Mental Health Institute, WHO Collaborating Research Center for Abuse and Health, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
* Author to whom correspondence should be addressed: Email bmwhomhi{at}cs.hn.cn
(Received 1 April 2003; first review notified 8 September 2003; in revised form 16 October 2003; accepted 24 October 2003)
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ABSTRACT |
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INTRODUCTION |
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SUBJECTS AND METHODS |
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Instrument
An alcohol use and health status survey questionnaire provided by WHO, with minor modifications for social and cultural background, was used for assessing demographic characteristics (e.g. gender, age, ethnic group, occupation, current marital status, education level, family income per person per month, self-assessment on family income), drinking patterns and effects (frequency of drinking, amount of alcohol per occasion, beverage preference, acute alcohol intoxication, cost of drinking in the past week and heavy drinking), health status-related drinking, and physical and psychological diseases suffered in the past year. A copy of the survey questionnaire can be obtained on request from the first author.
An alcohol related-problems screening test (APST) was developed based on the Diagnostic Interview Schedule (DIS) (which was used in the author's survey of 1993; Hao et al., 1998a). Each item in the test has two possible answers, yes or no. Items 1 and 2 deal with drinking amount and frequency, and items 311 are for acute intoxication, craving, physical dependence, withdrawal symptoms and social dysfunction problems. If two yes answers were given (one of which must relate to items 1 or 2), a positive result was obtained.
The structured interview on drinking-related problems focused mainly on the diagnosis of alcohol-related psychiatric disorders based on DSM-III-R (American Psychiatric Association, 1987) criteria and was also used in the author's survey of 1993. A hierarchical diagnostic system was adopted in diagnosing abuse and dependence, uncomplicated alcohol withdrawal and withdrawal delirium, and alcohol amnestic disorder and dementia associated with alcoholism.
The survey took place during the period September 16October 31, 2001.
Quality control
Interviewers were psychiatrists with at least 5 years clinical experience and experience of epidemiological surveys, and they were trained using a standard training manual for 7 days prior to the interviews. Lecture presentations were used to explain the purposes of the survey and the variables of the questionnaires, the conception of psychoactive substance misuse and dependence, and the diagnostic criteria of psychoactive substances in DSM-III-R. A pilot study was conducted after training in each site.
In order to maximize the rate of response, interviewers were trained in techniques for gaining entry to a household and maintaining rapport with respondents. Instructions also focused on guaranteeing respondents' anonymity, public relations with the community and seeking the help of community leaders. After each interview, the questionnaire was checked by the interviewers. If certain items had been missed, the participant was requested to complete them.
Statistical methods
For categorical data and ordinal categorical data, chi-squared statistics with Yates' continuity correction test and the chi-squared test of linear trend (Su, 2002) were used respectively. Student's t-tests, dependent and independent, were used for comparison of group means and one-way analysis of variance (ANOVA) was used for comparison of group means and the post hoc test for multiple comparisons. Stepwise regression models (Huang, 1995
) were developed using the self-rating of health status and the variables on sociodemographic characteristics, drinking and smoking. Two tailed P-values were considered to be significant at <0.05. SPSS version 11.0 for Windows was used for all data analyses.
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RESULTS |
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Demographic characteristics
As shown in Table 1, data from 24 992 cases were gathered in the five areas. There were significant differences among the five areas in age (F = 105.483, P < 0.0001), education level (F = 826.194, P < 0.0001) and marital status (F = 463.914, P < 0.0001). The ratio of men (n = 13 992) to women (n = 11 000) in the total sample was 1.00:0.79, with the proportions in four areas (except JN) consistent with that of the country census data of 2000. The average age of the respondents was 40.2 years (SD = 15.6). The mean age of men (mean 40.4, SD 15.4) was significantly higher than that of their female counterparts (mean 39.6, SD 15.8; P < 0.0001). Han national constituted 87.0% of the sample, Korean comprised 12.6%, with the proportion of Korean people being significantly higher in YJ (2 = 13 582.166, d.f. = 4, P < 0.0001). 75.4% of respondents were married. The education level of the men (mean 9.1 years, SD 3.8) was significantly higher than that of the women (mean 8.0 years, SD 4.1) with the average years of education being 8.6 (SD 4.0) among all respondents (t = 22.182, P < 0.0001). The average family incomes in CD, YJ, JN and HY were significantly higher than that in FY (F = 770.259, P < 0.0001).
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The average (±SD) annual consumption per capita in pure alcohol among all respondents aged 15 years or above was 4.47 ± 10.93 l. Men drank 13.4 times more than women (P < 0.001). The average annual consumption in pure alcohol for male, female and total 1-year drinkers was 10.1, 1.5 and 7.6 l, respectively. Heavy drinkers defined as those who had more than 50 ml (40 g) or more pure alcohol per day accounted for 6.7% (1674/24 992) of the sample, and consumed 55.3% of the total alcohol consumption.
Unrecorded alcoholic beverage consumption
In China, home-brewed alcohol beverages, tax-free beverages and counterfeited alcohol beverages (unscrupulous merchant-produced illicit alcohol beverages marketed as famous brands), were regarded as unrecorded alcohol beverages. The 3-month use rate and amounts of the unrecorded alcohol beverages consumed were higher in both HY and CD than in the other sites (2 = 2779.664, d.f. = 4, P < 0.0001).The 3-month use rate of the unrecorded alcohol beverages was 7.1% (1761/24 992) among all the respondents, the most frequent types of unrecorded alcohol beverages being rice wine and paddy wine. The proportion of unrecorded alcohol beverage accounted for 14.9% of total alcohol consumption, and those in CD and HY sites were 25.5 and 29.9% of each site's consumption, while the other three sites accounted for less than 1% each.
Types of beverages consumed
Preferences expressed by men and women are shown in the Table 4. Beer was the first choice of the all respondents, more than a half of the 1-year drinkers having consumed beer in the past year. Strong distilled spirits and weaker distilled spirits were the second and third choices in men, while grape wine was the second choice in women. Strong distilled spirit, beer and weaker distilled spirit were the main types of beverages consumed in China in the past year, accounting for 35.6, 24.4, 20.5 and 80.1%, respectively, of the overall alcohol consumption.
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Health status related to drinking
All respondents across the five areas self-assessed their health status using a structured questionnaire, in which the respondents had five choices: (1) very good; (2) good; (3) fair; (4) bad; (5) very bad. Physical and psychological diseases suffered in the 12 months preceding the interview were also recorded. The respondent rate was 96.1% (24 020/24 992). The results showed that the a significant difference existed between the drinkers and the non-drinkers in terms of self-rated health status, 16.8% of the drinkers and 22.6% of the non-drinkers considered that they were in very good health, and 3.0 % of the drinkers and 7.8 % of the non-drinkers thought that they were in bad or very bad health (2 = 297.493, d.f. = 4, P < 0.0001) (see Table 5). Considering influence of age and sex on health status, comparison of self-rating health status between 1-year drinkers and abstainers was stratified by sex and age. The results of self-rating level of health status among sex and age groups were inconsistent; so the sex and age might be confounding factors for health status (see Table 6).
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DISCUSSION |
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In this study, 24 992 respondents in five areas of China were interviewed by using a questionnaire on drinking behaviour and health status related to drinking provided by WHO. The results showed the 1-year drinking rate in the whole sample was 59.0%, which was almost equivalent to the survey done by authors in same areas in 1993 (Hao et al., 1998a). The 1-year drinking rate in men was 74.9%, a decrease of 10% compared with results obtained in 1993. The drinking rate in women was 38.8%, an increase of almost 10% compared with the 1993 results. The ratios of male-to-female drinking rates and annual alcohol consumption in pure alcohol were 1.9:1.0 and 13.4:1.0, respectively. The figures verified the prediction that the numbers of women drinking would increase in the 21st century, as in many other developed countries (Hao et al., 1995
). The women's liberation movement, changes of women's role in society and increasing of numbers of professional women in China are factors for explaining the reason for the increase in the female drinking rate. However, the ratio male-to-female drinking rates was still broader than that in industrial countries (Martin and Hubbard, 2000
). Since the Family Planning Policy was adopted in China, the number of single-child families has increased, children from these families have viewpoints (including those concerning alcohol drinking) that differ from those who were born before the Cultural Revolution (19661976). As China enters into the World Trade Organization (WTO) and there is even more rapid development in China's economy, the authors predict that the drinking rate in women will continue to increase, and that the ratio of male-to-female drinking will narrow in the coming decade.
Per capita alcohol consumption in pure alcohol for adults is an essential predictor of alcohol-related problems. Based on WHO data, the growth rate of per capita alcohol consumption was 402% from 1970 to 1996 (World Health Organization, 1999). In this study, the average annual alcohol consumption for individuals aged 15 years or above was 4.47 l; an increase of 0.87 l has taken place over the past 8 years, as indicated by the results of the 1993 survey (Hao et al., 1998a
).
In our survey, heavy drinkers were defined as those who used 50 ml or more pure alcohol per day. The results showed that 6.7% (1674/24 992) of the whole sample were heavy drinkers, who consumed 55.3% of the total alcohol consumption. It suggests that the heavy drinkers were the risk group for alcohol-related problems in the selected areas. The figure for average annual alcohol consumption was still low compared with that of the developed countries (World Health Organization, 1999), which was about 10.0 l yearly. For example, the recorded per capita consumption of pure alcohol per adult 15 years of age and over in 1996 was 11.90 l in Austria, 11.67 l in Germany, 11.27 l in Switzerland, 9.62 l in Italy, 9.55 l in Australia, 9.41 l in the UK and 8.90 l in the US. The current global trends on alcohol use were that per capital alcohol consumption in developed countries was decreasing sharply, and increasing steadily in developing countries. However, it is difficult to predict what the peak level of alcohol consumption is and when it will be reached in China. Thus, it is necessary to monitor the changes in the future in China.
The survey on unrecorded alcohol beverages could provide data with which to estimate the alcohol consumption in regions or nations. In the countries of the former Soviet Union and in many developing countries, alcohol production for home use or for the informed sector is extremely important, being as high as 80% of the total alcohol available for consumption. Reliable data exist regarding consumption of these forms of alcohol in more than 20 countries (World Health Organization, 1999). In China, people usually get alcoholic beverages from shop, restaurants or bars. In this study, counterfeit alcoholic beverages and home- and privately-brewed alcoholic beverages are defined as unrecorded. The results showed that 7.1% of respondents reported that they had used between one and three types of unrecorded alcoholic beverage in the 3 months prior to the interview, the amount of unrecorded alcoholic beverage (in pure alcohol) accounted for 14.9% of overall alcohol consumption in the five areas studied. However, the amount of unrecorded alcoholic beverage consumed varied across the five survey areas. For example, the rates of unrecorded alcoholic beverage use in HY and CD were 24.1 and 9.7%, respectively; the amounts of these beverages as a proportion of the overall alcohol consumption were 29.9 and 25.5%, respectively. However, the number of unrecorded alcoholic beverage users and the volume of beverage consumed was insignificant in other three survey areas. The differences in unrecorded alcoholic beverage consumption among the survey areas are related to specific drinking customs in HY and CD, where the population, especially those in rural areas, traditionally use home-brewed alcohol. We can conclude that unrecorded alcoholic beverages play an important role in the alcohol consumption in certain areas in Southern China. However, the survey is not representative of the total national population, because China is a large country with various drinking and brewing customs. It is necessary to carry out further surveys in more areas to reveal the true unrecorded alcoholic beverage consumption in China.
Alcohol use is related to a wide range of physical, mental and social harms. Most health professionals now agree that practically no organ in the body is immune to alcohol-related harm (Bower, 1992). A number of conditions have been identified that are wholly caused by alcohol use, and other conditions have been identified that are partly caused by alcohol use. Over the last two decades, many researches have found a decrease in all-cause mortality among certain light-to-moderate drinkers of alcoholic beverages compared to non-drinkers and heavy drinkers; light-to-moderate drinking of alcohol apparently being protective against heart disease.
The relationship between health level and alcohol consumption of the population as a whole is not yet clear. Our survey was designed to determine health status related to drinking and incidences of physical and psychological conditions in drinkers and non-drinkers in five areas of China and to examine the causality relationship between alcohol drinking and the occurrence of these conditions. The single variable analysis in this study showed that health status in drinkers was different from that in non-drinkers, and that age and gender were confounding factors to health status. The results of stepwise multivariable regression on self-rated health status revealed that some sociodemographic characteristics, including age, marital status, education and gender, were less important than were time since first use of alcohol and smoking. The results suggest that alcohol consumption has a slight association to health and that the health status of the general population was determined mainly by many risk factors, though drinking and smoking were primary factors.
Alcohol-related mental disorders were considered to be caused wholly by alcohol drinking. In this study, 5.1% of the general population living in five areas of China in the past year met the criteria for a diagnosis of alcohol-related mental disorder in DSM-III-R, which was lower than that of the national probability sample in the US in 1994 (World Health Organization, 1999). The point prevalence rate of alcohol dependence was 3.8%, with an increase of 0.4% compared with the survey conducted in the same areas in 1993 (Hao, 1998b), and the 3-month prevalence rate of acute intoxication was 8.3%, which was higher than that of the survey in 1993. Although the rate of alcohol-related mental problems in China rose during 19932001, it is relatively low compared with that of developed countries.
This study also indicates that the incidence of certain physical diseases, such as gastritis/ulcer and insomnia, increased with increased alcohol consumption. The influence of alcohol on the heart is a separate issue. Numerous studies have suggested that light-to-moderate alcohol consumption reduces the risk of heart disease (Renaud et al., 1993; National Institute on Alcohol Abuse and Alcoholism, 1999
; Murray et al., 2002
). The result of our survey was that morbidity from heart disease (including coronary heart disease and heart attack), cerebral infarction and cerebral haemorrhage was higher both in non-drinkers and in heavy drinkers than in light-to-moderate drinkers, suggesting the protective effect of alcohol against cardiovascular disease existed in the studied population, and was consistent with that of an epidemiological survey in the US (Klatsky, 1994
). However, the results of the chi-squared test of linear trend for ordinal categorical variables suggested the 1-year morbidities of alcohol-related physical diseases except gastritis/ulcer had no association with alcohol consumption.
Traditionally, Chinese people believe that moderate drinking has a good effect on health and Traditional Chinese Medicine theory says that alcohol is the leader of all kinds of medicine. There are some Chinese alcoholic beverage medicines on the market for the treatment of health problems such as back and leg pain caused by rheumatism and sexual problems (e.g. impotence). In a survey sample of 2064 individuals aged 18 years or older performed in Xi'an rural areas in 1998, 6.1% drank alcoholic beverages for health reasons (Tao et al., 2002). However, it is not clear whether drinkers in this survey were more likely to suffer from disc problems and back pains than non-drinkers. Further investigation is required for clarification.
In general, the association between health and alcohol drinking is not simple. Alcohol consumption plays a role in the development of so-called alcohol-related physical diseases. There is no doubt that other factors, such as lifestyle and environment, also impact on health status. The authors therefore conclude that the health status of the individuals aged 15 years or older in the selected areas of China studied resulted from the integrative effects of many risk factors.
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ACKNOWLEDGEMENTS |
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