Objective and design:To assess the role of alcohol in drowning associated with recreational aquaticactivity by reviewing the English language literature published up to October 2003.Results:Alcohol is widely used in association with recreational aquatic activity in the United States, butthere is minimal information regarding the extent of use elsewhere. A priori and anecdotal evidencesuggests that alcohol is an important risk factor for drowning associated with recreational aquatic activity.Specific studies provide good evidence supporting this, but the extent of increased risk associated withalcohol use, and the attributable risk due to alcohol use, is not well characterised. Drowning appears to bethe overwhelming cause of death associated with recreational aquatic activity with alcohol detected in theblood in 30%–70% of persons who drown while involved in this activity. The few relevant studies on degreeof increased risk suggest persons with a blood alcohol level of 0.10 g/100 ml have about 10 times the riskof death associated with recreational boating compared with persons who have not been drinking, but thateven small amounts of alcohol can increase this risk. The population attributable risk seems to be in therange of about 10%–30%.Conclusions:Alcohol consumption significantly increases the likelihood of immersions resulting indrowning during aquatic activities. However, more information is required if appropriate preventionactivities are to be planned, initiated, and evaluated. This includes better information on alcohol use, andattitudes to alcohol use, in association with recreational aquatic activity, and the nature and extent ofincreased risk associated with alcohol use. Evaluation of interventions is also needed.