Prevalence and Patterns of Alcohol Use Among College Students: Comparing Scenario in Arunachal Pradesh and Kerala

PREVALENCE AND PATTERNS OF ALCOHOL USE AMONG COLLEGE STUDENTS: COMPARING SCENARIO IN ARUNACHAL PRADESH AND KERALA

Dr Tumge Loyi

Dissertation submitted in partial fulfillment of the requirements for the award of the degree of Master of Public Health

Achutha Menon Centre for Health Science Studies Sree Chitra Tirunal Institute for Medical Sciences and Technology Thiruvananthapuram, Kerala October 2009

ACKNOWLEDGEMENTS

Foremost, I would like to express my sincere gratitude to my guide Dr. Biju Soman, Associate Professor, AMCHSS for his supervision, advice and guidance throughout the time of research and writing of this thesis.

I thank Dr. K. R. Thanakappan, Professor and Head of AMCHSS and faculty members, Dr. V. Raman Kutty, Dr. T K Sundari Ravindran, Dr. P. S. Sarma Dr. Mala Ramanathan, Dr K. Srinivasan, and Dr.Manju R.Nair of AMCHSS for providing valuable suggestions for the study. I am also sincerely thankful to Mr. Sundar Jayasingh, Deputy Registrar, SCTIMST for his administrative and logistic support.

I would also like to extend my heartfelt thanks to the staff and the students of Mahatma Gandhi College, Trivandrum; Mar Ivanios College, Trivandrum; University College, Palayam; KNM College, Kanjiramkulam; St. Xavier‟s College, Thumba; Donyi- Polo Govt. College, Kamki for their kind help and cooperation and in particular I wish to express my gratitude to Shri Madhukumar, Father Mathew Manakarakavil, Smt. Chris George, Shri Sajesh Stephen, Father Sunny Jose and Dr. Motum Nomuk who were the Principals of these colleges. I also wish to thank Shri Godwin SK, Govt. Women‟s college for helping me in conducting the study.

Collective and individual acknowledgements are also owed to my colleagues, all MPH/DPH 2008 students, PhD scholars, Project staff for their help and support. Many thanks go in particular to Dr. Indrani and Dr.Madhu for their help and constant encouragement.

I cannot end without thanking my family, in particular Maen, on whose constant support and love I have relied throughout the duration of the study.

Certificate

This is to certify that the work embodied in this dissertation entitled “Prevalence and patterns of alcohol use among college students: Comparing scenario in Arunachal

Pradesh and Kerala” is a bona fide record of original research work undertaken by Dr

Tumge Loyi, in partial fulfillment of the requirements for the award of the degree of

„Master of Public Health‟ under my guidance and supervision.

Guide

Dr. Biju Soman MBBS, MD, MPH Associate Professor Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology

Thiruvananthapuram October 2009

DECLARATION

I hereby declare that the work embodied in this dissertation entitled

“Prevalence and patterns of alcohol use among college students: Comparing scenario in

Arunachal Pradesh and Kerala” is the result of original research and has not been submitted for award of any degree/diploma in any other university or institution.

Dr. Tumge Loyi Achutha Menon Centre for Health Science Studies Sree Chitra Tirunal Institute for Medical Sciences and Technology

Thiruvananthapuram

October 2009

TABLE OF CONTENTS

ABSTRACT……………………………………………………………………………………………………………………………. 8 CHAPTERS CHAPTER 1:REVIEW OF LITERATURE 1.1 Introduction………………………………………………………………………….…………...…………….………….... 9 1.2 History……………………………………………………………………………….…………...…………….…………...... 10 1.3 Current scenario…………………………………………………………………….………………………….…………… 10 1.4 Current patterns and trends of alcohol use in India……………………………….……………………….. 13 1.4.1 Drinking trend among youth…………………………………………………….…………….…………...... 14 1.4.2 Drinking trends among women……………………………………………………………….…………...... 15 1.5 Impact of alcohol on health………………………………………………………….…………..…………….……… 15 1.6 Positive effects of alcohol………………………………………………………….…………….…………….………. 17 1.7 Social impact of alcohol…………………………………………………………….………………………….………… 17 1.7.1 Alcohol consumption and the workplace……………………………………….…………….…………. 18 1.7.2 Alcohol consumption and the family………………………………………..….…………….…………… 18 1.7.3 Alcohol and poverty…………………………………………………………....…………….…………...... 19 1.7.4 Alcohol and domestic violence……………………………………………………………….…………...... 19 1.8 Economic impact of alcohol……………………………………………………….……………..…………….……. 19 1.9 Rationale for the study………………………………………………………….….…………………………………… 20 1.10 Objectives of the study………………………………………………………..….………………………………….. 21

CHAPTER 2: METHODOLOGY 2.1Study type………………………………………………………………………..….…………………………………………. 22 2.2 Study setting…………………………………………………………………….……………….…………………………… 22 2.3 Study population…………………………………………………………………….…………...………………………… 22 2.4 Time frame…………………………………………………………………….……………………………………………… 22 2.5 Sample size…………………………………………………………………….………………………………………………. 23 2.6 Sample selection procedure………………………………………………………….…………...………………….. 24 2.7 Data collection………………………………………………………….……………………….…………………………… 25 2.8 Data analysis………………………………………………………….………………………….……………………………. 26 2.9 Study variables………………………………………………………….………………………..………………………….. 27 2.9.1 Dependent variables……………………………………………………….…..………………………………….. 27 2.9.2 Independent variables……………………………………………………….……………………………………. 28 2.10 Ethical considerations………………………………………………………….……………………………………….. 31 2.11 Definitions………………………………………………………….………….……………….……………………………. 32 2.12 Spectrum of alcohol use………………………………………………………….…………….……………………… 33

CHAPTER 3:RESULTS 3.1 Sex………………………………………………………….………….………….……………...……………………………… 36 3.2 Religion………………………………………………………….………….………………………………………………….. 36 3.3 Monthly pocket money allowance of the respondents………………….……………………………….. 37 3.4 Residence………………………………………………………….…………………………………………………………… 38 3.5 Type of family………………………………………………………….……………………...... ………………………….. 38 3.6 Alcohol use………………………………………………………….…………………………………………………………. 38 3.7 Place where the first drink of alcohol was taken…………………………………………………………….. 38 3.8 Reason for trying alcohol for the first time……………………………………………………………………… 39 3.9 Type of alcohol that was first tried…………………………………………………………………………………. 39 3.10 With whom the first alcoholic drink was taken…………………………………………………………….. 39 3.11 The place where alcohol was obtained for the first time……………………………………………… 39 3.12 Usual place of drinking alcohol…………………………………………………………...... 40

3.13 Usual type of alcohol taken…………………………………………………………………………………………. 40 3.14 Frequency of getting drunk in the past 30 days…………………………………………………………... 40 3.15 Any trouble caused by drinking in the last 30 days………………………………………………………. 41 3.16 Monthly expenditure on alcohol………………………………………………………………………………….. 41 3.17 Managing money for alcohol……………………………………………………………………………………….. 41 3.18 Alcohol use among parents………………………………………………………………………………………….. 42 3.19 Alcohol use among siblings…………………………………………………………………...... 42 3.20 Discussion in the family about harmful effect of alcohol……………………………………………… 43 3.21 Discussion in the institute about harmful effect of alcohol………………………………………….. 43 3.22 Perceived reasons for drinking by others……………………………………………………….……………. 43 3.23 Perceived risk if alcohol was consumed once or twice in a year…………………………………… 44 3.24 Perceived risk if alcohol was consumed several times in a week…………………………………… 44 3.25 Type of alcohol that is safest………………………………………………………………………………………… 44 3.26 Perceived health benefit of alcohol consumption…………………………………………………………. 44 3.27 Prevalence of drinking problem………………………………………………………………...... 45 3.28 Prevalence of smoking………………………………………………………………………………………………….. 45 3.29 Prevalence of use of non-smoke tobacco……………………………………………………………………… 45 3.30 Bivariate Analysis Results……………………………………………………………………....…………………….. 45 3.30.1 Combined analysis for association with alcohol use……………………..………………..……… 46 3.30.2 Separate analysis for association with alcohol use………………………….……………………… 47 3.30.3 Combined analysis for association with problem drinking (CAGE) …….………………….. 49 3.31 Separate analysis for association with problem drinking (CAGE) ………………………………….. 50 3.32 Binary logistic regressions with ever alcohol……………………….………………………….……………. 52

CHAPTER : DISCUSSION 4.1 Prevalence and patterns…………………………………………………………………………..……………………. 54 4.2 Socio demographic characteristics………………………………………………………………………………… 58 4.3 Strengths of the study……………………………………………………………………………………………………. 59 4.4 Limitations of the study………………………………………………………………………….………………………. 59 4.5 Conclusion…………………………………………………….………………………………….……………..…………….. 60 4.6 Recommendations…………………………………………………….………………………….……………………….. 61

REFERENCES 62

ANNEXURES ANNEXURE 1………………………………………………………………………………………………………………. 67 ANNEXURE 2………………………………………………………………………………………………………………. 74 ANNEXURE 3………………………………………………………………………………………………………………. 75

TABLES 1.1 Annual per capita consumption of alcohol per adult 15 years of age and over……………….. 11 3.1 Sex distribution…………………………………………………….…………………………….………………………….. 36 3.2 Monthly pocket money allowance……………………………………………………………….………………… 37 3.3 Residence…………………………………………………….…………………………………..……………..…………….. 37 3.4 Alcohol use…………………………………………………….………………………………………………..…………….. 38 3.5 Frequency of getting drunk in the past 30 days……………………….……………………………………… 40 3.6 Any trouble caused by drinking in the last 30 days……………………………………………..………….. 41 3.7 Monthly expenditure on alcohol…………………………………………………………………………………….. 41 3.8 Alcohol use among parents……………………………………………………………………………………..……… 42 3.9 Alcohol use among siblings……………………………………………………………………...…………………….. 42

3.10 Discussion in the family about harmful effect of alcohol……………………………………………… 43 3.11Discussion in the institute about harmful effect of alcohol…………………………………………… 43 3.12 Perceived health benefit of alcohol consumption………………………………………………………… 44 3.13 Problem drinking…………………………………………………….………………………….……………..………… 45 3.14 Association with alcohol use………………………………………………………………………………………… 46 3.15 Separate bivaritate analysis with alcohol use…………………………………………………...…………. 47 3.16 Combined analysis with problem drinking……………………………………………………..……………. 49 3.17 Separate analysis with problem drinking……………………………………………………….…………….. 50 3.18 Regression with Ever use of alcohol…………………………………………………………………………….. 52

Abstract

Background

Alcohol consumption is a major public health issue in the world. Understanding regional differences in its use will help in planning for better interventions.

Objectives

The objective of this study was to assess and compare prevalence, patterns and harmful use of alcohol among college students in Arunachal Pradesh and Kerala.

Methodology

A self administered questionnaire survey done among college students in the selected districts of Arunachal (352 students) and Kerala (703 students). Scientific sampling method (stratified sampling using class divisions as strata) was used to select students. Questionnaire sought information on demography, patterns of alcohol use, alcohol use in family and among friends, beliefs and perceptions regarding alcohol, the CAGE questionnaire and tobacco practices. Univariate, bivariate and multiple logistic regression analysis were done using SPSS version 17.0.

Results

Prevalence of alcohol use among college student was 60.5% and 22% in Arunachal and Kerala respectively. Students having problem drinking was 32.3% and 8.1% in Arunachal and Kerala respectively. Majority (81.2%) of males and 38.6% of females used alcohol in Arunachal Pradesh. In Kerala 46.1% males and 5.9% females use alcohol. Mean age of initiation was earlier (11years) in Arunachal compared to Kerala (16 years). Most students (70.6%) in Arunachal got initiated into alcohol at own home and 44.9% continue to drink at home where as in Kerala these are 23.8 and 16.1 percent respectively. In Arunachal family members were present at initial drink in majority (63.3%) whereas it was only 24.5% in Kerala. Amount of pocket money, use among parents and siblings, discussions on harm of alcohol in family and school/colleges had an impact on use of alcohol.

Conclusions

Study highlights increased prevalence of alcohol among college students and emphasizes on regional difference in the practices and beliefs attached alcohol. Future interventions on alcohol menace should be made in tune with its regional differences.

Chapter 1

Review of Literature

1.1 Introduction.

Alcohol has been defined in the Webster‟s dictionary as any of a series of volatile hydroxyl compounds that are made from hydrocarbons by distillation. In common usage,

"alcohol" often refers simply to ethanol or "grain alcohol", which may be produced by fermentation of fruits or grains with yeast and is one of the oldest and most widely used recreational drugs in the world, typically taken in the form of an alcoholic beverage.

Ingestion in sufficient quantity results in a state known as drunkenness or intoxication.1

Alcohol is a psychoactive substance which has an effect on people in many ways. It mainly acts on central nervous system but it also affects almost all other body organs and systems. Alcoholic beverages contain ethyl alcohol (ethanol), produced as a result of the fermentation of starch which includes grains (beer), vegetables (vodka) and fruits (wine).

Ethyl alcohol has no taste and is a colorless liquid. Each alcoholic beverage is different in taste and the way it looks, due to the presence of other substances which are added deliberately or accidentally. The manufacturing process also gives a distinct flavor and color to the alcoholic beverage. Alcohol is absorbed directly into the bloodstream through the walls of the stomach and the small intestine, and is then quickly distributed all over the body. All alcohol that is consumed enters the bloodstream and then goes to the brain.

It takes only a few minutes for alcohol to reach the brain and begin to act. Liver is the main organ which metabolize alcohol, and on an average it takes about one hour for the liver to completely digest a standard alcoholic drink.2

1.2 History

Alcohol has been consumed by humanity since time immemorial.3 In every ancient civilization there is evidence of use of alcoholic beverages. It has been consumed in various forms and under various circumstances and for various reasons. In India too, alcoholic beverages seem to have been around since the Indus Valley civilization. These people not only fermented, but also distilled alcoholic beverages. An important thing to note here is that during this period itself the harmful effects of alcohol were identified and the ancient Vedas strictly prohibited its use.

In the Rig Veda it is mentioned that alcohol be strictly prohibited for Brahmins and students. The Sutras could serve it to guests or when a bride first enters her husband‟s house. The warrior class of Kshatriyas and the trading community of Vaishyas could take alcohol brewed from honey, mahua flowers or jaggery, but not from those made by distillation of fermented grains. Alcoholic beverages in those days were usually from fermented grains, flowers and fruits. Another variety was from the exudates of spathes of coconut or palmyra trees. These exudates were fermented to yield alcoholic beverages.

This variety is the so called toddy or tari, which is distilled to give arrack.

During the days of British India, the first distillery was established to produce IMFL

(Indian Made Foreign Liquor) in Kanpur in 1805. Following this, many more distilleries came up. This led to an appreciable increase in consumption. By the time India gained her

Independence, the makers of the Constitution of India included the prohibition of intoxicating drinks under the Directive Principles.4

1.3 Current scenario

Global alcohol consumption has increased in recent decades, with most or all of this increase occurring in developing countries.3 Both average volume of alcohol consumption and patterns of drinking vary dramatically between sub-regions. Average volume of

10 drinking is highest in Europe and North America, and lowest in the Eastern

Mediterranean and SEAR-D regions (Bangladesh, Bhutan, DPR Korea, India, Maldives,

Myanmar and Nepal). Alcohol causes 3.2 percent of deaths (1.8 million) and 4.0 percent of DALYs (58.3 million). Within sub-regions, the proportion of disease burden attributable to alcohol is greatest in the Americas and Europe. 3

Table 1.1 Annual per capita consumption of alcohol per adult 15 years of age and over Region Consumption Range Percentage of population (liters) covered

Africa 03.9 0.02 - 07.72 76.7 America 16.2 1.66 - 14.03 99.9 Eastern 00.4 0.05 - 10.00 90.4 Mediterranean European 10.5 0.85 - 15.12 99.9 South-East Asian 01.7 0.04 - 08.64 98.4 West Pacific 04.8 0.34 - 18.39 99.9 Source: Global Status Report on Alcohol, WHO 2004

South-East Asian societies are in a state of rapid transition. Traditional societies are gradually adopting modern lifestyles, giving rise to new problems. The alcohol industry is huge in the region. It is estimated that there are over 600 factories, 1582 distributors and thousands of retail outlets involved in alcohol production and retailing.

Over 4 million people are involved with the industry.5

Although India is regarded as a traditional „dry‟ country, it is the dominant producer of alcohol in the South-East Asia region (65 percent) and contributes to about 7 percent of the total alcohol beverage imports into the region. More than two thirds of the total beverage alcohol consumption within the region is in India. There has been a steady increase in the production of alcohol in the country, with the production doubling from

887.2 million liters in 1992-93 to 1,654 million liters in 1999-2000 and it was almost

2300 million liters by 2006-07. India is experiencing a massive increase in alcohol

11 consumption. This is coupled with the initiation age decreasing on an alarmingly. The recorded market and consumption levels are still very low as compared to the global standard. The illicit market consumption is far more than legal sales.4

Country liquor is a distilled alcoholic beverage made from locally available cheap raw material such as sugarcane, rice, palm, coconut and cheap grains, with alcohol content between 25-45 percent. Common varieties of country liquor are arrack, desi sharab and toddy. Illicit liquor is mostly produced in small production units with raw materials similar to that used for country liquor. With no legal quality control checks on them, alcohol concentration of illicit liquor varies (up to 56 percent). Adulteration is quite frequent, industrial methylated spirit being a common adulterant, which occasionally causes incidents like hooch tragedies. Cheaper than licensed country liquor, illicit liquor is popular among the poorer sections of the population. In many parts of India, illicit production of liquor and its marketing is a cottage industry with each village having one or two units operating illegally.6

Toddy is an alcoholic drink made by fermenting the sap of coconut or palm. It is white and sweet with a characteristic flavor. It has between 4-6 percent alcohol and has a shelf life of about 24 hours.7, 8 Toddy is popular among the lower socioeconomic groups in south India. Besides these, home production for self-consumption is also common in some parts of India. Toddy is brewed all along the coast. Besides toddy, home fermentation and distillation is also common in several tribal areas in the country, especially the north-eastern region of the country.

The area of Arunachal Pradesh boasts a rice wine called Apong (Poka). Rice beers like handia and chhung are also popular in the hills and the tribal belts. Distillates, however, are also common - from arrack to desi to the mahua used in the tribal belts. Toddy and

12 the rice brews are not considered very damaging to the health – being natural brews. Jack- fruit wine is an alcoholic beverage made by ethnic groups in the eastern hilly areas of

India. As its name suggests, it is produced from the pulp of jack-fruit (Artocarpus heterophyllus). Ripe fruit is peeled and the skin discarded. The seeds are removed and the pulp soaked in water. Using bamboo baskets, the pulp is ground to extract the juice, which is collected in earthenware pots. A little water is added to the pots along with fermented wine of a previous batch. This acts as the inoculums. The pots are covered with banana leaves and allowed to ferment at 18 to 30ºC for about one week. The liquid is then decanted and drunk. During fermentation, the pH of the wine reaches a value of 3.5 to

3.8, suggesting that an acidic fermentation takes place at the same time as the alcoholic fermentation. Final alcohol content is about 7 percent to 8 percent within a fortnight.8

1.4 Current patterns & trends of alcohol use in India

The prevalence of alcohol use is still low in India as compared to other countries. Though consumption is low, patterns of alcohol consumption vary widely through the country.

Punjab, Andhra Pradesh, Goa and the north-eastern states have a much higher proportion of male alcohol consumers than the rest of the country. Women tend to drink more in the states of Arunachal Pradesh, Assam and Sikkim in north-east; Madhya Pradesh,

Chhattisgarh, Orissa and Andhra Pradesh in central and east India; and Goa in the west, compared to other states.9 The unrecorded consumption and expenditure on alcohol still remains high in India.5

Repeated observations have documented that more than 50 percent of all drinkers in

India, satisfy the criteria for hazardous drinking. The people who indulge in hazardous drinking follow a pattern. They drink alone; drink predominantly IMFL and drink more than five standard drinks per occasion. Alcohol use is strongly associated with expectations of disinhibition and violence, especially among men, which 'legitimizes'

13 male drunkenness and violence. Patterns of alcohol consumption are probably more important than per capita levels of alcohol use in predicting whether people will experience problems with their drinking, making them better indices of the likelihood of harm in the population.4

Studies done on the inhabitants of Arunachal Pradesh have shown that the prevalence of alcohol use varies. A study done by Chaturvedi et al showed it to be 30 percent.10 Another study showed it to be 50 percent.11 This same study showed that prevalence of alcohol consumption was 64.2 percent among males and 34.7 percent among females. It also found that most of the alcohol users consumed local home beverages, and only very few consumed IMFL (Whisky/Rum/Brandy/Gin). The NFHS 3 found the prevalence of alcohol consumption among men in Arunachal Pradesh to be 61.1 percent and among women to be 33.6 percent.9

In the case of Kerala, it has been mentioned that the per capita alcohol consumption is highest in India.4 The NFHS 3 data shows the prevalence rates among men in Kerala to be 45.2 percent and 0.7 percent among women.9

1.4.1 Drinking trend among youth

The age of initiation to alcohol is going down. Different states have different legal minimum age limits for alcohol consumption, with the lowest being 18 years in

Karnataka and Kerala and the highest at 25 years in Delhi; Maharashtra has permissible age for beer and wine as 21 years and 25 years for spirits. There is increasing lobbying by the alcohol industry for reduction in the permissible age. Young people, especially teenagers, are more sensitive to alcohol use because their bodies and brains are still developing. Studies and findings around the world are conclusively underscoring the dangers of early alcohol use resulting in a much higher risk of dependence and abuse, but

14 the legal age in India for serving alcohol is seldom checked. In India, the young are being lured towards alcohol use. They are impressionable, want to be seen as fun, hip, cool &

„belonging‟ to their peer groups and friend circles. Alcohol also provides an „excuse‟ to behave in an uncontrolled manner. In a setup like India, alcohol consumption takes place without the knowledge of parents and family.4

1.4.2 Drinking trends among women

The little information that exists about patterns of consumption in India indicates that women consumers can have an equally explosive pattern of alcohol consumption as men.

Traditionally, their numbers have been lower but persuasive marketing and „advancing‟ urban lifestyles can make a significant change in this and they make another popular target group. A recent study in Karnataka reported no major difference between the amounts of alcohol drunk by men or women on any typical drinking occasion. The frequency of use varies between men and women, with men drinking more frequently than women. It might be noted that while almost 70 percent of the male drinkers drink daily or almost daily, 55 percent of women drinkers also drink at the same frequency.

This can hardly be termed “infrequent” drinking.

1.5 Impact of alcohol on health

It has been estimated by WHO that worldwide there are about 2 billion people who consume alcoholic beverages. 3 Of these 76.3 million have diagnosable alcohol use disorders. Globally, alcohol causes 3.2 percent of all deaths (1.8 million deaths) and 4 percent of Disability-Adjusted Life Years (58.3 million DALYs). This proportion is much higher in males (5.6 percent deaths and 6.5 percent of DALYs) than females (0.6 percent deaths and 1.3 percent DALYs).

Besides the direct effects of intoxication and addiction, alcohol is estimated to cause about 20-30 percent of each of the following worldwide: esophageal cancer, liver cancer, and cirrhosis of the liver, homicide, epilepsy, and motor vehicle accidents. For males in

European region, 50-75 percent of drownings, esophagus cancer, epilepsy, unintentional injuries, homicide, motor vehicle crashes and cirrhosis of the liver are attributed to alcohol.3, 12

In a study conducted in Bangalore, India, alcohol users reported more health problems than the non-users. The alcohol-users were found to be at approximately three times at higher risk of suffering from a health problem as compared to non-users.13

Alcohol affects almost every organ of the body. It can cause an endless list of negative health outcomes. Few of them are given here. Heartburn, nausea and gastritis, malabsorption syndromes, worsens complications of diabetes, anemia, reduced sexual capacity, increased risk of seizures, addiction and alcohol dependence, depression, anxiety, suicide and other psychiatric symptoms, abuse of other substances including tobacco, fatty liver, alcoholic hepatitis and cirrhosis, alcoholic pancreatitis, cardio- vascular effects include: poor blood pressure control, increased cerebral hemorrhage and strokes, cardiomegaly, cardiac failure, and arrhythmias, reduced immunity and increased susceptibility to infections, damages to the musculo-skeletal system, impaired sleep and memory, polyneuropathy, delirium tremens, Wernicke‟s encephalopathy and Korsakoff‟s syndrome and hallucinations.12, 14, 15 And especially for female users of alcoholic beverages, it has been proved that alcohol negatively affects the fetus leading to Fetal

Alcohol Syndrome. 16, 17 One study has even reported that alcohol use can be considered a risk factor for periodontitis.18 It has been reported time and again that alcohol leads to high-risk sexual behaviors. Alcohol consumption acts as a disinhibitor to high-risk sexual behavior. This might include wrong choice of partners, non use of condoms and also

16 having multiple partners.19-22 Alcohol is so harmful to the body that there is a list of diseases named solely upon alcohol. These are: 23, 24 Alcohol abuse, Alcoholic gastritis,

Alcoholic psychoses, Alcoholic liver cirrhosis, Alcoholic polyneuropathy, Alcoholic cardiomyopathy, Alcohol-dependence syndrome, excess blood alcohol and Ethanol and methanol toxicity.

1.6 Positive effects of alcohol:

Though there is much harm caused by consumption of alcoholic beverages, there are some documented positive effects too. The well known case is that of the protective effect of alcohol on Coronary Heart disease and Cerebrovascular diseases. Alcohol reduces the risk of Coronary and Cerebrovascular diseases by inhibiting formation of atheroma and decreasing rate of blood coagulation.25, 26 A study even showed that alcohol has a protective effect on hearing loss.27

1.7 Social impact of alcohol

Alcohol consumption is linked to many harmful consequences for the individual drinker, the drinker‟s immediate environment and society as a whole. Such social consequences as traffic accidents, workplace-related problems, family and domestic problems, and interpersonal violence have been receiving more public or research attention in recent years. Social consequences affect individuals other than the drinker, for examp le, passengers involved in traffic casualties, or family members affected by failure to fulfill social role obligations, or incidences of violence in the family.

1.7.1 Alcohol consumption and the workplace

Heavy drinking at the workplace may potentially lower productivity. Sickness absence associated with harmful use of alcohol and alcohol dependence entails a substantial cost to employees and social security systems. There is ample evidence that people with alcohol dependence and problem drinkers have higher rates of sickness absence than other employees.28 A number of studies have demonstrated an association between heavy drinking or alcohol abuse and unemployment. Here, a causal association may go in either direction, heavy drinking may lead to unemployment, but loss of work may also result in increased drinking, which may become heavy drinking. Alcohol may also lead to trauma at the workplace, especially in job profiles that involves machinery.29

1.7.2 Alcohol consumption and the family

It is well established that drinking can severely impair the individual‟s functioning in various social roles. Alcohol misuse is associated with many negative consequences both for the drinker‟s partner as well as the children. Maternal alcohol consumption during pregnancy can result in fetal alcohol syndrome in children, and parental drinking is correlated with child abuse and impacts a child‟s environment in social, psychological and economic ways.30 Drinking can impair performance as a parent, as a spouse or partner, and as a contributor to household functioning. There are also other aspects of drinking which may impair functioning as a family member. In many societies, drinking may be carried out primarily outside the family and the home. In this circumstance, time spent while drinking often competes with the time needed to carry on family life.

Drinking also costs money and can impact upon resources particularly of a poor family, leaving other family members destitute. Also, it is worth noting that events occurring when drunk can also have lasting consequences, through home accidents and family

18 violence.24 The effects of men's drinking on other members of the family is often particularly on women in their roles as mothers or wives of drinkers. The risks include violence, HIV infection, and an increased burden in their role of economic providers.

1.7.3 Alcohol and poverty

The economic consequences of expenditures on alcohol are significant especially in areas with high poverty. Besides money spent on alcohol, a heavy drinker also suffers other adverse economic effects. These include lowered wages (because of missed work and decreased efficiency on the job), lost employment opportunities, increased medical expenses for illness and accidents, legal cost of drink-related offences, and decreased eligibility for loans.24

1.7.4 Alcohol and domestic violence

Research has found that alcohol is present in a substantial number of domestic violence accidents. The most common pattern is drinking by both offender and victim. Alcohol has been shown to be a significant risk factor for husband-to-wife violence. Drinking frequently has been associated with intra-family violence. Studies based on interviews with abused wives tend to report higher proportions of alcohol involvement than do general population studies or police samples. Regarding partner violence, research evidence indicates that it is more strongly associated with heavy drinking.24

1.8 Economic impact of alcohol

It is a well established fact that the use of alcohol entails a large number of adverse economic consequences. 24 This could be in differing areas such as physical and mental health, traffic safety, violence, and labor productivity. But these are difficult to measure.

Therefore, social costs are considered as the negative economic impact of alcohol

19 consumption. Relatively few countries have attempted to estimate the costs of alcohol use.

1.9 Rational for the study:

Consumption of alcoholic beverages is a public health problem. It not only harms the person who consumes it but also harms the family and the society in general. In an attempt to generate more income, governments in many countries are promoting the sale of alcohol containing drinks. But it has been found the expenditure for the treatment of problems resulting due to consumption of alcohol is more than the income generated. 13

Over the years, the age of drinking has been reducing. More and more people have started having alcohol at younger ages. The college setting is an ideal place for initiation into the world of alcohol. The students are away from the watchful eyes of elders. They are young and want to try out any new thing. They are under pressure from friends to be like rest of the students. College students are at that phase of life when they start taking independe nt decisions.

Several studies that have been conducted elsewhere have tried to quantify the problem of alcohol use among the college students. They have looked into the patterns and beliefs related to alcohol use among college students. 31 32 These patterns and beliefs vary in the different region among different population groups. In India researchers have tried to address the issue of drinking among college students, but they are very few in number.

Also, there is paucity of data on any attempt to understand the difference in patterns and beliefs among different population groups in India.

The state of Arunachal Pradesh is in the extreme east of the country. The inhabitants of this region are mostly tribal. Consumption of alcohol is a part of the day to day life of these people. Consumption of alcohol is culturally accepted in most parts of Arunachal

Pradesh. The few studies which have been carried out in the state rank Arunachal Pradesh on top with respect to prevalence of alcohol use in India.9, 11 These studies also show that the prevalence of alcohol among women of Arunachal Pradesh is highest in India. On the other hand, the state of Kerala has very low acceptance to alcohol use. This is in direct contrast to the practice in Arunachal Pradesh. But even with this low acceptance of alcohol use in the society in Kerala, it has the highest rates of per capita consumption of alcohol in the country. It is evident that there are differences in the patterns and beliefs with regard to alcohol use in this two states.

For this reason an attempt was needed to study the prevalence, patterns and beliefs of alcohol use in these two states and compare the findings.

1.10 Objectives of the study:

1. To estimate the prevalence and patterns of alcohol use among the college students

of Arunachal Pradesh and Kerala.

2. Assess the prevalence and extent of harmful use of alcohol among the students.

3. To compare the prevalence and patterns of alcohol use among the college students

of Arunachal Pradesh and Kerala.

Chapter 2

Methodology

2.1 Study type:

It is a descriptive study. A self administered questionnaire survey was done among college students of Arunachal Pradesh and Kerala using a common pre-tested questionnaire survey tool to assess and compare prevalence and pattern of alcohol use among them.

2.2 Study setting:

West Siang district in Arunachal Pradesh and Trivandrum district in Kerala were selected for the study. The main reason for selection of these districts is logical convenience, but the fact that these districts are fairly representative of the respective states with respect to the question under study also contributed in their selection. In both the states the study was conducted in non-professional colleges. This was because there was only one college in West Siang district of Arunachal Pradesh, and the colleges in Kerala were selected to match with this college. Five colleges were selected from Kerala.

2.3 Study population:

The age group of students in Arunachal Pradesh was from 18-26 years and that in Kerala was from 18-30 years. All the students of the selected colleges who were 18 years and above were considered eligible for the study.

2.4 Time frame:

Data was collected done between June 2009 and August 2009.

2.5 Sample size:

Sample size was calculated based on the prevalence of use of alcohol in the general population. The sample sizes were calculated separately for both the states because the prevalence rate of use of alcohol among the general population was different. 9

In Arunachal Pradesh it was reported by the NFHS 3 that the prevalence of use of alcohol among men was 61.1 percent.9 Assuming that the rates were lower among the student population, the prevalence rate of 50 percent was taken for the students. The sample size was calculated as,

N=Z2*PQ/D2

Where,

N=sample size

Z=confidence limit factor (this is taken as 1.96 for 95 percent confidence interval)

P=assumed proportion of alcohol users (in this study it was taken as 50 percent)

Q= 1-P,

In this case Q= 1-50

= 0.5

D= precision factor (this is the difference between the assumed prevalence and lowest expected prevalence.) The lowest expected prevalence was taken as 44 percent.

Therefore, D= 0.50-0.44

=0.06

As student population was selected, a design effect of 1.5 was considered.

The final calculated sample size was,

N= [(1.962*0.50*0.50)/ 0.062]*1.5

=400

In Kerala also the prevalence of alcohol use among men was obtained from NFHS 3 and it was 45.2 percent.9 Assuming that the prevalence rate was lower in the college going students, it was considered to be 30 percent. The worst acceptable prevalence was taken as 26 percent, and hence the precision factor as 0.04. A design effect factor of 1.5 was also considered. Using the same formula as for Arunachal Pradesh, the sample size was calculated as,

N=Z2*PQ/D2

= [(1.962*0.30*0.70)/ 0.04]*1.5

= 758,

This value was rounded off to 800.

Final sample size in Arunachal Pradesh = 400

Final sample size in Kerala = 800

2.6 Sample selection procedures:

In Arunachal Pradesh:

The district of West Siang had only one college. This college was selected for the study.

A list of all class divisions in the college was made. By simple random sampling from this list, the class divisions were selected for distribution of the questionnaires.

In Kerala:

First of all a list of all non-professional colleges in Trivandrum district was made. By means of lottery method five colleges were selected from this list. Among these selected colleges, a list of all class divisions was made. By simple random sampling from this list, the class divisions wee selected for the distribution of the questionnaires.

2.7 Data collection:

Data was collected by the primary investigator. The tool used was a self administered questionnaire in English. (Annexure 1) It was pre-tested among a group of 15 students prior to actual data collection. It was anonymous so as to decrease any inhibition and extract maximum response from the respondents. This questionnaire was in English for easy understanding and also to maintain inter-state similarity. Data collection was conducted in the class-rooms. A standard drinks table was also provided along with the questionnaire. (Annexure 2) This table contained a list of alcoholic beverages, the amount of alcohol that constitutes a standard drink for each type of alcohol, the alcoholic contents of each type of alcohol and also the normal method of packaging. This table was given so that there might be uniformity in answering what a standard drink constitutes.

Permission was taken from the respective head of the institution of the selected colleges prior to data collection. A day was fixed for the distribution of the questionnaire which was decided based on a mutually convenient date and time for the respondents as well as the investigator. On the day of the data collection, the investigator gave a briefing on the questionnaire and the respondents were told the procedure of filling up of the questionnaire. The questionnaires were to be filled in the classroom itself and not to be filled outside or to be taken to their residences. Besides this, the participants were also requested not to disturb others during the filling up of the questionnaire. The students

25 were requested to answer honestly without any fear or shyness. They were informed that they need not give their names in the questionnaire. They were also informed that their privacy and the confidentiality of the information provided would be strictly maintained.

They were also requested to answer the questionnaire by themselves and not to discuss among themselves. In case of any doubt, they could ask the investigator, who was available in the classroom.

Following this briefing, the consent forms were distributed. (Annexure 3) When the consent forms were filled and returned, the questionnaire was distributed among the students. It was taken care that no elders or teachers were around when the students were filling up the questionnaire. After the questionnaire was filled, it was collected by the investigator. The respondents were verbally thanked for their participation.

2.8 Data analysis:

Primary data was collected and entered in Epidata software version 3.1. This was then imported to SPSS for windows version 17.0 to carry out further analysis. Data cleaning was performed, and some questionnaires which were incompletely filled for important variables were cleaned out. Univariate analysis was done to study the sample characteristics (baseline characteristics of the study sample was assessed using descriptive statistics). Bivariate analysis of the independent variables with respect to the dependent variables (Alcohol use and Problem drinking) was done using non parametric Chi square test of significance. For all the tests, p value of <0.05 was considered for statistical significance. Variables that had significant outcome in the bivariate analysis were considered for multivariate analysis. Multivariate analysis was done on these variables for adjustment of possible interaction and confounding factors to arrive at a final model.

2.9 Study variables:

The study variables on use of alcohol have been adopted from the Global school-based student health survey (GSHS) which is a school-based survey conducted primarily among students aged 13-15 years. 33 These variables have been specially developed for classroom based surveys. The GSHS uses a standardized scientific sample selection process, core questionnaire modules, core-expanded questions, and country-specific questions that are combined to form a self-administered questionnaire which can be administered during one regular class period. Some questions on drinking pattern were adopted from the AUDIT questionnaire for alcohol.34 The AUDIT questionnaire is generally used for detection of alcohol related drinking problems among adults; here it was adapted for use among college going students.35, 36

2.9.1 Dependent variables:

Alcohol use was a dependent variable. Any person who had ever taken alcohol was considered to be a user of alcohol. This included only those individuals who had taken alcohol more than a sip.

Problem drinking was another dependent variable. Problem drinking was estimated from the CAGE questionnaire. The CAGE questionnaire was developed by Dr. John

Ewing. CAGE is an internationally used assessment instrument for identifying problems with alcohol. 'CAGE' is an acronym formed from the italicized letters in the questionnaire

(cut-annoyed-guilty-eye).

CAGE is considered a validated screening technique, with one study determining that CAGE test scores >=2 had good sensitivity and specificity for the identification of problem drinkers.36-39

The CAGE Questionnaire for alcohol:

1. Have you ever felt you should cut down on your drinking? a. Yes b. No 2. Have people annoyed you by criticizing your drinking? a. Yes b. No 3. Have you felt bad or guilty about your drinking? a. Yes b. No 4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? a. Yes b. No Any respondent who answered yes for two or more of the questions was considered to have problem drinking. By combining the answers for the four questions, a new variab le

“CAGE” was derived.

2.9.2 Independent variables:

Age: Age was collected by asking the respondents to give their age in completed years as a continuous variable. No attempt was made to divide the age into age groups because the expected range was very small.

Sex: It is known that use of alcohol varies between the sexes. Studies which have been done elsewhere have time and again proved that the use of alcohol is more among males than among females.32, 40, 41

Religion: The religions that were included in the questionnaire were Buddhism,

Christianity, Donyi-Poloism (a religion followed in Arunachal Pradesh), Hinduism and

Muslim. “Others” option was provided for people who belonged to a religion other than the ones mentioned.

Pocket money: This variable was measured in INR and was initially collected by having six groups with a width of 500 each starting from “Less than 500” up to “more than 2500.

Later on , during the analysis, the categories were regrouped to “less than 500”, “500-

1000” and “more than 1000”, considering the low number of cases in the higher pocket money groups. The access to higher amount of pocket money is a direct indicator of the ability to spend more, and studies have proved this.42, 43

Residence: Residence meant the place of present residence of the respondent. This variable was included in the demographic variable, but apart from this it was included to see if there was any relation with place of stay and use of alcohol.

Type of family: This was a categorical variable which had the categories Nuclear,

Extended and Joint. Nuclear family was defined as a family which had the parents and the children. Extended family was a family which had the parents, children and the grandparents. Joint family was defined as a family that had the parents, children, grandparents and uncle and aunties.

Age at first drink: Respondents who reported that they had consumed alcohol had to inform about their age when they first tried alcohol. This was a continuous variable and option was given to report the age in years. If in case the respondent knew from their parents or elders that they had taken alcohol before one year of age, they could report it in months. This was done primarily because; use of alcohol is a part of the cultural practice of the inhabitants of Arunachal Pradesh. They frequently give home made rice beer to their children.

Place where alcohol was first tried: The alcohol using respondents also had to report the place where they first tried alcohol. This could be their home, friend‟s home, hostel,

29 restaurants, bars and a public place. The public place included any open area such as park, beach or streets.

Reason behind trying alcohol: To capture the various reasons under which an individual might first try alcohol, the relevant occasions were included.

Type of alcohol tried first: A list of alcoholic beverages was given from which the respondents could choose.

Alcohol use among parents : This was to assess if drinking of the parents had any effect on the use of alcohol on the children.

Variables on patterns of alcohol use: This included a set of questions such as the usual place of consumption, the people with whom alcohol was usually consumed, usual amount and maximum amount of standard drinks that were consumed and usual type of alcohol taken.

Alcohol use among siblings: The purpose of this variable was to see if there was any relation between alcohol use by siblings and alcohol use by the respondents.

Discussion about harm of using alcohol in the home: The respondents had to answer if there was any discussion about the negative effects of alcohol at home and if they were told that alcohol consumption was bad.

Discussion about harm of using alcohol in schools/colleges: Similarly, the respondents had to answer if there was any education or discussion in their classes about the harm of alcohol use.

Harm that is caused by drinking once or twice a year or several times a week: These two sets of questions intended to look into the knowledge of the respondents regarding the use of alcohol and its negative impacts.

Usual amount of alcohol that is needed to make a person drunk: The aim of this variable was to check the beliefs and perceptions of the respondents. In absence of better measures, this was taken as an indirect measurement of the amount the respondent would need to become drunk.

Tobacco use practices: People use tobacco. This use of tobacco might be in relation to alcohol. It is known that people tend to take more tobacco products while they are consuming alcohol. Options were included for tobacco products that are smoked and also for smoke less tobacco. Further, it was asked if they take more of these products while consuming alcohol.

2.10 Ethical considerations:

The primary consent to conduct the study was obtained from the head of the institute of the concerned colleges. The students were then invited to participate in the study which was conducted in their class rooms. Written informed consent was taken from the respondents at the beginning of the study.

Any participant whose age was less than 18 years was not considered for the study. Any student who wished not to participate in the study was permitted to do so. Also, anyone willing to discontinue filling the questionnaire midway was permitted to discontinue with the process.

2.11 Definitions:

Some terms were used in the study which needs further elaboration. There are different types of alcohol that is used in different places around the world. In India, the types of alcohol can be divided into locally brewed and the IMFL (Indian Made foreign liquor).

The common types of locally brewed alcoholic beverages in Arunachal Pradesh are poka, nyongin and raksi. Poka and nyongin fermented from rice while raksi is a distilled variety. In Kerala the locally prepared alcoholic beverages are toddy and arrack. Toddy is a fermented alcoholic beverage prepared from tender coconut palm while arrack is distilled variety. The volume by volume pure alcohol content of these local alcoholic beverages varies from 4-14 percent. Arrack is an exception and its alcoholic content may go up to 50 percent. With regard to the IMFLs, these are foreign brands that are brewed and distilled in India. The most common IMFLs are Brandy, Whisky, Rum and Vodka.

Given below is a table of the commonly used alcoholic beverages and the approximate alcohol content.

Alcoholic beverage and its alcohol content. Name of alcoholic beverage Alcohol content (%) Brandy 40-55 Whisky 40-55 Rum 40-55 Vodka 40-55 Wine 10-22 Beer, Breezer 4-8 Arrack 50-60 Toddy 5-10 Poka, Nyongin 5-10

Adapted from Alcohol use and abuse, what you should know. WHO 2006

2.12 Spectrum of alcohol use

Alcohol use, as the term implies, is the consumption of alcohol. It does not indicate the amount used or the extent of harm from use.44 Alcohol use usually starts as a social phenomenon. Many communities consider the occasional use of alcohol, for recreational purposes or on social occasions, as „normal‟ and „acceptable‟. There is little awareness that even the occasional or social use of alcohol does carry a risk of road traffic injuries or industrial accidents. Intoxication from occasional use can lead to violence or socially inappropriate or embarrassing behavior.

Harmful use

A pattern of alcohol consumption that causes damage to health.45 The damage may be physical (as in cases of hepatitis from prolonged use of alcohol) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol).

Harmful use of alcohol is a pattern of use which causes damage to an individual‟s health.44 Harmful use is not necessarily linked to drinking too much alcohol or drinking alcohol every day. Harmful drinking is usually related to the circumstances of drinking alcohol. Many patterns of consumption of alcohol can be considered as harmful use of alcohol, for example, drinking alcohol and driving which can lead to road traffic injuries,

“binge drinking” (drinking too much alcohol at one time) sometimes indulged in by teenagers, pay-day drinking when a person drinks heavily on the day he gets his salary, or pregnant women drinking alcohol.

Hazardous use

Hazardous use is a pattern of alcohol consumption carrying with it a risk of harmful consequences to the drinker.44 The damage may be to health–physical, or mental, or they

33 may include social consequences to the drinker or others. This is therefore called alcohol abuse.

Alcohol abuse, also called “problem drinking”, is a pattern of excessive drinking that result in adverse health and social consequences to the drinker, and often to those around the drinker. People with an alcohol abuse problem may show the following characteristics:

Use alcohol to help them change the way they feel about themselves and/or some

aspects of their lives.

Experience some problems associated with their alcohol use.

Get complaints about their alcohol use.

Lose interest in activities and hobbies that used to bring pleasure.

Get irritable as their usual drinking time approaches, especially if alcohol isn't

available.

Keep alcohol in unlikely places at home, at work and in the car.

Gulp drinks, become intoxicated intentionally.

Drink alone or in secret.

Dependence syndrome

A cluster of behavioral, cognitive, and physiological phenomena that develop after repeated alcohol use and that typically include a strong desire, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to alcohol use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state. 45

There are four main symptoms. These are:

Craving: A strong need, or compulsion to drink.

Impaired control: The inability to limit one's drinking on any given occasion.

Physical dependence: Withdrawal symptoms, such as nausea, sweating, shakiness,

and anxiety, when alcohol use is stopped after a period of heavy drinking.

Tolerance: The need for increasing amounts of alcohol in order to feel its effects.

Binge drinking:

Binge drinking is defined as the consumption of 5 or more standard alcoholic drinks on one occasion. 44

Standard drink:

One standard drink of alcohol is approximately equal to 10 grams of absolute alcohol. 44

One standard drink may consist of:

Spirit……………………………..30 ml

Wine……………………………...120 ml

Beer……………………………….285ml

Chapter 3

Results

3.1 Sex distribution of the study population:

Table 3.1 Sex distribution: State Frequency (%) Arunachal Male 181 (51.4) Pradesh Female 171 (48.6) Total 352 (100.0) Kerala Male 282 (40.1) Female 421 (59.9) Total 703 (100.0)

The total subjects in the study fall short of the original plan in both the states (by 48 in

Arunachal Pradesh and 90 in Kerala). Since a design effect of 1.5 was considered during the sample size calculation, the final figures are well within the range. Hence the validity of the study findings was not affected. Although there was no non response per se during the study, there were some incomplete or partially filled forms. These forms were not considered for further analysis.

In Kerala, the male representation was 40 percent. To confirm that this was a true representation of the male female distribution among the selected colleges, the male female percentage was checked from the enrolment registers in these colleges where data was collected. It was found that the percentage of males was 39.36 percent.

3.2 Religion:

In Arunachal Pradesh, the majority of the respondents were from the Donyi-Polo religion

(69.6 percent), followed by Christians who formed 20.5 percent. Distribution of the

36 population in other religions was very less. In Kerala, the followers of Hindu religion formed 68 percent, Christians 26 percent and Muslim 6 percent.

3.3 Monthly pocket money allowance of the respondents:

Table 3.2 Monthly pocket money allowance State INR Frequency (%) Arunachal <500 152 (41.8) Pradesh 501-1000 99 (27.3) >1001 113 (31.0) Kerala <500 618 (84.8) 501-1000 83 (11.4) >1001 28 (3.8)

The students from Arunachal seem to have been receiving higher amounts of pocket money than the students in Kerala.

3.4 Residence

Table 3.3 Residence State Frequency (%) Arunachal home 115 (33.0) Pradesh hostel 234 (67.0) Missing* 3 Kerala Home 632 (90.3) Hostel 68 (9.7) Missing* 3 *Missing are those people who didn‟t answer their place of residence.

Most of the Arunachal Pradesh students resided in hostels. This might have been because of the fact that there was only one college in the West Siang district and students from all over district came to study here. These students had to stay in hostels. The students in

Kerala mostly resided at their respective houses.

This finding of residence might explain why the students in Arunachal Pradesh had more pocket money than the students of Kerala. Since the students of Arunachal Pradesh stayed away from home, they had to have some money for their day to day expenditure.

3.5 Type of family:

The students of Arunachal Pradesh had joint family in 42.6 percent, nuclear family in

41.8 percent and extended family in 15.6 percent. In Kerala, majority were from nuclear family (88.9 percent).

3.6 Alcohol use:

Table 3.4 Alcohol use State Frequency (%) Arunachal No 150 (39.5) Pradesh Yes 225 (60.5) Kerala No 627 (78.0) Yes 166 (22.0)

It was also observed that 81.2 percent of males and 38.6 percent of females were ever users of alcohol in Arunachal Pradesh. Same was 46.1 percent in males and 5.9 percent among females in Kerala.

There is a difference in prevalence of use of alcohol between Kerala and Arunachal

Pradesh. But what is very evident is that a huge percentage of females used alcohol in

Arunachal Pradesh when compared to Kerala.

3.7 Place where the first drink of alcohol was taken:

In Arunachal Pradesh, 70.6 percent reported that they were in their homes when they had their first drink of alcohol. The other place was at friend‟s home (15.6 percent). The students of Kerala reported having their first drink at a public place (35.8 percent), at a

38 friend‟s home (33.2 percent) and at home (23.8 percent). In both of the states, very few students mentioned the hostel as a place of first drink.

3.8 Reason for trying alcohol for the first time:

The main reason stated in Arunachal Pradesh as the reason behind trying alcohol for the first time was family occasion (47.6 percent), followed by religious occasion (26.4 percent). The students of Kerala reported that pressure from friends (31.1 percent) was the main reason for trying alcohol for the first time.

3.9 Type of alcohol that was first tried:

The local drink, Poka, was the first alcohol tried by 75.5 percent of students in Arunachal

Pradesh. About 13 percent reported beer. In Kerala, the first type of alcohol tried was beer

(57 percent) in majority of the students. Indian Made Foreign Liquor (IMFL) was tried first by 32.7 percent of the respondents.

3.10 With whom the first alcoholic drink was taken:

Most of the students in Arunachal Pradesh had their first drink with their family members

(63.3 percent). Some of them had alcohol for the first time with friends (32.9 percent).

The students of Kerala consumed their first drink with their friends (74.8 percent), and with family members (24.5 percent).

3.11 The place where alcohol was obtained for the first time:

In Arunachal 68.1 percent reported that the alcohol was obtained from home. About 24 percent reported that they obtained it from friends. In Kerala 30.9 percent said they got it from friends which was closely followed by liquor shop (30.2 percent). Home was also reported as a source by 22.4 percent respondents.

3.12 Usual place of drinking alcohol:

The favorite place in Arunachal Pradesh was home (44.9 percent), then a public place (31.9 percent) followed by friend‟s home (15.7 percent). Any public place was the usual place of drinking in Kerala (41.9 percent), followed by friend‟s home (36.3 percent) and home (16.1 percent)

3.13 Usual type of alcohol taken:

Majority of the Arunachal Pradesh students said that they usually take Poka (54 percent).

Beer was also a favorite at 30.7 percent. Only 13.2 percent said that they usually take

IMFL. In Kerala, the most commonly taken drink was beer (56.9 percent), then IMFL

(26.9 percent). Wine was reported by 13.1 percent respondents.

It may be observed from the results 3.6, 3.8, 3.9 and 3.10 that the students in Arunachal

Pradesh usually consumed home made alcoholic beverage, consumed with family members and in the house during family or religious occasions. We may interpret from these findings that the consumption of alcohol is culturally accepted in Arunachal

Pradesh. In case of Kerala, the trend is that the students tried to be away from the family members while consuming alcohol, which lead to interpret that consumption of alcohol is not culturally accepted in Kerala.

3.14 Frequency of getting drunk in the past 30 days:

Table 3.5 Frequency of getting drunk in the past 30 days State Frequency Percent Arunachal No 82 39.6 Pradesh Yes 125 50.4 Missing* 145 Kerala No 83 57.6 Yes 61 42.4 Missing* 559 *Missing are those who did not answer the respective fields.

3.15 Any trouble caused by drinking in the last 30 days:

Table 3.6 Any trouble caused by drinking in the last 30 days: State Frequency Percent Arunachal No 135 64.9 Pradesh Yes 73 35.1 Missing* 144 Kerala No 112 78.9 Yes 30 21.1 Missing* 561 *Missing are those who did not answer the respective fields.

3.16 Monthly expenditure on alcohol:

Table 3.7 Monthly expenditure on alcohol: State Frequency Percent Arunachal Pradesh <500 141 72.7 >500 53 27.3 Missing* 158 Kerala <500 94 84.7 >500 17 15.3 Missing* 592 *Missing are those who did not answer the respective fields.

3.17 Managing money for alcohol: In Arunachal Pradesh, 47.4 percent replied that they manage money from their pocket money, 33.5 percent said they get it free at home. In Kerala, 36.1 percent said they manage money from their pocket money, 18.9 percent said they borrowed from friends,

16.4 percent said they pool money among friends.

3.18 Alcohol use among parents:

Table 3.8 Alcohol use among parents: State Frequency Percent Arunachal Pradesh No 77 25.1 Yes 230 74.9 Missing* 45 Kerala No 394 64.6 Yes 216 35.4 Missing* 93 *Missing are those who did not answer the respective fields.

It was also observed that in Arunachal Pradesh, the parental drinking was 32.4 percent among father or male guardians, 4.5 percent among mother or female guardians and 28.4 percent reported that both their parents consumed alcohol. In Kerala, the use of alcohol among father or male guardian was 30.2 percent. There were no reports of maternal or female guardian using alcohol. Only 0.6 percent reported that both of their parents drink.

3.19 Alcohol use among siblings:

Table 3.9 Alcohol use among siblings: State Frequency Percent Arunachal No 144 47.4 Pradesh Yes 160 52.6 Missing* 48 Kerala No 596 89.8 Yes 68 10.2 Missing* 39 *Missing are those who did not answer the respective fields.

3.20 Discussion in the family about harmful effect of alcohol:

Table 3.10 Discussion in the family about harmful effect of alcohol: State Frequency Percent Arunachal No 78 22.2 Pradesh Yes 273 77.8 Missing* 1 Kerala No 219 31.6 Yes 473 68.4 Missing* 11 *Missing are those who did not answer the respective fields.

3.21 Discussion in the institute about harmful effect of alcohol:

Table 3.11Discussion in the institute about harmful effect of alcohol: State Frequency Percent Arunachal No 102 34.1 Pradesh Yes 197 65.9 Missing* 53 Kerala No 140 21.8 Yes 503 78.2 Missing* 60 *Missing are those who did not answer the respective fields

3.22 Perceived reasons for drinking by others: The respondents in Arunachal Pradesh thought that people drink alcohol because its fun

(28 percent), because culture permits (23.3 percent), to forget sorrows (13.6) and because friends drink (12.1 percent). The students in Kerala reported it was because friends drink

(22.8 percent), because it relaxes (15.6 percent) and 14.4 percent said people drank so as to forget sorrows and the same percentage of respondents said people drink to have fun.

3.23 Perceived risk if alcohol was consumed once or twice in a year:

Sixty one percent in Arunachal Pradesh and 49 percent in Kerala said that there was no risk. Others reported that consuming alcohol once or twice in a year is great risk, 12.8 percent in Arunachal Pradesh and 15.5 percent in Kerala.

3.24 Perceived risk if alcohol was consumed several times in a week:

It was perceived by 24.1 percent of students in Arunachal Pradesh that consuming alcohol several times in a week is of no risk, while 52.2 percent said it was a great risk. In Kerala,

13.3 percent said there was no risk and 61.9 percent said it was great risk.

3.25 Type of alcohol that is safest:

The students in Arunachal Pradesh considered Poka to be safest (56.1 percent), this was followed by beer (28.2 percent). A few considered wine to be safest (10.3 percent). IMFL came at 3.5 percent. The students of Kerala considered beer to be safest (47.6 percent), followed by wine (48.9 percent). The local drink toddy was considered safe by 5.6 percent. Only 5.1 percent thought IMFL to be safe.

3.26 Perceived health benefit of alcohol consumption:

Table 3.12 Perceived health benefit of alcohol consumption: State Frequency Percent

Arunachal No positive health benefit 240 70.2 Pradesh Protects the heart 9 2.6 Removes mental strain 64 18.7 Helps in socializing 29 8.5 Missing* 10 Kerala No positive health benefit 556 82.5 Protects the heart 28 4.2 Removes mental strain 70 10.4 Helps in socializing 20 3.0 Missing* 29 * Missing includes those did not mark the answers.

3.27 Prevalence of drinking problem:

Drinking problem was assessed by the CAGE questionnaire.

Table 3.13 Problem drinking State Frequency Percent Arunachal Pradesh No problem 228 67.7 Problem 109 32.3 Missing* 15 Kerala No problem 628 91.9 Problem 55 8.1 Missing* 20 *Missing are those who did not answer the respective fields.

3.28 Prevalence of smoking:

The prevalence of smoking in the Arunachal Pradesh population was 29.3 percent and that in Kerala was 9.9 percent. It was reported by 17.6 percent in Arunachal Pradesh and

4.2 percent in Kerala that they tend to smoke more while consuming alcohol.

3.29 Prevalence of use of non-smoke tobacco:

The prevalence of use of non-smoke tobacco was 20.1 percent in Arunachal Pradesh and

4.8 percent in Kerala. It was reported by 6.2 percent in Arunachal Pradesh 2.9 percent in

Kerala that they tend to use more non-smoke tobacco while consuming alcohol.

3.30 Bivariate Analysis Results:

Simple chi square analysis was done to examine whether prevalence of alcohol use was influenced by any of the above mentioned factors. This analysis was further divided as follows. The factors related to the prevalence of alcohol use among students in both the

States-Arunachal Pradesh and Kerala (combined) were analyzed first followed by those factors related to alcohol use among students in both the States independently.

3.30.1 Combined analysis for association with alcohol use:

Table 3.14 Association with alcohol use Variables Does not Use alcohol OR of use of Χ2 p use alcohol (%) alcohol (95% value (%) confidence interval) Residence Home 546(73.1) 209(26.9) 1 0.001 Hostel 136 (45.0) 166 (55.0) 3.32(2.51-4.38) Use of alcohol by No 369 (78.3) 102 (21.7) 1 0.001 parents Yes 207 (46.4) 239 (53.6) 4.17(3.13-5.60)

Use of alcohol by No 573 (77.4) 167 (22.6) 1 0.001 siblings Yes 62 (27.2) 166 (72.8) 9.18(6.54-12.90)

* Relation of pocket <500 537 (72.3) 206 (27.7) OR 0.001 money (in INR) 501-1000 90(51.1) 86 (49.0) >1001 60 (44.1) 76 (60.0)

Discussion about harm No 185 (62.3) 112 (37.7) 1 0.282 of alcohol in family Yes 491 (65.8) 255 (34.2) 0.85 (0.65-1.13)

Discussion about harm No 130 (53.7) 112 (46.3) 1 0.001 of alcohol in Yes 486 (69.4) 214 (30.6) 0.51(0.38-0.70) school/college *OR-Odds ratio not calculated

Combined analysis of both the States shows that use of alcohol was significantly higher among those students whose parents also used alcohol. Similarly, use of alcohol was significantly higher among those students whose siblings also used alcohol. As pocket money increases the use of alcohol also increases.

Use of alcohol was higher among those students who did not have any discussion in the family about the harm of alcohol but it did not show any statistical significance.

Use of alcohol was significantly higher among those students who did not have any discussion in the institute about the harm of alcohol.

3.30.2 Separate analysis for association with alcohol use:

Table 3.15 Separate bivaritate analysis with alcohol use Use of alcohol by parents State Does not Use OR of use of Χ2 p value use alcohol alcohol alcohol (95% (%) (%) confidence interval) Arunachal No 41(53.2) 36(46.8) 1 Pradesh Yes 66(28.7) 164(71.3) 2.83(1.66-4.81) 0.001 Kerala No 328(83.2) 66(16.8) 1 Yes 141(65.3) 78(34.7) 2.64(1.79-3.88) 0.001 Use of alcohol by siblings Arunachal No 78(54.2) 66(45.8) 1 Pradesh Yes 38(28.8) 122(76.2) 3.79(2.32-6.19) 0.001 Kerala No 495(83.1) 101(16.9) 1 Yes 24(35.3) 44(64.7) 8.98(5.22-15.44) 0.001 Discussion about harm of alcohol in family Arunachal No 33(42.3) 45(57.7) 1 Pradesh Yes 105(38.5) 168(61.5) 1.17(0.70-1.95) 0.540 Kerala No 152(69.4) 67(30.6) 1 Yes 386(81.6) 87(18.4) 0.51(0.35-0.74) 0.001 Discussion about harm of alcohol in school/college Arunachal No 36(35.3) 66(64.7) 1 Pradesh Yes 82(41.6) 115(58.4) 0.76(0.46-1.25) 0.288 Kerala No 94(67.1) 46(32.9) 1 Yes 404(80.3) 99(19.7) 0.50(0.33-0.75) 0.001 Relation of pocket money ( in INR) Arunachal <500 54 (36.7) 93(63.3) OR* Pradesh 501-1000 40(41.7) 56(58.3) 0.669 >1001 45(41.3) 64(58.7) Kerala <500 483(81.0) 113(19.0) 501-1000 50(62.5) 30(37.5) 0.001 >1001 15(55.6) 12(44.4) *OR-Odds ratio not calculated

In both States use of alcohol was significantly higher among those students whose parents also used alcohol. Similarly in both States use of alcohol was significantly higher among those students whose siblings also used alcohol.

In Arunachal Pradesh use of alcohol was significantly higher among those who had a discussion in the family about the harm of alcohol though it was not statistically significant. In Kerala use of alcohol was significantly higher among those students who did not have any discussion in the family about the harm of alcohol.

In Arunachal Pradesh use of alcohol was significantly higher among those who had a discussion in the institute about the harm of alcohol though it was not statistically significant. In Kerala use of alcohol was significantly higher among those students who did not have any discussion in the institute about the harm of alcohol.

In Arunachal Pradesh it is seen that as pocket money increases the use of alcohol also increases but it is not statistically significant. In Kerala as pocket money increases the use of alcohol decreases and it is statistically significant.

3.30.3 Combined analysis for association with problem drinking (CAGE)

Table 3.16 Combined analysis with problem drinking No drinking Drinking OR of use of Χ2 p value problem (%) problem (%) alcohol (95% confidence interval) Use of alcohol No 411 (90.7) 42 (9.3) 1 0.001 by parents Yes 323 (74.8) 109 (25.2) 3.30(2.24-4.85)

Use of alcohol No 641 (89.0) 79 (11.0) 1 0.001 by siblings Yes 145 (67.8) 69 (32.2) 3.86 (2.66-5.59)

Monthly <500 111 (50.7) 118 (49.3) 1 0.041 expenditure on alcoholic ≥500 24 (36.4) 42 (63.6) 1.80 (1.02-3.71) drinks

Discussion No 245 (87.0) 37 (13.1) 1 0.091 about harm of alcohol in Yes 599 (82.5) 127 (17.5) 1.40 (0.94-2.08) family

Discussion No 187 (80.6) 45 (19.4) 1 0.103 about harm of alcohol in Yes 579 (85.1) 101 (15.0) 0.72 (0.50-1.06) school/college

Parents drinking had a significant effect on drinking problem of the child. Students whose siblings drink had higher percent of drinking problem compared to the students whose siblings didn‟t drink.

As monthly expenditure increases drinking problem also increases among the students.

Drinking problem was more among students whose family did not have any discussion on harm of alcohol use, but it was not statistically significant.

Drinking problem was more among students who did not have any discussion on harm of alcohol use in their institution, but it was not statistically significant.

3.31 Separate analysis for association with problem drinking (CAGE)

3.17 Separate analysis with problem drinking Use of alcohol by parents State No drinking Drinking OR of use of alcohol Χ2 p problem (%) problem (%) (95% confidence value interval) Arunachal No 50(69.4) 22(30.6) 1 Pradesh Yes 141(63.8) 80(36.2) 1.28(0.72-2.28) 0.383 Kerala No 361(94.8) 20(5.2) 1 Yes 182(86.3) 29(13.7) 2.87(1.58-5.22) 0.001 Use of alcohol by siblings Arunachal No 97 (70.3) 41(29.7) 1 Pradesh Yes 96(63.2) 56(36.8) 1.4(.844-2.25) 0.199 Kerala No 544(93.5) 38(6.5) 1 Yes 49(79.0) 13(21.0) 3.79(1.89-7.60) 0.001 Monthly expenditure on alcoholic drinks Arunachal <500 62(47.7) 68(52.3) 1 Pradesh ≥500 15(29.4) 36(70.6) 2.18(1.09-4.37) 0.025 Kerala <500 49(55.1) 40(44.9) 1 ≥500 9(60.0) 6(40.0) .83(.27-2.52) 0.721 Discussion about harm of alcohol in family Arunachal No 59(83.1) 12(16.9) 1 Pradesh Yes 168(63.4) 97(36.6) 2.83(1.45-5.54) 0.002 Kerala No 186 (88.2) 25(11.8) 1 Yes 431 (93.5) 30(6.5) 0.51(0.29-0.90) 0.019 Discussion about harm of alcohol in school/college Arunachal No 75(77.3) 22(22.7) 1 Pradesh Yes 116(61.1) 74(38.9) 2.17(1.24-3.79) 0.006 Kerala No 112(83.0) 23(17.0) 1 Yes 463(95.5) 27(5.5) 0.28(0.15-0.51) 0.001

In Arunachal Pradesh parents drinking did not have much effect on drinking problem of the child whereas in Kerala the parents drinking had a significant effect on drinking problem of the child. Students whose siblings drink had higher percent of drinking problem in both Arunachal Pradesh and Kerala compared to the students whose siblings didn‟t drink, though it was not statistically significant in Arunachal Pradesh.

As monthly expenditure increases drinking problem decreases significantly among the students in Arunachal Pradesh whereas in Kerala as monthly expenditure increases drinking problem also increases among the students but it is not statistically significant.

In Arunachal Pradesh drinking problem was significantly associated with those who had a discussion in the family about the harm of alcohol. In Kerala the drinking problem was significantly associated with those who did not have family discussion on the harm of alcohol.

In Arunachal Pradesh drinking problem was significantly associated with those who had a discussion in the institute about the harm of alcohol. In Kerala the drinking problem was significantly associated with those who did not have any discussion on the harm of alcohol in the institute.

3.32 Binary logistic regressions with ever alcohol

3.18 Regression with Ever use of alcohol State Pocket p value OR ever use of money in alcohol (95% INR confidence interval) Arunachal Pocket money <500 1 Pradesh (in INR) 501-1000 0.027 0.47(0.24-0.91) >1001 0.918 0.96(0.49-1.9) Alcohol use by parents No 1 Yes 0.024 2.07(1.10-3.91) Alcohol use by siblings No 1 Yes 0.001 3.42(1.90-6.15) Discussion in family of No 1 harm of alcohol Yes 0.498 1.26(0.64-2.48) Kerala Pocket money <500 1 (in INR) 501-1000 0.001 2.72(1.50-4.90) >1001 0.015 3.22(1.26-8.23) Alcohol use by parents No 1 Yes 0.001 2.33(1.50-3.61) Alcohol use by siblings No 1 Yes 0.001 7.12(3.87-13.12) Discussion in family of No 1 harm of alcohol Yes 0.011 0.56(0.35-0.87)

In Arunachal Pradesh, three variables -pocket money, alcohol use by parents and alcohol use by siblings were found to be significantly associated with alcohol use by students.

Pocket money of Rs 500-1000 showed a protective exposure as compared to pocket money of

In Kerala, four variables pocket money, alcohol use by parents, alcohol use b y siblings and discussion in family about harm of alcohol were found to be significantly associated with alcohol use by students. Students who had Rs 500- 1000 as pocket money per month are three times more likely to use alcohol than those who had Rs 500 per month.

Likewise, students who had Rs 1000 or above are also three times more likely of using alcohol than those who had Rs 500 per month. Students whose parents drank alcohol were two times more likely to use alcohol themselves as compared to their counterparts.

Students whose siblings drank alcohol were seven times more likely to use alcohol as compared to their counterparts. Discussion in family about the harm of alcohol was a protective exposure, that is, if there was discussion in the family about harm of alcohol the use of alcohol among students was low.

Chapter 4

Discussion

The objective of this study was to assess and compare prevalence and pattern of alcohol use and problem drinking among students of selected colleges in Arunachal P radesh and

Kerala.

4.1 Prevalence and patterns

The prevalence of use of alcohol was very high in Arunachal Pradesh (60.5 percent). This is in conformation with the findings of NFHS 3 which found the prevalence to be 61.1 percent among the males of Arunachal Pradesh.9 The prevalence rate among males in Arunachal Pradesh was 81.5 percent and that among females was

38.6 percent. The prevalence rates in females confirm to a study previously conducted by

Deswal et al in Arunachal Pradesh which reported a prevalence rate of 34.7 percent.11 In

Kerala the rates were 46.1 percent among males, 5.4 percent among females and combined it was 22 percent. The rates in the male population is in agreement to the NFHS

3 data which states the prevalence to be 45.2 percent.9 The findings are similar to finding by Jinez et al and Ruth et al who said that male sex was associated with higher risk of drug and alcohol use.46, 47

Seventy percent of students in Arunachal Pradesh reported that they had their first drink at home. This reflects the fact that consumption of alcohol is socially accepted in

Arunachal Pradesh and hence they start at home. In Kerala since alcohol use is not part of the social customs and its use is not accepted in the society, most of the students reported that they had their first drink at a public area (35.8 percent) and at a friend‟s house (33.2 percent).

The main reason for consuming alcohol for the first time was stated in Arunachal Pradesh as family occasion (47.6 percent), which was followed by religious occasion (26.4 percent). In Arunachal Pradesh, no ceremony, celebration or festival is complete without the serving of locally brewed Poka. This is reflected in the reasons stated for initiation to alcohol. The students of Kerala on the other hand, reported that pressure from friends

(31.1 percent) was the main reason for trying alcohol. This conforms to the finding by

Hamilton et al who reported that drinking among peers was associated with higher odds of ever using alcohol.48 It was found in Mexico also by Jinez et al that peer pressure is a risk factor for drug and alcohol use among youngsters.46 A Thai study added that besides peer pressure, the desire to participate in social life led to trying alcohol.49

There was time when every house in certain districts of Arunachal Pradesh fermented rice to brew Poka. This was before IMFL was introduced into the state in the 1990‟s. Still now many continue to locally produce this beverage. It is easily available and served frequently at home. And this was the reason why 75.5 percent of the respondents of

Arunachal reported Poka as the first drink tried. Deswal et al has reported the use of local alcoholic beverage to be 53.3 percent in Arunachal Pradesh. 11 In Kerala, 57 percent of the students reported that the first type of drink tried was beer. This might be because of the perception that beer is safer than the other variety of alcoholic beverages. It might also be because beer comes in bottles from where it can be easily consumed.

From the discussions done above it may be assumed that the usual place of drinking might be the home among the respondents of Arunachal Pradesh. And this is true because it was reported by 44.9 percent of participants that they usually consume alcohol at home.

Any public place was the usual place of drinking in Kerala (41.9 percent), followed by friend‟s home (36.3 percent). Since drinking in home is not possible, the youngsters tend

55 to drink at alternative places such as a friends house or a secluded area such as quiet beach or park.

Majority of the Arunachal Pradesh students said that they usually take Poka (54 percent).

Beer was also a favorite at 30.7 percent. Only 13.2 percent said that they usually take

IMFL. In Kerala, the most commonly taken drink was beer (56.9 percent), then IMFL

(26.9 percent). Wine was reported by 13.1 percent respondents. It might be noted that beer was popular in both the states. The study done by Khosla et al too indicated that

47.3 percent preferred beer. 42 This finding might be because of the belief that beer is safe, also because it is sold at cheaper rates and because of the bottling. Beer in India is sold in a sealed bottle. It can be directly consumed from the bottle. There is no need to have another bottle and glass to carry and mix water, as is the case with IMFLs. Also, beer is sold chilled. India being a hot country, a chilled drink is always welcome.

The respondents had various means to manage money for alcohol. In Arunachal Pradesh,

47.4 percent replied that they manage money from their pocket money for buying alcohol,

33.5 percent said they get it free at home. In Kerala, 36.1 percent said they manage money from their pocket money, 18.9 percent said they borrowed from friends, 16.4 percent said they pool money among friends. In both the states majority used pocket money to buy alcohol. Availability of pocket money has been indicated in other states too as a reason to using abusive substances. Khosla et al did a study among college students in Punjab and found that those with access to pocket money were four times more likely to use alcohol when compared to their counterparts.42 Mohan et al in Kerala also had findings that relate substance use to pocket money.42, 43 Access to pocket money was also associated with problem drinking among the study population. (Table 3.14 and 3.15)

Another finding was the statistically significant association between alcohol use by parents and alcohol use by the respondents. In both the states, if the parents consumed alcohol, there was almost three times greater chance of alcohol use by the respondents.

Chaung et al from Taipei reported that parental drinking was influenced the drinking among young adults.50 Latendresse et al too found that parental drinking was associated adolescent alcohol use.51 Similar association was seen between alcohol use by siblings and alcohol use by respondents. If siblings consumed alcohol there four times greater risk of respondents using alcohol in Arunachal Pradesh, while in Kerala, if siblings consumed alcohol there was nine times greater risk that the respondent used alcohol. This finding is substantiated by the study done by Poelen et al which showed a strong association between drinking by friends and siblings and drinking among adolescents and young adults.52

Parenting plays an important part in monitoring the behavior of the adolescents.51 The finding of our study confirms that a discussion in the family about the harm of alcohol does affect the alcohol use among respondents. In Kerala, a statistically significant protective effect was found between parental advices and drinking among the students. A discussion in the family was associated with lower number of respondents consuming alcohol. In Arunachal Pradesh, it was found that if there was a discussion in the family about the harm alcohol causes, more number of respondents consumed alcohol. This is contrary to the popular belief that if there is proper education about the harmful substances, the children avoided these substances. The explanation might be that the young adults were already using alcohol and therefore there was a discussion that they should stop consuming alcohol. However, this relation was not statistically significant. A parent‟s positive reinforcing role is very important in molding the child‟s behavior with regard to harmful substances.53

Besides home, proper education about harm of alcohol could also be imparted at schools and colleges. In both the states it was found that such a discussion was protective. If the students were informed about the harm of alcohol, then fewer students consumed alcohol.

This relation was not statistically significant in Arunachal Pradesh, but statistically significant in Kerala.

4.2 Socio demographic characteristics

Maximum respondents of Arunachal Pradesh resided in hostels (66.5 percent) while in

Kerala majority resided at home (89.9 percent). There being only one college in the whole of West Siang district, students from throughout the district come to this college. This has led to students residing in hostels provided by the college as well as the nearby locals. In

Kerala, there are many colleges and the students select colleges that are nearer to home.

Moreover, the transport facility is very good. So even if the college is far away from the home, students prefer to go to college from home. An analysis to find the relation between residence and alcohol consumption is important because previous studies have found that place of residence is related to use of alcohol. A study in Massachusetts, USA done by Harford et al reported that those students staying in single gender dormitories were more likely to indulge in drinking when compared to those living off campus with parents.54 In our study too we find that the use of alcohol is more among hostel residing students than those residing in their own homes.(Table 3.14) This finding is statistically significant when we look into the combined population of Arunachal Pradesh and Kerala.

When we analyze them separately this relation is not statistically significant as 90 percent of the students in Kerala were staying at home. (Table 3.3)

4.3 Strengths of the study

The study used a tool that was adapted from the World Health Organization‟s Global

School-based Health Survey (GSHS).33 The prevalence of problem drinking was assessed by using the CAGE questionnaire which is an established standard. Some of the variables on drinking pattern were adopted from the AUDIT questionnaire. The AUDIT questionnaire too has been widely used and it has been recommended by Kokotailo et al that this can be used among college students.35

A standard drinks table was distributed along with the questionnaire. (Annexure 2) This table informed about what constitutes a standard drink. Use of this table decreased the chance of inter-respondent difference in reporting the questions related to amount of drinks.

To our knowledge no authentic studies have been undertaken till to date in finding the prevalence and patterns of alcohol use among college students of Arunachal Pradesh.

Also, no attempt has been made to compare the alcohol related prevalence, patterns and beliefs in between these two states.

A single investigator did the study in both the places, using the same standard too. So a chance of investigator bias is very less.

4.4 Limitations of the study

In this survey, we were depending on the statement of subjects for their and their parents drinking pattern. We have not used any objective criteria like blood biochemical investigation to ascertain their drinking pattern. However use of standardized tools like

CAGE and AUDIT might have reduced the bias to certain extent.

It was observed in the study that drinking is a socially accepted behavior in Arunachal

Pradesh whereas, it is not in Kerala. This could have differently affected the way students in the states have responded to the questions. Being a self administered questionnaire survey, there was no way to ascertain that the answers given by the respondents were genuine.

4.5 Conclusion

The study findings indicate that alcohol use is high among the college going students. In

Arunachal Pradesh the use of alcohol was mostly in the family setup, this highlights the fact that consumption of alcohol is culturally accepted in Arunachal Pradesh.

There is a strong relation between parental use of alcohol and alcohol use by the children.

Also, alcohol use by siblings was related to the use of alcohol by the respondents. The relation between use of alcohol by siblings and use of alcohol by respondents was stronger in Kerala than in Arunachal Pradesh. Peer pressure plays an important role in shaping the patterns related to alcohol use.

With regard to type of alcohol, in Arunachal Pradesh, people usually preferred the local

Poka, but this was closely followed by beer. In Kerala, the first preferred drink was beer.

Beer is very popular among college going students. Beer was considered safe by many of the respondents.

Overall place of initiation to alcohol was either home or a friend‟s home. The students usually prefer the home or a friend‟s home for drinking. The place of procurement of alcoholic beverages was also either home or a friend‟s home. For all these own home was the first option for Arunachal Pradesh whereas friend‟s home was for Kerala.

Large number of students managed money for alcohol from their pocket money. Also, the amount of pocket money had an incremental relationship with alcohol use and problem drinking and this relationship is even statistically significant in Kerala.

Family support is an important factor that moulds the way people perceive alcohol. It is important to inform the younger generation about the ill effects of alcohol before it‟s too late. This information, if imparted through schools and colleges will also be very effective in decreasing the harm of alcohol.

4.6 Recommendations and policy implications of the study

Adolescents should be warned against getting into the grip of social evils like alcoholism.

It is important to have culturally specific and contextualized interventions and health education methods against alcoholism. Intervention in Arunachal Pradesh should address the social drinking pattern, home brewing of alcoholic beverages and the tender age of initiation at first drink. In Kerala it should focus on preventing youngsters from catching the habit of alcohol use, proper guidance by parents and emphasis on reducing parental and sibling alcohol use.

Proper health education system should be developed not only for the younger generation, but also for the adults and parents. Parents should maintain strong positive influence on alcohol and other addictive substance use. The schools and colleges should give emphasis on students who are staying away from home.

Student should be given proper guidance on money management skills. Such skills should be given especially to those youngsters who are staying away from family.

A policy is needed which might look into altering the packaging of beer bottles. It should be emphasized that alcohol is not safe in any form, including beer.

REFERENCES

1. Webster's Online Dictionary. http://www.websters-online- dictionary.org/definition/ alcohol (accessed 15th Oct 2009)

2. Benegal V, Murthy P, A S, Janakiramaiah N. Alcohol Related Problems : A Manual For Medical Officers; 2002.

3. World Health Organisation. The world health report 2002 - Reducing Risks, Promoting Healthy Life. 2002.

4. IAPA. Alcohol atlas of India. Indian Alcohol Policy Alliance; 2008.

5. World Health Organisation. Prevention of harm from alcohol use, get high on life without alcohol. 2003.

6. Mohan D, Sharma H. International review series: alcohol and alcohol problems research. 6. India. Br J Addict. 1985;80(4):351-5.

7. The Schumacher Centre for Technology & Development. Toddy and palm wine – fermented plant saps. Technical Brief, Knowledge and Information Services. http://www.itdg.org/html/technical_enquiries/docs/toddy_palm_wine.pdf (accesed on 10th Sep 2009)

8. Battcock M, Azam-Ali S. Fermented fruits and vegetables: a global perspective. Agriculture and Consumer Protection; 1998.

9. International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS.

10. Chaturvedi H, Mahanta J. Sociocultural diversity and substance use pattern in Arunachal Pradesh, India. Drug Alcohol Depend 2004;74(1):97-104.

11. Deswal B, Jindal A, Gupta K. Epidemiology of Alcohol Use among Residents of Remote Hills of Arunachal Pradesh. Indian Journal of Community Medicine 2006;31(2):88-9.

12. Harrison T. Harrison's principles of internal medicine. 16 ed; 2005.

13. Gururaj G, Girish N, Benegal V. Burden and Socio-Economic Impact of Alcohol - -The Bangalore study. 2006. p. 72.

14. Adewuya A. Prevalence of major depressive disorder in Nigerian college students with alcohol-related problems. Gen Hosp Psychiatry.28(2):169-73.

15. Lamis D, Ellis J, Chumney F, Dula C. Reasons for living and alcohol use among college students. Death Stud 2009 ;33(3):277-86.

16. Bagheri M, Burd L, Martsolf J, Klug M. Fetal alcohol syndrome: maternal and neonatal characteristics. J Perinat Med 1998;26(4):263-9.

17. Abel E, Hannigan J. Maternal risk factors in fetal alcohol syndrome: provocative and permissive influences. Neurotoxicol Teratol. 1995;17(4):445-62.

18. Amaral CS, Vettore M, Leão A. The relationship of alcohol dependence and alcohol consumption with periodontitis: a systematic review. J Dent. 2009;37(9):643-51. 19. Randolph M, Torres H, Gore-Felton C, Lloyd B, McGarvey E. Alcohol use and sexual risk behavior among college students: understanding gender and ethnic differences. Am J Drug Alcohol Abuse. 2009;35(2):80-4.

20. Poulson R, Eppler M, Satterwhite T, Wuensch K, Bass L. Alcohol consumption, strength of religious beliefs, and risky sexual behavior in college students. J Am Coll Health.1998 ;46(5):227-32.

21. Anderson P, Mathieu D. College students' high-risk sexual behavior following alcohol consumption. J Sex Marital Ther. 1996;22(4):259-64.

22. Abbey A. Alcohol-related sexual assault: a common problem among college students. J Stud Alcohol Suppl. 2002;14:118-28.

23. Rehm J, Room R, Graham K, Monteiro M, Gmel G, Sempos C. The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addiction. 2003 ;98(9):1209-28.

24. World Health Oraganisation. Global Status Report on Alcohol 2004.

25. Sacco R, Elkind M, Boden-Albala B, Lin I, Kargman D, Hauser W, et al. The protective effect of moderate alcohol consumption on ischemic stroke. JAMA. 1999;281(1):53-60.

26. Kannel W, Ellison R. Alcohol and coronary heart disease: the evidence for a protective effect. Clin Chim Acta. 1996;246(1-2):59-76.

27. Popelka M, Cruickshanks K, Wiley T, Tweed T, Klein B, Klein R, et al. Moderate alcohol consumption and hearing loss: a protective effect. J Am Geriatr Soc. 2000;48(10):1273-8.

28. Klingemanna H, Gmel G. Mapping the social consequences of alcohol consumption. Alcohol and Alcoholism. 2002;37(1):103-4.

29. Costes J, Martineau H. Drugs and dependence - Indicators and trends in 2002.

30. Gmel G, Rehm J. Harmful alcohol use. Alcohol Res Health. 2003;27(1):52-62.

31. McAnulty R, McGuire L, Minder C, McAnulty D. A cross-cultural comparison of attitudes toward alcohol among French and United States college students. Int J Addict. 1989;24(12):1229-36.

32. Chang J, Shrake E, Rhee S. Patterns of alcohol use and attitudes toward drinking among Chinese and Korean American college students. J Ethn Subst Abuse. 2008;7(3):341-56.

33. WHO. Global school-based student health survey. 2008.

34. Babor T, Higgins JC, Saunders JB, Monteiro MG. AUDIT. 2nd ed: WHO; 2001.

35. Kokotailo P, Egan J, Gangnon R, Brown D, Mundt M, Fleming M. Validity of the alcohol use disorders identification test in college students. Alcohol Clin Exp Res. 2004 ;28(6):914-20.

36. Aertgeerts B, Buntinx F, Bande-Knops J, Vandermeulen C, Roelants M, Ansoms S, et al. The value of CAGE, CUGE, and AUDIT in screening for alcohol abuse and dependence among college freshmen. Alcohol Clin Exp Res. 2000;24(1):53-7.

37. Watkins J, Eisele G, Matthews K. Occupational medical program alcohol screening. Utility of the CAGE and BMAST. J Subst Abuse Treat. 2000; 19(1):51-7.

38. Amaral R, Malbergier A. Effectiveness of the CAGE questionnaire, gamma- glutamyltransferase and mean corpuscular volume of red blood cells as markers for alcohol-related problems in the workplace. Addict Behav. 2008;33(6):772-81.

39. Aertgeerts B, Buntinx F, Kester A. The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: a diagnostic meta-analysis. J Clin Epidemiol. 2004;57(1):30-9.

40. Adewuya A, Ola B, Aloba O. Gender differences in the relationship between alcohol use and anxiety symptoms among Nigerian college students. Drug Alcohol Depend. 2006;85(3):255-7.

41. Lawyer S, Karg R, Murphy J, McGlynn F. Heavy drinking among college students is influenced by anxiety sensitivity, gender, and contexts for alcohol use. J Anxiety Disord. 2002;16(2):165-73.

42. Khosla V, Thankappan K, Mini G, Sarma P. Prevalence & predictors of alcohol use among college students in Ludhiana, Punjab, India. Indian J Med Res. 2008;128(1):79-81.

43. Mohan S, Sarma PS, Thankappan K. Access to pocket money and low educational performance predict tobacco use among adolescent boys in Kerala, India. Preventive Medicine. 2005;41(2):685-92.

44. Nagpal J, Prasad D, Khurana A, Bhave S, Khanna S, Roy N. Alcohol use and abuse: what you should know. WHO; 2006.

45. World Health Organisation. ICD 10 (2009 version).

46. Jinez M, Molina de Souza R, Molina de Souza J, Pillon S. Drug use and risk factors among secondary students. Rev Lat Am Enfermagem.17(2):246-52.

47. Ruth C, David J. Gender differences in drinking patterns and problems among college students: A Review of the Literature. http://www.indiana.edu/~engs/articles/gender90.htm (accessed 17th Oct 2009)

48. Hamilton J, Noland M, Riggs R, Mullineaux D. Factors related to adolescent drinking in Appalachia. Am J Health Behav.34(2):249-56.

49. Assanangkornchai S, Saunders J, Conigrave K. Patterns of drinking in thai men. Alcohol and Alcoholism. 2000;35(3):263-9.

50. Chuang Y, Ennett S, Bauman K, Foshee V. Neighborhood influences on adolescent cigarette and alcohol use: mediating effects through parent and peer behaviors. J Health Soc Behav. 2005;46(2):187-204.

51. Latendresse S, Rose R, Viken R, Pulkkinen L, Kaprio J, Dick D. Parenting mechanisms in links between parents' and adolescents' alcohol use behaviors. Alcohol Clin Exp Res. 2008;32(2):322-30.

52. Poelen E, Scholte R, Willemsen G, Boomsma D, Engels R. Drinking by parents, siblings, and friends as predictors of regular alcohol use in adolescents and young adults: a longitudinal twin-family study. Alcohol Alcohol.42(4):362-9.

53. Weintraub Austin E, Chen Y. The relationship of parental reinforcement of media messages to college students' alcohol-related behaviors. J Health Commun.8(2):157-69.

54. Harford T, Wechsler H, Muthén B. The impact of current residence and high school drinking on alcohol problems among college students. J Stud Alcohol. 2002;63(3):271-9.

ANNEXURE 1

PREVALENCE AND PATTERNS OF ALCOHOL USE AMONG COLLEGE STUDENTS: COMPARING SCENARIO IN ARUNACHAL PRADESH AND KERALA.

QUESTIONNAIRE

Form number:

Date of data collection:

2009

Sl no. Question Response Code General information 1. State 1. Arunachal Pradesh gi01 2. Kerala

2. College gi02

3. Year of study 1. 1st year gi03 2. 2nd year 3. 3rd year 4. Age (in completed years) gi04

5. Sex 1. Male gi05 2. Female

6. Religion 1. Buddhist 2. Christian gi06 3. Donyi-Polo 4. Hindu 5. Muslim 6. Others (please specify)______

7. Average monthly family income gi07 (in Rupees) Rs______

8. How much pocket money do you 1. Less than 500 gi08 get per month? (in Rupees) 2. 501-1000 3. 1001-1500 4. 1501-2000 5. 2001-2500 6. More than 2500

9. Present residence 1. Home gi09 2. Hostel 3. Rented house 4. Relative's place 5. Others(please specify)______

10. Type of family 1. Nuclear gi10 2. Extended 3. Joint

Prevalence and pattern

11. Have you ever taken alcohol? 1. Yes pp01 (if NO, then please go to question 2. No no. 26)

12. How old were you when you had ______years pp02 your first drink of alcohol?

13. Where were you when you had 1. At home pp03 your first drink of alcohol? 2. At friends home 3. At college 4. At hostel 5. Out on the street, in a park, or in some other open area 6. At a bar, pub, or disco 7. In a restaurant 8. Some other place (please specify) ______

14. What was the reason behind your 1. Religious occasion pp04 first drink of alcohol? 2. Family occasion 3. Out of curiosity 4. Because of pressure from friends 5. To forget my sorrows 6. To show off / to feel older 7. Other reason (please specify) ______

15. What was the type of alcohol that 1. Beer 8. Toddy pp05 you first tried? 2. Wine 9. Arrack 3. Whisky 10. Poka 4. Rum 11. Nyongin 5. Brandy 12. Raksi 6. Vodka 13. Some other type 7. Gin (please specify) ______

16. Who all were there when you first Family members pp06 tried alcohol? Friends Strangers Nobody

17. Where from did you get the alcohol Home pp07 when you first tried alcohol? Liquor shop Bar From friend Some other place (please specify) ______

18. Where do you usually drink At home pp08 alcohol? At friends home (if not applicable, please go to At college question no. 21) At hostel Out on the street, in a park, or in some other open area At a restaurant, bar, pub, or disco Some other place (please specify) ______

19. What do you usually drink? Beer Toddy pp09 Wine Arrack Whisky Poka Rum Nyongin Brandy Raksi Vodka Some other type (please Gin specify) ______

20. What is the number of drinks you Less than one drink pp10 usually have on one occasion? 1 drink 2 drinks 3 drinks 4 drinks 5 or more drinks

21. What is the most number of drinks 1. Less than one drink pp11 you have had on one occasion? 2. 1 drink 3. 2 drinks 4. 3 drinks 5. 4 drinks 6. 5 or more drinks

22. During the past 30 days, how many 1. Never pp12 times did you drink so much 2. 1 or 2 times alcohol that you got really drunk? 3. 3 to 9 times 4. 10 or more times

23. During the past 30 days, how many 1. Never pp13 times did you have a hangover, feel 2. 1 or 2 times sick, get into trouble with your 3. 3 to 9 times family or friends, miss school, or 4. 10 or more times get into fights as a result of drinking alcohol?

24. What is your monthly expenditure 1. Less than 500 pp14 on alcoholic drinks? (in Rupees) 2. 501-1000 3. 1001-1500 4. 1501-2000 5. 2001-2500 6. More than 2500

25. How do you manage money for 1. From my pocket money pp15 alcoholic drinks? 2. Borrow from friends 3. Pool money among friends 4. I get it free at home 5. Some other source (please specify) ______6. Not applicable

Factors related to friends

26. How many of your friends consume 1. None ffr01 alcohol? 2. A few (2 out of 5) 3. Some (3 out of 5) 4. Most (4 out of 5) 5. All (5 out of 5)

27. How frequently do your friends get 1. Never ffr02 drunk? 2. Rarely (once in a month) 3. Sometimes (once in a week) 4. Most of the time (almost daily) 5. Always

28. If one of your best friends offered 1. Definitely not ffr03 you a drink of alcohol, would you 2. Probably not drink it? 3. Probably yes 4. Definitely yes

29. With whom do you usually drink 1. With my friends ffr04 alcohol? 2. With my family 3. With anyone who is ready to give me company 4. I usually drink alone 5. Not applicable

30. How frequently do you consume 1. Never ffr05 alcohol with your friends? 2. Sometimes 3. Most of the time 4. Always

Factors related to family

31. Which of your parents or guardians 1. Neither ffm01 drink alcohol? 2. My father or male guardian 3. My mother or female guardian 4. Both 5. I do not know

32. Do any of your siblings (brothers or 1. Yes ffm02 sisters) drink alcohol? 2. No 3. I do not know

33. Has anyone in your family 1. Yes ffm03 discussed with you about the 2. No harmful effect of drinking alcohol?

34. Were you ever taught in your 1. Yes ffm04 school/ college about the harmful 2. No effects of using alcohol? 3. I do not know

35. Do any of your parents/guardians 1. Yes ffm05 know that you drink alcohol? 2. No 3. I don‟t know 4. Not applicable

36. How often do you drink alcohol at 1. Never ffm06 home? 2. Sometimes 3. Most of the time 4. Always 5. Not applicable

Beliefs and perceptions

37. Why do people drink alcohol? 1. Because their parents let them bp01 2. Because their culture permits it 3. Because their friends drink 4. Because it's fun 5. Because it relaxes them 6. To forget sorrows 7. To show off / to feel older 8. Other reasons (please specify) ______

38. How much alcohol will a normal 1. Less than one drink bp02 person need to become drunk? 2. 1 drink 3. 2 drinks 4. 3 drinks 5. 4 drinks 6. 5 or more drinks 7. I don‟t know

39. How much do you think people 1. No risk bp03 harm themselves if they drink 2. Slight risk alcohol once or twice a year? 3. Moderate risk 4. Great risk 5. I don‟t know

40. How much do you think people 1. No risk bp04 harm themselves if they drink 2. Slight risk alcohol several times a week? 3. Moderate risk 4. Great risk 5. I don‟t know

41. What kind of drink do you think is 1. Beer 8. Toddy bp05 safest? 2. Wine 9. Arrack 3. Whisky 10. Poka 4. Rum 11. Nyongin 5. Brandy 12. Raksi 6. Vodka 13. Some other type 7. Gin (please specify) ______

42. What positive benefit can alcohol 1. No positive health benefit bp06 consuming give? 2. Protects the heart 3. Removes mental strain 4. Helps in socialising

The CAGE Questionnaire for alcohol

43. Have you ever felt you should cut 5. Yes cq01 down on your drinking? 6. No

44. Have people annoyed you by 1. Yes cq02 criticizing your drinking? 2. No

45. Have you felt bad or guilty about 1. Yes cq03 your drinking? 2. No

46. Have you ever had a drink first 1. Yes cq04 thing in the morning to steady your 2. No nerves or get rid of a hangover (eye-opener)?

Tobacco use practices while drinking.

47. Do you smoke any tobacco 1. Yes tp01 products? (such as beedi, cigarettes, 2. No cigars or pipes etc)

48. Do you smoke or smoke more than 1. Yes tp02 usual while drinking? 2. No

49. Do you use any smokeless tobacco? 1. Yes tp03 (such as snuff, chewing tobacco, 2. No betel with tobacco etc)

50. Do you use, or use more than usual 1. Yes tp04 smokeless tobacco when you drink? 2. No

ANNEXURE 2

Standard drinks table (approximates)

Name of beverage One Standard Alcohol content Packing Drink (%) Beer 285 ml 4-8 650 ml

Wine 120 ml 10-22 750 ml

Whisky Rum Brandy 30 ml 40-55 750 ml Vodka Gin

Toddy 5-10 Bottles, jugs, mugs, Poka 200 ml bamboo containers Nyongin

Arrack 25 ml 50-60 Packets and bottles

One standard drink contains approximately 10 grams of absolute alcohol.

ANNEXURE 3

Informed consent

My name is Dr. Tumge Loyi and I am a student of Master of Public Health at Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala. I am doing a study on the prevalence and patterns of alcohol use among college students in partial fulfillment of the course. As part of the study I would like you to fill a questionnaire which has questions regarding your alcohol consumption. While there is no direct benefit for you individually, it is possible that the findings of the study will enhance scientific knowledge and enable us to develop better health polices.

The information given by you will not be disclosed to anyone under any circumstances anywhere in the public at any time and kept confidential and will be used for research purposes only. Participation in this study is purely of voluntary nature. If at any time you want to stop answering questions or prefer not to answer some of the questions you are free to do so.

Consent statement

I understand the purpose of the study and I am willing to participate in the study.

Signature of the participant Date:

Name: Place:

In case of any queries or clarifications, please feel free to contact:

1. Dr. Tumge Loyi (principal investigator): Phone 09995931891/037832222792 or by email [email protected].

2. Dr. Anoop Kumar Thekkuveettil (I.E.C member secretary SCTIMST): Phone number 0471-2520256/7 or email [email protected].