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Relationship of Binge Drinking and Other Health-Compromising Behaviors among Urban Adolescents in China
Journal of Adolescent Health 39 (2006) 495–500
Original Article
Relationship of Binge Drinking and Other Health-Compromising Behaviors among Urban Adolescents in China Yi Xing, Ph.D.*, Chengye Ji, M.D., and Lin Zhang, B.S.P.H. Institute of Child and Adolescent Health, Peking University, Beijing, China Manuscript received November 4, 2005; manuscript accepted March 30, 2006
Abstract:
Purpose: To describe frequency and patterns of alcohol use and explore the association between binge drinking and other health-compromising behaviors among adolescents in urban China. Methods: Data on alcohol use and other behavioral risk factors were obtained from the 2004 China Adolescent Behavioral Risk Factor Survey conducted in 18 provincial capitals. Chi-square test was used to estimate the prevalence of alcohol use and compare differences in drinking frequency by gender, school type, and grade. Logistic regression was used to estimate the association between binge drinking and other health-compromising behaviors. Results: Data were available on 54,040 students in grades 7 to 12. In all, 51.1% of students reported ever using alcohol (male: 58.6%; female: 44.3%), 29.7% reported drinking before 13 years of age, and 14.1% had gotten drunk at least once during the past year. In the 30 days preceding the interview, 25.2% students reported consuming at least one alcoholic drink (male: 31.4%; female: 19.6%) and 10.3% reported at least one episode of binge drinking (male: 14.4%; female: 6.6%). Male students from vocational senior high schools reported the highest frequency of alcohol use. The prevalence of other risk behaviors, such as smoking, drug use, and fighting were significantly higher among students with a positive history of binge drinking. Conclusions: Alcohol use among urban adolescents is a major problem in China. A comprehensive alcohol control policy is needed, incorporating measures to educate the public about the dangers of adolescent alcohol use and regulating access and purchase of alcohol by minors. © 2006 Society for Adolescent Medicine. All rights reserved.
Keywords:
Alcohol use; Binge drinking; Health-compromising behaviors; Adolescent; China
Adolescent alcohol use can be a major problem resulting in significant disability and premature death [1,2]. Studies in developed countries show that although adolescents tend to drink less regularly than adults, they are more likely to drink excessively [2]. Alcohol use in adolescents is associated with alcohol poisoning, motor vehicle crashes, risky sexual behaviors, suicide attempts, drowning, and other drug use. Alcohol use is a significant contributor to injury in adolescents and may play a role in more than 50% of traumatic brain injuries in adolescents [2,3]. The greater the volume of
*Address correspondence to: Dr. Yi Xing, Institute of Child and Adolescent Health, Peking University, 38 Xueyuan Road, Beijing 100083, China. E-mail: [email protected]
alcohol consumed, the greater the risk of disability and premature death now and in the future [1– 6]. Studies of adolescent alcohol use in developing countries, however, have been limited. Since the 1980s, alcohol consumption has increased rapidly in China [5]. Total Chinese adult per capita consumption of pure alcohol in 1970 –1972 was 1.03 L, rapidly increasing to 5.17 L in 1994 –1996; this percentage change in alcohol consumption was second among 137 countries studied [5]. Surveys on adult alcohol use in China indicate that alcohol use is widespread, that alcohol dependence and other alcohol-related physical and social problems are increasing, and that alcohol dependency is beginning at a younger age [7,8]. In China, the prevalence of adolescent alcohol use has not been well characterized, with variable
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Y. Xing et al. / Journal of Adolescent Health 39 (2006) 495–500
Table 1 Percentage of school students who drank alcohol, by gender and school type, in 18 Chinese provincial capitalsa School type
n
Lifetime alcohol use
Current alcohol use
M
F
Total
M ⫾ SE
F ⫾ SE
Total ⫾ SE
M ⫾ SE
F ⫾ SE
Total ⫾ SE
Junior high school Model school Ordinary school Senior high school Model school Ordinary school Vocational school Total
10,974 5206 5768 14,566 5483 4890 4193 25,540
10,456 5018 5438 17,800 5548 5552 6700 28,256
21,430 10,224 11,206 32,366 11,031 10,442 10,893 53,796
42.9 ⫾ .5 41.9 ⫾ .7 43.8 ⫾ .7* 70.4 ⫾ .4 65.1 ⫾ .6 70.8 ⫾ .7 76.7 ⫾ .7*** 58.6 ⫾ .3
31.2 ⫾ .5 31.4 ⫾ .7 31.1 ⫾ .6ns 52.0 ⫾ .4 48.3 ⫾ .7 49.3 ⫾ .7 57.3 ⫾ .6*** 44.3 ⫾ .3
37.2 ⫾ .3 36.7 ⫾ .5 37.6 ⫾ .5ns 60.3 ⫾ .3 56.6 ⫾ .5 59.4 ⫾ .5 64.8 ⫾ .5*** 51.1 ⫾ .2
20.7 ⫾ .4 18.9 ⫾ .5 22.4 ⫾ .5*** 39.4 ⫾ .4 29.7 ⫾ .6 40.3 ⫾ .7 50.9 ⫾ .8*** 31.4 ⫾ .3
13.7 ⫾ .3 13.3 ⫾ .5 14.0 ⫾ .5ns 23.0 ⫾ .3 19.4 ⫾ .5 20.0 ⫾ .5 28.4 ⫾ .6*** 19.6 ⫾ .2
17.3 ⫾ .3 16.2 ⫾ .4 18.3 ⫾ .4*** 30.4 ⫾ .3 24.5 ⫾ .4 29.5 ⫾ .4 37.1 ⫾ .5*** 25.2 ⫾ .2
**p ⱕ .01; a All 2 values were significant at level of p ⱕ .001 compared across males and females. * p ⱕ .05; *** p ⱕ .001.
definitions of alcohol use. Surveys on the prevalence of alcohol use conducted in Beijing, Wuhan, Hefei, and Shanghai provinces found that 40 –53% of middle school students had ever used alcohol, 16 –31% were current users, and 4 –11% had gotten drunk in the past year [9 –12]. The survey in Beijing showed that 36% of students in grades 7–11 were current drinkers, 18% had engaged in binge drinking in the last month, and 38% initiated alcohol use before 13 years of age [11]. All the surveys showed that alcohol use was common among middle school students, but different definitions and limited geographic scope make regional comparisons difficult [9 –13]. Furthermore, no reports are available in China on the association between binge drinking and other behavioral risk factors. The China Adolescent Behavioral Risk Factor Survey (CABRFS) was conducted in urban schools in 18 of 31 provinces in 2004. The survey’s purpose was to assess the magnitude, identify patterns, and monitor future trends of major behavioral risk factors contributing to death, disability, and social problems among adolescents in China. Alcohol use and tobacco use were considered to be gateways to illegal drug use and had been becoming a serious public problem in China [12,14]. Sexual intercourse among adolescents is not accepted by Chinese culture, and most sexual intercourse among adolescents was unprotected, leading to a rapid increase in the prevalence of induced abortion and sexually transmitted infections (STIs) among adolescents [12,15]. Alcohol use had a positive effect on the likelihood of sexual intercourse and nonuse of contraception among adolescents [16]. In China, vehicle accidents, drowning, suicide, and homicide are leading causes of death among 10 –24-year-olds [12,16,17]. For example, over 60% of deaths in male juvenile students are attributed to drowning while swimming in rivers, lakes, and ponds without lifeguard or adult supervision [12,18]. Alcohol use is a significant contributor to injury in a wide variety of settings, including road traffic accident (vehicles, bicycles, pedestrians), drowning, suicide, and interpersonal violence. The presence of alcohol in the body at the time of injury may be associated with greater severity of injury and less positive outcomes in adolescents
[1–3]. Therefore, information on risky behaviors collected in the survey included alcohol and tobacco use, sexual behaviors, cycling, fighting, suicide attempts, and swimming practices. Information was collected using a standard questionnaire through interviews. Definitions of various behavior patterns were based on the United States’ Youth Risk Behaviors Surveillance System (YRBSS) [19]. Methods Data Collection and Sampling The survey questionnaire was adapted from the YRBSS and the Global School-based Student Health Survey (World Health Organization) [20,21]. The questionnaire was reviewed and validated by education and health experts and pilot-tested in Beijing and Jinan [22]. The appropriateness and feasibility for the actual survey were assessed through focus groups and interviews with the teachers and students. The survey was conducted by the Departments of School Health of the Provincial Centers for Disease Prevention and Control in 18 provincial capitals during October–December 2004. The cities include Harbin, Shenyang, Urumchi, Xining, Beijing, Tianjin, Shijiazhuang, Chengdu, Nanning, Guangzhou, Haikou, Zhengzhou, Wuhan, Nanjing, Changsha, Nanchang, Shanghai, and Fuzhou. Each city employed a two-stage cluster sampling method to produce a representative sample of students in grades 7–12. The first stage was drawn from a list of all schools in the city compiled by the local Educational Committee according to school type and enrollments. Schools were then divided into five groups according to school type: ordinary junior high school, model junior high school, ordinary senior high school, model senior high school, and vocational senior high school. In general, model schools have better facilities, more qualified teachers, and students with better grades. Vocational schools are a type of senior high school where students focus on learning a trade. A systematic sampling procedure was used to then select at least three schools in each category in each city. If the principal agreed, a list of all classes in the school was prepared and one to two
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Table 1 Continued Binge drinking
Heavy binge drinking
Got drunk
Drank before age 13
M ⫾ SE
F ⫾ SE
Total ⫾ SE
M ⫾ SE
F ⫾ SE
Total ⫾ SE
M ⫾ SE
F ⫾ SE
Total ⫾ SE
M ⫾ SE
F ⫾ SE
Total ⫾ SE
7.5 ⫾ .3 6.6 ⫾ .3 8.4 ⫾ .4*** 19.5 ⫾ .3 12.9 ⫾ .5 19.8 ⫾ .6 27.8 ⫾ .7*** 14.4 ⫾ .2
4.0 ⫾ .3 3.9 ⫾ .3 4.2 ⫾ .3ns 8.1 ⫾ .2 5.4 ⫾ .3 6.3 ⫾ .3 11.7 ⫾ .3*** 6.6 ⫾ .3
5.8 ⫾ .2 5.3 ⫾ .2 6.3 ⫾ .2*** 13.2 ⫾ .2 9.2 ⫾ .3 12.6 ⫾ .3 17.9 ⫾ .4*** 10.3 ⫾ .1
1.8 ⫾ .1 1.7 ⫾ .2 2.0 ⫾ .2ns 3.5 ⫾ .2 1.7 ⫾ .2 3.7 ⫾ .3 5.8 ⫾ .4*** 2.8 ⫾ .1
.6 ⫾ .1 0.5 ⫾ .2 0.6 ⫾ .2ns 1.1 ⫾ .1 .6 ⫾ .1 0.7 ⫾ .1 1.8 ⫾ .2*** .9 ⫾ .1
1.2 ⫾ .1 1.1 ⫾ .1 1.3 ⫾ .1ns 2.2 ⫾ .1 1.2 ⫾ .1 2.1 ⫾ .1 3.3 ⫾ .2*** 1.8 ⫾ .1
9.1 ⫾ .3 7.5 ⫾ .4 10.5 ⫾ .4*** 23.6 ⫾ .4 16.2 ⫾ .6 23.4 ⫾ .5 33.5 ⫾ .7*** 17.4 ⫾ .2
5.7 ⫾ .2 5.5 ⫾ .3 5.9 ⫾ .3ns 14.4 ⫾ .3 10.7 ⫾ .4 12.5 ⫾ .4 19.0 ⫾ .5*** 11.2 ⫾ .2
7.4 ⫾ .2 6.5 ⫾ .2 8.3 ⫾ .3*** 18.5 ⫾ .2 13.4 ⫾ .3 17.6 ⫾ .4 24.6 ⫾ .4*** 14.1 ⫾ .2
34.8 ⫾ .3 35.0 ⫾ .4 34.7 ⫾ .4*** 37.2 ⫾ .4 37.6 ⫾ .6 38.2 ⫾ .7 35.7 ⫾ .8*** 36.2 ⫾ .3
25.2 ⫾ .2 26.2 ⫾ .3 24.2 ⫾ .3*** 23.2 ⫾ .3 25.2 ⫾ .6 23.7 ⫾ .6 21.0 ⫾ .6*** 23.9 ⫾ .2
30.1 ⫾ .2 30.7 ⫾ .2 29.6 ⫾ .3ns 29.5 ⫾ .3 31.4 ⫾ .4 30.5 ⫾ .4 26.6 ⫾ .5*** 29.7 ⫾ .2
classes in each grade were randomly selected in each school. In each city, approximately 600 students from each category of school for a total of 3000 students completed a self-administered questionnaire. Informed consent was obtained verbally, and no personal identifying information was collected in order to protect privacy and confidentiality of the information. In all, 99% of students in selected classes consented to participate in the survey. The high consent rate of students can be found in the Global Schoolbased Student Health Survey in China and may be attributed to the traditional Chinese cultural norms, in which students take positive attitudes to the activities conducted in school [21]. On average, it took the students 35 to 50 minutes to finish the questionnaire. Measurement of Behavioral Risk Factors Patterns of alcohol consumption were defined as: lifetime (at least one previous drink), current (at least one alcoholic drink in the past 30 days), binge drinking (at least five alcoholic drinks per occasion in one day during the past 30 days), and heavy binge drinking (at least five alcoholic drinks per occasion six times or more during the past 30 days) [19,23]. Students who reported feeling sick or having headaches from alcohol consumption during the past 12 months were defined as having gotten drunk [19]. Current smoking was defined as smoking one or more cigarettes per day in the past 30 days [19]. Drug use was defined as any prior use of marijuana, cocaine, or methamphetamines [19]. High-risk cycling behavior was defined as any of the following during the past 12 months: (1) cycling without hands on handlebar; (2) cycling with hand on other vehicles; (3) chasing each other; (4) cycling in the wrong direction; (5) cycling with other people on the carrier; (6) cycling against red light or crossing road against rules. High-risk swimming behavior was defined as swimming without the company of adults or a lifeguard at least one time in the past 12 months. Fighting was defined as a physical fight at least once in the past 12 months [19]. Depression was defined as feeling sad or hopeless almost every day for at least two consecutive weeks during the past year. Suicide was defined as having considered suicide (suicide ideation), planned a suicide attempt but did not act (suicidal plan), and attempted suicide [19]. Sexual inter-
course was defined as any previous sexual intercourse [19]. Socio-demographic information such as gender, grade, school type, parental education level, and parents’ marriage status were also collected. Data Analysis We used EpiData 3.0 (The EpiData Association, Odense, Denmark) to enter the data, and SPSS v11.0 (SPSS-China, Beijing, China) for analysis. We calculated the prevalence of alcohol use and used the chi-square test to compare the prevalence of alcohol use across gender and different school types. Adjusted multivariate logistic regression model were employed to estimate the odds ratios of risk behaviors among the students with and without a history of binge drinking while accounting for gender, grade, school type, and family structure. Separate regression analyses were conducted for each risk behavior. Because the prevalence of most health-compromising behaviors was higher than 10%, a correction was made to estimate the relative risk from the odds ratios [24]: RR ⫽ OR ⁄ 关共1 ⫺ P0兲 ⫹ 共P0 ⫻ OR兲兴 in which P0 is the prevalence of risk behavior among students without binge drinking, and OR is the results from logistic regression. Results Demographic Information A total of 54,040 students (99% of eligible) completed the questionnaire, of which 11,345 were from 64 ordinary junior high schools, 10,270 from 52 model junior high schools, 10,463 from 57 ordinary senior high schools, 11,051 from 58 model senior high schools, and 10,911 from 52 vocational senior high schools. The average age of students in junior high schools (grades 7–9) was 13.8 years (SD ⫽ 1.1). Females accounted for 48.7% and males accounted for 51.3%. The average age of students in senior high schools (grades 10 –12) was 16.7 years (SD ⫽ 1.0). Females accounted for 55.0% and males accounted for 45.0%. In total, 65.2% of students live with their parents (nuclear families); 19.4% lived with their parents and grandparents (extended family); 13.8% lived with
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Table 2 Adjusted odds ratiosa and 95% confidence intervals for involvement in other health-compromising behaviors among students engaged in binge drinking, and heavy binge drinking to those without binge drinking Health-compromising behaviors (Dependent variables)
n
Drug use Current smoking Sexual intercoursec Attempted suicide Suicidal plan Suicidal ideation Felt sad or hopeless Physical fight High-risk swimming High-risk cycling
53,739 53,667 30,784 52,359 52,474 53,566 53,645 53,629 29,475 48,988
Without binge drinking % .3 7.0 2.7 2.3 6.4 19.7 14.8 21.5 15.7 44.0
Binge drinking in 1–5 days
Heavy binge drinking
%
ORadja
95% CI
RRb
95% CI
%
ORadja
95% CI
RRb
95% CI
5.8 43.9 14.2 7.3 13.7 31.0 27.6 48.0 28.0 60.6
18.2 8.0 4.8 3.5 2.6 2.1 2.1 3.5 1.9 1.7
(14.6–22.5) (7.4–8.6) (4.2–5.4) (3.1–4.1) (2.4–2.9) (1.9–2.2) (2.0–2.3) (3.3–3.8) (1.7–2.1) (1.6–1.9)
18.1 7.4 4.7 3.4 2.4 1.7 1.8 2.7 1.6 1.0
(14.6–22.4) (6.9–8.0) (4.1–5.3) (3.0–4.0) (2.2–2.7) (1.5–1.8) (1.7–2.0) (2.6–3.0) (1.4–1.8) (.9–1.1)
20.6 58.8 24.3 14.8 23.4 36.5 33.7 62.6 45.5 67.7
74.2 14.4 8.7 7.9 5.3 2.8 2.9 5.8 3.7 2.3
(58.6–93.9) (12.5–16.6) (7.2–10.6) (6.5–9.7) (4.5–6.2) (2.4–3.2) (2.5–3.3) (5.0–6.7) (3.1–4.3) (2.0–2.7)
74.0 13.4 8.5 7.7 5.0 2.2 2.5 4.6 3.1 1.3
(58.4–93.6) (11.6–15.4) (7.0–10.3) (6.4–9.5) (4.2–5.8) (1.9–2.6) (2.1–2.8) (3.9–5.3) (2.6–3.6) (1.1–1.5)
a
Accounting for sex, school type, grade, family structure. Corrected relative ratio. c Sexual intercourse only reported by high school students. b
single or composite parents (broken family); and 1.6% lived with other people such as uncles and aunts. Prevalence of Alcohol Use In total, 51.1% of students had ever consumed alcohol; 25.2% were current users; 10.3% engaged in binge drinking; 1.8% engaged in heavy binge drinking; 14.1% had ever got drunk; and 29.7% reported first drinking before the age of 13 years (Table 1). In male students, 14.4% were binge drinkers, and 2.8% were heavy binge drinkers, higher rates than for females (binge drinker: 6.6%; heavy binge drinker: .9%). Senior high school students reported a higher rate of binge drinking (13.2%) and heavy binge drinking (2.2%) than junior high school students (binge drinker: 5.8%; heavy binge drinker: 1.2%). More students from vocational senior high schools reported drinking to excess than those from ordinary schools and model schools. For example, binge drinkers accounted for 17.9% in vocational senior high schools, compared with 6.3% in ordinary schools and 5.4% in model schools. The prevalence of heavy binge drinking in vocational senior high school students was 3.3%, compared with 2.1% in ordinary schools and 1.2% in model schools. The Association Between Binge Drinking and Other Health-Compromising Behaviors The prevalence of other behavioral risk factors was highest among students who engaged in heavy binge drinking and the lowest among students who had never engaged in binge drinking (Table 2). The logistic regression also showed the same pattern. For all behavioral risk factors, odds ratios for heavy binge drinking and binge drinking were greater than 1.0 compared to students without a history of binge drinking, with a positive trend associated with level of drinking. The odds ratio for different health-compromising behaviors differed substantially, the highest for drug use
and the lowest for high-risk cycling; meaning binge drinkers were at different risk for various health-compromising behaviors. The adjusted relative ratios showed a similar pattern, except for risk cycling, which had a relative ratio of 1.0 in binge drinking. Discussion This study indicates that the majority of students (51.1%) in grades 7–12 in capital cities of China have consumed alcohol, with the highest prevalence of use in male students, senior high school students, and vocational senior high school students. This result is similar to other studies in China [9 –12]. Generally, lifetime, current, and binge alcohol use among Chinese students is lower than that of American, Japanese, and European students [2,19]. Studies in California and Hawaii also show that Chinese youth report lower alcohol use than Whites, Pacific Islanders and Native Hawaiians, Japanese, and Filipinos [25]. We found much variability in the prevalence of alcohol use among subgroups of adolescents in China. Male adolescents were far more likely than female adolescents to have consumed alcohol at all levels of use, similar to findings in other Western Pacific Regions and European countries, but different from findings in the United States [2,19]. Alcohol use and binge drinking were more common among senior high school students, especially among vocational senior high school students. In our study, 70.4% of male students in senior high schools were lifetime alcohol users and 39.4% were current alcohol users. These two figures are close to their American counterparts in grades 9 –12 (73.7% and 43.8%, respectively) [19]. Among male senior high school students, 19.5% were binge drinkers, lower than the 29.0% attributed to their American counterparts [19]. Male students from vocational senior high schools reported higher rates of lifetime and current alcohol use than their
Y. Xing et al. / Journal of Adolescent Health 39 (2006) 495–500
American counterparts, but reported a similar rate of binge drinking [19]. Among female senior high school students, the rates of lifetime, current, and binge alcohol use are much lower than their American counterparts (52.0%, 23.0%, 8.1%, respectively, in China vs. 76.1%, 45.8%, 27.5%, respectively, in America) [19]. Another finding is that binge drinking among adolescent drinkers is common. Binge drinkers accounted for 34% of current drinkers in junior high schools and 41% in senior high schools, higher than that of American students (30%) [3]. In most developing countries, many adolescent drinkers tend to drink large amounts when they drink [26]. This drinking pattern in developing countries is conducive to a fairly high degree of alcohol-related harms per liter of alcohol consumed [26]. The study also indicates that adolescents start alcohol use earlier in China than in other countries [2]. In this study, 29.7% of Chinese students initiated alcohol use before 13 years of age. This rate is higher than that of other countries, with the exception of the United Kingdom, Denmark, Finland, and the Russian Federation [2]. A study in China showed that the percentage of those initiating alcohol use before age 13 years had been increasing from 1998 to 2003. This increase might result from cultural and socioeconomic changes in China [9]. For most adolescents, alcohol use is accepted and sometimes encouraged by parents and peers because drinking alcohol is considered an important method of social communication in Chinese culture. Nearly half of senior high school students in China drink at home with their parents or out with their peers [27,28]. Some studies from Western countries show that the earlier people begin drinking, the more likely they are to become alcohol dependent later in life and to experience alcohol-related unintentional injuries [2,29]. Currently in China, there are no age restrictions on on-premises or off-premises purchases of beer and no restrictions on alcohol advertising on television, radio, or print [30]. International experience suggests that a comprehensive alcohol policy to prevent youth from alcohol use should not only incorporate measures to educate the public about the dangers of hazardous and harmful use of alcohol, but should also put in place regulations and other environmental supports that affect the price and availability of alcoholic beverages [2,6]. Our study suggests that the more frequently the students engage in binge drinking, the more likely they are to report illegal drug use, tobacco use, sexual intercourse, suicide behaviors, physical fights, and risk-swimming behaviors; these associations have all been well documented in Western countries [2,14,16,31–33]. A study of high school students in two large northern cities also showed that current alcohol use, tobacco use, physical fights, and suicidal ideation clustered in the moderate- or high-risk groups of students [22]. Logistic regression confirmed this result. The more frequently students engaged in binge drinking, the greater their risk for being exposed to health-compromising
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behaviors. Although binge drinking was positively associated with other health-compromising behaviors, the strength of the associations was different for different health-compromising behaviors. This indicates that alcohol use probably contributes to related harms with different magnitude. The impact of alcohol use on the mortality and mobility of Chinese young people is likely to be of equivalent or greater magnitude as a result of the relative lack of health care services and other mitigating and protective factors [3,12,27]. There were some limitations in our research. First, only 18 of 31 provinces conducted the survey voluntarily, so the pattern of alcohol use may not represent all Chinese high school students. Second, these data were self-reported and subject to report bias. However, some research has shown that self-reported data from adolescents are valid and reliable when the students’ privacy can be protected; our survey guaranteed the subjects’ privacy by anonymous, voluntary participation without the presence of school staff [34,35]. Third, the research was a cross-sectional survey, which can provide information only on associations between binge drinking and other health-compromising behaviors but not on the temporal relationship between these behaviors. Finally, the study was part of health-compromising behaviors research, and not a survey designed for alcohol use. Thus, the risk factors and style of alcohol use among Chinese adolescent cannot be concluded. The findings suggest that more studies are needed to examine the patterns, trends, and negative consequences of alcohol use among adolescents in China. Alcohol use prevention efforts must start in elementary school and continue through senior high school and aim to keep adolescents from starting to drink or to prevent the escalation of drinking and its negative consequences. Acknowledgments The study was funded by the Ministry of Health People’s Republic of China and the World Health Organization. Thanks to Dr. Lisa Lee for the editing of the manuscript. References [1] World Health Organization. Global Status Report on Alcohol 2004. Geneva: World Health Organization, 2004. [2] Jernigan DH. Global Status Report: Alcohol and Young People. Geneva: World Health Organization, 2001. [3] Zeigler DW, Wang CC, Yoast RA, et al. The neurocognitive effects of alcohol on adolescents and college students. Prev Med 2005;40: 23–32. [4] Halpern-Felsher BL, Cornell JL. Preventing underage alcohol use: where do we go from here? J Adolesc Health 2005;37:1–3. [5] World Health Organization. Global Status Report On Alcohol. Geneva: World Health Organization, 1999. [6] Bauman A, Phongsavan P. Epidemiology of substance use in adolescence: prevalence, trends and policy implications. Drug Alcohol Depend 1999;55:187–207.
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Original Article
Relationship of Binge Drinking and Other Health-Compromising Behaviors among Urban Adolescents in China Yi Xing, Ph.D.*, Chengye Ji, M.D., and Lin Zhang, B.S.P.H. Institute of Child and Adolescent Health, Peking University, Beijing, China Manuscript received November 4, 2005; manuscript accepted March 30, 2006
Abstract:
Purpose: To describe frequency and patterns of alcohol use and explore the association between binge drinking and other health-compromising behaviors among adolescents in urban China. Methods: Data on alcohol use and other behavioral risk factors were obtained from the 2004 China Adolescent Behavioral Risk Factor Survey conducted in 18 provincial capitals. Chi-square test was used to estimate the prevalence of alcohol use and compare differences in drinking frequency by gender, school type, and grade. Logistic regression was used to estimate the association between binge drinking and other health-compromising behaviors. Results: Data were available on 54,040 students in grades 7 to 12. In all, 51.1% of students reported ever using alcohol (male: 58.6%; female: 44.3%), 29.7% reported drinking before 13 years of age, and 14.1% had gotten drunk at least once during the past year. In the 30 days preceding the interview, 25.2% students reported consuming at least one alcoholic drink (male: 31.4%; female: 19.6%) and 10.3% reported at least one episode of binge drinking (male: 14.4%; female: 6.6%). Male students from vocational senior high schools reported the highest frequency of alcohol use. The prevalence of other risk behaviors, such as smoking, drug use, and fighting were significantly higher among students with a positive history of binge drinking. Conclusions: Alcohol use among urban adolescents is a major problem in China. A comprehensive alcohol control policy is needed, incorporating measures to educate the public about the dangers of adolescent alcohol use and regulating access and purchase of alcohol by minors. © 2006 Society for Adolescent Medicine. All rights reserved.
Keywords:
Alcohol use; Binge drinking; Health-compromising behaviors; Adolescent; China
Adolescent alcohol use can be a major problem resulting in significant disability and premature death [1,2]. Studies in developed countries show that although adolescents tend to drink less regularly than adults, they are more likely to drink excessively [2]. Alcohol use in adolescents is associated with alcohol poisoning, motor vehicle crashes, risky sexual behaviors, suicide attempts, drowning, and other drug use. Alcohol use is a significant contributor to injury in adolescents and may play a role in more than 50% of traumatic brain injuries in adolescents [2,3]. The greater the volume of
*Address correspondence to: Dr. Yi Xing, Institute of Child and Adolescent Health, Peking University, 38 Xueyuan Road, Beijing 100083, China. E-mail: [email protected]
alcohol consumed, the greater the risk of disability and premature death now and in the future [1– 6]. Studies of adolescent alcohol use in developing countries, however, have been limited. Since the 1980s, alcohol consumption has increased rapidly in China [5]. Total Chinese adult per capita consumption of pure alcohol in 1970 –1972 was 1.03 L, rapidly increasing to 5.17 L in 1994 –1996; this percentage change in alcohol consumption was second among 137 countries studied [5]. Surveys on adult alcohol use in China indicate that alcohol use is widespread, that alcohol dependence and other alcohol-related physical and social problems are increasing, and that alcohol dependency is beginning at a younger age [7,8]. In China, the prevalence of adolescent alcohol use has not been well characterized, with variable
1054-139X/06/$ – see front matter © 2006 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2006.03.014
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Table 1 Percentage of school students who drank alcohol, by gender and school type, in 18 Chinese provincial capitalsa School type
n
Lifetime alcohol use
Current alcohol use
M
F
Total
M ⫾ SE
F ⫾ SE
Total ⫾ SE
M ⫾ SE
F ⫾ SE
Total ⫾ SE
Junior high school Model school Ordinary school Senior high school Model school Ordinary school Vocational school Total
10,974 5206 5768 14,566 5483 4890 4193 25,540
10,456 5018 5438 17,800 5548 5552 6700 28,256
21,430 10,224 11,206 32,366 11,031 10,442 10,893 53,796
42.9 ⫾ .5 41.9 ⫾ .7 43.8 ⫾ .7* 70.4 ⫾ .4 65.1 ⫾ .6 70.8 ⫾ .7 76.7 ⫾ .7*** 58.6 ⫾ .3
31.2 ⫾ .5 31.4 ⫾ .7 31.1 ⫾ .6ns 52.0 ⫾ .4 48.3 ⫾ .7 49.3 ⫾ .7 57.3 ⫾ .6*** 44.3 ⫾ .3
37.2 ⫾ .3 36.7 ⫾ .5 37.6 ⫾ .5ns 60.3 ⫾ .3 56.6 ⫾ .5 59.4 ⫾ .5 64.8 ⫾ .5*** 51.1 ⫾ .2
20.7 ⫾ .4 18.9 ⫾ .5 22.4 ⫾ .5*** 39.4 ⫾ .4 29.7 ⫾ .6 40.3 ⫾ .7 50.9 ⫾ .8*** 31.4 ⫾ .3
13.7 ⫾ .3 13.3 ⫾ .5 14.0 ⫾ .5ns 23.0 ⫾ .3 19.4 ⫾ .5 20.0 ⫾ .5 28.4 ⫾ .6*** 19.6 ⫾ .2
17.3 ⫾ .3 16.2 ⫾ .4 18.3 ⫾ .4*** 30.4 ⫾ .3 24.5 ⫾ .4 29.5 ⫾ .4 37.1 ⫾ .5*** 25.2 ⫾ .2
**p ⱕ .01; a All 2 values were significant at level of p ⱕ .001 compared across males and females. * p ⱕ .05; *** p ⱕ .001.
definitions of alcohol use. Surveys on the prevalence of alcohol use conducted in Beijing, Wuhan, Hefei, and Shanghai provinces found that 40 –53% of middle school students had ever used alcohol, 16 –31% were current users, and 4 –11% had gotten drunk in the past year [9 –12]. The survey in Beijing showed that 36% of students in grades 7–11 were current drinkers, 18% had engaged in binge drinking in the last month, and 38% initiated alcohol use before 13 years of age [11]. All the surveys showed that alcohol use was common among middle school students, but different definitions and limited geographic scope make regional comparisons difficult [9 –13]. Furthermore, no reports are available in China on the association between binge drinking and other behavioral risk factors. The China Adolescent Behavioral Risk Factor Survey (CABRFS) was conducted in urban schools in 18 of 31 provinces in 2004. The survey’s purpose was to assess the magnitude, identify patterns, and monitor future trends of major behavioral risk factors contributing to death, disability, and social problems among adolescents in China. Alcohol use and tobacco use were considered to be gateways to illegal drug use and had been becoming a serious public problem in China [12,14]. Sexual intercourse among adolescents is not accepted by Chinese culture, and most sexual intercourse among adolescents was unprotected, leading to a rapid increase in the prevalence of induced abortion and sexually transmitted infections (STIs) among adolescents [12,15]. Alcohol use had a positive effect on the likelihood of sexual intercourse and nonuse of contraception among adolescents [16]. In China, vehicle accidents, drowning, suicide, and homicide are leading causes of death among 10 –24-year-olds [12,16,17]. For example, over 60% of deaths in male juvenile students are attributed to drowning while swimming in rivers, lakes, and ponds without lifeguard or adult supervision [12,18]. Alcohol use is a significant contributor to injury in a wide variety of settings, including road traffic accident (vehicles, bicycles, pedestrians), drowning, suicide, and interpersonal violence. The presence of alcohol in the body at the time of injury may be associated with greater severity of injury and less positive outcomes in adolescents
[1–3]. Therefore, information on risky behaviors collected in the survey included alcohol and tobacco use, sexual behaviors, cycling, fighting, suicide attempts, and swimming practices. Information was collected using a standard questionnaire through interviews. Definitions of various behavior patterns were based on the United States’ Youth Risk Behaviors Surveillance System (YRBSS) [19]. Methods Data Collection and Sampling The survey questionnaire was adapted from the YRBSS and the Global School-based Student Health Survey (World Health Organization) [20,21]. The questionnaire was reviewed and validated by education and health experts and pilot-tested in Beijing and Jinan [22]. The appropriateness and feasibility for the actual survey were assessed through focus groups and interviews with the teachers and students. The survey was conducted by the Departments of School Health of the Provincial Centers for Disease Prevention and Control in 18 provincial capitals during October–December 2004. The cities include Harbin, Shenyang, Urumchi, Xining, Beijing, Tianjin, Shijiazhuang, Chengdu, Nanning, Guangzhou, Haikou, Zhengzhou, Wuhan, Nanjing, Changsha, Nanchang, Shanghai, and Fuzhou. Each city employed a two-stage cluster sampling method to produce a representative sample of students in grades 7–12. The first stage was drawn from a list of all schools in the city compiled by the local Educational Committee according to school type and enrollments. Schools were then divided into five groups according to school type: ordinary junior high school, model junior high school, ordinary senior high school, model senior high school, and vocational senior high school. In general, model schools have better facilities, more qualified teachers, and students with better grades. Vocational schools are a type of senior high school where students focus on learning a trade. A systematic sampling procedure was used to then select at least three schools in each category in each city. If the principal agreed, a list of all classes in the school was prepared and one to two
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497
Table 1 Continued Binge drinking
Heavy binge drinking
Got drunk
Drank before age 13
M ⫾ SE
F ⫾ SE
Total ⫾ SE
M ⫾ SE
F ⫾ SE
Total ⫾ SE
M ⫾ SE
F ⫾ SE
Total ⫾ SE
M ⫾ SE
F ⫾ SE
Total ⫾ SE
7.5 ⫾ .3 6.6 ⫾ .3 8.4 ⫾ .4*** 19.5 ⫾ .3 12.9 ⫾ .5 19.8 ⫾ .6 27.8 ⫾ .7*** 14.4 ⫾ .2
4.0 ⫾ .3 3.9 ⫾ .3 4.2 ⫾ .3ns 8.1 ⫾ .2 5.4 ⫾ .3 6.3 ⫾ .3 11.7 ⫾ .3*** 6.6 ⫾ .3
5.8 ⫾ .2 5.3 ⫾ .2 6.3 ⫾ .2*** 13.2 ⫾ .2 9.2 ⫾ .3 12.6 ⫾ .3 17.9 ⫾ .4*** 10.3 ⫾ .1
1.8 ⫾ .1 1.7 ⫾ .2 2.0 ⫾ .2ns 3.5 ⫾ .2 1.7 ⫾ .2 3.7 ⫾ .3 5.8 ⫾ .4*** 2.8 ⫾ .1
.6 ⫾ .1 0.5 ⫾ .2 0.6 ⫾ .2ns 1.1 ⫾ .1 .6 ⫾ .1 0.7 ⫾ .1 1.8 ⫾ .2*** .9 ⫾ .1
1.2 ⫾ .1 1.1 ⫾ .1 1.3 ⫾ .1ns 2.2 ⫾ .1 1.2 ⫾ .1 2.1 ⫾ .1 3.3 ⫾ .2*** 1.8 ⫾ .1
9.1 ⫾ .3 7.5 ⫾ .4 10.5 ⫾ .4*** 23.6 ⫾ .4 16.2 ⫾ .6 23.4 ⫾ .5 33.5 ⫾ .7*** 17.4 ⫾ .2
5.7 ⫾ .2 5.5 ⫾ .3 5.9 ⫾ .3ns 14.4 ⫾ .3 10.7 ⫾ .4 12.5 ⫾ .4 19.0 ⫾ .5*** 11.2 ⫾ .2
7.4 ⫾ .2 6.5 ⫾ .2 8.3 ⫾ .3*** 18.5 ⫾ .2 13.4 ⫾ .3 17.6 ⫾ .4 24.6 ⫾ .4*** 14.1 ⫾ .2
34.8 ⫾ .3 35.0 ⫾ .4 34.7 ⫾ .4*** 37.2 ⫾ .4 37.6 ⫾ .6 38.2 ⫾ .7 35.7 ⫾ .8*** 36.2 ⫾ .3
25.2 ⫾ .2 26.2 ⫾ .3 24.2 ⫾ .3*** 23.2 ⫾ .3 25.2 ⫾ .6 23.7 ⫾ .6 21.0 ⫾ .6*** 23.9 ⫾ .2
30.1 ⫾ .2 30.7 ⫾ .2 29.6 ⫾ .3ns 29.5 ⫾ .3 31.4 ⫾ .4 30.5 ⫾ .4 26.6 ⫾ .5*** 29.7 ⫾ .2
classes in each grade were randomly selected in each school. In each city, approximately 600 students from each category of school for a total of 3000 students completed a self-administered questionnaire. Informed consent was obtained verbally, and no personal identifying information was collected in order to protect privacy and confidentiality of the information. In all, 99% of students in selected classes consented to participate in the survey. The high consent rate of students can be found in the Global Schoolbased Student Health Survey in China and may be attributed to the traditional Chinese cultural norms, in which students take positive attitudes to the activities conducted in school [21]. On average, it took the students 35 to 50 minutes to finish the questionnaire. Measurement of Behavioral Risk Factors Patterns of alcohol consumption were defined as: lifetime (at least one previous drink), current (at least one alcoholic drink in the past 30 days), binge drinking (at least five alcoholic drinks per occasion in one day during the past 30 days), and heavy binge drinking (at least five alcoholic drinks per occasion six times or more during the past 30 days) [19,23]. Students who reported feeling sick or having headaches from alcohol consumption during the past 12 months were defined as having gotten drunk [19]. Current smoking was defined as smoking one or more cigarettes per day in the past 30 days [19]. Drug use was defined as any prior use of marijuana, cocaine, or methamphetamines [19]. High-risk cycling behavior was defined as any of the following during the past 12 months: (1) cycling without hands on handlebar; (2) cycling with hand on other vehicles; (3) chasing each other; (4) cycling in the wrong direction; (5) cycling with other people on the carrier; (6) cycling against red light or crossing road against rules. High-risk swimming behavior was defined as swimming without the company of adults or a lifeguard at least one time in the past 12 months. Fighting was defined as a physical fight at least once in the past 12 months [19]. Depression was defined as feeling sad or hopeless almost every day for at least two consecutive weeks during the past year. Suicide was defined as having considered suicide (suicide ideation), planned a suicide attempt but did not act (suicidal plan), and attempted suicide [19]. Sexual inter-
course was defined as any previous sexual intercourse [19]. Socio-demographic information such as gender, grade, school type, parental education level, and parents’ marriage status were also collected. Data Analysis We used EpiData 3.0 (The EpiData Association, Odense, Denmark) to enter the data, and SPSS v11.0 (SPSS-China, Beijing, China) for analysis. We calculated the prevalence of alcohol use and used the chi-square test to compare the prevalence of alcohol use across gender and different school types. Adjusted multivariate logistic regression model were employed to estimate the odds ratios of risk behaviors among the students with and without a history of binge drinking while accounting for gender, grade, school type, and family structure. Separate regression analyses were conducted for each risk behavior. Because the prevalence of most health-compromising behaviors was higher than 10%, a correction was made to estimate the relative risk from the odds ratios [24]: RR ⫽ OR ⁄ 关共1 ⫺ P0兲 ⫹ 共P0 ⫻ OR兲兴 in which P0 is the prevalence of risk behavior among students without binge drinking, and OR is the results from logistic regression. Results Demographic Information A total of 54,040 students (99% of eligible) completed the questionnaire, of which 11,345 were from 64 ordinary junior high schools, 10,270 from 52 model junior high schools, 10,463 from 57 ordinary senior high schools, 11,051 from 58 model senior high schools, and 10,911 from 52 vocational senior high schools. The average age of students in junior high schools (grades 7–9) was 13.8 years (SD ⫽ 1.1). Females accounted for 48.7% and males accounted for 51.3%. The average age of students in senior high schools (grades 10 –12) was 16.7 years (SD ⫽ 1.0). Females accounted for 55.0% and males accounted for 45.0%. In total, 65.2% of students live with their parents (nuclear families); 19.4% lived with their parents and grandparents (extended family); 13.8% lived with
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Table 2 Adjusted odds ratiosa and 95% confidence intervals for involvement in other health-compromising behaviors among students engaged in binge drinking, and heavy binge drinking to those without binge drinking Health-compromising behaviors (Dependent variables)
n
Drug use Current smoking Sexual intercoursec Attempted suicide Suicidal plan Suicidal ideation Felt sad or hopeless Physical fight High-risk swimming High-risk cycling
53,739 53,667 30,784 52,359 52,474 53,566 53,645 53,629 29,475 48,988
Without binge drinking % .3 7.0 2.7 2.3 6.4 19.7 14.8 21.5 15.7 44.0
Binge drinking in 1–5 days
Heavy binge drinking
%
ORadja
95% CI
RRb
95% CI
%
ORadja
95% CI
RRb
95% CI
5.8 43.9 14.2 7.3 13.7 31.0 27.6 48.0 28.0 60.6
18.2 8.0 4.8 3.5 2.6 2.1 2.1 3.5 1.9 1.7
(14.6–22.5) (7.4–8.6) (4.2–5.4) (3.1–4.1) (2.4–2.9) (1.9–2.2) (2.0–2.3) (3.3–3.8) (1.7–2.1) (1.6–1.9)
18.1 7.4 4.7 3.4 2.4 1.7 1.8 2.7 1.6 1.0
(14.6–22.4) (6.9–8.0) (4.1–5.3) (3.0–4.0) (2.2–2.7) (1.5–1.8) (1.7–2.0) (2.6–3.0) (1.4–1.8) (.9–1.1)
20.6 58.8 24.3 14.8 23.4 36.5 33.7 62.6 45.5 67.7
74.2 14.4 8.7 7.9 5.3 2.8 2.9 5.8 3.7 2.3
(58.6–93.9) (12.5–16.6) (7.2–10.6) (6.5–9.7) (4.5–6.2) (2.4–3.2) (2.5–3.3) (5.0–6.7) (3.1–4.3) (2.0–2.7)
74.0 13.4 8.5 7.7 5.0 2.2 2.5 4.6 3.1 1.3
(58.4–93.6) (11.6–15.4) (7.0–10.3) (6.4–9.5) (4.2–5.8) (1.9–2.6) (2.1–2.8) (3.9–5.3) (2.6–3.6) (1.1–1.5)
a
Accounting for sex, school type, grade, family structure. Corrected relative ratio. c Sexual intercourse only reported by high school students. b
single or composite parents (broken family); and 1.6% lived with other people such as uncles and aunts. Prevalence of Alcohol Use In total, 51.1% of students had ever consumed alcohol; 25.2% were current users; 10.3% engaged in binge drinking; 1.8% engaged in heavy binge drinking; 14.1% had ever got drunk; and 29.7% reported first drinking before the age of 13 years (Table 1). In male students, 14.4% were binge drinkers, and 2.8% were heavy binge drinkers, higher rates than for females (binge drinker: 6.6%; heavy binge drinker: .9%). Senior high school students reported a higher rate of binge drinking (13.2%) and heavy binge drinking (2.2%) than junior high school students (binge drinker: 5.8%; heavy binge drinker: 1.2%). More students from vocational senior high schools reported drinking to excess than those from ordinary schools and model schools. For example, binge drinkers accounted for 17.9% in vocational senior high schools, compared with 6.3% in ordinary schools and 5.4% in model schools. The prevalence of heavy binge drinking in vocational senior high school students was 3.3%, compared with 2.1% in ordinary schools and 1.2% in model schools. The Association Between Binge Drinking and Other Health-Compromising Behaviors The prevalence of other behavioral risk factors was highest among students who engaged in heavy binge drinking and the lowest among students who had never engaged in binge drinking (Table 2). The logistic regression also showed the same pattern. For all behavioral risk factors, odds ratios for heavy binge drinking and binge drinking were greater than 1.0 compared to students without a history of binge drinking, with a positive trend associated with level of drinking. The odds ratio for different health-compromising behaviors differed substantially, the highest for drug use
and the lowest for high-risk cycling; meaning binge drinkers were at different risk for various health-compromising behaviors. The adjusted relative ratios showed a similar pattern, except for risk cycling, which had a relative ratio of 1.0 in binge drinking. Discussion This study indicates that the majority of students (51.1%) in grades 7–12 in capital cities of China have consumed alcohol, with the highest prevalence of use in male students, senior high school students, and vocational senior high school students. This result is similar to other studies in China [9 –12]. Generally, lifetime, current, and binge alcohol use among Chinese students is lower than that of American, Japanese, and European students [2,19]. Studies in California and Hawaii also show that Chinese youth report lower alcohol use than Whites, Pacific Islanders and Native Hawaiians, Japanese, and Filipinos [25]. We found much variability in the prevalence of alcohol use among subgroups of adolescents in China. Male adolescents were far more likely than female adolescents to have consumed alcohol at all levels of use, similar to findings in other Western Pacific Regions and European countries, but different from findings in the United States [2,19]. Alcohol use and binge drinking were more common among senior high school students, especially among vocational senior high school students. In our study, 70.4% of male students in senior high schools were lifetime alcohol users and 39.4% were current alcohol users. These two figures are close to their American counterparts in grades 9 –12 (73.7% and 43.8%, respectively) [19]. Among male senior high school students, 19.5% were binge drinkers, lower than the 29.0% attributed to their American counterparts [19]. Male students from vocational senior high schools reported higher rates of lifetime and current alcohol use than their
Y. Xing et al. / Journal of Adolescent Health 39 (2006) 495–500
American counterparts, but reported a similar rate of binge drinking [19]. Among female senior high school students, the rates of lifetime, current, and binge alcohol use are much lower than their American counterparts (52.0%, 23.0%, 8.1%, respectively, in China vs. 76.1%, 45.8%, 27.5%, respectively, in America) [19]. Another finding is that binge drinking among adolescent drinkers is common. Binge drinkers accounted for 34% of current drinkers in junior high schools and 41% in senior high schools, higher than that of American students (30%) [3]. In most developing countries, many adolescent drinkers tend to drink large amounts when they drink [26]. This drinking pattern in developing countries is conducive to a fairly high degree of alcohol-related harms per liter of alcohol consumed [26]. The study also indicates that adolescents start alcohol use earlier in China than in other countries [2]. In this study, 29.7% of Chinese students initiated alcohol use before 13 years of age. This rate is higher than that of other countries, with the exception of the United Kingdom, Denmark, Finland, and the Russian Federation [2]. A study in China showed that the percentage of those initiating alcohol use before age 13 years had been increasing from 1998 to 2003. This increase might result from cultural and socioeconomic changes in China [9]. For most adolescents, alcohol use is accepted and sometimes encouraged by parents and peers because drinking alcohol is considered an important method of social communication in Chinese culture. Nearly half of senior high school students in China drink at home with their parents or out with their peers [27,28]. Some studies from Western countries show that the earlier people begin drinking, the more likely they are to become alcohol dependent later in life and to experience alcohol-related unintentional injuries [2,29]. Currently in China, there are no age restrictions on on-premises or off-premises purchases of beer and no restrictions on alcohol advertising on television, radio, or print [30]. International experience suggests that a comprehensive alcohol policy to prevent youth from alcohol use should not only incorporate measures to educate the public about the dangers of hazardous and harmful use of alcohol, but should also put in place regulations and other environmental supports that affect the price and availability of alcoholic beverages [2,6]. Our study suggests that the more frequently the students engage in binge drinking, the more likely they are to report illegal drug use, tobacco use, sexual intercourse, suicide behaviors, physical fights, and risk-swimming behaviors; these associations have all been well documented in Western countries [2,14,16,31–33]. A study of high school students in two large northern cities also showed that current alcohol use, tobacco use, physical fights, and suicidal ideation clustered in the moderate- or high-risk groups of students [22]. Logistic regression confirmed this result. The more frequently students engaged in binge drinking, the greater their risk for being exposed to health-compromising
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behaviors. Although binge drinking was positively associated with other health-compromising behaviors, the strength of the associations was different for different health-compromising behaviors. This indicates that alcohol use probably contributes to related harms with different magnitude. The impact of alcohol use on the mortality and mobility of Chinese young people is likely to be of equivalent or greater magnitude as a result of the relative lack of health care services and other mitigating and protective factors [3,12,27]. There were some limitations in our research. First, only 18 of 31 provinces conducted the survey voluntarily, so the pattern of alcohol use may not represent all Chinese high school students. Second, these data were self-reported and subject to report bias. However, some research has shown that self-reported data from adolescents are valid and reliable when the students’ privacy can be protected; our survey guaranteed the subjects’ privacy by anonymous, voluntary participation without the presence of school staff [34,35]. Third, the research was a cross-sectional survey, which can provide information only on associations between binge drinking and other health-compromising behaviors but not on the temporal relationship between these behaviors. Finally, the study was part of health-compromising behaviors research, and not a survey designed for alcohol use. Thus, the risk factors and style of alcohol use among Chinese adolescent cannot be concluded. The findings suggest that more studies are needed to examine the patterns, trends, and negative consequences of alcohol use among adolescents in China. Alcohol use prevention efforts must start in elementary school and continue through senior high school and aim to keep adolescents from starting to drink or to prevent the escalation of drinking and its negative consequences. Acknowledgments The study was funded by the Ministry of Health People’s Republic of China and the World Health Organization. Thanks to Dr. Lisa Lee for the editing of the manuscript. References [1] World Health Organization. Global Status Report on Alcohol 2004. Geneva: World Health Organization, 2004. [2] Jernigan DH. Global Status Report: Alcohol and Young People. Geneva: World Health Organization, 2001. [3] Zeigler DW, Wang CC, Yoast RA, et al. The neurocognitive effects of alcohol on adolescents and college students. Prev Med 2005;40: 23–32. [4] Halpern-Felsher BL, Cornell JL. Preventing underage alcohol use: where do we go from here? J Adolesc Health 2005;37:1–3. [5] World Health Organization. Global Status Report On Alcohol. Geneva: World Health Organization, 1999. [6] Bauman A, Phongsavan P. Epidemiology of substance use in adolescence: prevalence, trends and policy implications. Drug Alcohol Depend 1999;55:187–207.
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