qualitative research on alcohol consumption

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• Published: 24 May 2014

A qualitative exploration of attitudes towards alcohol, and the role of parents and peers of two alcohol-attitude-based segments of the adolescent population

• Meriam M Janssen 1 , 2 ,
• Jolanda JP Mathijssen 1 ,
• Marja JH van Bon-Martens 1 , 3 ,
• Hans AM van Oers 1 , 4 &
• Henk FL Garretsen 1  

Substance Abuse Treatment, Prevention, and Policy volume  9 , Article number:  20 ( 2014 ) Cite this article

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An earlier study using social marketing and audience segmentation distinguished five segments of Dutch adolescents aged 12–18 years based on their attitudes towards alcohol. The present, qualitative study focuses on two of these five segments ( ‘ordinaries’ and ‘ordinary sobers’ ) and explores the attitudes of these two segments towards alcohol, and the role of parents and peers in their alcohol use in more detail.

This qualitative study was conducted in the province of North-Brabant, the Netherlands. With a 28-item questionnaire, segments of adolescents were identified. From the ordinaries and ordinary sobers who were willing to participate in a focus group, 55 adolescents (30 ordinaries and 25 ordinary sobers ) were selected and invited to participate. Finally, six focus groups were conducted with 12–17 year olds, i.e., three interviews with 17 ordinaries and three interviews with 20 ordinary sobers at three different high schools.

The ordinaries thought that drinking alcohol was fun and relaxing. Curiosity was an important factor in starting to drink alcohol. Peer pressure played a role, e.g., it was difficult not to drink when peers were drinking. Most parents advised their child to drink a small amount only. The attitude of ordinary sobers towards alcohol was that drinking alcohol was stupid; moreover, they did not feel the need to drink. Most parents set strict rules and prohibited the use of alcohol before the age of 16.

Conclusions

Qualitative insight into the attitudes towards alcohol and the role played by parents and peers, revealed differences between ordinaries and ordinary sobers . Based on these differences and on health education theories, starting points for the development of interventions, for both parents and adolescents, are formulated. Important starting points for interventions targeting ordinaries are reducing perceived peer pressure and learning to make one’s own choices. For the ordinary sobers , an important starting point includes enabling them to express to others that they do not feel the need to drink alcohol. Starting points for parents include setting strict rules, restricting alcohol availability at home and monitoring their child’s alcohol use.

Alcohol use among European adolescents is widespread. In 2009–2010, 4% percent of 11 year old European adolescents and 8% of 13 year olds drank at least once a week [ 1 ]. Of the students aged 15–16 years, 87% have consumed alcohol and 57% drank alcohol in the last month. One fifth of all 15 year olds drank at least once a week, with over one-third (39%) of all 15–16 year olds drinking five or more drinks on one occasion (binge drinking) in the past 30 days [ 1 , 2 ].

There is much evidence that adolescent drinking behaviour is influenced by their parents [ 3 ]. For example, parental disapproval to the drunkenness of their child can decrease adolescents’ alcohol use [ 4 ]. On the other hand, mild parental attitudes towards adolescent drinking have been shown to result in more excessive drinking in adolescents [ 5 ]. Parents have an active role in monitoring the use of alcohol of their child [ 6 – 9 ], in reducing the availability of alcohol at home [ 7 , 10 ], and in prohibiting their child to drink alcohol [ 9 – 12 ]. A more stringent parental approach is likely to reduce adolescent drinking, whereas a more tolerant approach increases adolescent drinking [ 6 , 10 ].

Adolescents’ drinking behaviour is strongly influenced by peers [ 3 ]. On one hand, the use of alcohol by peers [ 4 , 12 , 13 ] and getting respect from peers when drinking [ 4 ] contributes to adolescent alcohol use. On the other hand, greater peer disapproval of heavy drinking results in less alcohol use and less heavy episodic drinking among adolescents [ 6 ]. Moreover, adolescents have an ambivalent view on drinking peers, i.e., they see drinking peers as relatively well adjusted but also as rebellious [ 14 ].

Due to the widespread use of alcohol by adolescents, and because of the influence of parents and peers on adolescent alcohol drinking, it is important to identify strategies which effectively target these groups to reduce alcohol-related harm to adolescents. However, until now, there has not been much evidence that alcohol education is effective in the long term [ 15 ]. A possible explanation is that adolescents are targeted as a homogeneous group in a one-size-fits-all approach in alcohol education. Therefore, we are ultimately interested in developing social marketing based interventions targeting adolescent drinking, because an important principle of social marketing is audience segmentation. This involves dividing a population into smaller and more homogeneous segments [ 16 ] based on socio-demographic data or on attitudes and behaviour [ 16 – 18 ]. Applying segmentation based on attitudes/behaviour enables a health educator to tailor a health education intervention to the attitudes and behaviour of a specific segment. Such a tailored health education intervention would be more appealing for this specific segment than applying a one-size-fits-all intervention [ 16 – 18 ]. Moreover, a specific segment would show more similarities with respect to how they might react to such tailored education efforts than the total population [ 18 , 19 ].

To be able to develop tailored social marketing alcohol interventions for adolescents, adolescents need to be segmented based on their attitudes/behaviour towards alcohol. Therefore, in an earlier study, after applying audience segmentation on alcohol attitudes of Dutch adolescents aged 12–18 years, we distinguished five segments: ordinaries (42%), high spirits (22%), consciously sobers (17%), ordinary sobers (11%), and socials (8%). Each segment had its own specific set of attitudes towards alcohol, based on five differentiating attitude factors: ‘aversion to intoxication’, ‘alcohol is the norm’, ‘need for approval’, ‘hedonistic associations with alcohol’, and ‘lack of interest in alcohol’ [ 20 ]. The ordinaries think alcohol is the norm, have hedonistic associations with alcohol, and have no aversion to intoxication. The high spirits are interested in alcohol, have strong hedonistic associations with alcohol, and have no aversion to intoxication. The consciously sobers do not have hedonistic associations with alcohol, are not interested in alcohol, and have an aversion to intoxication. Ordinary sobers think alcohol is the norm, have hedonistic associations with alcohol, but have an aversion to intoxication and are not interested in alcohol. Finally, the socials have a strong need for approval, do not think alcohol is the norm, are interested in alcohol, but have an aversion to intoxication [ 20 ].

With this insight, during an expert meeting with public health professionals, a well-considered choice was made to develop tailored alcohol prevention interventions for two of the five segments. This choice was based on theoretical and practical health gains. First, the ordinaries were chosen as they were the largest segment (42%) and most of them already drank alcohol; they were considered to be receptive to (tailored) interventions because they are more likely to be in control of their drinking. Second, the ordinary sobers were chosen as most of them do not (yet) drink alcohol. However, because they think alcohol is ‘normal’ and have hedonistic associations with alcohol, they are at risk of starting drinking while growing older. Therefore, the ordinary sobers were chosen with the aim to encourage continuation of their healthy non-drinking behaviour and delay the initiation of regular drinking. Because the high spirits are a high risk group that like to drink alcohol and do not set limits on the amount of alcohol consumed, it could be expected that they were also chosen for intervention development as well. However, since the high spirits were considered not to be a target group aimed at preventing to start drinking but rather a target group for treatment they were not chosen.

We already had insight into the attitudes of the ordinaries and ordinary sobers based on the quantitative audience segmentation study [ 20 ]. However, to develop tailored interventions for these two segments, in-depth insight into their alcohol attitudes and drinking behaviour, as well as the influence of parents and peers on their drinking behaviour, was needed. Alcohol attitudes and drinking behaviour may vary for different groups of adolescents; because these differences may not be revealed with quantitative data alone, qualitative data are required [ 21 ].

Therefore, for the ordinaries and ordinary sobers, the present study explores in-depth: 1) their attitudes towards alcohol, 2) their use of alcohol, 3) the role of their parents, and 4) the role of peers on their use of alcohol. The added value of the present study consists of two elements. First, the present study explored these attitudes in-depth (qualitatively) for the ordinaries and ordinary sobers. Second, the study also explored the role of parents and peers, which was not studied in the quantitative audience segmentation study. Both are expected to reveal new and important information for intervention development.

For this qualitative study, focus groups were held among students of three Dutch high schools. This study is in compliance with the Helsinki Declaration.

Selection of participants

Participants (12–17 years) were selected from three high schools in the working area of the Regional Public Health Service ‘Hart voor Brabant’. In this working area, all 51 high schools received an email with a brief introduction to the study and an invitation to participate. Two schools were immediately interested and another school became interested after additional details about the study and amount of time involved were provided. Of these three schools, the first is a high school offering pre-university education (students’ age 12–18 years), the second offers lower and higher general secondary education (students’ age 12–17 years), and the third offers lower general secondary education (students’ age 12–16 years).

For this study, ordinaries and ordinary sobers were required to participate in the focus groups. Therefore, the questionnaire of the audience segmentation study (consisting of 28 questions, based on the five attitude factors described earlier), with which adolescents’ segment can be determined, was used to divide adolescents into one of the five segments described above [ 20 ]. The 28 questions needed to determine students’ segment are included in Additional file 1 . First, students filled in socio-demographic data (name, address, educational level, gender, and age). This information was only used by the researchers to select participants for the focus groups based on these variables and to send an invitation-letter for the focus groups to their home address. Second, students completed the 28 questions needed to determine their segment. Last, students answered a question about whether they were willing to participate in a focus group. Students filled in this questionnaire online, in class, independently from each other. Completion of this questionnaire took approximately 25 minutes.

Students of 16 classes of the first school, 11 classes of the second and 13 classes of the third school completed this questionnaire. In total, 871 students completed the questionnaire. Using SPSS, all ordinaries (n = 414) and ordinary sobers (n = 58) were identified. Then, per school, we identified all those who also wanted to participate in a focus group, resulting in 188 ordinaries and 28 ordinary sobers. Of these ordinaries and ordinary sobers, a selection per school was made by the researchers to achieve an adequate representation of age and gender. We aimed to invite 10 adolescents per focus group, in order to be able to conduct the focus groups with a minimum of five adolescents (with some drop-outs per focus group in mind). For the ordinary sobers, this was impossible because we only found 28 ordinary sobers that were willing to participate in a focus group: 13 at the first school, six at the second school, and nine at the third school. Subsequently, 30 selected ordinaries and 25 ordinary sobers were invited to participate in the focus groups.

Parents of invited ordinaries/ordinary sobers received a postal letter explaining the study and informing them of the selection of their son/daughter for participation. If parents did not agree they could mail/telephone to cancel the participation of their son/daughter. Invited ordinaries and ordinary sobers also received a postal letter with information about the date, time and location of the focus groups, and a short introduction about the focus group. They also received an email reminder two days before the focus group.

Focus group participants received a €10 cinema voucher for their participation.

Focus groups

Six focus groups were conducted in February and March 2012, one focus group with ordinaries and one with ordinary sobers per school. Each focus group consisted of five to eight participants. A moderator and an assistant moderator (one researcher (the first author) and one assistant researcher) conducted the focus groups following a semi-structured interview guideline. The focus group explored attitudes towards alcohol, use of alcohol, the role of parents and peers on alcohol use, advised norms of alcohol use for adolescents (no alcohol consumption until reaching the minimum legal drinking age; after reaching the minimum legal drinking age, advised norms (for Dutch adolescents) are 1 glass per occasion for girls and 2 glasses per occasion for boys), activities in spare time, and alcohol prevention interventions. The focus groups lasted 70–90 min and took place at school, during school time.

Results of the first three topics (attitudes towards and use of alcohol of the ordinaries and ordinary sobers, and parental and peer influence on alcohol use of ordinaries and ordinary sobers) are presented in this manuscript. Results of the other topics are used for the development of the interventions.

All focus groups were audiotaped and transcribed verbatim. Analysis was done in three phases after completion of the six focus groups. All authors contributed to the analysis. First, two focus groups (one with ordinaries, one with ordinary sobers) were coded in an open way by three researchers independently from each other. In regular discussions, consensus was reached about the codes, which emerged from descriptive to analytical codes, resulting in a code list. In addition, it was discussed whether a certain quotation would be given the same code. Second, two researchers, independently from each other, coded two focus groups (one with ordinaries, one with ordinary sobers) with the code list developed in the first phase. In regular discussions, the code list was strengthened and finalised. Third, one researcher coded the last two focus groups using this final code list. The focus group coding was done manually, using Atlas Ti 7.

For this study, five Atlas Ti-families (categories of several codes) were created (see Table  1 ) and analysed.

In the Results section, quotations are used for illustrative purposes. Each focus group (and related quotations) is identified by a unique focus group code. Codes are constructed using the letter(s) of the segment (‘O’ for ordinaries and ‘OS’ for ordinary sobers) and date of the focus group (d(d)-m-yy), e.g., O1312 indicates focus group with ordinaries on March 1, 2012 and OS15312 indicates focus group with ordinary sobers on March 15, 2012. Quotations in square brackets below indicate spoken text of the moderator.

Of the 55 selected adolescents aged 12–17 years, 37 (response rate 67%) participated in the focus groups: 17 (out of 30 invited) ordinaries and 20 (out of 25 invited) ordinary sobers. A description of age, gender and educational level of focus group participants is added in Table  2 . Beforehand, parents of two adolescents and four adolescents themselves withdrew from participation. On the day of the focus group 12 participants (nine ordinaries, three ordinary sobers) failed to attend, without notification of cancelation.

To interpret the results of the focus groups in relation to the drinking age of the adolescents, it should be noted that, at the time of the study, the legal age to purchase alcohol in the Netherlands was 16 years for soft alcoholic drinks (≤15% alcohol) and 18 years for strong alcoholic drinks (≥15% alcohol).

Attitudes towards alcohol

Ordinaries liked drinking alcohol and associated it with fun and togetherness. They liked to get tipsy, but not drunk. Ordinaries were curious about alcohol and this often led them to drink, despite their parents’ warnings not to drink alcohol before the age of 16 years.

My parents always warned me not to drink before the age of 16 because alcohol is bad for you, but I was very curious about it … just that curiosity, that rules (O28212).

I don’t want to get drunk - and when I start to feel tipsy I stop drinking alcohol and start drinking a soda or water, or something (O29212).

Ordinary sobers had a reserved attitude towards alcohol for this moment: drinking alcohol is stupid, it can ruin your life, and drinking too much can make you do things you will regret later on. Moreover, they did not like the taste of alcohol. Some ordinary sobers had a more positive attitude for the future (when reaching the minimal legal drinking age): they imagined drinking alcohol as being pleasant and that it would be nice to reach the age at which you can legally buy alcohol.

My brothers always tell stories about people who do stupid things that they’ll regret. You also hear stories - and also, if you drink a lot of alcohol or drink yourself into a coma - you get talked about and you don’t want that … (OS15312).

My grandfather always likes to drink a glass of alcohol while I drink a glass of iced tea, which I think has a better taste - and is also better (for my health). (OS15312).

Use of alcohol

Most of the ordinaries drank alcohol and, in their opinion, they did not drink much. For them, ‘not much’ was two—eight glasses on one occasion. Being tipsy was their limit, then they switched from alcohol to water/soft drink. Ordinaries drank their first glass of alcohol when aged 14–15 years.

I don’t drink a little - but also, not a lot. When I go out, four glasses of beer – maybe up to six. If we’re really having a good time, we also drink shots - quite a lot (O28212).

I drink, I think, six to eight glasses of beer in one evening (O29212).

Most of the ordinary sobers did not drink alcohol and did not feel the need to drink. Some had tasted alcohol at some time and some drank alcohol once in a while. Ordinary sobers did not really like the taste of alcohol. The ordinary sobers who drank, drank one—three glasses on one occasion.

Yes, I’m allowed to drink, - well, I don’t feel the need to drink alcohol (OS15312).

Once, at New Year, my mother or my father gave me a glass of champagne - but I really didn’t like the taste (OS15312).

Role of parents

Most ordinaries reported that they did not talk with their parents about (the use of) alcohol. Some ordinaries told their parents that they drank alcohol, whereas some did not (always) tell their parents. According to the ordinaries, the mothers of some ordinaries did not agree with the drinking of their child, while the fathers seemed less concerned. If ordinaries and parents talked about alcohol, the conversations were mainly about school performance, and the amount of alcoholic drinks and the kind of alcoholic drinks (strong drinks/liquor). Some ordinaries reported that their parents set rules, like forbidding their son/daughter to drink alcohol before age 16 years. Some ordinaries reported that their parents did not set rules; ordinaries reported that their parents only advised them not to drink too much, or to only start drinking after reaching the legal age of 16 years.

My mother actually doesn’t know and my father … he used to drink, himself. So, when I don’t drink too much, he doesn’t care (O1312).

No, most of the time, when I go to a party, they just say, yes, don’t drink too much, and I stick to that, or … I know for myself.

[Yes, so she advises you, but you can decide for yourself?]

Yes (O1312).

My mother still thinks that I don’t drink a lot - when I’ve been out she asked me how many drinks I had - and I told her two beers - or something. She got into a panic, but, actually, I drank eight beers - or something like that. But I don’t tell her because she’ll go out of her mind, I think; it really bothers my mother. And yes, actually it’s weird, because my brother went out every week when he was 16 and it didn’t bother her at all. (O29212).

Ordinary sobers reported that they and their parents seldom talked about (the use of) alcohol. First, ordinary sobers reported that drinking alcohol was not an issue for them, and their parents knew this and trusted their children. Second, ordinary sobers reported that most of their parents prohibited the use of alcohol and, therefore, they were not allowed to drink until age 16. Ordinary sobers respected these parental rules and, therefore, did not drink alcohol. However, some ordinary sobers told that they were allowed to drink a small glass on special occasions, e.g., carnival time, or a birthday at home.

It doesn’t cross my mind to start drinking alcohol - and my parents know this, so they don’t start talking about alcohol. But … they just know whatever I know, that I will never drink alcohol before the age of 16, so … they don’t talk to me about alcohol (OS15312).

[Did you make agreements with your parents?]

No, they just know that I won’t drink alcohol.

[No? You also told us that they do not drink alcohol themselves]

No…at home, no alcohol is available.

[So, you did not make concrete agreements?]

No … yes - they think drinking alcohol is not wise, and neither do I (OS22312).

Role of peers

For the ordinaries, peer pressure played an important role. They considered it difficult to say ‘no’ to alcohol when peers drank alcohol; with drinking peers, ordinaries drank alcohol more often than with their non-drinking peers. However, some ordinaries also indicated that, on occasion, they would drink a soft drink while their peers drank alcohol. When peers drank soda, then ordinaries also drank soda; they did not drink alcohol when being the only one. Ordinaries stated that alcohol was not a necessary ingredient for having fun. According to them, it should be emphasised that someone does not have to be ashamed of drinking water or a soft drink.

The ordinaries saw their drinking peers as happy, more relaxed and noisier than non-drinking peers. Moreover, it was stated that adolescents aged ≤16 years (i.e., under the legal drinking age and not allowed to buy alcohol) asked adolescents aged ≥16 years to buy alcohol for them, thereby by-passing the rules. Generally, ordinaries did not talk about (drinking) alcohol.

I think a little,…when everybody is - I would not drink a lot but would think, well, then I’ll also drink a glass of alcohol; it’s easier than when they don’t drink.

[All right, so if everybody drinks a soft drink, it makes it easier for you to drink a non-alcoholic drink. But when your peers are drinking, you would be inclined to …]

Yes, I’d be inclined to drink alcohol (O1312).

[You say, when everybody is having a beer, it’s difficult for you to have a cola…]

Yes, I stuck to a soft drink for a long time, in grade 8 (13 – 14 year olds) everybody already drank a lot of alcohol. My friends as well … I can’t remember my turning point, but suddenly I thought … one alcoholic drink is okay (O29212).

Most of the ordinary sobers turned down an alcoholic drink when it was offered. Friends respected their choice not to drink alcohol. However, one ordinary sober reported she felt insecure when alcohol was offered which she did not want, whereas she also felt happy because she managed to say ‘no’ to drinking this alcohol. Two ordinary sobers accepted an offered alcoholic drink; for them it was too difficult to say ‘no’. It frightened ordinary sobers when their friends under the age of 16 drank alcohol, and they felt uncomfortable with drunken friends whilst they were sober. According to the ordinary sobers, self-confidence was an important factor for refusing alcohol when it was offered.

I generally feel uncomfortable when friends of mine, like at carnival time, get offered an alcoholic drink … and yes, I was the only one that turned it down. So, I felt insecure … but also happy that I turned it down (OS15312).

Last school party, all of a sudden my friends were drinking alcohol … and that shocked me (OS15312).

Yes and no: yes, one of my best friends - she drinks alcohol and that makes me … join her - when I happen to be at her place (OS22312).

This study showed new insights into the differences in alcohol-attitudes and alcohol drinking behaviour between the ordinaries and ordinary sobers. Ordinaries had a positive attitude towards alcohol, associated it with fun and started drinking because they were curious. Most of the ordinaries already drank alcohol. Most ordinary sobers did not drink alcohol, did not like the taste of alcohol, nor did they feel the need to drink. They had a reserved attitude towards alcohol. Moreover, this study showed that parents played a different role in alcohol education for these two segments. Although parents of some ordinaries set rules about alcohol use, the majority only advised their son/daughter not to drink too much or to start drinking only after reaching the minimum legal drinking age. Ordinary sobers reported that their parents generally set rules about not drinking alcohol until age 16, which were respected by the ordinary sobers. Last, it was found in this study that peers also influenced the attitudes and alcohol use of the ordinaries and ordinary sobers in a different way. Ordinaries experienced peer pressure and were inclined to drink alcohol when peers were drinking, whereas most ordinary sobers were able to resist an offered alcoholic drink, a choice that was respected by peers.

For the ordinary sobers, there appeared to be a difference in their attitude towards alcohol in the results found in this current qualitative study and in the earlier quantitative audience segmentation study. In the focus groups, the ordinary sobers expressed a reserved attitude towards alcohol and they were not interested in alcohol. However, results from the earlier quantitative audience segmentation study [ 20 ] showed that the ordinary sobers appeared to have a positive attitude towards alcohol: thinking about alcohol made them think of the having fun, of letting go, and of adulthood. A possible explanation for these differences in attitudes is that the positive attitude found in the audience segmentation study is a future-directed attitude, whereas the attitude explored in the focus groups described the attitude of the ordinary sobers for this moment, influenced by the strict rules of parents and the fact that ordinary sobers are not allowed to drink alcohol before the age of 16. Because of this, their attitude does not lead to intentions to drink and to actual alcohol drinking behaviour.

Other qualitative studies have found alcohol-related attitudes of adolescents that are in agreement with that found in the ordinaries segment. Adolescents appeared to drink alcohol to relax, to have fun, and to belong to the group [ 22 ] and alcohol was seen by adolescents as a central marker of maturity and was used to gain social recognition [ 23 ]. According to a review of drinking motives, most young people drink because of social motives being either positive (social camaraderie) or negative (peer pressure, not to feel left out) [ 24 ]. If we translate the results of these studies to the present study, it appears that the ordinaries drink because they experienced peer pressure, which can be seen as a struggle for social recognition and a need to belong to the group. The attitudes of the ordinary sobers were not reflected in the review of drinking motives [ 24 ], because only drinking adolescents were studied in this review study. The added value of the current study was that we found differences in alcohol-attitudes between the ordinaries and the ordinary sobers by applying audience segmentation. These differences will enable us to tailor social marketing alcohol health education to these different attitudes of the two segments.

Many of the constructs emerging from the focus groups are aligned with key theories that explain lifestyle behaviours, like drinking alcohol. Key theories for explaining lifestyle behaviours are the “Theory of Planned Behavior” [ 25 , 26 ], “Drinking Refusal Self-Efficacy” [ 27 – 29 ] and the “Social Cognitive Theory” [ 30 ]. These theories are also useful to underpin intervention development. The “Theory of Planned Behavior” states that behavioural intentions are influenced by three determinants: the attitude towards the behaviour, the subjective norm, and the perceived behavioural control. Behaviour (change) is influenced by the intentions [ 25 , 26 ]. The second theoretical construct to explain the results of this study is the “Drinking Refusal Self-Efficacy”-theory [ 27 – 29 ]. Drinking refusal self-efficacy is a person’s belief about his/her ability to refuse alcohol in certain situations [ 29 ] and, according to this theory, drinking refusal self-efficacy is a predictor of alcohol consumption [ 27 ]. A third and final theoretical construct to explain the results of this study is the “Social Cognitive Theory” [ 30 ], which states that (expectations of) ‘environmental events’, ‘personal factors’, and ‘behaviour’ influence each other continually.

Based on the results of the present study and the theoretical constructs, starting points for preventive alcohol interventions for adolescents can be formulated, based on the specific insights into the ordinaries and ordinary sobers. It is important that interventions for adolescents are aimed at the ordinaries and ordinary sobers, as well as their peers, as peers might help them to say ‘no’ to alcohol or to respect that the ordinary sobers do not feel the need to drink alcohol.

Starting points for the ordinaries are based on the subjective norm and on the perceived behavioural control. Ordinaries experience social pressure of drinking peers, and their perceived behavioural control of drinking a soft drink while peers drink alcohol is low. Therefore, an important starting point for an intervention for the ordinaries is peer pressure. Another important starting point is increasing their perceived behavioural control; this can be done by emphasizing that it is important to make your own choice and by practicing this in skills-training. Besides, this can be done by creating respect for each other’s choices, even when ordinaries make their own choices which might differ from those of their peers. Some ordinaries were drinking large volumes of alcohol on one occasion. Drinking (a lot of) alcohol at a young age can for example harm the immature and developing brains of adolescents and can result in alcohol poisoning. Therefore, it is important to incorporate knowledge about the harm alcohol can cause in an intervention for the ordinaries.

The starting point for the ordinary sobers is based on their reserved attitude towards alcohol and is aimed at continuing this reserved attitude. The ordinary sobers do not (yet) drink alcohol. For this moment, they do not feel the need to drink alcohol. However, because they think alcohol is the norm and have hedonistic associations with alcohol [ 20 ], they might start drinking alcohol when turning older. Based on these insights, a starting point for an intervention for ordinary sobers is to enable them to express to their peers that they do not feel the need to drink alcohol and to create respect for their choice not to drink alcohol.

It is advised to also focus on the parents in interventions. This study showed that parents of both groups conducted their alcohol education role in different ways. Parents of the ordinaries rarely set strict rules about alcohol and advised their children not to drink too much, whereas parents of the ordinary sobers set clear rules about not drinking until reaching age 16 years.

In general, parents do their best to minimise harm and promote healthy alcohol behaviour in their children [ 31 , 32 ]. Alcohol use by ordinaries and ordinary sobers can be influenced by parental alcohol education. Parental measures (e.g., monitoring their child’s use of alcohol, restricting the availability of alcohol at home, and setting rules about the use of alcohol) are important and effective measures [ 6 – 12 ]. Because parents can influence the attitude and alcohol use of their child by applying such measures, these should be the starting points for interventions for parents of both ordinaries and ordinary sobers. For parents of ordinaries, it could be stressed that setting strict rules and maintaining these rules might help their son/daughter not to drink (too much) alcohol. For the parents of the ordinary sobers, it could be stressed that they continue setting rules after their son/daughter reaches the minimum legal drinking age, i.e., rules about the amount of days/week the ordinary sober is allowed to drink alcohol or of the amount of glasses an ordinary sobers consumes per occasion.

Besides, it is important to educate the parents of both the ordinaries and the ordinary sobers about the short-term and long-term alcohol-related harm of adolescent alcohol drinking, i.e., alcohol poisoning, brain damage, the risk of conducting risky sexual behaviour, neurological damage, and having an increased risk of becoming dependent or addicted in later life.

Study limitations

Of the 55 invited adolescents, 18 did not participate due to withdrawal by the adolescents themselves (four in advance, 12 not showing on the day of the focus group) or because their parents did not want them to participate, which was the case for two adolescents.

Focus groups took place at school during school time. Possible reasons for withdrawal or not showing up are: having an examination/test, wanting to follow lessons due to poor school results, forgetting the date (despite an email reminder), and/or being ill. Of the 18 non-participants, 13 were ordinaries and five were ordinary sobers. In total, 57% of the invited ordinaries and 80% of the invited ordinary sobers participated in the focus groups. We did not ask for reasons for withdrawal. Besides the above-mentioned reasons, a possible explanation for withdrawal for the ordinaries (based on their attitudes about alcohol) is that they might be less inclined to participate in a focus group and share their opinion/experiences about alcohol (use).

The researchers composed the focus groups with a good mix of age and gender. Therefore, boys and girls, of a younger and older age, participated together in a focus group. It might be possible that the composition of the focus groups has hindered participants to be totally honest about their opinion. However, we did not notice so; all participants participated actively in the focus groups. Besides, the researchers paid attention that all participants could and did express their own opinion. The segmentation based on alcohol attitudes might have helped in this; the participants of one focus group shared the same attitudes towards alcohol. Moreover, it might be possible that results differ per school and, thus, per educational level and were influenced by an overrepresentation of girls in the focus groups with the ordinary sobers. However, because the segments were based on attitudes towards alcohol, and not on socio-demographic variables, this seems less relevant. Finally, it might be possible that group dynamics (participants know each other or even might be friends) influenced the results. During the focus groups, some participants seemed to know each other, however, researchers did not observe the participants to be friends. Each participant answered upon his/her own individual opinion.

This type of qualitative research provides deeper insight into the attitudes of ordinaries and ordinary sobers towards alcohol, and the role of their parents and peers in the Netherlands. In order to explore cross-cultural applications of this study, more research is needed.

Qualitative insight into the attitudes and use of alcohol of the ordinaries and ordinary sobers, and the role of their parents and peers has revealed new differences between these two segments. Most of the ordinaries already drink alcohol. Ordinaries experience peer pressure and are inclined to drink alcohol when peers are drinking. The majority of the parents of ordinaries only advised their son/daughter not to drink too much or to start drinking only after reaching the minimum legal drinking age.

Most ordinary sobers do not drink alcohol nor do they feel the need to drink. Ordinary sobers respected parental rules about not drinking alcohol until age 16. These differences led to different starting points for interventions. For intervention development, it is advised that an intervention is aimed at adolescents, as well as at their parents and peers. Starting points for an intervention for ordinaries are reducing peer pressure and asking peers to respect their friends’ choices which might differ from their choices. A starting point for an intervention for ordinary sobers is prompting them to confirm that they do not feel the need to drink. Starting points for an intervention for parents are monitoring the use of alcohol of their child, restricting the availability of alcohol at home, and setting clear rules about alcohol use.

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Acknowledgements

This study is funded by a grant from ZonMW, the Netherlands Organization for Health Research and Development (204001005).

The authors thank Marijn den Uijl for being the assistant moderator during the focus groups and for transcribing all focus groups verbatim.

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Janssen, M.M., Mathijssen, J.J., van Bon-Martens, M.J. et al. A qualitative exploration of attitudes towards alcohol, and the role of parents and peers of two alcohol-attitude-based segments of the adolescent population. Subst Abuse Treat Prev Policy 9 , 20 (2014). https://doi.org/10.1186/1747-597X-9-20

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• Published: 15 November 2022

Alcohol consumption and its associated factors among adolescents in a rural community in central Thailand: a mixed-methods study

• Pichak Pramaunururut 1 ,
• Pijak Anuntakulnathee 1 ,
• Piti Wangroongsarb 1 ,
• Thanapat Vongchansathapat 1 ,
• Kullanith Romsaithong 1 ,
• Jareewan Rangwanich 1 ,
• Nuttamon Nukaeow 1 ,
• Poonyawee Chansaenwilai 1 ,
• Ploynaphat Greeviroj 1 ,
• Pimchanok Worawitrattanakul 1 ,
• Pamornwat Rojanaprapai 1 ,
• Veerapatra Tantisirirux 1 ,
• Pongpisut Thakhampaeng 2 ,
• Wanida Rattanasumawong 3 ,
• Ram Rangsin 2 ,
• Mathirut Mungthin 4 &
• Boonsub Sakboonyarat 2  

Scientific Reports volume  12 , Article number:  19605 ( 2022 ) Cite this article

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• Epidemiology
• Public health
• Risk factors

Early onset of alcohol use was associated with alcohol dependence and other health problems. We aimed to identify the prevalence and factors associated with alcohol consumption among adolescents in a rural community in Thailand. A mixed-methods study was carried out in 2021 using an explanatory sequential design. The study enrolled a total of 413 adolescents. On average, young adolescents initiated alcohol consumption at age 13. The lifetime drinking prevalence among adolescents was 60.5%, while the 1-year drinking prevalence was 53.0%. The prevalence of hazardous drinking among current drinkers was 42.0%. Alcohol consumption was associated with females (adjusted prevalence ratio (APR): 1.19; 95% CI 1.01–1.41), age ≥ 16 years (APR: 1.28; 95% CI 1.09–1.50), having close friends consuming alcohol (APR: 1.75; 95% CI 1.43–2.14), night out (APR: 1.93; 95% CI 1.53–2.45), being a current smoker (APR: 1.39; 95% CI 1.15–1.69), and having relationship (with boyfriend/girlfriend) problems (APR: 1.18; 95% CI 1.01–1.38). Qualitative data demonstrated that individual and environmental factors, including friends, family, social media use, and alcohol accessibility, affect alcohol use in this population. Therefore, effective strategies should be implemented across multiple levels of the socio-ecological model simultaneously to alleviate alcohol consumption and attenuate its complications.

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Introduction.

Alcohol consumption is associated with various health issues, such as maternal and child health, infectious diseases, noncommunicable diseases, mental health, and injuries 1 .

The National Statistical Office (NSO) in Thailand reported that, during 2003–2015, the prevalence of current alcohol consumption among adults aged at least 15 years consistently ranged from 32.7 to 34.0% and then reduced slightly to 28.4% in 2017 2 . Current alcohol consumption among Thai males (47.5%) is more likely to be higher than that among females (10.6%). As regards the residential area, the prevalence of current alcohol consumption was 29.3% and 27.4% outside and within the municipal area, respectively 2 .

Early onset of alcohol consumption was associated with a higher risk of heavy alcohol drinking 3 , substance use 4 , and poorer performance in psychomotor speed and visual attention 5 . In Thailand, national policies and interventions to solve this issue have been implemented, including the national legal minimum age for on-/off-premises sales of alcoholic beverages, restrictions for on-/off-premises sales of alcoholic beverages (hours, days/places, and density), and national level government support for community action 1 . Unfortunately, a continuous increase in the incidence of early alcohol consumption (before the age of 20 years) has been observed, which ranged from 8.9% in 2007 to 10.9% in 2017 6 , 7 .

The Global School-Based Student Health survey illustrated that the prevalence of current alcohol use among Thai adolescents aged 13–17 years increased from 14.8% in 2008 to 22.2% in 2015 8 . Furthermore, the Global Status Report on Alcohol and Health 2018 presented that alcohol consumption among Thai adolescents was top-ranking in Southeast Asia 1 . Recent studies revealed several factors associated with current alcohol consumption among adolescents, such as family problems, direct observation of friends’ drinking, having parents store alcohol at home, and exposure to alcohol advertising. In addition, risky sexual and suicidal behaviors were associated with alcohol use 9 , 10 .

Although national data include information about alcohol consumption in Thailand 2 , sufficient information about the socio-ecological context associated with alcohol consumption among adolescents in a particular community is still limited. A few studies investigating alcohol consumption among adolescents were conducted in urban and suburban areas, presenting an estimated prevalence of current alcohol consumption ranging from 10.4 to 18.6% 9 , 10 , 11 . Nowadays, one-half of the Thai population still resides in rural areas where healthcare provider characteristics, health literacy, and socioeconomic contexts may differ from those in urban areas 12 . Recently, a related quantitative study about the substance abuse situation in a remote rural community, Chachoengsao Province, detected that 36.8% of adolescents reported being a current alcohol drinker and indicated that alcohol drinking was associated with substance abuse in the rural community 4 , which was considered a major health issue in the Thai rural community. Unfortunately, information regarding risk factors for alcohol consumption among adolescents in this remote rural area was not uncovered.

The present study aimed to identify the prevalence and factors associated with alcohol consumption among adolescents in a remote rural area using quantitative methods. Moreover, a qualitative study will explore the socio-ecological factors affecting alcohol consumption, including family members and friends, store and accessibility, and social and environmental factors. If factors associated with alcohol consumption among adolescents are explored, appropriate strategies and practical interventions may be implemented in this population to resolve this issue in the future.

Study design and subjects

The current study was performed in a remote rural area in Thakradan Subdistrict, Sanam Chai Khet District, at the border area of Chachoengsao Province, central Thailand, 160 km east of Bangkok. Due to their location in the border area of the province, a total of five villages (from 23 villages) in the Thakradan Subdistrict were selected to conduct the study. Furthermore, since 2002, these five villages have been known as the Na-Yao community, where Phramongkutklao College of Medicine established the teaching community for undertaking community-based research. In 2018, a related study in this community revealed that alcohol use among adolescents in this rural area is relatively high (36.8%) and also related to substance use. Nevertheless, information on factors associated with alcohol use was unavailable. Therefore, we aimed to employ a mixed-methods study using explanatory sequential design in this area to explore the magnitude of alcohol use and also determine socio-ecological factors affecting alcohol use among adolescents in this rural context. Regarding the explanatory sequential mixed method, we collected quantitative data about adolescents and then collected qualitative data through the use of in-depth interviews and focus group discussions among adolescents, teachers, parents, and adults in the community to help explain the quantitative results.

Quantitative part

We conducted a cross-sectional quantitative study to identify the prevalence and factors associated with alcohol consumption among adolescents in March 2021. The minimal calculated sample size of 341 was determined according to the 2018 Global Status Report on Alcohol and Health of Thai adolescents 1 , 13 . We expected that 25% of available adolescents would be unable to participate. Thus, 427 were finally estimated to mitigate the effect of possible losses. We carried out a quantitative method at school A , which is a government high school providing education for adolescents aged 13 to 18 years residing in this community. The exclusion criteria included individuals who did not provide informed consent or could not answer the questionnaire. Four hundred twenty-five adolescents in school A were invited to participate in the study, and 413 individuals agreed to participate.

Qualitative part

We also performed a qualitative study to investigate the socio-ecological factors that affect alcohol consumption among adolescents. At high school A , the investigator invited adolescents, teachers, parents, and adults in the community to participate in the qualitative study. Moreover, advertising posters were provided at school to encourage target participants to participate in the study. Purposive sampling was also utilized for selecting six adolescents, three teachers, six parents, and adults in this community for in-depth interviews. Forty-nine adolescents, seven teachers, and five parents and adults in the community were purposively selected for focus group discussions. Nine focus groups (FGs) included adolescents, teachers, parents, and adults in the community. The first FG to seventh FG (n = 7/group) consisted of adolescents. The eighth FG (n = 7) comprised teachers from high school, whereas the ninth FG (n = 5) comprised parents of adolescents and adults. Forty-nine adolescents who participated in the quantitative study also participated in the FGs.

Data collection

After permission was received from the director of school A , the investigators invited adolescents in school A to participate in the quantitative part of the study. Additionally, an advertising poster of the present study was provided in front of the classroom to encourage them to participate in the study. Furthermore, information sheets, objectives, and study methods were provided to the subjects. Informed consent was obtained prior to the research. During the study, self-reported questionnaires were utilized to obtain essential information from participants within 20 min. The questionnaires were self-administered and delivered in an envelope. To de-identify, a unique identification number was used instead of the names and identities of the volunteers. An adolescent could decide not to participate in the study. This decision does not affect any dimensions of adolescents, such as education and health care.

Standardized questionnaires developed by the investigators for the current study were divided into three parts as follows: demographic characteristics, associated factors, and history of alcohol consumption. They included information regarding demographics, including sex, age, parental status, religion, educational level, and grade point average (GPA). The characteristics of alcohol consumption were collected through the use of standardized questionnaires asking about lifetime prevalence and the last 12-month prevalence of alcohol consumption, age at initial alcohol consumption, and categories of alcoholic beverages including beer, whiskey, white liquor, and wort. Lifetime alcohol consumption and the last 12-month prevalence of alcohol consumption were defined based on the data obtained from the responses to the following questions: (1) “Have you ever consumed any alcohol such as beer, wine, spirits, and wort?” and (2) “Have you consumed any alcohol within the past 12 months?”, respectively 14 . Among the participants consuming alcohol in the last 12 months, hazardous drinking was assessed using the Alcohol Use Disorders Identification Test (AUDIT) (score ≥ 8) 15 .

The investigators (BS, TV, PT, and VT), who were the interviewers, were trained at the Phramongkutklao College of Medicine before conducting the qualitative study. The interviews were done in the meeting room of high school A in the community. Informed consent was obtained before the research. Two researchers (BS and TV) conducted in-depth interviews and took notes on non-verbal communication. Interviews of the nine FGs were facilitated by two investigators (BS and TV). In addition, notes on non-verbal communication and other notable items were taken by two researchers (PT and VT). All investigators wrote additional notes after the interviews of the FGs. The interviews were carried out with questions and probes for further questioning, covering questions on the factors influencing alcohol consumption among adolescents, how adolescents access alcohol, and existing interventions in the community (Supplementary File 1 ). The data were collected continuously until the contents were saturated. The conversations were taped using a voice recorder and transcribed into text. Two investigators (BS and TV) reviewed the transcription to check the errors before performing an analysis.

Statistical analysis

Data were analyzed using StataCorp, 2021, Stata Statistical Software: Release 17 , College Station, TX, USA, StataCorp LLC. Demographic characteristics were determined through the use of descriptive statistics. The age of participants was categorized into two groups (< 16 and \(\ge\) 16 years) regarding median age. According to the NSO report in Thailand, the age at initiation of alcohol consumption was categorized into two groups: < 15 and \(\ge\) 15 years. The frequency distribution of categorical variables by strata was compared using the Chi -square test, while continuous data were compared using Student’s t -test. Through descriptive statistics, lifetime prevalence and last 12-month prevalence of alcohol consumption were reported as a percentage with a 95% confidence interval (CI). The univariable analysis was utilized to identify the associated factors of the last 12 months of alcohol consumption. Multivariable analysis was performed. After running a logit model, the adjrr (margin) command was used to calculate the adjusted prevalence ratio (APR), which was presented with a corresponding 95% CI. A two-sided  p -value less than 0.05 was considered statistically significant.

The qualitative study employed a thematic analysis. Analytic rigor in the qualitative analysis was ensured through investigator triangulation 16 . Transcripts were compared to the investigators' notes taken during the in-depth interviews and focus groups (BS and TV). The text-based data transcribed from the conversation were sorted and coded. Inductive and deductive coding were used, and analytic categories and themes were then developed. Initial coding and themes (by BS and TV) were checked by the other investigators (PP and VT) 17 . The quotations below best represent the range of ideas voiced around key themes.

Ethics consideration

The current study was reviewed and approved by the Institutional Review Board, Royal Thai Army Medical Department according to international guidelines including the Declaration of Helsinki, the Belmont Report, CIOMS Guidelines, and the International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use-Good Clinical Practice (ICH-GCP) (approval number R190q/63). Written informed consent was obtained from the participants according to the WMA Declaration of Helsinki Ethics Principles for medical research involving human subjects.

Quantitative study

Demographic characteristics of participants.

In a rural community, a total of 425 adolescents were invited to the present study, among which 413 (97.2%) responded to participate in the study. The demographic data of these participants are shown in Table 1 . Among them, 250 (60.5%) were females. The average age of the participants was 15.5 ± 1.6 years (ranging from 13 to 18). The adolescents were in grades 7 to 12 and vocational training. One-half of the participants (49.9%) lived with both a father and a mother.

Prevalence of alcohol consumption among adolescents in a Thai rural community

The characteristics of alcohol consumption among adolescents are presented in Table 2 . The average age at initial alcohol consumption was 13.9 ± 1.8 years (ranging from 10 to 18); 59.6% of drinkers started drinking at age less than 15. The lifetime drinking prevalence among adolescents was 60.5% (95% CI 55.6–65.3%). The overall one-year drinking prevalence was 53.0% (95% CI 48.1–57.9%) and was comparable between 52.1% (95% CI 44.2–60.0%) among males and 53.6% (95% CI 47.2–59.9%) among females ( p -value = 0.772). Hazardous drinking determined by AUDIT score among current drinkers was 42.0, 41.2, and 42.5% among total, male, and female participants ( p -value = 0.842), respectively. Beer and whiskey were the most prevalent beverages among adolescents accounting for 59.3 and 20.0%, respectively.

Associated factors of alcohol consumption among adolescents in a Thai rural community

Univariable and multivariable analyses were carried out to identify the associated factors of alcohol consumption within 12 months (Tables 3 , 4 ). After adjusting for potential confounders, the independent factors associated with alcohol consumption within 12 months included females (APR: 1.19; 95% CI 1.01–1.41), age ≥ 16 years (APR: 1.28; 95% CI 1.09–1.50), having close friends consuming alcohol (APR: 1.75; 95% CI 1.43–2.14), night out (APR: 1.93; 95% CI 1.53–2.45), being a current smoker (APR: 1.39; 95% CI 1.15–1.69), and having relationship (with boyfriend/girlfriend) problems (APR: 1.18; 95% CI 1.01–1.38).

Qualitative study

For in-depth interviews, data were collected from a total of 15 participants, including 6 adolescents, 6 parents and adults in the community, and 3 teachers. For focus group discussions, data were gathered from a total of 61 participants, including 49 adolescents (aged 13 to 18 years), 5 parents and adults in the community (aged 19 to 63 years), and 7 teachers (aged 44 to 48 years). The information from in-depth interviews and focus group discussions can be grouped into more factors and interventions.

Knowledge of disadvantages of alcohol consumption among adolescents

Adolescents were aware of the short-term negative effects of alcohol consumption on mental and physical health, for instance, encouraging aggression, decreasing the level of consciousness, and facilitating road traffic accidents. However, they did not realize the long-term health risks of excessive alcohol use, including chronic liver disease and gastrointestinal hemorrhage. A 21-year-old man, working freelance, said, “If you know the disadvantage, you will drink less. It can be reduced anyway”. A 13-year-old talked about the disadvantages of consuming alcohol, “create a bad mood, more aggressive and threatening behaviors to other people. Some people even hurt family members. I have seen people whose motorcycles collide because they drove drunk”. From the inquiries of the participants, regarding the pros and cons of consuming alcohol, many commented that they did not have knowledge regarding the effects of alcohol on the body, like health aspects including liver disease and mental health.

Personal factors affecting alcohol consumption among adolescents

Curiosity and ignorance of individuals provoke the urge for trial and entertainment, especially during important festivals such as the Songkran water festival and New Year’s Eve. An adolescent stated, “I wanted to try drinking so I asked my dad”. However, the parents believed that adolescents with good judgment tended to drink lightly. As they disclosed, “If the adolescent can think for himself/herself, then abstinence may be possible, but if he/she drinks and goes partying at night and has a group of friends who do the same, then the chances of quitting are quite low”. “Teens drink according to their judgment and will regarding their knowledge of the pros and cons of alcohol”.

Friends affecting alcohol consumption among adolescents

Most adolescents thought that their initial alcohol consumption was due to an invitation from their friends or seniors. A 19-year-old maintained, “I was in grade 7 in a boarding school and often visited my senior’s flat to hang out with my friends”. Another 13-year-old girl commented, “a friend tricked her into drinking by putting alcohol in the bottle and affirmed that it was punch. Friends often hang out in groups to drink in private areas”. “Her friends invite her on weekends to a friend’s house or a restaurant that sells alcohol”.

Teachers pointed out that adolescents without sufficient care in the family would be persuaded by their friends to consume alcohol. A 48-year-old teacher stated, “He saw an 18-year-old teen drink after work with his/her friend during a festival because his/her friend invited him. Some kids do not reside with their parents and live with their grandparents who may lack sufficient care”. Parents believed that friends were a major facilitator of alcohol consumption among adolescents. One parent group mentioned, “Friends are the main contributors to consuming alcohol. In the curiosity of the adolescents, they thought that everyone who drinks seems to enjoy themselves and a person who gets drunk will be seen as a funny person, which was inaccurate”.

Family factors affecting alcohol consumption among adolescents

Some adolescents faced family disharmony including the separation of their parents, while others had grandparents and relatives as their main guardians. Therefore, adolescents were not taken care of and expressed inappropriate behaviors including alcohol consumption. A 60-year-old uncle reported, “Most of the parents did not know that the children drank because the children drank outside of the home”. The parents commented, “the influence of family members consuming alcohol facilitates the children to drink. Another contributing factor is problems in the family institution, such as separation”.

Furthermore, one teacher believed that smoking may initiate alcohol consumption. Alcohol consumption among adolescents resulted from imitating family members who smoke, which could lead them to consume alcohol later. A 44-year-old teacher revealed, “When children begin to show up to be at risk, the first thing you can find is that the cigarette may not be a real cigarette. Sometimes a paper substitute can be a simulated behavior. Cigarettes are easier to find than alcohol because parents and other older members had them at home. Children could pick them up easily. Then they may arrange an appointment with friends to buy liquor and drink as the next step”. On the other hand, adolescents believed that alcohol use in the family would not influence teenagers to drink alcohol accordingly.

Social and environmental factors affecting alcohol consumption among adolescents

Children gain various experiences in the society and environment in which they grow up. Thus, these factors will greatly affect their behaviors when they become adolescents. A 44-year-old teacher indicated, “Environment and society have a great effect on teenager experience. The new generation is growing by changing their lifestyle to create their own identity. After an adolescent receives information, they cannot distinguish right or wrong, and the bad things are easier than the good”. Another teacher suggested, “I think children are used to behaving well, but they have changed over time and by their friends; however, this group can repent and be guided correctly. On the other hand, if the family did not help from the beginning, for example, some children are born unwilling or do not feel what the word “love” is, this group will be a little tricky. It means that it is his/her way of life which is very difficult to change”.

Advertising and cyber society factors affecting alcohol consumption among adolescents

Teachers and parents thought that adolescents easily access advertising and cyber society, in which the evolution of technology is present. Therefore, adolescents could watch any story including alcohol-drinking behavior on social media which may influence their behavior in the future. A 44-year-old teacher explained, “Lacking media literacy and using too much technology on the mobile phone, celebrity, games, or anything easy to access and fast, these things are shaping and creating the new generation without an appropriate evaluation”. A group of parents responded, “Some children watch the drinking behavior from the media and think it is normal”.

Financial factors affecting alcohol consumption among adolescents

Many people thought that drinking alcohol could solve financial problems, for example, and that stress problems and anxiety would be eliminated by drinking. Unfortunately, it placed additional financial burden on them because they had to find more money to buy alcohol. A 21-year-old man expressed, “I started smoking and drinking for the first time in grade 6 because of stress from the fact that people had more money to go to school than me. He added that money to buy alcohol comes in various ways, saying there are many ways to get money—from parents, stealing, and doing illegal things. Having voiced that, what can be converted into money, for example, to steal a phone”.

Access to alcohol in the rural community

Young people could easily buy alcohol in the shops. Sellers did not have restrictions about selling liquor to children under 20 years, so teenagers could buy and drink by themselves. They did not ask about the age of the children when buying alcohol. If there were children to buy alcohol, they tended to understand that their parents asked them to buy. In addition, alcohol could be bought in the area around the school. A 13-year-old boy alleged, “easy access to the shops nearby school. In some stores, children can buy by themselves”. A 14-year-old girl acknowledged, “You can buy liquor from a store without any limited age. The merchant thinks they buy it for adults”. A 53-year-old woman replied, “The liquor store sells to even children under 18, not strict. Sometimes the child claims to buy it for his parents, and the shop sells it”. A 44-year-old teacher said, “Access to alcohol, I think, is not difficult. Teenagers can find all these things everywhere. The word shame should never exist in the minds of these teenagers”.

Alcohol consumption intervention in a Thai rural community

The existing intervention included education from schools, health services, or policies for controlling alcohol access within the school-based program. A 15-year-old boy asserted, “The school has a rule that bringing alcohol to school is not allowed by random examination”. A 13-year-old girl insisted, “Public health service used to give information, but it is not effective”, A 15-year-old boy also said, “There is teaching about drinking alcohol too. Nevertheless, I think this class is not interesting”. The expected intervention is that volunteers come up with an idea. A 16-year-old declared, “I would like the community to teach more about the disadvantages of drinking alcohol. If they know that drinking has drawbacks, they can reduce drinking”. A parent suggested, “If there is a control measure for being stricter to selling alcohol, for example, not selling it to children under 18 years old”. A group of teachers maintained, “We want the government to get involved in providing knowledge and assistance community by supporting the budget and staff”.

The current study illustrated the extreme lifetime prevalence and the last 12-month prevalence of alcohol consumption among adolescents in a Thai rural community. In comparison with the 2018 Global Status Report on Alcohol and Health indicating that the prevalence of current alcohol consumption among young Thai adults accounted for 27.3% 1 , the present study demonstrated that the prevalence was substantially high (53.0%). Furthermore, a 2018 study in this rural area revealed that the last 12-month prevalence of alcohol consumption among adolescents was 36.8% 4 . Thus, the prevalence of alcohol consumption has risen dramatically over three years. Most related reports demonstrated that young males tended to consume alcohol more than females 1 , 6 . Unexpectedly, the last 12-month prevalence of alcohol consumption among males (52.1%) was comparable to that among females (53.6%) in the present study. Additionally, after adjusting for potential confounders, we found that alcohol use within 12 months among females was relatively high. Hazardous and harmful alcohol use were assessed by AUDIT score, revealing that two-fifths of current drinkers were classified into hazardous and harmful alcohol consumption which was higher than those in the data from the Thai National Household Survey for Substance and Alcohol Use 18 .

The current study demonstrated that adolescents aged ≥ 16 years tended to consume alcohol within 12 months in comparison to those who are younger. However, the average age at initiation of alcohol consumption was 13.9 years. Moreover, approximately 60% of drinkers started alcohol use at the age of less than 15 years. These initiation ages were low compared to the NSO in Thailand, which demonstrated that the average age to start drinking among Thai people outside the municipal area was 20.5 years, and 12.5% of drinkers started consuming alcohol at the age of < 15 years 2 . This phenomenon may be explained by our qualitative data as follows: although the national legal minimum age for on-/off-premises sales of alcoholic beverages was implemented, adolescents in this remote rural area could still easily access alcohol. Retailers did not enforce the policy or recognize the age of adolescents when they purchased alcohol. Moreover, they tended to understand that parents had asked their children to buy alcohol for them. Additionally, we found that adolescents did not know the long-term risks of alcohol consumption; they only recognized short-term effects such as being drunk and decreased level of consciousness. The study conducted by Hingson et al. illustrated that people who initiate drinking before age 14 were more likely to experience alcohol dependence than those who began drinking at age 21 (adjusted hazard ratio of 1.78) 19 . In addition, the early onset of alcohol consumption was associated with substance use 4 , family violence, injuries, suicide, and sexual behaviors 5 . Our study suggested that these issues should be solved promptly. Primary prevention programs should be implemented in the community. Regarding hazardous drinkers, effective therapy may be initiated and delivered by nurses working at primary care units in this rural area 20 .

Current drinker status among adolescents in this community was associated with individual and environmental factors. A significant association was found between current smokers and alcohol consumption. This finding was in compliance with related reports in the US 21 , 22 and the UK 23 that people who decided to try smoking tended to try alcohol and vice versa 22 . From the qualitative information, the teachers believed that smoking may initiate alcohol consumption which resulted from imitating the behaviors of family members.

Both quantitative and qualitative findings indicated that adolescents having friends consuming alcohol tended to be current drinkers. Adolescents, parents, and teachers affirmed that adolescents were provided an opportunity to consume alcohol by their friends. For instance, when adolescents have a party, they themselves claim that their friends do not influence their choice of action, and when a friend allows alcohol, their decision to try alcohol lies in their own hands. This finding is also in accordance with a related study in eastern Thailand, indicating that adolescents who directly observe their friends’ drinking were more likely to be drinkers 9 . On the other hand, support from friends can help the drinkers have a chance to alleviate alcohol use 24 .

Social media use may be a potential factor affecting alcohol consumption among adolescents. Although social media use was no longer associated with current drinker status, information from the qualitative study demonstrated that adolescents could access any content via social media platforms, such as peer alcohol behavior and alcohol advertising, because of unregulated marketing on social media 25 , 26 . Therefore, adolescents could perceive inappropriate behaviors such as alcohol consumption as usual. Social media also facilitate pro-alcohol environments and encourage drinking 25 , 27 . This may be explained by social learning theory 28 , 29 , suggesting that adolescents realize alcohol use by observing and imitating the behavior of others. For instance, adolescents repeatedly exposed to alcohol content shared by their friends could motivate the initiation of alcohol use or increase drinking 30 , 31 .

The present study indicated that alcohol consumption may contribute to further problems including love relationships between adolescents and their boyfriends/girlfriends. Related studies supporting this finding demonstrated that alcohol consumption negatively affects relationships 32 . In addition, a meta‐analysis of a longitudinal study illustrated that becoming single was associated with increased consumption at follow-up 33 . Furthermore, qualitative data revealed that alcohol consumption among adolescents may be associated with financial problems and, consequently, illegal behaviors such as thievery. This finding may be explained by adolescents excessively spending money on buying alcohol to consume, resulting in financial issues. Some evidence supported that higher debt and financial strain were positively associated with alcohol use 34 , 35 . Other related evidence also indicated that illegal acts, including theft and acts against persons, were more likely to be higher under the influence of alcohol. Furthermore, the acute use of alcohol, alone or in combination with other drugs, was involved with the illegal acts 36 .

To date, the existing intervention that helps in solving alcohol-related problems among adolescents in this rural area is the conventional health education provided in the school. However, the qualitative study indicated that adolescents were not interested in that program. Although the national legal minimum age for on-/off-premises sales of alcoholic beverages and restrictions for on-/off-premises sales of alcoholic beverages have been established (hours, days/places, and density), adolescents aged less than 18 years are still able to purchase alcohol at stores in this community.

It is observed that alcohol consumption among adolescents in this remote rural area is still a substantial issue related to not only personal factors but also socio-ecological context, including family members, peers, and community members, as well as social and cultural norms. Our results suggest that the primary prevention programs to attenuate alcohol-related problems among adolescents in this community must be implemented across multiple levels of the socio-ecological model simultaneously 37 . A specific approach should promote attitudes, beliefs, and behaviors preventing alcohol use at the individual level 38 . Generally, knowledge about the disadvantages of alcohol use should be provided, both short- and long-term consequences on physical and mental health, such as cognitive impairment, family violence, suicide, and sexual behaviors 39 .

Another level is the relationship with family and peers. The related evidence demonstrated that parental monitoring and supervision effectively prevent the onset of alcohol consumption and misuse. For instance, parents monitor their adolescents during free time and time with friends and provide active supervision by being present during youth activities 40 , 41 . Effective strategies such as school strategies should be also implemented in the community 38 . The related evidence established that a routine interactive educational program encouraged adolescents to be actively engaged in forming social norms to reduce alcohol use 42 , 43 . Furthermore, school-based prevention can focus on self-esteem and self-efficacy, concentrating on interpersonal interactions and educating about alcohol and its harmful effects 44 , 45 . Besides, our findings suggested that local authorities should seriously force alcohol sellers in the community to follow the minimum age regulations for on-/off-premises sales of alcoholic beverages. The strategies at the societal level, such as establishing norms that support nonuse, are crucial for preventing alcohol use and misuse. Moreover, other social institutions, such as Buddhist temples, may play an essential role through religious beliefs that can potentially assist in preventing alcohol use 46 . Additionally, the active participation of people and community engagement will serve as potential facilitators to alleviate underage drinking 47 .

In terms of limitations, firstly, the study utilized a cross-sectional survey, which made it difficult to determine a cause-and-effect relationship between associated factors and alcohol consumption. Secondly, we carried out a quantitative study at a school in the community; therefore, a few adolescents who were outside school were not included in the present study. Thirdly, there were missing data in some variables regarding the questions in the case report form that may comprise sensitive issues; the participants may not voluntarily answer those questions. Therefore, some variables, such as GPA (missing data for 57.3%), would not be included in the multivariable analysis. Fourthly, some variables, such as personal media literacy, were not collected; therefore, unmeasured confounders may not be included in the final model. Another limitation of this study was that only adolescents in this rural area were included; thus, the study may not be generalized to the whole country but may reflect the real experience of adolescents residing in rural communities in Thailand.

To sum up, we presented the situation of alcohol consumption among adolescents in a remote rural community in Thailand. The current study revealed that the prevalence of alcohol consumption was extremely high among males and females. On average, young adolescents initiate alcohol consumption at age 13. The factors affecting alcohol use included individual and environmental factors. Therefore, effective strategies should be implemented across multiple levels of the socio-ecological model simultaneously to alleviate alcohol consumption among adolescents and attenuate its complications.

Data availability

The datasets generated during and/or analyzed during the current study are not publicly available because the data set contains sensitive identifying information. Because ethical restrictions have been placed, the data sets are available from the corresponding author on reasonable request (contact Boonsub Sakboonyarat via [email protected]).

Abbreviations

National Statistic Office

Alcohol use disorders identification test

Adjusted prevalence ratio

Confidence interval

Standard deviation

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Acknowledgements

The authors express their grateful thanks to the director, teachers, healthcare workers and village health volunteers of Baan-Na-Yao Health Promoting Hospital, Chachoengsao Province. The authors thank all the staff of the Department of Military and Community Medicine, Phramongkutklao College of Medicine, for their support in completing this study.

This research was supported by the Phramongkutklao College of Medicine, Bangkok, Thailand.

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Pichak Pramaunururut, Pijak Anuntakulnathee, Piti Wangroongsarb, Thanapat Vongchansathapat, Kullanith Romsaithong, Jareewan Rangwanich, Nuttamon Nukaeow, Poonyawee Chansaenwilai, Ploynaphat Greeviroj, Pimchanok Worawitrattanakul, Pamornwat Rojanaprapai & Veerapatra Tantisirirux

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The concept for the study was developed by P.P., P.A., P.W., T.V., K.R., J.R., N.N., P.C., P.G., P.W., P.R., V.T., P.T., M.M., W.R., R.R. and B.S. P.P., P.A., P.W., T.V., K.R., J.R., N.N., P.C., P.G., P.W., P.R., V.T. and B.S. collected the data. P.P., P.A., and B.S. analyzed the data. P.P., P.A., T.V., M.M. and B.S. wrote the first draft, and all authors contributed and approved the final version.

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Correspondence to Mathirut Mungthin or Boonsub Sakboonyarat .

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Pramaunururut, P., Anuntakulnathee, P., Wangroongsarb, P. et al. Alcohol consumption and its associated factors among adolescents in a rural community in central Thailand: a mixed-methods study. Sci Rep 12 , 19605 (2022). https://doi.org/10.1038/s41598-022-24243-0

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DOI : https://doi.org/10.1038/s41598-022-24243-0

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eTable 1. Health Deficits of the Frailty Index in the UK Biobank Cohort

eTable 2. Association of Wine Preference and Drinking During Meals With Mortality in Older Drinkers From the UK Biobank Cohort

eTable 3. Association of Average Alcohol Intake Status With Mortality in Older Drinkers From the UK Biobank Cohort, Excluding Participants With Prevalent Cancer at Baseline for Cancer Mortality, or Those With Prevalent CVD at Baseline for CVD Mortality

eTable 4. Association of Wine Preference or Drinking During Meals With Mortality in Older Drinkers From the UK Biobank Cohort, Excluding Participants With Prevalent Cancer at Baseline for Cancer Mortality, or Those With Prevalent CVD at Baseline for CVD Mortality

eTable 5. Association of Wine Preference and Drinking During Meals With Mortality in Older Drinkers From the UK Biobank Cohort, Excluding Participants With Prevalent Cancer at Baseline for Cancer Mortality, or Those With Prevalent CVD at Baseline for CVD Mortality

eTable 6. Association of Average Alcohol Intake Status With Mortality in Older Drinkers From the UK Biobank Cohort, by Drinking Patterns, Excluding Participants With Prevalent Cancer at Baseline for Cancer Mortality, or Those With Prevalent CVD at Baseline for CVD Mortality

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Ortolá R , Sotos-Prieto M , García-Esquinas E , Galán I , Rodríguez-Artalejo F. Alcohol Consumption Patterns and Mortality Among Older Adults With Health-Related or Socioeconomic Risk Factors. JAMA Netw Open. 2024;7(8):e2424495. doi:10.1001/jamanetworkopen.2024.24495

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Alcohol Consumption Patterns and Mortality Among Older Adults With Health-Related or Socioeconomic Risk Factors

• 1 Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain
• 2 Center for Biomedical Research in Epidemiology and Public Health, Madrid, Spain
• 3 Department of Environmental Health and Nutrition, Harvard T.H. Chan School of Public Health. Boston, Massachusetts
• 4 Madrid Institute for Advanced Studies Food Institute, Campus of International Excellence Universidad Autónoma de Madrid + Spanish National Research Council, Madrid, Spain
• 5 Department of Chronic Diseases, National Center for Epidemiology, Carlos III Health Institute, Madrid, Spain

Question   Do health-related or socioeconomic risk factors modify the associations of alcohol consumption patterns with mortality among older drinkers?

Findings   This cohort study in 135 103 older drinkers found that even low-risk drinking was associated with higher mortality among older adults with health-related or socioeconomic risk factors. Wine preference and drinking only with meals were associated with attenuating the excess mortality associated with alcohol consumption.

Meaning   This cohort study identified inequalities in the detrimental health outcomes associated with alcohol that should be addressed to reduce the high disease burden of alcohol use.

Importance   Alcohol consumption is a leading cause of morbidity and mortality that may be more important in older adults with socioeconomic or health-related risk factors.

Objective   To examine the association of alcohol consumption patterns with 12-year mortality and its modification by health-related or socioeconomic risk factors.

Design, Setting, and Participants   This prospective cohort study used data from the UK Biobank, a population-based cohort. Participants were current drinkers aged 60 years or older. Data were analyzed from September 2023 to May 2024.

Exposure   According to their mean alcohol intake in grams per day, participants’ drinking patterns were classified as occasional: ≤2.86 g/d), low risk (men: >2.86-20.00 g/d; women: >2.86-10.00 g/d), moderate risk (men: >20.00-40.00 g/d; women: >10.00-20.00 g/d) and high risk (men: >40.00 g/d; women: >20.00 g/d).

Main Outcomes and Measures   Health-related risk factors were assessed with the frailty index, and socioeconomic risk factors were assessed with the Townsend deprivation index. All-cause and cause-specific mortality were obtained from death certificates held by the national registries. Analyses excluded deaths in the first 2 years of follow-up and adjusted for potential confounders, including drinking patterns and preferences.

Results   A total of 135 103 participants (median [IQR] age, 64.0 [62.0-67.0] years; 67 693 [50.1%] women) were included. In the total analytical sample, compared with occasional drinking, high-risk drinking was associated with higher all-cause (hazard ratio [HR], 1.33; 95% CI, 1.24-1.42), cancer (HR, 1.39; 95% CI, 1.26-1.53), and cardiovascular (HR, 1.21; 95% CI, 1.04-1.41) mortality; moderate-risk drinking was associated with higher all-cause (HR, 1.10; 95% CI, 1.03-1.18) and cancer (HR, 1.15; 95% CI, 1.05-1.27) mortality, and low-risk drinking was associated with higher cancer mortality (HR, 1.11; 95% CI, 1.01-1.22). While no associations were found for low- or moderate-risk drinking patterns vs occasional drinking among individuals without socioeconomic or health-related risk factors, low-risk drinking was associated with higher cancer mortality (HR, 1.15; 95% CI, 1.01-1.30) and moderate-risk drinking with higher all-cause (HR, 1.10; 95% CI, 1.01-1.19) and cancer (HR, 1.19; 95% CI, 1.05-1.35) mortality among those with health-related risk factors; low-risk and moderate-risk drinking patterns were associated with higher mortality from all causes (low risk: HR, 1.14; 95% CI, 1.01-1.28; moderate risk: HR, 1.17; 95% CI, 1.03-1.32) and cancer (low risk: HR, 1.25; 95% CI, 1.04-1.50; moderate risk: HR, 1.36; 95% CI, 1.13-1.63) among those with socioeconomic risk factors. Wine preference (>80% of alcohol from wine) and drinking with meals showed small protective associations with mortality, especially from cancer, but only in drinkers with socioeconomic or health-related risk factors and was associated with attenuating the excess mortality associated with high-, moderate- and even low-risk drinking.

Conclusions and Relevance   In this cohort study of older drinkers from the UK, even low-risk drinking was associated with higher mortality among older adults with health-related or socioeconomic risk factors. The attenuation of mortality observed for wine preference and drinking only during meals requires further investigation, as it may mostly reflect the effect of healthier lifestyles, slower alcohol absorption, or nonalcoholic components of beverages.

Alcohol consumption is a leading cause of morbidity and mortality, accounting for approximately 5.1% of the global burden of disease and 5.3% of all deaths and being responsible for significant social and economic losses, thus representing a major public health problem. 1 Additionally, the assumed benefits of drinking low amounts of alcohol, especially on cardiovascular disease (CVD) mortality, 2 - 4 are being questioned due to selection biases, reverse causation, and residual confounding, 5 supporting health messaging that the safest level of drinking is no drinking at all or less is better. 6 , 7 Selection biases are often overlooked, but they can lead to a systematic underestimation of alcohol-related burden. That is the case of the abstainer bias, whereby the apparently lower mortality of light drinkers compared with abstainers could be explained by the higher death risk of the abstainers because they include former drinkers who quit alcohol due to poor health, as well as lifetime abstainers, 5 who often have worse lifestyle and health characteristics than regular drinkers. 8 Also, the healthy drinker/survivor bias, caused by overrepresentation of healthier drinkers who have survived the deleterious effects of alcohol, can distort comparisons, especially in older age. 5 In addition, drinking habits may influence the association between the amount of alcohol consumed and health. In this context, wine preference has been associated with lower risk of death, 9 CVD morbimortality, 10 and diabetes, 11 attributing the beneficial associations of wine to its high content in polyphenols. 12 Furthermore, drinking with meals has been associated with lower risk of all-cause, non-CVD, and cancer deaths 13 and frailty, 14 so this might be a safer option for alcohol drinkers along with moderate consumption. 15

The health impact of alcohol consumption may be greater in individuals with socioeconomic or health-related risk factors. On one hand, older adults with health-related risk factors are more susceptible to the harmful outcomes associated with alcohol due to their greater morbidity, higher use of alcohol-interacting drugs, and reduced tolerance. 16 , 17 However, some studies have observed benefits of alcohol on unhealthy aging or frailty, especially of light alcohol intake 18 , 19 and of a Mediterranean alcohol drinking pattern, defined as moderate alcohol consumption, preferably wine and accompanying meals, 14 , 20 suggesting that the protective associations of these potentially beneficial drinking patterns might be greater in individuals with ill health, although they might be due to the aforementioned methodological issues. 5 Therefore, it would be of interest to examine whether health-related risk factors modify the associations between alcohol consumption patterns and mortality.

On the other hand, there is evidence that socioeconomically disadvantaged populations have higher rates of alcohol-related harms for equivalent and even lower amounts of alcohol, probably due to the coexistence of other health challenges, including less healthy lifestyles, and lower social support or access to health care. 21 , 22 Also, the potentially beneficial associations of wine preference and drinking during meals might be more important in individuals with socioeconomic risk factors. However, to our knowledge, no previous research has examined whether socioeconomic status modifies the associations between these potentially beneficial drinking patterns and health.

Therefore, the aim of our study is to examine the associations of several potentially beneficial alcohol consumption patterns, that is, consumption of low amounts of alcohol, wine preference, and drinking only during meals, with all-cause, cancer, and CVD mortality in older adults and their modification by health-related or socioeconomic risk factors, while addressing the main methodological issues deemed to bias such associations. Thus, we restrict analyses to current drinkers and use occasional drinkers instead of abstainers as the reference group to prevent selection biases, exclude deaths in the first 2 years of follow-up to reduce reverse causation, and adjust analyses for many sociodemographic, lifestyle, and clinical variables to palliate residual confounding. We also restrict analyses to older adults because most deaths occur in this population group, which also has a high prevalence of health-related risk factors and because the protective associations of alcohol consumption have been specifically observed in older adults, 6 which is consistent with our aim to study potentially beneficial drinking patterns.

This cohort study was approved by the North West Multi-Centre Research Ethics Committee, and all participants provided written informed consent before enrollment. This study is reported following the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We used data from the UK Biobank cohort, a multicenter, prospective, population-based study with more than 500 000 participants aged 40 to 69 years identified from National Health Service primary care registers and enrolled at 22 assessment sites across England, Scotland, and Wales between 2006 and 2010. At the baseline assessment visit, they completed a computer-assisted interview and a touch-screen questionnaire on sociodemographic, lifestyle, and clinical characteristics, provided biological samples, and underwent physical and medical examinations. They were followed-up for mortality through linkage to national death registries. Additional information on the UK Biobank study has been reported elsewhere. 23 , 24

At the baseline assessment visit, study participants were asked about the frequency and mean amount of the main types of alcoholic beverages that they consumed, and alcohol content was estimated by multiplying the volume ingested (in milliliters) by the volume percentage of alcohol (4.5% for beer and cider, 11.5% for white and sparkling wine, 13% for red wine, 20% for fortified wine, and 40% for spirits) and by the specific gravity of ethanol (0.789 g/mL). According to their mean alcohol intake, drinking patterns were classified into occasional (≤2.86 g/d), low risk (men: >2.86-20.00 g/d; women: >2.86-10.00 g/d), moderate risk (men: >20.00-40.00 g/d; women: >10-20.00 g/d), and high risk (men: >40.00 g/d; women: >20.00 g/d), a categorization based on the recommendations from health authorities that we have used in previous studies. 25 - 27 When more than 80% of alcohol came from a certain type of beverage, drinkers were classified as with preference for wine, with preference for other drinks, or with no preference. 27 Participants were also classified as drinkers only during meals and as drinkers either only outside of meals or at any time. Finally, participants were classified as drinkers with no wine preference nor drinking only during meals, drinkers with wine preference or drinking only during meals, and drinkers with wine preference and drinking only during meals.

Health-related risk was assessed at baseline using the frailty index (FI) developed specifically for the UK Biobank 28 based on the procedure used by Rockwood et al. 29 A total of 49 health deficits were considered, most dichotomously (1 point if present and 0 points otherwise), and a few according to severity (0 points for no deficit, 0.25-0.75 points for mild to moderate deficits, and 1 point for severe deficit). The FI score was calculated as the total sum of points assigned to each health deficit divided by the number of deficits considered and ranged from 0.00 to 0.57. The complete list of health deficits and associated scores can be found in eTable 1 in Supplement 1 . Participants were considered to have health-related risk factors if they were prefrail or frail (FI > 0.12). 28

Socioeconomic risk was assessed at baseline using the Townsend deprivation index (TDI), 30 which measures the level of an area’s socioeconomic deprivation. TDI ranges from −6.26 to 10.16, with higher score indicating greater deprivation. Participants were considered to have socioeconomic risk factors if they lived in more deprived areas (TDI > 0) and not if they lived in more affluent areas (TDI ≤ 0).

Information on mortality was obtained from death certificates held by the National Health Service (NHS) Information Centre (NHS England) up to September 30, 2021, for participants in England and Wales, and by the NHS Central Register Scotland (National Records of Scotland) up to October 31, 2021, for participants in Scotland. 31 , 32 Length of follow-up was estimated as the time from the baseline assessment visit to the date of death or administrative censoring, whichever came first. Cause-specific mortality was ascertained with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) classification 33 : codes C00 to C97 as primary cause of death for cancer and codes I00 to I99 for CVD.

We also used baseline information on sociodemographic, lifestyle, and clinical characteristics, including sex, age, self-reported race and ethnicity, education (college or university degree; A levels, AS levels, or equivalent; O levels, General Certificate of Secondary Education, or equivalent; Certificate of Secondary Education or equivalent; National Vocational Qualification, Higher National Diploma, Higher National Certificate, or equivalent; other professional qualifications; and no qualifications), tobacco smoking (never, former, or current), leisure-time physical activity (metabolic equivalents of task-hours per week), time spent watching television (hours per day), and prevalent morbidities (diabetes, CVD, and cancer) that could have a potential effect on the amount of alcohol consumed. In the UK Biobank, race and ethnicity are classified as Asian (Indian, Pakistani, Bangladeshi, any other Asian background), Black (Caribbean, African, any other Black background), Chinese, multiple (White and Black Caribbean, White and Black African, White and Asian, any other mixed background), White (British, Irish, any other White background), and other (any group not specified, eg, Arab).

From 217 462 participants aged at least 60 years in the UK Biobank cohort, we excluded 36 284 with incomplete information on alcohol consumption, 10 456 never drinkers, 8295 former drinkers, and 20 167 known binge drinkers (those who consumed ≥6 units of alcohol in 1 session) to avoid classifying binge drinkers with low mean alcohol intake as low-risk drinkers. We additionally excluded 1140 participants who died in the first 2 years of follow-up and 6017 participants with missing information on the FI (194 participants), the TDI (116 participants), and potential confounders (5707 participants). Thus, the analytical sample included 135 103 individuals.

The associations of alcohol consumption patterns (mean alcohol intake status, wine preference, and drinking during meals) at baseline with all-cause and cause-specific mortality were summarized with hazard ratios (HRs) and their 95% CIs obtained from Cox regression; the models included interactions between alcohol consumption patterns and health-related or socioeconomic risk factors and adjusted for baseline sociodemographic (sex, age, race and ethnicity, education, and TDI [except when stratifying by socioeconomic risk factors]), lifestyle (tobacco smoking, leisure-time physical activity, and time spent watching television), and clinical characteristics (diabetes, CVD, cancer, and FI score [except when stratifying by health-related risk factors]) of study participants. Analyses of alcohol intake were further adjusted for wine preference and drinking during meals, whereas analyses of wine preference and drinking during meals were further adjusted for mean alcohol intake and the other drinking pattern.

To characterize whether wine preference and drinking during meals modified the association of mean alcohol intake with mortality, we tested interaction terms defined as the product of the categories of mean alcohol intake by 3 categories of drinking patterns (no wine preference nor drinking only during meals, wine preference or drinking only during meals, and wine preference and drinking only during meals).

Additionally, we assessed whether sociodemographic and lifestyle variables modified the study associations by testing interaction terms defined as the product of alcohol consumption patterns by categories of such variables (except mean alcohol intake status by sex, as sex was included in the definition of alcohol intake status). Since no interactions were found, the results are presented for the total sample. Finally, we performed additional sensitivity analyses excluding participants with prevalent cancer at baseline for cancer mortality or those with prevalent CVD at baseline for CVD mortality.

Statistical significance was set at 2-sided P  < .05. Analyses were performed with Stata software version 17 (StataCorp). Data were analyzed from September 2023 to May 2024.

A total of 135 103 participants (median [IQR] age, 64.0 [62.0-67.0] years; 67 693 [50.1%] women) were included. Occasional drinkers less often identified as White; were more frequently residents in England, women, and never smokers; were less physically active; had a lower educational level, a lower prevalence of CVD; and had a higher prevalence of diabetes, cancer, and health-related risk factors. Having socioeconomic risk factors was less frequent in low- and moderate-risk drinkers ( Table 1 ).

Over a median (range) follow-up of 12.4 (2.0 to 14.8) years, 15 833 deaths were recorded, including 7871 cancer deaths and 3215 CVD deaths. Compared with occasional drinking, low-risk drinking was associated with higher cancer mortality (HR, 1.11; 95% CI, 1.01-1.22); moderate-risk drinking was associated with higher all-cause (HR, 1.10; 95% CI, 1.03-1.18) and cancer (HR, 1.15; 95% CI, 1.05-1.27) mortality; and high-risk drinking was associated with higher all-cause (HR, 1.33; 95% CI, 1.24-1.42), cancer (HR, 1.39; 95% CI, 1.26-1.53), and CVD (HR, 1.21; 95% CI, 1.04-1.41) mortality ( Table 2 ). Hazards were greater in individuals with health-related or socioeconomic risk factors vs those without across categories of alcohol intake. Interestingly, while no associations with mortality were found in participants without health-related or socioeconomic risk factors among low- or moderate-risk drinkers, low-risk drinkers with health-related risk factors had higher cancer mortality (HR, 1.15; 95% CI, 1.01-1.30) and moderate-risk drinkers with health-related risk factors had higher all-cause (HR, 1.10; 95% CI, 1.01-1.19) and cancer (HR, 1.19; 95% CI, 1.05-1.35) mortality ( Table 2 ). Likewise, both low-risk and moderate-risk drinkers with socioeconomic risk factors showed higher mortality from all causes (low risk: HR, 1.14; 1.01-1.28; moderate risk: 1.17; 95% CI, 1.03-1.32) and cancer (low-risk: HR, 1.25; 95% CI, 1.04-1.50; moderate risk: HR, 1.36; 95% CI, 1.13-1.63) ( Table 2 ).

Wine preference and drinking only during meals were associated with lower all-cause mortality only in participants with health-related risk factors (wine preference: HR, 0.92; 95% CI, 0.87-0.97; drinking only during meals: HR, 0.93; 95% CI, 0.89-0.97), as well as in participants with socioeconomic risk factors (wine preference: HR, 0.84; 95% CI, 0.78-0.90; drinking only during meals: HR, 0.83; 95% CI, 0.78-0.89) ( Table 3 ). Drinking only during meals was also associated with lower cancer mortality in participants with health-related risk factors (HR, 0.92; 95% CI, 0.86-0.99) or socioeconomic risk factors (HR, 0.85; 95% CI, 0.78-0.94) ( Table 3 ). Furthermore, in individuals with socioeconomic risk factors, wine preference was associated with lower cancer mortality (HR, 0.89; 95% CI, 0.80-0.99) and drinking only during meals with lower CVD mortality (HR, 0.86; 95% CI, 0.75-1.00) ( Table 3 ). Adhering to both drinking patterns was associated with lower all-cause, cancer, and CVD mortality in drinkers with health-related or socioeconomic risk factors, and to a lesser extent, with lower all-cause death in drinkers without health-related risk factors (eTable 2 in Supplement 1 ). Importantly, wine preference and drinking during meals modified the association of mean alcohol intake with mortality: the excess risk of all-cause, cancer, and CVD death for high-risk drinkers, of all-cause and cancer death for moderate-risk drinkers, and of cancer death for low-risk drinkers vs occasional drinkers was attenuated and even lost among individuals with these drinking patterns ( Table 4 ). Analyses excluding participants with prevalent cancer at baseline for cancer mortality, or those with prevalent CVD at baseline for CVD mortality showed consistent results (eTables 3-6 in Supplement 1 ).

This cohort study in older alcohol drinkers from the UK found that compared with occasional drinkers, low-risk drinkers had higher cancer mortality, moderate-risk drinkers had higher all-cause and cancer mortality, and high-risk drinkers had higher all-cause, cancer, and CVD mortality. The excess mortality associated with alcohol consumption was higher in individuals with health-related and socioeconomic risk factors, among whom even low-risk drinkers had higher mortality, especially from cancer. Wine preference and drinking only with meals showed small protective associations with mortality, especially from cancer, among drinkers with health-related and socioeconomic risk factors, and these 2 drinking patterns attenuated the excess mortality associated with high-, moderate-, and even low-risk drinking.

In line with recent research on the associations between alcohol use and health, 6 , 34 , 35 our results corroborate the detrimental outcomes associated with heavy drinking in older adults. However, we also found higher risk for all-cause and cancer deaths in moderate-risk drinkers, unlike most previous research, which has reported protective associations of low to moderate alcohol consumption, mainly for all-cause 2 - 4 , 36 and CVD 3 , 36 , 37 mortality, ischemic heart disease, 3 , 6 , 34 and diabetes, 6 or null associations with all-cause mortality, 38 CVD, 39 and unhealthy aging. 20 This discrepancy may be due to the implementation of an important methodological improvement in our analyses, that is, using occasional drinkers as the reference group instead of lifetime abstainers, to prevent selection bias caused by misclassification of former drinkers as abstainers, and to palliate residual confounding because they are more like light drinkers than are never drinkers. 40 , 41 In fact, another analysis of the UK Biobank cohort that also avoided selection biases found an increased CVD risk in the general population for drinking up to 14 units per week. 42

To our knowledge, there are no studies examining the potential modification of health-related risk factors on the association between alcohol use and health. The stronger associations between mean alcohol intake and mortality observed in older adults with health-related risk factors make sense, since they have more morbid conditions potentially aggravated by alcohol and greater use of alcohol-interacting medications than their counterparts without health-related risk factors. 16 , 17 The fact that even low-risk drinkers with these risk factors had higher risk of cancer death is an important finding, which is consistent with the reported increased risk of several types of cancer and cancer mortality even with very low amounts of alcohol. 6 , 36 , 37 , 43

Our results also suggest that socioeconomic status acts as a modifier of the association between the amount of alcohol consumed and mortality, as mortality hazard was much greater in individuals with socioeconomic risk factors than in individuals without, in line with previous research. 21 , 22 , 44 , 45 We even found a detrimental association of low amounts of alcohol with all-cause and cancer mortality in this group, unlike the MORGAM study by DiCasetnuovo et al 44 reporting a lower mortality associated with consuming no more than 10 g/d of alcohol, which was clearer in individuals with higher vs lower education. 44 These discrepant results could again be explained by the different reference groups used: occasional drinkers in our study and never drinkers in the MORGAM study. Importantly, although older adults with socioeconomic risk factors have a higher risk of ill health and death, probably due to the coexistence of other health challenges, especially poorer lifestyles, 21 , 22 the observed associations in our study were independent of lifestyles, suggesting that other factors should account for them.

Regarding the potentially beneficial drinking patterns, that is, wine preference and drinking during meals, the literature is inconsistent. A 2018 pool of studies 34 reported a nondifferential association of specific types of alcoholic drinks with all-cause mortality and several CVD outcomes, whereas other studies have found protective health associations for wine but not other beverages. 15 , 46 Drinking with meals has also shown protective associations with several health outcomes. 15 In our analysis, these drinking patterns modified the association between alcohol intake and death risk. On one hand, the protective association for mortality of these patterns was only observed in individuals with socioeconomic or health-related risk factors, independently of the amount of alcohol consumed. On the other hand, the detrimental association of alcohol intake was more evident in individuals without these patterns. These findings suggest that the less detrimental associations of alcohol intake from wine or during meals are not due to alcohol itself, but to other factors, including nonalcoholic components of wine, such as antioxidants, slower absorption of alcohol ingested with meals and its consequent reduced alcoholaemia, as well as spacing drinks when drinking only with meals, or more moderate attitudes in individuals who choose to adhere to these drinking patterns.

Our study has several strengths, such as the large sample size, the long follow-up, and the methodological improvements implemented to prevent selection biases and reduce reverse causation. However, it also has some limitations. First, alcohol intake was self-reported, and therefore prone to some degree of misclassification. Also, alcohol intake was measured only at baseline and not at multiple time points over the life span, not allowing us to take into account changes in alcohol intake before the baseline assessment or to redistribute former drinkers among categories of current drinkers to reduce selection bias; this may have led to an underestimation of the true effects of alcohol consumption. 5 Second, as in any observational study, we cannot entirely rule out residual confounding, despite adjusting for many potential confounders. And third, this study was conducted in older adults in the UK with a high proportion of White participants, so our results may not be generalizable to other racial ethnic groups or populations with different lifestyles, drinking patterns, or socioeconomic development.

This cohort study among older drinkers from the UK did not find evidence of a beneficial association between low-risk alcohol consumption and mortality; however, we observed a detrimental association of even low-risk drinking in individuals with socioeconomic or health-related risk factors, especially for cancer deaths. The attenuation of the excess mortality associated with alcohol among individuals who preferred to drink wine or drink only during meals requires further investigation to elucidate the factors that may explain it. Finally, these results have important public health implications because they identify inequalities in the detrimental health outcomes associated with alcohol that should be addressed to reduce the high burden of disease of alcohol use.

Accepted for Publication: May 30, 2024.

Published: August 12, 2024. doi:10.1001/jamanetworkopen.2024.24495

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Ortolá R et al. JAMA Network Open .

Corresponding Author: Rosario Ortolá, MD, PhD, Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid, Calle del Arzobispo Morcillo 4, 28029 Madrid, Spain ( [email protected] ).

Author Contributions: Dr Ortolá had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ortolá.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Ortolá.

Critical review of the manuscript for important intellectual content: Sotos-Prieto, García-Esquinas, Galán, Rodríguez-Artalejo.

Statistical analysis: Ortolá.

Obtained funding: Sotos-Prieto, Rodríguez-Artalejo.

Administrative, technical, or material support: Rodríguez-Artalejo.

Supervision: García-Esquinas, Galán.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by the Plan Nacional sobre Drogas, Ministry of Health of Spain (grant No. 2020/17), Instituto de Salud Carlos III, State Secretary of R+D+I and Fondo Europeo de Desarrollo Regional/Fondo Social Europeo (Fondo de Investigación en Salud grants No. 19/319, 20/896, and 22/1111), Agencia Estatal de Investigación (grant No. CNS2022-135623), Carlos III Health Institute and the European Union “NextGenerationEU (grant No. PMP21/00093), and the Fundación Francisco Soria Melguizo (Papel de la Disfunción Mitocondrial en la Relación Entre Multimorbilidad Crónica y Deterioro Funcional en Ancianos project grant). Mercedes Sotos-Prieto holds a Ramón y Cajal contract (contract No. RYC-2018-025069-I) from the Ministry of Science, Innovation and Universities.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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• Research article
• Open access
• Published: 23 October 2012

The ‘other’ in patterns of drinking: A qualitative study of attitudes towards alcohol use among professional, managerial and clerical workers

• Jonathan Ling 1 ,
• Karen E Smith 1 ,
• Graeme B Wilson 2 ,
• Lyn Brierley-Jones 1 ,
• Ann Crosland 1 ,
• Eileen FS Kaner 2 &
• Catherine A Haighton 2  

BMC Public Health volume  12 , Article number:  892 ( 2012 ) Cite this article

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Recent evidence shows that workers in white collar roles consume more alcohol than other groups within the workforce, yet little is known about their views of drinking.

Focus groups were conducted in five workplaces to examine the views of white collar workers regarding the effect of alcohol use on personal and professional lives, drinking patterns and perceived norms. Analysis followed the method of constant comparison.

Alcohol use was part of everyday routine. Acceptable consumption and ‘excess’ were framed around personal experience and ability to function rather than quantity of alcohol consumed. Public health messages or the risk of adverse health consequences had little impact on views of alcohol consumption or reported drinking.

Conclusions

When developing public health alcohol interventions it is important to consider the views of differing groups within the population. Our sample considered public health messages to be of no relevance to them, rather they reinforced perceptions that their own alcohol use was controlled and acceptable. To develop effective public health alcohol interventions the views of this group should be examined in more detail.

Peer Review reports

Increasing alcohol consumption and the associated health, social and economic harms are key public health concerns [ 1 – 4 ]. While some research has investigated the relationships between job status and alcohol intake [ 5 ] and between alcohol consumption, work-related stress and occupational role [ 6 , 7 ], people in higher socio-economic groups are generally under-represented in alcohol research. Recent statistics show however that households with an adult working in a managerial or professional capacity have the highest proportion of alcohol consumption in the previous seven days [ 8 ]. Similarly, adults in managerial and professional households are significantly more likely than those in routine and manual households to have had an alcoholic drink on five or more days in the previous week. No research has yet examined how alcohol is viewed by this largely unconsulted section of the population: those in occupations that are managerial, supervisory, clerical or professional – frequently referred to as white collar workers (contrasting with ‘blue collar’, unskilled or manual workers).

Alcohol holds an established role within British culture where it is associated with socialising, pleasure, celebration and escape from pressure [ 1 , 4 ]. While the majority of alcohol users are sensible drinkers, alcohol use outside socially defined acceptable parameters is viewed negatively and is also strongly associated with illness and crime [ 9 , 10 ]. Recent public health policies have focussed upon young people, binge drinking and the socially visible consequences of problematic drinkers, largely disregarding the harmful health and social effects of average alcohol consumption over time [ 1 , 3 , 9 ]. The UK Government’s latest alcohol strategy does acknowledge the health impact of alcohol use; however its focus remains “turn[ing] the tide against irresponsible drinking” [ 4 ], p4].

In the UK there has been a shift away from drinking within leisure premises and an increase in home drinking [ 1 , 4 ], where the majority of drinking now takes place [ 11 ]. Home drinking is generally portrayed as safe and responsible despite being typically uncontrolled and unregulated [ 11 ]. At a population level, there is increasing awareness of the daily guidelines for responsible drinking [ 4 , 12 ], however these are not applied consistently to personal behaviour [ 1 , 13 ]. Higher levels of alcohol consumption have become normalised [ 1 , 14 ] and many people now adhere to a personally-interpreted definition of moderate drinking that could put them in danger of short- and long-term negative consequences [ 12 ]. Almost a quarter of the population report regularly drinking in excess of current guidance, an overwhelming majority of whom do not think they are causing any risk to their long term health and, unlike people who smoke - most of whom would like to quit - less than a fifth of those regularly drinking in excess of the recommended guidance want to drink less [ 4 ]. This presents a significant and growing health burden [ 11 , 15 ] and has important implications for future public health approaches around alcohol use [ 9 ].

Accessing individuals in the workplace provides an important opportunity to increase understanding of the views underpinning health behaviours of working people, who form a significant proportion of the adult population. This study explored white collar workers’ views of alcohol use. Going beyond a discussion of consumption, we sought to develop an understanding of how public health alcohol messages were viewed, as well as exploring contextually the role of alcohol within the personal and professional lives of white collar workers.

Participants

An opportunity sample of 49 people (17 male, 32 female) participated. Ages ranged from 21 to 55. All participants were working full-time - at least 35 hours per week - in managerial, supervisory, clerical or other professional roles. Participation was voluntary and staff were recruited on behalf of the research team by a co-ordinator within each workplace. Co-ordinators were typically from human resources or a health improvement/health and safety officer. Lunch was provided and a £5 voucher offered to each participant in thanks.

Data collection

Focus groups were held in five workplaces during employee lunch breaks and were attended by employees from that organisation only.

  Focus groups 1 and 2 - local government offices. Focus Group 1 consisted of 9 females with ages ranging from 21 to 55. Focus Group 2 was composed of 8 females and 1 male, aged from 25 to 55.

  Focus group 3 – a private sector chemical storage company. This group consisted of 1 female and 9 males, aged from 25 to 55.

  Focus group 4 - a prison. The focus group consisted of 7 females and 4 males who ranged in age from 22 to 54.

  Focus group 5 – a tax office. The focus group consisted of 7 females and 3 males who were aged from 36 to 51.

Each focus group was facilitated by two researchers. Prior to focus groups, participants were given an overview of the research aims to enable provision of informed written consent. At the start of each group ground rules were established to observe confidentiality and facilitate mutual respect. Participants were advised that the facilitators were not seeking personally sensitive information, such as the quantity or frequency of alcohol consumption. Open-ended questions were posed around loosely constructed themes enabling members of the focus groups to raise issues of significance to them, as well as exploring areas of agreement and disagreement. Focus group facilitators worked from a flexible schedule of open-ended questions. These questions were continually reframed in light of emerging concepts based on views related to four themes related to drinking:

  lifestyle behaviours

  drinking in the home

  variations in consumption through the week

  the effect of drinking on work

Focus groups lasted between 40 and 75 minutes and were audio recorded and transcribed verbatim, with personal information anonymised prior to analysis.

Data analysis

Data were analysed using the method of constant comparison. Constant comparison requires that data be simultaneously encoded and analysed to enable hypothesis discovery and theory generation [ 16 ]. All data were analysed for classification into initial categories, with thematic categories being compared both within and across transcripts. Responses from earlier groups informed discussions in later groups. Comparison continued until saturation. Categories were subsequently integrated into a set of higher level concepts in a process of initial theory generation. Data were first analysed independently by focus group facilitators, and later by other members of the research team who had not been involved in data collection. Regular research team meetings were held to discuss issues arising and to ensure analytic rigor.

Within all focus groups, drinking alcohol was seen as a reward after fulfilling work commitments and family obligations, and as a way to unwind, alleviate stress or socialise. As discussions developed, socially-acceptable norms were continually negotiated. These norms were constructed around generic drinking behaviours rather than personal consumption (‘you’ and ‘they’ rather than ‘I’) and language and terminology were used to enhance statements, invite consensus from other group members, and identify deviance from these norms.

Three themes emerged:

  perceptions of harmful, unacceptable or problematic alcohol use as ‘the other’

  normalisation of alcohol use when perceived to be controlled and harm free

  the ability to function as an endorsement of acceptable alcohol use

Perceptions of harmful, unacceptable or problematic alcohol use as ‘the other’

Focus groups considered unacceptable or problematic use of alcohol to be associated with long-term, heavy and binge drinking. Perceptions of excessive alcohol intake were assessed in relation to how a person looks and behaves rather than the quantity or frequency of consumption. Clear distinctions were made between personal use of alcohol and that of ‘others’ by using broadly constructed stereotypes of individuals with complex needs, those using alcohol as a coping mechanism, or those outside their own peer groups such as ‘young people’.

" The people who are predominantly doing it [drinking problematically] are in a society and a culture where it just becomes the norm; they don’t know any different - they can’t get out of it - but then you are moving into a situation where you are looking at far more than just the alcohol side of things. (Female, Focus group 1)"

The stigma associated with alcohol problems was further highlighted in relation to seeking information or support. If colleagues or peers were experiencing problems with alcohol it was felt likely that there would be an underlying causal factor. Someone experiencing alcohol-related problems was viewed as less worthy of sympathy than someone experiencing other health problems. It was felt that experiencing problems with alcohol would provoke shame, a reluctance to discuss problems with colleagues, especially managers, and an avoidance of any support or services within the workplace.

" I was just thinking for me personally… if I thought my drinking was a problem, the last thing I would want to do then is admit that within work, because then that becomes a double problem: I've got my drinking that's a problem outside of work, and it's impacting on my work and having to admit that. (Female, Focus group 5)"

Personal drinking was viewed as something group members choose to do, not something they need to do. The idea that drinking could have an adverse impact on their health was refuted. With the exception of messages around drinking and driving, no connection was made between personal behaviour and current public health messages or potential risks to health.

" Just speaking for myself, I am fully aware of all the information and fully aware of what I should be doing and what I shouldn’t be doing and how I should drink and when I should drink, but I am making a choice. I've seen all the education, I don’t think I drink excessively but if you put me on a scale according to the Government I am off the scale but, I feel fit, healthy.. (Male, Focus group 3)"

When discussions focused upon the more severe health and social order impact of alcohol use, negative language and the construction of stereotypes were used to dissociate this from personal ‘acceptable’ use. ‘ Young people’ and those for whom it was ‘too late’ were commonly identified as ‘those people’ for whom public health messages should be targeted.

" I know what you mean yeah drinking to excess - when you see these young teenagers on the streets can’t walk, sort of like collapsed in a heap cos they've drank that much. (Female, Focus group 5)"

Throughout the focus groups, socially acceptable norms were continually negotiated among participants. As such, these can be considered as some of the factors underlying the mechanisms controlling alcohol consumption. In some groups when comments or anecdotal incidents were recounted around alcohol use that fell outside the negotiated or anticipated ‘group norm’ this line of discussion ceased instantly and in some groups those participants raising these issues fell quiet for a period of time.

…the safe drinking limit 2–3 units a day for women, which I suppose is the government sensible recommended daily drinking allowance, however to me and you that's like a couple of glasses of wine, and for me yeah that's sensible but I would have another couple until I got like bladdered, do you know what I mean so, it's…

-I think it's a lot. I think it's a lot

-What's a lot?

-To say 2–3 units a day,

-It does sound a lot doesn’t it?

- I would be worried if I was having 2–3 units a day, every day, personally.

- That's just a glass of wine,

- And it's a unit, isn’t necessarily a big glass of wine, so it's a small wine

- I would be worried if I was having that every day anyway. (Interaction between two females, Focus group 1)

Where issues were discussed which were considered to fall outwith the socially defined acceptable norm, negative terms such as ‘shouldn’t’, ‘you just wouldn’t’, ‘that just doesn’t happen anymore’ and ‘isn’t it’ were used along with vocal emphasis to invite group consensus greatly influenced the direction of discussions. This created an environment where only the more confident individuals might have felt comfortable raising opposing views and was particularly apparent when talking about lunchtime drinking, drink driving and smelling of alcohol while at work.

Normalisation of alcohol use when perceived to be controlled and harm free

Home drinking was considered to be widespread, socially acceptable and convenient. Focus groups reported that they now drank less often within leisure premises. Low cost and easy availability of alcohol and avoidance of drink driving were highlighted as key factors underpinning this change; alcohol was cited as a standard item on supermarket shopping lists. Home responsibilities were also acknowledged as influencing how participants drank and many described completing household chores and family routines before eating a meal with wine or settling down, with a drink, to relax. Drinking was considered a socially acceptable form of relaxation and a marker of the transition from work or parental responsibilities, to ‘me time’.

" I drink one, because I've had a stressful day at work, two because I've had a stressful day at home. I have four children so what I do is children things and so then when I do get the kids off to bed sometimes it's nice to have a drink because it actually makes you feel like an adult again…. Like I say alcohol at home is cheap, [at] your supermarkets you can get a nice bottle of wine for £5 you go to a pub or restaurant and you’re paying £20 for it, so it's more accessible and it's easier and it's more comfortable in your own environment. (Male, Focus group 3)"

Alcohol use was considered part of everyday routine but something which does not interfere with other aspects of life. Alcohol consumption on nights during the working week was considered commonplace and acceptable provided that work and other responsibilities will be fulfilled the following day. Such drinking was interpreted as essentially harm free, despite discussions identifying consumption often greater than that currently recommended for responsible alcohol use. Drinking was also associated with social rituals, such as wine with meals or beer while watching sport.

" I think you probably drink more if you are at home simply because you haven’t got the chew of going up to the bar to buy another drink and losing your seat and all that goes with it. At home you just, I would presume, just sit with the bottle next to you . (Male, Focus Group 2)"

It was acknowledged that heavier drinking sessions took place; however these were associated with time off work. They were typically pre-planned, usually going out in groups of friends, often of the same gender, with the predetermined aim of drinking what were considered large quantities. Contingency plans for transport home, childcare and recovery time were also typically prearranged. The preplanning and infrequent nature of these sessions reinforced perceptions that personal alcohol use was controlled and acceptable.

Current drinking behaviours were not considered to have a negative impact upon short or long-term health. Alcohol use was moderated according to personal awareness and previous experience, with behaviour based upon how group members felt while drinking, how they anticipated they would feel the next day and commitments they would have to fulfil while potentially impaired. The amount of alcohol which constitutes ‘too much’ was evaluated in terms of a person’s size, metabolism and overall state of health. Alcohol intake was gauged according to perceived tolerance levels, rather than according to an absolute number of units of alcohol. Perceptions of excessive alcohol intake in particular, were based on past experience.

" I think you just know how you feel and you have to judge it like that because you couldn’t read every bottle in every bar in every pub so I think people tend to just go on how they feel. (Male, Focus Group 5)"

Where adverse effects were considered these were only discussed in terms of coping with a hangover and the inconvenience of lost time while unwell.

" I think more people care about what they look like on the outside than the inside so if you are not putting a lot of weight on I don’t think people care that much unless you start weeing blood or something . (Male, Focus group 3)"

The ability to function as an endorsement of acceptable alcohol use

The ability to function at work and act as a responsible adults were considered to be crucial indicators that drinking remains within acceptable levels. The implication was that, as the members of the focus groups were able to maintain employment in skilled roles, they were by definition drinking in a way that cannot be hazardous or harmful. One participant did however highlight the tendency for the ‘functioning alcoholic’ to be overlooked within society.

Within all focus groups ‘smelling of alcohol’ while at work was considered negative and stigmatising; an unprofessional way to present oneself which will lead to a loss of professional credibility. Lunchtime drinking was considered taboo, very much a thing of the past.

Although awareness of the recommended guidelines for responsible drinking exist, little notice was taken of them and there was much confusion as to what constitutes ‘a unit’ and how this equates in terms of drinks consumed. Guidelines were discredited and considered a form of ‘nanny stateism’ .

" Well it's been discredited anyway hasn’t it recently, because I mean the last thing I read about units etc. , is that this man had just decided all by himself what a unit was and that then became the recommended guidance. So really it wasn’t backed up by anything particular, it was just this bloke thought 'that sounds about right' and after that it was given out as recommended guidance. (Female, Focus Group 2)"

Across all focus groups, driving was identified as the greatest factor influencing drinking behaviour, being integral to professional and personal lives. Drinking and driving were consistently expressed as unacceptable and losing the ability to drive was seen as impacting upon social status and income, disrupting routine life and stigmatising self and family.

" The driving bit stops me because I hate to not have my car and that is the big thing with me so that stops me from drinking when I know I am out the next day in the car . (Male, Focus group 4)"

Many members of the focus groups had children and other family commitments and while alcohol use was identified as routine, responsibilities were prioritised. Alcohol use was typically negotiated with partners around responsibilities, or took place after commitments were fulfilled; again reinforcing perceptions that such alcohol use was controlled and acceptable.

People working in white collar occupations are under-represented within alcohol research. In this study we found that they considered their alcohol use to be positive and within personal control. A socially-constructed concept of acceptable use was widely agreed, this was both justified and reinforced by the construction of stereotypes of the deviant ‘other’ to describe less acceptable alcohol use. This supports existing evidence which suggests that alcohol use that conforms to socially-defined parameters is an established element of British culture [ 1 , 10 , 14 ].

A cultural shift was reported away from drinking alcohol in leisure premises and drinking at lunchtimes or directly after work to less public drinking within the home, a pattern identified by Foster et al. [ 11 ]. We found that while drinking was still associated with sociability, home drinking was described as more convenient and more affordable than going out, especially for those with family responsibilities. Importantly, however, home drinking is typically less regulated than drinking in licensed premises and while there was some awareness of recommended guidelines for alcohol consumption, there was widespread confusion as to how these translate into drinks consumed.

Despite discussions indicating that reported alcohol use exceeds recommended guidelines for both amount and frequency of consumption, there was no acknowledgement that personal alcohol use - almost invariably considered by participants to be moderate - can incur any harmful health or social consequences. Notions of moderate drinking are underpinned by normative explanations such as the presumed behaviour of others and ‘acceptability’ and ‘excess’ are judged by the ability to function and act responsibly. This supports recent work that concluded that the UK population has become habituated to high levels of alcohol consumption [ 14 ]. As people tend to overestimate and exaggerate the drinking of their peers [ 17 ], this is likely to have considerable health consequences and could present a significant challenge for public health and treatment services [ 11 , 15 ]. This issue is of particular concern as frequent heavy drinking has been found to have more significant consequences for health than episodic binge drinking [ 10 , 18 ].

In recent years, public health policies have largely focused upon young people and the social and criminal disorder associated with alcohol use [ 1 , 9 ]. Our study has found that these messages had some unintended consequences as focus groups readily identified alcohol problems as being the domain of young people and disordered drinking. Recent public health alcohol messages have therefore not only failed to resonate with white collar workers, they have actively reinforced their view that their own alcohol use was problem-free. The ‘problem drinker’, or the individual likely to experience health problems in later life, was not viewed as the stay-at-home evening wine drinker, able to drive when required, provide and care for their family and function effectively within the workplace. Therefore, with the exception of drink driving campaigns, recent public health alcohol messages have failed to impact on the behaviour of a large audience, with potentially significant financial and public health cost implications. Having a better understanding of how ‘acceptable’, ‘moderate’ and ‘problematic’ drinking are viewed among differing groups within the population can help focus the development of future public health alcohol interventions. This is of particular relevance in light of recent findings showing that increased alcohol consumption established in early and mid life are likely to be continued into later life [ 1 , 19 ].

Strengths and limitations

This is one of the first studies to investigate drinking patterns among white collar workers. The qualitative approach, using focus groups to collect data, allowed themes relating to views of alcohol use to emerge. This study helps reveal the meanings attached to alcohol use by white collar workers and identifies resistance to public health messages. The relative consistency of data across all focus groups indicates that their norms may reflect a wider cultural discourse independent of group variables such as the presence of ‘strong personalities’ in the group or the nature of the business of the workplace involved.

The context of focus groups - in the workplace, with colleagues - is likely to have impacted upon willingness to express views on alcohol and alcohol use that were felt to be counter to group expectations. Discussions within groups constitute public discourse and reactions and expectations shaped how conversations proceeded: where a contribution was anticipated as likely to be questioned or questionable, there was sometimes an attempt to reinforce the validity of statements by asserting an unprovable extreme – ‘everybody drinks’ or ‘the vast majority’, usually with some emphasis. This is likely to have influenced subsequent contributions by others [ 20 ] although social norms will have predominated, which was the central aim of this study.

Implications for practice and future research

The shift to home drinking reported in this study has ramifications for the future development of public health alcohol interventions particularly as focus group members consider themselves to be moderate drinkers. This study has shown that convenience and affordability are factors underpinning the shift to home drinking - where consumption is largely unregulated. Current proposals to address alcohol use in the UK at a population level by curbing the availability of cheap alcohol include minimum unit pricing and the ‘Responsibility Deal’ with the alcohol industry [ 4 ]. As with most products, price, availability and available income do influence purchasing behaviour [ 14 ], however little is known about whether the UK population will support moves to increase alcohol prices and it is possible that people will absorb increased costs in order to maintain levels of alcohol consumption by sacrificing other expenditure. While there is a growing body of evidence to support these approaches [ 21 , 22 ], such policies may widen public health inequalities and, if cheaper and stronger forms of alcohol or other intoxicating substances are chosen instead, exacerbate existing drug and alcohol problems.

The latest UK Government’s Alcohol Strategy [ 4 ] proposes a review of the guidelines for responsible drinking. Our study has shown that while there was awareness among white collar workers of current guidelines, they found them confusing and not readily translatable into the drinks they consume. As well as reviewing the guidance it would be prudent to also examine how messages are communicated to different segments of the population.

This study found driving to be a key factor underpinning reported alcohol behaviour. Focus groups considered current public health messages relating to the responsible use of alcohol to have little or no relevance to them with the exception of campaigns against drinking and driving. Emslie et al. [ 1 ] similarly found that driving was a key reason (whether valid or not) offered by respondents to resist friendly pressure to drink. The failure of existing public health messages to engage this group indicates that a different approach should be considered. The latest UK Government’s Alcohol Strategy [ 4 ] outlines a commitment to increase the scope and funding for ‘Drinkaware’ to best direct interventions to specific target groups within the population. Our research has shown that a campaign interweaving health messages with those around drink driving would potentially resonate with this group for whom other campaigns have failed to impact.

Further research is needed to identify what other factors would engage white collar workers to consider changing their views and drinking behaviours. All but one of the focus groups comprised male and female participants so what emerged were norms negotiated across genders – people tended not to seem as if they were excluding anyone present from the in-group. Nonetheless, gender specific focus groups with this population might be another avenue for future research, particularly given recent research which has observed gender-related socioeconomic patterning in alcohol consumption [ 23 ].

The results of this study provide insight into white collar workers’ views of alcohol use. For our focus groups, the problem drinker was constructed around visibility and an inability to function, making excessive drinking the province of the ‘other’, something which was far removed from their own behaviour or that of their peers. These findings suggest that current public health interventions have not been effective in engaging this group who are likely to drink at unhealthy levels but be highly resistant to reducing their alcohol consumption - especially as they do not consider their use to be problematic unless it impairs their capacity to fulfil responsibilities or function at work. Future public health messages around alcohol should be less focussed upon the crime and personal safety implications of irresponsible drinking and be more sensitive to the lifestyles and long-term health of the populations they target.

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Acknowledgements

This work was supported by Public Health NHS Directorate Stockton-on-Tees. It was an independent piece of work and does not necessarily reflect the views of the funder. We would like to thank the participants who gave their time and shared their views with us and Scott Lloyd of Public Health Directorate NHS Stockton-on-Tees and the participating workplaces for their help with this study.

Jonathan Ling and Catherine Haighton are funded as staff members of Fuse, the Centre for Translational Research in Public Health, a UKCRC Public Health Research Centre of Excellence. Funding for Fuse from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged.

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Jonathan Ling, Karen E Smith, Lyn Brierley-Jones & Ann Crosland

Institute of Health & Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK

Graeme B Wilson, Eileen FS Kaner & Catherine A Haighton

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JL conceived the study and participated in its design and coordination and drafted the manuscript. KS & GBW carried out data collection and drafted the manuscript. AC, EK & LBJ helped to draft the manuscript. CH conceived the study and participated in its design and coordination. All authors read and approved the final manuscript.

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Ling, J., Smith, K.E., Wilson, G.B. et al. The ‘other’ in patterns of drinking: A qualitative study of attitudes towards alcohol use among professional, managerial and clerical workers. BMC Public Health 12 , 892 (2012). https://doi.org/10.1186/1471-2458-12-892

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Article Contents

Introduction, supplementary data.

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A scoping review of qualitative research on perceptions of one’s own alcohol use

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Stephanie Morris, Duncan Stewart, Mary Madden, Jim McCambridge, A scoping review of qualitative research on perceptions of one’s own alcohol use, European Journal of Public Health , Volume 31, Issue 2, April 2021, Pages 432–436, https://doi.org/10.1093/eurpub/ckaa211

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This scoping review aims to map the extent, range and nature of qualitative research on people’s ‘perceptions’ of their own alcohol consumption.

A systematic search of five electronic databases was conducted. A total of 915 abstracts were screened and 452 full texts examined, of which 313 papers met the inclusion criteria (including a report of qualitative data on perceptions, experiences or views of people’s own drinking in peer-reviewed journals published in English).

This study maps the available literature assembled over approximately 30 years, which was found to be extensive and diverse. Many existing studies are focused largely on people’s ‘experiences’ of their own drinking behaviours, particularly when they were drinking in ways commonly understood as heavy, risky or problematic. Fewer studies focused on populations whose drinking was not heavy or was risky in less obvious ways, such as older adults prescribed medications for chronic health conditions. Most studies were conducted since 2010, with the rate of publications increasing since 2014.

This review identifies gaps in the evidence regarding people’s perceptions of their own drinking and opportunities for qualitative studies to make valuable contributions to alcohol research. Gaps discussed include patterns of drinking that are less obviously problematic, and in relation to consumption of alcohol in those parts of the world where overall consumption and harms from alcohol are high. Such studies could usefully be informed by existing studies in the evidence mapping.

This scoping review maps the extent, range and nature of qualitative research on people’s perceptions of their own alcohol consumption.

This study identifies significant gaps in the available qualitative literature

This review provides directions for how future qualitative research can make valuable contributions to the alcohol literature

The existent literature is extensive and diverse, but most commonly explores risky or problematic drinking

More research on how people make sense of, and reflect on, their own drinking would be valuable.

In many, but not all, countries alcohol is deeply embedded in cultures and within many but not all, people’s lives within these countries, and this has been the case for many centuries. Alcohol is used in a variety of settings, in relation to other practices such as leisure, food, and celebrations, and is commonly associated with relaxation and pleasure. 1 Despite its affordances within social life, alcohol is now known to be a harmful and addictive psychoactive drug. 2 Although legal in many countries, it is known to be a cause of over 200 diseases, injuries and related conditions, including multiple cancers, and drinking even at low levels can be harmful to health. 3 Globally, alcohol is also implicated directly and indirectly in a number of social harms, including on work and family life and in sexual and violent offenses. 4

Studies using qualitative approaches offer a means to understand how people perceive their own alcohol use, including how people consider the advantages and disadvantages of drinking, and how they negotiate the risks to their own and others’ health and safety. This may be useful in many ways, including for designing health messages around alcohol and other interventions. A recent systematic review of qualitative studies on constructions of drinking practices by non-problematized middle-aged drinkers highlighted that health was not a significant concern in their perceptions of their own drinking, though only 13 studies were included. 5 Similarly, a systematic review of qualitative studies regarding older people’s drinking included 14 studies and found that drinking was intertwined with social engagements and there was scepticism about the risks that alcohol posed. 6 The extent to which the existing qualitative literature has investigated broader perceptions of one’s own drinking in other populations is unknown. Existing reviews have synthesized a small number of studies but have not mapped the broader literature across populations.

This scoping review 7 aims to map the extent, range and nature of qualitative research on people’s perceptions, experiences and views of their own alcohol consumption. We thus seek to establish what research exists on how people perceive their own drinking behaviours, and to provide an overview characterizing its content. We did not in any way seek to restrict the disciplinary basis or content of included studies. It was expected that this study could be useful in highlighting gaps where future research could make valuable contributions, creating the basis for future systematic reviews, and for researchers considering undertaking qualitative studies in other ways.

This study drew on Arksey and O’Malley’s account of a scoping review, 7 in which systematic data collection methods were used for rigour, replicability and reliability. We used the PRISMA guidance on reporting of scoping reviews. 8 We did not publish or register our study protocol.

Search strategy

We searched five electronic databases: Medline, Psych INFO, Web of Science Core Collection, Scopus and CINHAL. The search strategy was developed with the aid of an information specialist in a series of iterations, and search terms were tested against qualitative filters. 9 The final searches were conducted on 12 April 2019. The search strategy used for PsychINFO was the following: ((qualitative or ethnograph*) and ((their or own or personal* or experience* or feeling* or attitud* or perspective* or perce* or thought* or view* or opinion* or narrat* or account* or belief* or understand*) adj3 (alcohol or drinking))).ti, ab. and (drink* or alcohol or wine or beer or spirit or whiskey or vodka or gin).m_titl. The search strategy used for PsychINFO was adapted for other databases. The search was limited to peer-reviewed journal articles from 1900 (or the earliest date possible) onwards in English. One author (SM) conducted forward and backward citation searches to locate additional candidates for inclusion.

Selection criteria

We sought studies that aimed to explore people’s perceptions of their own drinking, not attitudes and beliefs about drinking in general or the drinking of others. We used the umbrella term ‘perceptions’ to include any thoughts, views or experiences of one’s own drinking. Inclusion criteria required that the record included an abstract and that qualitative data or qualitative methods be identified in that abstract. Records were also excluded if they were not published in English or were not in peer-reviewed journals. No quality criteria or alcohol consumption details were included in the selection criteria.

Study selection

The lead author (S.M.) screened titles and abstracts, which were retained for full text screening if inclusion criteria were met or if it was not possible to determine this from the abstract text. To screen the full texts, SM read the introduction, methods and first paragraph of the results using the selection criteria described above. A total number of 915 abstracts were screened and 452 full texts examined. Other reviewers (D.S. and M.M.) were involved in double screening 75 full texts and came to a consensus on the small number of records where initial assessments differed. We concluded there was no need for further duplication of screening.

Data charting

Relevant information from the included studies was extracted using a structured form in Microsoft Excel, initially piloted by 2 reviewers on a sub-sample of 10 studies. It included data categories for mapping the extent and range of studies on perceptions of alcohol use including, journal discipline, sex, age, and size of sample, types of drinkers, study location, data collection method and whether the paper reported solely the qualitative study. See Supplementary appendix S1 for further details of the study characteristics extracted and how they were defined. The bibliographic details of all included studies are presented in Supplementary appendix S2 , and the basis of categorization of journals in Supplementary appendix S3 .

Text was directly extracted on study aims and results text from abstracts (see Supplementary appendices S4 and S5 for all data). Study topic categories were inductively developed from the titles and aims text of each study. Categories were clustered and renamed where appropriate. Each publication was mapped to between one and four topic categories. Publications were categorized as having either a ‘primary aim’ relating to perceptions of one’s own drinking, or a ‘secondary aim’ where such material was identified as relevant to the primary aims of the study. SM charted the data from all included records, with MM duplicating a random sample of 37 studies. There was 89% agreement on study aims categorization, and 100% agreement on all other data. Discussion resolved the discrepancies on aims, and we concluded no further duplication of data collection was necessary.

Data are presented primarily in tables and figures with access to underlying text on aims content and abstract results as described above. We compared the scope of the content in studies primarily aimed at perceptions of one’s own alcohol use with those where this was a secondary aim. In light of observed publication trends, we examined whether older publications (pre-2014) were different from more recent ones (2014-onwards).

The extent, range and nature of available studies

A summary of the selection of sources, including the reasons for exclusion at full text screening, is shown in the PRISMA flow diagram in figure 1 . The included publications spanned from 1989 to 2019. A total of 173 (55%) studies concerned people’s perceptions of their own alcohol use as their primary aim, according to our categorization (see Supplementary appendix S4 for the underlying aims content and contextual information). The other 140 (45%) concerned people’s perceptions of own alcohol use as a secondary, or as part of a wider study, aim. Most (87%) of the papers reported solely a qualitative study, and 13% reported on a mixed methods study, which mostly included results from randomized controlled trials and/or quantitative questionnaires.

Prisma 2009 flow diagram

Various characteristics of the included literature are summarized in the figures and tables. Table 1 presents study characteristics across the literature as a whole, both overall, and before and after 2014 when the numbers of studies published increased. Table 1 shows that few studies were conducted with older adults. Two-thirds of studies were of mixed sex participants, but more studies were conducted with women only than men only. The most commonly studied subgroups of drinkers were heavy drinkers and students. From 2014 onwards, fewer studies were conducted with young people and sample sizes tended to decrease. The majority (65%) of studies used semi-structured interviews to explore people’s experiences of their own drinking, usually in isolation, but sometimes combined with focus groups ( table 2 ). There were no longitudinal studies and few that explored retrospective perceptions of drinking over the life course. Table 2 shows that the studies were mainly conducted in English speaking countries. Table 2 also shows the publication years and journal disciplines across the studies. There is a wealth of literature regarding young people but little of this is published in youth studies journals.

Distribution of characteristics across studies

Distribution of when and where studies were published and conducted, and what methods they used

Food, Culture and Society; Social Media and Society; Emotion Space and Society, Social Science and Medicine; Health, Risk and Society; International Journal of Law Crime and Justice; Journal of Sex Research; Sex Roles; Journal of International Women's Studies.

PLOS One; Journal of Mixed Methods Research; Appetite.

Includes friendship group discussions and group interviews.

Comprises case studies, think aloud interviews, photo-elicitation interviews, open-ended questionnaires, mixed participatory methods and Photovoice.

For example, focus groups and written narratives; semi-structured interviews, focus groups and photo-elicitation.

Some studies were conducted in two or more locations.

The specific population focus and topics explored in studies where people’s experiences or perceptions of their own alcohol use were the primary aim are detailed in table 3 . The people and topics covered in other included studies ( n  = 140) did not differ greatly to the studies summarized in table 3 , and therefore are presented in Supplementary appendix S6 . As can be seen from table 3 , specific populations and topics studied were diverse and tended to focus on people and types of drinking which were in some way problematic or risky (e.g. pregnant women or mothers, adolescents, and dependent or previously dependent people). Clustering the topics together may be undertaken in various ways to summarize aspects of what is being studied. For example, experiences and perspectives from different professions (e.g. veterans, GPs), various groups who may be particularly vulnerable (e.g. refugees, people with severe mental illness, individuals experiencing homelessness), different stages of the life course (e.g. mid-life, adolescent) and in social contexts (e.g. life stressors, family influences), as well as particular health issues and risks (e.g. pregnancy, severe mental illness, HIV risk)

Populations and topics in studies exploring people’s experiences or perceptions of their own alcohol use as their primary aim

The results text in the abstracts provides a crude but nevertheless parsimonious summary of the nature of study findings (see Supplementary appendix S5 ). This text identifies a range of influences on perceptions of own drinking, including for example, norms and stigma. Results are derived mainly from descriptive thematic analyses. Other analytic approaches have been used much less commonly. Results data specific to perceptions of one’s own drinking require interpretation in relation to, and extrication from, reported study findings on alcohol consumption more generally. There is much description of drinking patterns and experiences relating to them, or their circumstances or putative determinants, as well as of reasons for use, with findings often shaped in distinct disciplinary terms. Studies seek to locate the perceptions under study here in relation to peer, familial, contextual or cultural influences and cover identity and relationships, in various ways and to various extents. As a result, there is extensive research available on a wide range of subjects relating to perceptions of one’s own drinking, providing an important foundation for future studies.

We included 313 publications of which the majority report on a qualitative study alone. We found that most publications report studies that used semi-structured interviews, many of which had medium sample sizes, suggesting breadth rather than depth of analysis. Most studies have been published since 2010, with many publications focusing on the subgroups of young people and heavy drinkers.

We undertook a scoping review rather than a systematic review because the study aimed to map the literature rather than to undertake a rigorous synthesis of findings. The large number of included studies would make the latter a highly complex endeavour. It should, however, be noted there are some important limitations of the scoping review methodology used. Our search strategy used specific terms such as ‘qualitative’ or ‘ethnography/ethnographic’ in the title or abstract, and did not use terms that would specifically locate studies regarding dependence. The findings indicate that we did not capture older publications (pre -1989) in our search. This may be due to changes in reporting requirements for journal abstracts, which have tended to require more methodological detail over time. This probably also reflects the tradition of publishing qualitative social science and humanities research in books and monographs, 10 as well as the distinct increase in publication outputs in recent decades. 11 We developed the search strategy in an iterative process, tested the search terms with an information specialist and against qualitative filters, 9 and found the most relevant papers were included. Scoping reviews typically do not involve any quality appraisal of the studies or analysis of included study findings. The approach we used required only examination of the abstracts, stated aims and methods, and first paragraph of the results sections to ascertain inclusion. We then investigated the relevance of the study in relation to our research aims, and summarized the topic areas studied, making brief comments on included study findings. Study inclusion may be affected by different disciplinary reporting conventions and the poor reporting of methods and empirical results in some abstracts or full texts. Moreover, the aims of qualitative studies can be broad and the findings presented in the papers may consist of unanticipated themes, which our approach would have missed.

The spread of the international qualitative literature reviewed shows that the South American nations and Central/Southern European nations, which have high alcohol consumption levels 3 are underrepresented, representing a gap in the English language literature.

The apparent increase in the number of studies on perceptions of one’s own alcohol use published over time (1989–2019) probably reflects broader trends in publication of all types of research, rather than an upsurge in the extent of qualitative research in particular. Nonetheless, proportionally there is less of a focus on young people and fewer larger studies in more recent years. Smaller studies may be indicative of less breadth and more depth, which may reflect well on the development of the literature over time. We note that many studies, however, remain focused largely on describing people’s experiences of their own drinking behaviours rather than investigating perceptions more deeply.

Many studies were conducted with people who may be more vulnerable to hazardous or harmful drinking, including adolescents, veterans, refugees, gang members and young offenders. It probably remains the case that researchers tend to be funded to investigate the risks or harms of alcohol, whether directly or indirectly, to the same extent as previously. In this respect, the findings of the current study are supported by Muhlack and colleagues whose qualitative systematic review of non-problematized middle-aged drinkers included only 13 studies. 5 Drinking, which is not regarded as obviously risky or problematic, may be an area where further research is needed. The same may be true of the underlying dynamics of problem perceptions.

Interestingly, though men drink at higher levels across the globe, 3 more of the studies included in this review, which specify a particular sex, were conducted with women. This may partially reflect the closing male–female gap in alcohol consumption. 12 The focus on the potential harms of mothers’ drinking and/or drinking during pregnancy seems also a likely explanation, and the absence of any studies on perceptions of own drinking by fathers (though there was data on masculinity) is noteworthy in comparison.

The studies were conducted with diverse participants and covered varying topics concerning people’s health, yet studies with people with chronic alcohol-related health conditions were limited, in contrast to infectious diseases (e.g. HIV), which were often associated with risky sexual behaviours or intravenous drug use. We found few studies of older adults’ experiences of alcohol use in later life. This dearth of research is notable because in countries such as the UK older people (aged 55–64) are now the most likely age group to be drinking at hazardous levels. They are also more likely to be taking multiple prescription medications for chronic health conditions, 13 for which alcohol poses additional risks to health and the effectiveness of their medicines. 14 Since our systematic search was conducted, another study has been published that describes how older drinkers who take multiple medications conceptualize their risks from alcohol use. 15 It may be expected that further studies will continue to be added to the literature at a rate similar to, or faster than, has been seen in recent years.

This scoping review maps the research reported from 30 years of published qualitative studies that aimed to explore people’s perceptions of their own drinking. We found the literature to be extensive and diverse, and the topics of study that were most commonly explored were to do with risky or problematic drinking. For the first time, this study identifies significant gaps in the available qualitative literature based on an overview of what has already been done, with clear directions for how future qualitative research can make valuable contributions to the alcohol literature. More research on how people make sense of, and reflect on, their own drinking would be valuable for informing development of diverse population level alcohol interventions. In particular, we draw attention to the need to further study; (i) perceptions of own alcohol consumption among older adults that seem less obviously problematic, including both those with and without chronic health problems and (ii) perceptions of people’s own drinking in non-English speaking countries, particularly where consumption or harms to health are known to be high.

Supplementary data are available at EURPUB online.

This study is funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research [RP-PG-0216-20002]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Conflicts of interest: None declared.

Meier PS , Warde A , Holmes J. All drinking is not equal: how a social practice theory lens could enhance public health research on alcohol and other health behaviours . Addiction 2018 ; 113 : 206 – 13 .

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Qualitative epidemiologic methods can improve local prevention programming among adolescents

• Population and Public Health Sciences

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• Geriatrics and Gerontology

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T1 - Qualitative epidemiologic methods can improve local prevention programming among adolescents

AU - Daniulaityte, Raminta

AU - Siegal, Harvey A.

AU - Carlson, Robert G.

AU - Kenne, Deric R.

AU - Starr, Sanford

AU - De Camp, Brad

PY - 2004/9

Y1 - 2004/9

UR - http://www.scopus.com/inward/record.url?scp=13244249747&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=13244249747&partnerID=8YFLogxK

M3 - Article

AN - SCOPUS:13244249747

SN - 0090-1482

JO - Journal of Alcohol and Drug Education

JF - Journal of Alcohol and Drug Education

Health burden of alcohol highlighted in report

20 August 2024

The harm alcohol consumption can cause to health has been laid bare in new University of Otago, Wellington-led research.

It found 901 deaths, 1250 cancers, 29,282 hospitalisations, and 128,963 ACC claims were attributable to alcohol in 2018.

Of the deaths, 42 per cent were from cancer, 33 per cent from injuries, and 25 per cent from conditions such as liver cirrhosis, pancreatitis and epilepsy. Males accounted for the vast majority of health harms, and the rate of alcohol-attributable mortality was twice as high for Māori.

These health conditions impact even lower-level drinkers, with two standard drinks per week increasing the risk of developing several types of cancer including breast and colon cancer.

The assessment of the burden of ill health caused by alcohol consumption – Estimated alcohol-attributable health burden in Aotearoa New Zealand (2024) – is published today by Health New Zealand | Te Whatu Ora.

Focusing on individuals aged 15 and over, the study includes 26 different diseases and conditions related to drinking and was conducted in collaboration with the University of Victoria’s Canadian Institute for Substance Use Research. It is the first time such analysis has been done since 2013, which was based on data from 2007.

Co-author Dr Anja Mizdrak, of Otago’s Department of Public Health, says the report highlights the substantial preventable health burden alcohol causes.

“The findings aren’t surprising – previous research, both here and overseas, has consistently shown alcohol contributes significantly to disease burden. This research shows that alcohol continues to have a big negative impact on health in New Zealand and contributes to inequities,” she says.

She also notes the results are underestimates.

“They don’t capture the true burden of alcohol harms as they only consider harms to the drinker. For example, we don't capture harms to those injured by drink driving who weren't under the influence of alcohol or the knock-on impacts from the extra pressure on the health system.”

While the report covers the data from 2018, Dr Mizdrak stresses the results would be similar today.

“Alcohol has a detrimental effect on health and contributes to injuries and multiple cancers – including some of the most common cancers like breast and bowel cancers.

“Even moderate levels of alcohol consumption are harmful – more than two standard drinks per week will increase your risk of developing cancer, and each additional standard drink radically increases the risk of alcohol-related consequences,” she says.

The report outlines several policy avenues for reducing the alcohol-attributable health burden, including placing restrictions on alcohol marketing and availability; increasing excise tax; and implementing a national screening and brief intervention programme.

“There is a lot we can do to reduce the harm that alcohol does in our communities. The large social and economic impacts on individuals and the government, and the pressure that alcohol places on our already stretched health system should give us reason to act.”

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A Qualitative Study of Service Provision for Alcohol Related Health Issues in Mid to Later Life

Catherine haighton.

1 Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom

Graeme Wilson

Jonathan ling.

2 Department of Pharmacy, Health and Well-being, Sunderland University, Sunderland, United Kingdom

Karen McCabe

Ann crosland, eileen kaner.

Conceived and designed the experiments: CH JL AC EK. Performed the experiments: GW KM. Analyzed the data: GW KM. Wrote the paper: CH GW JL KM AC EK.

Associated Data

Participants provided written informed consent to participate in this study. In line with the terms of consent to which participants agreed, the data are not publicly available.

Epidemiological surveys over the last 20 years show a steady increase in the amount of alcohol consumed by older age groups. Physiological changes and an increased likelihood of health problems and medication use make older people more likely than younger age groups to suffer negative consequences of alcohol consumption, often at lower levels. However, health services targeting excessive drinking tend to be aimed at younger age groups. The aim of this study was to gain an in-depth understanding of experiences of, and attitudes towards, support for alcohol related health issues in people aged 50 and over.

Qualitative interviews (n = 24, 12 male/12 female, ages 51–90 years) and focus groups (n = 27, 6 male/21 female, ages 50–95 years) were carried out with a purposive sample of participants who consumed alcohol or had been dependent.

Participants’ alcohol misuse was often covert, isolated and carefully regulated. Participants tended to look first to their General Practitioner for help with alcohol. Detoxification courses had been found effective for dependent participants but only in the short term; rehabilitation facilities were appreciated but seen as difficult to access. Activities, informal groups and drop-in centres were endorsed. It was seen as difficult to secure treatment for alcohol and mental health problems together. Barriers to seeking help included functioning at a high level, concern about losing positive aspects of drinking, perceived stigma, service orientation to younger people, and fatalistic attitudes to help-seeking. Facilitators included concern about risk of fatal illness or pressure from significant people.

Primary care professionals need training on improving the detection and treatment of alcohol problems among older people. There is also a compelling need to ensure that aftercare is in place to prevent relapse. Strong preferences were expressed for support to be provided by those who had experienced alcohol problems themselves.

Introduction

Population ageing is taking place in nearly all the countries of the world and this is expected to continue over the coming years [ 1 ]. Alcohol problems can accumulate in mid to later life and are associated with social, psychological, physical and economic consequences[ 2 ]. Alcohol is a risk factor for coronary heart disease, stroke, high blood pressure, cancers, pancreatitis and liver cirrhosis[ 3 ]. However as people age, physiological changes mean that that older people are more sensitive to the effects of alcohol, and experience problems at lower levels of consumption[ 4 ][ 5 ] Because the average person aged 50 or above can be taking at least four prescribed medications a day[ 6 ] and alcohol is a major contraindication for many of these drugs, alcohol and medication interactions are common[ 7 ]. Combined alcohol and medication use is estimated to affect up to 19% of older Americans[ 8 ] while drinking alcohol for medicinal purposes is also prevalent[ 9 ][ 10 ].

Alcohol consumption has been associated with impairments in the instrumental activities of daily living[ 11 ] and can contribute to the onset of dementia and other age-related cognitive deficits[ 12 ], Parkinson’s disease and a range of psychological problems including depression and anxiety[ 13 ] Alcohol use is implicated in one-third of all suicides in the older population[ 14 ]. One in five older men and one in ten older women are drinking at harmful levels and these figures have increased by 40% and 100% respectively over the past 20 years[ 15 ]. However in mid to later life, alcohol problems are often misdiagnosed, under-detected and under-reported[ 16 ][ 17 ]. The ageing of populations worldwide means that the absolute number of older people with alcohol problems is increasing and a real danger exists that a “silent epidemic” may be evolving[ 16 ].

Recent research has suggested that age-specific practices required to meet the needs of older people, in relation to alcohol consumption, and draw them into treatment are poorly understood[ 18 ]. However research on alcohol consumption in older adults is still relatively scarce, there are notably few quantitative studies and no qualitative studies investigating support for alcohol related health issues in older people[ 9 ][ 10 ][ 19 – 21 ]. Therefore this research contributes to the limited body of in-depth qualitative evidence regarding the issues surrounding alcohol consumption in mid to later life. This paper is novel in aiming to gain an in-depth understanding of experiences of, and attitudes towards, support for alcohol related health issues in mid to later life. This has allowed recommendations to be made for future service provision tailored to this age group.

Mid to later life has been defined as individuals aged 50 and over to reflect the eligibility criteria of the UKs leading charity for older people. The study[ 22 ] was based in an urban area in North East England, a region with an older population and high rates of heavy drinking.

The study involved qualitative interviews and focus groups with a purposive sample of middle aged and older people. Ethical approval was issued by Newcastle University Research Ethics Committee (application no. 000224/2009). Participants provided written informed consent to participate in this study. In line with the terms of consent to which participants agreed, the data are not publicly available and are not available to be shared outside the project team.

Twenty-four in-depth interviews (12 male, 12 female) were conducted between 19/11/09 and 15/03/10. Purposive sampling (a non-random method of ensuring that particular categories of cases within a sampling universe are represented in the final sample)[ 23 ] aimed to recruit both genders and represent a broad range of ages and self-reported drinking practices and was intended to reflect those who might request help or support from the UKs leading charity for older people. Three branches of a national charity aiming to improve later life (Age UK) and two services for alcohol problems covering a wide geographical area distributed research information leaflets to clients aged 50 and over with experience of drinking alcohol. Staff members from the recruiting organisations invited clients to consider participating in an interview, answered any questions they had about the research and asked those who were interested to complete a consent form. All potential participants were contacted by telephone by one of the authors (GW) to arrange an interview. As the initial sample appeared to consist of a large proportion of participants who described themselves as recovering dependent drinkers, strategic ‘snowballing’ was used to add further interviewees. This involved existing study subjects recruiting future subjects, who were not using services and therefore not recovering dependent drinkers, from among their acquaintances. Considerable diversity was ultimately achieved (see Table 1 ).

a Recovering dependent drinker defined as meeting the diagnostic criteria for full remission of alcohol dependence[ 24 ]

b Currently consuming alcohol

c Sensible drinker defined as drinking within the governments recommended limits for sensible alcohol consumption at the time of interview (men no more than three to four units of alcohol per day/women no more than two to three units of alcohol per day)[ 25 ]

d Dependent drinker defined as psychiatric diagnosis in which an individual is physically or psychologically dependent upon drinking alcohol[ 26 ]

To compare individual accounts with socially negotiated versions of drinking in mid to later life, three focus groups were facilitated between 15/03/10 and 19/10/10. Staff at the three branches of Age UK distributed research information leaflets to members with experience of drinking alcohol and invited them to consider participating in a focus group, answered any questions they had about the research and asked those who were interested to complete a consent form. The first group comprised 9 participants (1 male, 8 female, ages 79–95); the second group comprised 12 participants (5 male, 7 female, ages 50–85) and the third comprised 6 participants (all female, ages 51–76). To encourage participation, focus group participants were not required to disclose personal details other than age and date of birth; these data were gathered on consent forms. At the groups, participants were invited by the facilitator (GW) to offer views in general rather than recounting personal experience in front of others.

Interviews and focus groups were conducted by GW, an experienced post-doctoral researcher, and lasted between 40 and 150 minutes either at individual respondent’s homes or the offices of participating organisations. The research team prepared topic guides (available on request) to initiate or return discussion to the research topics. Interview and focus group data were audio recorded, transcribed verbatim, anonymised and loaded into NVivo qualitative software, version 10[ 27 ]. Data were analysed using a grounded approach to identify axial codes [ 28 – 29 ] and involved repeatedly reading transcripts and identifying emerging codes; early analysis informed later interviews and focus groups. Codes were refined through discussion amongst the authors with consideration of deviant cases in order to provide a full account of participants’ views. Focus group data were used to triangulate findings from individual interviews. In the results section below we report findings from individual interviews, then consider how the focus group data inform or challenge these codes. This paper is not exhaustive in its presentation of the analysis rather it focuses on specific codes with each subheading representing a distinct code emerging from the data relating to service provision and use.

Drinking in mid to later life

Nine of 15 participants still drinking alcohol described themselves as currently drinking sensibly, having reduced their alcohol consumption from previously higher levels. However some individuals had not reduced their drinking. The heaviest drinker reported consuming nine pints and a bottle of wine most days. Most women who reported drinking little nevertheless felt they had increased their consumption as they entered mid to later life.

Going out to drink was a feature of the accounts of younger interviewees (50–69 years), with special occasions associated with heavier drinking:

I’ve had the nights out with the girls, where we’ve got all of our troubles over in the last half hour and then concentrated on having a few good drinks and all that. I’ve had that, done that, been there, thoroughly enjoyed it, liked the feeling that it gave me. (22; female, 59yrs)

Choice of where to drink was limited for interviewees aged 70+ by their mobility or other circumstances, for instance if in a care home. Two of the older interviewees described being influenced to drink more by people living close to them. One older woman found she started to drink more when she became less mobile and received frequent visits at home from a neighbour who drank heavily.

Interviewees who reported dependence described their drinking in mid to later life as increasingly taking place alone and at home. For female dependent drinkers this was a consequence of being at home much of the time; male dependent drinkers associated starting to drink at home with a shift to using alcohol as a coping strategy, or finding that drinking with other people inhibited their drinking. However, some dependent drinkers of both sexes valued social drinking as being less boring than drinking in the house alone. Some problem drinkers described drinking as a continuous process through the day, saving something at the end of an evening for an ‘eye-opener’ the next morning:

I’ll come down on a morning after I’ve taken a bath upstairs. I hardly ever touch the drink upstairs, I’ll bring it down. I take my tablets with the whisky…and then I might have some breakfast. (8, male, 74yrs)

Since drinking had become a solitary activity for some, getting out of the house could be seen as an important measure in reducing or avoiding consumption. One woman who no longer allowed drink in her house explained:

I used to go out to begin with, that was when I started drinking, and then I started staying in. That was when I started on the vodka because I thought well I’m in the house, if I get drunk nobody can see me. I can get as drunk as I want. I can make as big a fool of myself as I want. I’ve only got to get upstairs to bed, I haven’t got to walk up any banks or owt [anything] like that, and it just went downhill. (16; female, 52yrs)

In contrast to the individual interviews which were personalized, focus group participants tended to present themselves as responsible drinkers but described ‘other’ middle aged or older people they knew or knew of whose drinking was excessive or dependent.

M: I knew a bloke who used to go in the [name] club, and he was, when he used to go in he’d say “I stand here, seven nights a week”, thinking he’s clever. Do you know where he is now? He’s got a leg off [amputated], aye he’s in a home, and he doesn’t know anybody, and it’s all down to drink. (Focus group 2)

Some participants in particular described quite strict drinking habits or routines, for instance meeting particular groups of friends in pubs or clubs on specific nights, to help minimize the chance of heavy drinking. Those still working or volunteering during the week described drinking only on weekend nights when they would not be working the next day, or spoke of ‘waiting till the sun passes the yardarm’ :

F: If it was after six in the evening I'd probably offer a drink before I would offer a tea or a coffee. (Focus group 3)

Routines included a drink out with a meal at lunchtime in the afternoon or merely a ‘ nightcap ’. For some participants, special occasions were the only times they reported having a drink. There were also suggestions that when away from home or on holiday, participants might drink greater amounts or more frequently:

F1: It's relaxing, a glass of wine, it's what you do abroad isn't it?

GW: Is it? Do things change once you're on holiday?

F3: Oh yes. Totally different on holiday.

F2: Oh I think everybody changes when they're on holiday.

F4: I drink more on holiday, well I do, I drink a lot when I go on holiday. (Focus group 3)

Deciding to change

Interviewees described consumption in pints, bottles, or cans rather than units and while some were aware of the UK government’s recommended guidelines they tended to be skeptical regarding their helpfulness. It was frequently argued that guidelines would not be relevant to everyone because they did not take account of individual differences in tolerance:

I mean nobody goes out for a drink and says ‘I wonder how many units is in this? I better not drink that’ you know–nobody’s going to say that. (11; female, 55yrs)

Interviewees described themselves as aware of health campaigns targeting drinking, indeed some complained of their ubiquity. For some, public health messages were perceived as class-based ‘preaching’:

I think the random, the average adult doesn’t drink too much in this country, but I don’t know, because I’ve got no figures and I think figures are done, are; they are created, put together by middle class people who haven’t worked at the coal mine or had a fishing boat or in the shipyards and they don’t see the socialisation, the outcomes of it, they only see the bad side of it. (21; male, 56yrs)

It was acknowledged that pressure from family or friends could build the impetus to change drinking behaviour. Older interviewees living in sheltered accommodation described censure from family members if they were thought to have been drinking too much, even though these relatives gave them bottles of alcohol as presents. Interviewees younger than 60 described realising that reducing their drinking might alleviate conflict in their family; for instance having received ultimatums from partners and children:

Then one night he took the kids away from me and I pulled myself together overnight. I just got up one morning and said ‘enough’s enough–I want my kids back’ because my kids were my life. (2; female, 59yrs)

Some younger interviewees had sought help when their partner pointed out the impact of their drinking on the family. One interviewee described his carer as ‘bossy’, but was going to attend counselling because she had persisted in suggesting he do so. Family pressure was not always in the direction of reducing alcohol consumption; if other family members drank dependently, they could be seen as likely to increase the interviewee’s own alcohol consumption. Some interviewees recalled that their family had left them to their drinking, or that it had not been discussed when they came to visit. Some interviewees described themselves as disinclined to drink to excess because of anxiety around alcohol dependency. They recounted that acquaintances or family members had become dependent on alcohol or died from it, and this had made them cautious about drinking.

Concern about the impact of alcohol on older bodies was voiced as likely to make older people reduce their drinking. Amongst those aged under 70 years, hangovers and the time ‘lost’ to them were seen as getting worse with age, and the desire to avoid them strengthened. Other strong incentives to limit consumption for this age group included ambitions for foreign travel and a desire to live more healthily, particularly to ensure a longer relationship with grandchildren or great-grandchildren. For interviewees aged 70+, fear of falling and the desire to avoid gaining weight were influential concerns. These incentives to reduce drinking were raised by both male and female interviewees.

However, when interviewees talked about giving up alcohol, they also recalled varied concerns about the consequences of not drinking, such as the loss of an enjoyable part of their lives, possibly the only one left to them:

I’d like to cut it down altogether, but even the last time–I cannot be going away and just sitting on my own. I don’t smoke, I don’t have nowt else and that’s the only pleasure I’ve got–drinking. (4; male, 61yrs)

Dependent drinkers were concerned about severe withdrawals or that they might be unable to cope with a return or worsening of their mental health problems. One interviewee with chronic obstructive pulmonary disease was concerned that cutting down had led her to smoke more. Others thought it would be difficult to spend time with friends or family if they did not drink:

I couldn’t understand how you can have fun just going out and having a cup of coffee. You think how boring. I felt as though I could open up a lot more, you know, when you’ve had a few drinks. (11; female, 55yrs)

Those who had been dependent but had reduced their drinking cited severe medical events, or a warning from a doctor that this was imminent, as powerful incentives to change; for instance, bringing up blood, a diagnosis of pancreatitis or identification of an enlarged liver. Some interviewees felt it was ‘too late’ for them to attempt to change their dependent drinking:

If you’re an alcoholic or an addict and say you’re 25 you have basically maybe 45 years to go, you know, of life. A person who is say 55 and drinking a lot says to himself ‘ah well I'm 55 now what’s there to look forward to now? Doesn’t matter if I stop drinking’ (6; male, 59yrs)

A number of reasons emerged why middle aged and older dependent drinkers might have delayed seeking help with their problem. For example, some perceived it as something to be dealt with by themselves, they felt able to function while drinking and perceived a strong stigma attached to being a dependent drinker, and they had been unaware or uncertain of what help was available.

Only a few participants from the focus groups correctly specified what the recommended guidelines for alcohol consumption were, and most agreed that calculating units was confusing:

M: I’ve seen it on the TV, so many units; I watched a programme about it on the TV, but I can’t remember the units…but they reckon is more, in theory, what women drink, there’s more in the wine, than what it is for beer. (Focus group 2)

At two of the focus groups, participants suggested that many middle aged and older people would regard advertising campaigns against excessive drinking as targeting those who got themselves drunk or lost self-control when drinking, and therefore not relevant to themselves. Participants were also critical of mixed messages from research reports in the media over whether red wine was beneficial or not.

Some incentives were mentioned by participants for moderating drinking, including diets, driving, the desire to see one’s grandchildren grow up, and the desire not to appear foolish:

M: I could go out and drink 7, 8 pints, but it would be making a fool of myself really, you know. (Focus group 2)

One group suggested that many middle aged and older people were motivated to avoid alcohol or minimise their intake because of fears they might become alcoholic.

Experiences of primary care

Interviewees who recounted problems with alcohol indicated that General Practitioners (GPs) were the first source of help encountered. Participants may have sought help either for their drinking, or for mental health problems with which the drinking was associated:

At the time I was suffering from depression as well and obviously if you want something, some medication, that’s [GP’s] where you’re going to go. (6; male, 59yrs)

However, asking a GP for help usually meant overcoming a reluctance to do so, or to admit to being ‘drunk all the time’ or having an alcohol problem, which could be uncomfortable or embarrassing. One woman had not managed to face asking her GP for help until a friend took her along. Such interviewees recalled trying to hide their drinking from their GP or play down its extent. Some saw GPs as not wanting to treat drinkers, or did not see drinking as a ‘legitimate’ illness to trouble a doctor with:

But you can’t imagine somebody going in [to the doctor] and saying ‘oh, I’ve got a problem, I’m drinking far too much, what help can I get?’ can you? (12; female, 51yrs)

While some participants felt they had been successful in hiding their drinking others recalled that their GP had asked about drinking because of the smell of alcohol:

He [GP] said ‘have you been drinking?’ and I just said ‘aye, 1 or 2’ he said ‘do you know what time it is?’ I said ‘I’m quite aware of the time’ he said ‘I think you’ve got a problem’. (10; male, 60yrs)

GPs were identified, by some, as a source of pressure for changing behaviour. When they had been encouraging about a reduction in consumption, this was seen as positive. However, GPs could also be viewed as having high expectations of abstinence or drastic reductions that participants might have felt unable to meet. They had usually directed participants seeking help to contact a support service or group, or made a referral for detoxification or a psychiatric nurse rather than offering advice on how to cut down themselves:

But Dr [name] is the type of doctor where he’s so laid back, he didn’t specifically say to me ‘that can happen with your liver–that can happen with your brain–that can happen…’ I didn’t get that information. It was just ‘you’ve got a problem–here’s a card now go and deal with it’. (10; male, 60yrs)

One participant thought that many GPs did not understand problems that middle aged and older people faced with drink, but simply referred them on without necessarily knowing the most appropriate service. Some participants felt that their GPs had tried to prescribe them medication in relation to their alcohol problem or associated mental health problems without listening to them or considering alternatives to medication.

No clear differences emerged in experiences of primary care between men and women. Among the oldest group of interviewees (aged 70+), all but one said their GP no longer asked about alcohol; one explained this was “because they know I don’t drink”. The one man who said his GP still asked him about alcohol attributed this to his having had a stroke.

At all three focus groups, participants thought that it was important for doctors to be able to ask about all areas of health, but one group agreed that doctors were overly prone to look to alcohol consumption to explain the symptoms they visited about. Older women in sheltered accommodation on the other hand said that they were never asked, or felt that their doctors knew them well enough personally to know that they had no problems with alcohol. As one woman put it ‘they [doctors] have never had to pick me off the ground’.

Experience of detoxification and rehabilitation

Most interviewees who reported a serious alcohol problem had been through a detoxification programme at least once, in many cases several times, usually inpatient programmes or emergency responses to a hospitalisation. One interviewee who did not view himself as having any alcohol problems had been outraged to find that he received detox medication when hospitalised for a stroke:

I says ‘get the forms, I’ll sign myself out’. I says ‘all you are thinking about is me being an alcoholic’… They were injecting something into my stomach. (24; male, 72yrs)

Some interviewees had been unable to arrange for a home detox because they lived in temporary accommodation or did not have 24 hour support. Others found it had been difficult to secure a referral for detox because they were not drinking enough at the time, including one woman who said she had been told to reduce her drinking to one bottle of cider a day, but was then told she drank too little to qualify.

Detox programmes had enabled problem drinkers to stop drinking and, for instance, start eating again, but this had almost always been a temporary change. For one interviewee, the abstinence achieved had always been succeeded by complacency and relapse some months down the line. More often participants complained that after detoxification, they had returned to the settings or problems that had fueled their drinking with little or no follow-up to help them avoid alcohol:

Detox and then back to your normal life. I mean the nurses come out every day and they give you vitamin injections which last 6 month[s]. Then come the end of the week, that’s it: they’re gone and you’re back to just keeping away from the pub. You know what I’m saying? It’s hard. (16; f, 52yrs)

Some complained that no attempt was made to address mental health problems alongside a detox. Those referred for detox by counselling services did feel they had been supported through counselling before and after, and appreciated this. One man, for instance, felt that the programme he was about to undertake was more likely than his previous referral to make a difference because of the ten weeks of counselling to prepare him for it.

Rehabilitation programmes were viewed as more expensive, and referrals to them as harder to secure. This required one to demonstrate likelihood to achieve and sustain abstinence. One interviewee did not think that the rehabilitation facilities available were necessarily appropriate for middle aged or older people, describing one establishment as ‘scary’ as it accommodated ‘real winos’. Few participants mentioned having been through rehabilitation, but those who had, described it as an important part of their recovery. Views differed on the usefulness of the group work and activities that formed part of the programme, but the experience of sustained support and individual advice away from everyday routines was seen as a positive factor. They felt again that the support they required during the period after they left the programme had not always been available:

It’s when you come out and you’ve got nobody–that’s when you need them. I came out…I went in on the 30th November, and I was only away a week…I think it was the second week in January I got a letter to say ‘make an appointment to see me’. (11; f, 55yrs)

The lack of support to follow up rehabilitation made relapse likelier, and one woman estimated she had been through five programmes. Long waiting lists were also viewed as a problem, meaning that the impulse or readiness to make a change in behaviour might have passed by the time a place became available.

Due to the smaller numbers of participants experiencing detoxification and rehabilitation there were no differences that could be meaningfully attributed to age or gender.

Experience of counselling and therapy

Those who had given up drinking as a response to counselling were positive about the help they had received; those who were still drinking and had received counselling appreciated the chance to talk to someone in private but did not see it as having had a significant effect. Counselling was seen as helping to deal with underlying problems, preparing them for other interventions, or supporting abstinence and relapse prevention. One participant whose GP had referred her to a psychotherapist for her mental health problems described this help as ‘brilliant’, as it had helped her understand why she drank. However, the experience of turnover in counsellors, when one moved to a new job, was unsettling, making participants feel as if they had to start from scratch in developing a relationship with the new counsellor, and one participant was inclined not to try counselling again because of this.

Some participants expressed a preference for services that were not specifically dealing with alcohol problems, partly because they felt alcohol services brought them into contact with alcoholics who were likely to encourage relapse; for instance one interviewee said of Alcoholics Anonymous:

It’s just a load of sob stories. I think ‘well I’ve got enough of my own’ without listening to somebody else’s. It made me feel depressed and I wanted a drink when I came out. (11; f, 55yrs)

Groups tended to be appreciated more when they were not focused solely on drinking. Relaxation, alternative therapies and arts classes were popular, helping to fill the day and allowing interviewees to expand their social circle. Both activity groups and drop-in centres (Drop-in centres, generally run by voluntary organisations and local councils, offer emotional support, companionship and practical advice to vulnerable people who live independently in the community) were enthusiastically endorsed as forms of support that gave access to other people to talk with on an ad-hoc basis:

They know where you’re coming from and they're volunteers and they sit and they talk to you and you just chat and it's a way of putting in your time without going to the boozer or getting a drink. (6; m, 59yrs)

It was frequently emphasised that support was best coming from people at the same stage of struggling with alcohol as themselves, or from an ex-alcoholic, in part because they were seen as less likely to be judgmental about drinking and relapses. A voluntary organisation staffed by recovering drinkers was praised because volunteers understood the problems involved but presented the example of health and stability to aspire to. They were seen as a ‘little family’ with which interviewees could connect in the face of isolation experienced elsewhere:

My world is drink and people who drink. The people in the [shopping centre], they might as well–either I might as well not be there or they might as well not be there because I can’t equate with them. (15; m, 65yrs)

Doubts were often expressed about people who had not been through alcohol problems themselves offering help because they lacked first-hand knowledge. Some people were also critical of receiving help from people much younger than themselves who did not know what alcohol problems were like for middle aged or older people, though others thought the age of the person helping you made no difference.

Due to the smaller numbers of participants experiencing counselling and therapy there were no differences that could be reliably attributed to age or gender.

Middle aged and older people’s alcohol misuse may be covert, isolated and carefully regulated and is therefore unlikely to be as obvious as that of young people drinking in public or in external networks of friendship or work groups. Targeting of health messages is therefore important. However the people who we spoke to were skeptical about recommended guidelines for alcohol and rarely measured consumption in units. This is consistent with the literature that older people are one of the least well informed groups about alcohol units both in the UK[ 30 ] and Australia[ 31 ]. People, in this sample, were also dismissive of the value of health education in line with the lack of evidence regarding effectiveness of such campaigns[ 30 , 32 ].

Primary health care emerged as important in the identification of problems and provision of advice since this is where middle aged and older people had looked first for help with alcohol problems. This is also consistent with previous research which showed that GPs were the preferred first point of contact for adults with alcohol problems[ 33 ]. Screening and brief interventions are effective for middle aged and older adults in primary health care[ 34 – 41 ] yet interviewees felt they had been able to conceal their drinking from GPs, or were not asked about it, and there was broad recognition that it would be difficult to initiate talk about alcohol with a doctor. Research has shown that even when GPs are encouraged to screen for alcohol problems they under-deliver health-promoting advice to older people[ 42 ] while nurses report avoiding engagement with older people about alcohol use as they worry about depriving them of the social benefits of drinking[ 43 , 44 ]. Research from the US also shows that primary care physicians may under detect alcohol use disorders among older patients[ 45 ]. Primary care professionals should be aware of the need to ask middle aged and older people about their alcohol consumption and of their possible reasons for concealment; support or training for asking and advising middle aged and older people about alcohol should be available if staff feel uncomfortable with this. In particular it has been suggested that there is a need for the training of community nurses to be focused on improving the detection and treatment of alcohol problems among older people[ 46 ].

People in this sample who had experienced alcohol dependence felt that detoxification services had been effective at least in the short term. Other research from the US has reported that older people are at least as likely to benefit from treatment as younger people; and they tend to follow treatment regimens more diligently too[ 47 , 48 ]. However relatively few older drinkers receive referrals to support services[ 49 ] which is consistent with the accounts of our interviewees. Our findings also suggest a compelling need to ensure that aftercare in the form of rehabilitation, counselling, or advice is in place to prevent relapse, or to deal with mental health problems. Strong preferences were expressed by some for support to be provided by those who had experienced alcohol problems themselves but not via a designated alcohol service.

This age group may perceive distinct barriers and incentives to seeking help for alcohol. People described feeling ashamed of being seen as an alcoholic, feeling that services regarded them as ‘on the shelf’, and perceiving themselves as too late in life to change or benefit from treatment. They were concerned about how to cope with boredom, isolation and other health problems without alcohol. However most of those we spoke to had reduced their drinking with or without specialist help. The goals of prolonging life and rebuilding family relationships were reported as strong incentives to change. Evidence for treatment regimes for older people suggest that uptake and success of interventions could be enhanced by facilitating understanding that alcohol problems need not represent an inevitable decline, and helping older people to plan for sustaining an active and involved lifestyle[ 47 , 48 ] Similar but smaller scale qualitative research with older people that were in specialist alcohol treatment services reported that older drinkers had different stressors, precipitating factors and risk factors for relapse than younger drinkers. They also faced a number of unique barriers to treatment and were more likely to remain ‘hidden’ from services[ 18 ].

It has been postulated that behaviour is influenced not only by individual-level attributes but also the conditions under which people live[ 50 ]. Participants in this research often cited physical, temporal and social structures as influencing drinking behaviour. Alcohol interventions often disregard these contextual factors which can lead to high relapse once an intervention has ended[ 51 ]. Social ecology may be a more appropriate way to target excessive alcohol consumption as it explicitly considers factors in the physical environment that affect health status[ 52 ] and suggests a shift away from interventions aimed at changing individual’s health behaviour towards comprehensive ecological designs that address the interdependencies between socioeconomic, cultural, political, environmental, organisational, psychological and biological determinants of health[ 51 ]. Examples of social and ecological interventions include social norms marketing and restricting alcohol advertising[ 53 ].

Differences by age and gender were attributed to codes where all participants could provide an opinion but not to codes where only a proportion of participants had experience. There were subtle differences in results by age but not gender. Going out to drink was a feature of the accounts of younger interviewees while choice of where to drink could be limited for interviewees aged 70 or more by their mobility or other circumstances, for instance if in a care home. While this change in drinking location seemed to be a direct result of the ageing process there is currently a national trend for less on-trade and more off trade alcohol consumption[ 54 ]. Concern about the impact of alcohol on older bodies was also voiced as likely to make older people reduce their drinking. Amongst those aged under 70 years, hangovers and the time ‘lost’ to them were widely seen as getting worse with age, and the desire to avoid them strengthened. Despite lower levels of alcohol consumption, more older people are admitted to UK hospitals with an alcohol-related condition than younger age groups[ 55 ]. Other strong incentives to limit consumption for this age group included ambitions for foreign travel and a desire to live more healthily, particularly to ensure a longer or better relationship with grandchildren or great-grandchildren. For interviewees aged 70 years and over, fear of falling and the desire to avoid gaining weight were influential concerns. No clear differences emerged in experiences of primary care between different genders however all but one of the interviewees in the oldest group said their GP no longer asked about alcohol. Due to the smaller numbers of participants experiencing detoxification, rehabilitation, counselling and therapy there were no differences that could be reliably attributed to age or gender.

This research contributes to the limited body of in-depth qualitative data regarding the issues surrounding alcohol consumption in mid to later life, highlighting the needs of middle aged and older people in relation to service provision around alcohol and health. While the sample was relatively small and restricted to a single region of the UK it did provide a depth of data which could not have been achieved via a large quantitative sample. It must be acknowledged however that while one of the aims of purposive sampling was to recruit both genders, females were over represented in the focus groups. Nevertheless considerable diversity was achieved in individual interviews with males well represented. Yet it appears that there is growing international recognition of the needs of older people in relation to alcohol consumption[ 56 ]. The most recent Alcohol Strategy for England[ 25 ] has requested a review of the current alcohol guidelines for adults including whether separate advice is desirable for older adults. In addition alcohol identification and any subsequent brief advice needed has been included in NHS Health Checks for adults from age 40 to 75 for the first time. Sections of the Models of Care for Alcohol Misusers (MoCAM) also refer specifically to older people[ 57 ]. However while organisational standards for drug and alcohol teams contain special guidelines for services for children and young people and for drug-using parents there are no guidelines for older people[ 58 ]. In addition the addictive properties of alcohol and access to specialist care for alcohol problems are not mentioned in the National Service Framework for Older People[ 59 ]. Finally it was reported in 2008 that the UK had no designated alcohol services for older people[ 60 ] and that there was an urgent need for these. We found only one out of 46 services in this large geographical region provided a specific or tailored intervention for middle aged and older people with alcohol related problems[ 61 ].

It has been suggested that tailored screening tools perform better with older people[ 62 ] and that treatment should be tailored to the unique needs of older people as it becomes more efficacious when it is not generic[ 63 ]. The people we spoke to endorse the need for specific support services, tailored to their health in relation to alcohol, to which health professionals feel comfortable referring older people. Primary care professionals, particularly those based in the community, need training on improving the detection and treatment of alcohol problems among middle aged and older people. There is also a compelling need to ensure that aftercare in the form of rehabilitation, counselling, or advice is in place to prevent relapse, or to deal with mental health problems. Strong preferences were expressed by some for support to be provided by those who had experienced alcohol problems themselves but not via a designated alcohol service. Tailored advice would ideally recognise the different issues that we identified for older and younger old for example advice should focus on hangovers and lost time for those in the younger age bracket, compared with fear of falls, seeing grandchildren and the need for doctors to ask proactively with the older age group. These motivating factors are an important basis for tailoring advice and communicating this to primary caregivers who are best placed to offer advice. For example a World Health Organisation (WHO) report suggests that advice about falls risk should be used to reinforce programmes to reduce alcohol use in older people[ 64 ]. Promoting the avoidance of harmful use of alcohol is also highlighted by the WHO in their life-course approach to healthy and active ageing[ 65 ]. At a broader level, specific policy in relation to older people’s health and alcohol will facilitate WHO objectives of helping people stay healthy and active even at the oldest ages, and helping those who can no longer look after themselves to live with dignity and enjoyment.

Acknowledgments

We are most grateful and extend our sincere thanks to all the people who took part in the study. This research was supported by a grant from the United Kingdom Charity Age UK South Tyneside ( http://www.ageuk.org.uk/southtyneside/ ). The organisation assisted in the identification and recruitment of study participants as described in the methods section of the manuscript. Apart from this, the funders had no role in study design, analysis, decision to publish, or preparation of the manuscript. CH and JL are fully funded staff members and AC and EK are Senior Investigators of Fuse the Centre for Translational Research in Public Health, a UKCRC Public Health Research Centre of Excellence. Funding for Fuse from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, is gratefully acknowledged.

Funding Statement

This research was supported by a grant from the United Kingdom Charity Age UK South Tyneside ( http://www.ageuk.org.uk/southtyneside/ ). The organisation assisted in the identification and recruitment of study participants as described in the methods section of the manuscript. Apart from this, the funders had no role in study design, analysis, decision to publish, or preparation of the manuscript. CH and JL are fully funded staff members and AC and EK are Senior Investigators of Fuse the Centre for Translational Research in Public Health, a UKCRC Public Health Research Centre of Excellence. Funding for Fuse from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, is gratefully acknowledged.

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Women's views and experiences of occasional alcohol consumption during pregnancy: A systematic review of qualitative studies and their recommendations

Affiliations.

• 1 School of Health Sciences (Haute Ecole de Santé Vaud - HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), 21, Avenue de Beaumont, Lausanne CH-1011, Switzerland. Electronic address: [email protected].
• 2 School of Health Sciences (Haute Ecole de Santé Vaud - HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), 21, Avenue de Beaumont, Lausanne CH-1011, Switzerland. Electronic address: [email protected].
• PMID: 35567866
• DOI: 10.1016/j.midw.2022.103357

Objective: Official guidelines advocate abstinence from alcohol during pregnancy. However, a number of women consume alcohol while pregnant. Understanding women's reasons and the context for drinking during pregnancy outside the context of an alcohol use disorder may be helpful for interventions of healthcare providers and health policymakers. This paper reports a systematic review of qualitative studies focusing on women's perspectives of the issue of alcohol consumption during pregnancy on one hand, and on recommendations on the other.

Design: Seven electronic databases and citation lists of published papers were searched for peer-reviewed articles published between 2002 and 2019 in English and French, reporting primary empirical research, using qualitative design and exploring women's views and experiences about the issue of alcohol and pregnancy. Studies involving participant women identified as having an alcohol use disorder while pregnant were excluded. Using the thematic synthesis method, we extracted and coded findings and recommendations from the selected studies.

Setting and participants: Women who mostly reported being abstinent or having reduced their alcohol consumption during pregnancy, and non-pregnant women FINDINGS: We included 27 studies from 11 different countries. The quality of studies was assessed using the CASP tool. We developed five analytical themes synthesising women's views and experiences of abstinence and occasional alcohol consumption during pregnancy: lack of reliable information; inadequate information from health professionals; women's perception of public health messages; women's experiences and perception of risk; and social norms and cultural context. Six analytical themes synthesising recommendations were generated: improving health professionals' knowledge and screening practice; diversification of information sources; improving women's information; empowering women's choice; delivering appropriate messages; and addressing socio-structural factors.

Key conclusions: Our review provides evidence that information on the issue of alcohol consumption during pregnancy should be improved in both qualitative and quantitative terms. However, the reasons for pregnant women's occasional drinking are complex and influenced by a range of socio-cultural factors. Therefore, healthcare professionals and policymakers should take into account women's experiences and the context of their everyday lives when conveying preventive messages. Our review demonstrates that awareness strategies should not focus solely on women's individual responsibility. They should also address a wider audience and foster a more supportive socio-structural environment.

Implications for practice: The understanding of women's perspective is essential to designing sound prevention interventions and credible messages. Our review provides a comprehensive summary of the state of qualitative research on women's experience of the risk of alcohol use during pregnancy, as well as the literature's recommendations about how to address this issue. This review also contributes to identifying overlooked areas of recommendations that require further reflection and research.

Keywords: Alcohol; Pregnancy; Qualitative systematic review; Recommendations; Women's experiences.

Copyright © 2022. Published by Elsevier Ltd.

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Conflict of interest statement

Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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