 10
No 2770 85 7468 89 4766 87 4142 88 9398 90
Heavy Drinking (Total) 3267 95 8403 96 5496 96 4706 93 10457 95
Yes 237 7 607 7 351 6 340 7 570 5
No 3030 93 7796 93 5145 94 4366 93 9887 95
Veteran Status (Total) 3443 100 8737 100 5732 100 5044 100 10971 100
Non-veteran female 1805 52 5090 58 3128 55 2777 55 6255 57
Veteran female 68 2 117 1 75 11 69 1 165 2
Non-veteran male 1070 31 2400 28 1636 29 1504 30 2936 27
Veteran male 500 15 1130 13 893 16 694 14 1615 15
Age (Total) 3451 100 8745 100 5742 100 5059 100 11005 100
25 – 34 456 13 626 7 509 9 510 10 1000 9
35 – 44 495 14 940 11 569 10 615 12 1322 12
45 – 54 709 21 1492 17 868 15 803 16 1859 17
55 – 64 898 26 2301 26 1476 26 1133 22 2486 23
65 or older 893 26 3386 39 2320 40 1998 39 4338 40
Education level (Total) 3431 99 8718 100 5723 100 5025 99 10972 100
Graduated 1333 39 3428 39 2062 36 2052 41 3537 32
Did not graduate 2098 61 5290 61 3661 64 2973 59 7435 68
Income level (Total) 3096 90 7794 89 4724 82 4139 82 9000 82
0 - <$25,000 652 21 2142 27 1274 27 1042 25 2814 31
$25,000 - <$50,000 627 20 2075 27 1428 30 1090 26 2424 27
$50,000+ 1817 59 3577 46 2022 43 2007 48 3762 42
Marital Status (Total) 3420 99 8705 100 5715 100 4978 99 10940 99
Married 1962 57 4887 56 3281 57 2780 56 6007 55
Not Married 1458 43 3818 44 2434 43 2198 44 4933 45
Race (Total) 3361 97 8629 99 5650 98 4944 98 10742 98
White, non-Hispanic 2436 72 8359 97 4962 88 4283 87 7553 70
Other 925 28 270 3 688 12 661 13 3189 30
Depression (Total) 3429 99 8715 100 5711 99 5026 99 10931 99
Ever diagnosed 531 15 1974 23 1114 20 1280 25 2141 20
Never diagnosed 2898 85 6741 77 4597 80 3746 75 8790 80
Tobacco Use (Total) 3348 97 8523 97 5598 97 4829 95 10648 97
Current Smoker 597 18 1255 15 867 15 663 14 1688 16
Non-smoker 2751 82 7268 85 4731 85 4166 86 8960 84

Table 1: Sample characteristics by state.

Analysis

Frequency distributions were used to assess sample characteristics and identify any issues with the distribution of variables. Data from multiple states was used separately to determine patterns among variable relations across similar samples. Multiple logistic regression analyses by state were used to assess the relationship between alcohol misuse (separately for use, binge, and heavy) by veteran and gender status after controlling for demographic factors, depression, and tobacco use.

Any observations with missing data for any variable were removed from the multivariate models. The adjusted results for alcohol outcomes and veteran and gender status are shown in Table 2. All statistical analyses were conducted using R version 3.3.3 (2017-03-06; Copyright (C) 2017 The R Foundation for Statistical Computing).

Models Alcohol Use a Binge Drinking a Heavy Drinking a
AOR 95% CI AOR 95% CI AOR 95% CI
Alaska  -  -  -  -  -  -
Non-veteran female Ref - - Ref - -
Veteran female 0.95 0.53, 1.71 0.84 0.34, 2.06 0.36 0.09, 1.54
Non-veteran male 1.63 1.36, 1.95 2.51 1.99, 3.16 0.92 0.67, 1.26
Veteran male 1.46 1.15, 1.84 1.45 1.03, 2.05 0.53 0.31, 0.88
Maine  -  -  -  -  -  -
Non-veteran female Ref - - Ref - -
Veteran female 0.64 0.42, 0.97 0.76 0.34, 1.69 0.41 0.15, 1.15
Non-veteran male 1.45 1.29,1.63 2.57 2.18, 3.03 0.91 0.74, 1.11
Veteran male 1.47 1.26, 1.72 2.12 1.66, 2.71 0.87 0.66, 1.16
Montana  -  -  -  -  -  -
Non-veteran female Ref - - Ref - -
Veteran female 1.01 0.60, 1.69 0.79 0.33, 1.89 0.23 0.32, 1.67
Non-veteran male 1.58 1.37, 1.83 2.36 1.94, 2.86 1.28 0.98, 1.68
Veteran male 1.29 1.08, 1.54 1.87 1.43, 2.45 1.12 0.79, 1.60
Oregon  -  -  -  -  -  -
Non-veteran female Ref - - Ref - -
Veteran female 1.82 0.98, 3.39 1.54 0.68, 3.48 1.39 0.61, 3.61
Non-veteran male 1.3 1.11, 1.53 1.84 1.49, 2.28 1.65 0.64, 1.13
Veteran male 1.29 1.05, 1.59 1.78 1.30, 2.45 1.44 0.66, 1.81
South Carolina  -  -  -  -  -  -
Non-veteran female Ref - - Ref - -
Veteran female 1.03 0.72, 1.49 0.5 0.23, 1.10 1.39 0.69, 2.82
Non-veteran male 1.72 1.54, 1.92 2.54 2.17, 2.98 1.65 1.34, 2.03
Veteran male 1.7 1.49, 1.95 2.05 1.65, 2.56 1.44 1.10, 1.88

Table 2: Results of multiple logistic regression for alcohol outcomes by state.

Results

Descriptive

Participant characteristics are shown in Table 1. Across states for alcohol outcomes, about half of participants reported any alcohol use (44-59%), and fewer reported binge drinking (10-15%) or heavy drinking (5-7%). For veteran and gender status across states, about half were non veteran female (52-58%) and far fewer were veteran female (1-11%) or veteran male (13-16%).

Overall, most participants were white, non-Hispanic (70-97%) and ages 45 and older (73-83%), who reported no depression diagnosis (77-85%) or smoking (82-85%). In addition, the majority was married (55-57%), had graduate college or technical school (59-68%), and reported an annual income of $50,000 or more (42-59%).

Adjusted

As shown in Table 2, the results of multiple logistic regression analyses showed that alcohol use and binge drinking differed significantly by veteran and gender status in all five states. Compared to female non veterans, alcohol use was about 1.5 to 2 times more likely to be reported by non-veteran males and by veteran males across states. In addition, across states, binge drinking was about 1.5 to 2.5 times more likely to be reported by non-veteran males and veteran males when compared to nonveteran females. Overall, there was no pattern across states for heavy drinking by veteran and gender status.

The results also indicated that binge drinking and heavy drinking differed by tobacco use in all five states (not shown in Table 2). Compared to non-smokers, current smokers were 2.09 to 2.95 times more likely to report binge drinking (Alaska: OR=2.95, 95% CI=2.27, 3.83, large effect size; Maine: OR=2.45, 95% CI=2.02, 2.97, moderate effect size; Montana: OR=2.09, 95% CI=1.67, 2.61, moderate effect size; Oregon: OR=2.69, 95% CI=2.09, 3.47, large effect size; South Carolina: OR=2.52, 95% CI=2.12, 3.00, large effect size). In addition, current smokers were 2.61 to 3.25 times more likely to report heavy drinking than nonsmokers (Alaska: OR=3.25, 95% CI=2.30, 4.58, large effect size; Maine: OR=2.94, 95% CI=2.35, 3.67, large effect size; Montana: OR=2.61, 95% CI=1.95, 3.49, large effect size; Oregon: OR=3.20, 95% CI=2.34, 4.36, large effect size; South Carolina: OR=2.78, 95% CI=2.23, 3.47, large effect size).

Discussion

The purpose of this study was to assess whether alcohol use, binge drinking, and heavy drinking differed by veteran and gender status in U.S. adults ages 25 and older in the general population. Across the five states, about half of participants reported alcohol use (44-59%), and few reported binge drinking (10-15%) or heavy drinking (5-7%). The results of multiple logistic regression indicated that in all five states, non-veteran males and veteran males were more likely to report alcohol use and binge drinking than non-veteran females, while there were no patterns for veteran females or for heavy drinking. Our findings that alcohol use and misuse differed by gender but not by veteran status in the United States contradict results from previous studies showing that male veterans were less likely to report binge drinking but more likely to report heavy drinking than non-veteran males [8] and veteran males were more likely to report heavy drinking than veteran females [9]. These findings are also inconsistent with research findings indicating that gender was not significantly related to prevalence of alcohol use [10].

Our differing results could be due to variations in the assessment of alcohol misuse, data sources, and target populations [2,7]. Our study used self-reported drink count for veterans and non-veterans in the general population, whereas other research uses patient data from Veterans Affairs and diagnostic criteria for substance abuse [2,5,7]. In their systematic review of substance use rates among veterans, Lan et al. [2] found that research using diagnostic criteria report higher prevalence rates of substance use disorders among veterans than do studies using general questions. However, our results may also support a lowering trend of reported alcohol misuse among veterans. Lan et al. [2] also found that rates of substance abuse among US veterans have declined over time. Therefore, any previous differences in veteran and non-veteran alcohol use, especially by gender, may not be the case any longer. In most research, males report higher alcohol use and misuse rates than females and our results indicate that as well. In addition, current smoking was also found to be significantly related to alcohol misuse (binge and heavy) in this study, which is consistent with prior research [5].

Limitations

The BRFSS data allowed use of large similar general population samples for assessing patterns among variable relations. However, BRFSS data is cross-sectional, lacks in-depth questioning on topics, and is collected through telephone selfreport, which can lead to sample bias, recall bias, and social desirability bias. Interestingly, initial primary care provider information from each patient may be similar—information from patients willing to go for medical care (sample bias) who briefly self-report an overview of their health history, behaviors, and symptoms at one time point (cross-sectional, lack of detail, recall bias, and social desirability bias)—but the provider still has to act on the information provided. With more and more veterans acquiring medical care outside of the Veteran Administration [12,13], our purpose was to assess patterns of relations over similar samples to add to the evidence from which to base medical questioning and decision-making about whether or not veteran status should be a strong consideration for alcohol misuse in general practice.

Additionally, the BRFSS data did not include variables such as physical violence, sexual trauma, PTSD, and other mental health disorders, which were found in previous studies to be related to substance use for veterans [7,10,14-16]. Research indicates that if substance use problems are related to trauma, then treating substance use independently will not be as successful as providing integrated care for trauma and substance use [14-16]. Trauma may be related to alcohol use in civilian populations was as well, so future research should include trauma-related factors in assessing differences in alcohol outcomes among veterans and non-veterans in the general population. Furthermore, there were very small percentages of female veterans in this study. Future research assessing differences in alcohol outcomes by veteran and gender status needs to include more female veterans from the general population.

Conclusion

The results of this population based-study may be generalizable to adults ages 25 and older, including veterans and non-veterans, in a primary care setting. For this target population, there may be moderate levels of alcohol use (44-59%) and low levels of binge drinking (10-15%), heavy drinking (5-7%), and smoking (14-18%). This study found significant and consistent patterns across multiple samples that indicate that both veteran and non-veteran males may be more likely to report alcohol use and binge drinking, and that current smokers are more likely to report binge drinking and heavy drinking. For primary care providers, the standard of care is to screen automatically for alcohol and tobacco use in all patients. However, if signs of alcohol or tobacco use are present, especially in males, providers should consider a more in-depth screen for alcohol misuse. Patient education and resources for substance use treatment should be provided as needed and providers should be aware of veteran services in their area. In addition, primary care providers may also want to screen for unresolved past trauma so that any co-occurring mental health and substance issues can be identified and referrals can be made to integrated care settings.

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