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Drunkenness and its association with health risk behaviors among adolescents and young adults in three Asian cities: Hanoi, Shanghai, Taipei
Drug and Alcohol Dependence 147 (2015) 251–256
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Drunkenness and its association with health risk behaviors among adolescents and young adults in three Asian cities: Hanoi, Shanghai, Taipei Qianqian Zhu a,b , Chaohua Lou b,∗ , Ersheng Gao b , Yan Cheng b , Laurie S. Zabin c , Mark R. Emerson c a
School of Public Health, Fudan University, Shanghai 200032, PR China Department of Epidemiology and Social Science, Key Laboratory of Family Planning Device of National Population and Family Planning Commission, Shanghai Institute of Planned Parenthood Research, Shanghai 200237, PR China c Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205,USA b
a r t i c l e
i n f o
Article history: Received 29 May 2014 Received in revised form 25 October 2014 Accepted 25 October 2014 Available online 2 December 2014 Keywords: Adolescent Alcohol Drunkenness Heath risk behaviors Eastern Asian city
a b s t r a c t Purpose: To assess the prevalence of drunkenness among adolescents in Hanoi, Shanghai, and Taipei and explore the association between heavy drinking and other health risk behaviors. Methods: The data are drawn from the Three-city Collaborative Study of Adolescent Health, conducted in Hanoi, Shanghai, and Taipei in 2006. A sample of 17,016 adolescents and young adults, aged 15–24 years, was selected by multistage sampling. Descriptive analysis was used to estimate the proportion of drunkenness and other health risk behaviors. Multivariate logistic regression was used to investigate relationships between drunkenness and risky health behaviors. Results: The proportions of the sample getting drunk during the past month were 6.36%, 4.53%, and 8.47% in Hanoi, Shanghai, and Taipei, respectively. More males than females reported drunkenness in all three cities, with the difference highest in Hanoi (11.08% vs. 1.14%) and lowest in Taipei (9.69% vs. 7.18%). Different levels of relationship between drunkenness and health risk behaviors, such as anxiety, suicidal ideation, smoking, gambling, fighting, drinking and driving, and having sexual intercourse, were found across the three cities; an exception was nonuse of contraception. Conclusion: Drunkenness was positively associated with many health risk behaviors. It may serve as an indicator of other risky behaviors. Interventions to reduce drinking and drunkenness may contribute considerably to the prevention of other risk behaviors and to adolescent safety and well-being. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction As one of the most common health risk behaviors among adolescents and young adults, alcohol use seriously threatens their health and well-being. Alcohol is now the leading risk factor contributing to disability-adjusted life years in 10–24-year-olds globally (Fiona et al., 2011). According to a report by the World Health Organization (2011), alcohol is a factor in almost 10% of deaths among young people. The three most frequent forms of mortality among adolescents–accidental death, homicide, and suicide–are
∗ Corresponding author at: Shanghai Institute of Planned Parenthood Research, 779 Lao Hu Min Road, Shanghai 200237, PR China. Tel.: +86 21 64771589; fax: +86 2164771589. E-mail address: [email protected] (C. Lou). http://dx.doi.org/10.1016/j.drugalcdep.2014.10.029 0376-8716/© 2014 Elsevier Ireland Ltd. All rights reserved.
associated with alcohol use (Balogun et al., 2014). Its use among adolescents and young adults, especially excessive drinking, often leading to drunkenness, has become a major public health concern. Adolescence is the time when alcohol use typically begins and escalates. Alcohol is thought to be important in adolescent development and socialization as it helps young people to integrate with their peers and to negotiate their passage into the adult world (Hughes et al., 1997). Hughes et al. (1997) reported that children aged 12 and 13 years used alcohol to experience the adult world and to satisfy their curiosity, and those aged 14 and 15 were testing out their limits and getting drunk to share the experience with others. In the 2003 National Youth Risk Behavior Survey, Miller et al. (2007) found 44.9% of US high school students reported drinking alcohol during the past 30 days, and 28.8% reported binge drinking. A Web-based survey from ten North Carolina universities revealed
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63.6% of students described themselves as current (past 30 days) drinkers, and 35% reported getting drunk at least once a week (O’Brien et al., 2006). Although excessive drinking has been a relatively common behavior among adolescents in western countries, little is known about adolescent drunkenness in Asia. To fill this gap, we conducted a cross-sectional study to evaluate drunkenness among adolescents and young adults in three Asian cities – Hanoi, Shanghai, and Taipei – which have shared the same Confucian-based culture for thousands of years. With an emphasis on moderation, Confucianism has likely provided some constraint to excessive drinking (Iris and James, 1989; Weatherspoon et al., 2001) and may possibly mitigate the risk associated with alcohol use. However, in the past several decades, Hanoi, Shanghai, and Taipei have been undergoing marked sociocultural change in the wake of modernization, rapid industrialization, and globalization, accompanied by the adoption of more Western lifestyles. The gradual erosion of traditional Confucian values influences attitudes toward drinking and alcohol consumption; consequently, western drinking practices are gradually becoming accepted, especially among young people. As these three cities have opened to the West at different times (Taipei has the longest exposure to the West, Hanoi’s exposure is the most recent, and Shanghai is between the two), traditional values may have eroded to different extents, and western drinking patterns, especially excessive alcohol consumption leading to drunkenness, may also have been adopted at different levels. We hypothesize that the prevalence of drunkenness varies across the three cities; specifically, the longer the city has been exposed to the West, the higher the prevalence of drunkenness. Adolescence is an important transition period when many adolescents can get involved in different problem behaviors such as smoking, alcohol use, and fighting (Guilamo et al., 2005). According to Jessor’s problem behavior theory (Jessor and Jessor, 1977), adolescents’ involvement in any one problem behavior or health behavior increases the likelihood of involvement in others because they share many common causes. Concern about alcohol consumption among adolescents and young adults has led to increased exploration of the association of alcohol use with other health risk behaviors, often finding positive relationship. For example, research found that alcohol drinking and smoking had a high probability of co-occurrence (Istvan and Matarazzo, 1984). Adolescent internalizing anxiety and suicide were found to be related to adolescent alcohol use (Juan et al., 2010; Trim et al., 2007). Miller et al. (2007) reported that binge drinkers were 10.8 times more likely to ride with a driver who had been drinking alcohol than nondrinkers, and were 4.4 times more likely to be involved in a physical fight. Research has also suggested positive relationship between alcohol use and risky sexual behaviors, such as premarital sex, multiple sexual partners, and pregnancy (or getting a partner pregnant)(Lin et al., 2005; Miller et al., 2007; Stickley et al., 2013). Most of this research has been conducted in western countries, with a paucity of studies exploring these relationships in Asian cities. Therefore, this study will examine whether the association of drunkenness with a variety of different health risk behaviors exists, and if it do then we explore the extent to which this relationship varies across the three cities. We hypothesize that drunkenness is associated with health risk behaviors across the sites. Research (Donohew et al., 2000) has found sensation-seeking plays a crucial role in adolescents’ susceptibility to alcohol use and other risky behaviors. When drunkenness is more prevalent, it may not meet adolescents’ need for novelty and sensation, making them more likely to seek alternative sources of stimulation such as fighting or sexual behaviors. Therefore, we also hypothesize that the strength of the association between drunkenness and other health risk behaviors will vary across cities–being strong in Taipei, and relatively weak in Hanoi.
2. Methods 2.1. Sampling and data collection Data for this study were drawn from the Three-city Collaborative Study of Adolescent Health by a team of researchers from the Johns Hopkins Bloomberg School of Public Health, the Population and Health Research Center in Taiwan’s Bureau of Health Promotion, the Shanghai Institute for Planned Parenthood Research and the Hanoi Institute for Family and Gender Studies. This was a cross-sectional survey conducted in metropolitan Hanoi, Shanghai, and Taipei, including both their urban and surrounding rural areas. After obtaining ethical approval from the Committee on Human Research at the Johns Hopkins University as well as the collaborating local organizations, 17,016 adolescents and young adults aged 15–24 years were selected by multistage sampling methods in 2006. In Hanoi and Shanghai, both private residences and group living facilities were sampled. In Taipei, students were interviewed in school, with a small nonstudent subsample interviewed at their private residences and group living facilities. More details on the study design have been described previously (Zabin et al., 2009). The interview was conducted face-to-face, but to ensure the privacy of adolescents, participants could reply to sensitive questions with direct computer entry. In this article, we focus on the 16,554 unmarried adolescents. 2.2. Measures 2.2.1. Alcohol use and drunkenness. Respondents’ involvement with alcohol was assessed with the question: “Have you ever had a glass of beer, wine, or a shot of liquor (not including while with your family at a banquet or celebration)?”. If the response was “Yes”, then a series of alcohol-related questions were asked to assess alcohol use. Respondents who drank alcohol in the past month were classified as current drinkers. Drunkenness was assessed based on self-evaluation through the question “In the past 30 days, how many times were you drunk?”. The alternative responses were never, once, 2–3 times, more than 3 times. 2.2.2. Health risk behaviors. Health risk behaviors in this study included the following: (1) Anxiety – being worried, to the point of not being able to sleep, more than 3 times in the past 6 months; (2) Suicide ideation – having thought about hurting oneself physically or killing oneself, during the past 12 months; (3) Smoking on one or more days in the past month; (4) Gambling for money (lifetime); (5) Running away from home for at least one night (lifetime); (6) Fighting – being in a physical fight with anyone for any reason in the last 12 months; (7) Drinking and driving – driving a car, motorcycle or other motorized vehicle after drinking alcohol, or being a passenger in a vehicle driven by someone who had been drinking alcohol, in the past month; (8) Having sexual intercourse (lifetime); (9) Nonuse of contraception during first coitus, among respondents who reported having had sexual intercourse. 2.2.3. Control variables. Demographic characteristics – age, gender, economic status, and school status – were controlled in the analysis. Respondents’ ages were divided into two groups according to different phases of development: age 15–19 years (older adolescents) and age 20–24 years (young adults). Economic status was assessed by the number of listed appliances that the family currently owns, and coded as above average/average/below average based on tertiles calculated separately by city. School status was divided into four categories: currently a student with a job, currently a student but without a job, currently not a student but with a job, and currently not a student and without a job. City was treated as an effect modifier, because we wanted to test cross-city differences in association between drunkenness and other health risk behaviors. 2.3. Statistical analysis Descriptive analyses were conducted to estimate and compare the prevalence of alcohol drinking, drunkenness and health risk behaviors by city. Multivariable logistic regressions predicting risky sexual behaviors with controls for age, gender, economic status, school status, drunkenness, city, and an interaction between city and drunkenness were run, testing (1) the adjusted association between drunkenness and health risk behaviors, and (2) the differences in the association between drunkenness and these behaviors across cities. Adjusted odds ratios of drunkenness with behavior across cities were estimated by including city fixed effects to control for unmeasured differences between cities and permit significance testing of the between-city differences with the interaction term (Madkour et al., 2010). The sample was weighted according to the probability of each respondent being selected from the sample.
3. Results Alcohol drinking, drunkenness and health risk behaviors by city are shown in Table 1. Significant differences between cities were found across all variables. In all three cities, more than half of the respondents reported having a history of alcohol use in their lifetimes, with the highest in Taipei and the lowest in Hanoi. The
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Table 1 Alcohol drinking, drunkenness and health risk behaviors among adolescents and young adults in Hanoi, Shanghai and Taipei: prevalence (95% confidence intervals) and p values.
Drinking in the lifetime Drinking in the past month Drunkenness in the past month Anxiety Suicidal ideation Smoking Gambling Running away from home Fighting Drinking and driving Sexual intercourse Nonuse of contraceptionb at first sex a b
Hanoi (n = 6155) %(95%CI)
Shanghai (n = 6039) %(95%CI)
Taipei (n = 4850) %(95%CI)
p valuea
51.83 (46.06–57.59) 34.45 (28.93–39.96) 6.36 (5.32–7.41) 10.38 (9.04–11.73) 2.28 (1.63–2.92) 17.32 (12.71–21.94) 8.89 (7.05–10.74) 6.61 (5.30–7.91) 16.32 (13.68–18.95) 15.54 (13.41–17.68) 4.77 (3.61–5.93) 44.47 (34.28–54.65)
54.83 (51.72–57.95) 27.95 (25.90–30.00) 4.53 (3.87–5.19) 8.12 (7.14–9.09) 8.12 (6.96–9.28) 15.42 (14.14–16.69) 10.66 (9.50–11.83) 9.00 (7.42–10.58) 8.79 (7.72–9.86) 3.75 (3.15–4.35) 12.34 (11.04–13.65) 54.51 (49.20–59.82)
65.58 (62.43–68.73) 33.39 (30.44–36.33) 8.47 (6.71–10.23) 16.94 (14.83–19.06) 16.94 (14.89–18.99) 17.93 (13.75–22.11) 25.54 (22.28–28.79) 9.72 (6.87–12.57) 12.34 (9.36–15.32) 11.75 (9.59–13.91) 33.62 (28.48–38.75) 31.36 (27.52–35.20)
<0.001 <0.001 <0.001 <0.001 <0.001 <0.01 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
Chi-square test for differences between cities. Restricted to those who ever had sexual intercourse.
prevalence of alcohol drinking in the past month varied from a low of 27.95% in Shanghai to a high of 34.45% in Hanoi. The highest prevalence of drunkenness was found in Taipei (8.47%), and the lowest in Shanghai (4.53%). The prevalences of suicidal ideation, gambling, running away from home, and having sexual intercourse were highest in Taipei, followed by Shanghai, and lowest in Hanoi. With respect to fighting and drinking and driving, the prevalences were highest in Hanoi, and lowest in Taipei. Among respondents having had sexual intercourse, 54.51% did not use any contraception at first sex in Shanghai; prevalences were lower in Hanoi (44.47%) and Taipei (31.36%). Table 2 presents the multivariate logistic regression results of health risk behaviors. Respondents in Hanoi were less likely to engage in suicidal ideation, gambling, running away from home, and having sexual intercourse than those in Shanghai and Taipei, but were more likely to report fighting and drinking and driving. After adjusting other possible influencing factors, drunkenness was significantly positively associated with all health risk behaviors, with the exception of nonuse of contraception at first sex. In addition, the strength of this association varied across health risk behaviors. Older respondents were more likely to express anxiety, and to engage in smoking, drinking and driving, and sexual intercourse, while the younger respondents had higher probabilities of experiencing suicidal ideation, running away from home, and fighting. Compared with females, males were more likely to engage in all health risk behaviors (adjusted odds ratios (AOR) range from 1.19 to 10.74), with the exception of anxiety, suicidal ideation, and nonuse of contraception at first sex. Working respondents and those with neither a job nor currently in school were more likely to report smoking, gambling, running away from home, fighting, drinking and driving, and having had sexual intercourse than students in school and without a job. Table 3 presents AOR estimates for drunkenness by health risk behaviors and by city. A positive association between drunkenness and different types of risky behaviors was observed across cities, with the exception of nonuse of contraception at first sex. Associations of drunkenness with smoking and drinking and driving were stronger than those between drunkenness and other health risk behaviors in each city. Tests of interaction terms supported significant between-city differences in the magnitude of the associations between drunkenness and smoking, gambling, and drinking and driving. Associations of drunkenness with smoking and drinking and driving were significantly stronger in Shanghai and Taipei than in Hanoi; those with a history of drunkenness had 3.60 times the odds of smoking than those without drunkenness in Hanoi, while the odds were 8.49 times in Taipei. However, the relationship of drunkenness and gambling was significantly stronger in Hanoi and Shanghai than that in Taipei. Although drunkenness was
positively related to anxiety, suicidal ideation, running away from home, fighting, and having sexual intercourse across cities, tests of the interaction terms indicated that the magnitude of associations was not significantly different between cities.
4. Discussion This study estimated and compared alcohol drinking and drunkenness among 15–24 years olds across Hanoi, Shanghai and Taipei, and examined the extent to which the relationship between drunkenness and health risk behaviors varied across the three cities. Drunkenness was defined by the subjective appraisal of respondents rather than measured with specific numbers of drinks (usually set at 5+) for these reasons – the number of drinks needed to become drunk was influenced by many factors, such as gender, age, and ethnicity. Thus, self-evaluation may provide a better way to define drunkenness in large, cross-national surveys; to adjust for individual differences in the effects of alcohol, perceived drunkenness maybe a better predictor of alcohol-related problems among adolescents than objective measures (Andersson and Hibell, 2007; Müller et al., 2011). In the multivariate logistic regression, we controlled for student status as it was related to drunkenness; compared with students, the employed respondents may have greater resources to buy alcohol and greater access to it (Benjet et al., 2014). In this study, more than half of respondents reported alcohol drinking in their lifetimes, with the highest levels in Taipei and the lowest in Hanoi. For drunkenness in the past month, the highest prevalence was in Taipei (8.47%), and the lowest in Shanghai (4.53%). However, drunkenness was still relatively uncommon in the three Asian cities compared to the West: a study (Hingson et al., 2013) with a nationally representative sample of 10th graders in the United States reported 23% of respondents had gotten drunk in the past month. Among the three cities, Taipei had the longest contact with the West, and in theory was influenced most by western drinking patterns; thus, it was no surprise that the proportion of drunkenness was highest in Taipei. However, an unexpected outcome was that, although Shanghai had longer exposure to the West than Hanoi, the proportion getting drunk among adolescents and young adults was lower. One possible explanation for this result was the difference in the legal age of drinking. In Vietnam, there is no age limit for alcohol, whereas the legal drinking age is 18 in Shanghai (China bans under-age drinking, 2006). The positive association between drunkenness and health risk behaviors was found in all three cities, with the exception of nonuse of contraception at first sex – findings consistent with many previous studies. For example, some research revealed that psychiatric problems such as anxiety, depression, and suicide were reported
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Table 2 Multivariate logistic regression predicting health risk behaviors among adolescents and young adults: adjusted odds ratios and 95% confidence intervals.
Drunk*Shanghai Drunk*Taipei * ** *** a
Suicidal ideation
Smoking
Gambling
Running away from home
Fighting
Drinking and driving
Sexual intercourse
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
1.00 1.30 (1.13–1.50)***
1.00 0.58 (0.49–0.69)***
1.00 1.36 (1.10–1.68)**
1.00 1.08 (0.94–1.24)
1.00 0.84 (0.71–0.99)*
1.00 0.38 (0.32–0.45)***
1.00 1.67 (1.41–1.97)***
1.00 3.41 (2.71–4.29)***
1.00 1.02 (0.78–1.34)
1.00 0.93 (0.82–1.05)
1.00 0.61 (0.53–0.71)***
1.00 10.74 (7.89–14.62)***
1.00 4.89 (4.27–5.61)***
1.00 1.95 (1.59–2.38)***
1.00 1.81 (1.52–2.15)***
1.00 1.99 (1.70–2.33)***
1.00 1.82 (1.55–2.15)***
1.00 1.19 (0.97–1.45)
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
0.98 (0.83–1.15) 0.97 (0.81–1.17)
1.13 (0.96–1.34) 1.17 (0.95–1.45)
0.91 (0.75–1.09) 0.92 (0.74–1.15)
1.12 (0.94–1.33) 1.04 (0.86–1.25)
0.91 (0.74–1.13) 0.92 (0.75–1.12)
1.12 (0.95–1.31) 1.12 (0.93–1.36)
1.01 (0.85–1.20) 1.11 (0.91–1.36)
1.14 (0.95–1.37) 1.33 (1.12–1.59)**
0.91 (0.63–1.32) 0.66 (0.47–0.94)*
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.28 (1.12–1.47)***
1.01 (0.83–1.23)
1.86 (1.37–2.53)***
1.50 (1.25–1.80)***
1.66 (1.33–2.08)***
1.15 (0.94–1.40)
1.74 (1.47–2.08)***
2.39 (1.87–3.07)***
1.27 (0.97–1.68)
0.92 (0.71–1.18)
1.07 (0.84–1.36)
4.95 (3.95–6.21)***
1.64 (1.36–1.98)***
2.04 (1.63–2.54)***
1.16 (0.95–1.42)
1.52 (1.28–1.82)***
3.59 (2.93–4.41)***
1.28 (0.99–1.66)
1.00 (0.76–1.30)
0.98 (0.68–1.41)
***
4.22 (3.27–5.43)
***
1.69 (1.28–2.24)
***
2.55 (1.89–3.44)
1.25 (0.96–1.62)
***
1.65 (1.33–2.05)
***
0.88 (0.62–1.24)
1.00 0.81 (0.67–0.98)* 1.62 (1.34–1.97)*** 2.14 (1.54–2.98)***
1.00 3.59 (2.60–4.97)*** 8.60 (6.07–12.18)*** 2.12 (1.33–3.38)**
1.00 0.96 (0.74–1.24) 1.22 (0.87–1.71) 3.60 (2.56–5.05)***
1.00 1.40 (1.08–1.81)* 4.51 (3.40–5.99)*** 3.64 (2.17–6.10)***
1.00 1.50 (1.11–2.03)** 1.60 (1.13–2.26)** 2.77 (2.03–3.78)***
1.00 0.44 (0.35–0.55)*** 0.67 (0.50–0.89)*** 2.77 (2.10–3.67)***
1.00 0.22 (0.17–0.28)*** 0.62 (0.51–0.75)*** 3.43 (2.64–4.45)***
0.92 (0.56–1.51)
1.03 (0.57–1.84)
1.29 (0.80–2.06)
0.97 (0.49–1.93)
0.99 (0.62–1.60)
1.51 (1.03–2.22)*
1.15 (0.66–2.01)
1.13 (0.59–2.18)
1.11 (0.35–3.52)
1.13 (0.71–1.79)
0.93 (0.56–1.55)
2.36 (1.31–4.26)**
0.50 (0.28–0.89)*
1.05 (0.66–1.66)
1.12 (0.73–1.70)
1.71 (1.17–2.49)**
1.49 (0.76–2.91)
1.26 (0.45–3.52)
p < 0.05. p < 0.01. p < 0.001. Restricted to those who ever had sexual intercourse.
2.91 (2.22–3.81)
1.00 3.60 (2.72–4.76)*** 14.71 (10.81–20.03)*** 2.08 (1.16–3.74)*
1.00 1.57 (0.96–2.56) 0.59 (0.37–0.92)* 0.93 (0.37–2.31)
Q. Zhu et al. / Drug and Alcohol Dependence 147 (2015) 251–256
Age 15–19 20–24 Gender Female Male Economic status Below average Average Above average School status A student without a job A student with a job Not a student with a job Not a student and without a job City Hanoi Shanghai Taipei Drunk Interactions
The first sex nonuse of contraceptiona Adj.OR (95%CI)
Anxiety
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255
Table 3 Adjusted odds ratio estimates of drunkenness for health risk behaviors by city. Drunkenness
Anxiety Suicidal ideation Smoking Gambling Running away from home Fighting Drinking and driving Sexual intercourse Nonuse of contraceptionc at first sex * ** *** a b c
Hanoi (n = 6155) Adj.OR (95%CI)a
Shanghai (n = 6039) Adj.OR (95%CI)a
Taipei (n = 4850) Adj.OR (95%CI)a
Interaction p-valueb
2.14 (1.54–2.98)*** 2.12 (1.33–3.38)** 3.60 (2.56–5.05)*** 3.64 (2.17–6.10)*** 2.77 (2.03–3.78)*** 2.77 (2.10–3.67)*** 3.43 (2.64–4.45)*** 2.08 (1.16–3.74)* 0.93 (0.37–2.31)
1.97 (1.37–2.83)*** 2.18 (1.47–3.23)*** 4.63 (3.35–6.39)*** 3.53 (2.49–5.02)*** 2.76 (1.91–3.98)*** 4.19 (3.14–5.59)*** 3.94 (2.43–6.38)*** 2.35 (1.70–3.26)*** 1.03 (0.61–1.73)
2.41 (1.73–3.36)*** 1.97 (1.57–2.47)*** 8.49 (5.22–13.83)*** 1.80 (1.36–2.39)*** 2.90 (2.03–4.14)*** 3.10 (2.24–4.31)*** 5.85 (4.45–7.69)*** 3.10 (2.15–4.47)*** 1.17 (0.72–1.92)
0.709 0.889 0.018 0.002 0.976 0.104 0.019 0.397 0.862
p < 0.05. p < 0.01. p < 0.001. Adjusted odds ratio from multivariable logistic models. Joint test of significance for all interaction terms in model. Restricted to those who ever had sexual intercourse.
more frequently by youth with alcohol disorders and episodic heavy drinking patterns (Chen et al., 2008; Miller et al., 2007). The “shared vulnerability model” posits that there are underlying genetic or other general susceptibility traits that contribute to both alcohol use and observed psychological disturbances (Baigent, 2005). In addition, adolescents may choose alcohol as one way to escape from or cope with distress and relieve depression. A range of studies (Wagner and Anthony, 2002; Willner, 2001) found evidence that alcohol preceded the use of other substances such as tobacco and illicit drugs and increased the risk of their use, thus supporting the hypothesis that alcohol is a “gateway” drug in relation to other substances (Kandel, 2002). A positive association between adolescent excessive drinking and violence has also been reported (Bye and Rossow, 2010) and Cirillo et al. (1998) offered the explanation that adolescents who abused alcohol may rely on violence as a coping strategy more than others who do not. The strong crosssectional relationship between excessive drinking and impaired driving has been described in previous studies (Flowers et al., 2008; Naimi et al., 2009); it is well known that people who drive after drinking are more likely to speed, are less likely to wear seat belts, and are less likely to appreciate their increased crash risk than when sober. Finally, literature has well-documented the association of alcohol use with increased sexual risk behaviors (Hingson et al., 2003; Kaljee et al., 2005; Lin et al., 2005); drunkenness may directly impair judgment and cause social disinhibition, resulting in an increased likelihood of sexual risk behaviors. Leigh and Stall (1993) proposed a personality-based mechanism, in which alcohol use and risk-taking sexual behaviors may both be indicators of a risk-taking or sensation-seeking personality type. Previous research about the relationship between drunkenness and nonuse of contraception was not consistent. While some studies report that adolescents who drink heavily are less likely to use condoms (Graves, 1995); others found no significant relationship (Lin et al., 2005; Morrison et al., 2003). Leigh (2002) proposed that drinking was not necessarily linked to unprotected intercourse, which is more dependent on context and the sexual experience of the partners. Among the positive association between drunkenness and a variety of different health risk behaviors, the associations of drunkenness with smoking and driving and drinking were stronger than other associations in each city, suggesting that a history of drunkenness is more related to both than to other behaviors. These associations varied significantly across the three cities – the strongest in Taipei, followed by Shanghai, and the weakest in Hanoi – which supported our hypothesis. Thus, exposure to the West appears to influence the strength of the associations. However, the relation between drunkenness and gambling varied inversely with
the extent of exposure to the West, which was not expected. It is possible that adolescents getting drunkenness often have high seeking of novel and intense sensations (Donohew et al., 2000). Gambling is more prevalent in Taipei than in Shanghai and Vietnam, so these adolescents with drunkenness in Taipei are less likely to engage in gambling, which is not novel and stimulating. Several limitations of this study should be noted. First, as the research used cross-sectional data and global correlations to measure relationship between drunkenness and health risk behaviors, the temporal relation between them cannot be established. It may be that environments in which heavy drinking is common are conducive to other risks, as well. Longitudinal studies and event analyses could determine the direction of causality. Second, the data were obtained by self-report, and subject to report bias. However, computer-assisted interviews were used to improve the accuracy of response. Third, as different sampling approaches were adopted in Taipei and the other two cities, the different demographic characteristics of respondents, especially economic status and school status, could affect their risk behaviors. However, sample weighting was used to adjust for these differences. Fourth, owing to small cell counts, it was difficult to investigate the dose effect of drunkenness (1 time, 2–3 times, and more than 3 times) with risk behaviors. It is possible that some differences existed between them. In the three cities, Taipei with the longest exposure to the West has the highest proportion of drunkenness, which is related with the influence of alcohol use in the West (Newman, 2002). The availability of western brands of alcohol, the development of brew pubs, and western drinking practices displayed in alcohol advertising and portrayed in movies, television, and other images from the West may create special appeals for young people. Therefore public health interventions should be adopted to address these issues. Such measures include the implementation of community-based education to raise awareness of the risks of excessive alcohol consumption, reduced exposure of underage youth to alcohol advertising, legislation about the purchase and selling of alcohol, and the use of severe fines for those selling alcohol to minors. With drunkenness significantly associated with other health risk behaviors in the three cities, our results have implications for prevention, intervention, and health promotion programs directed at adolescents and young adults: interventions aimed at reducing one risk behavior should not ignore the array of other coexisting behaviors. Noting the existence of one risk behavior in an adolescent should be a red flag, suggesting that other such behaviors may be concurrent or imminent (Tu et al., 2012). Measures to reduce drunkenness among adolescents may therefore be an
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effective way to lower the prevalence of other health risk behaviors. For example, the strength of relationship between drunkenness and gambling in Vietnam and Shanghai suggests that more attention should be paid to adolescents and young adults getting drunk to reduce gambling in these cities. Similarly, intervention to prevent smoking and drunk driving may be more effective for young people with drunkenness in Taipei than in Vietnam or Shanghai. The present study points to some new directions for future research. With drunkenness in Asian cities related to exposure to the West, further research should explore how drunkenness is influenced by western drinking practices in more detail; pathway analysis should be developed to understand what mechanisms are involved in the relationship between drunkenness and other health risk behaviors in the future studies. Role of funding source Funding for this study was provided by Bill and Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA (grant no. 979-2020). Contributors Qianqian Zhu wrote the first draft of the manuscript and undertook the statistical analysis. Chaohua Lou, Ersheng Gao and Laurie S. Zabin were responsible for obtaining funding, implementation of the survey and quality control during field work. Yan Cheng participated in the implementation of the survey and supervision of fieldwork. Mark R. Emerson made a significant intellectual contribution to the study design and the statistical analysis. All authors contributed to and have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest. Acknowledgements We thank the Bill and Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA, who provided financial support for the study. We would also like to sincerely thank all the researchers at the Hanoi Institute of Family and Gender Studies, the health Research Center in Taiwan’s Bureau of Health Promotion and the Shanghai Institute of Planned Parenthood Research for their contributions to the project. References Andersson, B., Hibell, B., 2007. Drunken Behaviour, Expectancies and Consequences Among European Students. Youth Drinking Cultures-European Experiences. Ashgate, Hampshire, pp. 41–64. Baigent, M.F., 2005. Understanding alcohol misuse and comorbid psychiatric disorders. Curr. Opin. Psychiatry 18, 223–228. Balogun, O., Koyanagi, A., Stickley, A., Gilmour, S., Shibuya, K., 2014. Alcohol consumption and psychological distress in adolescents: a multi-country study. J. Adolesc. Health 54, 228–234. Benjet, C., Borges, G., Méndez, E., Casanova, L., Medina-Mora, M.E., 2014. Adolescent alcohol use and alcohol use disorders in Mexico City. Drug Alcohol Depend. 136, 43–50. Bye, E.K., Rossow, I., 2010. The impact of drinking pattern on alcohol-related violence among adolescents: an international comparative analysis. Drug Alcohol Rev. 29, 131–137. Chen, C., Storr, C.L., Tang, G., Huang, S., Hsiao, C.K., Chen, W.J., 2008. Early alcohol experiences and adolescent mental health: a population-based study in Taiwan. Drug Alcohol Depend. 95, 209–218. 2006. China Bans Under-age Drinking. China Daily, http://www.chinadaily.com.cn/ english/doc/2006-01/06/content 510002.htm (retrieved 03.02.08).
Cirillo, K.J., Pruitt, B.E., Colwell, B., Kingery, P.M., Hurley, R.S., Ballard, D., 1998. School violence: prevalence and intervention strategies for at-risk adolescents. Adolescence 33, 319–330. Donohew, L., Zimmerman, R., Cupp, P.S., Novak, S., Colon, S., Abell, R., 2000. Sensation seeking, impulsive decision-making, and risky sex: implications for risk-taking and design of interventions. Personal. Individ. Differ. 28, 1079–1091. Fiona, M.G., Paul, J.N.B., George, C.P., et al., 2011. Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet 377, 2093–2102. Flowers, N.T., Naimi, T.S., Brewer, R.D., Elder, R.W., Shults, R.A., Jiles, R., 2008. Patterns of alcohol consumption and alcohol-impaired driving in the United States. Alcohol. Clin. Exp. Res. 32, 639–644. Graves, K.L., 1995. Risky sexual behavior and alcohol use among young adults: results from a national survey. Am. J. Health Promot. 10, 27–36. Guilamo, R.V., Litardo, H.A., Jaccard, J., 2005. Prevention programs for reducing adolescent problem behaviors: implications of the co-occurrence of problem behaviors in adolescence. J. Adolesc. Health 36, 82–86. Hingson, R., Heeren, T., Winter, M.R., Wechsler, H., 2003. Early age of first drunkenness as a factor in college students’ unplanned and unprotected sex attributable to drinking. Pediatrics 111, 34–41. Hingson, R.W., Zha, W., Iannotti, R.J., Bruce, S.M., 2013. Physician advice to adolescents about drinking and other health behaviors. Pediatrics 131, 249–257. Hughes, K., MacKintosh, A.M., Hastings, G., Wheeler, C., Watson, J., Inglis, J., 1997. Young people, alcohol, and designer drinks: quantitative and qualitative study. BMJ 314, 414. Iris, C., James, E.L.H., 1989. Differences in drinking behavior among three AsianAmerican groups. J. Stud. Alcohol 50, 15–23. Istvan, J., Matarazzo, J.D., 1984. Tobacco, alcohol, and caffeine use: a review of their interrelationships. Psychol. Bull. 95, 301–326. Jessor, R., Jessor, S.L., 1977. Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. Academic Press, New York. Juan, W., Xiao, J.D., Jia, J.W., Xin, W.W., Liang, X., 2010. The associations between health risk behaviors and suicidal ideation and attempts in an urban Chinese sample of adolescents. J. Affect. Disord. 126, 180–187. Kaljee, L.M., Genberg, B.L., Minh, T.T., Tho, L.H., Thoa, L.T.K., Stanton, B., 2005. Alcohol use and HIV risk behaviors among rural adolescents in Khanh Hoa province Vietnam. Health Educ. Res. 20, 71–80. Kandel, D.B., 2002. Stages and Pathways of Drug Involvement: Examining the GateWay Hypothesis. Cambridge University Press, Cambridge. Leigh, B.C., 2002. Alcohol and condom use: a meta-analysis of event-level studies. Sex Transm. Dis. 29, 476–482. Leigh, B.C., Stall, R., 1993. Substance use and risky sexual behavior for exposure to HIV: issues in methodology, interpretation, and prevention. Am. Psychol. 48, 1035–1045. Lin, D., Li, X., Yang, H., Fang, X., Stanton, B., Chen, X., Abbey, A., Liu, H., 2005. Alcohol intoxication and sexual risk behaviors among rural-to-urban migrants in China. Drug Alcohol Depend. 79, 103–112. Madkour, A.S., Farhat, T., Halpern, C.T., Godeau, E., Gabhainn, S.N., 2010. Early adolescent sexual initiation as a problem behavior: a comparative study of five nations. J. Adolesc. Health 47, 389–398. Miller, J.W., Naimi, T.S., Brewer, R.D., Jones, S.E., 2007. Binge drinking and associated health risk behaviors among high school students. Pediatrics 119, 76–85. Morrison, D.M., Gillmore, M.R., Hoppe, M.J., Gaylord, J., Leigh, B.C., Rainey, D., 2003. Adolescent drinking and sex: findings from a daily diary study. Perspect. Sex. Reprod. Health 35, 162–168. Müller, S., Piontek, D., Pabst, A., Kraus, L., 2011. The relationship between alcohol consumption and perceived drunkenness: a multilevel cross-national comparison in samples of adolescents. Alcohol Alcohol. 46, 399–406. Naimi, T.S., Nelson, D.E., Brewer, R.D., 2009. Driving after binge drinking. Am. J. Prev. Med. 37, 314–320. Newman Ian, Cultural aspects of drinking patterns and alcohol controls in China, The Globe (Global Alcohol Policy Alliance, London). 1, 2002, 18–21. O’Brien, M.C., McCoy, T.P., Champion, H., Mitra, A., Robbins, A., Teuschlser, H., Wolfson, M., DuRant, R.H., 2006. Single question about drunkenness to detect college students at risk for injury. Acad. Emerg. Med. 13, 629–636. Stickley, A., Koyanagi, A., Koposov, R., Razvodovsky, Y., Ruchkin, V., 2013. Adolescent binge drinking and risky health behaviours: findings from northern Russia. Drug Alcohol Depend. 133, 838–844. Trim, R.S., Meehan, B.T., King, K.M., Chassin, L., 2007. The relation between adolescent substance use and young adult internalizing symptoms: findings from a highrisk longitudinal sample. Psychol. Addict. Behav. 21, 97–107. Tu, X.W., Lou, C.H., Gao, E.S., Li, N., Zabin, L.S., 2012. The relationship between sexual behavior and nonsexual risk behaviors among unmarried youth in three Asian cities. J. Adolesc. Health 50, S75–S82. Wagner, F.A., Anthony, J.C., 2002. Into the world of illegal drug use: exposure opportunity and other mechanisms linking the use of alcohol, tobacco, marijuana, and cocaine. Am. J. Epidemiol. 155, 918–925. Weatherspoon, A.J., Park, J.Y., Johnson, R.C., 2001. A family study of homeland Korean alcohol use. Addict. Behav. 26, 101–113. Willner, P., 2001. A view through the gateway: expectancies as a possible pathway from alcohol to cannabis. Addiction 96, 691–703. World Health Organization, 2011. Global Status Report on Alcohol and Health. WHO Library Cataloguing-in-Publication Data. WHO, Geneva. Zabin, L.S., Emerson, M.R., Nan, L., Chaohua, L., Ersheng, G., Minh, N.H., Chuang, Y.L., Hurng, B.S., Bishai, D., Blum, R.W., 2009. Levels of change in adolescent sexual behavior in three Asian Cities. Stud. Fam. Plann. 40, 1–12.
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Drunkenness and its association with health risk behaviors among adolescents and young adults in three Asian cities: Hanoi, Shanghai, Taipei Qianqian Zhu a,b , Chaohua Lou b,∗ , Ersheng Gao b , Yan Cheng b , Laurie S. Zabin c , Mark R. Emerson c a
School of Public Health, Fudan University, Shanghai 200032, PR China Department of Epidemiology and Social Science, Key Laboratory of Family Planning Device of National Population and Family Planning Commission, Shanghai Institute of Planned Parenthood Research, Shanghai 200237, PR China c Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205,USA b
a r t i c l e
i n f o
Article history: Received 29 May 2014 Received in revised form 25 October 2014 Accepted 25 October 2014 Available online 2 December 2014 Keywords: Adolescent Alcohol Drunkenness Heath risk behaviors Eastern Asian city
a b s t r a c t Purpose: To assess the prevalence of drunkenness among adolescents in Hanoi, Shanghai, and Taipei and explore the association between heavy drinking and other health risk behaviors. Methods: The data are drawn from the Three-city Collaborative Study of Adolescent Health, conducted in Hanoi, Shanghai, and Taipei in 2006. A sample of 17,016 adolescents and young adults, aged 15–24 years, was selected by multistage sampling. Descriptive analysis was used to estimate the proportion of drunkenness and other health risk behaviors. Multivariate logistic regression was used to investigate relationships between drunkenness and risky health behaviors. Results: The proportions of the sample getting drunk during the past month were 6.36%, 4.53%, and 8.47% in Hanoi, Shanghai, and Taipei, respectively. More males than females reported drunkenness in all three cities, with the difference highest in Hanoi (11.08% vs. 1.14%) and lowest in Taipei (9.69% vs. 7.18%). Different levels of relationship between drunkenness and health risk behaviors, such as anxiety, suicidal ideation, smoking, gambling, fighting, drinking and driving, and having sexual intercourse, were found across the three cities; an exception was nonuse of contraception. Conclusion: Drunkenness was positively associated with many health risk behaviors. It may serve as an indicator of other risky behaviors. Interventions to reduce drinking and drunkenness may contribute considerably to the prevention of other risk behaviors and to adolescent safety and well-being. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction As one of the most common health risk behaviors among adolescents and young adults, alcohol use seriously threatens their health and well-being. Alcohol is now the leading risk factor contributing to disability-adjusted life years in 10–24-year-olds globally (Fiona et al., 2011). According to a report by the World Health Organization (2011), alcohol is a factor in almost 10% of deaths among young people. The three most frequent forms of mortality among adolescents–accidental death, homicide, and suicide–are
∗ Corresponding author at: Shanghai Institute of Planned Parenthood Research, 779 Lao Hu Min Road, Shanghai 200237, PR China. Tel.: +86 21 64771589; fax: +86 2164771589. E-mail address: [email protected] (C. Lou). http://dx.doi.org/10.1016/j.drugalcdep.2014.10.029 0376-8716/© 2014 Elsevier Ireland Ltd. All rights reserved.
associated with alcohol use (Balogun et al., 2014). Its use among adolescents and young adults, especially excessive drinking, often leading to drunkenness, has become a major public health concern. Adolescence is the time when alcohol use typically begins and escalates. Alcohol is thought to be important in adolescent development and socialization as it helps young people to integrate with their peers and to negotiate their passage into the adult world (Hughes et al., 1997). Hughes et al. (1997) reported that children aged 12 and 13 years used alcohol to experience the adult world and to satisfy their curiosity, and those aged 14 and 15 were testing out their limits and getting drunk to share the experience with others. In the 2003 National Youth Risk Behavior Survey, Miller et al. (2007) found 44.9% of US high school students reported drinking alcohol during the past 30 days, and 28.8% reported binge drinking. A Web-based survey from ten North Carolina universities revealed
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63.6% of students described themselves as current (past 30 days) drinkers, and 35% reported getting drunk at least once a week (O’Brien et al., 2006). Although excessive drinking has been a relatively common behavior among adolescents in western countries, little is known about adolescent drunkenness in Asia. To fill this gap, we conducted a cross-sectional study to evaluate drunkenness among adolescents and young adults in three Asian cities – Hanoi, Shanghai, and Taipei – which have shared the same Confucian-based culture for thousands of years. With an emphasis on moderation, Confucianism has likely provided some constraint to excessive drinking (Iris and James, 1989; Weatherspoon et al., 2001) and may possibly mitigate the risk associated with alcohol use. However, in the past several decades, Hanoi, Shanghai, and Taipei have been undergoing marked sociocultural change in the wake of modernization, rapid industrialization, and globalization, accompanied by the adoption of more Western lifestyles. The gradual erosion of traditional Confucian values influences attitudes toward drinking and alcohol consumption; consequently, western drinking practices are gradually becoming accepted, especially among young people. As these three cities have opened to the West at different times (Taipei has the longest exposure to the West, Hanoi’s exposure is the most recent, and Shanghai is between the two), traditional values may have eroded to different extents, and western drinking patterns, especially excessive alcohol consumption leading to drunkenness, may also have been adopted at different levels. We hypothesize that the prevalence of drunkenness varies across the three cities; specifically, the longer the city has been exposed to the West, the higher the prevalence of drunkenness. Adolescence is an important transition period when many adolescents can get involved in different problem behaviors such as smoking, alcohol use, and fighting (Guilamo et al., 2005). According to Jessor’s problem behavior theory (Jessor and Jessor, 1977), adolescents’ involvement in any one problem behavior or health behavior increases the likelihood of involvement in others because they share many common causes. Concern about alcohol consumption among adolescents and young adults has led to increased exploration of the association of alcohol use with other health risk behaviors, often finding positive relationship. For example, research found that alcohol drinking and smoking had a high probability of co-occurrence (Istvan and Matarazzo, 1984). Adolescent internalizing anxiety and suicide were found to be related to adolescent alcohol use (Juan et al., 2010; Trim et al., 2007). Miller et al. (2007) reported that binge drinkers were 10.8 times more likely to ride with a driver who had been drinking alcohol than nondrinkers, and were 4.4 times more likely to be involved in a physical fight. Research has also suggested positive relationship between alcohol use and risky sexual behaviors, such as premarital sex, multiple sexual partners, and pregnancy (or getting a partner pregnant)(Lin et al., 2005; Miller et al., 2007; Stickley et al., 2013). Most of this research has been conducted in western countries, with a paucity of studies exploring these relationships in Asian cities. Therefore, this study will examine whether the association of drunkenness with a variety of different health risk behaviors exists, and if it do then we explore the extent to which this relationship varies across the three cities. We hypothesize that drunkenness is associated with health risk behaviors across the sites. Research (Donohew et al., 2000) has found sensation-seeking plays a crucial role in adolescents’ susceptibility to alcohol use and other risky behaviors. When drunkenness is more prevalent, it may not meet adolescents’ need for novelty and sensation, making them more likely to seek alternative sources of stimulation such as fighting or sexual behaviors. Therefore, we also hypothesize that the strength of the association between drunkenness and other health risk behaviors will vary across cities–being strong in Taipei, and relatively weak in Hanoi.
2. Methods 2.1. Sampling and data collection Data for this study were drawn from the Three-city Collaborative Study of Adolescent Health by a team of researchers from the Johns Hopkins Bloomberg School of Public Health, the Population and Health Research Center in Taiwan’s Bureau of Health Promotion, the Shanghai Institute for Planned Parenthood Research and the Hanoi Institute for Family and Gender Studies. This was a cross-sectional survey conducted in metropolitan Hanoi, Shanghai, and Taipei, including both their urban and surrounding rural areas. After obtaining ethical approval from the Committee on Human Research at the Johns Hopkins University as well as the collaborating local organizations, 17,016 adolescents and young adults aged 15–24 years were selected by multistage sampling methods in 2006. In Hanoi and Shanghai, both private residences and group living facilities were sampled. In Taipei, students were interviewed in school, with a small nonstudent subsample interviewed at their private residences and group living facilities. More details on the study design have been described previously (Zabin et al., 2009). The interview was conducted face-to-face, but to ensure the privacy of adolescents, participants could reply to sensitive questions with direct computer entry. In this article, we focus on the 16,554 unmarried adolescents. 2.2. Measures 2.2.1. Alcohol use and drunkenness. Respondents’ involvement with alcohol was assessed with the question: “Have you ever had a glass of beer, wine, or a shot of liquor (not including while with your family at a banquet or celebration)?”. If the response was “Yes”, then a series of alcohol-related questions were asked to assess alcohol use. Respondents who drank alcohol in the past month were classified as current drinkers. Drunkenness was assessed based on self-evaluation through the question “In the past 30 days, how many times were you drunk?”. The alternative responses were never, once, 2–3 times, more than 3 times. 2.2.2. Health risk behaviors. Health risk behaviors in this study included the following: (1) Anxiety – being worried, to the point of not being able to sleep, more than 3 times in the past 6 months; (2) Suicide ideation – having thought about hurting oneself physically or killing oneself, during the past 12 months; (3) Smoking on one or more days in the past month; (4) Gambling for money (lifetime); (5) Running away from home for at least one night (lifetime); (6) Fighting – being in a physical fight with anyone for any reason in the last 12 months; (7) Drinking and driving – driving a car, motorcycle or other motorized vehicle after drinking alcohol, or being a passenger in a vehicle driven by someone who had been drinking alcohol, in the past month; (8) Having sexual intercourse (lifetime); (9) Nonuse of contraception during first coitus, among respondents who reported having had sexual intercourse. 2.2.3. Control variables. Demographic characteristics – age, gender, economic status, and school status – were controlled in the analysis. Respondents’ ages were divided into two groups according to different phases of development: age 15–19 years (older adolescents) and age 20–24 years (young adults). Economic status was assessed by the number of listed appliances that the family currently owns, and coded as above average/average/below average based on tertiles calculated separately by city. School status was divided into four categories: currently a student with a job, currently a student but without a job, currently not a student but with a job, and currently not a student and without a job. City was treated as an effect modifier, because we wanted to test cross-city differences in association between drunkenness and other health risk behaviors. 2.3. Statistical analysis Descriptive analyses were conducted to estimate and compare the prevalence of alcohol drinking, drunkenness and health risk behaviors by city. Multivariable logistic regressions predicting risky sexual behaviors with controls for age, gender, economic status, school status, drunkenness, city, and an interaction between city and drunkenness were run, testing (1) the adjusted association between drunkenness and health risk behaviors, and (2) the differences in the association between drunkenness and these behaviors across cities. Adjusted odds ratios of drunkenness with behavior across cities were estimated by including city fixed effects to control for unmeasured differences between cities and permit significance testing of the between-city differences with the interaction term (Madkour et al., 2010). The sample was weighted according to the probability of each respondent being selected from the sample.
3. Results Alcohol drinking, drunkenness and health risk behaviors by city are shown in Table 1. Significant differences between cities were found across all variables. In all three cities, more than half of the respondents reported having a history of alcohol use in their lifetimes, with the highest in Taipei and the lowest in Hanoi. The
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Table 1 Alcohol drinking, drunkenness and health risk behaviors among adolescents and young adults in Hanoi, Shanghai and Taipei: prevalence (95% confidence intervals) and p values.
Drinking in the lifetime Drinking in the past month Drunkenness in the past month Anxiety Suicidal ideation Smoking Gambling Running away from home Fighting Drinking and driving Sexual intercourse Nonuse of contraceptionb at first sex a b
Hanoi (n = 6155) %(95%CI)
Shanghai (n = 6039) %(95%CI)
Taipei (n = 4850) %(95%CI)
p valuea
51.83 (46.06–57.59) 34.45 (28.93–39.96) 6.36 (5.32–7.41) 10.38 (9.04–11.73) 2.28 (1.63–2.92) 17.32 (12.71–21.94) 8.89 (7.05–10.74) 6.61 (5.30–7.91) 16.32 (13.68–18.95) 15.54 (13.41–17.68) 4.77 (3.61–5.93) 44.47 (34.28–54.65)
54.83 (51.72–57.95) 27.95 (25.90–30.00) 4.53 (3.87–5.19) 8.12 (7.14–9.09) 8.12 (6.96–9.28) 15.42 (14.14–16.69) 10.66 (9.50–11.83) 9.00 (7.42–10.58) 8.79 (7.72–9.86) 3.75 (3.15–4.35) 12.34 (11.04–13.65) 54.51 (49.20–59.82)
65.58 (62.43–68.73) 33.39 (30.44–36.33) 8.47 (6.71–10.23) 16.94 (14.83–19.06) 16.94 (14.89–18.99) 17.93 (13.75–22.11) 25.54 (22.28–28.79) 9.72 (6.87–12.57) 12.34 (9.36–15.32) 11.75 (9.59–13.91) 33.62 (28.48–38.75) 31.36 (27.52–35.20)
<0.001 <0.001 <0.001 <0.001 <0.001 <0.01 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
Chi-square test for differences between cities. Restricted to those who ever had sexual intercourse.
prevalence of alcohol drinking in the past month varied from a low of 27.95% in Shanghai to a high of 34.45% in Hanoi. The highest prevalence of drunkenness was found in Taipei (8.47%), and the lowest in Shanghai (4.53%). The prevalences of suicidal ideation, gambling, running away from home, and having sexual intercourse were highest in Taipei, followed by Shanghai, and lowest in Hanoi. With respect to fighting and drinking and driving, the prevalences were highest in Hanoi, and lowest in Taipei. Among respondents having had sexual intercourse, 54.51% did not use any contraception at first sex in Shanghai; prevalences were lower in Hanoi (44.47%) and Taipei (31.36%). Table 2 presents the multivariate logistic regression results of health risk behaviors. Respondents in Hanoi were less likely to engage in suicidal ideation, gambling, running away from home, and having sexual intercourse than those in Shanghai and Taipei, but were more likely to report fighting and drinking and driving. After adjusting other possible influencing factors, drunkenness was significantly positively associated with all health risk behaviors, with the exception of nonuse of contraception at first sex. In addition, the strength of this association varied across health risk behaviors. Older respondents were more likely to express anxiety, and to engage in smoking, drinking and driving, and sexual intercourse, while the younger respondents had higher probabilities of experiencing suicidal ideation, running away from home, and fighting. Compared with females, males were more likely to engage in all health risk behaviors (adjusted odds ratios (AOR) range from 1.19 to 10.74), with the exception of anxiety, suicidal ideation, and nonuse of contraception at first sex. Working respondents and those with neither a job nor currently in school were more likely to report smoking, gambling, running away from home, fighting, drinking and driving, and having had sexual intercourse than students in school and without a job. Table 3 presents AOR estimates for drunkenness by health risk behaviors and by city. A positive association between drunkenness and different types of risky behaviors was observed across cities, with the exception of nonuse of contraception at first sex. Associations of drunkenness with smoking and drinking and driving were stronger than those between drunkenness and other health risk behaviors in each city. Tests of interaction terms supported significant between-city differences in the magnitude of the associations between drunkenness and smoking, gambling, and drinking and driving. Associations of drunkenness with smoking and drinking and driving were significantly stronger in Shanghai and Taipei than in Hanoi; those with a history of drunkenness had 3.60 times the odds of smoking than those without drunkenness in Hanoi, while the odds were 8.49 times in Taipei. However, the relationship of drunkenness and gambling was significantly stronger in Hanoi and Shanghai than that in Taipei. Although drunkenness was
positively related to anxiety, suicidal ideation, running away from home, fighting, and having sexual intercourse across cities, tests of the interaction terms indicated that the magnitude of associations was not significantly different between cities.
4. Discussion This study estimated and compared alcohol drinking and drunkenness among 15–24 years olds across Hanoi, Shanghai and Taipei, and examined the extent to which the relationship between drunkenness and health risk behaviors varied across the three cities. Drunkenness was defined by the subjective appraisal of respondents rather than measured with specific numbers of drinks (usually set at 5+) for these reasons – the number of drinks needed to become drunk was influenced by many factors, such as gender, age, and ethnicity. Thus, self-evaluation may provide a better way to define drunkenness in large, cross-national surveys; to adjust for individual differences in the effects of alcohol, perceived drunkenness maybe a better predictor of alcohol-related problems among adolescents than objective measures (Andersson and Hibell, 2007; Müller et al., 2011). In the multivariate logistic regression, we controlled for student status as it was related to drunkenness; compared with students, the employed respondents may have greater resources to buy alcohol and greater access to it (Benjet et al., 2014). In this study, more than half of respondents reported alcohol drinking in their lifetimes, with the highest levels in Taipei and the lowest in Hanoi. For drunkenness in the past month, the highest prevalence was in Taipei (8.47%), and the lowest in Shanghai (4.53%). However, drunkenness was still relatively uncommon in the three Asian cities compared to the West: a study (Hingson et al., 2013) with a nationally representative sample of 10th graders in the United States reported 23% of respondents had gotten drunk in the past month. Among the three cities, Taipei had the longest contact with the West, and in theory was influenced most by western drinking patterns; thus, it was no surprise that the proportion of drunkenness was highest in Taipei. However, an unexpected outcome was that, although Shanghai had longer exposure to the West than Hanoi, the proportion getting drunk among adolescents and young adults was lower. One possible explanation for this result was the difference in the legal age of drinking. In Vietnam, there is no age limit for alcohol, whereas the legal drinking age is 18 in Shanghai (China bans under-age drinking, 2006). The positive association between drunkenness and health risk behaviors was found in all three cities, with the exception of nonuse of contraception at first sex – findings consistent with many previous studies. For example, some research revealed that psychiatric problems such as anxiety, depression, and suicide were reported
254
Table 2 Multivariate logistic regression predicting health risk behaviors among adolescents and young adults: adjusted odds ratios and 95% confidence intervals.
Drunk*Shanghai Drunk*Taipei * ** *** a
Suicidal ideation
Smoking
Gambling
Running away from home
Fighting
Drinking and driving
Sexual intercourse
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
Adj.OR (95%CI)
1.00 1.30 (1.13–1.50)***
1.00 0.58 (0.49–0.69)***
1.00 1.36 (1.10–1.68)**
1.00 1.08 (0.94–1.24)
1.00 0.84 (0.71–0.99)*
1.00 0.38 (0.32–0.45)***
1.00 1.67 (1.41–1.97)***
1.00 3.41 (2.71–4.29)***
1.00 1.02 (0.78–1.34)
1.00 0.93 (0.82–1.05)
1.00 0.61 (0.53–0.71)***
1.00 10.74 (7.89–14.62)***
1.00 4.89 (4.27–5.61)***
1.00 1.95 (1.59–2.38)***
1.00 1.81 (1.52–2.15)***
1.00 1.99 (1.70–2.33)***
1.00 1.82 (1.55–2.15)***
1.00 1.19 (0.97–1.45)
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
0.98 (0.83–1.15) 0.97 (0.81–1.17)
1.13 (0.96–1.34) 1.17 (0.95–1.45)
0.91 (0.75–1.09) 0.92 (0.74–1.15)
1.12 (0.94–1.33) 1.04 (0.86–1.25)
0.91 (0.74–1.13) 0.92 (0.75–1.12)
1.12 (0.95–1.31) 1.12 (0.93–1.36)
1.01 (0.85–1.20) 1.11 (0.91–1.36)
1.14 (0.95–1.37) 1.33 (1.12–1.59)**
0.91 (0.63–1.32) 0.66 (0.47–0.94)*
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.28 (1.12–1.47)***
1.01 (0.83–1.23)
1.86 (1.37–2.53)***
1.50 (1.25–1.80)***
1.66 (1.33–2.08)***
1.15 (0.94–1.40)
1.74 (1.47–2.08)***
2.39 (1.87–3.07)***
1.27 (0.97–1.68)
0.92 (0.71–1.18)
1.07 (0.84–1.36)
4.95 (3.95–6.21)***
1.64 (1.36–1.98)***
2.04 (1.63–2.54)***
1.16 (0.95–1.42)
1.52 (1.28–1.82)***
3.59 (2.93–4.41)***
1.28 (0.99–1.66)
1.00 (0.76–1.30)
0.98 (0.68–1.41)
***
4.22 (3.27–5.43)
***
1.69 (1.28–2.24)
***
2.55 (1.89–3.44)
1.25 (0.96–1.62)
***
1.65 (1.33–2.05)
***
0.88 (0.62–1.24)
1.00 0.81 (0.67–0.98)* 1.62 (1.34–1.97)*** 2.14 (1.54–2.98)***
1.00 3.59 (2.60–4.97)*** 8.60 (6.07–12.18)*** 2.12 (1.33–3.38)**
1.00 0.96 (0.74–1.24) 1.22 (0.87–1.71) 3.60 (2.56–5.05)***
1.00 1.40 (1.08–1.81)* 4.51 (3.40–5.99)*** 3.64 (2.17–6.10)***
1.00 1.50 (1.11–2.03)** 1.60 (1.13–2.26)** 2.77 (2.03–3.78)***
1.00 0.44 (0.35–0.55)*** 0.67 (0.50–0.89)*** 2.77 (2.10–3.67)***
1.00 0.22 (0.17–0.28)*** 0.62 (0.51–0.75)*** 3.43 (2.64–4.45)***
0.92 (0.56–1.51)
1.03 (0.57–1.84)
1.29 (0.80–2.06)
0.97 (0.49–1.93)
0.99 (0.62–1.60)
1.51 (1.03–2.22)*
1.15 (0.66–2.01)
1.13 (0.59–2.18)
1.11 (0.35–3.52)
1.13 (0.71–1.79)
0.93 (0.56–1.55)
2.36 (1.31–4.26)**
0.50 (0.28–0.89)*
1.05 (0.66–1.66)
1.12 (0.73–1.70)
1.71 (1.17–2.49)**
1.49 (0.76–2.91)
1.26 (0.45–3.52)
p < 0.05. p < 0.01. p < 0.001. Restricted to those who ever had sexual intercourse.
2.91 (2.22–3.81)
1.00 3.60 (2.72–4.76)*** 14.71 (10.81–20.03)*** 2.08 (1.16–3.74)*
1.00 1.57 (0.96–2.56) 0.59 (0.37–0.92)* 0.93 (0.37–2.31)
Q. Zhu et al. / Drug and Alcohol Dependence 147 (2015) 251–256
Age 15–19 20–24 Gender Female Male Economic status Below average Average Above average School status A student without a job A student with a job Not a student with a job Not a student and without a job City Hanoi Shanghai Taipei Drunk Interactions
The first sex nonuse of contraceptiona Adj.OR (95%CI)
Anxiety
Q. Zhu et al. / Drug and Alcohol Dependence 147 (2015) 251–256
255
Table 3 Adjusted odds ratio estimates of drunkenness for health risk behaviors by city. Drunkenness
Anxiety Suicidal ideation Smoking Gambling Running away from home Fighting Drinking and driving Sexual intercourse Nonuse of contraceptionc at first sex * ** *** a b c
Hanoi (n = 6155) Adj.OR (95%CI)a
Shanghai (n = 6039) Adj.OR (95%CI)a
Taipei (n = 4850) Adj.OR (95%CI)a
Interaction p-valueb
2.14 (1.54–2.98)*** 2.12 (1.33–3.38)** 3.60 (2.56–5.05)*** 3.64 (2.17–6.10)*** 2.77 (2.03–3.78)*** 2.77 (2.10–3.67)*** 3.43 (2.64–4.45)*** 2.08 (1.16–3.74)* 0.93 (0.37–2.31)
1.97 (1.37–2.83)*** 2.18 (1.47–3.23)*** 4.63 (3.35–6.39)*** 3.53 (2.49–5.02)*** 2.76 (1.91–3.98)*** 4.19 (3.14–5.59)*** 3.94 (2.43–6.38)*** 2.35 (1.70–3.26)*** 1.03 (0.61–1.73)
2.41 (1.73–3.36)*** 1.97 (1.57–2.47)*** 8.49 (5.22–13.83)*** 1.80 (1.36–2.39)*** 2.90 (2.03–4.14)*** 3.10 (2.24–4.31)*** 5.85 (4.45–7.69)*** 3.10 (2.15–4.47)*** 1.17 (0.72–1.92)
0.709 0.889 0.018 0.002 0.976 0.104 0.019 0.397 0.862
p < 0.05. p < 0.01. p < 0.001. Adjusted odds ratio from multivariable logistic models. Joint test of significance for all interaction terms in model. Restricted to those who ever had sexual intercourse.
more frequently by youth with alcohol disorders and episodic heavy drinking patterns (Chen et al., 2008; Miller et al., 2007). The “shared vulnerability model” posits that there are underlying genetic or other general susceptibility traits that contribute to both alcohol use and observed psychological disturbances (Baigent, 2005). In addition, adolescents may choose alcohol as one way to escape from or cope with distress and relieve depression. A range of studies (Wagner and Anthony, 2002; Willner, 2001) found evidence that alcohol preceded the use of other substances such as tobacco and illicit drugs and increased the risk of their use, thus supporting the hypothesis that alcohol is a “gateway” drug in relation to other substances (Kandel, 2002). A positive association between adolescent excessive drinking and violence has also been reported (Bye and Rossow, 2010) and Cirillo et al. (1998) offered the explanation that adolescents who abused alcohol may rely on violence as a coping strategy more than others who do not. The strong crosssectional relationship between excessive drinking and impaired driving has been described in previous studies (Flowers et al., 2008; Naimi et al., 2009); it is well known that people who drive after drinking are more likely to speed, are less likely to wear seat belts, and are less likely to appreciate their increased crash risk than when sober. Finally, literature has well-documented the association of alcohol use with increased sexual risk behaviors (Hingson et al., 2003; Kaljee et al., 2005; Lin et al., 2005); drunkenness may directly impair judgment and cause social disinhibition, resulting in an increased likelihood of sexual risk behaviors. Leigh and Stall (1993) proposed a personality-based mechanism, in which alcohol use and risk-taking sexual behaviors may both be indicators of a risk-taking or sensation-seeking personality type. Previous research about the relationship between drunkenness and nonuse of contraception was not consistent. While some studies report that adolescents who drink heavily are less likely to use condoms (Graves, 1995); others found no significant relationship (Lin et al., 2005; Morrison et al., 2003). Leigh (2002) proposed that drinking was not necessarily linked to unprotected intercourse, which is more dependent on context and the sexual experience of the partners. Among the positive association between drunkenness and a variety of different health risk behaviors, the associations of drunkenness with smoking and driving and drinking were stronger than other associations in each city, suggesting that a history of drunkenness is more related to both than to other behaviors. These associations varied significantly across the three cities – the strongest in Taipei, followed by Shanghai, and the weakest in Hanoi – which supported our hypothesis. Thus, exposure to the West appears to influence the strength of the associations. However, the relation between drunkenness and gambling varied inversely with
the extent of exposure to the West, which was not expected. It is possible that adolescents getting drunkenness often have high seeking of novel and intense sensations (Donohew et al., 2000). Gambling is more prevalent in Taipei than in Shanghai and Vietnam, so these adolescents with drunkenness in Taipei are less likely to engage in gambling, which is not novel and stimulating. Several limitations of this study should be noted. First, as the research used cross-sectional data and global correlations to measure relationship between drunkenness and health risk behaviors, the temporal relation between them cannot be established. It may be that environments in which heavy drinking is common are conducive to other risks, as well. Longitudinal studies and event analyses could determine the direction of causality. Second, the data were obtained by self-report, and subject to report bias. However, computer-assisted interviews were used to improve the accuracy of response. Third, as different sampling approaches were adopted in Taipei and the other two cities, the different demographic characteristics of respondents, especially economic status and school status, could affect their risk behaviors. However, sample weighting was used to adjust for these differences. Fourth, owing to small cell counts, it was difficult to investigate the dose effect of drunkenness (1 time, 2–3 times, and more than 3 times) with risk behaviors. It is possible that some differences existed between them. In the three cities, Taipei with the longest exposure to the West has the highest proportion of drunkenness, which is related with the influence of alcohol use in the West (Newman, 2002). The availability of western brands of alcohol, the development of brew pubs, and western drinking practices displayed in alcohol advertising and portrayed in movies, television, and other images from the West may create special appeals for young people. Therefore public health interventions should be adopted to address these issues. Such measures include the implementation of community-based education to raise awareness of the risks of excessive alcohol consumption, reduced exposure of underage youth to alcohol advertising, legislation about the purchase and selling of alcohol, and the use of severe fines for those selling alcohol to minors. With drunkenness significantly associated with other health risk behaviors in the three cities, our results have implications for prevention, intervention, and health promotion programs directed at adolescents and young adults: interventions aimed at reducing one risk behavior should not ignore the array of other coexisting behaviors. Noting the existence of one risk behavior in an adolescent should be a red flag, suggesting that other such behaviors may be concurrent or imminent (Tu et al., 2012). Measures to reduce drunkenness among adolescents may therefore be an
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effective way to lower the prevalence of other health risk behaviors. For example, the strength of relationship between drunkenness and gambling in Vietnam and Shanghai suggests that more attention should be paid to adolescents and young adults getting drunk to reduce gambling in these cities. Similarly, intervention to prevent smoking and drunk driving may be more effective for young people with drunkenness in Taipei than in Vietnam or Shanghai. The present study points to some new directions for future research. With drunkenness in Asian cities related to exposure to the West, further research should explore how drunkenness is influenced by western drinking practices in more detail; pathway analysis should be developed to understand what mechanisms are involved in the relationship between drunkenness and other health risk behaviors in the future studies. Role of funding source Funding for this study was provided by Bill and Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA (grant no. 979-2020). Contributors Qianqian Zhu wrote the first draft of the manuscript and undertook the statistical analysis. Chaohua Lou, Ersheng Gao and Laurie S. Zabin were responsible for obtaining funding, implementation of the survey and quality control during field work. Yan Cheng participated in the implementation of the survey and supervision of fieldwork. Mark R. Emerson made a significant intellectual contribution to the study design and the statistical analysis. All authors contributed to and have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest. Acknowledgements We thank the Bill and Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA, who provided financial support for the study. We would also like to sincerely thank all the researchers at the Hanoi Institute of Family and Gender Studies, the health Research Center in Taiwan’s Bureau of Health Promotion and the Shanghai Institute of Planned Parenthood Research for their contributions to the project. References Andersson, B., Hibell, B., 2007. Drunken Behaviour, Expectancies and Consequences Among European Students. Youth Drinking Cultures-European Experiences. Ashgate, Hampshire, pp. 41–64. Baigent, M.F., 2005. Understanding alcohol misuse and comorbid psychiatric disorders. Curr. Opin. Psychiatry 18, 223–228. Balogun, O., Koyanagi, A., Stickley, A., Gilmour, S., Shibuya, K., 2014. Alcohol consumption and psychological distress in adolescents: a multi-country study. J. Adolesc. Health 54, 228–234. Benjet, C., Borges, G., Méndez, E., Casanova, L., Medina-Mora, M.E., 2014. Adolescent alcohol use and alcohol use disorders in Mexico City. Drug Alcohol Depend. 136, 43–50. Bye, E.K., Rossow, I., 2010. The impact of drinking pattern on alcohol-related violence among adolescents: an international comparative analysis. Drug Alcohol Rev. 29, 131–137. Chen, C., Storr, C.L., Tang, G., Huang, S., Hsiao, C.K., Chen, W.J., 2008. Early alcohol experiences and adolescent mental health: a population-based study in Taiwan. Drug Alcohol Depend. 95, 209–218. 2006. China Bans Under-age Drinking. China Daily, http://www.chinadaily.com.cn/ english/doc/2006-01/06/content 510002.htm (retrieved 03.02.08).
Cirillo, K.J., Pruitt, B.E., Colwell, B., Kingery, P.M., Hurley, R.S., Ballard, D., 1998. School violence: prevalence and intervention strategies for at-risk adolescents. Adolescence 33, 319–330. Donohew, L., Zimmerman, R., Cupp, P.S., Novak, S., Colon, S., Abell, R., 2000. Sensation seeking, impulsive decision-making, and risky sex: implications for risk-taking and design of interventions. Personal. Individ. Differ. 28, 1079–1091. Fiona, M.G., Paul, J.N.B., George, C.P., et al., 2011. Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet 377, 2093–2102. Flowers, N.T., Naimi, T.S., Brewer, R.D., Elder, R.W., Shults, R.A., Jiles, R., 2008. Patterns of alcohol consumption and alcohol-impaired driving in the United States. Alcohol. Clin. Exp. Res. 32, 639–644. Graves, K.L., 1995. Risky sexual behavior and alcohol use among young adults: results from a national survey. Am. J. Health Promot. 10, 27–36. Guilamo, R.V., Litardo, H.A., Jaccard, J., 2005. Prevention programs for reducing adolescent problem behaviors: implications of the co-occurrence of problem behaviors in adolescence. J. Adolesc. Health 36, 82–86. Hingson, R., Heeren, T., Winter, M.R., Wechsler, H., 2003. Early age of first drunkenness as a factor in college students’ unplanned and unprotected sex attributable to drinking. Pediatrics 111, 34–41. Hingson, R.W., Zha, W., Iannotti, R.J., Bruce, S.M., 2013. Physician advice to adolescents about drinking and other health behaviors. Pediatrics 131, 249–257. Hughes, K., MacKintosh, A.M., Hastings, G., Wheeler, C., Watson, J., Inglis, J., 1997. Young people, alcohol, and designer drinks: quantitative and qualitative study. BMJ 314, 414. Iris, C., James, E.L.H., 1989. Differences in drinking behavior among three AsianAmerican groups. J. Stud. Alcohol 50, 15–23. Istvan, J., Matarazzo, J.D., 1984. Tobacco, alcohol, and caffeine use: a review of their interrelationships. Psychol. Bull. 95, 301–326. Jessor, R., Jessor, S.L., 1977. Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. Academic Press, New York. Juan, W., Xiao, J.D., Jia, J.W., Xin, W.W., Liang, X., 2010. The associations between health risk behaviors and suicidal ideation and attempts in an urban Chinese sample of adolescents. J. Affect. Disord. 126, 180–187. Kaljee, L.M., Genberg, B.L., Minh, T.T., Tho, L.H., Thoa, L.T.K., Stanton, B., 2005. Alcohol use and HIV risk behaviors among rural adolescents in Khanh Hoa province Vietnam. Health Educ. Res. 20, 71–80. Kandel, D.B., 2002. Stages and Pathways of Drug Involvement: Examining the GateWay Hypothesis. Cambridge University Press, Cambridge. Leigh, B.C., 2002. Alcohol and condom use: a meta-analysis of event-level studies. Sex Transm. Dis. 29, 476–482. Leigh, B.C., Stall, R., 1993. Substance use and risky sexual behavior for exposure to HIV: issues in methodology, interpretation, and prevention. Am. Psychol. 48, 1035–1045. Lin, D., Li, X., Yang, H., Fang, X., Stanton, B., Chen, X., Abbey, A., Liu, H., 2005. Alcohol intoxication and sexual risk behaviors among rural-to-urban migrants in China. Drug Alcohol Depend. 79, 103–112. Madkour, A.S., Farhat, T., Halpern, C.T., Godeau, E., Gabhainn, S.N., 2010. Early adolescent sexual initiation as a problem behavior: a comparative study of five nations. J. Adolesc. Health 47, 389–398. Miller, J.W., Naimi, T.S., Brewer, R.D., Jones, S.E., 2007. Binge drinking and associated health risk behaviors among high school students. Pediatrics 119, 76–85. Morrison, D.M., Gillmore, M.R., Hoppe, M.J., Gaylord, J., Leigh, B.C., Rainey, D., 2003. Adolescent drinking and sex: findings from a daily diary study. Perspect. Sex. Reprod. Health 35, 162–168. Müller, S., Piontek, D., Pabst, A., Kraus, L., 2011. The relationship between alcohol consumption and perceived drunkenness: a multilevel cross-national comparison in samples of adolescents. Alcohol Alcohol. 46, 399–406. Naimi, T.S., Nelson, D.E., Brewer, R.D., 2009. Driving after binge drinking. Am. J. Prev. Med. 37, 314–320. Newman Ian, Cultural aspects of drinking patterns and alcohol controls in China, The Globe (Global Alcohol Policy Alliance, London). 1, 2002, 18–21. O’Brien, M.C., McCoy, T.P., Champion, H., Mitra, A., Robbins, A., Teuschlser, H., Wolfson, M., DuRant, R.H., 2006. Single question about drunkenness to detect college students at risk for injury. Acad. Emerg. Med. 13, 629–636. Stickley, A., Koyanagi, A., Koposov, R., Razvodovsky, Y., Ruchkin, V., 2013. Adolescent binge drinking and risky health behaviours: findings from northern Russia. Drug Alcohol Depend. 133, 838–844. Trim, R.S., Meehan, B.T., King, K.M., Chassin, L., 2007. The relation between adolescent substance use and young adult internalizing symptoms: findings from a highrisk longitudinal sample. Psychol. Addict. Behav. 21, 97–107. Tu, X.W., Lou, C.H., Gao, E.S., Li, N., Zabin, L.S., 2012. The relationship between sexual behavior and nonsexual risk behaviors among unmarried youth in three Asian cities. J. Adolesc. Health 50, S75–S82. Wagner, F.A., Anthony, J.C., 2002. Into the world of illegal drug use: exposure opportunity and other mechanisms linking the use of alcohol, tobacco, marijuana, and cocaine. Am. J. Epidemiol. 155, 918–925. Weatherspoon, A.J., Park, J.Y., Johnson, R.C., 2001. A family study of homeland Korean alcohol use. Addict. Behav. 26, 101–113. Willner, P., 2001. A view through the gateway: expectancies as a possible pathway from alcohol to cannabis. Addiction 96, 691–703. World Health Organization, 2011. Global Status Report on Alcohol and Health. WHO Library Cataloguing-in-Publication Data. WHO, Geneva. Zabin, L.S., Emerson, M.R., Nan, L., Chaohua, L., Ersheng, G., Minh, N.H., Chuang, Y.L., Hurng, B.S., Bishai, D., Blum, R.W., 2009. Levels of change in adolescent sexual behavior in three Asian Cities. Stud. Fam. Plann. 40, 1–12.