CAGE Questionnaire: A Full Guide for Researchers and Clinicians
Published
The CAGE Questionnaire is a four-item yes/no screen for alcoholism and problem drinking. Learn what CAGE stands for, how to score it, and its cut-offs.
Introduction
The CAGE Questionnaire is a set of four clinical interview questions that helps identify alcoholism and problem drinking. John A. Ewing, MD, of the Center for Alcohol Studies at the University of North Carolina, developed it. Each question is answered yes or no, and the 1984 JAMA article has received more than 6,780 citations.
CAGE is an acronym for its four questions: Cut down drinking, Annoyed by criticism, Guilty feelings and Eye-opener. This guide explains its items, scoring, cut-offs and evidence on reliability and validity.
Key Features of the CAGE Questionnaire
Purpose and Use
The CAGE was developed as a brief set of four clinical interview questions to help identify alcoholism and problem drinking. It works mainly by raising the clinician's index of suspicion and prompting further inquiry. It can also be used as a self-screening tool to identify possible alcohol use problems, but it cannot diagnose Alcohol Use Disorder (AUD) or determine its severity.
Target Population
The CAGE is intended for adults aged 18 and older. No specific normative age ranges have been reported. Its performance has also been studied in adolescents.
Structure
The CAGE has four items, one for each indicator of problematic alcohol use:
Letter
Indicator
C – Cut down
Need or desire to cut down on drinking
A – Annoyed
Annoyance at criticism of one's drinking
G – Guilty
Guilt or bad feelings about drinking
E – Eye-opener
Drinking in the morning to steady the nerves or relieve a hangover
Scoring Method
Each question is answered yes or no:
No: scores 0Yes: scores 1Total score: the sum of the four answers, from 0 to 4Interpreting scores:
Positive answers
Meaning
1
The original Ewing report stated that even one positive answer should prompt further inquiry
2 or 3
Should create a high index of suspicion
4
Seen as pathognomonic for alcoholism
Mayfield and colleagues tested one-, two-, three- and four-positive-response criteria and found the two- or three-positive-response criteria most useful for identifying alcoholism.
Administration Format
The CAGE was designed as clinical interview questions. A positive result is not diagnostic: it should alert the interviewer to a high likelihood of alcoholism. Diagnosis is made by a healthcare professional using DSM-5 criteria, which classify AUD as mild, moderate or severe.
Applications of the CAGE Questionnaire
The CAGE supports several uses:
Clinical screening: raising the index of suspicion for alcoholism during an interview.Self-screening: identifying possible alcohol use problems.Research: detecting alcohol abuse and dependence in medical, surgical and psychiatric samples.Languages and availability
The CAGE has been used and validated in several languages:
English: original articleSpanish: validation of the KFA, CBA and CAGE questionnairesGerman: CAGE-G (Rumpf, Hapke and John, 2003); see also this studyPortuguese: validation in a Brazilian psychiatric inpatient settingJapanese: reliability and validity of the Japanese version (Kawakami and colleagues, 1993)Researchers and clinicians who publish studies using the CAGE should cite the original reference (Ewing, 1984). No other permission is needed unless the CAGE is used in a profit-making endeavor, in which case the Bowles Center for Alcohol Studies would require a negotiated payment.
Reliability and Validity
In the original validation, criterion-related validity was shown against a multidisciplinary clinical classification of alcoholism. Correlations were about 0.89 when two or three positive responses were used as criteria, and individual-item correlations ranged from 0.60 to 0.89.
A review of validation studies reported:
Test–retest reliability: high, from 0.80 to 0.95Correlations with other screening instruments: adequate, from 0.48 to 0.70Accuracy: a valid tool for detecting alcohol abuse and dependence in medical and surgical inpatients, ambulatory medical patients and psychiatric inpatients, with an average sensitivity of 0.71 and specificity of 0.90Validation studies:
The CAGE questionnaire: validation of a new alcoholism screening instrument (1974): study linkValidation of the CAGE (4M) questions in Latinos living in the United States (1999): study linkValidity of the CAGE questionnaire in hospital (2005): study linkThe CAGE questionnaire for alcohol misuse: a review of reliability and validity studies (2007): study linkAUDIT and CAGE in Tanzanian Swahili for a traumatic brain injury population (2017): study linkPsychometric properties of the CAGE among middle-aged and older adults in Iran (2023): study linkLimitations and Considerations
Keep these points in mind:
Narrow focus: the CAGE focuses on alcohol-related problems and does not assess drinking quantity or frequency, or all dimensions of AUD. It is also less effective at detecting less severe forms of alcohol use disorders.Age: it lacks validation in adolescents.Social desirability bias: the CAGE uses non-confrontational questions about the consequences of drinking to reduce denial, but as a self-report of stigmatized behaviors it may still be affected by under-reporting.Mixed performance: results in primary care patients have varied, and it has not performed well in white women, prenatal women and college students.Original evidence: the original validation was based mostly on psychiatric inpatients.Other Versions And Related Questionnaires
The CAGE-AID questionnaire is an adaptation that also helps detect people with other substance use disorders.
These questionnaires are related:
Michigan Alcoholism Screening Test (MAST) and the Brief MASTAlcohol Use Disorders Identification Test (AUDIT) and AUDIT-Consumption (AUDIT-C); see the ResRef AUDIT guideSingle Alcohol Screen Questionnaire (SASQ)When Saunders and Kershaw compared the CAGE with the MAST in a community survey, they found the CAGE easier to use and more sensitive.
Additional Resources
The original article: linkThe CAGE information sheet from the U.S. Preventive Services Task Force: linkA systematic review of screening for alcohol problems in primary care: linkDr. John A. Ewing, the developer and founding Director of the Bowles Center for Alcohol Studies at UNC Chapel Hill, died in 2006.Browse more psychiatry questionnaires in the ResRef database.Frequently Asked Questions (FAQ)
What does CAGE stand for?CAGE is an acronym for its four questions: Cut down on drinking, Annoyed by criticism of drinking, Guilty feelings about drinking and Eye-opener, meaning a morning drink to steady the nerves or relieve a hangover.
How is the CAGE Questionnaire scored?Each yes answer scores 1 and each no answer scores 0. Adding the four answers gives a total from 0 to 4, where more positive answers indicate a higher likelihood of alcoholism.
What is the CAGE cut-off score?Two or three positive answers should create a high index of suspicion, and four is seen as pathognomonic for alcoholism. The original report advised that even one positive answer should prompt further inquiry.
Can the CAGE diagnose alcohol use disorder?No. The CAGE can identify possible alcohol use problems, but it cannot diagnose AUD or determine its severity. A healthcare professional makes the diagnosis using DSM-5 criteria.
A Word from ResRef About the CAGE Questionnaire
The CAGE is a brief four-item instrument developed to identify possible alcoholism and problem drinking in clinical and research settings. The original validation study found substantially stronger criterion correlations when two or three positive responses were used rather than requiring all four. Its original evidence was based predominantly on psychiatric inpatients, and the authors recommended further evaluation in different populations and settings.
References
Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire. JAMA, 252(14), 1905–1907. https://doi.org/10.1001/jama.1984.03350140051025Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE questionnaire: validation of a new alcoholism screening instrument. The American Journal of Psychiatry, 131(10), 1121–3. https://doi.org/10.1176/ajp.131.10.1121Dhalla, S., & Kopec, J. A. (2007). The CAGE questionnaire for alcohol misuse: a review of reliability and validity studies. Clinical and Investigative Medicine. Medecine Clinique et Experimentale, 30(1), 33–41. https://doi.org/10.25011/cim.v30i1.447Saitz, R., Lepore, M. F., Sullivan, L. M., Amaro, H., & Samet, J. H. (1999). Alcohol abuse and dependence in Latinos living in the United States: validation of the CAGE (4M) questions. Archives of Internal Medicine, 159(7), 718–24. https://doi.org/10.1001/archinte.159.7.718Vissoci, J. R. N., Hertz, J., El-Gabri, D., Andrade Do Nascimento, J. R., Pestillo De Oliveira, L., Mmbaga, B. T., Mvungi, M., & Staton, C. A. (2017). Cross-Cultural Adaptation and Psychometric Properties of the AUDIT and CAGE Questionnaires in Tanzanian Swahili for a Traumatic Brain Injury Population. Alcohol and Alcoholism, 53(1), 112–120. https://doi.org/10.1093/alcalc/agx058Malet, L., Schwan, R., Boussiron, D., Aublet-Cuvelier, B., & Llorca, P. M. (2005). Validity of the CAGE questionnaire in hospital. European Psychiatry: the Journal of the Association of European Psychiatrists, 20(7), 484–9. https://doi.org/10.1016/j.eurpsy.2004.06.027Chung, T., Colby, S. M., Barnett, N. P., Rohsenow, D. J., Spirito, A., & Monti, P. M. (2000). Screening adolescents for problem drinking: performance of brief screens against DSM-IV alcohol diagnoses. Journal of Studies on Alcohol, 61(4), 579–87. https://doi.org/10.15288/jsa.2000.61.579Masur, J., & Monteiro, M. G. (1983). Validation of the "CAGE" alcoholism screening test in a Brazilian psychiatric inpatient hospital setting. Brazilian Journal of Medical and Biological Research = Revista Brasileira de Pesquisas Medicas e Biologicas, 16(3), 215–8. https://pubmed.ncbi.nlm.nih.gov/6652293/Fiellin, D. A., Reid, M. C., & O'Connor, P. G. (2000). Screening for alcohol problems in primary care: A systematic review. Archives of Internal Medicine, 160(13), 1977. https://doi.org/10.1001/archinte.160.13.1977Asadollahi, A., Kaveh, M. H., Saberi, L. F., Karimi, M., & Ahmad, N. (2023). Psychometric Properties of the CAGE Questionnaire Amongst Middle-Aged and Older Adults in Khuzistan Province of Iran. Journal of Cross-Cultural Gerontology. https://doi.org/10.1007/s10823-023-09470-w