Deliberate induction of alcohol tolerance: empirical introduction to a novel health risk (2024)

Abstract

Keywords: Alcohol dependence, heavy drinking, symptom, tolerance, training

INTRODUCTION

Alcohol tolerance, defined as (1) the need for noticeably increased amounts of alcohol in order to achieve the desired effect or (2) diminished effect with continued use of the same amount, is a hallmark diagnostic criterion of alcohol dependence [1–2] and is associated with myriad health risks (e.g. blackouts, morning drinking [3]). Because alcohol tolerance has such negative implications, it is not viewed typically as an attribute that individuals would seek out voluntarily.

Nevertheless, some individuals may pursue acquiring tolerance. In many US colleges, heavy drinking is highly prevalent [4] and often associated with many harmful or even fatal outcomes [5]. However, heavy consumption is sometimes viewed as a social asset, or a way to earn peer admiration via being able to drink more than others before feeling the effects [6]. Thus, rather than working to avoid tolerance, students may practice, or ‘train’ (as an athlete trains for a competitive event), to increase their tolerance for alcohol at heavy drinking events.

Such ‘training’ has not yet been studied empirically, although some entertainment media make reference to the phenomenon [7]. Even so, ‘training’, if it occurred with any frequency in the population, could pose a harmful personal and public health risk. Thus, we initiated an empirical investigation in a sample of 990 US college student drinkers by surveying whether they ever engaged in this behavior. We also surveyed them about the specifics of ‘training’, and we estimated its association with heavy and risky drinking.

METHODS

RESULTS

Ninety-seven individuals (9.9% of the sample) reported having ‘trained’. Men were more likely than women to ‘train’ [odds ratio (OR) = 3.68, 95% confidence interval (CI) = 2.31–5.89], and Greeks were more likely than non-Greeks to ‘train’ (OR = 1.78, 95% CI = 1.17–2.73). There were no group differences in ‘training’ status as a function of age, class year or race. During ‘training’, students reported increasing drinking from approximately seven–10 to 12–15 standard drinks in a night over approximately 2–3 weeks (t 90 = 11.90, P < 0.001); for women, five–six to nine–11 (t 21 = 9.18, P < 0.001) and for men, eight–11 to 12–17 (t 68 = 9.37, P < 0.001).

Table 1 shows additional characteristics of ‘trainers’. For example, individuals endorsed ‘training’ for a number of events and reasons, with a Friday night/weekend being the most popular event, and not wanting to pass out too early being the most popular reason. Individuals reported ‘training’ for an average of three events (range = 0–13, where 22.7% reported ‘training’ for just one event and 67.0% ‘trained’ for three or fewer). Although men were more likely to ‘train’ in general, they were less likely than women to ‘train’ for a birthday (OR = 0.33, 95% CI = 0.13–0.89) or for spring break (OR = 0.37, 95% CI = 0.14–0.93), social events often associated with extremely high consumption [10–11]. These were the only sex differences in events or reasons for ‘training’, and there were no race differences. Greeks, however, were more likely than non-Greeks to ‘train’ for Superbowl (OR = 7.73, 95% CI = 1.59–37.52), a football game (OR = 4.05, 95% CI = 1.54–10.64), birthday (OR = 3.68, 95% CI = 1.40–9.69), spring break (OR = 3.32, 95% CI = 1.36–8.12) and Homecoming (OR = 2.72, 95% CI = 1.01–7.28).

Table 1 also shows that ‘trainers’ are far more at risk than their counterparts for heavy and risky drinking. Notably, the rate of frequent binge drinking in non-‘trainers’ (34.4%) is roughly comparable to the 2-week prevalence of binge drinking in a nationally representative sample of full-time college students (40.0%) [4], while the rate is much higher in ‘trainers’ (76.3%). Differences hold when statistically controlling for sex, race and Greek membership.

DISCUSSION

Our findings indicate that ‘training’ to increase alcohol tolerance is a risky phenomenon in a non-trivial number of college students. Notably, the majority of the sample (95.4%) was under the US legal drinking age (i.e. 21 years), suggesting ‘training’ occurred before students could legally drink. When young adults deliberately induce tolerance, they may increase the risk of alcohol poisoning and may prompt associated symptoms of alcohol dependence [12]. Importantly, these findings are potentially applicable to young adult populations in many countries where heavy drinking is problematic [13] and real or imagined social status is afforded to those who can ‘hold their liquor’.

‘Training’ challenges professional conceptualizations of the desirability of alcohol-related pathology, although it should not be surprising that many youths would want to drink at a party without feeling too intoxicated, sedated or sick. Nevertheless, some of these individuals, rather than moderating drinking to avoid negative consequences (and reduce risk), opt to enhance tolerance and, presumably, increase their likelihood of becoming alcohol-dependent.

Notable limitations of this work can inform future research directions. For example, no ‘training’ questionnaire existed previously, and it could certainly have been more exhaustive (e.g. including questions about drinking games, ‘training’ goals and additional alcohol measures and correlates) and more rigorous (e.g. counterbalancing questions to reduce respondent biases). It did not delineate fully whether ‘training’ is employed for specific events, or for becoming a ‘better’ heavy drinker in general. Furthermore, longitudinal research could capture more effectively ‘training’ processes, drinking behaviors, tolerance increases over time, the durability of induced tolerance and could address the alternative hypothesis that ‘training’ reflects incidental increases in tolerance (and exists merely as a way to rationalize increased tolerance as an intended result). Nationally representative and cross-national studies could help to determine the full scope of the problem, also elucidating whether ‘training’ may be a function of minimum legal drinking age laws.

This phenomenon has clear implications for alcohol intervention efforts. That is, both prevention and treatment interventions might be developed to reduce the appeal of ‘training’, or the perceived importance of ‘badges of honor’ associated with heavy drinking. Similarly, cognitively reframing such ‘badges’ as ‘symptoms’ of dependence might help drinkers to view the dark side of increased tolerance. Educational and feedback-based interventions might incorporate some discussion on this possible paradox for students, that increased tolerance seems beneficial (by presumably allowing more drinking with less sickness) although is indeed quite harmful.

Acknowledgements

This research was supported by grants to Kenneth J. Sher, PhD (K05AA017242 and T32AA013526), Douglas Steinley PhD (K25 AA017456), Julia A. Martinez (F31 AA018590) and Andrew C. Heath PhD (P50 AA11998), from the National Institute on Alcohol Abuse and Alcoholism. All the authors have full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The authors would like to thank Margie Gurwit BA (University of Missouri) for her assistance in data management. The authors would also like to thank Molly Trull (University of Missouri) for her assistance in data collection.

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