Drug and Alcohol Dependence 132 (2013) 290–294
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Alcohol consumption among high-risk Thai youth after raising the legal drinking age Susan G. Sherman a,∗ , Bangorn Srirojn b , Shivani A. Patel a , Noya Galai a , Kamolrawee Sintupat b , Rupali J. Limaye a , Sutassa Manowanna b , David D. Celentano a , A. Aramrattana b a b
Johns Hopkins Bloomberg School of Public Health, United States Chiang Mai University, Thailand
a r t i c l e
i n f o
Article history: Received 24 October 2012 Received in revised form 9 February 2013 Accepted 17 February 2013 Available online 15 March 2013 Keywords: Under-aged drinking Methamphetamine users Legal changes Thai youth
a b s t r a c t Objective: Methamphetamine and alcohol are the leading substances abused by Thai youth. In 2008 the government passed laws that limited alcohol availability and increased the legal drinking age from 18 to 20. We assessed whether the law reduced drinking among methamphetamine-using 18–19 year olds in Chiang Mai. Method: The study compares drinking patterns among methamphetamine smokers aged 18–19 years (n = 136) collected prior to the legal changes, to a comparable post-law sample (n = 142). Statistical tests for differences between the pre- and post-law samples on problem drinking and recent drinking frequency and drunkenness were conducted. Logistic regression modeled the relative odds of frequent drunkenness, controlling for demographic characteristics. Results: A high prevalence of problematic drinking was present in both samples, with no difference detected. The post-law sample reported a significantly higher median days drunk/month (9 vs. 4, p ≤ 0.01); in adjusted analysis, frequent drunkenness (>5.5 days/month) was more common in the postlaw compared to pre-law period in the presence of other variables (AOR: 2.2; 95%CI: 1.3, 3.9). Post-law participants demonstrated a low level of knowledge about the law’s components. Conclusions: The study suggests that the new laws did not reduce drinking among high-risk, methamphetamine-smoking 18–19 year olds; rather, the post-law period was associated with increased drinking levels. The data indicate that the law is not reaching high-risk under-aged youth who are at risk of a number of deleterious outcomes as a result of their substance use. © 2013 Published by Elsevier Ireland Ltd.
1. Introduction As is the case throughout the world, alcohol is the most widely abused substance among adolescents and young adults in Thailand. Based on a national survey of school students, it is estimated that one in four men and one in seven women consumed alcohol in the past year, while roughly 10% of men and 4% of women reported binge drinking in the past month (Assanangkornchai et al., 2009). In a national household study, 18% and 7% of men and women, respectively, aged 12–19 years report drinking in the past 12 months; among these, 5% and 3% reported drinking daily (Assanangkornchai et al., 2010). The public health burden of alcohol consumption in Thailand is not minor; alcohol plays a role in 90% of road casualties in Thailand, resulting in 37 lost lives per day (National Economic and Social Development Board, 2005). In the general population,
∗ Corresponding author at: Johns Hopkins Bloomberg School of Public Health, Epidemiology, 615 N. Wolfe Street, E6543, Baltimore, MD 21205, United States. Tel.: +1 410 614 3518; fax: +1 410 955 1383. E-mail address:
[email protected] (S.G. Sherman). 0376-8716/$ – see front matter © 2013 Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.drugalcdep.2013.02.023
12.1% of all Disability-Adjusted Life Years (DALYs) among men and 1.2% of DALYs among women are due to alcohol consumption (Rehm et al., 2009). Methamphetamine (MA) use is as common as alcohol use among young men and women in the general population in some regions of Thailand (Ruangkanchanasetr et al., 2005). MA is the most commonly used illegal substance in Thailand (Verachai et al., 2001; Farrell et al., 2002), with the estimated number of MA users having increased from 850,000 in 1999, to more than 2.5 million in 2002 (Thailand Narcotics Annual Report, 2003). The largest increase was among males aged 12–24. MA smoking in Thailand has reached epidemic proportion among young Thais (Farrell et al., 2002; Melbye et al., 2002; Sattah et al., 2002; Razak et al., 2003), and MA has been shown to be independently associated with a number of deleterious sexual (i.e., inconsistent condom use, multiple sex partners) and other risk behaviors such as fighting and motorcycle accidents; Kipke et al., 1995; Molitor et al., 1998; McNall and Remafedi, 1999; Nemoto et al., 2002). Concurrent alcohol use among MA users is common and may lead to greater harm for those engaging in both behaviors. A study conducted among adolescents in Chiang Rai (n = 1725) found that
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alcohol consumption in the past three months was associated with a four-fold greater odds of MA use after controlling for other factors (Sattah et al., 2002); similarly, young people who consumed alcohol were more likely to use illicit substances in a national survey of students (Assanangkornchai et al., 2009). In our previous work among Chiang Mai youth aged 18–20 years with a history of MA use and heavy alcohol consumption, we found alarmingly high rates of sexually transmitted infections (24% positive for Chlamydia and 6% positive for gonorrhea; Celentano et al., 2008), higher subsequent depressive symptoms among current MA users (Sutcliffe et al., 2009), and higher risk of incarceration for MA users who consumed alcohol (Sherman et al., 2010). Governments worldwide have imposed regulations in an effort to reduce both the demand and negative outcomes associated with alcohol consumption, particularly among youth (McCartt et al., 2010, 2009). In Thailand, the rise in morbidity and mortality associated with high rates of underage alcohol consumption prompted the passage of new laws in February 2008 that govern both alcohol availability and increasing the legal drinking age from 18 to 20 years old. The laws ban certain alcohol advertisements, restricted selling hours for alcohol, and prohibited alcohol sales as well as consumption in educational, religious, and recreational venues as well as government offices and public parks (Alcohol Beverage Control Laws, 2008). The laws describe alcohol as a threat to “health and family” which “affect the overall social and economic condition of the country,” and aims to reduce these negative impacts by protecting children and youths against easy access to alcohol beverage (Alcohol Beverage Control Laws, 2008, p. 13). Structural and economic changes such as increasing the legal drinking age, restricting alcohol availability, price increases through taxation, reduction in alcohol advertising, and restrictions on alcohol availability have successfully reduced youth alcohol consumption (Kuo et al., 2003; Makowsky and Whitehead, 1991; Treno et al., 2003). However, such interventions may not impact high-risk youth, like MA users, in the same manner. The effect of such broad structural interventions targeting alcohol consumption among high-risk youth has not been previously examined in the Southeast Asian setting. The current study compares drinking patterns among 18–19 year old MA users prior to and after the legal changes, by examining if the legal changes are associated with reduction in problem drinking, frequency of drinking and frequency of drunkenness among these high-risk youth. We also report additional alcohol related knowledge and behaviors among these youth after the laws were enacted. Given the deleterious impact and pervasiveness of both MA and alcohol use, we were interested in exploring how the legal changes specifically impacted MA-using youth.
2. Methods 2.1. Sample recruitment The study population comprises samples recruited before (referred to as “pre-law”) and after (referred to as “post-law”) the implementation of the Alcohol Beverage Control laws in February 2008. The pre-law sample was recruited as a part of randomized behavioral trial examining the effect of peer-educator, network-oriented intervention on HIV risk behaviors and sexually transmitted infections, and has been described in detail previously (Sherman et al., 2009). Between April 2005 and June 2006, prelaw participants were recruited from bars, restaurants, nightclubs, and karaoke clubs. Recruitment sites were informed by an extensive 18-month formative, ethnographic research stage prior to the development and implementation of the trial (German et al., 2006; Sherman et al., 2008).
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Index participants were eligible for the parent trial if they were between the ages of 18 and 25 at screening, used methamphetamine at least three times and had sex at least three times in the past three months, and were able to enroll at least one of their sex or drug network members in the study within 45 days of screening. Participants were excluded if they refused to have blood drawn or provide urine, if they were enrolled in another prevention study, or if they refused to provide locator information. Of 1263 young adults screened, 1189 were eligible (94%) and 983 (78%) were enrolled (415 index participants and 568 members of their drug and/or sexual networks aged 18–25 years). For the prelaw comparison group in the current study, we used data from the baseline pre-intervention visit from randomly selected 18 and 19 year old index participants (n = 136) who were matched on gender with the post-law sample (n = 142). The post-law sample was recruited between March and June 2010 through methods parallel to those used for the pre-law recruitment. Twenty-seven pre-law study participants were contacted to verify the usefulness of recruitment venues used in the pre-law sample as well as to provide additional recruitment venues for MA using youth. The inclusion criteria were the same as those described above. Both studies were approved by the Institutional Review Board (IRB) at Johns Hopkins Bloomberg School of Public Health and the Human Experimentation Committee at the Research Institute for Health Sciences, Chiang Mai University. 2.2. Data collection Pre-law survey data were collected via an intervieweradministered survey, which included questions on the participant’s sociodemographic background, substance use and alcohol history, sexual history, and involvement in the drug economy. Post-law survey data were collected by interviewers on a personal digital assistant (PDA) and ascertained questions on participant’s sociodemographic background, substance use and extensive alcohol history. Participants in both studies were compensated 200 baht ($5 USD) for completing the survey and providing a urine sample. 2.3. Measures The outcome of interest, alcohol consumption, was measured by the total number of days in the past 30 days that the participant reported drinking alcohol (frequency of drinking in the past month; drinking days/month) and the total number of days in the past 30 days that the participant reported being drunk from alcohol (frequency of drunkenness in the past month; drunken days/month). Problems with alcohol were measured using the four-item Cut down, Annoyed, Guilty, Eye-opener (CAGE) tool, using the standard cutoff of two or greater (Ewing, 1984). MA use was measured as the frequency (days) of MA use in the past month. Socio-demographic characteristics of interest included age, religion, education level, student status, residence (living with family versus elsewhere), and average monthly income over the past three months were collected for both samples. For the post-law sample only, we additionally asked about knowledge of the legal restrictions, source of alcohol, preferred drinking locations, and possession of a fake ID. 2.4. Statistical analysis Sample socio-demographic composition is reported and the pre- versus post-law samples are compared using chi-square tests for categorical variables. Monthly income and frequency of MA use were categorized into tertiles based on the combined sample. Median and interquartile range values (IQRs) are reported for
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Table 1 Sample characteristics.
Demographic characteristics Male 18 years old Buddhist Completed high school Currently studying Median monthly income, USD (IQR) Alcohol and MA behaviors 2+ CAGE score Median drinking days/month (IQR) Median drunk days/month (IQR) Past month MA use 0–3 days 4–10 days >10 days * **
Pre-law n (%) n = 136
Post-law n (%) n = 142
p-Value*
108 (79.4) 88 (64.7) 132 (97.1) 14 (10.29) 64 (47.1) 113 (85–177)
113 (79.6) 83 (58.5) 134 (94.4) 40 (28.2) 54 (38.0) 123 (85–142)
0.97 0.28 0.27 <0.01 0.13 0.64**
101 (74.3) 17.5 (8–24.5) 4 (1–10)
114 (80.3) 19 (12–25) 9 (2–20)
0.23 0.27** <0.01**
63 (46.3) 41 (30.2) 32 (23.5)
49 (34.5) 51 (35.9) 42 (29.6)
0.13
p-Values are based on chi-square tests except where indicated by (**). p-Values based on Wilcoxon rank-sum test.
Table 2 Relative odds of frequent drinking and drunkenness among 18–19 year olds with a history of MA use after raising the legal age for alcohol consumption from 18 to 20 years (n = 278). Frequent drinking (>18 days/month)
Post-law sample (ref = pre-law) * **
OR
95% CI
1.1
0.7
Frequent drunkenness (>5.5 days/month)
Adjusted*
Unadjusted
1.8
Adjusted**
Unadjusted
OR
95% CI
1.0
0.6
1.6
OR
95% CI
2.3
1.4
3.7
OR
95% CI
2.2
1.3
3.9
Adjusted for income, MA frequency, age, and high school completion. Adjusted for above factors and for monthly frequency of drinking (in days).
continuous variables with skewed distributions; between-sample differences are compared using nonparametric rank-sum tests. Frequency of drinking and drunkenness were each dichotomized by the median values of the combined sample. “Frequent drinking” was defined as above-median number of drinking days/month, while “Frequent drunkenness” was defined as above-median number of drunken days/month. Unadjusted and adjusted logistic regression was used to assess the effect of the legal changes on frequent drinking and frequent drunkenness, in separate models, controlling for age, high school completion, residence, income tertiles, and tertiles of MA frequency. The model for frequent drunkenness included frequent drinking as an explanatory variable. Knowledge and practices related to alcohol reported by the post-law sample are described. All analyses were performed using SAS 9.2 software (SAS Institute Inc, Cary, North Carolina).
monthly income, and MA use frequency, frequent drinking (>18 days/month) was not associated with the change in the law. Controlling for age, high school completion, monthly income, and MA use frequency, and frequent drinking, frequent drunkenness (>5.5 days/month) was more common in the post-law period (AOR: 2.4; 95%CI: 1.3, 3.9). Table 3 displays post-law participants’ knowledge of the law. Participants correctly knew a median of six (60%) of ten alcohol related restrictions that were asked [data not shown]. Most participants (97%) believed that the legal drinking age was still 18 years. Though underage, 68% reported their most frequent location for drinking to be a public venue where alcohol was served; the majority (93%) reported purchasing alcohol directly from the vendor (i.e., no middleman). Only 3% of participants reported having a fake ID card. 4. Discussion
3. Results Demographic and substance use characteristics are displayed in Table 1. The pre- and post-law samples had an average age of 18.4 years old and the large majority of the sample was Buddhist. The pre-law sample was significantly less likely to have completed high school (10% vs. 28%, p < 0.01) compared to the post-law sample. There were no significant differences between samples regarding the median reported number of drinking days per month but the post-law sample reported a significantly higher median days drunk per month (9 vs. 4, p < 0.01). Liquor was the most common drink consumed followed by beer in both samples, and both had high rates of problematic drinking as indicated by the CAGE. MA use was similar across both samples, with the majority reporting use at least four days per month. Table 2 shows the results of two multivariate models, examining correlates of frequent drinking and frequent drunkenness, respectively. Controlling for age, completion of high school,
The current study found that restrictive federal drinking laws, which included raising the legal drinking age from 18 to 20 years old, did not decrease drinking levels among high-risk youth aged 18–19 years in Chiang Mai, Thailand. Comparing a sample of youth recruited several years before to a sample recruited over one year Table 3 Alcohol related knowledge and practices among the post-law sample (n = 142). n (%) Believe that the legal drinking age is still 18 Most common drinking locations Private locations (e.g., within home) Public venue, not alcohol-oriented (e.g., school, temple) Public venue, alcohol-oriented (e.g., bar, club, alcohol stall) Most common alcohol source Purchased by others Purchase directly from market (e.g., bar, grocery store) Owns fake ID
138 (97) 34 (24) 5 (4) 96 (68) 10 (7) 132 (93) 4 (3)
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after the legal changes, no reductions were reported in a high number of drinking days per month. To the contrary, more than twice as many drunk days per month were reported after the legal change in our sample. Very few post-law participants knew that the law changed the legal drinking age; only 4% of the sample reportedly aware that the drinking age had increased. While both preand post-law participants were identified at drinking venues, postlaw participants were legally underage for alcohol consumption and purchase at the time of recruitment. Despite this, most (97%) post-law participants reported not owning fake IDs. This indicates the continuing ease of alcohol accessibility, despite current legal restrictions prohibiting consumption and purchasing, among this age group. In summary, the law seemed to have limited effect on the drinking patterns and levels of problematic drinking among a sample of high-risk youth. The study underscores the importance of the manner in which laws are implemented, with the simultaneous need to enhance knowledge of the legal changes and enforce the restrictions at drinking venues. Participants reported low levels of awareness of the legal changes, which could have been attributed to an ineffectual implementation or lack of publicity around the changes. Sustained high rates of drinking among the sample population could be attributed to these factors, in addition to a lack of enforcement. This study is based on a high-risk population. All participants have a history of MA use, and over half of each pre- and postlaw samples reported MA use more than three times in the past month. The vast majority of participant concurrently reported alcohol-related problems, according to the four-item CAGE score. Two-thirds of both samples reported a score of two or above on the CAGE, indicative of problematic drinking. The combined MA history and the CAGE score reflect that this population may be particularly at risk for harms associated with alcohol use. To the best of our knowledge, there is no other study of the effect of heightened legal restrictions for alcohol consumption and purchase among such high-risk youth in Thailand. Our findings may point to a secular change in the pattern of alcohol consumption among high-risk youth. While frequency of drinking was stable across both samples, the reported median of nine days drunk in the past month by the post-law sample was twice that of the pre-law sample. We observed the same pattern among those aged 20 and older in the parent study (excluded from present analysis; data not shown). The results potentially signal a rise in excessive alcohol consumption, while overall frequency of drinking remains unchanged. The findings should be viewed in light of several limitations. The pre-post study design prevents us from examining causal effects of the legal changes on drinking behaviors, because we are unable to measure and account for all the factors that may confound observed associations between youth drinking behaviors and the legal changes. Our study population was relatively small (n = 278). While there was a risk of sampling bias due to recruitment time periods and locations, the variety of recruitment venues and our study staff’s extensive research experience with the current population mitigated this concern. Moreover, most background characteristics and the frequency of MA use, an important characteristic of the compared samples, did not significantly change over time. Given the inclusion criteria for both samples, the study’s generalizability is limited to high-risk youth in Chiang Mai. Both the pre- and post-law samples were restricted to sexually active MA users because the pre-law sample was originally recruited for a randomized trial aimed to reduce MA use and HIV risk behaviors (Sherman et al., 2009). Our participants reported drinking a median of more than 15 days per month, relatively high compared to other samples of similarly aged youth in the general population (Ruangkanchanasetr et al., 2005). Additionally, data were collected through two different self-report methods, paper survey and PDA,
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which are both subject to social desirability and distinct forms of data collections. In light of these limitations, the study provides insights into the degree of harmful alcohol consumption among risky youth subsequent to national legal changes targeting youth drinking. A number of factors influence the effectiveness of laws on the books, primary of which is the nature of their implementation. More robust quantitative research is needed in Thailand about the effects of the law in a broader cross sample of under-aged youth. Additionally, qualitative research could inform the nature of the law’s implementation. In the US, research on the effects of legal changes in drinking ages played a role in informing political debates that resulted in raising the legal drinking age in numerous states in the 1980s (Wagenaar, 1993). Most post-law participants (68%) reported purchasing alcohol from grocery stores or at venues serving alcohol, while only 7% of these under-aged individuals reported obtaining alcohol for consumption from others. Seemingly minimal attention has been paid to the law’s implementation, based on both low knowledge and ease of access that continues after the passage of restrictions. Among this high-risk population, the data indicate no changes in drinking patterns except for increased frequent drunkenness, reflecting the ineffectiveness of legal changes several years after the law had been implemented. The new Thai drinking laws failed to create an environment that reduced harmful alcohol consumption among 18–19 year old patrons frequenting popular drinking venues. Our study did not demonstrate reductions among high-risk youth and underscores the lack of effectiveness of the law for its intended consequences. Additional efforts are needed to abate the prevalence of drinking and alcohol-related morbidities among Thai youth who are high-risk for substance abuse. Role of funding sources This study was funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The NIAAA had no role in executing the study or this manuscript. Contributors S.G. Sherman, MPH, PhD: principal investigator of the project, conceptualized the study and wrote the first draft of the manuscript. S. Bangorn, MA: director of the project, and oversaw participant recruitment and data collection and manuscript review. SA Patel MPH conducted all analyses for the manuscript and helped with the writing of the paper. K. Sintupat, BA: data manager and translator. R. Limaye, MPH: instrument development, analytic design and data interpretation. S. Manowanna, MA: assisted in data collection and managemnt. D.D. Celentano, ScD: co-investigator, design of the study and manuscript review. S.G. Sherman, MPH, PhD: principal investigator of the project, designed study, manuscript development and review. All authors contributed to and have approved the final manuscript. A. Aramrattana, MD, PhD: co-investigator, executed the protocol and manuscript review. Conflict of interest statement No conflict declared. References Alcohol Beverage Control Act. 2008. Thailand Ministry of Justice. Assanangkornchai, S., Mukthong, A., Intanont, T., 2009. Prevalence and patterns of alcohol consumption and health: risk behaviors among high school students in Thailand. Alcohol. Clin. Exp. Res. 33, 2037–2046. Assanangkornchai, S., Sam-Angsri, N., Rerngpongpan, S., Lertnakorn, A., 2010. Patterns of alcohol consumption in the Thai population: results of the National Household Survey of 2007. Alcohol Alcohol. 45, 278–285. Celentano, D.D., Sirirojn, B., Sutcliffe, C.G., Quan, V.M., Thomson, N., Keawvichit, R., Wongworapat, K., Latkin, C., Taechareonkul, S., Sherman, S.G., Aramrattana, A., 2008. Sexually transmitted infections and sexual and substance use correlates among young adults in Chiang Mai, Thailand. Sex. Transm. Dis. 35, 400–405. Ewing, J.A., 1984. Detecting alcoholism. The CAGE questionnaire. JAMA 252, 1905–1907.
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