Introduction

Alcohol has been widely used in many cultures for centuries, but it is associated with significant health risks and harms. Drinking alcohol is associated with risks of noncommunicable diseases such as different types of cancers, liver diseases, heart diseases, mental health, depression, anxiety, and alcohol use disorders [1]. Driving under the influence of alcohol (drink-driving) is a key risk factor for 27% of all road injuries, and road traffic crashes are the leading cause of death among people aged 15–29 years [2].

Risky consumption of alcohol means drinking above the recommended daily, weekly, or per-occasion amounts but not meeting criteria for alcohol use disorder [3]. The level of risk of alcohol-related harm depends on the amount consumed, frequency of drinking, the health status of the individual, age, gender, and other personal characteristics, as well as the context in which alcohol consumption occurs [1]. Binge drinking or high volume consumption over a short time, or excessive alcohol use, increases the risk of injuries, poisoning, violence [4], chronic disease, learning memory problems [5,6], increases the likelihood of unsafe sexual behavior and the risk of sexually transmitted infections and unintentional pregnancy, also increases the likelihood of a falls, burns, drownings, and car crashes [7]. Binge drinking is defined as consuming 4 or more drinks for women and 5 or more drinks for men on a single occasion [5,6].

According to research data on the burden of disease, alcohol consumption in Serbia is the eighth of the ten most common risk factors for premature mortality and disability [8].

In Serbia, drinking alcoholic beverages is a widely accepted social behavior, and alcohol use is deeply rooted in our society, and it is a part of most social rituals [9]. Although alcohol causes many health problems [1], data from the Serbian National Health Survey (SNHS) showed that approximately half of the population aged 20 and over consumed alcohol occasionally or daily, and that in the period from 2000 to 2019, there were no major changes in the frequency of drinking this substance. Of concern is the increasing number of adolescents who have engaged in binge drinking in the previous 30 days in the reference period [10]. Despite this, Serbia does not have a formal national policy or National action plan for alcohol prevention [11].

In general population samples, alcohol use tends to vary along demographic, health, and social characteristics [12]. Factors influencing levels and patterns of alcohol consumption can be at the individual level and the societal level. Personal factors include age, gender, family circumstances, and socioeconomic status; societal factors include economic development, culture, social norms, and availability of alcohol [1]. Females are less often current drinkers than males, and when they drink, they consume less alcohol [11], therefore, contributing factors for alcohol use are male gender [13,14], smoking [13–15], being single, being young adults [14], and low level of education [13,16]. Moreover, in England, factors such as retirement, income, and marital status were also associated with high-risk alcohol consumption for people over 50 [17]. Evidence about the influence of socioeconomic status on drinking behavior is inconsistent in the literature [16,18,19]. Rates of alcohol use are higher for urban than rural residents, and rates of alcohol use disorder tend to be similar across rural and urban environments [20]. Alcohol is often consumed before, along with, or after other psychoactive substance use, and the comorbidity of alcohol and tobacco dependence is strong and well documented [11].

These patterns have been documented internationally, and we want to understand how they manifest in specific national contexts, which is essential for developing effective public health responses.

The Autonomous Province of Vojvodina (APV) is the northern Province within the Republic of Serbia, and daily alcohol consumption in Vojvodina is among the highest in Serbia [21]. To the best of our knowledge, there is little research in the literature about the prevalence and predictors of binge drinking in Serbia. Examining predictors of binge drinking could be used to target at-risk groups or to conceptualize intervention and prevention strategies for reducing risky alcohol use, which is a public health priority.

In this study, we examined the association between binge drinking and sociodemographic characteristics as well as health-related lifestyle factors among the adult population in Autonomous Province of Vojvodina.

Methods

Results

This cross-sectional survey included 3,910 persons, aged 18 and over, who were beneficiaries of primary health care, in APV, Serbia, in 2024. The average age of the respondents was 49.3 years (SD = 17.5). Among the respondents, the female population was 51.8%. Out of a total, 60.2% of respondents lived in urban settlements. According to marital status, more than half of the respondents stated that they live in marriage or live with their partner (57.3% of females and 61.7% of males). Out of the total, 19.7% of the respondents stated that they had never married, 15.3% were female, and 24.4% male. The largest percentage of residents has a secondary education (59.3%). According to the self-assessment of material status, the largest number of respondents indicated an average material status (46.2%). At the time of the survey, more than half of the respondents (61.6%) were employed or self-employed, while 32.6% were not in the labor force (27.0% of males and 37.8% of females). Smoking prevalence was 35.2%, and it was more prevalent among males than females (39.4% vs. 31.3%). There was 31.3% of the physically inactive population (29.2% of males and 33.3% of females). In APV in 2024, 45.8% of the population drank alcohol in the last 30 days (Table 1).

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Table 1. Sociodemographic and health-related lifestyle characteristics of respondents, Autonomous Province of Vojvodina (АPV), Serbia, 2024 (n = 3,910).

https://doi.org/10.1371/journal.pone.0350125.t001

The prevalence of binge drinking in 2024 was 19.3% (95%CI 18.0–20.7). There were statistically significant differences in the percentage of binge drinkers among different sociodemographic groups aged 18 years and older. The highest prevalence was recorded in males (31.4%; 95%CI 29.1–33.7), the age 18–34 years (26.1%; 95%CI 23.1–29.3), in never-married persons (27.6%; 95%CI 24.3–31.2), and in the population with secondary education (20.4%; 95%CI 18.7–22.3). The highest percentage was also recorded in the employed population (23.8%; 95%CI 22.0–25.7), while the lowest was in the category not in the labor force (10.6%; 95%CI 8.9–12.5). The highest rate of binge drinkers was among smokers (31.1%; 95%CI 28.4–33.8), and among those who were not physically inactive (21.4%; 95%CI 19.7–23.1). In the respondents from rural settlements and among respondents with very good material status, the prevalence was the highest, but there was no statistical difference (Table 2).

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Table 2. Prevalence of binge drinking by sociodemographic and health-related lifestyle characteristics of respondents in AP Vojvodina, 2024.

https://doi.org/10.1371/journal.pone.0350125.t002

Males were four times more likely to be binge drinkers (OR=4.3; 95% CI = 3.5–5.2; p < 0.001), and younger respondents had a higher chance of being binge drinkers than those who belonged to the category 65 and over (p < 0.001). The females respondents in the category never married were two times more likely to be binge drinkers (OR=2.1; 95% CI = 1.4–3.5; p = 0.002), than those who belong to the category married/living with a partner and females with poor and very poor material status had similary elevated odds compared to females with very good or good material status (OR=2.1; 95% CI = 1.2–3.9; p = 0.014). Higher odds of binge drinking were found in females who were former smokers (OR=1.8; 95% CI = 1.1–3.3; p = 0.033), while smokers had almost three times higher odds of being binge drinkers (OR=2.8; 95% CI = 2.3–3.5; p < 0.001), and considering gender- stratified odds ratios, this was relevant for both genders. Regarding physical inactivity, male respondents who were not physically inactive had higher odds of being binge drinkers (OR=1.7; 95% CI = 1.3–2.2; p < 0.001). Lower odds of binge drinking were observed among unemployed females compared to those who were employed or self-employed females (OR=0.4; 95% CI = 0.2–1.0; p = 0.036) (Table 3).

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Table 3. Binge drinking in AP Vojvodina according to the sociodemographic and health-related lifestyle factors and multivariable binary logistic regression (gender-stratified odds ratios), 2024.

https://doi.org/10.1371/journal.pone.0350125.t003

Discussion

The findings of this study present the data from the new behavioral factors surveillance system on the subnational level, in APV, Serbia (“SBRF-NCD-V”). In our work, we wanted to identify sociodemographic and health-related lifestyle factors that are important covariates of binge drinking. The findings of this study align with drinking rates previously reported in the SNHS conducted in 2019, where almost 50% of the population drank alcohol [21]. According to the results of the surveillance carried out in Italy that applied the same methodology, 57.9% of respondents consumed alcohol in the 30 days before the survey [28], while according to the latest available results of the BRFSS survey in the US, that percentage was 53.4% [29]. The determined prevalence of binge drinking in 2024 in Vojvodina was 19.3%. These results showed a higher prevalence of binge drinking in comparison with SNHS, where at least once during the month, in the last 12 months, 10.9% of the population of Serbia drank more than six alcoholic drinks on one occasion, 18.3% of men and 4.5% of women [21]. In neighboring countries, using the same methodology as SNHS, that percentage is somewhat higher, reaching 12.6% in the Republic of Croatia [30] and 20.3% in the Republic of Slovenia [31].

Another study in Serbia has revealed that the prevalence of binge drinking in 2014, was 28.4%, and the highest rate was in APV, where every third person was a binge drinker [32]. The different results in our research can be explained by the methodology differences (mostly because of differences in study design and criteria cut-off, such as age limit or observed drinking period). In the literature, there are different but similar indicators for calculating the prevalence of binge drinking. For example, the World Health Organisation (WHO) defines binge drinking as consuming six or more standard drinks on at least one occasion in the last three months [33], and National Institute on Alcoholism and Alcohol Abuse (NIAAA), defines binge drinking as drinking 4 drinks for women and 5 drinks for men in about 2 hours [7]. This discrepancy may also be attributed to differences in sampling methodology, as our sample is based on beneficiaries of compulsory health insurance across all PHCs in APV. The prevalence of binge drinking in our results compared to research that applied the same methodology of drinking patterns is higher than in the United States (US) where 17% of the population were binge drinkers, and in Italy, where 9.6% population was binge drinkers [28,29], but less than in Peru (22.4%) [18].

This research shows that the statistically more binge drinkers in 2024 were among men, younger people, those who have never been married, those with a secondary level of education, those who are employed, smokers, and those who were not physically inactive. Across models, the strongest predictors of binge drinking were male gender and current smoking. Males had several times higher odds of binge drinking, which is consistent with other research [18,32,34–37]. Biological as well as cultural differences are among the main drivers of these differences that need to be further studied [38]. The highest frequency of binge drinking has been found among younger population groups; the odds for binge drinking decrease with age, where adolescents and young adults are the population group at the highest risk of this behaviour, which is consistent with results from Peru, Italy, Spain, and Ontario, Canada [18,28,39,40]. In our research, never-married females had almost 2 times higher chances of binge drinking, compared to married females. Our study confirmed findings that single persons have higher odds of binge drinking [32], but in our research, like in Peru, that is only in females [18]. Research conducted among adults aged 50 and over in 28 European countries and Israel showed that men not living with a spouse, compared to married men, had a higher likelihood of hazardous alcohol use, while in women, widowhood was associated with a lower likelihood of this behavior [36].

The inconsistencies of these results with our research could be explained due to the methodology differences, because in our study, we combined a group of divorced individuals with those who were separated, and a group of married individuals with those living with a partner.

In our study, the higher prevalence of binge drinking was in rural than in urban settlements, although the association was not significant. Similarly, another study conducted in Serbia found no significant association between binge drinking and the type of settlement [32]. In contrast, studies conducted in Ontario, Canada, and Spain revealed that binge drinking was associated with living in rural areas [39,40], while research conducted in several European countries found that living in non-rural residences increased the likelihood of at-risk drinking (Norway, Denmark, and Belgium) [37]. Rates of alcohol use and alcohol use disorder vary with geographic location. Research on risks for alcohol use between rural and urban settings is complicated by the varied systems used to classify locations [20], which may explain differences between our results and those in the literature. Studies comparing the prevalence of heavy or binge drinking based on a dichotomous urban/rural classification have mixed findings when compared with those using more detailed urban-to-rural categories [20].

Regarding education, our findings suggest that the highest percentage of the population who are binge drinkers was among those with secondary education, but in models, educational status wasn’t a predictor of binge drinking, which is consistent with research conducted in Serbia in 2014 [32]. However, research conducted in Ontario, Canada, has shown that lower educational attainment was associated with binge drinking [39], while in other countries, higher educational attainment was significantly associated with increased risks of binge or other at-risk drinking compared with formal education [18,37]. A recent study suggested that higher educational attainment is associated with a higher frequency of alcohol use but a lower risk for alcohol dependence [41]. It should be acknowledged that educational classifications may vary between countries, which can explain differences in results.

In Ontario, Canada, unemployed people were more likely to binge drink [39], while in our research, results show that unemployed women had less chance of binge drinking than employed women. That can be due to insufficient income. Collins revealed that although groups with greater socioeconomic advantages had similar or greater levels of alcohol consumption than those with fewer advantages, the groups with fewer socioeconomic advantages were at greater risk for alcohol-related problems [12], which can explain why women with poor material status in our results had a higher chance of binge drinking than women with good material status. Research conducted in Serbia in 2014 found no association between binge drinking and self-assessment of socioeconomic status [32], while in Peru, higher income was significantly associated with binge drinking, especially in women [18]. Other research found that binge-drinking prevalence was highest among those with the highest income, but frequency and intensity were highest among those with the lowest income [42]. These differences may be partly explained by differences in the methods used to assess socioeconomic status.

In our research, male respondents who were not physically inactive had higher odds of being binge drinkers. Individuals who drink heavily may engage in frequent physical exercise to compensate for the extra calories gained through drinking or to counterbalance the negative health effects of drinking [43]. Another study found that participants engaging in strengthening and team sports were more likely to binge drink more frequently in the past 30 days than inactive participants [44]. A lifespan study showed that people drank more than usual on the same days that they engaged in more PA than usual [45]. This finding provides insights that alcohol may be used as a reward for being physically active, and, on the other hand, people may be exercising to help offset the caloric intake associated with alcohol use [44]. In our study, we did not analyze the intensity and level of physical activity, which may represent a methodological limitation. In a study conducted on a student population, it was found that among men, strength training is associated with a higher likelihood of binge drinking, whereas this association was not confirmed in women, however, among women, aerobic physical activity was associated with binge drinking. These findings suggest that different forms of physical activity may have distinct patterns of association with risky behaviors [46] A study by Liu et al. also found that this association depends on the type of physical activity—specifically, occupational and transportation-related physical activity are often positively associated with alcohol consumption, while individuals who engage in moderate to vigorous recreational physical activity have a lower likelihood of binge drinking [47].

According to the results of the Behavioral Risk Factor Surveillance System conducted in the United States, the prevalence of binge drinking among smokers is nearly double that of non-smokers [6]. In our study, smokers had almost 3 times higher odds of binge drinking. That follows many results [32,34,37]. The previous study has shown a bidirectional relationship between alcohol and tobacco consumption, where one behavior increases the chance of the other [48]. Female smokers had a higher likelihood of binge drinking compared to males, which follows other research [18,36,49]. Also, women who were former smokers had a higher chance of binge drinking.

Conclusion

The findings of this study presented the second-year data from the newly developed behavioural risk-factors surveillance system on the sub-national level, in the Autonomous Province of Vojvodina, Serbia (“SBRF-NCD-V“), showing that binge drinking occurs in about one-fifth of adults. The sociodemographic factors in the model vary by gender: males, younger, never-married females, females with poor material status, smokers, females who were former smokers, and physically active males are more likely to binge drink, while unemployed women are less likely. To our knowledge, this is the first study that reports the differential impact of factors associated with binge drinking according to gender in Vojvodina.

Future studies should explore social influences, while current findings highlight the need for monitoring and examination of the influencing factors of binge drinking. Identifying socio-demographic factors may inform clinical intervention in primary care settings to screen and support patients who are at risk for or engaged in risky alcohol use.

Acknowledgments

The authors are grateful to the people who agreed to participate in the research, to health professionals in 44 Primary Health Care Centers for their help in recruiting and interviewing respondents, and to the whole team, which includes interviewers, supervisors, and a computer engineer, research scientists from IPHV and Faculty of Medicine of the University of Novi Sad.