Alcohol and Alcoholism Advance Access originally published online on May 11, 2007
Alcohol and Alcoholism 2007 42(4):354-361; doi:10.1093/alcalc/agm017
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Trends in alcohol consumption in Singapore 1992–2004
1 Epidemiology and Disease Control Division, Ministry of Health Singapore, 16 College Road, College of Medicine Building, Singapore 169854, Singapore
* Author to whom correspondence should be addressed at: Epidemiology and Disease Control Division, Ministry of Health Singapore, 16 College Road, College of Medicine Building, Singapore 169854, Singapore; E-mail: Lim_Wei_Yen{at}moh.gov.sg
Received 6 December 2006; first review notified 19 January 2007; in revised form 5 March 2007; accepted 5 March 2007
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ABSTRACT |
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Aims: To present trends in alcohol consumption between 1992 and 2004 in Singapore. Methods: Alcohol consumption data were derived from national health surveys conducted in 1992, 1998 and 2004. Age-adjusted prevalence of frequent (drinking 1–4 days a week), regular (drinking more than 4 days a week) and binge (having five or more drinks during a drinking session at least once in the month) drinking by gender and age group for the three surveys were compared. Multivariate analyses for binge drinking in 2004 were performed using logistic regression models. Results: Prevalence of frequent, regular and binge drinking increased between 1992 and 2004. Prevalence increase in binge drinking was highest (from 5.1 to 10.0%), followed by frequent drinking (from 4.5 to 7.5%) and regular drinking (from 2.9 to 3.1%). Uptake in binge drinking increased in both genders and across all age groups but was most evident among adults aged 18–29. Frequent drinking increase was observed for both genders but was most pronounced among women aged 18–29. The level of regular drinking declined in men but increased in women, especially those aged 18–29 and 30–49. Being younger, male, separated, divorced or widowed, a current smoker, or having a monthly household income of S$6000 and above were attributes positively associated with binge drinking. Conclusions: Alcohol consumption, especially binge drinking, has increased among Singaporeans between 1992 and 2004. There is gender convergence in alcohol consumption.
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Introduction |
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Alcohol consumption is associated with numerous medical problems such as hepatitis, cirrhosis, cancers of the oro-pharyngeal tract and colo-rectum, addiction and depression and encephalopathy. (WHO, 2002
) Alcohol consumption is also linked to road traffic accidents and physical injuries (Mura et al., 2003), family violence (Lipsky et al., 2005) and other social problems such as unemployment. (Lee et al., 1990) While, in recent years, researchers have recognized that moderate alcohol intake may be beneficial, (Corrao et al., 2000) it is generally accepted that the potential for harm far outweighs that for benefit in alcohol consumption.
Recent studies have postulated that the pattern of alcohol consumption is as important as the total quantity of alcohol consumed. In particular, excess alcohol intake during a single session (binge drinking), defined as five or more units of alcohol consumed during a single episode, has been recognized as being harmful, and is believed to contribute to mortality patterns in some countries. (Chenet et al., 2001; Evans et al., 2000) Binge drinking is associated with an increase in the risk of coronary heart disease (Murray et al., 2002). It is linked to mental and behavioural problems in children (of mothers who binge drink during pregnancy) (Bailey et al., 2004). Binge-drinkers are more likely to report mental distress and depression (Okoro et al., 2004) and to exhibit cognitive deficits (Hartley et al., 2004). Binge drinking is associated with offending and disorderly behaviour (Richardson and Budd, 2003), drink-driving (Duncan, 1997), unplanned pregnancies (Naimi et al., 2003) and risky sexual behaviours (Dunn et al., 2003).
Singapore is a multi-ethnic city-state located at the tip of the Malayan peninsula in South-East Asia, with a resident population of 3.55 million persons in 2005 (MCYS, 2006), of which 75.6% are Chinese, 13.6% Malays and 8.7% Indians. Singapore is wholly urban, and has undergone rapid economic and demographic transitions over the last 40 years, from a poor country with a high fertility rate, to a rich one with one of the lowest fertility rates in Asia and a rapidly aging population. Concomitant with these changes have been a cultural shift within Singapore. Anecdotal evidence suggests an increasingly permissive society that is beginning to shed traditional negative views of excessive alcohol use.
Alcohol consumption data in Singapore have previously been reported, most recently in 1994 using consumer expenditure data on alcoholic beverages (Curry, 1994). In this paper, we update data on the prevalence of alcohol drinking by looking at the secular trend in prevalence of alcohol consumption over three consecutive population-based cross-sectional surveys. We also report on the trend and prevalence of binge-drinking in Singapore, which to our knowledge, have not been reported before.
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Methods |
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The National Health Survey (NHS) is a national cross-sectional survey conducted every 6 years by the Ministry of Health to determine the current prevalence of major non-communicable diseases and their risk factors in Singapore. Data for this study were drawn from three past NHS surveys conducted in 1992, 1998 and 2004 on the resident Singapore population of Chinese, Malays and Indians aged 18–69 years in the respective survey years.
The three surveys shared a similar survey methodology which has been previously described (Epidemiology and Disease Control Division, 2004). In brief, a 2-stage stratified sampling method was used to obtain the sample. In the first stage, a probability sample of household addresses was selected from a household sampling frame maintained by the Department of Statistics. In the second stage, a random sample for the NHS was selected from all eligible individuals (criteria were based on age and ethnicity) living in those households. Over-sampling of Malay and Indian minority ethnic groups was done in order to give sufficient sample sizes for statistical comparison between ethnic groups.
Survey respondents underwent a health screening and answered a questionnaire in a structured interview administered by trained nurses at designated survey centres. The questionnaire included questions on alcohol consumption and binge drinking. Frequent drinking and regular drinking were defined as having consumed at least one drink (any alcohol) per day for 1 to 4 days a week, and more than 4 days a week respectively in the past 12 months of the survey. Binge drinking was defined as having consumed five or more drinks (any alcohol) in any one drinking session during the past month of the survey. Subjects who had at least one but less than five drinks (any alcohol) in any one drinking session during the past month of the survey were not considered to have binge drinking. Show cards of one drink of the various alcohol (for example, beer, wine and spirits) and alcohol equivalents (for example, 1 small glass of wine = 1 drink and 1 bottle of beer = 3 drinks) were shown to subjects during the survey interview.
The sample size for the 1992 survey was 4915, with 3568 participants, giving a response rate of 72.6%. In 1998, 4723 participated out of a sample of 7325 persons, giving a response rate of 64.5%. Four thousand eighty four individuals out of a sample of 7078 individuals participated in 2004, giving a response rate of 57.7%.
Statistical analyses were performed using Statistical Package for Social Sciences (SPSS, Chicago IL, USA) version 13.0. The survey sample data were adjusted to the age, ethnic group and sex distributions of the respective Singapore resident population of each year. Age-standardization of prevalence rates were calculated by the direct method, using the 2000 Singapore resident population as the standard. To compare changes in prevalence levels by gender and age groups between 1992 and 1998, differences between age-standardized rates for 1992 and 1998 were computed and tested whether they are significantly different from zero using the Z-test statistics (Armitage and Berry, 1987). The same was done to compare changes in prevalence levels between 1998 and 2004. A P value less than 0.05 denotes significant increase or decrease in the age-standardized rates pertaining to the respective age groups between the 2 years being considered.
To determine the socio-demographic factors associated with binge drinking, we ran univariate and multivariate analyses with binge-drinking as the dependent variable and various socio-demographic factors as predictor variables.
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Results |
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Table 1 shows the crude and age-standardized prevalence of frequent drinking (drinking 1–4 days a week) by gender and age group for the three survey years. Significant increases in overall age-standardized prevalence were observed over both time periods (1992–1998, and 1998–2004). The increase in prevalence was seen in both genders and across all age groups except for men in the 30–49 age group for period 1998–2004. However, the increase in prevalence in women in age group 18–29 was markedly higher compared to men. For women, increases in prevalence across all age groups were higher in the 1998–2004 period relative to the 1992–1998 period.
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Table 2 shows the crude and age-standardized prevalence of regular drinking (drinking more than 4 days a week) by gender and age group for the three survey years. The age-standardized prevalence of regular drinking has not changed much although the trends in men and women were strikingly different. The prevalence in men consistently declined between 1992 and 2004, whereas that in women consistently increased. Increase in the prevalence of regular drinking was evident in the 18–29 age group for both genders. For women, the increases in prevalence across all age groups were observed to be higher between 1998 and 2004 than that between 1992 and 1998.
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Table 3 shows the crude and age-standardized prevalence of binge drinking (having had five or more drinks within one drinking session at least once in the past month) by gender and age group for the three survey years. Binge drinking prevalence doubled from 5.0% in 1998 to 10.0% in 2004. The increase was seen in both genders and across all age-groups, but was most pronounced in the 18–29 age group. For both genders, higher increases in prevalence across all age groups occurred in the 1998–2004 period relative to the 1992–1998 period. The increase in prevalence was higher among men compared to women in all age groups, but the increase taken as a proportion of the baseline prevalence was higher in women.
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Tables 1–3 show that binge drinking was most common among Singaporeans (9.6%) in 2004, followed by frequent drinking (7.0%) and regular drinking (3.2%). Men across all age groups had a higher prevalence of the three types of alcohol consumption compared to women. Among men, binge drinking was most prevalent (15.6%) in 2004 followed by frequent drinking (9.4%) and regular drinking (4.3%). However, frequent drinking was most common among women (4.6%) in 2004 followed by binge drinking (3.7%) and regular drinking (2.0%).
We further investigated the relationship between gender differences in alcohol consumption and ethnicity (results not shown). Gender convergence was seen mostly in the Malays and Chinese, especially amongst those aged 18–29. For example, more Malay women reported being frequent drinkers than Malay men in 2004 (1.2% vs 0.7%), compared to 1998 (0.2% and 1.5% respectively). This reversal in prevalence was almost entirely due to the increase in Malay women aged 18–29. The prevalence of binge drinking in Malays between men and women were comparable (3.7% in men and 2.5% in women), and in Malays aged 18–29, more women (7.1%) reported binge drinking than men (6.3%). In the Chinese, more men (18.0%) reported binge drinking than women (4.3%) in 2004, but the increase in women between 1998 and 2004 was proportionately greater.
Table 4 shows the multivariate associations between binge drinking and socio-demographic characteristics and smoking. Age, gender, ethnicity, marital status, household income and smoking status were positively associated with binge drinking. Compared to non-binge drinkers, binge drinkers were more likely to be younger, male, Chinese or Indian, be separated/divorced/widowed, have a household income of S$6000 and above, and be a current or ex-smoker. Educational qualifications, physical exercise, body mass index, presence of diabetes, hypertension and high blood cholesterol levels were not associated with binge drinking.
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Discussion |
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Our data showed an increase in the proportion of Singaporeans consuming alcohol over the last 12 years. The increase was especially large between 1998 and 2004, in younger age groups and in women. A study in the United States has reported population prevalence rates of current drinking (within the past month) of 50.3% (Substance Abuse and Mental Health Services Administration, 2004
). A 1994/95 study in Russia (Malyutina et al., 2001) showed that 38.3% of men and 6.5% of women drank at least one alcoholic drink a week, and recent data from England (Department of Health, 2004) showed that 73% of men and 60% of women older than 16 had had at least one alcoholic drink in the 7 days prior to the survey. In the 2004 survey, 50.8% of the adult population in Singapore reported consuming alcohol within the past 12 months, compared to a prevalence of 40.5% in 1998 (data not shown). The population prevalence of alcohol consumption in Singapore is rising and approaching Western levels.
Results from Hong Kong's Behavioural Risk Factor Surveillance System reported on the Hong Kong Centre for Health Protection website (Centre for Health Protection, 2006) suggest that alcohol consumption in Hong Kong is comparable to and perhaps slightly higher than Singapore's. The April 2006 results from the survey reported 21.5% of adult men consumed alcohol 1–3 days a week, and 9.5% consumed alcohol 4 or more days a week. Results for women were 5.5% and 1.9% respectively (that is, 31% of men and 7.4% of women consumed alcohol at least one time a week). The corresponding results for Chinese Singaporeans are 15.4% in men and 7.9% in women. Binge drinking was reported by 15.4 % of adult men and 2.1% of adult women in Hong Kong. These levels were similar to Singapore's prevalence in 2004 (15.6% and 3.7% in men and women respectively.)
Our data provided evidence of an evolving drinking culture where frequent and binge drinking are becoming more popular. Binge drinking was more common among the young than the elderly and among men than women. There was evidence of convergence in binge drinking levels between the genders, especially among those aged 18–29. Binge drinking prevalence for men and women aged 18–69 in 2004 were almost two and five times respectively the corresponding levels in 1992. Although different studies have used different criteria and methods to define binge drinking, binge drinking rates appear comparatively lower than those reported in the US (Serdula et al., 2004), (about 33%), Russia (Malyutina et al., 2001), (51% of men and 5% of women) and the UK (Jefferis et al., 2005), (rates of 37% and 18% at 22 years of age, 28% and 13% at 32 years of age and 31% and 14% at 42 years of age for men and women respectively, in a nationally representative birth cohort).
There appears to be a convergence in drinking prevalence between men and women over the last 12 years, particularly amongst the Malays and Chinese, and among the young. While the prevalence of frequent and regular drinking was higher in males than in females, the between-survey increases in women were substantially higher. The different trends in regular drinking prevalence observed for men (decrease in prevalence between 1992 and 2004) and women (increase in prevalence between the 2 years) resulted in little changes in the overall regular drinking prevalence in the period. Although regular drinking prevalence in men appears to be decreasing, binge drinking prevalence is increasing. We believe this reflects a cultural shift in the way Singaporeans use alcohol, and do not consider these results to be inconsistent. (We believe that the gender convergence observed represents a similar cultural shift, with the fading of traditional societal disapproval of women consuming alcohol publicly, and women becoming more assertive and less bound to traditional expectations.)
Binge-drinkers were likely to be younger, male, or an ex- or current smoker. These findings are consistent with those previously reported (Kuntsche et al., 2004), which have also found that binge drinking to be a particular problem in young males, and that it tended to co-occur with other substance use, including smoking. Malays were least likely to binge drink and this is probably because of the Islamic religious injunctions against alcohol use.
Malyutina et al., 2004 reported an inverse relationship between binge drinking and educational status. We did not observe a similar relationship. Binge drinking was instead associated with high monthly household income; this is probably because of the relatively high prices of alcohol beverages in this country. Compared to married males, separated, divorced and widowed males were more likely to report binge drinking. Other studies have demonstrated poorer health and increased morbidity experiences in persons who have been recently divorced or widowed. It is possible that unwise alcohol consumption patterns may partially explain these adverse health experiences.
Binge drinking was not associated with other health risk factors such as leisure physical activity, body mass index, diabetes, hypertension and high blood cholesterol level. Other researchers have reported associations between binge drinking and obesity (Arif and Rohrer, 2005) and diabetes. We may not have been able to demonstrate similar associations because the proportion of binge drinkers in our survey was relatively small. Moreover, alcohol use may fluctuate over time, and the impact of binge drinking is likely to result from long-term exposure.
Alcohol consumption and binge drinking should be monitored. If the prevalence continues to increase rapidly, an alcohol addiction survey may be necessary to determine the number of Singaporeans who would fit DSM IV criteria for alcohol addiction and dependency. While a fairly comprehensive set of measures aimed at curbing excessive and risky alcohol consumption has been put in place (including taxation on alcohol, limiting alcohol purchases to those aged 18 and above, and legislation and campaigns against drink-driving), further enhancements of these measures, perhaps through means such as adjusting the alcohol tariff structure, and increasing the legal age of purchase of alcohol may need to be considered if alcohol misuse continues to increase. A focused health promotion programme may also need to be developed to highlight the negative consequences of heavy alcohol consumption.
Given the relationship between smoking and binge drinking, alcohol consumption education, in particular on the negative consequences of binge drinking, could be targeted at smokers and ex-smokers, perhaps in smoking cessation clinics. Family physicians who are aware that their patients are smokers may also discreetly highlight the problems of binge drinking to their patients. Additionally, national alcohol use campaigns could focus on higher risk individuals such as men and young adults.
Our study had some limitations. Alcohol consumption was based on self-report to a questionnaire administered by trained nurses and may be subject to the problems of recall bias and inaccurate estimation on the part of the participants. Interviewer bias could not be totally ruled out although this was minimized by the rigorous and standardized training of the interviewers.
A literature review on the validity of self-reported alcohol consumption found that accurate disclosure of information was dependent on a number of factors such as the interview situation, how the information is elicited and the context of the interview (Midanik, 1988, 1989). We believe that the re-iteration of survey objective and the Singapore Ministry of Health's assurance of information confidentiality by trained nurses prior to the interview greatly diminished respondents’ motivation for under- or over-reporting.
We did not validate self-reports with a food diary or other means. Our estimates of consumption levels were taken from a single point in time and we are therefore not able to trace changes in alcohol consumption from the life-course perspective. In addition, our cut-off of five drinks or more for binge drinking is different from other researchers who used a lower cut-off of four drinks or more for women, in acknowledgement of gender differences in physiology and body mass. This makes inter-country comparisons difficult.
We also experienced a decline in response rates over the three surveys. The main incentive for undergoing the survey is a free health screening for subjects. However, health screenings are getting more common and affordable. Subjects who are employees are usually given free or heavily subsidized health screenings by their companies. In addition, subjects who donate to charities and hospitals run by voluntary welfare organizations in Singapore are often offered free health screenings on a yearly basis.
In a follow-up survey on non-respondents to the 2004 NHS survey, ’just had health screening within the past 3 months’ was one of the top five reasons cited by selected subjects for not participating in the NHS survey. It appears that free health screening as an incentive for participation in NHS surveys could be losing its appeal and have resulted in declining response rate across the surveys.
This declining response rate could affect the validity of our findings, since subjects who chose not to respond may differ systematically from the general population, resulting in over-or under-estimates of the true prevalence of alcohol consumption and binge drinking. We are unable to correct for this potential bias, nor, a priori, are able to predict how non-respondents may differ from respondents. We will have to devise new and innovative incentives to persuade people to participate in order to arrest the increasing non-respondent rates for future surveys.
In summary, we report an increasing prevalence of regular and frequent drinking, and binge drinking in the Singapore population. This increase is particularly marked for binge drinking, in the 18–29 age group and in women. Our study also provided evidence of convergence between genders in alcohol consumption.
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