Though alcohol is enjoyed responsibly by millions of Americans every day, it is also misused by many — and over consumption can have serious consequences. Excessive drinking is the third leading preventable cause of death in the United States.

About a fifth of American adults regularly consumed unhealthy amounts of alcohol in 2018, the latest year for which data is available.

To identify the U.S. metro areas with the highest excessive drinking rates, 24/7 Tempo reviewed the percentage of adults 18 and older who report binge or heavy drinking within a 30-day period across all 382 metro areas in the country. Data came from the 2021 County Health Rankings & Roadmaps, a Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute joint program.

Excessive drinking includes both binge and heavy drinking. Heavy drinking is defined as consuming at least 15 drinks a week or averaging two or more drinks a day for men, according to the CDC. For women, it’s eight drinks or more per week or more than one drink on average a day. Binge drinking is defined as a pattern of alcohol consumption that brings a person’s blood alcohol concentration level to 0.08% or higher — estimated to take about five or more drinks within two hours for men and four or more drinks for women.

Excessive alcohol consumption rates appear associated with some economic factors. Alcohol can be expensive, and people’s ability to drink to excess can be limited by their income. Cities with higher excessive drinking rates tend to have higher incomes, and vice-versa.

Social factors also play a role. In Wisconsin, alcohol consumption is, for many, an integral part of the state’s culture. Twelve of the 20 heaviest drinking cities on this list are in Wisconsin.

On the other end of the spectrum, large segments of the population in Utah are teetotalers. Four of the five cities with the lowest rates of excessive drinking are in Utah. About 68% of the state’s population identify as Mormon, a religion that teaches its followers to avoid alcohol consumption.

Regular and excessive consumption of alcohol can result in chronic conditions and other long-term health problems, such as high blood pressure, heart disease, stroke, liver disease, and certain cancers. About half of alcohol-related deaths nationwide are due to liver disease or overdoses involving alcohol or alcohol combined with other drugs. These are the 25 most dangerous drugs currently on the market.

Click here for the 50 drunkest cities in the U.S.

While the health risks associated with excessive alcohol consumption are well established, having a large share of excessive drinkers often does not translate to poor health outcomes across a population. Alcohol consumption is just one of many factors that can affect a person’s health. In fact, because cities with higher excessive drinking rates also tend to have higher incomes, residents tend to have easier access to quality health care and can afford healthier diets and lifestyles.

In fact, just one of the 20 cities with the highest excessive drinking rates is home to a larger share of adults in fair or poor health than the 16.5% national average.

Fatal car accidents that involve alcohol appear to be more common in the cities with the highest excessive drinking rates. Nationwide, 27.0% of all driving deaths involve alcohol. In all but 14 of the 50 cities with the highest excessive drinking rates, the share is lower than the nationwide rate.