ALCOHOL CONSUMPTION AMONG MIDDLE-AGED AND ELDERLY MEN: A COMMUNITY STUDY FROM WESTERN INDIA

Prakash C. Gupta, Shekhar Saxena1,*, Mangesh S. Pednekar and Pallab K. Maulik1

Tata Institute of Fundamental Research, Homi Bhabha Road, Colaba, Mumbai 400 005, India and
1 Mental Health: Evidence and Research, Department of Mental Health and Substance Dependence, World Health Organization, Geneva 27, CH 1211, Switzerland

Received 30 November 2002; in revised form 20 January 2003; accepted 27 February 2003


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Aims: To assess the prevalence and pattern of alcohol use in a middle-aged and elderly population in Mumbai, India. Methods: 50 220 men aged ≥45 years from the lower and lower-middle section of the general population were interviewed. Results: 18.8% were currently consuming alcoholic beverages, of whom 32.8% drank on at least 6 days per week. The most popular beverage was locally distilled products of fruits and grain (country liquor). Seventy-five per cent of the consumers of country liquor would consume over 53 g of ethanol on a day when they drank, with 46.6% of these doing so on at least 6 days per week. Conclusions: Abstinence, and also heavy and frequent use of alcohol, are common in this population and the latter is likely to have significant public health implications.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Alcohol use disorders have been prevalent across all societies. The pattern of alcohol use varies depending on age, religion, education, type of drink and other socio-demographic characteristics. The consumption pattern also varies between different cultures and societies and the last 20 years have seen substantial changes (Room et al., 2002Go). Alcohol use is increasing in developing countries, but reliable data are not available. Since 1970, 47% of developing countries in transition and 35% of developed countries have increased their consumption of absolute alcohol per adult (World Health Organization, 1999Go). Alcohol causes 4% of the total Disability Adjusted Life Years (DALYs) and alcohol use disorders account for 1.4% of the total burden of disease, according to recent estimates (World Health Organization, 2002Go). In view of the public health importance of alcohol-related health and social consequences, it is important to estimate the amount of alcohol consumed and gather information on the pattern of drinking. Such information is scarce from developing countries.

Alcohol has been consumed in India for centuries. A number of mythological and religious books have highlighted the role it played in society. The pattern of drinking in India has undergone a change from occasional and ritualistic use to being a social event. Today, the common purpose of consuming alcohol is to get drunk (Mohan et al., 2001Go). These developments have raised concerns about the health and the social consequences of excessive drinking (Saxena, 1999Go). Large or nationally representative epidemiological studies on alcohol consumption have not been carried out in India due to resource constraints. However, there have been a number of studies conducted on smaller populations in different regions of the country.

Studies in northern India found the 1 year prevalence of alcohol use to be between 25 and 40% (Mohan et al., 1978Go; Varma et al., 1980Go). In southern India, the prevalence of current alcohol use varies between 33 and 50%, with a higher prevalence among the lesser educated and the poor (Chakravarthy,1990Go). Mohan et al. (2001)Go conducted a survey in three districts (central, north and north-east India), which involved 32 000 people and used standardized questionnaires based on DSM III R (American Psychiatric Association, 1987Go). They reported a prevalence of current alcohol use of 20–38% in males and of 10% among females.

Fewer studies have assessed the prevalence among middle-aged and elderly populations. Sethi and Trivedi (1979)Go found alcohol misuse to be 11.3% among the 55–64 year age group and 16.8% among the 65–74 year age group in a rural population in north India. Varma et al. (1980)Go found 18.3% of the 50+ age group to be current users of alcohol and 23.3% to be ‘ever’ users of alcohol. Mohan et al. (2001)Go found current use of alcohol to vary between 19.6 and 27.8% amongst the 50+ age group in the three sites. Current heavy users, i.e. those consuming 75 ml or more of absolute alcohol in a day, accounted for between 79.9 and 84.1% of this 50+ age group of users.

The findings of the above studies need to be interpreted with caution, because they used relatively small samples, except for the survey by Mohan et al. (2001)Go. The operational criteria for ‘ever’ use, current use and dependence also varied considerably. However, some conclusions can still be drawn. These studies found that 60% or more of the adult population were completely abstinent. This is in marked contrast to most developed countries, where complete abstinence rates are much lower. The studies have shown that alcohol consumption rates are much higher among men than women. No clear findings for association of drinking with socio-economic categories are available, but there are indications to suggest that drinking may be more prevalent among lower categories and among the poorly educated.

We report here results pertaining to alcohol consumption obtained in a community survey carried out in the city of Mumbai (old name Bombay) as a part of a cohort study for estimating tobacco-attributable mortality. Information on alcohol use was collected only in the second phase of the recruitment of the cohort, which was restricted to males aged 45 years or over. The aim was to assess the prevalence and pattern of alcohol use in middle and old age. This is a baseline survey for a long-term cohort mortality study.


    MATERIALS AND METHODS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Mumbai is a large densely populated metropolitan city divided into three parts: the main city, suburbs and extended suburbs. The survey was confined to the main city, which is most densely populated, covering an area of about 70 km2 and was restricted to men aged 45 years and above.

The voters’ lists were used as the sampling frame. These lists provided name, age, sex and address of all individuals aged 18 years and over. The lists are fairly complete, since almost everyone is entitled to vote and registration is not necessary; lists are updated before every major election through house-to-house visits.

Once a list was selected, all individuals aged 45 years and above in the list were approached by investigators for interview. About 50% of individuals estimated to be eligible in the voters’ list were available for the interview. The selection of lists, however, was not random. The surveyed population largely consisted of individuals belonging to lower and lower-middle class, and apartment complexes that housed upper-middle and rich classes could not be included. The reasons were: (1) difficulty of approach due to their security precautions; (2) a lack of cooperation from these individuals, as they did not perceive any material gain from participation. The proportion excluded varied from area to area. Some areas that were known to be affluent, e.g. those containing apartment complexes, were completely excluded, whereas, in other areas, fewer than 10% of the sample were excluded (Gupta, 1996Go).

Sometimes individuals not listed on the voters’ list were also interviewed and included in the sample when they insisted that they have been permanent residents of the place. Such individuals formed about 5% of the sample. Their residence status was confirmed through a ‘ration card’ that is issued by the Bombay Municipal Corporation. Every household keeps it, because, apart from obtaining certain food items at subsidized prices, it functions as a residence card for access to all city and state government services.

The interviews were conducted by trained investigators using hand-held computers (electronic diaries) from June 1994 to June 1997. The details of the method have been published elsewhere (Gupta, 1996Go).

Alcoholic beverages used in Mumbai are divided into several types. India Made Foreign Liquor (IMFL) includes whisky, rum, brandy and gin distilled and marketed in India. For the present paper, IMFL has been divided into two groups ‘IMFL-whisky’ and ‘IMFL-others’. This was done as whisky is consumed in a much larger amount, compared with other IMFLs, and has been analysed separately. Country liquor is a distilled alcoholic beverage made from locally available sugar cane, palm, coconut or cheap grains and available in retail outlets under licence, though some unlicensed amount of the same is also available. Beer is also produced in India and sold through licensed outlets. The alcoholic content of these beverages was calculated by volume as 42% for IMFL-whisky, around 45% for country liquor and around 6% for beer. Past users were defined as those who had given up drinking for 6 months or more. Current and past users combined were ‘ever’ users.


    RESULTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Table 1Go outlines the socio-demographic profile of the interviewed population. A total of 50 220 men were questioned about their alcohol use. Current alcohol use was reported by 18.8% and past use by 4.9%. More than 76% of the individuals had ‘never used’ alcohol. The current use prevalence decreased rather rapidly in higher age groups (from 21.5% in the 55–59 age group to 5.7% in the 85+ age group). The ever use prevalence peaked to 27.5% in the 55–59 age group and declined thereafter. Differences according to the subjects’s first language were notable: the ever use prevalence was about 15% or less among Gujarati-, Hindi- and Urdu-speaking persons, vs over 40% among Kannada-, Malayalam-, Tamil-, Telugu-speaking persons (all these languages are spoken by people from South India). The prevalence was 29% among the Marathi-speaking persons, who constituted the largest group, being the predominant language of the area surveyed. The prevalence by religion showed even wider variations. The highest prevalence for ever use was among Christians (61.2%) closely followed by Buddhists (58.6%). The lowest prevalence was among Muslims (9.4%). The prevalence was high among illiterates (25.6%), peaked among those with primary education (27.1%) and then declined steadily to 18.1% among those with college education.


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Table 1. Prevalence of alcohol use in the community by age, language and religious group
 
Table 2Go shows frequency of alcohol intake among current users by age group of the user and type of drink. There was little variation by age. Daily drinking seemed to be somewhat more common in extreme age groups compared with middle ones. About a third of all drinkers (32.8%) reported drinking almost every day (six or more days per week), and over half (50.6%), four or more days per week. Country liquor and IMFL-whisky were the preferred drinks. Forty-three per cent of those drinking country liquor consumed it almost every day compared with 6.5% of those drinking beer.


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Table 2. Frequency of consumption of alcoholic beverages by current users according to the age of user and the type of beverage
 
Table 3Go shows the frequency of drinking of various quantities for those consuming IMFL-whisky. Results show that 37.7% of those who drank more than 100 ml of IMFL-whisky (>33.3 g of absolute alcohol), drank four or more times a week, whereas 63.9% of those who drank less than 100 ml of IMFL-whisky (<33.2 g of absolute alcohol), drank just about once a week or less.


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Table 3. Pre-coded quantities of beverage: numbers of current drinkers consuming these amounts, and frequencies of consumption of these amounts, separately for (a) IMFL-whisky, (b) country liquor and (c) beer
 
For country liquor, Table 3Go shows that only 9.6% reported drinking less than 100 ml (<35.6 g of absolute alcohol) in a day whereas 90.4% reported drinking more than 100 ml of country liquor (>35.6 g of absolute alcohol in a day); 76.4% of consumers of country liquor would consume over 53 g of ethanol on a day when they drank, 46.6% of whom would do that on at least 6 days per week. Most (93.1%) of the 422 individuals who reported drinking over 500 ml of country liquor (>177.8 g of absolute alcohol), drank almost every day.

Table 3Go shows results for those drinking beer. Consumption both by quantity (converted to grams of ethanol) and frequency was lower for beer, than for spirit drinkers.


    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
This community survey is one of the larger surveys ever done in India and one of the first looking at the pattern of drinking among the middle-aged and elderly population. The reliability of self-report data, always questionable in surveys of drinking, was aided by employing trained interviewers. The study included only middle-aged and elderly group males and did not include members of the more affluent community.

The high abstinence rate has been reported in other parts of India. The high abstinence rate among Muslims can be explained by the religious teachings of Islam. The high rate of drinking among illiterates was reported by Chakravarthy (1990)Go. Country liquor and IMFL-whisky accounted for 91.5% of the drinks consumed. Country liquor is the most frequently consumed type of alcoholic beverage, due to the extensive network of outlets serving country liquor and to its low price. Among IMFL, whisky is the most widely consumed type of alcoholic beverage.

The majority of current users of alcohol drank almost every day of the week. There seems to be a culture of heavy daily drinking among lower and lower-middle sections of the society in Mumbai, where working class men assemble around liquor shops every evening and enjoy drinking and socializing. This pattern is not unique to Mumbai. The frequency of drinking as well as the frequency of heavier drinking occasions are important dimensions of the social meaning of drinking, as well as a source of potential harmful consequences (Room, 2000Go). For indicating risk from alcohol consumption, different cut-off points have been used in different studies, e.g. more than 30 g of absolute alcohol per day as moderate risk by the British Medical Association (1995)Go and 40 g by English et al.(1995)Go. In this study, a very high percentage of current alcohol users (30.7% of those drinking IMFL-whisky and 55.1% of those drinking country liquor) consumed more than 30 g of absolute alcohol for more than 4 days/week. Amongst those drinking country liquor for more than 4 days/week, 33.9% were consuming more than 71.2 g of absolute alcohol per day. This finding is probably not unique to India, as some recent studies from other countries have also found similar skewed drinking patterns (Greenfield and Rogers, 1999Go; Assanangkornchai et al., 2000Go; Obot, 2001Go). A point of interest was that frequent beer drinkers were a minority in this population and also consumed lesser amounts of alcohol per day. This may be related to the high price of beer, compared with spirits for equivalent amounts of absolute alcohol.

Increased alcohol consumption is related to increased risk of mortality and morbidity due to physical illnesses (Duffy, 1992Go; Anderson, 1995Go; Thun et al., 1997Go). Thun et al.(1997)Go describe the J-shaped relation between alcohol consumption, cardiovascular disorders and mortality among the middle-aged and elderly. There is an exponential relation between the amount of alcohol consumed and criminal behaviour, including drunken driving and legal arrests (Midanik et al., 1994Go). Social functioning is also affected by the amount of alcohol consumed per day (Room et al., 1994Go; Klingemann and Gmel, 2001Go). Adequate policies, programmes and legislation to control alcohol problems should be implemented.

In the present study, the number of people consuming alcohol was found to be lower than, for example, in developed countries, but the amount of alcohol consumed by drinkers was high, which suggests the risk of serious public health problems. Steps that can be taken to reduce the impact of alcohol on society include raising taxes and other tariffs on alcohol, curbing advertisements of alcoholic beverages, strictly implementing regulations related to drunken driving and undertaking preventive programmes (Edwards et al., 1994Go). The policy implications for a country like India are immense, keeping in view that resources are few, while the frequency of heavy alcohol use appears to be rising.

Growing awareness of alcohol problems in India has been reflected in several recent policy initiatives (Saxena, 2000Go). Prohibition was undertaken in some states, but it largely failed to reduce alcohol-related problems and gave rise to some additional problems. Alcoholic beverages are highly taxed, but this has not kept pace with inflation, making alcoholic beverages relatively cheap. Advertisement of alcoholic beverages is not allowed, but companies find innovative ways of bypassing this restriction by surrogate advertising. The state governments are responsible for preventive strategies and treatment and are supported by community initiatives undertaken by non-governmental organizations and consumer groups. However, these measures have not been successful in limiting the consumption of alcoholic beverages. The extent of heavy drinking among the middle-aged and elderly revealed by this survey suggests the need for more effective public health policies and programmes.


    FOOTNOTES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
* Author to whom correspondence should be addressed. Back


    REFERENCES
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 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
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