Blood alcohol content: Difference between revisions

Blood alcohol content
Blood alcohol content
	Ethanol
Synonyms	Blood alcohol concentration, blood ethanol concentration, blood alcohol level, blood alcohol
LOINC	5639-0, 5640-8, 15120-9, 56478-1

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Revision as of 14:02, 24 June 2024

Blood alcohol content (BAC), also called blood alcohol concentration or blood alcohol level, is a measurement of alcohol intoxication used for legal or medical purposes.^[1]

BAC is expressed as mass of alcohol per volume of blood. In the US and many international publications, BAC levels are written as a percentage such as 0.08%, meaning that there is 0.08 g of alcohol for every 100 mL of blood.^[1]^[2] In different countries, the maximum permitted BAC when driving ranges from the limit of detection (zero tolerance) to 0.08%.^[3]^[2] BAC levels above 0.40% are potentially fatal.^[1]

Units of measurement

BAC is generally defined as a fraction of weight of alcohol per volume of blood, with an SI coherent derived unit of kg/m³ or equivalently grams per liter (g/L). Countries differ in how this quantity is normally expressed. Common formats are listed in the table below. For example, the US and many international publications present BAC as a percentage, such as 0.05%. This would be interpreted as 0.05 grams per deciliter of blood. This same concentration could be expressed as 0.5‰ or 50 mg% in other countries.^[4]

Sign	Units	Used in
1 percent (%), 1 g%^[5]	1 g/dL = 1 cg/mL = 10 g/L = 1 g/100 mL	US, Australia,^[5]^[6] Canada^[7]
1 per mille (‰)^[a]	1 g/L = 1 mg/mL = 100 mg/1 dL	Austria, Belgium, France, Germany, Spain,^[5] Bulgaria, Czech Republic, Latvia, Lithuania, Netherlands, Poland, Portugal, Romania, Russia, Slovenia, Sweden, Switzerland, Turkey^{[citation needed]}
1 mg%^[5]	1 mg/dL = 0.01 g/L = 1 mg/100 mL	United Kingdom^[9] Ireland, Canada, New Zealand^[5]

It is also possible to use other units. For example, in the 1930s Widmark measured alcohol and blood by mass, and thus reported his concentrations in units of g/kg or mg/g, weight alcohol per weight blood. 1 mL of blood has a mass of approximately 1.055 grams, thus a mass-volume BAC of 1 g/L corresponds to a mass-mass BAC of 0.948 mg/g. Sweden, Denmark, Norway, Finland, Germany, and Switzerland use mass-mass concentrations in their laws,^[5] but this distinction is often skipped over in public materials,^[10] implicitly assuming that 1 L of blood weighs 1 kg.^[11]

In pharmacokinetics, it is common to use the amount of substance, in moles, to quantify the dose. As the molar mass of ethanol is 46.07 g/mol, a BAC of 1 g/L is 21.706 mmol/L (21.706 mM).^[12]

Effects by alcohol level

Alcohol level	Effects	Ref
BAC	Effects	Ref	per mille	mg%
0.01–0.05%	0.1–0.5	10–50	Mild relaxation and reduced social inhibition; impaired judgment and coordination	^[13]
0.06–0.20%	0.6–2	60–200	Emotional swings, impaired vision, hearing, speech, and motor skills	^[13]
0.2–0.3%	2–3	200–300	Urinary incontinence, vomiting, and symptoms of alcohol intoxication	^[14]^[15]
0.3–0.4%	3–4	300–400	Potential total loss of consciousness; signs of severe alcohol intoxication	^[14]^[15]
>0.4%	>4	>400	Potentially fatal, may result in a coma or respiratory failure	^[14]^[15]

The magnitude of sensory impairment may vary in people of differing weights.^[16] The NIAAA defines the term "binge drinking" as a pattern of drinking that brings a person's blood alcohol concentration (BAC) to 0.08 grams percent or above.^[13]

Estimation

Direct measurement

Blood samples for BAC analysis are typically obtained by taking a venous blood sample from the arm. A variety of methods exist for determining blood-alcohol concentration in a blood sample.^[17] Forensic laboratories typically use headspace-gas chromatography combined with mass spectrometry or flame ionization detection,^[18] as this method is accurate and efficient.^[17] Hospitals typically use enzyme multiplied immunoassay, which measures the co-enzyme NADH. This method is more subject to error but may be performed rapidly in parallel with other blood sample measurements.^[19]

In Germany, BAC is determined by measuring the serum level and then converting to whole blood by dividing by the factor 1.236. This calculation underestimates BAC by 4% to 10% compared to other methods.^[20]

By breathalyzer

Joke "Breathalyser 'pint'" beer glass, about 2 inches tall, dating from around the time of the introduction of breathalyzers in the United Kingdom, in 1967

The amount of alcohol on the breath can be measured, without requiring drawing blood, by blowing into a breathalyzer, resulting in a breath alcohol content (BrAC). The BrAC specifically correlates with the concentration of alcohol in arterial blood, satisfying the equation $BAC arterial = BrAC \times 2251 \pm 46$ . Its correlation with the standard BAC found by drawing venous blood is less strong.^[21] Jurisdictions vary in the statutory conversion factor from BrAC to BAC, from 2000 to 2400. Many factors may affect the accuracy of a breathalyzer test,^[22] but they are the most common method for measuring alcohol concentrations in most jurisdictions.^[23]

By intake

Blood alcohol content can be quickly estimated by a model developed by Swedish professor Erik Widmark in the 1920s.^[24] The model corresponds to a pharmacokinetic single-compartment model with instantaneous absorption and zero-order kinetics for elimination. The model is most accurate when used to estimate BAC a few hours after drinking a single dose of alcohol in a fasted state, and can be within 20% CV of the true value.^[25]^[26] It is not at all realistic for the absorption phase, and is not accurate for BAC levels below 0.2 g/L (alcohol is not eliminated as quickly as predicted) and consumption with food (overestimating the peak BAC and time to return to zero).^[27]^[5] The equation varies depending on the units and approximations used, but in its simplest form is given by:^[28]

EBAC={\frac {A}{V_{d}}}-\beta \times T

where:

$EBAC$ is the estimated blood alcohol concentration (in g/L)
$A$ is the mass of alcohol consumed (g).
$T$ is the amount time during which alcohol was present in the blood (usually time since consumption began), in hours.
$β$ is the rate at which alcohol is eliminated, averaging around 0.15 g/L/hr.^[29]
$V d$ is the volume of distribution (L); typically body weight (kg) multiplied by 0.71 L/kg for men and 0.58 L/kg for women^[30]^[31] although estimation using TBW is more accurate.^[32]

Examples:

A 80 kg man drinks 2 US standard drinks (3 oz) of 40% ABV vodka, containing 14 grams of ethanol each (28 g total). After two hours:

$EBAC=28/(0.71\cdot 80)-(0.148\cdot 2)\approx 0.197{\text{g/L}}=0.0197\%{\text{BAC}}$

A 70 kg woman drinks 63 g of 40% ABV vodka, containing 21 grams of ethanol. After two hours:

$EBAC=21/(0.58\cdot 70)-(0.156\cdot 2)\approx 0.205{\text{g/L}}=0.0205\%{\text{BAC}}$

In terms of fluid ounces of alcohol consumed and weight in pounds, Widmark's formula can be simply approximated as^[24]

EBAC=8\times {\text{fl oz}}/{\text{weight in pounds}}-\beta \times T

for a man or

EBAC=10\times {\text{fl oz}}/{\text{weight in pounds}}-\beta \times T

for a woman, where EBAC and $β$ factors are given as g/dL (% BAC), such as a $β$ factor of 0.015% BAC per hour.^[24]

By standard drinks

United States standard drinks of beer, malt liquor, wine, and spirits compared. Each contains about 14 grams or 17.7 mL of ethanol.

The examples above define a standard drink as 0.6 fluid ounces (14 g or 17.7 mL) of ethanol, whereas other definitions exist, for example 10 grams of ethanol.

Approximate blood alcohol percentage (by volume)^[33]
Based on one drink having 0.5 US fl oz (15 mL) alcohol by volume
Drinks	Sex	Body weight
Drinks	Sex	40 kg 90 lb	45 kg 100 lb	55 kg 120 lb	64 kg 140 lb	73 kg 160 lb	82 kg 180 lb	91 kg 200 lb	100 kg 220 lb	109 kg 240 lb
1	Male	–	0.04	0.03	0.03	0.02	0.02	0.02	0.02	0.02
1	Female	0.05	0.05	0.04	0.03	0.03	0.03	0.02	0.02	0.02
2	Male	–	0.08	0.06	0.05	0.05	0.04	0.04	0.03	0.03
2	Female	0.10	0.09	0.08	0.07	0.06	0.05	0.05	0.04	0.04
3	Male	–	0.11	0.09	0.08	0.07	0.06	0.06	0.05	0.05
3	Female	0.15	0.14	0.11	0.10	0.09	0.08	0.07	0.06	0.06
4	Male	–	0.15	0.12	0.11	0.09	0.08	0.08	0.07	0.06
4	Female	0.20	0.18	0.15	0.13	0.11	0.10	0.09	0.08	0.08
5	Male	–	0.19	0.16	0.13	0.12	0.11	0.09	0.09	0.08
5	Female	0.25	0.23	0.19	0.16	0.14	0.13	0.11	0.10	0.09
6	Male	–	0.23	0.19	0.16	0.14	0.13	0.11	0.10	0.09
6	Female	0.30	0.27	0.23	0.19	0.17	0.15	0.14	0.12	0.11
7	Male	–	0.26	0.22	0.19	0.16	0.15	0.13	0.12	0.11
7	Female	0.35	0.32	0.27	0.23	0.20	0.18	0.16	0.14	0.13
8	Male	–	0.30	0.25	0.21	0.19	0.17	0.15	0.14	0.13
8	Female	0.40	0.36	0.30	0.26	0.23	0.20	0.18	0.17	0.15
9	Male	–	0.34	0.28	0.24	0.21	0.19	0.17	0.15	0.14
9	Female	0.45	0.41	0.34	0.29	0.26	0.23	0.20	0.19	0.17
10	Male	–	0.38	0.31	0.27	0.23	0.21	0.19	0.17	0.16
10	Female	0.51	0.45	0.38	0.32	0.28	0.25	0.23	0.21	0.19
Subtract approximately 0.01 every 40 minutes after drinking.

By training

If individuals are asked to estimate their BAC, then given accurate feedback via a breathalyzer, and this procedure is repeated a number of times during a drinking session, studies show that these individuals can learn to discriminate their BAC, to within a mean error of 9 mg/100 mL (0.009% BAC).^[34] The ability is robust to different types of alcohol, different drink quantities, and drinks with unknown levels of alcohol. Trained individuals can even drink alcoholic drinks so as to adjust or maintain their BAC at a desired level.^[35] Training the ability does not appear to require any information or procedure besides breathalyzer feedback, although most studies have provided information such as intoxication symptoms at different BAC levels. Subjects continue to retain the ability one month after training.^[36]

Post-mortem

After fatal accidents, it is common to check the blood alcohol levels of involved persons. However, soon after death, the body begins to putrefy, a biological process which produces ethanol. This can make it difficult to conclusively determine the blood alcohol content in autopsies, particularly in bodies recovered from water.^[37]^[38]^[39]^[40] For instance, following the 1975 Moorgate tube crash, the driver's kidneys had a blood alcohol concentration of 80 mg/100 mL, but it could not be established how much of this could be attributed to natural decomposition.^[41] Newer research has shown that vitreous (eye) fluid provides an accurate estimate of blood alcohol concentration that is less subject to the effects of decomposition or contamination.^[42]

Legal limits

Map of Europe showing countries' blood alcohol limits as defined in g/dL for the general population

For purposes of law enforcement, blood alcohol content is used to define intoxication and provides a rough measure of impairment. Although the degree of impairment may vary among individuals with the same blood alcohol content, it can be measured objectively and is therefore legally useful and difficult to contest in court. Most countries forbid operation of motor vehicles and heavy machinery above prescribed levels of blood alcohol content. Operation of boats and aircraft is also regulated. Some jurisdictions also regulate bicycling under the influence. The alcohol level at which a person is considered legally impaired to drive varies by country.

Test assumptions

Extrapolation

Retrograde extrapolation is the mathematical process by which someone's blood alcohol concentration at the time of driving is estimated by projecting backwards from a later chemical test. This involves estimating the absorption and elimination of alcohol in the interim between driving and testing. The rate of elimination in the average person is commonly estimated at 0.015 to 0.020 grams per deciliter per hour (g/dL/h),^[43] although again this can vary from person to person and in a given person from one moment to another. Metabolism can be affected by numerous factors, including such things as body temperature, the type of alcoholic beverage consumed, and the amount and type of food consumed.

In an increasing number of states, laws have been enacted to facilitate this speculative task: the blood alcohol content at the time of driving is legally presumed to be the same as when later tested. There are usually time limits put on this presumption, commonly two or three hours, and the defendant is permitted to offer evidence to rebut this presumption.

Forward extrapolation can also be attempted. If the amount of alcohol consumed is known, along with such variables as the weight and sex of the subject and period and rate of consumption, the blood alcohol level can be estimated by extrapolating forward. Although subject to the same infirmities as retrograde extrapolation—guessing based upon averages and unknown variables—this can be relevant in estimating BAC when driving and/or corroborating or contradicting the results of a later chemical test.

Metabolism

The pharmacokinetics of ethanol are well characterized by the ADME acronym (absorption, distribution, metabolism, excretion). Besides the dose ingested, factors such as the person's total body water, speed of drinking, the drink's nutritional content, and the contents of the stomach all influence the profile of blood alcohol content (BAC) over time. Breath alcohol content (BrAC) and BAC have similar profile shapes, so most forensic pharmacokinetic calculations can be done with either. Relatively few studies directly compare BrAC and BAC within subjects and characterize the difference in pharmacokinetic parameters. Comparing arterial and venous BAC, arterial BAC is higher during the absorption phase and lower in the postabsorptive declining phase.^[44]

Highest levels

There have been reported cases of blood alcohol content higher than 1%:

In 1982, a 24-year-old woman was admitted to the UCLA emergency room with a serum alcohol content of 1.51%, corresponding to a blood alcohol content of 1.33%. She was alert and oriented to person and place and survived.^[45] Serum alcohol concentration is not equal to nor calculated in the same way as blood alcohol content.^[46]
In 1984, a 30-year-old man survived a blood alcohol concentration of 1.5% after vigorous medical intervention that included dialysis and intravenous therapy with fructose.^[47]
In 1995, a man from Wrocław, Poland, caused a car accident near his hometown. He had a blood alcohol content of 1.48%; he was tested five times, with each test returning the same reading. He died a few days later of injuries from the accident.^[48]
In 2004, an unidentified Taiwanese woman died of alcohol intoxication after immersion for twelve hours in a bathtub filled with 40% ethanol. Her blood alcohol content was 1.35%. It was believed that she had immersed herself as a response to the SARS epidemic.^[49]
In South Africa, a man driving a Mercedes-Benz Vito light van containing 15 sheep allegedly stolen from nearby farms was arrested on December 22, 2010, near Queenstown in Eastern Cape. His blood had an alcohol content of 1.6%. Also in the vehicle were five boys and a woman, who were also arrested.^[50]^{[dubious – discuss]}
On 26 October 2012, a man from Gmina Olszewo-Borki, Poland, who died in a car accident, recorded a blood alcohol content of 2.23%; however, the blood sample was collected from a wound and thus possibly contaminated.^[48]
On 26 July 2013 a 30-year-old man from Alfredówka, Poland, was found by Municipal Police Patrol from Nowa Dęba lying in the ditch along the road in Tarnowska Wola. At the hospital, it was recorded that the man had a blood alcohol content of 1.374%. The man survived.^[51]^[52]

Notes

^ In Germany, Finland, Netherlands and Sweden, the local language term promille is used; this is occasionally provided as a courtesy in English texts.^[8]

References

Citations

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^ Maskell, Peter D.; Cooper, Gail A. A. (September 2020). "The Contribution of Body Mass and Volume of Distribution to the Estimated Uncertainty Associated with the Widmark Equation". Journal of Forensic Sciences. 65 (5): 1676–1684. doi:10.1111/1556-4029.14447. PMID 32421216. S2CID 218677989.
^ Maskell, Peter D.; Jones, A. Wayne; Heymsfield, Steven B.; Shapses, Sue; Johnston, Atholl (November 2020). "Total body water is the preferred method to use in forensic blood-alcohol calculations rather than ethanol's volume of distribution". Forensic Science International. 316: 110532. doi:10.1016/j.forsciint.2020.110532. PMID 33099270. S2CID 224966411.
^ BAC Charts Archived June 30, 2007, at the Wayback Machine from Virginia Tech
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^ ^a ^b Łuba, Marcin (24 October 2012). "Śmiertelny rekord: Kierowca z powiatu ostrołęckiego miał 22 promile alkoholu! Zginął w wypadku". eOstroleka.pl (in Polish). Retrieved 4 November 2017.
^ Wu, Yen-Liang; Guo, How-Ran; Lin, Hung-Jung (2005). "Fatal alcohol immersion during the SARS epidemic in Taiwan". Forensic Science International. 149 (2–3): 287. doi:10.1016/j.forsciint.2004.06.014. PMC 7131152. PMID 15749375.
^ Mashaba, Sibongile (24 December 2010). "Drunkest driver in SA arrested". Sowetan. Retrieved 31 March 2022.
^ "Miał 13,74 promila alkoholu we krwi. I przeżył. Rekord świata?" [He had 13.74 blood alcohol levels. And he survived. World record?]. Archived from the original on 11 August 2013. Retrieved 8 August 2013.
^ "Informacje".

General and cited references

Carnegie Library of Pittsburgh. Science and Technology Department. The Handy Science Answer Book. Pittsburgh: The Carnegie Library, 1997. ISBN 978-0-7876-1013-5.
Perham, Nick; Moore, Simon C.; Shepherd, Jonathan; Cusens, Bryany (2007). "Identifying drunkenness in the night-time economy". Addiction. 102 (3): 377–80. doi:10.1111/j.1360-0443.2006.01699.x. PMID 17298644.
Taylor, L., and S. Oberman. Drunk Driving Defense, 6th edition. New York: Aspen Law and Business, 2006. ISBN 978-0-7355-5429-0.

External links

Estimated alcohol

[9] In Germany, Finland, Netherlands and Sweden, the local language term promille is used; this is occasionally provided as a courtesy in English texts.^[8]

[Med2019-1] "Blood Alcohol Level". MedlinePlus. National Library of Medicine. 3 December 2020.

[BAC-2] "Legal BAC limits by country". World Health Organization. Retrieved 12 November 2023.

[3] "Drink-drivers in Nepal face the 'smell test' crackdown". Yahoo News. 22 July 2012.

[4] "BAC Formats" (PDF). Retrieved 3 November 2023.

[Jones2011-5] ^ ^a ^b ^c ^d ^e ^f ^g Jones, AW (July 2011). "Pharmacokinetics of Ethanol - Issues of Forensic Importance". Forensic Science Review. 23 (2): 91–136. PMID 26231237.

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[12] Nager, Anna (4 May 2020). "Alkoholpromille, beräkning" [Calculation of alcohol per mille]. Netdoktor (in Swedish). Retrieved 13 April 2024. I detta sammanhang räknar man med att 1 liter blod väger 1 kilo. [In this context, it is assumed that 1 liter of blood weighs 1 kilogram.]

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[34] BAC Charts Archived June 30, 2007, at the Wayback Machine from Virginia Tech

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@@ Line 19: / Line 19: @@
 }}
-'''Blood alcohol content''' ('''BAC'''), also called '''blood alcohol concentration''' or '''blood alcohol level''', is a measurement of [[alcohol intoxication]] used for legal or medical purposes;<ref name=Med2019/> it is expressed as mass of alcohol per volume of blood. For example, a BAC of 0.10 (0.10% or one tenth of one percent) means that there is 0.10&nbsp;[[Gram|g]] of alcohol for every 100&nbsp;{{abbr|mL|milliliter}} of blood.<ref>{{cite book |last1=McCune |first1=Anne |title=ABC of Alcohol |date=2015 |publisher=John Wiley & Sons |isbn=978-1-118-54396-2 |page=14 |url=https://books.google.com/books?id=G_TqCAAAQBAJ&pg=PA14 |language=en}}</ref> A BAC of 0 is [[sobriety|sober]]. In different countries the maximum permitted BAC when driving ranges from the [[limit of detection]] to 0.08%.<ref>{{cite news |title=Drink-drivers in Nepal face the 'smell test' crackdown |url=https://sg.news.yahoo.com/drink-drivers-nepal-face-smell-test-crackdown-034220138.html |work=Yahoo News |date=22 July 2012 |language=en-SG}}</ref><ref name=BAC>{{cite web|url=http://apps.who.int/gho/data/view.main.54600|title =Legal BAC limits by country|publisher =[[World Health Organization]]|access-date =12 November 2023|ref =none}}</ref> BAC levels over 0.08% are considered impaired; above 0.40% is potentially fatal.<ref name=Med2019>{{cite web |title=Blood Alcohol Level|url=https://medlineplus.gov/lab-tests/blood-alcohol-level/ |publisher=National Library of Medicine|website=MedlinePlus |date=3 December 2020|language=en}}</ref>
+'''Blood alcohol content''' ('''BAC'''), also called '''blood alcohol concentration''' or '''blood alcohol level''', is a measurement of [[alcohol intoxication]] used for legal or medical purposes.<ref name="Med2019">{{cite web |date=3 December 2020 |title=Blood Alcohol Level |url=https://medlineplus.gov/lab-tests/blood-alcohol-level/ |website=MedlinePlus |publisher=National Library of Medicine |language=en}}</ref>
+BAC is expressed as mass of [[alcohol (drug)|alcohol]] per volume of blood. In the US and many international publications, BAC levels are written as a percentage such as 0.08%, meaning that there is 0.08 g of alcohol for every 100 {{abbr|mL|milliliters}} of blood.<ref name="Med2019" /><ref name="BAC"/> In different countries, the maximum permitted BAC when driving ranges from the [[limit of detection]] ([[zero tolerance]]) to 0.08%.<ref>{{cite news |title=Drink-drivers in Nepal face the 'smell test' crackdown |url=https://sg.news.yahoo.com/drink-drivers-nepal-face-smell-test-crackdown-034220138.html |work=Yahoo News |date=22 July 2012 |language=en-SG}}</ref><ref name="BAC">{{cite web|url=http://apps.who.int/gho/data/view.main.54600|title =Legal BAC limits by country|publisher =[[World Health Organization]]|access-date =12 November 2023|ref =none}}</ref> BAC levels above 0.40% are potentially fatal.<ref name="Med2019" />
+== Units of measurement ==
+BAC is generally defined as a fraction of weight of alcohol per volume of blood, with an [[SI coherent derived unit]] of [[Kilogram per cubic metre|kg/m<sup>3</sup>]] or equivalently grams per liter (g/L). Countries differ in how this quantity is normally expressed. Common formats are listed in the table below. For example, the US and many international publications present BAC as a percentage, such as 0.05%. This would be interpreted as 0.05 grams per deciliter of blood. This same concentration could be expressed as 0.5‰ or 50&nbsp;mg% in other countries.<ref>{{cite web |title=BAC Formats |url=http://www.mecinca.net/ALCOHOLIMETROS_Alcosim/BAC%20BrAC%20conversion%20table[1].pdf |access-date=3 November 2023}}</ref>
+{| class="wikitable" style="margin: 1em auto 1em auto"
+! Sign !! Units !! Used in
+|-
+| 1 percent (%), 1 g%<ref name="Jones2011" /> || {{val|1|u=g/dL}} = {{val|1|u=cg/mL}} = {{val|10|u=g/L}} = 1&nbsp;g/100&nbsp;mL || US, Australia,<ref name="Jones2011" /><ref>{{Cite web |date=8 February 2022 |orig-date=Original date 14 February 2017 |title=Blood alcohol levels |url=https://adf.org.au/insights/blood-alcohol-levels/ |website=Alcohol and Drug Foundation (Australia)}}</ref> Canada<ref>{{Cite web |date=n.d. |title=Blood Alcohol Concentration (BAC) |url=https://madd.ca/pages/impaired-driving/overview/blood-alcohol-concentration-bac/ |access-date=21 July 2022 |website=Mothers Against Drunk Driving (MADD Canada)}}</ref>
+|-
+| 1 [[per mille]] (‰){{efn|In Germany, Finland, Netherlands and Sweden, the local language term ''[[per mille|promille]]'' is used; this is occasionally provided as a courtesy in English texts.<ref name="HRB BAL">{{cite web |title=Blood alcohol level (BAL) |publisher=Health Research Board (Ireland) |url=https://www.drugsandalcohol.ie/glossary/info/blood_alcohol_level }}</ref>}}   || {{val|1|u=g/L}} = {{val|1|u=mg/mL}} = 100&nbsp;mg/1&nbsp;dL || Austria, Belgium, France, Germany, Spain,<ref name="Jones2011" /> Bulgaria, Czech Republic, Latvia, Lithuania, Netherlands, Poland, Portugal, Romania, Russia, Slovenia, Sweden, Switzerland, Turkey{{cn|date=November 2023}}
+|-
+| 1 [[Milligram per cent|mg%]]<ref name="Jones2011" /> || {{val|1|u=mg/dL}} = {{val|0.01|u=g/L}} = 1&nbsp;mg/100&nbsp;mL || United Kingdom<ref>{{cite web |title=The drink drive limit |url=https://www.gov.uk/drink-drive-limit |access-date=3 November 2023 |website=GOV.UK |language=en}}</ref> Ireland, Canada, New Zealand<ref name="Jones2011" />
+|}
+It is also possible to use other units. For example, in the 1930s Widmark measured alcohol and blood by mass, and thus reported his concentrations in units of g/kg or mg/g, weight alcohol per weight blood. 1 mL of blood has a mass of approximately 1.055&nbsp;grams, thus a mass-volume BAC of 1 g/L corresponds to a mass-mass BAC of 0.948&nbsp;mg/g. Sweden, Denmark, Norway, Finland, Germany, and Switzerland use mass-mass concentrations in their laws,<ref name="Jones2011" /> but this distinction is often skipped over in public materials,<ref>{{cite web |title=Drink-driving: What are the rules? |url=https://www.ch.ch/en/vehicles-and-traffic/how-to-behave-in-road-traffic/traffic-regulations/alcohol-in-road-traffic-and-navigation/#how-much-wine-or-beer-can-i-drink |website=www.ch.ch |language=en}}</ref> implicitly assuming that 1 L of blood weighs 1 kg.<ref>{{cite news |last1=Nager |first1=Anna |title=Alkoholpromille, beräkning|trans-title=Calculation of alcohol per mille |url=https://www.netdoktor.se/psykiatri/missbruk-beroende/sjukdomar/alkoholpromille-berakning/ |access-date=13 April 2024 |work=Netdoktor |date=4 May 2020 |language=sv-SE|quote=I detta sammanhang räknar man med att 1 liter blod väger 1 kilo.|trans-quote=In this context, it is assumed that 1 liter of blood weighs 1 kilogram.}}</ref>
+In [[pharmacokinetics]], it is common to use the [[amount of substance]], in [[Mole (unit)|mole]]s, to quantify the dose. As the [[molar mass]] of ethanol is 46.07 g/mol, a BAC of 1 g/L is 21.706&nbsp;mmol/L (21.706&nbsp;mM).<ref>{{cite web |title=Ethanol |url=https://pubchem.ncbi.nlm.nih.gov/compound/Ethanol |access-date=3 November 2023 |website=pubchem.ncbi.nlm.nih.gov |language=en}}</ref>
 == Effects by alcohol level ==
 {{Further|Short-term effects of alcohol consumption}}
+{| class="wikitable"
+|-
-At BAC 0.01–0.05%, people may experience mild relaxation and reduced [[social inhibition]], along with impaired judgment and coordination. At BAC 0.06–0.20%, effects can include emotional swings, impaired vision, hearing, speech, and [[motor skill]]s. The [[National Institute on Alcohol Abuse and Alcoholism|NIAAA]] defines the term "[[binge drinking]]" as a pattern of drinking that brings a person's blood alcohol concentration (BAC) to 0.08 grams percent or above.<ref name="cdc.gov">"Quick Stats: Binge Drinking." The Centers for Disease Control and Prevention. April 2008.[https://www.cdc.gov/alcohol/quickstats/binge_drinking.htm].</ref>
+!colspan=3" | Alcohol level
+!rowspan="2" | Effects
-Beginning at a BAC greater than 0.2%, people may experience [[urinary incontinence]], [[vomiting]], and symptoms of [[alcohol intoxication]]. At a BAC greater than 0.3%, people may experience total loss of consciousness and show signs of severe alcohol intoxication. A BAC of 0.4% or higher is potentially fatal and can result in a [[coma]] or [[respiratory failure]].<ref>{{Citation |last=Dasgupta |first=Amitava |title=Alcohol, Drugs, Genes and the Clinical Laboratory: An Overview for Healthcare and Safety Professionals |date=2017-01-01 |url=https://www.sciencedirect.com/science/article/pii/B9780128054550000014 |work= |pages=1–21 |editor-last=Dasgupta |editor-first=Amitava |access-date=2023-05-24 |chapter=Alcohol a double-edged sword: Health benefits with moderate consumption but a health hazard with excess alcohol intake |publisher=Academic Press |language=en |doi=10.1016/b978-0-12-805455-0.00001-4 |isbn=978-0-12-805455-0}}</ref><ref>{{Citation |last1=Haghparast |first1=Parna |title=Alcoholic beverages and health effects |date=2022-01-01 |url=https://www.sciencedirect.com/science/article/pii/B978012824315200244X |work=Reference Module in Biomedical Sciences |access-date=2023-05-24 |publisher=Elsevier |language=en |doi=10.1016/b978-0-12-824315-2.00244-x |isbn=978-0-12-801238-3 |last2=Tchalikian |first2=Tina N.}}</ref> The magnitude of sensory impairment may vary in people of differing weights.<ref>{{Cite journal |last1=Dunn |first1=Richard A. |last2=Tefft |first2=Nathan W. |date=2014 |title=Has Increased Body Weight Made Driving Safer? |journal=Health Economics |language=en |volume=23 |issue=11 |pages=1374–1389 |doi=10.1002/hec.2991 |pmc=4135023 |pmid=24038409}}</ref>
+!rowspan="2" | Ref
+|-
+!BAC
+!per mille
+!mg%
+|-
+|0.01–0.05%
+|0.1–0.5
+|10–50
+|Mild relaxation and reduced [[social inhibition]]; impaired judgment and coordination
+|<ref name="cdc.gov" />
+|-
+|0.06–0.20%
+|0.6–2
+|60–200
+|Emotional swings, impaired vision, hearing, speech, and [[motor skill]]s
+|<ref name="cdc.gov" />
+|-
+|0.2–0.3%
+|2–3
+|200–300
+|[[Urinary incontinence]], [[vomiting]], and symptoms of [[alcohol intoxication]]
+|<ref name=":0">{{Citation |last=Dasgupta |first=Amitava |title=Alcohol, Drugs, Genes and the Clinical Laboratory: An Overview for Healthcare and Safety Professionals |date=2017-01-01 |work= |pages=1–21 |editor-last=Dasgupta |editor-first=Amitava |url=https://www.sciencedirect.com/science/article/pii/B9780128054550000014 |access-date=2023-05-24 |chapter=Alcohol a double-edged sword: Health benefits with moderate consumption but a health hazard with excess alcohol intake |publisher=Academic Press |language=en |doi=10.1016/b978-0-12-805455-0.00001-4 |isbn=978-0-12-805455-0}}</ref><ref name=":1">{{Citation |last1=Haghparast |first1=Parna |title=Alcoholic beverages and health effects |date=2022-01-01 |work=Reference Module in Biomedical Sciences |url=https://www.sciencedirect.com/science/article/pii/B978012824315200244X |access-date=2023-05-24 |publisher=Elsevier |language=en |doi=10.1016/b978-0-12-824315-2.00244-x |isbn=978-0-12-801238-3 |last2=Tchalikian |first2=Tina N.}}</ref>
+|-
+|0.3–0.4%
+|3–4
+|300–400
+|Potential total loss of consciousness; signs of severe alcohol intoxication
+|<ref name=":0" /><ref name=":1" />
+|-
+|>0.4%
+|>4
+|>400
+|Potentially fatal, may result in a [[coma]] or [[respiratory failure]]
+|<ref name=":0" />'''<ref name=":1" />'''
+|}
+The magnitude of sensory impairment may vary in people of differing weights.<ref>{{Cite journal |last1=Dunn |first1=Richard A. |last2=Tefft |first2=Nathan W. |date=2014 |title=Has Increased Body Weight Made Driving Safer? |journal=Health Economics |language=en |volume=23 |issue=11 |pages=1374–1389 |doi=10.1002/hec.2991 |pmc=4135023 |pmid=24038409}}</ref> The [[National Institute on Alcohol Abuse and Alcoholism|NIAAA]] defines the term "[[binge drinking]]" as a pattern of drinking that brings a person's blood alcohol concentration (BAC) to 0.08 grams percent or above.<ref name="cdc.gov">"Quick Stats: Binge Drinking." The Centers for Disease Control and Prevention. April 2008.[https://www.cdc.gov/alcohol/quickstats/binge_drinking.htm].</ref>
 == Estimation ==
 === Direct measurement ===
 Blood samples for BAC analysis are typically obtained by taking a venous blood sample from the arm. A variety of methods exist for determining blood-alcohol concentration in a blood sample.<ref name="Dubowski">{{cite journal |last1=Dubowski |first1=Kurt M. |title=Alcohol Determination in the Clinical Laboratory |journal=American Journal of Clinical Pathology |date=1 November 1980 |volume=74 |issue=5 |pages=747–750 |doi=10.1093/ajcp/74.5.747 |pmid=7446484 |url=https://www.researchgate.net/publication/15751585}}</ref> Forensic laboratories typically use [[Headspace gas chromatography for dissolved gas measurement|headspace-gas chromatography]] combined with mass spectrometry or flame ionization detection,<ref>{{cite journal |last1=Zamengo |first1=Luca |last2=Tedeschi |first2=Gianpaola |last3=Frison |first3=Giampietro |last4=Griffoni |first4=Carlo |last5=Ponzin |first5=Diego |last6=Jones |first6=Alan Wayne |title=Inter-laboratory proficiency results of blood alcohol determinations at clinical and forensic laboratories in Italy |journal=Forensic Science International |date=1 February 2019 |volume=295 |pages=213–218 |doi=10.1016/j.forsciint.2018.12.018 |pmid=30611561 |s2cid=58591654 |issn=0379-0738}}</ref> as this method is accurate and efficient.<ref name="Dubowski"/> Hospitals typically use [[enzyme multiplied immunoassay technique|enzyme multiplied immunoassay]], which measures the co-enzyme [[NADH]]. This method is more subject to error but may be performed rapidly in parallel with other blood sample measurements.<ref>{{cite web |title=Hospital Blood Alcohol Lab Results: Are They Forensically Reliable? |url=https://www.new-jersey-dui-defense.com/hospital-blood-alcohol-lab-results-are-they-forensically-reliable.aspx |website=Law Offices of Christopher L. Baxter |date=30 April 2020}}</ref>
+In Germany, BAC is determined by measuring the serum level and then converting to whole blood by dividing by the factor 1.236. This calculation underestimates BAC by 4% to 10% compared to other methods.<ref>{{cite journal |last1=Jones |first1=Alan Wayne |title=Concentration units used to report blood‐ and breath‐alcohol concentration for legal purposes differ between countries which is important to consider when blood/breath ratios of alcohol are compared and contrasted |journal=Journal of Forensic Sciences |date=22 March 2024 |doi=10.1111/1556-4029.15511}}</ref>
 === By breathalyzer ===
@@ Line 38: / Line 97: @@
 === By intake ===
+{{Main|Pharmacology of ethanol#Modeling}}
-Blood alcohol content can be estimated by a model developed by Swedish professor Erik Widmark in the 1920s.<ref name=Ed>{{cite web |last1=Ed Kuwatch |title=Fast Eddie's 8/10 Method of Hand Calculating Blood Alcohol Concentration: A Simple Method For Using Widmark's Formula |url=http://www.dui-law.com/810art.htm|archive-url=https://web.archive.org/web/20031202155933/http://www.dui-law.com/810art.htm |archive-date=2003-12-02 }}</ref> The model corresponds to a [[pharmacokinetic]] single-compartment model with instantaneous absorption and [[zero-order kinetics]] for elimination. The model is most accurate when used to estimate BAC a few hours after drinking a single dose of alcohol in a fasted state, and can be within 20% [[Coefficient of variation|CV]] of the true value.<ref>{{cite conference |last1=Zuba |first1=Dariusz |last2=Piekoszewski |first2=Wojciech |title=Uncertainty in Theoretical Calculations of Alcohol Concentration |book-title=Proc. 17th Internat. Conf. on Alcohol, Drugs and Traffic Safety |date=2004 |url=https://www.researchgate.net/publication/255499090}}</ref><ref>{{cite journal |last1=Gullberg |first1=Rod G. |title=Estimating the uncertainty associated with Widmark's equation as commonly applied in forensic toxicology |journal=Forensic Science International |date=October 2007 |volume=172 |issue=1 |pages=33–39 |doi=10.1016/j.forsciint.2006.11.010 |pmid=17210238}}</ref> It is less accurate for BAC levels below 0.2 g/L (alcohol is not eliminated as quickly as predicted) and consumption with food (overestimating the peak BAC and time to return to zero).<ref>{{cite journal |last1=Searle |first1=John |title=Alcohol calculations and their uncertainty |journal=Medicine, Science and the Law |date=January 2015 |volume=55 |issue=1 |pages=58–64 |doi=10.1177/0025802414524385 |pmid=24644224|pmc=4361698 }}</ref><ref name="Jones2011">{{cite journal |last1=Jones |first1=AW |title=Pharmacokinetics of Ethanol - Issues of Forensic Importance. |journal=Forensic Science Review |date=July 2011 |volume=23 |issue=2 |pages=91–136 |pmid=26231237 |url=https://www.researchgate.net/publication/280602837}}</ref> The equation varies depending on the units and approximations used, but in its simplest form is given by:
+Blood alcohol content can be quickly estimated by a model developed by Swedish professor Erik Widmark in the 1920s.<ref name=Ed>{{cite web |last1=Ed Kuwatch |title=Fast Eddie's 8/10 Method of Hand Calculating Blood Alcohol Concentration: A Simple Method For Using Widmark's Formula |url=http://www.dui-law.com/810art.htm|archive-url=https://web.archive.org/web/20031202155933/http://www.dui-law.com/810art.htm |archive-date=2003-12-02 }}</ref> The model corresponds to a [[pharmacokinetic]] single-compartment model with instantaneous absorption and [[zero-order kinetics]] for elimination. The model is most accurate when used to estimate BAC a few hours after drinking a single dose of alcohol in a fasted state, and can be within 20% [[Coefficient of variation|CV]] of the true value.<ref>{{cite conference |last1=Zuba |first1=Dariusz |last2=Piekoszewski |first2=Wojciech |title=Uncertainty in Theoretical Calculations of Alcohol Concentration |book-title=Proc. 17th Internat. Conf. on Alcohol, Drugs and Traffic Safety |date=2004 |url=https://www.researchgate.net/publication/255499090}}</ref><ref>{{cite journal |last1=Gullberg |first1=Rod G. |title=Estimating the uncertainty associated with Widmark's equation as commonly applied in forensic toxicology |journal=Forensic Science International |date=October 2007 |volume=172 |issue=1 |pages=33–39 |doi=10.1016/j.forsciint.2006.11.010 |pmid=17210238}}</ref> It is not at all realistic for the absorption phase, and is not accurate for BAC levels below 0.2 g/L (alcohol is not eliminated as quickly as predicted) and consumption with food (overestimating the peak BAC and time to return to zero).<ref>{{cite journal |last1=Searle |first1=John |title=Alcohol calculations and their uncertainty |journal=Medicine, Science and the Law |date=January 2015 |volume=55 |issue=1 |pages=58–64 |doi=10.1177/0025802414524385 |pmid=24644224|pmc=4361698 }}</ref><ref name="Jones2011">{{cite journal |last1=Jones |first1=AW |title=Pharmacokinetics of Ethanol - Issues of Forensic Importance. |journal=Forensic Science Review |date=July 2011 |volume=23 |issue=2 |pages=91–136 |pmid=26231237 |url=https://www.researchgate.net/publication/280602837}}</ref> The equation varies depending on the units and approximations used, but in its simplest form is given by:<ref>{{cite journal |last1=Maskell |first1=Peter D. |last2=Jones |first2=A. Wayne |last3=Heymsfield |first3=Steven B. |last4=Shapses |first4=Sue |last5=Johnston |first5=Atholl |title=Total body water is the preferred method to use in forensic blood-alcohol calculations rather than ethanol's volume of distribution |journal=Forensic Science International |date=November 2020 |volume=316 |pages=110532 |doi=10.1016/j.forsciint.2020.110532|pmid=33099270 |s2cid=224966411 }}</ref>
 :<math>EBAC = \frac{A}{V_d}-\beta\times T</math>
 where:
@@ Line 45: / Line 104: @@
 *{{mvar|A}} is the mass of alcohol consumed (g).
 *{{mvar|T}} is the amount time during which alcohol was present in the blood (usually time since consumption began), in hours.
-*{{mvar|β}} is the rate at which alcohol is [[Elimination (pharmacology)|eliminated]], averaging around 0.15 g/L/hr
+*{{mvar|β}} is the rate at which alcohol is [[Elimination (pharmacology)|eliminated]], averaging around 0.15 g/L/hr.<ref>{{cite journal |last1=Jones |first1=Alan Wayne |title=Evidence-based survey of the elimination rates of ethanol from blood with applications in forensic casework |journal=Forensic Science International |date=July 2010 |volume=200 |issue=1–3 |pages=1–20 |doi=10.1016/j.forsciint.2010.02.021|pmid=20304569 }}</ref>
+*{{mvar|V<sub>d</sub>}} is the [[volume of distribution]] (L); typically body weight (kg) multiplied by 0.71 L/kg for men and 0.58 L/kg for women<ref name="MaskellVd">{{cite journal |last1=Maskell |first1=Peter D. |last2=Heymsfield |first2=Steven B. |last3=Shapses |first3=Sue |last4=Limoges |first4=Jennifer F. |title=Population ranges for the volume of distribution ( V_d ) of alcohol for use in forensic alcohol calculations |journal=Journal of Forensic Sciences |date=September 2023 |volume=68 |issue=5 |pages=1843–1845 |doi=10.1111/1556-4029.15317|pmid=37345356 |doi-access=free }}</ref><ref name="MaskellMass">{{cite journal |last1=Maskell |first1=Peter D. |last2=Cooper |first2=Gail A. A. |title=The Contribution of Body Mass and Volume of Distribution to the Estimated Uncertainty Associated with the Widmark Equation |journal=Journal of Forensic Sciences |date=September 2020 |volume=65 |issue=5 |pages=1676–1684 |doi=10.1111/1556-4029.14447|pmid=32421216 |s2cid=218677989 }}</ref> although estimation using TBW is more accurate.<ref>{{cite journal |last1=Maskell |first1=Peter D. |last2=Jones |first2=A. Wayne |last3=Heymsfield |first3=Steven B. |last4=Shapses |first4=Sue |last5=Johnston |first5=Atholl |title=Total body water is the preferred method to use in forensic blood-alcohol calculations rather than ethanol's volume of distribution |journal=Forensic Science International |date=November 2020 |volume=316 |pages=110532 |doi=10.1016/j.forsciint.2020.110532|pmid=33099270 |s2cid=224966411 }}</ref>
-*{{mvar|V<sub>d</sub>}} is the [[volume of distribution]] (L); typically body weight (kg) multiplied by 0.71 L/kg for men and 0.58 L/kg for women
 Examples:
@@ Line 53: / Line 112: @@
 * A 70&nbsp;kg woman drinks 63 g of 40% ABV vodka, containing 21 grams of ethanol. After two hours:
 <math display="block"> EBAC = 21/(0.58 \cdot 70) - (0.156 \cdot 2) \approx 0.205 \text{g/L} = 0.0205% \text{BAC}</math>
-The volume of distribution {{mvar|V<sub>d</sub>}} contributes about 15% of the uncertainty to Widmark's equation<ref name="MaskellMass">{{cite journal |last1=Maskell |first1=Peter D. |last2=Cooper |first2=Gail A. A. |title=The Contribution of Body Mass and Volume of Distribution to the Estimated Uncertainty Associated with the Widmark Equation |journal=Journal of Forensic Sciences |date=September 2020 |volume=65 |issue=5 |pages=1676–1684 |doi=10.1111/1556-4029.14447|pmid=32421216 |s2cid=218677989 }}</ref> and has been the subject of much research. It corresponds to the volume of the blood in the body.<ref name=Ed/> In his research, Widmark used units of mass (g/kg) for EBAC, thus he calculated the apparent {{em|mass}} of distribution {{mvar|M<sub>d</sub>}} or mass of blood in kilograms. He fitted an equation <math>M_d=\rho_m W</math> of the body weight {{mvar|W}} in kg, finding an average rho-factor of 0.68 for men and 0.55 for women. This {{mvar|ρ<sub>m</sub>}} has units of dose per body weight (g/kg) divided by concentration (g/kg) and is therefore dimensionless. However, modern calculations use weight/volume concentrations (g/L) for EBAC, so Widmark's rho-factors must be adjusted for the density of blood, 1.055 g/mL. This <math>\rho_v = V_d / W</math> has units of dose per body weight (g/kg) divided by concentration (g/L blood) - calculation gives values of 0.64 L/kg for men and 0.52 L/kg for women, lower than the original.<ref name="Jones2011"/> Newer studies have updated these values to population-average {{mvar|ρ<sub>v</sub>}} of 0.71 L/kg for men and 0.58 L/kg for women. But individual {{mvar|V<sub>d</sub>}} values may vary significantly - the 95% range for {{mvar|ρ<sub>v</sub>}} is 0.58-0.83 L/kg for males and 0.43-0.73 L/kg for females.<ref name="MaskellVd">{{cite journal |last1=Maskell |first1=Peter D. |last2=Heymsfield |first2=Steven B. |last3=Shapses |first3=Sue |last4=Limoges |first4=Jennifer F. |title=Population ranges for the volume of distribution ( V_d ) of alcohol for use in forensic alcohol calculations |journal=Journal of Forensic Sciences |date=September 2023 |volume=68 |issue=5 |pages=1843–1845 |doi=10.1111/1556-4029.15317|pmid=37345356 |doi-access=free }}</ref> A more accurate method for calculating {{mvar|V<sub>d</sub>}} is to use [[total body water]] (TBW) - experiments have confirmed that alcohol distributes almost exactly in proportion to TBW. TBW may be calculated using [[body composition]] analysis or estimated using anthropometric formulas based on age, height, and weight. {{mvar|V<sub>d</sub>}} is then given by <math>TBW_\text{kg} / F_{\text{water}}</math>, where <math>F_{\text{water}}</math> is the water content of blood, approximately 0.825 w/v for men and 0.838 w/v for women.<ref>{{cite journal |last1=Maskell |first1=Peter D. |last2=Jones |first2=A. Wayne |last3=Heymsfield |first3=Steven B. |last4=Shapses |first4=Sue |last5=Johnston |first5=Atholl |title=Total body water is the preferred method to use in forensic blood-alcohol calculations rather than ethanol's volume of distribution |journal=Forensic Science International |date=November 2020 |volume=316 |pages=110532 |doi=10.1016/j.forsciint.2020.110532|pmid=33099270 |s2cid=224966411 }}</ref>
-The elimination rate from the blood, {{mvar|β}}, is perhaps the more important parameter, contributing 60% of the uncertainty to Widmark's equation.<ref name="MaskellMass"/> Similarly to {{mvar|ρ}}, its value depends on the units used for blood.<ref name="Jones2011"/> {{mvar|β}} varies 58% by occasion and 42% between subjects; it is thus difficult to determine {{mvar|β}} precisely, and more practical to use a mean and a range of values. The mean values for 164 men and 156 women were 0.148 g/L/h and 0.156 g/L/h respectively. Although statistically significant, the difference between sexes is small compared to the overall uncertainty, so Jones recommends using the value 0.15 for the mean and the range 0.10 - 0.25 g/L/h for forensic purposes, for all subjects.<ref>{{cite journal |last1=Jones |first1=Alan Wayne |title=Evidence-based survey of the elimination rates of ethanol from blood with applications in forensic casework |journal=Forensic Science International |date=July 2010 |volume=200 |issue=1–3 |pages=1–20 |doi=10.1016/j.forsciint.2010.02.021|pmid=20304569 }}</ref> Explanations for the gender difference are quite varied and include liver size, secondary effects of the volume of distribution, and sex-specific hormones.<ref>{{cite journal |last1=Dettling |first1=A. |last2=Skopp |first2=G. |last3=Graw |first3=M. |last4=Haffner |first4=H.-Th. |title=The influence of sex hormones on the elimination kinetics of ethanol |journal=Forensic Science International |date=May 2008 |volume=177 |issue=2–3 |pages=85–89 |doi=10.1016/j.forsciint.2007.11.002|pmid=18079079 }}</ref> Elaborating on the secondary effects, zero-order kinetics are not an adequate model for ethanol elimination; the elimination rate is better described by [[Michaelis–Menten kinetics]]. M-M kinetics are approximately zero-order above a BAC of 0.15-0.20 g/L, but below this value alcohol is eliminated more slowly and the elimination rate more closely follows first-order kinetics. This change in behavior was not noticed by Widmark because he could not analyze low BAC levels.<ref name="Jones2011"/> A 2023 study using a more complex two-compartment model with M-M elimination kinetics, with data from 60 men and 12 women, found statistically small effects of gender on maximal elimination rate and excluded them from the final model. Eating food in proximity to drinking increases elimination rate significantly.<ref>{{cite journal |last1=Büsker |first1=Sören |last2=Jones |first2=Alan Wayne |last3=Hahn |first3=Robert G. |last4=Taubert |first4=Max |last5=Klotz |first5=Ulrich |last6=Schwab |first6=Matthias |last7=Fuhr |first7=Uwe |title=Population Pharmacokinetics as a Tool to Reevaluate the Complex Disposition of Ethanol in the Fed and Fasted States |journal=The Journal of Clinical Pharmacology |date=June 2023 |volume=63 |issue=6 |pages=681–694 |doi=10.1002/jcph.2205|pmid=36688276 |doi-access=free }}</ref>
 In terms of [[fluid ounce]]s of alcohol consumed and weight in pounds, Widmark's formula can be simply approximated as<ref name=Ed/>
@@ Line 62: / Line 117: @@
 for a man or
 :<math>EBAC=10\times\text{fl oz}/\text{weight in pounds}-\beta\times T</math>
-for a woman, where EBAC and {{mvar|β}} factors are given as g/dL (% BAC), such as a {{mvar|β}} factor of 0.0015% BAC per hour.<ref name=Ed/>
+for a woman, where EBAC and {{mvar|β}} factors are given as g/dL (% BAC), such as a {{mvar|β}} factor of 0.015% BAC per hour.<ref name=Ed/>
 ===By standard drinks===
@@ Line 132: / Line 187: @@
 If individuals are asked to estimate their BAC, then given accurate feedback via a breathalyzer, and this procedure is repeated a number of times during a drinking session, studies show that these individuals can learn to discriminate their BAC, to within a mean error of 9&nbsp;mg/100 mL (0.009% BAC).<ref>{{cite journal |last1=Huber |first1=H |last2=Karlin |first2=R |last3=Nathan |first3=P E |title=Blood alcohol level discrimination by nonalcoholics. The role of internal and external cues. |journal=Journal of Studies on Alcohol |date=January 1976 |volume=37 |issue=1 |pages=27–39 |doi=10.15288/jsa.1976.37.27|pmid=2811 }}</ref> The ability is robust to different types of alcohol, different drink quantities, and drinks with unknown levels of alcohol. Trained individuals can even drink alcoholic drinks so as to adjust or maintain their BAC at a desired level.<ref>{{cite journal |last1=Rowan |first1=D. C. |title=The Role of Blood Alcohol Level Estimation in Training Alcoholics to become Controlled Drinkers |journal=British Journal of Addiction to Alcohol & Other Drugs |date=March 1978 |volume=73 |issue=3 |pages=316–318 |doi=10.1111/j.1360-0443.1978.tb00159.x|pmid=280356 }}</ref> Training the ability does not appear to require any information or procedure besides breathalyzer feedback, although most studies have provided information such as intoxication symptoms at different BAC levels. Subjects continue to retain the ability one month after training.<ref>{{cite journal |last1=Kelly |first1=Alexandra R. |last2=Fillmore |first2=Mark T. |title=Use of mindfulness training to improve BAC self-estimation during a drinking episode. |journal=Psychology of Addictive Behaviors |date=24 August 2023 |doi=10.1037/adb0000955|pmid=37616096 |pmc=10907993 |pmc-embargo-date=February 24, 2025 |s2cid=261098937 }}</ref>
-===Other methods===
+===Post-mortem===
+After fatal accidents, it is common to check the blood alcohol levels of involved persons. However, soon after death, the body begins to [[Putrefaction|putrefy]], a biological process which produces ethanol. This can make it difficult to conclusively determine the blood alcohol content in autopsies, particularly in bodies recovered from water.<ref>{{Cite journal |last1=Kugelberg |first1=Fredrik C. |last2=Jones |first2=Alan Wayne |date=5 January 2007 |title=Interpreting results of ethanol analysis in postmortem specimens: A review of the literature |url=https://www.sciencedirect.com/science/article/pii/S0379073806002891 |journal=[[Forensic Science International]] |volume=165 |issue=1 |pages=10–27 |doi=10.1016/j.forsciint.2006.05.004 |pmid=16782292 |access-date=20 May 2020}}</ref><ref>{{Cite journal|url=https://pubmed.ncbi.nlm.nih.gov/20232748/|pmid = 20232748|year = 2010|last1 = Xie|first1 = Y.|last2 = Deng|first2 = Z. H.|title = Analysis of alcohol mass concentration in corpse blood|journal = Fa Yi Xue Za Zhi|volume = 26|issue = 1|pages = 59–63}}</ref><ref>{{Cite journal|url=https://pubmed.ncbi.nlm.nih.gov/8373563/|pmid = 8373563|year = 1993|last1 = Felby|first1 = S.|last2 = Nielsen|first2 = E.|title = Postmortem blood alcohol concentration|journal = Blutalkohol|volume = 30|issue = 4|pages = 244–250}}</ref><ref>{{Cite journal|url=https://doi.org/10.1016/j.yrtph.2016.03.020|doi = 10.1016/j.yrtph.2016.03.020|title = Best-practices approach to determination of blood alcohol concentration (BAC) at specific time points: Combination of ante-mortem alcohol pharmacokinetic modeling and post-mortem alcohol generation and transport considerations|year = 2016|last1 = Cowan|first1 = Dallas M.|last2 = Maskrey|first2 = Joshua R.|last3 = Fung|first3 = Ernest S.|last4 = Woods|first4 = Tyler A.|last5 = Stabryla|first5 = Lisa M.|last6 = Scott|first6 = Paul K.|last7 = Finley|first7 = Brent L.|journal = Regulatory Toxicology and Pharmacology|volume = 78|pages = 24–36|pmid = 27041394}}</ref> For instance, following the 1975 [[Moorgate tube crash]], the driver's kidneys had a blood alcohol concentration of 80&nbsp;mg/100&nbsp;mL, but it could not be established how much of this could be attributed to natural decomposition.<ref>{{cite news|title=Moorgate Alcohol Finding|work=The Guardian|date=16 April 1975|page=24}}</ref> Newer research has shown that vitreous (eye) fluid provides an accurate estimate of blood alcohol concentration that is less subject to the effects of decomposition or contamination.<ref>{{cite journal |last1=Savini |first1=F |last2=Tartaglia |first2=A |last3=Coccia |first3=L |last4=Palestini |first4=D |last5=D'Ovidio |first5=C |last6=de Grazia |first6=U |last7=Merone |first7=GM |last8=Bassotti |first8=E |last9=Locatelli |first9=M |title=Ethanol Determination in Post-Mortem Samples: Correlation between Blood and Vitreous Humor Concentration. |journal=Molecules (Basel, Switzerland) |date=12 June 2020 |volume=25 |issue=12 |doi=10.3390/molecules25122724|doi-access=free |pmid=32545471|pmc=7355602 }}</ref>
-Vitreous (eye) fluid provides an accurate account of blood alcohol concentration in cadavers.<ref>{{Cite journal |last1=Honey |first1=Donna |last2=Caylor |first2=Curtis |last3=Luthi |first3=Ruth|author3-link=Ruth Lüthi|last4=Kerrigan |first4=Sarah |date=July 2005 |title=Comparative alcohol concentrations in blood and vitreous fluid with illustrative case studies |url=https://pubmed.ncbi.nlm.nih.gov/16105262/ |journal=Journal of Analytical Toxicology |volume=29 |issue=5 |pages=365–369 |doi=10.1093/jat/29.5.365 |issn=0146-4760 |pmid=16105262}}</ref>
-== Units of measurement ==
-BAC is generally defined as a fraction of weight of alcohol per volume of blood, with a [[coherent unit]] of grams per liter. Countries differ in how this number is normally expressed. Common formats are listed in the table below. For example, the US and many international publications present BAC as a percentage, such as 0.05%. This would be interpreted as 0.05 grams per deciliter of blood. This same concentration could be expressed as 0.5‰ or 50&nbsp;mg% in other countries.<ref>{{cite web |title=BAC Formats |url=http://www.mecinca.net/ALCOHOLIMETROS_Alcosim/BAC%20BrAC%20conversion%20table[1].pdf |access-date=3 November 2023}}</ref>
-{| class="wikitable" style="margin: 1em auto 1em auto"
-! Sign !! Units !! Used in
-|-
-| 1 percent (%), 1 g%<ref name="Jones2011"/> || {{val|1|u=g/dL}} = {{val|1|u=cg/mL}} = {{val|10|u=g/L}} = 1&nbsp;g/100&nbsp;mL || US, Australia,<ref name="Jones2011"/><ref>{{Cite web |title=Blood alcohol levels |website=Alcohol and Drug Foundation (Australia)|date=8 February 2022|orig-date=Original date 14 February 2017 |url= https://adf.org.au/insights/blood-alcohol-levels/}}</ref> Canada<ref>{{Cite web |title=Blood Alcohol Concentration (BAC) |website=Mothers Against Drunk Driving (MADD Canada) |date=n.d. |access-date=21 July 2022 |url= https://madd.ca/pages/impaired-driving/overview/blood-alcohol-concentration-bac/}}</ref>
-|-
-| 1 [[per mille]] (‰){{efn|In Germany, Finland, Netherlands and Sweden, the local language term ''[[per mille|promille]]'' is used; this is occasionally provided as a courtesy in English texts.<ref name="HRB BAL">{{cite web |title=Blood alcohol level (BAL) |publisher=Health Research Board (Ireland) |url=https://www.drugsandalcohol.ie/glossary/info/blood_alcohol_level }}</ref>}}   || {{val|1|u=g/L}} = {{val|1|u=mg/mL}} || Austria, Belgium, France, Germany, Spain,<ref name="Jones2011"/> Bulgaria, Czech Republic, Latvia, Lithuania, Netherlands, Poland, Portugal, Romania, Russia, Slovenia, Sweden, Switzerland, Turkey{{cn|date=November 2023}}
-|-
-| 1 [[Milligram per cent|mg%]]<ref name="Jones2011"/> || {{val|1|u=mg/dL}} = {{val|0.01|u=g/L}} = 1&nbsp;mg/100&nbsp;mL || United Kingdom<ref>{{cite web |title=The drink drive limit |url=https://www.gov.uk/drink-drive-limit |website=GOV.UK |access-date=3 November 2023 |language=en}}</ref> Ireland, Canada, New Zealand<ref name="Jones2011"/>
-|}
-It is also possible to use other units, but these have become uncommon. For example, in the 1930s Widmark measured alcohol and blood by mass, and thus reported his concentrations in units of g/kg or mg/g, weight alcohol per weight blood. 1 mL of blood has a mass of approximately 1.055&nbsp;grams, thus a mass-volume BAC of 1 g/L corresponds to a mass-mass BAC of 0.948&nbsp;mg/g. Sweden, Denmark, Norway, Finland, Germany, and Switzerland use mass-mass concentrations in their laws,<ref name="Jones2011"/> but this distinction is often skipped over in public materials.<ref>{{cite web |title=Drink-driving: What are the rules? |url=https://www.ch.ch/en/vehicles-and-traffic/how-to-behave-in-road-traffic/traffic-regulations/alcohol-in-road-traffic-and-navigation/#how-much-wine-or-beer-can-i-drink |website=www.ch.ch |language=en}}</ref>
-In [[pharmacokinetics]], it is common to use the [[amount of substance]], in [[Mole (unit)|mole]]s, to quantify the dose. As the [[molar mass]] of ethanol is 46.07 g/mol, a BAC of 1 g/L is 21.706&nbsp;mmol/L.<ref>{{cite web |title=Ethanol |url=https://pubchem.ncbi.nlm.nih.gov/compound/Ethanol |website=pubchem.ncbi.nlm.nih.gov |access-date=3 November 2023 |language=en}}</ref>
 == Legal limits ==
@@ Line 160: / Line 197: @@
 == Test assumptions ==
-{{More citations needed|date=July 2007}}
-After fatal accidents, it is common to check the blood alcohol levels of involved persons. However, soon after death, the body begins to [[Putrefaction|putrefy]], a biological process which produces ethanol. This can make it difficult to conclusively determine the blood alcohol content in autopsies, particularly in bodies recovered from water.<ref>{{Cite journal |last1=Kugelberg |first1=Fredrik C. |last2=Jones |first2=Alan Wayne |date=5 January 2007 |title=Interpreting results of ethanol analysis in postmortem specimens: A review of the literature |url=https://www.sciencedirect.com/science/article/pii/S0379073806002891 |journal=[[Forensic Science International]] |volume=165 |issue=1 |pages=10–27 |doi=10.1016/j.forsciint.2006.05.004 |pmid=16782292 |access-date=20 May 2020}}</ref><ref>{{Cite journal|url=https://pubmed.ncbi.nlm.nih.gov/20232748/|pmid = 20232748|year = 2010|last1 = Xie|first1 = Y.|last2 = Deng|first2 = Z. H.|title = Analysis of alcohol mass concentration in corpse blood|journal = Fa Yi Xue Za Zhi|volume = 26|issue = 1|pages = 59–63}}</ref><ref>{{Cite journal|url=https://pubmed.ncbi.nlm.nih.gov/8373563/|pmid = 8373563|year = 1993|last1 = Felby|first1 = S.|last2 = Nielsen|first2 = E.|title = Postmortem blood alcohol concentration|journal = Blutalkohol|volume = 30|issue = 4|pages = 244–250}}</ref><ref>{{Cite journal|url=https://doi.org/10.1016/j.yrtph.2016.03.020|doi = 10.1016/j.yrtph.2016.03.020|title = Best-practices approach to determination of blood alcohol concentration (BAC) at specific time points: Combination of ante-mortem alcohol pharmacokinetic modeling and post-mortem alcohol generation and transport considerations|year = 2016|last1 = Cowan|first1 = Dallas M.|last2 = Maskrey|first2 = Joshua R.|last3 = Fung|first3 = Ernest S.|last4 = Woods|first4 = Tyler A.|last5 = Stabryla|first5 = Lisa M.|last6 = Scott|first6 = Paul K.|last7 = Finley|first7 = Brent L.|journal = Regulatory Toxicology and Pharmacology|volume = 78|pages = 24–36|pmid = 27041394}}</ref> For instance, following the [[Moorgate tube crash]], the driver had a blood alcohol concentration of 80&nbsp;mg/100&nbsp;mL, but it could not be established how much of this could be attributed to natural decomposition.
 ===Extrapolation===
@@ Line 172: / Line 206: @@
 ==Metabolism==
+{{Main|Pharmacology of ethanol#Pharmacokinetics}}
-Alcohol is absorbed throughout the gastrointestinal tract, but more slowly in the stomach than in the small or large intestine. For this reason, alcohol consumed with food is absorbed more slowly, because it spends a longer time in the stomach.<ref name=ARFs/> Furthermore, [[alcohol dehydrogenase]] is present in the stomach lining. After absorption, the alcohol passes to the liver through the [[hepatic portal vein]], where it undergoes a first pass of metabolism before entering the general bloodstream.<ref>{{cite book|title=Handbook of alcoholic beverages : technical, analytical and nutritional aspects|year=2011|publisher=Wiley|location=Chichester|isbn=978-0-470-97665-4|url=https://books.google.com/books?id=gNc34oNpg0AC&pg=PT219|editor=Alan J.Buglass|access-date=6 July 2013}}</ref>
+The [[pharmacokinetic]]s of ethanol are well characterized by the [[ADME]] acronym (absorption, distribution, metabolism, excretion). Besides the dose ingested, factors such as the person's [[total body water]], speed of drinking, the drink's nutritional content, and the contents of the stomach all influence the profile of blood alcohol content (BAC) over time. Breath alcohol content (BrAC) and BAC have similar profile shapes, so most forensic pharmacokinetic calculations can be done with either. Relatively few studies directly compare BrAC and BAC within subjects and characterize the difference in pharmacokinetic parameters. Comparing arterial and venous BAC, arterial BAC is higher during the absorption phase and lower in the postabsorptive declining phase.<ref name="Jones2019">{{cite journal |last1=Jones |first1=Alan W. |title=Alcohol, its absorption, distribution, metabolism, and excretion in the body and pharmacokinetic calculations |journal=WIREs Forensic Science |date=September 2019 |volume=1 |issue=5 |doi=10.1002/wfs2.1340|doi-access=free}}</ref>
-Alcohol is removed from the bloodstream by a combination of [[metabolism]], excretion, and evaporation. Alcohol is metabolized mainly by the group of six [[enzyme]]s collectively called alcohol dehydrogenase. These convert the ethanol into [[acetaldehyde]] (an intermediate more toxic than ethanol). The enzyme [[acetaldehyde dehydrogenase]] then converts the acetaldehyde into non-toxic acetic acid.
-Many physiologically active materials are removed from the bloodstream (whether by [[metabolism]] or excretion) at a rate proportional to the current concentration, so that they exhibit [[exponential decay]] with a characteristic [[half-life#Half-life in biology and pharmacology|half-life]] (see [[pharmacokinetics]]). This is not true for alcohol, however. Typical doses of alcohol actually saturate the enzymes' capacity, so that alcohol is removed from the bloodstream at an approximately constant rate. This rate varies considerably between individuals. Another sex-based difference is in the elimination of alcohol. For females, the concentration of alcohol in breast milk produced during lactation is closely correlated to the individual's blood alcohol content.<ref>{{Cite journal |last1=Haastrup |first1=Maija Bruun |last2=Pottegård |first2=Anton |last3=Damkier |first3=Per |date=2014 |title=Alcohol and Breastfeeding |url=https://onlinelibrary.wiley.com/doi/10.1111/bcpt.12149 |journal=Basic & Clinical Pharmacology & Toxicology |language=en |volume=114 |issue=2 |pages=168–173 |doi=10.1111/bcpt.12149|pmid=24118767 }}</ref> People under 25, women,<ref>{{cite book |doi=10.1007/0-306-47138-8_9 |chapter=Gender Differences in Alcohol Metabolism |year=2002 |last1=Thomasson |first1=Holly R. |title=Recent Developments in Alcoholism |isbn=978-0-306-44921-5 |volume=12 |pages=[https://archive.org/details/recentdevelopment12gala/page/163 163–72] |pmid=7624539 |chapter-url-access=registration |chapter-url=https://archive.org/details/recentdevelopment12gala/page/163 }}</ref> or people with liver disease may process alcohol more slowly. Falsely high BAC readings may be seen in patients with kidney or liver disease or failure.{{Citation needed|date=June 2021}}
-Such persons also have impaired acetaldehyde dehydrogenase, which causes acetaldehyde levels to peak higher, producing more severe [[hangover]]s and other effects such as flushing and tachycardia.  Conversely, members of certain ethnicities that traditionally did not use alcoholic beverages have lower levels of alcohol dehydrogenases and thus "sober up" very slowly but reach lower aldehyde concentrations and have milder hangovers.  The rate of detoxification of alcohol can also be slowed by certain drugs which interfere with the action of alcohol dehydrogenases, notably [[aspirin]], [[furfural]] (which may be found in [[fusel alcohol]]), fumes of [[trichloroethylene|certain solvents]], many [[Heavy metal (chemistry)|heavy metals]], and some [[pyrazole]] compounds. Also suspected of having this effect are [[cimetidine]], [[ranitidine]], and [[paracetamol|acetaminophen]] (paracetamol).
-Currently, the only known substance that can increase the rate of alcohol metabolism is [[fructose]]. The effect can vary significantly from person to person, but a 100&nbsp;g dose of fructose has been shown to increase alcohol metabolism by an average of 80%. Fructose also increases false positives of high BAC readings in anyone with proteinuria and hematuria, due to kidney-liver metabolism.<ref name="#">Fructose & ethanol{{synthesis inline|date=March 2019}}
-* {{cite journal |last1=Carpenter |first1=Thorne M.|last2=Lee |first2=Robert C |title=The effect of fructose on the metabolism of ethyl alcohol in man |journal=Journal of Pharmacology and Experimental Therapeutics |date=1937 |volume=60 |issue=3 |url=http://jpet.aspetjournals.org/content/60/3/286.short |access-date=23 June 2016}}
-* {{cite journal|last1=Tygstrup|first1=Niels|last2=Winkler|first2=Kjeld|last3=Lundquist|first3=Frank|title=The Mechanism of the Fructose Effect on the Ethanol Metabolism of the Human Liver*|journal=Journal of Clinical Investigation|date=1 May 1965|volume=44|issue=5|pages=817–830|doi=10.1172/JCI105194|pmid=14276139|pmc=292558}}
-* {{cite journal|last1=Patel|first1=AR|last2=Paton|first2=AM|last3=Rowan|first3=T|last4=Lawson|first4=DH|last5=Linton|first5=AL|title=Clinical studies on the effect of laevulose on the rate of metabolism of ethyl alcohol.|journal=Scottish Medical Journal|date=August 1969|volume=14|issue=8|pages=268–71|pmid=5812044|doi=10.1177/003693306901400803|s2cid=3067691}}
-* {{cite journal|last1=Lowenstein|first1=LM|last2=Simone|first2=R|last3=Boulter|first3=P|last4=Nathan|first4=P|title=Effect of fructose on alcohol concentrations in the blood in man.|journal=JAMA|date=14 September 1970|volume=213|issue=11|pages=1899–901|pmid=4318655|doi=10.1001/jama.1970.03170370083021}}
-* {{cite journal|last1=Pawan|first1=GL|title=Metabolism of alcohol (ethanol) in man.|journal=The Proceedings of the Nutrition Society|date=September 1972|volume=31|issue=2|pages=83–9|pmid=4563296|doi=10.1079/pns19720020|doi-access=free}}
-* {{cite journal|last1=Thieden|first1=HI|last2=Grunnet|first2=N|last3=Damgaard|first3=SE|last4=Sestoft|first4=L|title=Effect of fructose and glyceraldehyde on ethanol metabolism in human liver and in rat liver.|journal=European Journal of Biochemistry|date=October 1972|volume=30|issue=2|pages=250–61|pmid=4145889|doi=10.1111/j.1432-1033.1972.tb02093.x|doi-access=free}}
-* {{cite journal|last1=Soterakis|first1=J|last2=Iber|first2=FL|title=Increased rate of alcohol removal from blood with oral fructose and sucrose.|journal=The American Journal of Clinical Nutrition|date=March 1975|volume=28|issue=3|pages=254–7|pmid=1119423|doi=10.1093/ajcn/28.3.254}}
-* {{cite journal|last1=Rawat|first1=AK|title=Effects of fructose and other substances on ethanol and acetaldehyde metabolism in man.|journal=Research Communications in Chemical Pathology and Pharmacology|date=February 1977|volume=16|issue=2|pages=281–90|pmid=847286}}
-* {{cite journal|last1=Iber|first1=FL|title=The effect of fructose on alcohol metabolism.|journal=Archives of Internal Medicine|date=September 1977|volume=137|issue=9|pages=1121|pmid=901079|doi=10.1001/archinte.137.9.1121}}
-* {{cite journal|last1=Bode|first1=JC|last2=Bode|first2=C|last3=Thiele|first3=D|title=Alcohol metabolism in man: effect of intravenous fructose infusion on blood ethanol elimination rate following stimulation by phenobarbital treatment or chronic alcohol consumption.|journal=Klinische Wochenschrift|date=1 February 1979|volume=57|issue=3|pages=125–30|pmid=439778|doi=10.1007/bf01476052|s2cid=8813046}}
-* {{cite journal|last1=Sprandel|first1=U|last2=Tröger|first2=HD|last3=Liebhardt|first3=EW|last4=Zöllner|first4=N|title=Acceleration of ethanol elimination with fructose in man.|journal=Nutrition & Metabolism|date=1980|volume=24|issue=5|pages=324–30|pmid=7443107|doi=10.1159/000176278}}
-* {{cite journal|last1=Meyer|first1=BH|last2=Müller|first2=FO|last3=Hundt|first3=HK|title=The effect of fructose on blood alcohol levels in man.|journal=South African Medical Journal (Suid-Afrikaanse Tydskrif vir Geneeskunde) |date=6 November 1982|volume=62|issue=20|pages=719–21|pmid=6753183}}
-* {{cite journal|last1=Crownover|first1=BP|last2=La Dine|first2=J|last3=Bradford|first3=B|last4=Glassman|first4=E|last5=Forman|first5=D|last6=Schneider|first6=H|last7=Thurman|first7=RG|title=Activation of ethanol metabolism in humans by fructose: importance of experimental design.|journal=The Journal of Pharmacology and Experimental Therapeutics|date=March 1986|volume=236|issue=3|pages=574–9|pmid=3950864}}
-* {{cite journal|last1=Mascord|first1=D|last2=Smith|first2=J|last3=Starmer|first3=GA|last4=Whitfield|first4=JB|title=The effect of fructose on alcohol metabolism and on the [lactate]/[pyruvate] ratio in man.|journal=Alcohol and Alcoholism|date=1991|volume=26|issue=1|pages=53–9|pmid=1854373}}
-* {{cite journal|last1=Onyesom|first1=I|last2=Anosike|first2=EO|title=Oral fructose-induced changes in blood ethanol oxidokinetic data among healthy Nigerians.|journal=The Southeast Asian Journal of Tropical Medicine and Public Health|date=June 2004|volume=35|issue=2|pages=476–80|pmid=15691159}}
-* {{cite journal|last1=Uzuegbu|first1=UE|last2=Onyesom|first2=I|title=Fructose-induced increase in ethanol metabolism and the risk of Syndrome X in man.|journal=Comptes Rendus Biologies|date=June 2009|volume=332|issue=6|pages=534–8|pmid=19520316|doi=10.1016/j.crvi.2009.01.007|url=https://comptes-rendus.academie-sciences.fr/biologies/articles/10.1016/j.crvi.2009.01.007/ }}
-</ref>
-The peak of blood alcohol level (or concentration of alcohol) is reduced after a large meal.<ref name=ARFs>{{cite web |url=http://www.bhs.umn.edu/alcohol-drugs/absorption-rate-factors.htm |title=Absorption Rate Factors |website=BHS.UMN.edu |archive-date=18 January 2013 |url-status=dead |archive-url=https://web.archive.org/web/20130118020512/http://www.bhs.umn.edu/alcohol-drugs/absorption-rate-factors.htm |quote=When food is ingested, the pyloric valve at the bottom of the stomach will close in order to hold food in the stomach for digestion and thus keep the alcohol from reaching the small intestine. The larger the meal and closer in time to drinking, the lower the peak of alcohol concentration; some studies indicate up to a 20% reduction in peak blood alcohol level.<br />Stress causes the stomach to empty directly into the small intestine, where alcohol is absorbed even faster.<br />Liquor mixed with soda or other bubbly drinks speeds up the passage of alcohol from the stomach to the small intestine, which increases the speed of absorption. |access-date=6 March 2018 }}</ref>
 == Highest levels ==