Journal of Studieson Alcohol, Vol. 52, No.

6, 1991

Use of the CAGE Scale in a Population Survey

of Drinking*
REGINALD G. SMART, PH.D., EDWARD M. ADLAF, M.A., AND DELLA KNOKE, B.A.
Addiction Research Foundation, 33 Russell Street, Toronto, Ontario M5S 2S1, Canada

ABSTRACT. This article examines the use of the CAGE scale, a

drinkers who consumefour or more standarddrinks daily, derived

4-item self-reportscreening
testdesigned
to identifyproblemdrinkers, among703 drinkersaged18 andover interviewedin a general
populationsurvey.The resultsshowedthat 10.9% of drinkersreportedtwo or moreitemsaffirmatively,the suggested
cut-offindicative of problemdrinking.This rate is similarto the percentage
of

from aggregate
per capitaconsumption
estimates.Factoranalysisof
the items showeda unidimensional
scalewith good psychometric
properties.Other cut-offs are also comparedwith other alcoholism
estimates.In general,the resultsindicatedsomeutility of the CAGE
in generalpopulationsurveys.(J. Stud. Alcohol52: 593-596, 1991)

HECAGESCALE
(anacronym
forcutdown,
annoy,

guilty and "eye opener") is a 4-item, self-report

screeningtest designedto identify alcoholics(Ewing and
Rouse, 1970; Mayfield et al., 1974). Since its validation
in 1974 (Mayfield et al., 1974), the CAGE has been used
in a variety of researchand clinical situationsto identify
alcoholicsand other typesof problemdrinkers.The advantagesof the CAGE have been its brevity and a high
level of clinical validity. Despitetheseadvantages,it has
not been used much in generalpopulationsurveysabout
drinking. In this article, we briefly examineits use in
sucha survey,includinginformationon the proportionof
drinkersclassifiedas problemdrinkersat various cutoff
points,the relationshipbetweenthe proportionsof CAGEidentifiedproblemdrinkersandthosederivedfrom survey
estimates and the Jellinek estimation formula.

The CAGE was developedas a short, easily administered, valid screeningtest. It has clear advantagesin
length over the MAST (25 items), Mortimer-Filkins(58
items), SADQ (33 items) and DSM-III derivatives(e.g.,
criteria for PsychoactiveSubstanceDependenceincludes
at least 10 items). Most validation studies with clinical
sampleshave indicatedthat the CAGE identifies most
known alcoholics.For example, Mayfield et al. (1974)
foundthat a cuttingpoint of two or more affirmativeresponsesgave a correlationof .89 with clinical diagnosis
of alcoholism. Another study on an orthopedic surgery
service(Beresfordet al., 1982) found that, of CAGE pos-

Received:September22, 1989. Revision:January22, 1990.

*The views expressedin this article are thoseof the authorsand do
not necessarilyreflect thoseof the AddictionResearchFoundation.
593

itives (2+ items), 97% were alcoholics.Similarly, of patients in an alcoholicrehabilitationservice(Ewing, 1984),

those answering2+ CAGE items affirmatively included
all of the acknowledgedalcoholics, 97% of the heavy
drinkers,92% of thosewho deniedalcoholismand only
4% of the nonalcoholics.Similar results were found by
Bush et al. (1987) for alcoholic patients admitted to an
orthopedicand medical service.
Despitethis discriminatingability, someproblemshave
been noted with the CAGE when comparedwith other
tests. For example, Bernadt et al. (1984) found that the
CAGE

had a lower discriminant

MAST

and identified

25%

function

of normal

than the brief

drinkers

as false

positives. Also, Mischke and Venneri (1987) found the

CAGE was poor at discriminatingproblem drinkers in a
driving-while-intoxicatedassessment
center. Whereas the
MAST identified 85% of problemdrinkersas definedby
counselors,the CAGE identified only 60%. Saunders
and Kershaw(1980) found that the CAGE identified only
57 of 129 problem drinkers found in hospital records
and later interviewed. This finding must be considered
carefully, however,becauseof two problems:the cut-off
score used for the CAGE is not given and the CAGE
was administered18-24 months after the diagnosisof
alcoholproblems,whereasin most validity studiesit is
administeredat about the same time as the diagnosisis
made.

To date, no study has examinedthe use of the CAGE in

a general population survey and compared results with
otheraggregateestimatesof alcoholproblems.In a survey
application, the CAGE may be useful not as a clinical
screeningdevice, but as a meansof measuringa dimension of alcohol problemsamong the general population.

594

JOURNAL

OF STUDIES

ON ALCOHOL

This article reportsits use in sucha studyand providesa

factoranalysisand comparisons
with aggregateindicesof

/ NOVEMBER

TABLE1. CAGE itemsand scoresby sex amongdrinkersin Ontario,

in percent

alcoholism.

Male

Item
Method

We employdata gatheredfrom a surveyof 1,092 persons aged 18 and over personallyinterviewedin early
1989. The responsesanalyzedhere include 703 drinkers
(350 female and 353 male), representing83% of the total
sample.Drinkersare thosewho reporteddrinkingduring
the 12 monthsprior to the survey.The survey,fielded by
the Gallup Organization,maintainsa modifiedprobability
sample in all areas over 1,000 in population. A quota
sampleis used in rural farm and rural nonfarmcenters.
The samplingprocedure,designedto producean approximation of the adult civilian population, 18 years of age
and older and living in Ontario (exceptfor thosepersons
in institutionssuch as prisonsor hospitalsor those residingin far Northernregions),incorporates
stratification
by six community-sized
groupsbasedon mostrecentcensusdata:citiesof 500,000 populationand over;thosebetween 100,000 and 500,000; 30,000 to 100,000; 10,000
to 30,000; 1,000 to 10,000; and rural and nonrural farm

areas.Within theseclassifications,the populationis arrayed, by censusenumerationareas, in geographicorder

by community size. Enumerationareas, on the average,
containabout500 to 1,000 people.A total of 210 enumeration areasare selectedrandomlyfrom this array. Within
urban centers, a random block sampling procedure is
usedto selectstartingpointsfor interviewers.Within the
household,the youngestman 18 years of age and over
and at homeat the time of the interview is questioned.If
thereis no man available,or whenthe male quotais completed, the youngestavailablewoman 18 years and over
is interviewed.

The designof the Gallup poll sampleis basedon population statistics of the census of Canada which are also

employedso that the age-by-gender

distributionreflects
the Ontario adult population.The data are weightedto
proportionately
reflect this populationdistribution.
The questionnaire
itemsof interestto us hereare those
on frequencyof drinkingin the past12 months,frequency
of drinkingfive or moredrinkson a singleoccasionin the
past 12 monthsand the four CAGE items. For the CAGE
items, individualsrespondedpositivelyor negativelyto
the followingquestions:
(1) Haveyoueverfelt the needto
cut down on your drinking?(2) Have you ever felt annoyedby criticismof your drinking?(3) Have you ever
felt guilty aboutdrinking?(4) Did you evertake a morning eye opener?A scoreof two or more affirmative answersyields a positiveCAGE score.All data are derived
from respondents'
self-reports.

1991

(n = 353)

Female

Total

(n = 350)

(n = 703)

121
50

11.0
4.2

49
19

18.9
7.7

171
69

85
41

6.3
2.3

29
10

12.6
5.6

114
51

Cut down
Criticized

26.7
11.1

Guilty
Morning

18.8
9.0

0
1
2

61.2
21.6
9.5

277
98
43

83.4
12.1
3.3

374
54
15

72.3
16.9
6.4

650
152
58

3
4

5.7
2.0

26
9

1.0
0.2

5
1

3.4
1.1

30
10

Mean (- SD)

0.66 _ 1.00

0.23 - 0.57

0.44 _+0.84

score

Results
Overall

CAGE

results

As seenin Table 1, the mostcommonlyendorseditem

was "need to cut down" (18.9% of drinkersagreed),followedby "felt guilty aboutdrinking" (12.6%). The least
commonly endorseditems were sensitivityto criticism
about drinking (7.7%) and morning drinking (5.6%).
Gender differencesare striking: men were two to three
times more likely to report a desire to cut down, being criticizedfor drinkingand feelingguilty aboutdrinking and aboutfour times more likely to reportmorning
drinking.

In total, 10.9% of drinkers(9.0% of the total sample)

had a CAGE positivescore(i.e., responded
affirmatively
to two or more items). Only 4.5% had a scoreof threeor
more. Again men were more likely than women to be

CAGEpositive
(17.2%vs4.5%,respectively)
(X2 = 28.94,
4 df, p < .0001). All itemswerehighlyandsignificantly
intercorrelatedwith an averagetetrachoriccorrelationof
.580 md rangein valuesfrom .448 (morning-cutdown)to
.786 (guilty-cutdown).
In orderto examinethe psychometric
propertiesof the
CAGE scale, we factor analyzeditems with tISCOM,,
a
computerprogramthat providesa weighted(generalized)
leastsquaressolutionespeciallysuitedfor skewed,dichotomousitems(Muthen, 1987).With respectto age(not tabled), the percentagereporting CAGE positive varied

minimallybetweenthe agesof 18 and49 (12.6% among

18-29 yearolds, 11.2% among30-39 and 15.4%among
40-49), but declinedthereafter(7.9% among50-64 year
olds and 5.3% among65 and over). Only one factorthat

showed
a significant
fit couldbeextracted
(X2= 1.22,2
df, p = 0.54). The factor loadingswere as follows:cut
down.852, annoyed.731, guilty.920 andmorningdrinking .554. Psychometrically,
in our sample the CAGE
itemssuggesta unidimensional
scalewith goodpsychometric properties.

SMART, ADLAF AND KNOKE

T^BLe 2. CAGE scoresfor daily and heavydrinkersin Ontario,
in percent
Drinks

Drinks daily
(n = 90)

CAGE score
0
I
2
3
4

Mean (- SD) score

or morepositiveanswers(3.4%). Furthermore,respondentsscoringthreeor moreare alsomuchmorelikely to

reportdaily drinkingandfrequentheavydrinking.

or more

Drinks

drinks at

or more

a sittinga
(n = 487)

drinksweekly
(n = 101)

53.2
23.8
12.1
8.8
2.1

58.6
24.0
9.3
6.0
2.0

34.8
26.0
18.1
14.6
6.4

0.83 +- 1.09

0.69 +- 1.01

1.31 - 1.27

Table 2 relates CAGE positive scoreswith indicesof

heavy drinking. Obtaininga scoreof 2 or more was not
commonamongdaily drinkers(23%) or amongthosewho
drank five or more drinks at a single sitting (17.3%).
However,39.1% of thosewho drank heavily (5+ drinks)
and regularly(at leastoncea week) were CAGE positive.
CAGE scoreswerealsosignificantlycorrelated(p < .001)
with frequencyof drinking (r = 0.28) and frequencyof
consumingfive or more drinks (r = 0.45).
Comparisonof CAGE and aggregateestimates
In Table 3, we comparethe CAGE estimateswith two
aggregatemethodsof indicatingthe level of alcoholproblems.

Rush(1987) hasusedsurveydataon alcoholconsumption and per capita consumptionfor Ontario to generate

estimatesof the proportionsof Ontariodrinkersconsuming oneto eight or moredrinksper day. Someof the data
from this studyare shownin Table 3 for 1985-6, the last
year for which estimatesare available.(Since per capita
consumptionis essentiallystablein Ontario, there should
be no real changebetween1986 and 1988.) About 11.9%
drinkers consumed about four or more drinks

per day, a figure that is comparableto the 10.9% identified by the CAGE (2+ positive).About 3.9% of Ontario

drinkersconsumein excessof eight drinks per day, an

amount exceededby most alcoholics.This is about the
proportionidentifiedby the CAGE, usinga cutoffof three
T^BIe 3. Estimatesof CAGE and other alcoholproblem methods
amongdrinkersin Ontario
Year

Estimates

Measure

1985-6

(%)

Rush4 or more standarddrinks/day

Rush 6 or more standarddrinks/day
Rush 8 or more standarddrinks/day

1985-6
1985-6
1985-6

11.9
6.4
3.9

1989
1989
1989
1989

2.3
10.9
3.4
I. 1

Jellinek estimation formula

CAGE estimate score of 2+
CAGE estimate score of 3+
CAGE estimate score of 4+

Table 3 also shows that about 2.3% of Ontario drinkers

would be expectedto be alcoholicsusing the Jellinek estimate. This is slightlylower than the estimatefor drinkers consumingeight or more drinksdaily and closeto the
estimateof problemdrinkerson the CAGE, usinga cutoff

of three or more positiveanswers(3.4%). One possible

explanationfor the higher rate basedon the CAGE estimates is its focus on lifetime rather than current alcohol

problems.

aAt least onceper year.

of Ontario

595

Summary and Discussion

The useof the CAGE scalein a generalpopulationsurvey indicatesthat about10.9% of drinkershad drinking
problemsas determinedby two or more positive responses.
Problemsweremorelikely to occuramongmen
and heavydrinkers.The factoranalysisindicatesthat the
fourCAGEitemsmeasure
a singledimension,
presumably
problemdrinking, and exhibit good internalreliability.
Comparisons
with surveyandper capitaconsumption
data
suggestthat the CAGE cutoff of two positive answers
identifiesheavydrinkersconsumingaboutfour drinksper
day. A cutoff of three or more positive answersgives
overallpercentages
that are comparableto thosefor drinkers takingeightor moredrinksdaily but somewhathigher
than the proportionof alcoholicsfound with the Jellinek
formula.

In general,the resultsshowsomeutility of the CAGE

in generalpopulationsurveys.The resultsobtainedare
consistentwith expectationsfrom other methods,and the
CAGE seemsto reliably tap a singleproblem-drinking
factor.Moreover,the CAGE is easyto self-administer
and

is shorterthanmostscreening
tests.Threeareasof inquiry
are suggestedby this research.First, more extensivesurvey work with differentpopulations(e.g., youngpersons,
heavyusers,etc.) shouldbe undertaken
to furtherclarify
the valueof the CAGE in generalsurveys.Second,there
is a need to externallyvalidateCAGE positivecasesto
someexternalcriteria,suchas is donein clinicalsettings.
And finally, more researchneedsto examinethe CAGE's
possibleover-estimation
of alcoholproblemsdue to its focus on lifetime prevalenceof problems.
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