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The rate and pattern of alcohol consumption among Chinese adolescents
J O U R N A L OF ADOLESCENT H E A L T H 1996;19:353-361
INTERNATIONAL ARTICLE
The Rate and Pattern of Alcohol Consumption Among Chinese Adolescents XIAOMING LI, Ph.D., XIAOYI FANG, Ph.D., BONITA STANTON, M.D., SUSAN FEIGELMAN, M.D., AND QI DONG, Ph.D.
Objective: To assess the prevalence and pattern of alcohol consumption and its relation to participation in other social activities and problem behaviors among adolescents residing in the People's Republic of China. Methods: Data were collected from a sample of 1,040 students in 6th, 8th, and 10th grades from five public schools in Beijing, China by using a self-administered questionnaire. Chi-square statistics and two-way ANOVA were used to assess the gender and grade difference in lifetime alcohol use of various alcoholic beverages. The age-adjusted and grade-adjusted odds ratio was used to assess the association between alcohol use and selected social activities and problem behaviors. Results: Approximately 70% of the study sample reported prior alcohol consumption. The rate of drinking among males was significantly higher than among females (78% vs. 61%, p < .00001), and the rates among both genders increased with advancing grade (54%, 72%, and 84%, respectively, p < .001). Beer was the most commonly consumed alcoholic beverage. The results also suggested a progression from beer to wine and/or liquor. Drinking behavior was positively associated with participation in unstructured social activities and other problem behaviors. Conclusions: Alcohol use was prevalent among adolescents residing in China. The findings underscore the need for and importance of intervention efforts targeting alcohol consumption among early adolescents in China.
From the Department qf Pediatrics, University of Ma~land School of Medicine, Baltimore, Maryland; Center for Minority Health Research, University of Maryland at Baltimore, Baltimore, Maryland; and Institute of Developmental Psychology, Beijing Normal University, Beijing, China. Address reprint requests to: X&oming Li, Ph.D., Department of Pediatrics, University of Maryland School of Medicine, 712 West Lombard Street, Baltimore, MD 21201-1010. Manuscript accepted May 6, 1996.
KEY WORDS:
Adolescents Alcohol use Chinese Problem behaviors Social activities
Introduction Adolescent use or misuse of alcohol has been recognized as a major public health problem and has become an important social concern worldwide (1). Alcohol consumption and production have been escalating in many Asian countries including China over the last two decades (2). The rapid growth of alcohol consumption in developing countries may presage an increase in alcohol-related problems that would impose a severe strain on scarce economic and social resources (3). While there is a voluminous literature concerning the health and social effects of alcohol use in the United States and other Western countries, very limited empirical data are available regarding alcohol use among adolescents residing in the People's Republic of China, where alcohol poses a potential serious threat to over one-fifth of the world's population (4). We are aware of only one published study addressing this topic in China (5). In a survey conducted in 1991 among 1,916 8th-12th grade Chinese adolescents, 30% of respondents reported having been intoxicated at least once in their lifetime. The average age of first use of alcohol was 12 years. The majority of the students had used alcoholic beverages once or twice in the previous month. These data suggest that alcohol use is problematic among Chi-
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nese youth. However, no data exist as to the possible correlates and patterns of this risk behavior. The larger literature addressing alcohol use among adolescents in Western countries can be used to generate hypotheses regarding alcohol use among Chinese adolescents. American and Western-based literature provides support for the concept that substance use among adolescents occurs in a series of stages, beginning with lower alcohol content beverages and tobacco ("gateway drugs"), before moving on to higher content beverages or illegal drugs, such as marijuana, cocaine, and heroin (6,7). According to the stage theory (8), adolescents progress from nonuse to the use of beer and wine (stage 1), to hard liquor a n d / o r cigarettes (stage 2), marijuana (stage 3), and other illicit drugs (stage 4). Studies on adolescent alcohol use have also found variability in drinking patterns (9). For most people, these patterns change between adolescence and young adulthood and then stabilize (10,11). In Western countries few associations have been found between alcohol use and family socioeconomic status as measured by parental education and occupation (12,13). However, adolescent alcohol use and other drug use appears to be positively associated with increasing involvement in unstructured social activities such as "hanging around with friends" (14,15) and inversely correlated with academic activities such as doing homework and school projects (16). Alcohol use among adolescents has been associated with other problem behaviors, such as cigarette smoking, delinquency, use of illicit drugs, and precocious sexual behavior (15,17-21). China has a recorded history of alcohol use for social and ceremonial occasions of approximately 4,000 years (4). Historically, Chinese attitudes toward alcohol were influenced by Confucian and Taoist philosophy that emphasized the need for moderation (22,23). However, in recent years, a combination of relaxed market economics and responses to the Western influence made it possible for Chinese to hold a more permissive attitude towards alcohol use and increased consumption (4). Considering the notable changes in the economic and cultural environment in China, adolescents are not immune to the alcohol-associated problems faced by adults. There is an urgent need to examine adolescent alcohol use and its health and social consequences in China. Accordingly, the present study was designed to examine: (1) use rates and patterns of alcohol use among 6th, 8th, and 10th grade Chinese adolescents; and (2) the associations of
JOURNAL OF ADOLESCENT HEALTH Vol. 19, No. 5
alcohol use with demographic variables, social activities, and problem behaviors.
Method Sample The data used in the current study were gathered from September-October, 1991 as part of a larger study examining cigarette smoking and alcohol use among Chinese adolescents. The subjects were 1,040 6th-grade, 8th-grade, and 10th-grade public school students residing in Beijing, China. Two education professionals with extensive experience in conducting research in the local schools were asked to identify schools based on three criteria. First, the schools had to be "ordinary" schools, serving the general public in the city (as opposed to the "keyschools," into which entrance is more competitive). Second, the schools had to serve students from a wide range of socioeconomic backgrounds. Third, at least one-half of the students from each school had to progress together to an upper school following school transitions (e.g., from elementary school to junior high school or from junior high school to senior high school). The minimum "50% transition rate" was required to ensure that a sufficient number of the baseline participants could be longitudinally followed in the future through subsequent questionnaires in a small number of schools after the school transition. Eligible schools were randomly chosen and asked to participate. Twelve schools were approached until five schools agreed to participate: two elementary schools (grades 1-6) and three middle schools that were composed of junior high schools (grade 7-9) and senior high schools (grades 10-12). The data at each grade level were collected from at least two schools. Sixth graders were assessed at the two elementary schools. Both 8th and 10th graders were assessed at two of the middle schools. Owing to smaller class size in 10th grade, an additional middle school was used for 10th grade students. A selfadministered questionnaire was distributed to all of the students in attendance in the selected grades on the day of the survey. The students were told by the researchers that the survey was for research purposes only and participation in the survey was voluntary. The school teachers were asked to leave the classrooms during administration of the survey. The responses were anonymous and participants were assured of the confidentiality of their responses. Written consent was not obtained from individual students as it is not required in China.
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Measures
Alcohol use. Three types of alcoholic beverages were assessed in the survey: beer, wine, and hard liquor. In addition, the combination of these three alcoholic beverages was considered as "any type." For each type of alcoholic beverage as well as "any type," a set of three indicators was derived from three questionnaire items to measure Chinese adolescent alcohol use: 1. "Lifetime use:" participants were asked how many times they had ever consumed an alcoholic beverage (beer, wine, or hard liquor) on a 6-point scale ("never," "1-5 times," "6-9 times," "10-19 times," "20-39 times," and "40 times or more"). The responses to the items were recorded to create dichotomous measures ("no" /"yes"); 2. "Current use;" participants were asked how many times they had used an alcoholic beverage (beer, wine, or hard liquor) in the previous week. The responses were recorded to create dichotomous measures ("no"/"yes"); 3. "Regular use:" a third item asked the participants to describe their use based on a 6-point scale: 1 = "never use," 2 = "very light use," 3 = "light use," 4 = "moderate use," 5 = "heavy use," and 6 = "very heavy use." For the purpose of data analysis in this study, "very light use" and "light use" were combined into "occasional use" and "moderate use," "heavy use," and "very heavy use" were combined into "regular use." The internal consistency estimates (Cronbach ~) of the three indexes (i.e., lifetime use, current use, and regular use) with the modified scales were .76, .73, .80, and .74 for beer, wine, liquor, and "any type," respectively. Parental education. Education levels for both father (or male guardian) and mother (or female guardian) were assessed on a 6-point scale: 1 = "junior high school or less," 2 = "some high school," 3 = "completed high school," 4 = "vocational school," 5 = "some college," and 6 = "completed college or more." The higher level achieved by either the father or the mother was used as an index of parents' highest education level. Missing data on one of the two variables were allowed. School performance. Subjects were asked to categorize their school performance in terms of grades they usually received in school on a 6-point scale: 1 = "mostly Ds or worse," 2 = "mostly Ds," 3 = "mostly
CHINESEADOLESCENTALCOHOLUSE
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Cs and Ds," 4 = "mostly Bs and Cs," 5 = "mostly As and Bs," and 6 = "mostly As." Educational expectation. The subjects were asked how much schooling they thought they would complete in the future on a 6-point scale: 1 = "junior high school or less," 2 = "some high school," 3 = "high school," 4 = "vocational school," 5 = "college," and 6 = "graduate school." Compulsory education in China, which was implemented in the late 1980s, consists of a total of 9 years including a 6-year elementary school (grade 1-6) and a 3-year junior high school. Generally, children start school at age 6 (urban) or age 7 (rural) years. Social activities. Participation in social activities was measured by a 20-item scale adapted from Johnston, Bachman, and O'Malley (24). Subjects were asked how often they were involved in a variety of activities with their friends (e.g., watch TV, go to concerts, hang out at a shopping center). Subjects could choose their answers from a 5-point scale (1 = "never," 2 = "several times in one year," 3 = "once or twice per month," 4 = "at least once a week," and 5 = "almost daily"). The Cronbach oL for the scale was .82. Principal component factor analysis with varimax (i.e., orthogonal) rotation was conducted on the original scale to extract common factors. The items in a factor were assessed for internal consistency (Cronbach oL). An item was deleted from the factor if the consistency estimation could be improved after deletion. Finally, five factors were extracted from the original scale and all items except one from the initial 20-item scale were retained: School/youth group related ("study, work on school projects," "sit around and talk with friends," "play sports on a team," "do volunteer work," and "attend youth group", Cronbach ~ = .59); play in band ("play in the school band," "play in a band, not at school," Cronbach ~ = .62); hang out ("cruise around," "get together with friends and hang out," and "hang out at a shopping center," Cronbach ~ = .80), telephone/ music activities ("talk on the telephone," "go to concerts," "listen to music," "dance", and "sing", Cronbach ~ = .61); and games/entertainment ("play video games," "play cards or board games," "go to movies," and "watch TV", Cronbach cx = .65). The raw items in each factor were averaged to form a composite score. Problem behaviors. Subjects were asked how often they had engaged in eight deviant activities in the
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Table 1. Mean (SD) of Selected Sample Characteristics Among 1,040 Adolescents Residing in Beijing, China
Age in years Parental education School performance Educational expectation
Overall (n = 1040) 13.65 (1.81) 4.10 (1.85) 4.41 (.89) 4.52 (1.04)
Female (n = 505) 13.62 (1.75) 4.07 (1.81) 4.51 (.86) 4.52 (.98)
Male (n = 535) 13.68 (1.87) 4.12 (1.88) 4.32 (.91)* 4.51 (1.10)
Grade 6 (n = 366) 11.60 (.64) 3.50 (1.84) 4.55 (1.00) 4.25 (1.18)
Grade 8 (n = 322) 13.73 (.62) 4.24 (1.77) 4.37 (.91) 4.43 (1.04)
Grade 10 (n = 352) 15.71 (.56)** 4.51 (1.79)** 4.30 (.72)* 4.88 (.76)**
Note: statistical tests were conducted to test the gender and overall grade differences. *p < .001, **p < .0001.
previous year (e.g., were truant from school, ran a w a y from home, intentionally d a m a g e d school property). Subjects selected their answers from a 5-point scale (1 = "never," 2 = "once," 3 = "twice," 4 = "three times," and 5 = "more than three times"). This 8-item scale was a modification of a similar scale used by Sloane and Potvin (25). The Cronbach o~ for the modified scale was .60. Following the same procedure as that used for the social activity scale, three factors were extracted from the problem behavior scale and six of the eight items in the scale were retained: school t r u a n c y / r u n a w a y ("run a w a y from home," "skip a d a y from school without a real excuse", Cronbach a = .35); steal ("steal something worth u n d e r 20 y u a n [Chinese currency]," "Steal something worth over 20 yuan," Cronbach R = .66); and fight ("Get into a serious fight," "take part in a fight with a group of friends against another group," Cronbach ~ = .57). In addition, cigarette smoking, a separate measure in the questionnaire, was also considered as a problem behavior in the current study. Those y o u t h who had any positive answer to the question " h o w m a n y times have y o u ever smoked a cigarette?" were grouped as "ever-smoked;" the remaining were classified as "nonsmokers."
Analysis First, the gender and grade differences in lifetime use of different forms of alcoholic beverages were assessed using Chi-square statistics. The percent of "regular users" and "current users" a m o n g those w h o reported having ever used were also compared by gender and grade. The gender and grade differences associated with lifetime use of various alcoholic beverages were also assessed using a two-way ANOVA. Second, the patterns of alcoholic beverage type a m o n g lifetime and current users were also assessed by examining the frequency distribution of all possible combinations of different alcohol types.
Third, the associations between use of specific types of alcoholic beverages and selected demographic characteristics (i.e., school performance, parental education, educational expectation), specific social activities, and other problem behaviors were assessed using age-adjusted and gender-adjusted odds ratio. The adjusted odds ratio for each of the factors was obtained through logistic regression in which the age and gender were controlled. All analyses in the current s t u d y were conducted using SPSS/PC+ v5.01.
Results Sample Characteristics A total of 1,040 students (51% male) completed the survey. None of the students refused to participate in the study and about 5% of the students in the selected classrooms were absent from school on the day of the survey or returned invalid questionnaires. Because of similarities between schools for each given grade in terms of major demographic characteristics (26), the data from different schools were combined within each grade. As shown in Table 1, all major demographic variables except gender differed by grade. The mean age was 11.60 years, 13.73 years, and 15.71 years, for grade 6, 8, and 10, respectively (p ~ .0001). Parental education level and educational expectation increased with advancing grade level (p < .0001 for both). Self-assessed school performance decreased with advancing grade level (p < .001). Gender differences were only found in school performance with females reporting better grades than males (p < .001).
Rate of Lifetime Use As shown in Table 2, 63% (650) of the participants reported ever drinking beer, 54% (557) reported ever drinking wine, 11% (115) reported ever drinking hard liquor, and 69% (722) reported having con-
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CHINESE ADOLESCENTALCOHOLUSE
Table 2. Alcohol Use by Beverage Type Among Chinese Adolescents Overall (n = 1040) Beer lifetime use regular use current use Wine lifetime use regular use current use Liquor lifetime use regular use current use Any type lifetime use regular use current use
Female (n = 505)
Male (n = 535)
Grade 6 (n = 366)
Grade 8 (n = 322)
Grade 10 (n = 352)
n
%
n
%
n
%
n
%
n
%
n
%
650 115 174
63% 11% 17%
257 23 51
51% 5% 10%
393 92 123
73%**** 17%**** 23%**
160 12 57
44% 3% 16%
213 40 51
66% 12% 16%
277 63 66
79%**** 18%* 19%*
557 42 57
54% 4% 5%
239 12 20
47% 2% 4%
318 30 37
59%*** 6% 7%
147 7 29
40% 2% 8%
176 17 13
55% 5% 4%
234 18 15
66%**** 5% 4%**
115 15 22
11% 1% 2%
25 2 4
5% L, 1%
90 13 18
17%*** 2% 3%
9 2 2
2% 1% 1%
36 6 6
11% 2% 2%
70 7 14
20%**** 2% 4%
722 139 205
69% 13% 20%
307 32 62
61% 6% 12%
415 107 143
78%**** 20%**** 27%***
196 16 69
54% 4% 19%
231 48 57
72% 15% 18%
295 75 79
84%**** 21%*** 22%
Note: statistical tests were conducted to test the gender and overall grade differences; L~< .5%. *p < .05, **p < .001, ***p < .0001, ****p < .00001.
s u m e d at least one type of alcoholic beverage. Eighteen percent (115) of those w h o had ever used beer (i.e., 11% of the entire sample), 8% (42) of those w h o had ever used wine (i.e., 4% of the entire sample), and 13% (15) of those w h o h a d ever used liquor (i.e., 1% of the entire sample) reported regular use of the beverage. The use rates of all forms of alcohol increased with a d v a n c i n g grade level (p < .00001). F r o m the 6th g r a d e to the 10th grade, use increased by 35%, 26%, and 18% for beer, wine, and hard liquor, respectively. A m o n g the 10th g r a d e sample (an average age of 16 years), 79% had d r u n k beer (23% of the users identified themselves as regular users), 66% had d r u n k wine (8% of the users identified themselves as regular users), and 20% had d r u n k hard liquor (10% of the users identified themselves as regular users). There were significant g e n d e r differences in the use of all types of alcohol, with more males reporting use than females for each category (i.e., beer, 73% vs. 51%, p < .00001; wine: 59% vs. 47%, p < .0001; and liquor, 17% vs. 5%, p < .0001). T w o - w a y A N O V A revealed significant main effects (p < .0001) of both grade and gender for all types of alcohol use and a significant interaction between grade and gender for hard liquor (p < .0001). A further examination of the g r o u p profile revealed that the interaction was due to the rapid increase of liquor use a m o n g males in the higher grades: in the 6th grade, 2% of females and 3% of males reported lifetime use of liquor; in the 8th grade, the n u m b e r of female liquor users remained
about the same (3%), but male users increased to 24% (p < .00001); b y grade 10, 11% of females and 30% of males reported use of hard liquor.
Rate of Current Use Overall, 17%, 5%, and 2% of the participants reported h a v i n g used beer, wine, and liquor, respectively in the previous week (Table 2). In contrast to the positive association between a d v a n c i n g grade level and lifetime use of all beverage types, the 6th graders reported an equal or higher rate of current use of beer and wine (i.e., beer, 16%; wine, 8%) than students in the 8th and 10th grades (i.e., beer, 16% and 19%; wine, 4% and 4%, respectively for grade 8 and 10). Consistent with lifetime use, males had m u c h higher rates of current use than females for all forms of alcoholic beverages.
Use Pattern by Beverage Type Table 3 depicts the general pattern of alcohol use a m o n g participants. A m o n g those w h o "ever" used a n y of the three types of alcoholic beverages (beer, wine, hard liquor), 21% had c o n s u m e d beer only, 9% h a d d r u n k wine only, 55% had imbibed both beer and wine, and 15% had c o n s u m e d all three. Less than 1% had d r u n k liquor only or had d r u n k both wine and liquor without drinking beer. N o y o u t h had c o n s u m e d only beer and liquor (without wine).
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Table 3. Pattern of Lifetime and Current Alcohol Use Among Chinese Adolescents Alcoholic Beverage Beer
Wine
Lifetime use yes no no yes no no yes yes yes no no yes yes yes C u r r e n t use yes no no yes no no yes yes yes no no yes yes yes
Overall Liquor
Fema l e
Male
Grade 6
Grade 8
G r a d e 10
n
%
n
%
n
%
n
%
n
%
n
%
no no yes no yes yes yes
141 62 2 371 0 3 101
21 9 ~'. 55 0 ~ 15
63 44 0 165 0 1 23
21 15 0 56 0 L 8
78 16 2 206 8 2 78
20 5 1 53 2 1 20
40 32 1 103 1 0 6
22 17 '~ 56 c, 0 3
49 16 1 122 3 0 32
22 7 ~ 55 1 0 14
52 14 0 146 4 3 63
18 5 0 51 1 1 22
no no yes no yes yes yes
119 19 8 34 5 0 6
62 10 4 18 3 0 3
38 10 1 10 1 0 1
62 16 2 16 2 0 2
81 9 7 24 4 0 5
62 7 5 18 3 0 4
36 11 0 21 0 0 1
52 16 0 30 0 0 2
36 2 3 10 1 0 1
68 4 6 19 2 0 2
47 6 5 3 4 0 4
68 9 7 4 6 0 6
Note: The cases p r e s e n t e d in this table w e r e restricted to those w h o h a d v a l i d r e s p o n s e s to all t hre e categories (beer, w i ne , a n d liquor); ~ .5%.
Among those who reported current use (i.e., in the previous week) of any alcoholic beverage, 62% reported beer only, 10% wine only, 4% liquor only, 18% beer and wine, 3% beer and liquor, and 3% all three types listed. No youth had drunk wine and liquor without drinking beer. Among those who had ever used any kind of alcoholic beverage, over 90% had drunk beer. Among those who drank in the previous week, 86% had drunk beer. The proportion of female users who had drunk only wine was substantively higher than that of males for both lifetime use (15% vs. 5%) and current use (16% vs. 7%). Likewise, more 6th-grade users had drunk only wine than students in grades 8 and 10 for both lifetime use (17% vs. 7% and 5%) and current use (16% vs. 4% and 9%). The proportion of lifetime users who consumed all three kinds of alcoholic beverages rapidly increased with advancing grade level (3%, 14%, and 22% for grades 6, 8, and 10, respectively). The proportion of users who used both beer and wine in the previous week decreased with advancing grade level (i.e., 30%, 19%, and 4% for grades 6, 8, and 10, respectively).
characteristics, social activities, and problem behaviors are presented in Table 4. The demographic variables assessed were not associated with any type of alcohol use except that liquor users reported higher levels of parental education than nonusers (OR = 1.15, p < .05). The users were more likely to report engaging in "hanging out," "telephone/music activities," and "playing games/entertainment" than nonusers (p .05) regardless of what type of alcoholic beverages they had consumed. However, the odds ratios for those factors were greater for liquor than for beer or wine. The users and nonusers of any alcoholic beverage were not differentiated by involvement in "school or youth related" activities or whether they "play in band" (p ~ .05). With respect to problem behaviors, all forms of alcohol use were strongly associated with "cigarette smoking" and "school truancy/run away" (p < .05). In addition, users of wine were more likely than nonusers to report stealing (p < .05). Users of liquor were also more likely than nonusers to report stealing (p ~ .001) and, additionally, fighting (p < .0001).
Association of Alcohol use with Demographic Variables, Social Activities, and Problem Behaviors
Discussion
The age-adjusted and gender-adjusted odds ratio (OR) and associated 95% confidence interval (CI) for three types of alcohol use with selected demographic
This study indicates that alcohol use is prevalent among Chinese adolescents and increases with advancing grade such that by the 10th grade over four-fifths of youth have consumed alcohol. Similar
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359
Table 4. Age and Gender Adjusted Odds Ratio (OR) and 95% Confidence Interval (95%CI) of Demographic, Social Activity, and Problem Behavior Factors Related to Lifetime Alcohol Use Among Chinese Adolescents Beer OR Demographic characteristics school performance educational expectation parental education Social activities school/youth group related play in band hang out telephone/music games/entertainment Problem behaviors cigarette smoking school truancy/run away steal fight
95%CI
Wine OR
Liquor
95%CI
OR
95%CI
.92 1.00 .97
[ .90, 1.05] [ .83, 1.20] [ .90, 1.05]
.93 1.02 .97
[ .80, 1.07] [ .89, 1.15] [ .90, 1.04]
.84 1.04 1.15"
[ .66, 1.07] [ .87, 1.30] [1.02, 1.30]
1.06 .88 1.36"** 1.36"* 1.49"**
[ .88, [ .68, [1.16, [1.10, [1.22,
.99 .99 1.34"** 1.24" 1.31"*
[ .82, [ .77, [1.16, [1.03, [1.09,
1.19] 1.28] 1.54] 1.50] 1.57]
.89 1.43 1.76"*** 1.89"*** 1.50"*
[ .66, [ .96, [1.44, [1.43, [1,12,
1.19] 2.13] 2.15] 2.51] 1.99]
7.11 . . . . 5.05* 1.79 1.45
[4.2l, 12.01] [1.30, 19.61] [ .97, 3.28] [ .95, 2.20]
3.55**** 2.57* 1.76" 1.15
[2.44, [1.25, [1.07, [ .83,
5.17] 5.30] 2.92] 1.61]
[6.81, [1.39, [1.40, [1.66,
16.75] 3.58] 3.26] 3.51]
1.29] 1.14] 1.59] 1.67] 1.82]
10.68 . . . . 2.23*** 2.13"** 2.41 . . . .
*p < .05 **p < .01 ***p < .0001 ****p < .00001.
to the findings in the United States and other Western countries, a high percentage of Chinese adolescents initiated alcohol use at or before grade 6. Boys were significantly more likely than girls to report alcohol use. Previous studies conducted among Chinese youth living in North America (27,28) found that compared to non-Asian adolescents, Chinese youth had lower alcohol use rates and fewer regular drinkers. However, the results of the current study indicate that adolescents residing in China exhibit use rates similar to those of non-Asian adolescents in the United States. For example, in the 1991 United States study (29), 70% of 8th graders and 84% of 10th graders reported having ever used any alcohol; the corresponding percentages in the current study were 72% and 84%. The data also indicate that beer and wine users in the lower grade (i.e., those in the 6th grade) were just as likely as the users in the upper grades to use those beverage regularly. However, the relatively low rates of "regular use" of various alcohol beverages across grades suggest that the majority of Chinese adolescents were in the stage of experimentation. The pattern of alcohol use among Chinese adolescents suggests that youth may progress from low alcohol content beverages to higher alcohol content beverages (i.e., from beer to wine then to liquor). Although hard liquor and wine (rice wine or fruit wine) are traditional alcoholic beverages in China, the results of the current study suggests that beer has become the most commonly used alcoholic beverage among Chinese adolescents. Drinking beer may be
seen as a part of the Western lifestyle to which young people are attracted. Previous studies (30,31) likewise revealed that alcohol consumption among overseas Chinese students was related to the degree of assimilation into American society. Although more research is needed on the causal connections between beer and other beverage use, the fact that beer is the most popular beverage used by young Chinese students suggests a possible role for beer as a gateway beverage progressing to use of other alcoholic beverage among Chinese adolescents. Compared to males, more females reported drinking only wine. Likewise, more adolescents in the lower grade (i.e., 6th graders) reported drinking only wine. These findings are consistent with the findings of previous studies (32) that females or younger people tend to prefer wine. There are several findings in the current study that are consistent with the findings in the United States and other Western countries. First, the use of beer and wine among Chinese adolescents was not associated with level of parental education (12,13). Second, drinking behavior among Chinese adolescents was positively correlated with involvement in unstructured activities (i.e., "hang out") and other social and entertainment activities such as "telephone/music," and "games/entertainment." (14,15) Third, alcohol use was associated with problem behaviors and such associations varied based on the type of alcoholic beverages used (15,17-21). However, use of liquor is associated with higher levels of parental education among Chinese adoles-
360
LI ET AL.
cents. O n e possible explanation for this association is that the families with higher levels of parental education m a y be able to afford higher priced liquor in their homes. Adolescents f r o m those families m a y h a v e easier access to liquor. The second possible reason is parental influence. It has b e e n h y p o t h e sized that in c o n t e m p o r a r y Chinese society, the use of alcoholic b e v e r a g e s is associated w i t h the concept of p o w e r and social privilege, in the sense that parents with higher educational a c h i e v e m e n t s a n d m o r e prestigious occupations h a v e a greater risk of b e c o m i n g alcoholics (4). While the use of a n y alcoholic b e v e r a g e a m o n g early adolescents a n d m i d d l e adolescents is potentially h a r m f u l to their physical a n d psychologic dev e l o p m e n t , the use of h a r d liquor w a s f o u n d to be m o s t d a n g e r o u s as it w a s strongly associated with delinquent b e h a v i o r s such as stealing, physical fighting, school truancy, a n d cigarette smoking. These data p r o v i d e i m p o r t a n t suggestive evidence that the theory of p r o b l e m - p r o n e behavior, a theory develo p e d in the United States (33), m a y also be applicable to different cultural settings.
JOURNAL OF ADOLESCENT HEALTH Vol. 19, No. 5
Third, as with a n y cross-sectional study, causality cannot be inferred f r o m the o b s e r v e d associations b e t w e e n alcohol use and p r o b l e m behaviors.
Implications of Findings These data represent the only recent a s s e s s m e n t of prevalence of alcohol use and, to the best of o u r k n o w l e d g e , the first evaluation of risk factors associated with alcohol use a m o n g adolescents residing in China. The findings h a v e i m p o r t a n t implications for intervention or p r e v e n t i o n of alcohol use a m o n g Chinese adolescents. The fact that m a n y y o u t h u s e d alcohol in their preteens u n d e r s c o r e s the need for p r e v e n t i o n efforts starting f r o m e l e m e n t a r y school and continuing t h r o u g h junior and senior high schools. We thank our colleagues at the West City District Institute of Educational Research, Chao Yang District Institute of Educational Research, and the Institute of Developmental Psychology at the Beijing Normal University, Beijing, China for their assistance in collecting the data for this study. We also wish to thank all of the students and teachers in Beijing who participated in this study for their cooperation. Finally, we thank the anonymous reviewers for their substantial comments on an early version of this manuscript.
Potential Limitations First, these data are b a s e d on self-report b y the adolescents a n d therefore, are subject to self-report bias. A l t h o u g h the s u r v e y w a s a n o n y m o u s , y o u t h m a y h a v e m i s r e p r e s e n t e d their actual alcohol use behaviors. H o w e v e r , studies c o n d u c t e d in Western societies assessing self-report of alcohol use a m o n g adolescents h a v e generally f o u n d results to be valid a n d reliable (34). Second, the s a m p l e that w a s recruited in one of the largest cities in China, should not be v i e w e d as representative of the general n a t i o n w i d e population. China is a nation of varied ethnic g r o u p s a n d substantial differences in geographic, cultural, a n d socioeconomic b a c k g r o u n d s . There are 56 d o c u m e n t e d ethnic g r o u p s in China with different cultures, religious beliefs, or l a n g u a g e s (35). It has been f o u n d that in China alcohol use varies across regions, ethnicities, a n d occupations (4,36). Moreover, while efforts w e r e t a k e n to ensure that the s a m p l e w a s representative of student p o p u l a t i o n s of specific g r a d e s within the city, the subjects w e r e recruited b y c o n v e n i e n c e - s a m p l i n g rather than b y r a n d o m - s a m piing. Future studies with Chinese s a m p l e s f r o m different g e o g r a p h i c areas, different ethnic groups, and different socioeconomic b a c k g r o u n d s w o u l d facilitate an a p p r o p r i a t e generalization of the findings in the current study.
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INTERNATIONAL ARTICLE
The Rate and Pattern of Alcohol Consumption Among Chinese Adolescents XIAOMING LI, Ph.D., XIAOYI FANG, Ph.D., BONITA STANTON, M.D., SUSAN FEIGELMAN, M.D., AND QI DONG, Ph.D.
Objective: To assess the prevalence and pattern of alcohol consumption and its relation to participation in other social activities and problem behaviors among adolescents residing in the People's Republic of China. Methods: Data were collected from a sample of 1,040 students in 6th, 8th, and 10th grades from five public schools in Beijing, China by using a self-administered questionnaire. Chi-square statistics and two-way ANOVA were used to assess the gender and grade difference in lifetime alcohol use of various alcoholic beverages. The age-adjusted and grade-adjusted odds ratio was used to assess the association between alcohol use and selected social activities and problem behaviors. Results: Approximately 70% of the study sample reported prior alcohol consumption. The rate of drinking among males was significantly higher than among females (78% vs. 61%, p < .00001), and the rates among both genders increased with advancing grade (54%, 72%, and 84%, respectively, p < .001). Beer was the most commonly consumed alcoholic beverage. The results also suggested a progression from beer to wine and/or liquor. Drinking behavior was positively associated with participation in unstructured social activities and other problem behaviors. Conclusions: Alcohol use was prevalent among adolescents residing in China. The findings underscore the need for and importance of intervention efforts targeting alcohol consumption among early adolescents in China.
From the Department qf Pediatrics, University of Ma~land School of Medicine, Baltimore, Maryland; Center for Minority Health Research, University of Maryland at Baltimore, Baltimore, Maryland; and Institute of Developmental Psychology, Beijing Normal University, Beijing, China. Address reprint requests to: X&oming Li, Ph.D., Department of Pediatrics, University of Maryland School of Medicine, 712 West Lombard Street, Baltimore, MD 21201-1010. Manuscript accepted May 6, 1996.
KEY WORDS:
Adolescents Alcohol use Chinese Problem behaviors Social activities
Introduction Adolescent use or misuse of alcohol has been recognized as a major public health problem and has become an important social concern worldwide (1). Alcohol consumption and production have been escalating in many Asian countries including China over the last two decades (2). The rapid growth of alcohol consumption in developing countries may presage an increase in alcohol-related problems that would impose a severe strain on scarce economic and social resources (3). While there is a voluminous literature concerning the health and social effects of alcohol use in the United States and other Western countries, very limited empirical data are available regarding alcohol use among adolescents residing in the People's Republic of China, where alcohol poses a potential serious threat to over one-fifth of the world's population (4). We are aware of only one published study addressing this topic in China (5). In a survey conducted in 1991 among 1,916 8th-12th grade Chinese adolescents, 30% of respondents reported having been intoxicated at least once in their lifetime. The average age of first use of alcohol was 12 years. The majority of the students had used alcoholic beverages once or twice in the previous month. These data suggest that alcohol use is problematic among Chi-
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nese youth. However, no data exist as to the possible correlates and patterns of this risk behavior. The larger literature addressing alcohol use among adolescents in Western countries can be used to generate hypotheses regarding alcohol use among Chinese adolescents. American and Western-based literature provides support for the concept that substance use among adolescents occurs in a series of stages, beginning with lower alcohol content beverages and tobacco ("gateway drugs"), before moving on to higher content beverages or illegal drugs, such as marijuana, cocaine, and heroin (6,7). According to the stage theory (8), adolescents progress from nonuse to the use of beer and wine (stage 1), to hard liquor a n d / o r cigarettes (stage 2), marijuana (stage 3), and other illicit drugs (stage 4). Studies on adolescent alcohol use have also found variability in drinking patterns (9). For most people, these patterns change between adolescence and young adulthood and then stabilize (10,11). In Western countries few associations have been found between alcohol use and family socioeconomic status as measured by parental education and occupation (12,13). However, adolescent alcohol use and other drug use appears to be positively associated with increasing involvement in unstructured social activities such as "hanging around with friends" (14,15) and inversely correlated with academic activities such as doing homework and school projects (16). Alcohol use among adolescents has been associated with other problem behaviors, such as cigarette smoking, delinquency, use of illicit drugs, and precocious sexual behavior (15,17-21). China has a recorded history of alcohol use for social and ceremonial occasions of approximately 4,000 years (4). Historically, Chinese attitudes toward alcohol were influenced by Confucian and Taoist philosophy that emphasized the need for moderation (22,23). However, in recent years, a combination of relaxed market economics and responses to the Western influence made it possible for Chinese to hold a more permissive attitude towards alcohol use and increased consumption (4). Considering the notable changes in the economic and cultural environment in China, adolescents are not immune to the alcohol-associated problems faced by adults. There is an urgent need to examine adolescent alcohol use and its health and social consequences in China. Accordingly, the present study was designed to examine: (1) use rates and patterns of alcohol use among 6th, 8th, and 10th grade Chinese adolescents; and (2) the associations of
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alcohol use with demographic variables, social activities, and problem behaviors.
Method Sample The data used in the current study were gathered from September-October, 1991 as part of a larger study examining cigarette smoking and alcohol use among Chinese adolescents. The subjects were 1,040 6th-grade, 8th-grade, and 10th-grade public school students residing in Beijing, China. Two education professionals with extensive experience in conducting research in the local schools were asked to identify schools based on three criteria. First, the schools had to be "ordinary" schools, serving the general public in the city (as opposed to the "keyschools," into which entrance is more competitive). Second, the schools had to serve students from a wide range of socioeconomic backgrounds. Third, at least one-half of the students from each school had to progress together to an upper school following school transitions (e.g., from elementary school to junior high school or from junior high school to senior high school). The minimum "50% transition rate" was required to ensure that a sufficient number of the baseline participants could be longitudinally followed in the future through subsequent questionnaires in a small number of schools after the school transition. Eligible schools were randomly chosen and asked to participate. Twelve schools were approached until five schools agreed to participate: two elementary schools (grades 1-6) and three middle schools that were composed of junior high schools (grade 7-9) and senior high schools (grades 10-12). The data at each grade level were collected from at least two schools. Sixth graders were assessed at the two elementary schools. Both 8th and 10th graders were assessed at two of the middle schools. Owing to smaller class size in 10th grade, an additional middle school was used for 10th grade students. A selfadministered questionnaire was distributed to all of the students in attendance in the selected grades on the day of the survey. The students were told by the researchers that the survey was for research purposes only and participation in the survey was voluntary. The school teachers were asked to leave the classrooms during administration of the survey. The responses were anonymous and participants were assured of the confidentiality of their responses. Written consent was not obtained from individual students as it is not required in China.
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Measures
Alcohol use. Three types of alcoholic beverages were assessed in the survey: beer, wine, and hard liquor. In addition, the combination of these three alcoholic beverages was considered as "any type." For each type of alcoholic beverage as well as "any type," a set of three indicators was derived from three questionnaire items to measure Chinese adolescent alcohol use: 1. "Lifetime use:" participants were asked how many times they had ever consumed an alcoholic beverage (beer, wine, or hard liquor) on a 6-point scale ("never," "1-5 times," "6-9 times," "10-19 times," "20-39 times," and "40 times or more"). The responses to the items were recorded to create dichotomous measures ("no" /"yes"); 2. "Current use;" participants were asked how many times they had used an alcoholic beverage (beer, wine, or hard liquor) in the previous week. The responses were recorded to create dichotomous measures ("no"/"yes"); 3. "Regular use:" a third item asked the participants to describe their use based on a 6-point scale: 1 = "never use," 2 = "very light use," 3 = "light use," 4 = "moderate use," 5 = "heavy use," and 6 = "very heavy use." For the purpose of data analysis in this study, "very light use" and "light use" were combined into "occasional use" and "moderate use," "heavy use," and "very heavy use" were combined into "regular use." The internal consistency estimates (Cronbach ~) of the three indexes (i.e., lifetime use, current use, and regular use) with the modified scales were .76, .73, .80, and .74 for beer, wine, liquor, and "any type," respectively. Parental education. Education levels for both father (or male guardian) and mother (or female guardian) were assessed on a 6-point scale: 1 = "junior high school or less," 2 = "some high school," 3 = "completed high school," 4 = "vocational school," 5 = "some college," and 6 = "completed college or more." The higher level achieved by either the father or the mother was used as an index of parents' highest education level. Missing data on one of the two variables were allowed. School performance. Subjects were asked to categorize their school performance in terms of grades they usually received in school on a 6-point scale: 1 = "mostly Ds or worse," 2 = "mostly Ds," 3 = "mostly
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Cs and Ds," 4 = "mostly Bs and Cs," 5 = "mostly As and Bs," and 6 = "mostly As." Educational expectation. The subjects were asked how much schooling they thought they would complete in the future on a 6-point scale: 1 = "junior high school or less," 2 = "some high school," 3 = "high school," 4 = "vocational school," 5 = "college," and 6 = "graduate school." Compulsory education in China, which was implemented in the late 1980s, consists of a total of 9 years including a 6-year elementary school (grade 1-6) and a 3-year junior high school. Generally, children start school at age 6 (urban) or age 7 (rural) years. Social activities. Participation in social activities was measured by a 20-item scale adapted from Johnston, Bachman, and O'Malley (24). Subjects were asked how often they were involved in a variety of activities with their friends (e.g., watch TV, go to concerts, hang out at a shopping center). Subjects could choose their answers from a 5-point scale (1 = "never," 2 = "several times in one year," 3 = "once or twice per month," 4 = "at least once a week," and 5 = "almost daily"). The Cronbach oL for the scale was .82. Principal component factor analysis with varimax (i.e., orthogonal) rotation was conducted on the original scale to extract common factors. The items in a factor were assessed for internal consistency (Cronbach oL). An item was deleted from the factor if the consistency estimation could be improved after deletion. Finally, five factors were extracted from the original scale and all items except one from the initial 20-item scale were retained: School/youth group related ("study, work on school projects," "sit around and talk with friends," "play sports on a team," "do volunteer work," and "attend youth group", Cronbach ~ = .59); play in band ("play in the school band," "play in a band, not at school," Cronbach ~ = .62); hang out ("cruise around," "get together with friends and hang out," and "hang out at a shopping center," Cronbach ~ = .80), telephone/ music activities ("talk on the telephone," "go to concerts," "listen to music," "dance", and "sing", Cronbach ~ = .61); and games/entertainment ("play video games," "play cards or board games," "go to movies," and "watch TV", Cronbach cx = .65). The raw items in each factor were averaged to form a composite score. Problem behaviors. Subjects were asked how often they had engaged in eight deviant activities in the
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Table 1. Mean (SD) of Selected Sample Characteristics Among 1,040 Adolescents Residing in Beijing, China
Age in years Parental education School performance Educational expectation
Overall (n = 1040) 13.65 (1.81) 4.10 (1.85) 4.41 (.89) 4.52 (1.04)
Female (n = 505) 13.62 (1.75) 4.07 (1.81) 4.51 (.86) 4.52 (.98)
Male (n = 535) 13.68 (1.87) 4.12 (1.88) 4.32 (.91)* 4.51 (1.10)
Grade 6 (n = 366) 11.60 (.64) 3.50 (1.84) 4.55 (1.00) 4.25 (1.18)
Grade 8 (n = 322) 13.73 (.62) 4.24 (1.77) 4.37 (.91) 4.43 (1.04)
Grade 10 (n = 352) 15.71 (.56)** 4.51 (1.79)** 4.30 (.72)* 4.88 (.76)**
Note: statistical tests were conducted to test the gender and overall grade differences. *p < .001, **p < .0001.
previous year (e.g., were truant from school, ran a w a y from home, intentionally d a m a g e d school property). Subjects selected their answers from a 5-point scale (1 = "never," 2 = "once," 3 = "twice," 4 = "three times," and 5 = "more than three times"). This 8-item scale was a modification of a similar scale used by Sloane and Potvin (25). The Cronbach o~ for the modified scale was .60. Following the same procedure as that used for the social activity scale, three factors were extracted from the problem behavior scale and six of the eight items in the scale were retained: school t r u a n c y / r u n a w a y ("run a w a y from home," "skip a d a y from school without a real excuse", Cronbach a = .35); steal ("steal something worth u n d e r 20 y u a n [Chinese currency]," "Steal something worth over 20 yuan," Cronbach R = .66); and fight ("Get into a serious fight," "take part in a fight with a group of friends against another group," Cronbach ~ = .57). In addition, cigarette smoking, a separate measure in the questionnaire, was also considered as a problem behavior in the current study. Those y o u t h who had any positive answer to the question " h o w m a n y times have y o u ever smoked a cigarette?" were grouped as "ever-smoked;" the remaining were classified as "nonsmokers."
Analysis First, the gender and grade differences in lifetime use of different forms of alcoholic beverages were assessed using Chi-square statistics. The percent of "regular users" and "current users" a m o n g those w h o reported having ever used were also compared by gender and grade. The gender and grade differences associated with lifetime use of various alcoholic beverages were also assessed using a two-way ANOVA. Second, the patterns of alcoholic beverage type a m o n g lifetime and current users were also assessed by examining the frequency distribution of all possible combinations of different alcohol types.
Third, the associations between use of specific types of alcoholic beverages and selected demographic characteristics (i.e., school performance, parental education, educational expectation), specific social activities, and other problem behaviors were assessed using age-adjusted and gender-adjusted odds ratio. The adjusted odds ratio for each of the factors was obtained through logistic regression in which the age and gender were controlled. All analyses in the current s t u d y were conducted using SPSS/PC+ v5.01.
Results Sample Characteristics A total of 1,040 students (51% male) completed the survey. None of the students refused to participate in the study and about 5% of the students in the selected classrooms were absent from school on the day of the survey or returned invalid questionnaires. Because of similarities between schools for each given grade in terms of major demographic characteristics (26), the data from different schools were combined within each grade. As shown in Table 1, all major demographic variables except gender differed by grade. The mean age was 11.60 years, 13.73 years, and 15.71 years, for grade 6, 8, and 10, respectively (p ~ .0001). Parental education level and educational expectation increased with advancing grade level (p < .0001 for both). Self-assessed school performance decreased with advancing grade level (p < .001). Gender differences were only found in school performance with females reporting better grades than males (p < .001).
Rate of Lifetime Use As shown in Table 2, 63% (650) of the participants reported ever drinking beer, 54% (557) reported ever drinking wine, 11% (115) reported ever drinking hard liquor, and 69% (722) reported having con-
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CHINESE ADOLESCENTALCOHOLUSE
Table 2. Alcohol Use by Beverage Type Among Chinese Adolescents Overall (n = 1040) Beer lifetime use regular use current use Wine lifetime use regular use current use Liquor lifetime use regular use current use Any type lifetime use regular use current use
Female (n = 505)
Male (n = 535)
Grade 6 (n = 366)
Grade 8 (n = 322)
Grade 10 (n = 352)
n
%
n
%
n
%
n
%
n
%
n
%
650 115 174
63% 11% 17%
257 23 51
51% 5% 10%
393 92 123
73%**** 17%**** 23%**
160 12 57
44% 3% 16%
213 40 51
66% 12% 16%
277 63 66
79%**** 18%* 19%*
557 42 57
54% 4% 5%
239 12 20
47% 2% 4%
318 30 37
59%*** 6% 7%
147 7 29
40% 2% 8%
176 17 13
55% 5% 4%
234 18 15
66%**** 5% 4%**
115 15 22
11% 1% 2%
25 2 4
5% L, 1%
90 13 18
17%*** 2% 3%
9 2 2
2% 1% 1%
36 6 6
11% 2% 2%
70 7 14
20%**** 2% 4%
722 139 205
69% 13% 20%
307 32 62
61% 6% 12%
415 107 143
78%**** 20%**** 27%***
196 16 69
54% 4% 19%
231 48 57
72% 15% 18%
295 75 79
84%**** 21%*** 22%
Note: statistical tests were conducted to test the gender and overall grade differences; L~< .5%. *p < .05, **p < .001, ***p < .0001, ****p < .00001.
s u m e d at least one type of alcoholic beverage. Eighteen percent (115) of those w h o had ever used beer (i.e., 11% of the entire sample), 8% (42) of those w h o had ever used wine (i.e., 4% of the entire sample), and 13% (15) of those w h o h a d ever used liquor (i.e., 1% of the entire sample) reported regular use of the beverage. The use rates of all forms of alcohol increased with a d v a n c i n g grade level (p < .00001). F r o m the 6th g r a d e to the 10th grade, use increased by 35%, 26%, and 18% for beer, wine, and hard liquor, respectively. A m o n g the 10th g r a d e sample (an average age of 16 years), 79% had d r u n k beer (23% of the users identified themselves as regular users), 66% had d r u n k wine (8% of the users identified themselves as regular users), and 20% had d r u n k hard liquor (10% of the users identified themselves as regular users). There were significant g e n d e r differences in the use of all types of alcohol, with more males reporting use than females for each category (i.e., beer, 73% vs. 51%, p < .00001; wine: 59% vs. 47%, p < .0001; and liquor, 17% vs. 5%, p < .0001). T w o - w a y A N O V A revealed significant main effects (p < .0001) of both grade and gender for all types of alcohol use and a significant interaction between grade and gender for hard liquor (p < .0001). A further examination of the g r o u p profile revealed that the interaction was due to the rapid increase of liquor use a m o n g males in the higher grades: in the 6th grade, 2% of females and 3% of males reported lifetime use of liquor; in the 8th grade, the n u m b e r of female liquor users remained
about the same (3%), but male users increased to 24% (p < .00001); b y grade 10, 11% of females and 30% of males reported use of hard liquor.
Rate of Current Use Overall, 17%, 5%, and 2% of the participants reported h a v i n g used beer, wine, and liquor, respectively in the previous week (Table 2). In contrast to the positive association between a d v a n c i n g grade level and lifetime use of all beverage types, the 6th graders reported an equal or higher rate of current use of beer and wine (i.e., beer, 16%; wine, 8%) than students in the 8th and 10th grades (i.e., beer, 16% and 19%; wine, 4% and 4%, respectively for grade 8 and 10). Consistent with lifetime use, males had m u c h higher rates of current use than females for all forms of alcoholic beverages.
Use Pattern by Beverage Type Table 3 depicts the general pattern of alcohol use a m o n g participants. A m o n g those w h o "ever" used a n y of the three types of alcoholic beverages (beer, wine, hard liquor), 21% had c o n s u m e d beer only, 9% h a d d r u n k wine only, 55% had imbibed both beer and wine, and 15% had c o n s u m e d all three. Less than 1% had d r u n k liquor only or had d r u n k both wine and liquor without drinking beer. N o y o u t h had c o n s u m e d only beer and liquor (without wine).
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Table 3. Pattern of Lifetime and Current Alcohol Use Among Chinese Adolescents Alcoholic Beverage Beer
Wine
Lifetime use yes no no yes no no yes yes yes no no yes yes yes C u r r e n t use yes no no yes no no yes yes yes no no yes yes yes
Overall Liquor
Fema l e
Male
Grade 6
Grade 8
G r a d e 10
n
%
n
%
n
%
n
%
n
%
n
%
no no yes no yes yes yes
141 62 2 371 0 3 101
21 9 ~'. 55 0 ~ 15
63 44 0 165 0 1 23
21 15 0 56 0 L 8
78 16 2 206 8 2 78
20 5 1 53 2 1 20
40 32 1 103 1 0 6
22 17 '~ 56 c, 0 3
49 16 1 122 3 0 32
22 7 ~ 55 1 0 14
52 14 0 146 4 3 63
18 5 0 51 1 1 22
no no yes no yes yes yes
119 19 8 34 5 0 6
62 10 4 18 3 0 3
38 10 1 10 1 0 1
62 16 2 16 2 0 2
81 9 7 24 4 0 5
62 7 5 18 3 0 4
36 11 0 21 0 0 1
52 16 0 30 0 0 2
36 2 3 10 1 0 1
68 4 6 19 2 0 2
47 6 5 3 4 0 4
68 9 7 4 6 0 6
Note: The cases p r e s e n t e d in this table w e r e restricted to those w h o h a d v a l i d r e s p o n s e s to all t hre e categories (beer, w i ne , a n d liquor); ~ .5%.
Among those who reported current use (i.e., in the previous week) of any alcoholic beverage, 62% reported beer only, 10% wine only, 4% liquor only, 18% beer and wine, 3% beer and liquor, and 3% all three types listed. No youth had drunk wine and liquor without drinking beer. Among those who had ever used any kind of alcoholic beverage, over 90% had drunk beer. Among those who drank in the previous week, 86% had drunk beer. The proportion of female users who had drunk only wine was substantively higher than that of males for both lifetime use (15% vs. 5%) and current use (16% vs. 7%). Likewise, more 6th-grade users had drunk only wine than students in grades 8 and 10 for both lifetime use (17% vs. 7% and 5%) and current use (16% vs. 4% and 9%). The proportion of lifetime users who consumed all three kinds of alcoholic beverages rapidly increased with advancing grade level (3%, 14%, and 22% for grades 6, 8, and 10, respectively). The proportion of users who used both beer and wine in the previous week decreased with advancing grade level (i.e., 30%, 19%, and 4% for grades 6, 8, and 10, respectively).
characteristics, social activities, and problem behaviors are presented in Table 4. The demographic variables assessed were not associated with any type of alcohol use except that liquor users reported higher levels of parental education than nonusers (OR = 1.15, p < .05). The users were more likely to report engaging in "hanging out," "telephone/music activities," and "playing games/entertainment" than nonusers (p .05) regardless of what type of alcoholic beverages they had consumed. However, the odds ratios for those factors were greater for liquor than for beer or wine. The users and nonusers of any alcoholic beverage were not differentiated by involvement in "school or youth related" activities or whether they "play in band" (p ~ .05). With respect to problem behaviors, all forms of alcohol use were strongly associated with "cigarette smoking" and "school truancy/run away" (p < .05). In addition, users of wine were more likely than nonusers to report stealing (p < .05). Users of liquor were also more likely than nonusers to report stealing (p ~ .001) and, additionally, fighting (p < .0001).
Association of Alcohol use with Demographic Variables, Social Activities, and Problem Behaviors
Discussion
The age-adjusted and gender-adjusted odds ratio (OR) and associated 95% confidence interval (CI) for three types of alcohol use with selected demographic
This study indicates that alcohol use is prevalent among Chinese adolescents and increases with advancing grade such that by the 10th grade over four-fifths of youth have consumed alcohol. Similar
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CHINESE ADOLESCENT ALCOHOL USE
359
Table 4. Age and Gender Adjusted Odds Ratio (OR) and 95% Confidence Interval (95%CI) of Demographic, Social Activity, and Problem Behavior Factors Related to Lifetime Alcohol Use Among Chinese Adolescents Beer OR Demographic characteristics school performance educational expectation parental education Social activities school/youth group related play in band hang out telephone/music games/entertainment Problem behaviors cigarette smoking school truancy/run away steal fight
95%CI
Wine OR
Liquor
95%CI
OR
95%CI
.92 1.00 .97
[ .90, 1.05] [ .83, 1.20] [ .90, 1.05]
.93 1.02 .97
[ .80, 1.07] [ .89, 1.15] [ .90, 1.04]
.84 1.04 1.15"
[ .66, 1.07] [ .87, 1.30] [1.02, 1.30]
1.06 .88 1.36"** 1.36"* 1.49"**
[ .88, [ .68, [1.16, [1.10, [1.22,
.99 .99 1.34"** 1.24" 1.31"*
[ .82, [ .77, [1.16, [1.03, [1.09,
1.19] 1.28] 1.54] 1.50] 1.57]
.89 1.43 1.76"*** 1.89"*** 1.50"*
[ .66, [ .96, [1.44, [1.43, [1,12,
1.19] 2.13] 2.15] 2.51] 1.99]
7.11 . . . . 5.05* 1.79 1.45
[4.2l, 12.01] [1.30, 19.61] [ .97, 3.28] [ .95, 2.20]
3.55**** 2.57* 1.76" 1.15
[2.44, [1.25, [1.07, [ .83,
5.17] 5.30] 2.92] 1.61]
[6.81, [1.39, [1.40, [1.66,
16.75] 3.58] 3.26] 3.51]
1.29] 1.14] 1.59] 1.67] 1.82]
10.68 . . . . 2.23*** 2.13"** 2.41 . . . .
*p < .05 **p < .01 ***p < .0001 ****p < .00001.
to the findings in the United States and other Western countries, a high percentage of Chinese adolescents initiated alcohol use at or before grade 6. Boys were significantly more likely than girls to report alcohol use. Previous studies conducted among Chinese youth living in North America (27,28) found that compared to non-Asian adolescents, Chinese youth had lower alcohol use rates and fewer regular drinkers. However, the results of the current study indicate that adolescents residing in China exhibit use rates similar to those of non-Asian adolescents in the United States. For example, in the 1991 United States study (29), 70% of 8th graders and 84% of 10th graders reported having ever used any alcohol; the corresponding percentages in the current study were 72% and 84%. The data also indicate that beer and wine users in the lower grade (i.e., those in the 6th grade) were just as likely as the users in the upper grades to use those beverage regularly. However, the relatively low rates of "regular use" of various alcohol beverages across grades suggest that the majority of Chinese adolescents were in the stage of experimentation. The pattern of alcohol use among Chinese adolescents suggests that youth may progress from low alcohol content beverages to higher alcohol content beverages (i.e., from beer to wine then to liquor). Although hard liquor and wine (rice wine or fruit wine) are traditional alcoholic beverages in China, the results of the current study suggests that beer has become the most commonly used alcoholic beverage among Chinese adolescents. Drinking beer may be
seen as a part of the Western lifestyle to which young people are attracted. Previous studies (30,31) likewise revealed that alcohol consumption among overseas Chinese students was related to the degree of assimilation into American society. Although more research is needed on the causal connections between beer and other beverage use, the fact that beer is the most popular beverage used by young Chinese students suggests a possible role for beer as a gateway beverage progressing to use of other alcoholic beverage among Chinese adolescents. Compared to males, more females reported drinking only wine. Likewise, more adolescents in the lower grade (i.e., 6th graders) reported drinking only wine. These findings are consistent with the findings of previous studies (32) that females or younger people tend to prefer wine. There are several findings in the current study that are consistent with the findings in the United States and other Western countries. First, the use of beer and wine among Chinese adolescents was not associated with level of parental education (12,13). Second, drinking behavior among Chinese adolescents was positively correlated with involvement in unstructured activities (i.e., "hang out") and other social and entertainment activities such as "telephone/music," and "games/entertainment." (14,15) Third, alcohol use was associated with problem behaviors and such associations varied based on the type of alcoholic beverages used (15,17-21). However, use of liquor is associated with higher levels of parental education among Chinese adoles-
360
LI ET AL.
cents. O n e possible explanation for this association is that the families with higher levels of parental education m a y be able to afford higher priced liquor in their homes. Adolescents f r o m those families m a y h a v e easier access to liquor. The second possible reason is parental influence. It has b e e n h y p o t h e sized that in c o n t e m p o r a r y Chinese society, the use of alcoholic b e v e r a g e s is associated w i t h the concept of p o w e r and social privilege, in the sense that parents with higher educational a c h i e v e m e n t s a n d m o r e prestigious occupations h a v e a greater risk of b e c o m i n g alcoholics (4). While the use of a n y alcoholic b e v e r a g e a m o n g early adolescents a n d m i d d l e adolescents is potentially h a r m f u l to their physical a n d psychologic dev e l o p m e n t , the use of h a r d liquor w a s f o u n d to be m o s t d a n g e r o u s as it w a s strongly associated with delinquent b e h a v i o r s such as stealing, physical fighting, school truancy, a n d cigarette smoking. These data p r o v i d e i m p o r t a n t suggestive evidence that the theory of p r o b l e m - p r o n e behavior, a theory develo p e d in the United States (33), m a y also be applicable to different cultural settings.
JOURNAL OF ADOLESCENT HEALTH Vol. 19, No. 5
Third, as with a n y cross-sectional study, causality cannot be inferred f r o m the o b s e r v e d associations b e t w e e n alcohol use and p r o b l e m behaviors.
Implications of Findings These data represent the only recent a s s e s s m e n t of prevalence of alcohol use and, to the best of o u r k n o w l e d g e , the first evaluation of risk factors associated with alcohol use a m o n g adolescents residing in China. The findings h a v e i m p o r t a n t implications for intervention or p r e v e n t i o n of alcohol use a m o n g Chinese adolescents. The fact that m a n y y o u t h u s e d alcohol in their preteens u n d e r s c o r e s the need for p r e v e n t i o n efforts starting f r o m e l e m e n t a r y school and continuing t h r o u g h junior and senior high schools. We thank our colleagues at the West City District Institute of Educational Research, Chao Yang District Institute of Educational Research, and the Institute of Developmental Psychology at the Beijing Normal University, Beijing, China for their assistance in collecting the data for this study. We also wish to thank all of the students and teachers in Beijing who participated in this study for their cooperation. Finally, we thank the anonymous reviewers for their substantial comments on an early version of this manuscript.
Potential Limitations First, these data are b a s e d on self-report b y the adolescents a n d therefore, are subject to self-report bias. A l t h o u g h the s u r v e y w a s a n o n y m o u s , y o u t h m a y h a v e m i s r e p r e s e n t e d their actual alcohol use behaviors. H o w e v e r , studies c o n d u c t e d in Western societies assessing self-report of alcohol use a m o n g adolescents h a v e generally f o u n d results to be valid a n d reliable (34). Second, the s a m p l e that w a s recruited in one of the largest cities in China, should not be v i e w e d as representative of the general n a t i o n w i d e population. China is a nation of varied ethnic g r o u p s a n d substantial differences in geographic, cultural, a n d socioeconomic b a c k g r o u n d s . There are 56 d o c u m e n t e d ethnic g r o u p s in China with different cultures, religious beliefs, or l a n g u a g e s (35). It has been f o u n d that in China alcohol use varies across regions, ethnicities, a n d occupations (4,36). Moreover, while efforts w e r e t a k e n to ensure that the s a m p l e w a s representative of student p o p u l a t i o n s of specific g r a d e s within the city, the subjects w e r e recruited b y c o n v e n i e n c e - s a m p l i n g rather than b y r a n d o m - s a m piing. Future studies with Chinese s a m p l e s f r o m different g e o g r a p h i c areas, different ethnic groups, and different socioeconomic b a c k g r o u n d s w o u l d facilitate an a p p r o p r i a t e generalization of the findings in the current study.
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