1 Young people’s beliefs about the health effects of different alcoholic beverages: An exploratory comparison of the UK and France By Victoria BARBER A thesis submitted to Kingston University London For the degree of Doctor of Philosophy In the school of Psychology June 2016 1 2 Abstract Different kinds of alcoholic drink have different connotations for drinkers in terms of their potential to produce intoxication and their effects on health. These connotations are likely to be important influences on drinking behaviour. This mixed methods study examined how young people (18 to 24 years old) in two countries with different drinking cultures (France and the UK) perceive the costs and benefits of consuming particular kinds of alcoholic beverage, specifically contrasting beers (blonde and dark), wines (red and white) and spirits (clear and dark). More broadly, the project evaluated young peoples beliefs about the different beverage types, and the factors that influence their choices of beverage, including, peer influence, beliefs about drink-specific effects and how different kinds of drink affect body weight. A pilot study of online drinking diaries was conducted to establish drinking trends among young adults in the two countries. A number of key difference were found between the two countries which informed areas of discussion in the focus groups, including beverage preferences, the difference in levels of preloading and mixing drinks, as well as the relationship between alcohol and food. The qualitative part consisted of sixteen structured focus groups (8 in each country), which examined participants’ understanding and beliefs about the health consequences of consuming different kinds of alcoholic beverage. They also explored how different drinks are related to drinking styles. In both countries, participants highlighted ‘getting drunk’ as a reason for drinking, and they adopted similar justifications for their drinking behaviours. UK participants tended to view all drinks (except wine) as equally problematic for health, whereas French participants had more diverse beliefs about the health effects of different beverages. The quantitative phase consisted of a large survey distributed across the two countries (UK= 555 participants and France= 401), which looked further into people’s health beliefs about different beverage types. The notion that wine is healthier than other beverages was widely held in both countries, but was stronger in France than the UK and it had different determinants in the two countries. Also, in France, spirits were identified as particularly problematic for health, much more so than in the UK. In the UK, apart from wine, all beverages were considered to have a similar potential for causing health problems. Liver damage was identified as a key problem linked to chronic alcohol consumption; in France, it was most strongly associated with drinking dark spirits, whereas in the UK it 2 3 was not linked to any particular beverage type(s). In both countries, the acute effects on health were more salient than the chronic effects, and the primary concern relating to long-term consumption was addiction rather than damage to physical health. Lastly, 14 semi-structured interviews were conducted in the two countries (7 in each country) exploring the impacts of public information, media reports and peer influence on beliefs about different beverage types. Across the two countries the participants believed that there was a lack of information about the long-term health effects of alcohol, and expressed a lack of trust in the media (i.e. newspapers and television advertising). They believed that information should be more accessible through the internet, i.e. social media sites, and they also suggested the use of images to illustrate the major health impacts of alcohol consumption. To conclude: drinking practices and views about alcohol’s health effects appear to be converging across the two countries. Participants showed a limited understanding of (and concern about) long-term health problems associated with different drinks, and their views were confounded with stereotypes about typical consumers and beliefs about the “naturalness” or “authenticity” of different drink types. 3 4 Acknowledgements Firstly, I would like to thank my supervisors Professor Philip Terry, Ana Nikcevc and Jess Prior for their support, advice and encouragement. I would particularly like to thank Professor Philip Terry for his patience and for putting up with my ‘Barberisms’. Thank you to Chris Barnham, Christian Gatard and Yovan Hurgobin for their help in conducting and recruiting in the focus group phase. Thank you to all my friends and family, especially Mum, Dad and Liam Edwards for your continuous love, support and encouragement. Thank you to The European Foundation for Alcohol Research for funding this PhD. 4 5 Contents 1 Chapter 1: General introduction……………………………………...………...10 1.1 The place of alcohol in society……………………………...………….10 1.2 Alcohol consumption in the UK and worldwide……………...……......11 1.2.1 Patterns of alcohol consumption……………………………...………..11 1.2.2 Purchases and affordability of alcohol………………………..……......13 1.2.3 Patterns of drinking among young people…………………………...…13 1.3 Alcohol and its effects on health………………………...……………..15 1.3.1 Negative effects of alcohol consumption………………………...….....16 1.3.1.1 Physical illness………….…………………………………...…16 1.3.1.2 Cognitive function………………………………………..….....19 1.3.1.2 Weight gain………………………………………………….....20 1.3.2 Possible health benefits associated with moderate drinking……..…....21 1.3.2.1 Specific drink types………………………………………..…..22 1.4 Alcohol and its cost to society……………………………………….....25 1.5 Government strategy and advice…………………………………….....25 1.6 Beverage type………………………………………………………......29 1.6.1 Beverage preference patterns and stability across different countries....29 1.6.1.1 Adolescent beverage preferences………………..……………..34 1.6.2 Behaviours associated with beverage preference……………………....35 1.7 Young people’s knowledge of the alcohol content of drinks…………...….39 1.8 Beliefs and attitudes towards the health effects of alcohol……………...…41 1.8.1 Beliefs and attitudes towards specific alcoholic beverages………..…..42 1.9 Aims of the thesis………………………………………………...…..….....46 2 Chapter 2: Phase 1: Pilot study-online diaries………………………………….48 2.1 Introduction………………………………………………………….....48 2.2 Method………………………………………………………………….49 2.2.1 Participants………………………………………………………...…...49 2.2.2 Design……………………………………………………………...…...49 2.3 Data Analyses………………………………………………………......51 2.4 Results……………………………………………………………..…...51 2.4.1 Trends in beverage types consumed………………………………...….52 2.4.2 Brands consumed……………………………………………………….53 2.4.3 Location…………………………………………………………...……54 2.4.4 With whom is alcohol consumed? ……………………………………..55 2.4.5 Quantity of alcohol consumed………………………………………....58 2.4.6 Pre-loading. ………………………………………………………...….58 2.4.7 Reasons given for beverage choice………………………………….....59 2.5 Discussion………………………………………………………………60 3 Chapter 3: Phase 2: Focus groups…………………………………………..….62 3.1 Introduction……………………………………………………..……. .62 3.2 Method……………………………………………………………..…...65 3.2.1 Participants…………………………………………………………......67 3.2.2 Design……………………………………………………………...…...66 3.2.3 Procedure …………………………………………………………........67 3.2.4 Data analyses …………………………………………………………..68 3.3 Results: Focus groups…………………………………………………..70 3.3.1 Drinking to get drunk………………………………………………......72 5 6 3.3.1.1 Selecting specific drinks to get you drunk……………………...…..72 3.3.1.1.1 The taste of alcohol is disguised………………………………...72 3.3.1.1.2 Price and availability………………………………………...….73 3.3.2 Drinking rituals and strategies for getting drunk………………………..74 3.3.2.1 Pre-loading……………………………………………………….....76 3.3.2.2 Saving yourself for the weekend……………………………...…….76 3.3.3 Making judgments about the drinker and the drink……………………..77 3.3.3.1 Gender stereotypes……………………………………………...…..77 3.3.3.2 Lifestyle associations………………………………………………..79 3.3.3.3 Being young versus being old. ……………………………………..80 3.3.4 Justifications for drinking style and behaviour ……………………...…81 3.3.4.1 Parental and family influences on drinking behaviour………...……81 3.3.4.2 Feeling in control of my drinking…………………………………...83 3.3.4.3 Lack of education and knowledge about alcohol. ………………….83 3.3.4.3.1 Knowledge of units……………………………………………...84 3.3.4.4 ‘I don’t drink excessively’…………………………………………..85 3.3.5 What stops me drinking too much?..........................................................85 3.3.5.1 Feeling embarrassed……………………………………………...…85 3.3.5.2 Responsibilities……………………………………………………...86 3.3.5.3 Physical effects………………………………………………….......87 3.3.6 Perceptions of the health effects of alcohol……………………………..88 3.3.6.1 Calories and dieting. …………………………………………..…....88 3.3.6.2 Production and origin…………………………………………….....89 3.2.6.2.1 Natural versus artificial. ……………………………………......90 3.3.6.2.2 Industrial versus artisanal. …………………………………...…91 3.3.6.3 Positive health effects. ………………………………………….......93 3.3.6.4 Negative health effects. ………………………………………...…..94 3.3.6.5 “I just don’t think about health when I’ m drinking” ………...…….95 3.4 Discussion ……………………………………………………………...96 4 Chapter 4: Phase 3: Survey……………………………………………………102 4.1 Introduction………………………………………………………...…102 4.2 Method………………………………………………………………..105 4.2.1 Participants ……………………………………………………...……105 4.2.2 Design……………………………………………………………...….107 4.2.3 Procedure….…………………..…………………………………...….108 4.2.3.1 Age and drinking frequency………………………………......108 4.2.3.2 Cultural representations…………………………………….....108