Alcohol and Alcoholism Advance Access originally published online on March 25, 2008
Alcohol and Alcoholism 2008 43(4):460-469; doi:10.1093/alcalc/agn018
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Childhood and Current Determinants of Heavy Drinking in Early Adulthood
1 Department of Health and Functional Capacity, National Public Health Institute (KTL), Helsinki, Finland
2 Department of Public Health, University of Helsinki, Helsinki, Finland
3 Department of Psychiatry, Helsinki University Central Hospital, Finland
4 Finnish Foundation for Alcohol Studies, Helsinki, Finland
5 Department of Mental Health and Alcohol Research, National Public Health Institute (KTL), Helsinki, Finland
* Author to whom correspondence should be addressed: Department of Health and Functional Capacity, National Public Health Institute (KTL), Mannerheimintie 166, FI-00300 Helsinki, Finland. Tel.: +358-9-4744-8795; Fax: +358-9-4744-8760; E-mail: laura.kestila{at}ktl.fi
Received 6 September 2007; first review notified 15 November 2007; in revised form 22 January 2008; accepted 14 February 2008
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ABSTRACT |
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Aims: To explore the association of parental education, childhood living conditions and several adversities with heavy drinking in early adulthood, and to analyze the effect of the respondent's current circumstances on these associations. Method: The analyses were conducted in a sample of 1234 adults aged 18–29 years participating in the Finnish Health 2000 Survey (65% of the original representative two-stage cluster sample, N = 1894). The outcome measure was heavy drinking measured by g/week for pure alcohol (for men
280 g/week and for women 140 g/week). Results: 8% of young adult men and 5% of women were heavy drinkers. In both genders, parental alcohol problems and other childhood adversities, poor own education, and unemployment status increased the risk of heavy drinking. The impact of childhood on heavy drinking was partly independent and partly mediated by adult characteristics, in particular, for both genders, low level of education. Conclusions: Childhood adversities are associated with heavy drinking in early adulthood among both genders. Childhood social circumstances as well as low educational level and unemployment should be taken into account in planning preventive policies to tackle the harms caused by excessive alcohol use at the individual and population level. |
Introduction |
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TOPABSTRACTIntroductionData and MethodsResultsDiscussionConclusionsReferences |
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Young adults are at the stage of highest alcohol consumption in several countries (Anthony et al., 2000
; Casswell et al., 2003; Fillmore et al., 1991; Quigley et al., 1996). Many of them engage in heavy drinking and most show continuity of drinking patterns into later adulthood (Bennett et al., 1999; Paavola et al., 2004), in particular, those with very high levels of consumption (Pape et al., 1996). From the life-course perspective (Kuh and Ben-Sholomo, 2004), heavy drinking is considered to be one of the important pathways to poor health and serious diseases (Dong et al., 2003; Dube et al., 2003), premature mortality (Makela, 1999; Pensola, 2004), and health inequalities (Lantz et al., 2001; Schrijvers et al., 1999).
Various individual level determinants including sociodemographic, psychosocial, and biological factors affect alcohol intake (Holman et al., 1993; Pagan et al., 2006; Poikolainen, 2005). Men use excessive amounts of alcohol more often than women (Ahlstrom et al., 2001; Fillmore et al., 1991; Pitkanen et al., 2005; Poelen et al., 2005; Wittchen et al., 2005), young adults more often than older adults (Ahlstrom et al., 2001), and single and divorced persons more often than married ones (Bogart et al., 2005; Joung et al., 1995; Joutsenniemi et al., 2007). Persons with higher education drink more frequently but smaller quantities at time than less educated, and this also holds true for young adults (Casswell et al., 2003). Living in urban areas (Sundquist et al., 2004), childlessness (Ahlstrom et al., 2001), adverse life events (Dube et al., 2002), and psychiatric disorders (O’Donnell et al., 2006) have been reported to be risk factors for heavy drinking as well.
Also childhood circumstances associate with later alcohol use: low parental socioeconomic position (SEP) and adverse childhood circumstances appear to predict heavy drinking and alcohol problems in adolescence and adulthood (Droomers et al., 2003, 1999; McArdle et al., 2002; Zlotnick et al., 2004). Childhood circumstances found to be associated with unhealthy alcohol use in adulthood, assessed either by heavy drinking or alcohol use disorders, include parental divorce (Anda et al., 2002; Andreasson et al., 1993; Hope et al., 1998; Kuh and Maclean, 1990), poor family functioning (Engels et al., 2005; Jacob and Johnson, 1997), high family economy (Andreasson et al., 1993, 1992), parental mental health problems (Anda et al., 2002), and parental alcohol abuse (Anda et al., 2002; Andreasson et al., 1992; Pirkola et al., 2005), for example. However, it is not well known whether the effect of early social environment on heavy drinking is independent of later experiences or whether it is mediated through, for example, educational achievement, adult living conditions, and lifestyle (Pensola, 2004; Vågerö et al., 1995). Adult characteristics potentially mediate the effect of childhood circumstances on drinking behavior. This study explores the contribution of childhood and adult characteristics to heavy drinking in early adulthood. The specific aims are (a) to assess the association of parental education, childhood living conditions, and various adversities with heavy drinking and (b) to analyze the effect of the respondent's current circumstances on these associations.
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Data and Methods |
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TOPABSTRACTIntroductionData and MethodsResultsDiscussionConclusionsReferences |
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Participants
This study is based on a nationally representative two-stage cluster sample of 1894 young adults aged 18–29 years in Finland. The data were collected in 2000–2001 as part of the Health 2000 Survey (Aromaa et al., 2004
). The information was obtained with standardized structured computer-aided interviews (CAPI) and self-administered questionnaires. 79% (n = 1505) participated in the interview. Questions concerning childhood adversities and alcohol use were included, which 85% of the interviewed participants answered. Pregnant women (n = 51) were removed from the data and the final number of participants was 1234. Thus, the final participation rate was 65%.
Measures
The measure of heavy drinking was based on both the frequency of drinking and the consumed quantity at a time for different types of alcohol during the past 12 months. Participants were asked to report average consumption of "spirits," "wine," and "beer, cider, and long-drinks" (in Finland "long drink" refers to a pre-mixed mild alcoholic beverage). The total consumption was converted into grams of pure alcohol per week. Heavy drinking was classified as 140 (women) and 280 (men) g/week. The limits for risky use vary slightly between countries and this definition follows the Finnish recommendations based on the occurrence of health problems at various levels of alcohol use (Salaspuro et al., 2005) and agrees also with a recent meta-analysis on the effects of alcohol intake on mortality (Di Castelnuovo et al., 2006).
Childhood circumstances
Parental education was based on the participant's response concerning his/her mother's and father's basic and vocational education (Table 2). The parent with the higher educational level was chosen to indicate parental education. Family structure (at age 7) was based on the question "when starting school (i.e. when you were about 7 years old), did you live...?" with response alternatives "at home with both your parents," "with only one parent," "with relatives such as grandparents," and "in an orphanage or other institution," of which the last two alternatives were combined. The urbanization level of childhood residence was based on the participant's response of his/her place of residence during most of his/her childhood and categorized into "urban," "semiurban," and "rural" (Statistics Finland, 2000). Those having lived "abroad" were categorized as a separate group. Childhood adversities (prior to age 16) were based on 11-item question: "When you think about your growth years, i.e. before you were aged 16, did you...?" Seven adversities were explored as such and parental mental health problems were combined from mother's and father's mental health problems. The childhood indicators were chosen to indicate the financial, social as well as health-related problems of childhood living conditions. Parental alcohol problems were constructed on the basis of items concerning mother's and father's alcohol problems reported by the respondent. The pairwise correlations between different childhood adversities (including also parental alcohol problems) were below 0.34, except the one between serious conflicts within the family and parental alcohol problems (r = 0.44).
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Current circumstances Respondent’s own education referred to the highest completed degree (Table 2). The measure for students (23%) was based on the expected level of education, assuming the person to complete the ongoing studies. Five categories were constructed: "primary," "secondary," "lowest tertiary," "lower degree level tertiary," and "higher degree level tertiary or higher." Main economic activity was categorized as "full-time/part-time employed," "student," "unemployed/laid off," and "other." In men, the group "other" consisted mainly of those in the military service (71%) and in women those at home taking care of a family member(s) (90%). The urbanization level of current residence was categorized as "big cities" (ten biggest cities by population at the year 2000), "other urban and semiurban," and "rural" municipalities (Statistics Finland, 2000
) and current family structure as "married," "cohabiting," "living with own parents," "living with other(s) than a partner or parents," and "living alone." The category "living with other(s)" was very small in men (n = 6), whereas in women it was larger (n = 30) and included mostly single mothers. The respondents were also categorized as having children or not. Income quintiles were based on the self-reported household disposable income divided by the number of consumption units which was derived by giving a value of 1.0 to the first adult in the household, 0.7 to any additional adult, and 0.5 to each child (OECD, 1982).
Statistical analysis
The associations between heavy drinking and potential explanatory factors were analyzed using logistic regression analysis, producing odds ratios (ORs) for age-adjusted models (Table 2). The effect of most determinants did not vary according to gender. However, due to significant interactions between gender and parental serious illness or disability and between gender and main activity, the results are presented separately for genders. There were no significant interactions between age and the explanatory factors; however, we have adjusted for age in all analyses.
At least marginally statistically significant determinants (Wald test P < 0.1 for either or both genders, or if any category differed from the reference category with this significance level) were chosen for further modeling (Table 2). The 0.1 significance level was used because our aim was to study the effect of several potential factors on heavy drinking and all included factors have a theoretical connection with heavy drinking. This or an even less stringent inclusion criterion has been used in corresponding situations in previous studies as well. However, we have mostly reported the significant (P < 0.05) associations and discussed them. The childhood determinants were added to the model sequentially, starting with the factors concerning early childhood (around age 7), followed by variables describing the living conditions at a later phase (prior to age 16). At the next stage, the models were adjusted for the effect of adult characteristics (Tables 3 and 4). Results are presented as prevalences and ORs with 95% confidence intervals (95% CI). The sampling design and nonresponse were accounted for by using poststratification weights (Lehtonen et al., 1994) constructed specifically for the dataset and analyzed by the survey procedures of the STATA software (StataCorp, 2003).
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Results |
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Almost 90% of young adults were currently using alcohol (Table 1). Most abstainers were life-long nondrinkers and only a small proportion (2% in both women and men) were ex-drinkers. Heavy drinking was more common in men (8%) than in women (5%) (P = 0.035).
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Of childhood circumstances, single-parent family, financial problems and serious conflicts in childhood family, parental divorce, parental mental health and alcohol problems, parental serious illness or disability, and being bullied at school were at least marginally (P < 0.1) associated with heavy drinking among either or both genders in the age-adjusted models (Table 2). Also parental education was close to this level (for middle level education OR = 1.93 in men, P = 0.155). Although parental education was not a significant determinant of heavy drinking in the age-adjusted model, it was included in the further analyses due to its potential effect as a confounder, being associated with many of the other determinants. Of adult circumstances, the respondent's education, main economic activity, current residence, and family structure associated with heavy drinking. However, the urbanization level of childhood residence, parents’ regular unemployment, the respondent's own serious illness or disability, the respon- dent's income, and having children did not associate with heavy drinking (Table 2) and they were removed from further analyses.
The effect of childhood circumstances on heavy drinking
Even if parental education was not significantly associated with heavy drinking for either gender (Tables 3 and 4, Model 0), there were some apparent associations that did not quite reach statistical significance. For example, women with low parental education seemed to have a lower risk and men with middle parental education a higher risk of being a heavy drinker, also in fully adjusted models (Model VI).
In men, the significant association between heavy drinking and having lived in single parent family in childhood (OR = 3.23) remained significant when parental education was adjusted for (Model I) but disappeared after other childhood adversities were included in the model (Model II), mainly because of the effect of parental divorce. For women, the childhood family structure was not associated with heavy drinking (Table 3, Model 0).
In women, long-term financial problems (OR = 2.43) and serious conflicts within the childhood family (OR = 2.31) were associated with heavy drinking (Table 3, Model 0). Of these, the association between long-term financial problems and heavy drinking remained despite all adjustments, and the association between serious conflicts within the family and heavy drinking remained suggestive after controlling for the other explanatory variables (Model VI).
In men, parental divorce, parental mental health problem, parental serious illness or disability, and having been bullied at school were associated with heavy drinking in age-adjusted models (Table 4, Model 0). Of these, associations between heavy drinking and parental divorce as well as parental serious illness or disability disappeared after controlling for the respondent's educational level (Model IV). Associations with parental mental health problem and having been bullied at school disappeared already when other childhood factors were controlled for (Model II). However, the association with having been bullied at school re-emerged when all factors were adjusted for (Model VI).
There were significant associations between parental alcohol problems and heavy drinking in both genders in age-adjusted models. In women this association lost its significance when other childhood factors were controlled for (Table 3, Model III). In men, the strong association remained statistically significant even after adjusting for other childhood factors, own education, and main activity (Table 4, Model V), but after controlling for the current family structure and urbanization level of current residence, the association did not quite reach statistical significance. However, men whose both parents had alcohol problems differed from the reference category at the 0.1 significance level in the last model as well (Model VI).
Variation in heavy drinking by current life determinants
There were clear educational differences. Heavy drinking was most common in young adults with only primary level education (OR = 12.20 for men and OR = 10.74 for women) (Tables 3 and 4, Model 0). This group differed markedly from the other groups even when all other factors were controlled for (Model VI). Among unemployed and laid-off respondents, heavy drinking was more common than in the other main economic activity groups (OR = 3.63 for women, OR = 3.16 for men) (Tables 3 and 4 Model 0) and remained statistically significant in the fully adjusted model among both genders (Model V). In men, the group "other," which consisted mainly of conscripts, had higher odds in heavy drinking as well (OR = 3.49 compared to full-time/part-time employed). Current family structure was not a significant determinant of heavy drinking in women; however, cohabiting men seemed to be more likely to be heavy drinkers than married ones (OR = 4.85 after all adjustments) (Table 4, Model VI).
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Discussion |
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TOPABSTRACTIntroductionData and MethodsResultsDiscussionConclusionsReferences |
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A variety of childhood adversities predicted heavy drinking in our study. Our results strengthen the previous findings which show that adverse childhood circumstances predict alcohol use in adulthood (Anda et al., 2002
; Dube et al., 2002; Hope et al., 1998; Zlotnick et al., 2004). We found that the impact of childhood factors on heavy drinking was partly independent, but also mediated through other childhood and adult characteristics. In addition, these mechanisms were somewhat different in men and women. The strongest factor was the respondent's own educational level. The effect of the respondent's poor education and unemployment on heavy drinking remained significant after all adjustments as well, among both genders.
Independent and potential mediated effects of childhood circumstances
It has been suggested that childhood SEP has an independent effect on adult health-related behavior, the risk behaviors being particularly common in low childhood SEP groups (van de Mheen et al., 1998). Parental SEP has been found to be associated with alcohol use in adolescence and young adulthood (Droomers et al., 2003). We found no statistically significant associations between parental education and heavy drinking, although in mutually adjusted model among women, there were some indications that low parental education may associate with reduced level of drinking. However, self-reported long-term financial problems in the childhood family had a persistent effect on heavy drinking in women, independent of adult circumstances. Thus, the question of the association between parental SEP stays partly unsolved; different aspects of SEP may be differently associated with heavy drinking. In a large Swedish cohort study, socioeconomic status was found to decrease but the wealth of parents increase the risk of alcoholism among young adult men (Andreasson et al., 1993). The association between childhood SEP and heavy drinking in adulthood has been explained by the higher prevalence of familial alcohol problems and lower parental attachment among those from lower SEP groups, for example (Droomers et al., 2003).
Parental divorce before the respondent was 16 years old and living in a single parent family at the age of 7 predicted heavy drinking among men in our study. Corresponding results have been reported previously (Anda et al., 2002; Andreasson et al., 1993; Hope et al., 1998; Kuh and Maclean, 1990). However, the effect of living in a single parent family at the age of 7 became much weaker after adjusting for the experience of parental divorce before the age of 16, and further, the effect of parental divorce attenuated markedly after adjusting for the respondent's own education. In some studies, however, living with both parents was not associated with reduced levels of regular drinking and it has been suggested that living with both parents is a less robust barrier to substance use than qualitative aspects of family life (McArdle et al., 2002). The psychological and psychosocial effects of parental divorce are probably stronger than the effect of the living arrangement as such. The effect of parental divorce seemed to be mediated by the respondent's own educational level, as those having experienced divorce in childhood had lower education and further, were more likely to be heavy drinkers as well.
Our results support other data showing that children of parents with alcohol problems are at a higher risk of using excessive amounts of alcohol themselves (Anda et al., 2002; Pirkola et al., 2005), although we found significant associations only in the case of both parents’ alcohol problem. In men, parental alcohol problems had an independent effect on heavy drinking whereas among women the effect was explained by other childhood factors (mainly childhood finances). Both alcohol-specific and non-alcohol-specific parenting influences have been found to affect the development of alcohol abuse of the offspring (Jacob et al., 1997); following the example of parental drinking behavior, the development of alcohol-related attitudes, parent–child relationship, unpredictable home life, and genetic vulnerability, for example, are particularly relevant to the development of alcohol abuse (Anda et al., 2002; Steinhausen, 1995; Zeitlin, 1994).
Gender differences
Earlier research has revealed systematic gender differences in drinking patterns and determinants, and biological, social, and cultural reasons for these differences have been suggested (Ahlstrom et al., 2001; Holman et al., 1993; Kuntsche et al., 2006; Lo, 1996). However, in some studies only moderate gender differences have been found in adolescence (Bahr et al., 1995). We found differences and similarities also in the childhood determinants of heavy drinking in adulthood. In both men and women heavy drinking was affected by childhood circumstances; however, the significant childhood predictors of heavy drinking were partly different in men and women. More research should be addressed to explore the gender differences of the life-course determinants of drinking.
Educational differences and heavy drinking
We found that those in the lowest educational group were at higher risk of heavy drinking. The literature shows some inconsistency due to SEP and education differences in alcohol use, which may depend on which parameters of drinking (e.g. total consumption, frequency of drinking, heavy drinking occasions) are studied. In earlier research, heavy drinking was found to be more common in lower educational groups (Droomers et al., 1999; O’Donnell et al., 2006), but women with high SEP had been found to consume more alcohol in some studies (Ahlstrom et al., 2001). In young adults, the less educated have been found to drink significantly more on a drinking occasion, and those with high SEP to drink more frequently (Casswell et al., 2003; Indrei et al., 2004). Financial problems have been reported to contribute to the educational gradient in drinking (Droomers et al., 1999). We found no statistically significant association between income and heavy drinking in this study, possibly due to young adults’ unstable stage of life in regard to work and income.
Based on the (indirect) selection explanation, it is reasonable to assume that those who reach a higher level of education in adulthood have had better health and a health enhancing lifestyle already in childhood and adolescence, while those reaching only a low level of education have had poorer health and a health compromising lifestyle (Koivusilta et al., 1998; Koivusilta et al., 1999; Wood et al., 1997). A high level of education may promote adopting a healthy lifestyle, and educational differences in heavy drinking may be a result from the unequal distribution of important determinants of drinking in different educational groups. However, childhood social circumstances may affect this process as well; the observed educational differences in heavy drinking may arise from early life living conditions and experiences (Kuh and Maclean, 1990), which affect both education and alcohol use, although our results do not particularly support this notion as the effect of the respondent's own education on heavy drinking was rather independent of childhood circumstances.
We found an increased risk of heavy drinking among unemployed and laid-off young adults. Some previous studies have suggested that unemployment is strongly related to heavy alcohol use (Khlat et al., 2004; Lee et al., 1990; Luoto et al., 1998; Montgomery et al., 1998; Power et al., 1990), particularly in women (Ahlstrom et al., 2001), but converse results have also been reported (Hammer, 1992). It also seems that men in the military service are more likely to be heavy drinkers than full-time or part-time employed. This can be due to the culture of drinking heavily on the free weekends after being in the service through the weeks.
Methodological considerations
This study was based on a representative sample of young adults in Finland. The particular strengths of this study include the breadth of indicators of childhood living conditions and the potential to study their concordance with adult characteristics. However, the size of our data only allowed us to report on strong associations, and the cross-sectional and retrospective nature of the data raises some methodological issues that have been discussed in previous studies from the same data (Kestila et al., 2006a, 2006b; Pirkola et al., 2005). Results based on retrospective reports should be interpreted with caution (Dube et al., 2004; Hardt et al., 2004; O’Malley et al., 1986). In addition, when reporting on parental alcohol problems, respondents may have used different criteria in assessing their parents’ alcohol problems. This is a problem if the criteria vary systematically according to our explanatory variables; however, we have no reason to expect that.
The limits for risky use of alcohol are not self-evident for several reasons. First, in some cases the detrimental health consequences grow linearly without any specific threshold; second, respondents tend to under-estimate their drinking; and third, the available comparison group includes not only abstainers and moderate drinkers but also ex-drinkers, who may have quit drinking due to health-related problems. Furthermore, specifying total consumption can ignore that heavy episodic drinking may incur health damage even if total consumption does not surpass the limit (Salaspuro et al., 2005). Heavy episodic drinking would have been a relevant indicator of drinking problems in young adults: some studies have even suggested that the frequency of drunkenness may be the single best indicator of problem drinking in young adults (Bailey, 1999). However, we did not have the opportunity to use that measure in our study.
We suggest that the last year's average weekly consumption of alcohol gives a good estimate on average alcohol consumption firstly, because of the large intraindividual variation of alcohol consumption and secondly, because it is likely to indicate a more consistent pattern of drinking than, for example, alcohol consumption measured as last week's consumption.
The accuracy and validity of the self-reported measure of alcohol use have frequently been discussed (Del Boca et al., 2003); however, there is no reason to expect that childhood living conditions would markedly affect bias in self-reported drinking. It is also worth noting that many of those with severe substance use problems may not have answered the survey.
Our measure of the respondent's education could not take into account the fact that some subjects may have temporarily "finished" their education. However, regarding drinking habits, those who later continue their education may resemble those who already have a higher level of education. It is therefore possible that the effect of education would have been even stronger than we report if we had been able to anticipate the final level of education of all participants.
Regarding the measure of income in this study, we are aware that household income is not a good measure for those still living in parental home. However, it was the best indicator of income in our data set as 74% of men and 87% of women no longer lived with their parents. Moreover, the interaction between the current family structure and income was not significant.
We are aware that other factors in childhood and adolescence may affect drinking patterns in addition to, or in interaction with, familial factors. For example, the peer group, early onset of drinking, youth cultures, and the school contexts play a part in the formation of drinking behavior (Bahr et al., 1995; Bonomo, 2005; D’Amico et al., 2005; Holman et al., 1993; Jones-Webb et al., 1997; Pitkanen et al., 2005). However, we did not measure these.
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Conclusions |
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TOPABSTRACTIntroductionData and MethodsResultsDiscussionConclusionsReferences |
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Our study, in convergence with evidence from some other studies, suggests that childhood factors are associated with heavy drinking later in life. Childhood adversities associate with heavy drinking in both genders although the adversities and mechanisms are somewhat different for men and women. Childhood social circumstances should be taken into account in planning preventive policies to tackle the harms caused by excessive alcohol use at the individual and population level. For example, educational interventions on less-educated parents as well as social support to families with alcohol problems (Bauer et al., 2006
) would possibly improve the living conditions of children and decrease their risk of heavy alcohol use later in life. Recognizing needs of children in such circumstances would also be appreciated. Low educational level and unemployment status as strong characteristics of heavy drinking should be emphasized in planning preventive strategies. |
Acknowledgements |
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We are indebted to the doctoral program ‘Population, Health and Living Conditions’ and Yrjö Jahnsson Foundation for funding the study. Ossi Rahkonen was supported by the Academy of Finland (no. 210435). Special thanks are due to Tommi Härkänen at the National Public Health Institute for his methodological consultation.
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