Alcohol and Alcoholism Advance Access published online on January 29, 2008
Alcohol and Alcoholism, doi:10.1093/alcalc/agm181
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Prevalence and the Factors Associated with Binge Drinking, Alcohol Abuse, and Alcohol Dependence: A Population-Based Study of Chinese Adults in Hong Kong
1 The School of Public Health 2/F, The Chinese University of Hong Kong, Prince of Wales Hospital, New Territories, Hong Kong SAR
2 Department of Psychiatry, The Chinese University of Hong Kong, New Territories, Hong Kong SAR
* Author to whom correspondence should be addresses: Tel.: +852 2252 8700; Fax: +852 2145 8517; E-mail: siangriffiths{at}cuhk.edu.hk
Received 4 October 2007; first review notified 5 December 2007; ; accepted 12 December 2007
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ABSTRACT |
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Aims: To examine the patterns of drinking, the relationship between binge drinking, alcohol abuse, and dependence, and the sociodemographic factors associated with problem drinking among Hong Kong Chinese. Method: An anonymous, random telephone survey was conducted on 9860 Hong Kong Chinese adults from April to June, 2006. Results: The age-adjusted prevalence amongst men for binge drinking was 14.4% with 5.3% of males being alcohol abusers and 2.3% dependent on alcohol. The corresponding figures for women were all lower at 3.6%, 1.4%, and 0.7%, respectively. Younger age groups showed the highest prevalence of these drinking problems. Among male binge drinkers, 18.7% were also alcohol abusers and 12.3% were alcohol dependent. Among female binge drinkers, 16% reported alcohol abuse and 9.9% reported dependence. Male binge drinkers were less likely to be older, less likely to be students but more likely to be employed in the service industry. Female binge drinkers were less likely to be over 60 years of age or married but more likely to be smokers. In both genders, smoking was significantly associated with the likelihood of binge drinking (OR = 3.6–12.3), alcohol abuse (OR = 3.0–12.1), and dependence (OR = 5.2–20.6). Conclusions: Although binge drinking has been well tolerated in Chinese culture, it is strongly associated with alcohol abuse and dependence in both genders in Hong Kong. Our findings suggest that prevalence of problematic alcohol consumption warrants greater promotion of alcohol harms awareness. Higher rates of heavy drinking in younger-aged individuals may reflect changing lifestyle behaviors and herald higher future levels of alcohol-related health and social problems.
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INTRODUCTION |
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Alcohol-related deaths currently comprise 3.2% of all global mortality (WHO, 2007a
) and the impact of excessive alcohol consumption on the societal burden of health is well-documented in terms of increased psychosocial problems (Gmel and Rehm, 2003; French and Maclean, 2006) and psychiatric comorbidities, avoidable illness and disability (Rehm et al., 2003a; WHO, 2007a). Although great variations exist in regional drinking levels in accordance with sociocultural norms and the access to alcohol, in recent decades there has been a convergence in alcohol consumption levels around the world. Areas with historically high alcohol intakes such as Western Europe and North America have shown decreasing consumption while many countries that have traditionally had low per capita alcohol consumption have shown the greatest proportional increases in drinking levels (Rehm et al., 2003a; Room et al., 2003; WHO, 2007a; WHO, 2007b).
While China still reports drinking levels much lower than Asian countries such as Japan and South Korea (WHO, 2004), studies have reported rapidly increasing alcohol consumption with the per capita alcohol consumption tripling from 1.7 l in 1980 to 5.2 l in 2003 (WHO, 2007b). The noted increase in alcohol consumption has been attributed to westernization, the proliferation of alcohol beverage industry, and lifestyle changes brought about by greater affluence and industrialization (Hao et al., 1995; Cochrane, 2003; WHO, 2007b). In 2001, a large-scale study of 24,992 individuals over the age of 15 years in five Chinese provinces reported a past-year drinking prevalence of 74.9% among males and 38.8% among females (Hao et al., 2004). There has also been a concomitant rise in alcohol-related problems in China. A recent study noted that alcohol-related problems demonstrated the most dramatic rate of increase in all mental health problems in metropolitan areas of China (Lee et al., 2007).
Although 95% of the 6.9 million Hong Kong residents are ethnic Chinese, alcohol consumption patterns in Hong Kong are likely to differ substantially from those reported across the border in Mainland China due to Hong Kong's unusual history as a crossroads of East and West. Over a century of colonial rule has left a legacy of such westernizing influences as a British-style educational system, pervasive use of English, and a sizable expatriate population of 342,198 non-Chinese individuals (Hong Kong Census and Statistics Department, 2007). Additionally, unrestricted foreign travel has resulted in ever-increasing numbers of the population obtaining their education in United Kingdom, Canada, USA, and Australia. In 2006, 18,000 Hong Kong students were studying in the United Kingdom alone (Ha, 2006). After 1997, Hong Kong has retained a high degree of self-governance under the "one China, two systems" policy guaranteed by the Sino-British Joint Declaration of 1984. Hong Kong's laissez-faire capitalist economy has consistently been ranked the freest economy in the world according to the Index of Economic Freedom whereas Mainland China is ranked 95th (Fraser Institute, 2007). Due to Hong Kong's positive, noninterventionist economic policies, the effects of globalization such as widespread international commerce, the high penetration of uncensored international media and advertising, ready availability of foreign products, and large numbers of foreigner workers all have had comparatively stronger reverberations on Hong Kong's lifestyle than in most areas of Mainland China.
Despite evidence that Hong Kong's food consumption patterns have changed dramatically in recent decades (Leung et al., 2000; Wu and Cheung, 2002; Koo et al., 1997), population-based studies on alcohol consumption behaviors in Hong Kong are limited. Recently conducted studies have noted that 44.4% of males and 17.1% of females had consumed an alcohol drink in the past month (Hong Kong Centre for Health Protection, 2005) and that 15.4–18.5% of males and 2.1–7.9% of females reported past-month binge drinking (Centre for Health Protection, 2006; Department of Health and University of Hong Kong, 2005). School-based studies have revealed lower rates of lifetime alcohol consumption and binge drinking than in USA (Abdullah et al., 2002) but like in USA, binge drinking in Hong Kong has been associated with smoking and the male gender (Griffiths et al., 2006). Given that it is noncustomary for Chinese people to drink in solitude or on a daily basis and binge drinking on social occasions is generally considered acceptable (Yang, 2002; Cochrane et al., 2003), it important to clarify in a Chinese context the relationship between binge drinking and more pathological forms of alcohol problems such as abuse and dependence, and the factors associated with them.
The current study period, just prior to the reduction in alcohol import taxes, represents an opportune time to examine Hong Kong's alcohol consumption patterns. The data presented here may serve as baseline study for examining future trends. This paper presents the sociodemographic factors associated with binge drinking, alcohol abuse and alcohol dependence among Hong Kong Chinese adults and the interrelationship between these drinking behaviors.
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METHODS |
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The study population comprised all Hong Kong Chinese male and female adults of age 18–70 years. An anonymous cross-sectional telephone survey using a structured questionnaire was conducted in April through June of 2006 (n = 9896) using colloquial Cantonese. Two-way permit holders and temporary visitors were excluded from the study. Of our sample, 98.7% were permanent Hong Kong residents (thereby excluding practically all domestic helpers) whereas almost all the remaining 1.3% had come from Mainland China less than 7 years ago and were not yet eligible for permanent residency. Random telephone numbers were selected from up-to-date telephone directories (page, row, and column numbers) which cover nearly all households. In Hong Kong, approximately 98% of the households have a fixed telephone line (Lau and Tsui, 2003
). In order to avoid overrepresentation of unemployed persons, calls were made by trained interviewers from 6:30 p.m. to 10:00 p.m. each night. For unanswered calls, at least three other independent calls were made at different times before considering the number to be invalid. This was also done to reduce the possibility of underrepresenting social drinkers who may be out drinking. The household member whose birthday was the closest to the date of the interview was invited to join the study. Verbal informed consent was obtained from the respondents and ethics approval was obtained from the Ethics Committee of the Chinese University of Hong Kong. The response rate, defined as the number of completed interviews divided by the number of eligible households, was approximately 65.2%. The study was funded by funds from Li Ka Shing Foundation.
Measurements
The study instrument obtained information about the respondent's age, gender, marital status, education level, employment status, industry of employment, and smoking status. Respondents who reported ever having any habit of consuming alcoholic beverages in their lives were classified as ever drinkers whereas the rest were classified as lifetime nondrinkers. Those who drank alcohol in the 365 days prior to the date of interview (excluding unusual or accidental consumption of alcohol) were classified as current drinkers. Current drinkers were also asked about their average frequency of drinking in the past year (less than once a week, 1–3 times per week, 4+ times per week). Past-month binge drinking was assessed by asking whether the respondent had consumed five servings of alcohol on one occasion in the preceding 30 days (Wechsler and Isaac, 1992).
Alcohol dependence and alcohol abuse were determined from a battery of questions about problematic drinking from the Chinese Bilingual Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-IV that had been modified for cultural relevance and translated into Chinese based on DSM-IV criteria (American Psychiatric Association, 2000). The instrument has been shown to have a high degree of reliability (So et al., 2005). Specifically, respondents were classified as alcohol abusers if they reported having experienced any of the following items in the past 12 months: (i) Drinking frequently interfered with work or responsibilities at school, on the job or at home; (ii) Having been involved in legal issues because of drinking (such as being arrested by police for drunk behavior); (iii) Inability to stop drinking even though drinking caused arguments or other serious or repeated problems with family, friends, neighbors or coworkers; and (iv) Having, under the influence of alcohol, tried to do something that could affect one's safety, such as driving or operating machinery. Respondents who answered affirmatively to having experienced at least three of the following items in the past 12 months were categorized as being alcohol dependent: (i) Often drinking too much, or too long or more often than intended; (ii) Having periods of several days or more when one spent most of the time drinking, being drunk or recovering from the effects of alcohol; (iii) Having to drink more alcohol to get a "high" or relaxed feeling that drinking had given in the past; (iv) No longer being able to get a "high" or relaxed feeling on the amount one used to drink; (v) Experiencing times when one could not stop or cut down on one's drinking; (vi) Having given up or greatly reduced important activities such as work and seeing friends and family; (vii) Not being able to stop drinking even though drinking caused physical or emotional problems? (viii) Experiencing symptoms such as the following after cutting down or going without drinking: (a) sweating or fast pulse; (b) increased hand tremors; (c) insomnia; (d) nausea or vomiting; (e) psychomotor agitation; (f) anxiety; (g) grand mal seizures; (h) transient visual, tactile, or auditory hallucinations; and (ix) Drank to keep from having such symptoms. Responses to alcohol abuse and dependence questions were recoded into two binary variables for alcohol abuse and dependence.
Data analysis
Age-specific prevalence rates and 95% confidence intervals (CI) of binge drinking, alcohol abuse, and alcohol dependence were calculated for both males and females and direct age-standardized prevalence rates were calculated using the Hong Kong 2005 Census population as a reference population. Drinking frequency for those who reported binge drinking, alcohol abuse, and alcohol dependence were also reported for both genders.
Unadjusted odds ratios for sociodemographic factors associated with binge drinking, alcohol abuse, and alcohol dependence were calculated for males and females separately. Any factors that showed P < 0.20 association with these drinking variables were included as candidate variables for a stepwise multivariate logistic regression. Alcohol dependence and alcohol abuse were further examined with multivariate models that included binge drink as a candidate variable to examine the relationship between binge drinking and these other types of problematic drinking. Statistical significance was set at P < 0.05. All analyses were conducted using SPSS 14.0 (SPSS Inc., 2005).
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RESULTS |
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Characteristics of the study sample
The background attributes of the study sample (Table 1) were comparable to that of the general population in age distribution, marital status, smoking behaviors, and employment, but there was a slightly higher proportion reporting tertiary education attainment (28.8%) as compared to the general population (23%) which may be partially attributable to the fact that this sample did not include adults over 70 years of age who are noted to be less educated (Census and Statistics Department of Hong Kong, 2007). The sample also had a higher representation of individuals employed in the service industry (44.8%) as compared to the general population (31.3%).
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Alcohol use patterns
The alcohol use patterns of the study sample are shown in the following part (Fig. 1) (the entire study sample as the denominator for all percentages).
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Of the study sample, only two-thirds had ever consumed alcoholic beverages, slightly less than half were current drinkers, and 9% were current binge drinkers; 10.9% of the entire study sample (or 23% of current drinkers) reported at least one of the three types of problematic drinking. The prevalence of binge drinking in our study population was 14.5% among males and 3.5% among female respondents.
The large majority of nonbingers (95.1%) and binge drinkers (76.4%) were not found to have other problems with alcohol abuse and dependence (Table 2). Nevertheless, compared to nonbinge drinkers, binge drinkers had a significantly higher likelihood of being an alcohol abuser (3.8% versus 11.8%, P < 0.05) and more than 10-fold higher likelihood of being an alcohol dependent (0.5% versus 5.4%, P < 0.05). As compared to nonbingers, binge drinkers also reported a higher likelihood of simultaneously being an alcohol abuser and an alcohol dependent (0.6% versus 6.4%, P < 0.05). Binge drinkers with either alcohol abuse or dependence comorbidities were compared with nonbinge drinkers with alcohol abuse or dependence. Of the variables listed in Table 1, only older age was significantly associated with being a nonbinge drinker with comorbid alcohol problems. Among those reporting alcohol abuse or dependence, those who were 36–55 were more than 2.8 times more likely and those who were over 55 years of age were 15 times more likely to be nonbinge drinkers than in the 35-year and younger age group (P < 0.05).
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Age-specific rates of problematic alcohol use
The age-specific rates for ever drinking, binge drinking, alcohol abuse, dependence, abuse among binge drinkers, and dependence among binge drinkers for both genders, are shown in Table 3. Among males, the proportion of ever drinkers showed an inverted U-shaped curve trend with age. Males under 40 showed an increasing trend for lifetime alcohol use, peaking at 80% among men in their thirties and decreasing to 56% among males over 60. Among women, the trend was even more marked. Ever drinking was reported in 71.1% of women in their twenties and steadily decreased to 42.3% among women over 60 years of age. Trends for binge drinking, alcohol dependence, and alcohol abuse showed similar inverted U-shaped trends with age, peaking in the twenties for both men and women. The direct age-standardized rates showed that males had approximately fourfold increased risk for binge drinking, alcohol abuse, and alcohol dependence as compared to females.
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Binge drinking, alcohol abuse, alcohol dependence, and relation to the frequency of consumption
Problem drinkers were more likely to drink at least once per week. The percentage of males who drank at least once per week was 49.8% among binge drinkers versus 21.9% among nonbinge drinkers (P < 0.001); 47.5% among alcohol abusers versus 27.3% among nonabusers (P < 0.001); and 65.8% among those with alcohol dependence versus 27.6% who were not dependent (P < 0.001). Among females, 34.3% of binge drinkers versus 6.7% of nonbinge drinkers (P < 0.001), 24.3% of alcohol abusers versus 8.9% of nonabusers, and 40.7% of women with alcohol dependence versus 8.8% of nondependent women (P < 0.001) reported weekly drinking (data untabulated).
Sociodemographic and behavioral factors associated with problematic alcohol consumption
In the multivariate analysis, among males, binge drinking showed significant positive associations with employment in the service industry (OR = 1.3) and being a current smoker (OR = 3.7); binge drinking showed significant negative associations with age > 41 (OR = 0.4–0.6) and being a student (OR = 0.6) (Table 4). Alcohol abuse was significantly more prevalent in 21–30 year olds (OR = 2.8), divorce/widowed/separated men (OR = 2.5), smokers (OR = 2.7) and was less likely in retired men (OR = 0.3). Alcohol dependence was only significantly associated with being a current smoker (OR = 5.2) (Table 4).
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Factors associated with problem drinking among females are shown in Table 5. A multivariate analysis showed that 61– 70 year olds (OR = 0.1) and married women (OR = 0.6) were less likely to binge drink, whereas smokers were much more likely to binge drink (OR = 12.3). Students (OR = 0.1) and housewives (OR = 0.1) were much less likely to be alcohol abusers, whereas smokers were more likely to be abusers (OR = 9.5). Married women (OR = 0.3) were less likely to be alcohol dependent while smokers (OR = 20.6) were much more likely to be alcohol dependent.
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An additional multivariate model using binge drinking as a candidate variable for abuse and dependence (Tables 4 and 5) also revealed that among males, alcohol abuse was positively associated with divorced status (OR = 2.8) and being a smoker (OR = 1.7) and being a binge drinker (OR = 3.0) and negatively associated with being retired (OR = 0.3). Alcohol-dependent males were also more likely to be bingers (OR = 8.7) and smokers (OR = 2.5). Among females, there was a higher likelihood of alcohol abuse among binge drinkers (OR = 5.2) and smokers (OR = 3.4) and a lower likelihood in housewives (OR = 0.2). Females who were binge drinkers (OR = 5.8) and smokers (OR = 6.1) were more likely to be alcohol dependent in the adjusted models.
Among nonbinge drinkers, the only variables significantly associated in the multivariate model with higher likelihood of alcohol abuse were male gender (OR = 2.1, 95% CI = 1.4–3.2) while being retired (OR = 0.4, 95% CI = 0.2–0.9) and being a housewife (OR = 0.2, 95% CI = 0.1–0.8) were associated with a lower likelihood of alcohol abuse; no factors were associated with alcohol dependence (data not tabulated). Among binge drinkers, only being a smoker was associated with alcohol abuse (OR = 2.6, 95% CI = 1.8–3.6) and alcohol dependence (OR = 3.7, 95% CI = 2.4–5.8) in the multivariate models.
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DISCUSSION |
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This study has revealed that Hong Kong has lower population rates of ever alcohol consumption, binge drinking, alcohol abuse and dependence than the prevalence reported in USA and most of Western Europe (Dawson, 1996
, WHO, 2004). Nearly one-quarter of the males and nearly 40% of females were lifetime nondrinkers in our sample. Only 60.7% of males and 39.3% of females had consumed alcohol in the past year in stark contrast to USA (71% of males and 61% females), Canada (82.2% and 73.9%, respectively) and such Western European countries as France, Germany, and the United Kingdom (>90% of males and >85% of females) (WHO, 2004), indicating that alcohol consumption is still less normative than that in most societies in the Western European region and in North America. There is strong evidence indicating that the inability to metabolize ethanol may be a primary determinant in the high prevalence of abstainers (Chen et al., 1999; Peng et al., 2002; Rajendram et al., 2005). Studies have shown that as much as 89% of the Chinese carry the mutated ADH2 allele (Teng et al., 1979) that can lead to flushing and feelings of discomfort. A recently conducted study also noted that homozygosity of the ALDH2*2 allele was fully protective against alcoholism among Chinese living in Taiwan and that genotypic combinations of the polymorphic ADH2 and ALDH2 loci conferred varying levels of protection against alcoholism (Chen, 1999). Additionally, Asian males with an inactive ALDH2 (-) allele had one-third the prevalence of binge drinking and were three times more likely to be abstainers than those who had the active aldehyde dehydrogenase allele (Teng et al., 1979). Among our sample, 15.3% of respondents who reported flushing were binge drinkers, whereas 22% of respondents who did not have alcohol-related flushing were binge drinkers (P < 0.001).
Our study results, however, revealed that a smaller proportion of Hong Kong males (57.5%) drank in the past year as compared to the percentages reported in their Mainland Chinese counterparts (72.5%–84.1%) while a higher proportion of Hong Kong women (37.2%) drank in the past year compared to Mainland Chinese women (26.5%–29.3%) (Hao et al., 1999; WHO, 2004). Yet, the rates of past-month binge drinking were remarkably similar to that reported in the Chinese population in Singapore (18% for males, and 4.3% among females) (Lim et al., 2007). In addition to sharing many historical and socioeconomic similarities with Hong Kong as a port for entrepot trade, Singapore also has a legal drinking age of 18, has no restrictions on alcohol advertising, similar legal requirements for alcohol distribution but lower alcohol import duties based on volume rather than value (Government of Singapore, 2004).
Due to the cross-sectional nature of this study, it cannot be conclusively ascertained whether there is a secular trend for alcohol consumption in younger age groups or if drinking behaviors are curtailed after the age of 30. However, the inverted U-shaped trends in lifetime "ever drinking" are the strongest evidence of the secular trends in increasing alcohol uptake in Hong Kong. The marked difference in ever consumption of alcohol among females aged 21–30 (71.1%) when compared to women over the age of 60 (42.3%) is particularly noteworthy. A study conducted in 1988 in Hong Kong noted that only about 25% of males and "few women" ever drank alcohol and that the lifetime prevalence of alcohol abuse or dependence was 9% among men and 1% among women (Donnan, 1988) as compared to the 7.6% past-year prevalence among men and 4.9% among women in our data. The age of drinking initiation has steadily fallen among ever drinkers from a median age of 25.2 years among people over 75, steadily dropping to 18.1 years among 25–34 year olds (Department of Health and University of Hong Kong, 2005). There has been an increasing trend of underage drinking with 20% of youths currently admitting to drinking alcohol (Youth Research Center, 2000). In concordance with the life course approach (Smith, 1997), the age-specific data suggest that increased risk of ever drinking may lead to a higher risk of binge drinking, which in turn may result in a greater risk of alcohol abuse and dependence. Government data are suggestive of a shifting pattern of alcohol consumption with drinkers under 35 years of age preferentially consuming beer (75%) and table wine (21%) over Chinese wine (2%) and spirits (3.3%) (versus 40.6%, 11.1%, 35.0%, and 15.5%, respectively among those over 65 years) (Department of Health and University of Hong Kong, 2005).
Differences in alcohol consumption patterns between those noted in our study and studies from the past may be partially attributed to demographic changes in Hong Kong society. The shift from a manufacturing-based economy to a service-oriented industry in past two decades (Information Services Department, Hong Kong Government, 1997) is likely to have increased alcohol consumption levels since service industry employment was strongly associated with binge drinking among males. Moreover, women's changing roles in Hong Kong are likely to have contributed to increasing drinking levels. Studies around the world have noted that greater entry into the workforce has been associated with increased drinking levels among women (Allamani et al., 2000; Parker et al., 1980). Our study noted that married women and housewives were less likely to be problem drinkers. In the last few decades the proportion of women in the labor force has steadily increased to 53% and the age of marriage has been gradually increasing to the current mean age of 28.2 years (Hong Kong Census and Statistics Department, 2006). In Hong Kong, lifestyles of single, working women offer far more opportunities for regular social gatherings where alcohol is typically served. We cannot, however, determine unequivocally from our data whether alcohol consumption is curtailed after marriage or whether it is simply a cohort effect of greater drinking among younger women.
The prevalence of binge drinking among males (14.4%) and females (3.6%) in our study was similar to the prevalence reported by the Behavioral Risk Factor Survey (15.4% and 2.1%, respectively) (Centre for Health Protection, 2006) but somewhat lower than that reported by the Hong Kong Population Health Surveys (18.5% and 7.9%, respectively) (Department of Health and University of Hong Kong, 2005) but which may partially be due to differences in sampling and data collection methodologies. Nonetheless, in all available data, trends for binge drinking, alcohol dependence, and alcohol abuse peaked in the twenties and early thirties for both men and women, suggesting that these groups are a risk group for problematic drinking. If in fact, these data reflect a secular trend in alcohol consumption patterns, problematic drinking may be an emerging public health issue. It may therefore be the most cost-effective to target alcohol-related interventions before abuse and dependence problems surface. Similar to research conducted in other countries (Robin et al., 1998; Jennison, 2004), our data also showed a strong association between binge drinking, alcohol abuse, and alcohol dependence in both genders. Moreover, the much higher prevalence of alcohol-related co-morbidities among binge drinkers indicates that it would be strategic to target binge drinkers in future public health interventions. Since the cross-sectional nature of this study limits the causal inferences that can be drawn, longitudinal studies of binge drinkers should be conducted to examine the risk of developing alcohol abuse and/or alcohol dependence.
There is evidence to suggest that alcohol consumption patterns are heavily influenced by other lifestyle factors. As mentionedin the foregoing, being married or being a housewife was associated with lower likelihood of binge drinking, alcohol abuse, and dependence among women. Among males, binge drinking was positively associated with service industry employment, negatively associated with student status, and retired status was associated with lower risk of alcohol abuse. These observations indicate that the social context of drinking, work environment, and peer group norms are important to understanding drinking patterns in Hong Kong, particularly since Chinese do not customarily drink in solitude (Cochrane et al., 2003, 2004; Yang, 2002). It is normative in Chinese tradition to drink on social occasions (Yang, 2002; Cochrane et al., 2003). Social gatherings of young people commonly involve alcoholic beverages as a way to invoke a celebratory atmosphere, which may predispose individuals to binge drinking. At the same time, this means "binge drinking," as we defined it, may be perceived as normative and not necessarily seen as tantamount to future pathology. In our sample, only 4.5% of alcohol abusers and 4.1% of those with dependence have ever sought professional help. When the remaining respondents were queried as to why they did not seek help, 99% responded that they did perceive their drinking as problematic. Hence, drunken comportment, as defined by MacAndrew and Edgerton, may not be perceived as inappropriate under the context of celebration or socializing (MacAndrew and Edgerton, 1969). Moreover, in our study, drinking at least once per week was reported only among 47.5% of male alcohol abusers and 65.8% of males with alcohol dependence and in 24.3% of female alcohol abusers and 40.7% of women with alcohol dependence. The frequency of drinking amongst problem drinkers in Hong Kong may be less than that in other parts of the world given the general pattern of nondaily and nonsolitary drinking that is common in Chinese culture. Since the DSM-IV criteria for abuse and dependence do not stipulate the frequency of alcohol consumption, cultural variations in drinking frequency are possible within these categories. Whether or not Chinese with drinking problems drink less frequently and whether they are less likely to develop clinical and psychosocial complications should be examined in future studies.
The strong association between smoking and increased risk of binge drinking, alcohol abuse, and alcohol dependence in both genders indicates these behaviors may share similar risk factors such as peer effects or that the use of one substance influences the use or initiation of use of the other. The prevalence of smoking among middle school students in Hong Kong nearly doubled between 1994 and 2004 from 14% to 25% among boys and 8% to 13% among girls (Lai et al., 2005). Given the strong correlation of problem drinking with smoking, the increasing rates of smoking among youths in recent years is a cause for concern. It may thereby be prudent to include drinking awareness and interventions as part of smoking cessation programs. It will be worthwhile to examine whether the strong association between problematic alcohol use and smoking persists in the years following the 2007 regionwide ban on indoor smoking that was implemented despite vociferous opposition from local bar owners.
This study has a number of limitations. The first is about validity. The questions for assessing alcohol abuse and dependence, though carefully translated and adapted from the DSM-IV by the authors who have used similar diagnostic questions in large-scale community psychiatric surveys in Chinese communities (Lee et al., 2007), have not been validated. The anonymous nature of the telephone interviews also precluded us from conducting a second phase of face-to-face clinical reappraisals on a subsample of participants. More generally, the validity of self-reported alcohol use, particularly problematic drinking, which is considered sensitive information has always been brought to question in population surveys. Nonetheless, the authors feel that the anonymous nature of the telephone interviews, the largely nonpathological lay perception of alcohol drinking among Chinese people in Hong Kong, the use of standardized DSM IV items, which use neutral wording as much as possible, and the fact that the study was sponsored by local university, minimized underreporting of problematic alcohol consumption. The response rate of 65.2% was considered to be high for telephone surveys, which can be as low as 50% for sensitive survey topics (Lau et al., 2006a; Lau et al., 2006b). The study population was highly representative of the general population in terms of age and gender. However, our sample had higher representation of tertiary educated individuals (females among whom have higher binge drinking rates) and service industry workers (males among whom have higher binge drinking rates), which may result in slightly higher rates of binge drinking reported. Additionally, the questionnaire did not specifically ask about consumption of nonbranded alcohol. Anecdotally, homemade alcohol represents a negligible portion of alcoholic beverage consumption. In Hong Kong alcohol is typically consumed in bars, karaokes, and restaurants, which must be licensed to serve commercial, branded alcoholic beverages. Unlicensed establishments serving alcohol face stiff penalties. Lastly, the adequacy of the definition of 5+ serving of alcohol in one sitting for binge drinking that was defined by Wechsler (Wechsler and Isaac, 1992) is controversial. Due to the numerous definitions of binge drinking used in various surveys, it is difficult to make direct comparisons of the data. However, the use of other measures of high episodic alcohol consumption (e.g., blood alcohol content, breath test results) are impractical for large-scale, self-reported surveys.
Implications for policy for reducing the health burden of alcohol at the regional level
In Hong Kong, alcohol is subject to high import duties and law enforcement is primarily concerned with recovering revenues from smuggled alcoholic beverages (Customs and Excise Department, 2007). In addition to being frequently advertised in the media, alcohol is widely accessible in convenience stores and supermarkets. Although there is no minimum age for drinking, there is a minimum age of 18 for the sale of alcohol, which is occasionally enforced in drinking establishments but rarely in stores. Proprietors of drinking establishments may face a fine and possible imprisonment of up to 6 months if underage drinkers are found in a police raid (Hong Kong Legal Information Institute, 2007). There is no legislation prohibiting the sale of alcohol during certain times of the day or the number of drinks allowed to be sold to bar patrons.
In contrast to recent actions taken by the European Union to reduce the harm of alcohol use, comparatively little attention has been paid to drinking in Hong Kong. Most of the substance use efforts are directed towards the control of psychotropic drugs. However, the applicability to Hong Kong of measures such as restricting alcohol advertising near schools that have been proposed in Europe remains unclear because the cultural and political milieu differs greatly. For instance, our data show university students in Hong Kong are less likely to drink than their nonstudent peers of the same age. Although Hong Kong is duty-free port, the government has historically imposed a heavy luxury tax on alcoholic beverages of up to 100%. Since this study was conducted, the government has halved the import duty on table wine to 40% and beer to 20%, the very alcoholic beverages preferred by younger drinkers who are more likely to binge drink. Due to the noted price elasticity of alcohol (Keng and Huffman, 2007), a resulting increased uptake of alcohol consumption in these young drinkers may have long-term repercussions on the drinking habits of the Hong Kong population.
Alcohol policy research has shown better outcomes for individuals that receive timely intervention for their drinking problems (Room et al., 2005). Currently, there are almost no integrated alcohol-related health services in Hong Kong. Specialist medical clinics are segmentalized and deal largely with those suffering from advanced stages of alcohol-related medical or psychiatric complications, such as cirrhosis, depression, or psychosis. The local Alcoholics Anonymous group is focused on expatriates and conducts sessions almost exclusively in English. In other parts of the world, screening and brief interventions (SBI), typically administered by physicians, have been shown to substantially reduce alcohol consumption in high-risk drinkers before the onset of severe alcohol-related problems such as dependence (Moyer et al., 2002). The low level of perceived harms reported by problem drinkers and the yet low level of alcohol dependence reported in our study indicate that SBI may be a cost-effective intervention applicable to Hong Kong's drinking population. However, only 23.2% of Hong Kong's total population and only 14% of 15–35 year olds have regular health check-ups (Department of Health and University of Hong Kong, 2005). Hence, worksite alcohol interventions which have shown a measure of success in USA (Bennett et al., 2004) may be a more appropriate setting for targeting high-risk groups (younger people, service industry workers, unmarried working women). Work-site health promotion activities may be a cost-effective platform for delivering SBI. Additionally, internet-based self-screening and brief intervention for alcohol-problems has been shown to draw high volume of visitors (Saitz et al., 2004), have high degree of acceptability among young people (Kypri et al., 2003), and reduce problematic drinking levels (Linke et al., 2007). Given that Hong Kong has one of the highest internet penetration rates in the world (Miniwatts Marketing Group, 2007), it may also be worthwhile to examine the internet as a cost-effective platform for alcohol self-screening and brief intervention.
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This study was funded by the Li Ka Shing Foundation.
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