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  • v.14(10); 2022 Oct

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Effects of Alcohol Consumption on Various Systems of the Human Body: A Systematic Review

Jerin varghese.

1 Medical School, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND

Sarika Dakhode

2 Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND

Prolonged alcohol intake for many years has been known to cause serious ailments in human beings since time memorial. Even after knowing that this dangerous addiction paves the way to one’s own grave, there isn’t much difference in the way the community sees this deadly habit. Time and again history has proven that this fatal addiction could make the life of those who consume it terrible. Also, the lives of the dear ones of alcoholic people are affected as alcohol not only affects those who consume them but also kin and friends. Various research studies conducted over many years clearly show the association of prolonged alcohol intake in the causation, aggravation, worsening, and deterioration of the health of its consumers. Moreover, chronic alcohol intake single-handedly is one of the major etiological factors in various serious diseases.

Introduction and background

Through the ages, alcoholism has been undisputedly maintaining its position in the list of risk factors for preventable diseases in the world. According to a WHO report, 5.3% of all deaths that occurred worldwide in the year 2016 were because of harmful alcohol use [ 1 ]. It is the main culprit behind the advancing nature of many chronic diseases. It drastically increases the severity of diseases and also makes the treatments less effective. Alcohol not only affects the person physiologically, but it has many adverse effects psychologically and socially too. Also, the habit of alcoholism leads to huge expenses [ 2 ]. Apart from systemic involvement, which causes various clinical manifestations, there are certain signs and symptoms that are most of the times non-specific and that as such don’t point out or say lead to a particular diagnosis, such as nausea, agitation, vomiting, anxiety, diaphoresis, tremors, headache, visual hallucinations, tachycardia, seizures, delirium, temperature elevation, etc. It is not always necessary that these mentioned signs and symptoms are compulsorily linked with disease conditions.

Alcohol clearly plays a very important role in making many other diseases progress to their advanced stages. It has been also noted that alcohol intake and its related disorders are often associated with many other manifestations; for example, patients with alcoholic neuropathy often have associated nutritional deficiencies. Recent studies have clearly proved that alcoholism is associated with many types of cancers too and this understanding of alcoholism has spurred research minds all over the globe to find out the exact pathophysiology behind the same. Alcohol is a very easily available source of addiction, which is one of the main reasons why it remains a serious threat to the community. There is a huge variety that is available as far as alcoholic drinks are concerned. Alcohol is also one of the cheaply accessible means of addiction; this explains why alcoholism is so prevalent. A person may initially start consuming alcohol in very low amounts most probably with just a desire to try it, but once he or she gets addicted, then getting rid of the habit becomes extremely difficult. Even if a person is mentally resolute enough to quit alcoholism, his or her body, which has been modified because of the chronic use of alcohol, won’t be up to the challenge anytime soon; he or she has to overcome many hurdles put forward by the body, which could in an umbrella term be referred to as alcohol withdrawal syndrome.

There are many social stigmas associated with alcohol intake. Most people get into this addiction by getting inspired by the people whom they admire, like actors, celebrities, role models, etc. Also, exposure to the sight of family members, relatives and friends drinking alcohol has a huge impact on one’s mindset as he or she may take it to be something that is normal. In the long run, most of the time, even without their realization, people get pathetically trapped in this dangerous fatal habit of alcoholism, which eventually makes their lives pitiful in almost all aspects. Studies have shown that alcohol is also a key player in many other domains too like accidents, suicide, depression, hallucinations, violence, memory disturbances, etc.

The main purpose of this review article is to enable any person reading this article to get a comprehensive insight into the effects of alcohol on the various systems of the human body, and for the same, many recognized research articles published in numerous well-acknowledged journals across the globe are reviewed. The article is written using very basic and simple terminologies so that even a layperson who reads it would be able to understand it. For the easy acceptability and understanding of the reader, the discussion is written in such a way that almost every major system is reviewed one by one and the effect of alcohol on these systems put forward in very simple language. The strategies used for the establishment of this review article are summarised in Figure ​ Figure1; 1 ; these include considering research articles that have been published in journals with are indexed in reputed platforms, segregating articles according to the different systems, framing the review like a discussion section of an article where details are explained in simple and straight forward sentences, etc.

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Impact of alcohol on the central nervous system (CNS)

Alcohol exerts various effects on our CNS in various ways, the common ones being depression of the CNS, destruction of the brain cells, contraction of the tissues of the brain, suppression of the excitatory nerve pathway activity, neuronal injury, etc [ 3 ]. Alcohol’s impact on the functioning of the brain ranges from mild and anxiolytic disinhibitory effects, motor incoordination, sedation, emesis, amnesia, hypnosis and ultimately unconsciousness [ 4 ]. The synaptic transmission is heavily disturbed and altered by ethanol, and the intrinsic excitability in various areas of the brain is also compromised. The effects of ethanol may be pre-synaptic, post-synaptic, and at times, non-synaptic too. Alcohol being a psychotropic depressant of the CNS exerts a deeply profound impact on the neurons, which alters the biological and behavioural well-being of the one who consumes it by the promotion of interference in various neuronal pathways [ 5 ]. The treatments of many disorders of the CNS are shown to be affected by the consumption of alcohol, and thus, it is generally advised to keep oneself away from alcohol if one is undergoing treatment for any CNS manifestations, like anxiety or mood disorders [ 6 ].

Alcohol use disorder (AUD) is chronic in nature and is characterized by uncontrolled drinking and also a preoccupation with alcohol. The severity of AUD is a crucial factor in how it is going to affect the human body. AUD can be mild, moderate, or severe according to the symptoms a person experiences. The clinical manifestations of AUD include signs and symptoms such as inability to control the amount of alcohol intake, spending a lot of time drinking, feeling an uncontrollable craving for alcohol, loss of interest in social activities, failure to fulfil tasks within the time provided, etc. Most of the time, along with the person who consumes alcohol, several other factors are also to be taken care of in order to effectively manage alcohol-related health conditions. These factors can be social, environmental, genetic, psychological, etc, which make a considerable impact on how alcohol affects the behaviour and body of those consuming it. Binge drinking, i.e., drinking to such an extent on a single occasion that the blood alcohol concentration level becomes 0.08% or more, is a very relevant aspect of alcohol intake, which has to be dealt with, with utmost urgency. Certain research studies suggest that mild to moderate alcohol intake provides a certain sort of protection against a few CNS disorders like dementia, ischemia of neurons, etc, but this in no way should encourage the community in promoting alcohol intake as in reality, it is very difficult to remain within the limits of mild to moderate alcohol intake, and thus, eventually, people do end up as full-time severe alcohol abusers. Epilepsy, a seizure disorder caused by disturbed nerve cell activity in the brain, aggravates on excessive alcohol intake as alcohol increases the frequency of seizures in patients of epilepsy [ 7 ]. The issue becomes more severe in those epileptic patients who have refractory forms of epilepsy. As far as comorbidities are concerned, a valid history of abuse of substances or alcohol dependence is believed to be strongly associated with a high risk of sudden unexpected death in epilepsy (SUDEP) [ 8 ]. Heavy alcohol drinking over a long period of time has been found to have an intensely negative undesirable effect on the autonomic nervous system too.

Impact of alcohol on the cardiovascular system (CVS)

Chronic alcohol intake is undoubtedly a very important risk factor as far as cardiovascular diseases are concerned and several clinical trials do point out this fact. The results of several research studies conducted in various settings clearly indicate that increased intake of alcohol has increased adverse effects on our heart and its vasculature. Alcohol exerts its action on the cardiovascular system both directly and indirectly. Blood pressure, a very vital player in the domain of cardiovascular diseases, is in turn itself affected by increased alcohol consumption. Blood pressure gets increased on regular consumption of alcohol in a manner which is dose-dependent, which in turn increases the risk of hypertension and eventually leads to various cardiovascular complications. How exactly alcohol causes hypertension is still unclear with many pathophysiological theories out there. Atrial fibrillation, one of the most common causes of arrhythmia, is associated with the high-volume chronic intake of alcohol and above 14 g alcohol/day, the relative risk dramatically increases by 10% for each extra standard drink (14 g ethanol) [ 9 ].

Cerebrovascular accidents are increased to a great extent at almost all levels of alcohol intake [ 10 ]. Alcohol intake leads to both acute (depresses the cardiac function and also alters the blood flow of the involved region) and chronic cardiovascular manifestations [ 11 ]. Alcohol abuse along with other associated factors is one of the leading causes of secondary cardiomyopathy [ 12 ]. Cardiac arrhythmias get precipitated by alcohol consumption, be it acute or chronic. Heavy alcohol drinking is shown to impact the cardiovascular system in many ways, one of the most important among them being rebound hypertension [ 13 ]. Apart from congenital disorders of the cardiovascular system, it indeed is a very well-evident fact, which could be understood from the history of most of the patients diagnosed with cardiovascular disorders, that they used to consume a lot of alcohol for many years.

Impact of alcohol on the digestive system

Chronic alcoholism is found to have a very strong relationship with both acute pancreatitis and chronic pancreatitis. Chronic alcohol intake impairs the repair ability of the structures of the exocrine pancreas, thereby leading to pancreatic dysfunctioning [ 14 ]. Most of the patients diagnosed with pancreatitis have a strong history of chronic intake of alcohol. Liver diseases related to alcohol intake are known to humankind from the very beginning and probably are one of the oldest known forms of injury to the liver [ 15 ]. In liver diseases linked with alcohol, liver cirrhosis is a major concern. Statistics show that liver cirrhosis is one of the top 10 causes of death worldwide and this in itself indicates the severity of the same [ 16 ]. The changing lifestyle and also many people turning to prolonged alcohol intake for many years are contributing to the increased number of liver cirrhosis patients in the modern world. In liver cirrhosis patients, there occurs an increased severity of fibrosis due to the loss of parenchyma and fibrous scar proliferation [ 17 ]. Alcoholic liver disease (ALD) is an umbrella term which incorporates a wide range of injuries of the liver, spanning from simple steatosis to cirrhosis, and this also includes alcohol-related fatty liver disease (AFLD) and also alcoholic hepatitis [ 18 ]. Advancements in the diagnostic modalities have helped to diagnose ALD at an early phase and there is no doubt that newer and better investigations that have helped to detect more cases have led to a surge in the number of ALD patients on whole. Alcohol intake has a prominently bigger impact on the mortality of liver cirrhosis when compared with the morbidity [ 19 ]. A systemic review and meta-analysis suggests that women might be at a higher risk as far as developing liver cirrhosis is concerned even with little consumption of alcohol, as compared to men [ 20 ].

Impact of alcohol on the causation of cancer

Alcohol has much to do with cancers too and continuous research studies are conducted in order to find out the relationship between the two in detail. In a meta-analysis, it was found that women consuming alcohol had a later menopause onset, which is found to be associated with reduced cardiovascular disease risk and also all-cause mortality, but unfortunately, the happiness of this advantage gets compromised by the ironic fact that it has an increased risk of cancer (including ovarian and breast cancers) [ 21 , 22 ]. Large cohort studies, many meta-analyses, experimental research studies, etc are suggestive of the fact that the chronic intake of alcohol clearly increases colon and gastric cancer risk [ 23 ]. A causal association is also found between alcohol intake and cancers of the rectum, colon, liver, oesophagus, larynx, pharynx and oral cavity [ 24 ]. There are various theories put forward so as to understand the role of the consumption of alcohol in the development of cancer; there is suspicion that the rise in the number of alcohol users worldwide may be one of the reasons why the number of cancer patients is increasing at a global level. Chronic intake of alcohol may promote the genesis of cancer in many ways, some of the most notable ones being acetaldehyde (weak mutagen and carcinogen) production, cytochrome P450 2E1 induction associated oxidative stress, S-adenosylmethionine depletion/ which leads to global DNA hypomethylation induction, iron induction associated oxidative stress, retinoic acid metabolism impairment, etc [ 25 ].

Impact of alcohol on other systems

Apart from the systemic manifestations which do affect a particular system of the body, there are various disorders in which alcohol indirectly provides its crucial contribution. It is a common finding that one could perceive that alcohol is most of the time in the list of risk factors for various diseases. Alcohol has been found to adversely affect our immune system and the matter of concern as far as this issue is concerned is that immune responses are influenced by even moderate amounts of alcohol intake [ 26 ]. Alcohol affects innate immunity and also interferes with almost all the various aspects of the adaptive immune response. Alcohol is a key player in impairing anti-inflammatory cytokines and also promotes proinflammatory immune responses. The gastrointestinal biome is severely manipulated by the use of alcohol over a long period of time, which in turn is found to have a link with the establishment of various complications [ 27 ]. Alcohol and its metabolites are found to promote inflammation in the intestines and they do so through varied pathways [ 28 ]. Alcohol being a teratogen is documented to cause abnormalities of the brain, limbs, etc [ 29 ]. Multiple studies have been conducted across the globe to understand the effect of alcohol on humans; implications from certain such studies are put forth in Table ​ Table1 1 . 


Alcohol seldom leaves any system untouched as far as leaving its impression is concerned, spanning from single tissue involvement to complex organ system manifestations. Almost all the major organs that make up a human’s physiological being are dramatically affected by the overconsumption of alcohol. There is an enormous overall economic cost that is paid for alcohol abuse all over the world.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

  • Introduction
  • Conclusions
  • Article Information

BMI indicates body mass index; SES, socioeconomic status.

a Variables smoking status, SES, drinking pattern, former drinker bias only, occasional drinker bias, median age, and gender were removed.

b Variables race, diet, exercise, BMI, country, follow-up year, publication year, and unhealthy people exclusion were removed.

eAppendix. Methodology of Meta-analysis on All-Cause Mortality and Alcohol Consumption


eFigure 1. Flowchart of Systematic Search Process for Studies of Alcohol Consumption and Risk of All-Cause Mortality

eTable 1. Newly Included 20 Studies (194 Risk Estimates) of All-Cause Mortality and Consumption in 2015 to 2022

eFigure 2. Funnel Plot of Log-Relative Risk (In(RR)) of All-Cause Mortality Due to Alcohol Consumption Against Inverse of Standard Error of In(RR)

eFigure 3. Relative Risk (95% CI) of All-Cause Mortality Due to Any Alcohol Consumption Without Any Adjustment for Characteristics of New Studies Published between 2015 and 2022

eFigure 4. Unadjusted, Partially Adjusted, and Fully Adjusted Relative Risk (RR) of All-Cause Mortality for Drinkers (vs Nondrinkers), 1980 to 2022

eTable 2. Statistical Analysis of Unadjusted Mean Relative Risk (RR) of All-Cause Mortality for Different Categories of Drinkers for Testing Publication Bias and Heterogeneity of RR Estimates From Included Studies

eTable 3. Mean Relative Risk (RR) Estimates of All-Cause Mortality Due to Alcohol Consumption up to 2022 for Subgroups (Cohorts Recruited 50 Years of Age or Younger and Followed up to 60 Years of Age)

Data Sharing Statement

  • Errors in Figure and Supplement JAMA Network Open Correction May 9, 2023

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Zhao J , Stockwell T , Naimi T , Churchill S , Clay J , Sherk A. Association Between Daily Alcohol Intake and Risk of All-Cause Mortality : A Systematic Review and Meta-analyses . JAMA Netw Open. 2023;6(3):e236185. doi:10.1001/jamanetworkopen.2023.6185

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Association Between Daily Alcohol Intake and Risk of All-Cause Mortality : A Systematic Review and Meta-analyses

  • 1 Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
  • 2 Department of Psychology, University of Portsmouth, Portsmouth, Hampshire, United Kingdom
  • Correction Errors in Figure and Supplement JAMA Network Open

Question   What is the association between mean daily alcohol intake and all-cause mortality?

Findings   This systematic review and meta-analysis of 107 cohort studies involving more than 4.8 million participants found no significant reductions in risk of all-cause mortality for drinkers who drank less than 25 g of ethanol per day (about 2 Canadian standard drinks compared with lifetime nondrinkers) after adjustment for key study characteristics such as median age and sex of study cohorts. There was a significantly increased risk of all-cause mortality among female drinkers who drank 25 or more grams per day and among male drinkers who drank 45 or more grams per day.

Meaning   Low-volume alcohol drinking was not associated with protection against death from all causes.

Importance   A previous meta-analysis of the association between alcohol use and all-cause mortality found no statistically significant reductions in mortality risk at low levels of consumption compared with lifetime nondrinkers. However, the risk estimates may have been affected by the number and quality of studies then available, especially those for women and younger cohorts.

Objective   To investigate the association between alcohol use and all-cause mortality, and how sources of bias may change results.

Data Sources   A systematic search of PubMed and Web of Science was performed to identify studies published between January 1980 and July 2021.

Study Selection   Cohort studies were identified by systematic review to facilitate comparisons of studies with and without some degree of controls for biases affecting distinctions between abstainers and drinkers. The review identified 107 studies of alcohol use and all-cause mortality published from 1980 to July 2021.

Data Extraction and Synthesis   Mixed linear regression models were used to model relative risks, first pooled for all studies and then stratified by cohort median age (<56 vs ≥56 years) and sex (male vs female). Data were analyzed from September 2021 to August 2022.

Main Outcomes and Measures   Relative risk estimates for the association between mean daily alcohol intake and all-cause mortality.

Results   There were 724 risk estimates of all-cause mortality due to alcohol intake from the 107 cohort studies (4 838 825 participants and 425 564 deaths available) for the analysis. In models adjusting for potential confounding effects of sampling variation, former drinker bias, and other prespecified study-level quality criteria, the meta-analysis of all 107 included studies found no significantly reduced risk of all-cause mortality among occasional (>0 to <1.3 g of ethanol per day; relative risk [RR], 0.96; 95% CI, 0.86-1.06; P  = .41) or low-volume drinkers (1.3-24.0 g per day; RR, 0.93; P  = .07) compared with lifetime nondrinkers. In the fully adjusted model, there was a nonsignificantly increased risk of all-cause mortality among drinkers who drank 25 to 44 g per day (RR, 1.05; P  = .28) and significantly increased risk for drinkers who drank 45 to 64 and 65 or more grams per day (RR, 1.19 and 1.35; P  < .001). There were significantly larger risks of mortality among female drinkers compared with female lifetime nondrinkers (RR, 1.22; P  = .03).

Conclusions and Relevance   In this updated systematic review and meta-analysis, daily low or moderate alcohol intake was not significantly associated with all-cause mortality risk, while increased risk was evident at higher consumption levels, starting at lower levels for women than men.

The proposition that low-dose alcohol use protects against all-cause mortality in general populations continues to be controversial. 1 Observational studies tend to show that people classified as “moderate drinkers” have longer life expectancy and are less likely to die from heart disease than those classified as abstainers. 2 Systematic reviews and meta-analyses of this literature 3 confirm J-shaped risk curves (protective associations at low doses with increasing risk at higher doses). However, mounting evidence suggests these associations might be due to systematic biases that affect many studies. For example, light and moderate drinkers are systematically healthier than current abstainers on a range of health indicators unlikely to be associated with alcohol use eg, dental hygiene, exercise routines, diet, weight, income 4 ; lifetime abstainers may be systematically biased toward poorer health 5 ; studies fail to control for biases in the abstainer reference group, in particular failing to remove “sick quitters” or former drinkers, many of whom cut down or stop for health reasons 2 ; and most studies have nonrepresentative samples leading to an overrepresentation of older White men. Adjustment of cohort samples to make them more representative has been shown to eliminate apparent protective associations. 6 Mendelian randomization studies that control for the confounding effects of sociodemographic and environmental factors find no evidence of cardioprotection. 7

We published 2 previous systematic reviews and meta-analyses that investigated these hypotheses. The first of these focused on all-cause mortality, 8 finding negligible reductions in mortality risk with low-volume alcohol use when study-level controls were introduced for potential bias and confounding, such as the widespread practice of misclassifying former drinkers and/or current occasional drinkers as abstainers (ie, not restricting reference groups to lifetime abstainers). 8 Our alcohol and coronary heart disease (CHD) mortality meta-analysis of 45 cohort studies 9 found that CHD mortality risk differed widely by age ranges and sex of study populations. In particular, young cohorts followed up to old age did not show significant cardio-protection for low-volume use. Cardio-protection was only apparent among older cohorts that are more exposed to lifetime selection biases (ie, increasing numbers of “sick-quitters” in the abstainer reference groups and the disproportionate elimination of drinkers from the study sample who had died or were unwell).

The present study updates our earlier systematic review and meta-analysis for all-cause mortality and alcohol use, 8 including studies published up to July 2021 (ie, 6.5 years of additional publications). The study also investigated the risk of all-cause mortality for alcohol consumption according to (1) median ages of the study populations (younger than 56 years or 56 years and older), replicating the methods of Zhao et al 9 ; (2) the sex distribution of the study populations, and (3) studies of cohorts recruited before a median age of 51 years of age and followed up in health records until a median age of at least 60 years (ie, with stricter rules to further minimize lifetime selection biases). Because younger cohorts followed up to an age at which they may experience heart disease are less likely to be affected by lifetime selection biases, 9 we hypothesized that such studies would be less likely to show reduced mortality risks for low-volume drinkers. Finally, we reran the analyses using occasional drinkers (<1 drink per week) as the reference, for whom physiological health benefits are unlikely. Occasional drinkers are a more appropriate reference group, given evidence demonstrating that lifetime abstainers may be biased toward ill health. 10

The present study updates the systematic reviews and meta-analyses described above 8 by including studies published up to July 2021 to investigate whether the risk differed for subgroups. The study protocol was preregistered on the Open Science Framework. 11 Inclusion criteria, search strategy, study selection, data extraction, and statistical analytical methods of the study are summarized in later sections (see eAppendix in Supplement 1 for more details).

The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses ( PRISMA ) reporting guideline. 12 The review sought cohort studies of all-cause mortality and alcohol consumption. We identified all potentially relevant articles published up to July 31, 2021, regardless of language, by searching PubMed and Web of Science, through reference list cross-checking of previous meta-analyses (eFigure 1 in Supplement 1 ). There were 87 studies identified by Stockwell et al. 8 After inclusion of 20 new studies meeting inclusion criteria, there were a total of 107 cohort studies (eTable 1 in Supplement 1 ). 13 - 32

Three coders (J. Z., F. A., and J. C.) reviewed all eligible studies to extract and code data independently from all studies fulfilling the inclusion criteria. Data extracted included (1) outcome, all-cause mortality; (2) measures of alcohol consumption; (3) study characteristics, including cohort ages at recruitment and follow-up; (4) types of misclassification error of alcohol consumers and abstainers; (5) controlled variables in individual studies. Alcoholic drinks were converted into grams per day according to country-specific definitions if not otherwise defined. 33 , 34

We also assessed publication bias, heterogeneity, and confounding of covariates that might potentially affect the association of interest using several statistical approaches. 35 - 41 Relative risk (RR), including hazard ratios or rate ratios, were converted to natural log-transformed formats to deal with skewness. Publication bias was assessed through visual inspection of the funnel plot of log-RR of all-cause mortality due to alcohol consumption against the inverse standard error of log-RR 42 and Egger’s linear regression method. 36 We also plotted forest graphs of log-RR of all-cause mortality for any level of drinking to assess heterogeneity among studies. 42 The between-study heterogeneity of RRs were assessed using Cochran Q 37 and the I 2 statistic. 38 If heterogeneity was detected, mixed-effects models were used to obtain the summarized RR estimates. Mixed-effects regression analyses were performed in which drinking groups and control variables were treated as fixed-effects with a random study effect because of significant heterogeneity. 43

All analyses were weighted by the inverse of the estimated variance of the natural log relative risk. Variance was estimated from reported standard errors, confidence intervals, or number of deaths. The weights for each individual study were created using the inverse variance weight scheme and used in mixed regression analysis to get maximum precision for the main results of the meta-analysis. 42 In comparison with lifetime abstainers, the study estimated the mean RR of all-cause mortality for former drinkers (ie, now completely abstaining), current occasional (<9.1 g per week), low-volume (1.3-24.0 g per day), medium-volume (25.0-44.0 g per day), high-volume (45.0-64.0 g) and highest-volume drinkers (≥65.0 grams per day). The analyses adjusted for the potential confounding effects of study characteristics including the median age and sex distribution of study samples, drinker biases, country where a study was conducted, follow-up years and presence or absence of confounders. Analyses were also repeated using occasional drinkers as the reference group. We used t tests to calculate P values, and significance was set at .05. All statistical analyses were performed using SAS version 9.4 (SAS Institute) and the SAS MIXED procedure was used to model the log-transformed RR. 44 Data were analyzed from September 2021 to August 2022.

There were 724 estimates of the risk relationship between level of alcohol consumption and all-cause mortality from 107 unique studies 13 - 32 , 45 - 131 , including 4 838 825 participants and 425 564 deaths available for the analysis. Table 1 describes the sample characteristics of the metadata. Of 39 studies 13 , 15 , 18 , 21 , 23 - 26 , 29 , 31 , 45 - 47 , 49 , 50 , 52 - 54 , 57 - 59 , 62 , 64 , 70 , 80 , 81 , 85 , 87 , 91 , 94 , 96 , 100 , 104 , 107 , 118 , 124 , 125 , 127 , 130 reporting RR estimates for men and women separately, 33 14 , 17 , 48 , 51 , 61 , 63 , 66 , 68 , 69 , 72 , 76 , 79 , 83 , 84 , 86 , 88 , 90 , 92 , 93 , 97 , 98 , 101 , 103 , 105 , 109 - 111 , 113 - 115 , 119 , 120 , 128 were for males only, 8 16 , 65 , 73 , 99 , 102 , 108 , 112 , 123 for females only, and 30 13 , 19 - 22 , 26 - 30 , 32 , 55 , 56 , 67 , 71 , 74 , 75 , 77 , 78 , 82 , 84 , 89 , 95 , 106 , 116 , 117 , 121 , 122 , 126 , 129 for both sexes. Twenty-one studies 13 , 17 , 19 , 21 , 22 , 26 , 27 , 45 - 58 (220 risk estimates) were free from abstainer bias (ie, had a reference group of strictly defined lifetime abstainers). There were 50 studies 14 - 16 , 18 , 20 , 23 - 25 , 29 , 59 - 99 (265 risk estimates) with both former and occasional drinker bias; 28 studies 28 , 30 - 32 , 100 - 122 , 130 (177 risk estimates) with only former drinker bias; and 8 studies 123 - 129 , 131 (62 risk estimates) with only occasional drinker bias.

Unadjusted mean RR estimates for most study subgroups categorized by methods/sample characteristics showed markedly or significantly higher RRs for alcohol consumers as a group vs abstainers. Exceptions were for studies with less than 10 years of follow-up and those with some form of abstainer bias ( Table 1 ). Bivariable analyses showed that mortality risks for alcohol consumers varied considerably according to other study characteristics, such as quality of the alcohol consumption measure, whether unhealthy individuals were excluded at baseline, and whether socioeconomic status was controlled for ( Table 1 ).

No evidence of publication bias was detected either by inspection of symmetry in the funnel plot of log-RR estimates and their inverse standard errors (eFigure 2 in Supplement 1 ) or by Egger linear regression analysis (eTable 2 in Supplement 1 , all P > .05 for each study group). Significant heterogeneity was observed across studies for all drinking categories confirmed by both the Q statistic ( Q 723  = 5314.80; P  < .001) and I 2 estimates (all >85.87%). (See eFigure 3 in Supplement 1 for forest plot of unadjusted risk estimates of mortality risks for the 20 newly identified studies).

Pooled unadjusted estimates (724 observations) showed significantly higher risk for former drinkers (RR, 1.22; 95% CI, 1.11-1.33; P  = .001) and significantly lower risk for low-volume drinkers (RR, 0.85; 95% CI, 0.81-0.88; P  = .001) compared with abstainers as defined in the included studies ( Table 2 ; eFigure 4 in Supplement 1 ). In the fully adjusted model, mortality RR estimates increased for all drinking categories, becoming nonsignificant for low-volume drinkers (RR, 0.93; 95% CI, 0.85-1.01; P  = .07), occasional drinkers (>0 to <1.3 g of ethanol per day; RR, 0.96; 95% CI, 0.86-1.06; P  = .41), and drinkers who drank 25 to 44 g per day (RR, 1.05; 95% CI, 0.96-1.14; P  = .28). There was a significantly increased risk among drinkers who drank 45 to 64 g per day (RR, 1.19; 95% CI, 1.07-1.32; P  < .001) and 65 or more grams (RR, 1.35; 95% CI, 1.23-1.47; P  < .001). The Figure shows the changes in RR estimates for low-volume drinkers when removing each covariate from the fully adjusted model. In most cases, removing study-level covariates tended to yield lower risk estimates from alcohol use.

Table 2 presents the RR estimates when occasional drinkers were the reference group. In fully adjusted models, higher though nonsignificant mortality risks were observed for both abstainers and medium-volume drinkers (RR, 1.04; 95% CI, 0.94-1.16; P  = .44 and RR, 1.09; 95% CI, 0.96-1.25; P  = .19, respectively). There were significantly elevated risks for both high and higher volume drinkers (RR, 1.24; 95% CI, 1.07-1.44; P  = .004 and RR, 1.41; 95% CI, 1.23-1.61; . P  = 001, respectively).

As hypothesized, there was a significant interaction between cohort age and mortality risk ( P  = .02; F 601  = 2.93) and so RR estimates for drinkers were estimated in analyses stratified by median age of the study populations at enrollment ( Table 3 ). In unadjusted and partially adjusted analyses, older cohorts displayed larger reductions in mortality risk associated with low-volume consumption than younger cohorts. However, in fully adjusted analyses with multiple covariates included for study characteristics, these differences disappeared. Younger cohorts also displayed greater mortality risks than older cohorts at higher consumption levels. Among studies in which participants were recruited at age 50 years or younger and followed up to age 60 years (ie, there was likely reduced risk of lifetime selection bias) higher RR estimates were observed for all drinking groups vs lifetime abstainers. These differences were significant in all drinking groups except low-volume drinkers (eTable 3 in Supplement 1 ).

Across all levels of alcohol consumption, female drinkers had a higher RR of all-cause mortality than males ( P for interaction  = .001). As can be seen in Table 4 , all female drinkers had a significantly increased mortality risk compared with female lifetime nondrinkers (RR, 1.22; 95% CI, 1.02-1.46; P  = .03). Compared with lifetime abstainers, there was significantly increased risk of all-cause mortality among male drinkers who drank 45 to 64 g per day (RR, 1.15; 95% CI, 1.03-1.28; P  = .01) and drank 65 or more (RR, 1.34; 95% CI, 1.23-1.47; P  < .001), and among female drinkers who drank 25 to 44 g per day (RR, 1.21; 95% CI, 1.08-1.36; P  < .01), 45 to 64 g (RR, 1.34; 95% CI, 1.11-1.63; P  < .01) and 65 or more grams (RR, 1.61; 95% CI, 1.44-1.80; P  = .001).

In fully adjusted, prespecified models that accounted for effects of sampling, between-study variation, and potential confounding from former drinker bias and other study-level covariates, our meta-analysis of 107 studies found (1) no significant protective associations of occasional or low-volume drinking (moderate drinking) with all-cause mortality; and (2) an increased risk of all-cause mortality for drinkers who drank 25 g or more and a significantly increased risk when drinking 45 g or more per day.

Several meta-analytic strategies were used to explore the role of abstainer reference group biases caused by drinker misclassification errors and also the potential confounding effects of other study-level quality covariates in studies. 2 Drinker misclassification errors were common. Of 107 studies identified, 86 included former drinkers and/or occasional drinkers in the abstainer reference group, and only 21 were free of both these abstainer biases. The importance of controlling for former drinker bias/misclassification is highlighted once more in our results which are consistent with prior studies showing that former drinkers have significantly elevated mortality risks compared with lifetime abstainers.

In addition to presenting our fully adjusted models, a strength of the study was the examination of the differences in relative risks according to unadjusted and partially adjusted models, including the effect of removing individual covariates from the fully adjusted model. We found evidence that abstainer biases and other study characteristics changed the shape of the risk relationship between mortality and rising alcohol consumption, and that most study-level controls increased the observed risks from alcohol, or attenuated protective associations at low levels of consumption such that they were no longer significant. The reduced RR estimates for occasional or moderate drinkers observed without adjustment may be due to the misclassification of former and occasional drinkers into the reference group, a possibility which is more likely to have occurred in studies of older cohorts which use current abstainers as the reference group. This study also demonstrates the degree to which observed associations between consumption and mortality are highly dependent on the modeling strategy used and the degree to which efforts are made to minimize confounding and other threats to validity.

It also examined risk estimates when using occasional drinkers rather than lifetime abstainers as the reference group. The occasional drinker reference group avoids the issue of former drinker misclassification that can affect the abstainer reference group, and may reduce confounding to the extent that occasional drinkers are more like low-volume drinkers than are lifetime abstainers. 2 , 8 , 132 In the unadjusted and partially adjusted analyses, using occasional drinkers as the reference group resulted in nonsignificant protective associations and lower point estimates for low-volume drinkers compared with significant protective associations and higher point estimates when using lifetime nondrinkers as the reference group. In the fully adjusted models, there were nonsignificant protective associations for low-volume drinkers whether using lifetime abstainers or occasional drinkers as the reference group, though this was only a RR of 0.97 for the latter.

Across all studies, there were few differences in risk for studies when stratified by median age of enrollment above or below age 56 years in the fully adjusted analyses. However, in the subset of studies who enrolled participants aged 50 years or younger who were followed for at least 10 years, occasional drinkers and medium-volume drinkers had significantly increased risk of mortality and substantially higher risk estimates for high- and higher-volume consumption compared with results from all studies. This is consistent with our previous meta-analysis for CHD, 9 in which younger cohorts followed up to older age did not show a significantly beneficial association of low-volume consumption, while older cohorts, with more opportunity for lifetime selection bias, showed marked, significant protective associations.

Our study also found sex differences in the risk of all-cause mortality. A larger risk of all-cause mortality for women than men was observed when drinking 25 or more grams per day, including a significant increase in risk for medium-level consumption for women that was not observed for men. However, mortality risk for mean consumption up to 25 g per day were very similar for both sexes.

A number of limitations need to be acknowledged. A major limitation involves imperfect measurement of alcohol consumption in most included studies, and the fact that consumption in many studies was assessed at only 1 point in time. Self-reported alcohol consumption is underreported in most epidemiological studies 133 , 134 and even the classification of drinkers as lifetime abstainers can be unreliable, with several studies in developed countries finding that the majority of self-reported lifetime abstainers are in fact former drinkers. 135 , 136 If this is the case, the risks of various levels of alcohol consumption relative to presumed lifetime abstainers are underestimates. Merely removing former drinkers from analyses may bias studies in favor of drinkers, since former drinkers may be unhealthy, and should rightly be reallocated to drinking groups according to their history. However, this has only been explored in very few studies. Our study found that mortality risk differed significantly by cohort age and sex. It might be that the risk is also higher for other subgroups, such as people living with HIV, 137 a possibility future research should investigate.

The number of available studies in some stratified analyses was small, so there may be limited power to control for potential study level confounders. However, the required number of estimates per variable for linear regression can be much smaller than in logistic regression, and a minimum of at least 2 estimates per variable is recommended for linear regression analysis, 138 suggesting the sample sizes were adequate in all models presented. It has been demonstrated that a pattern of binge (ie, heavy episodic) drinking removes the appearance of reduced health risks even when mean daily volume is low. 139 Too few studies adequately controlled for this variable to investigate its association with different outcomes across studies. Additionally, our findings only apply to the net effect of alcohol at different doses on all-cause mortality, and different risk associations likely apply for specific disease categories. The biases identified here likely apply to estimates of risk for alcohol and all diseases. It is likely that correcting for these biases will raise risk estimates for many types of outcome compared with most existing estimates.

This updated meta-analysis did not find significantly reduced risk of all-cause mortality associated with low-volume alcohol consumption after adjusting for potential confounding effects of influential study characteristics. Future longitudinal studies in this field should attempt to minimize lifetime selection biases by not including former and occasional drinkers in the reference group, and by using younger cohorts (ie, age distributions that are more representative of drinkers in the general population) at baseline.

Accepted for Publication: February 17, 2023.

Published: March 31, 2023. doi:10.1001/jamanetworkopen.2023.6185

Correction: This article was corrected on May 9, 2023, to fix errors in the Figure and Supplement.

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Zhao J et al. JAMA Network Open .

Corresponding Author: Jinhui Zhao, PhD, Canadian Institute for Substance Use Research, University of Victoria, PO Box 1700 STN CSC, Victoria, BC V8Y 2E4, Canada ( [email protected] ).

Author Contributions: Drs Zhao and Stockwell had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Zhao, Stockwell, Naimi, Churchill, Sherk.

Acquisition, analysis, or interpretation of data: Zhao, Stockwell, Naimi, Clay.

Drafting of the manuscript: Zhao, Stockwell, Clay.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Zhao, Churchill.

Obtained funding: Zhao, Stockwell, Sherk.

Administrative, technical, or material support: Zhao, Stockwell, Naimi.

Supervision: Zhao, Stockwell, Naimi.

Conflict of Interest Disclosures: Dr Stockwell reported receiving personal fees from Ontario Public Servants Employees Union for expert witness testimony and personal fees from Alko outside the submitted work. Dr Sherk reported receiving grants from Canadian Centre on Substance Use and Addiction (CCSA) during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was partly funded by the CCSA as a subcontract for a Health Canada grant to develop guidance for Canadians on alcohol and health.

Role of the Funder/Sponsor: Health Canada had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. CCSA staff conducted a preliminary search to identify potentially relevant articles but did not participate in decisions about inclusion/exclusion of studies, coding, analysis, interpretation of results or approving the final manuscript.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: We gratefully acknowledge contributions by Christine Levesque, PhD (CCSA), and Nitika Sanger, PhD (CCSA), who conducted a preliminary literature search for potentially relevant articles. We also acknowledge the leadership of Drs Catherine Paradis, PhD (CCSA), and Peter Butt, MD (University of Saskatchewan), who cochaired the process of developing Canada’s new guidance on alcohol and health, a larger project which contributed some funds for the work undertaken for this study. We are grateful to Fariha Alam, MPH (Canadian Institute for Substance Use and Research), for her help coding the studies used in this study. None of them received any compensation beyond their normal salaries for this work.

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The prevalence of alcohol references in music and their effect on people's drinking behavior: A systematic review and meta-analysis


  • 1 Centre for Alcohol Policy Research, La Trobe University, Melbourne, Victoria, Australia.
  • 2 Department of Public Health, College of Medicine and Health Science, Debre Markos University, Debre Markos, Ethiopia.
  • 3 Department of Computer Science and Information Technology, La Trobe University, Melbourne, Victoria, Australia.
  • PMID: 38367006
  • DOI: 10.1111/acer.15262

Understanding the prevalence of alcohol references in music and their impact on alcohol drinking behavior is important given the increased accessibility to daily music listening with the proliferation of smart devices. In this review, we estimate the pooled prevalence of alcohol references in music and its association with drinking behavior. Systematic searches were conducted across four major databases (MEDLINE, PsycINFO, EMBASE, and CINHAL). Articles were selected following duplicate checking, title and abstract screening, and full-text review. Studies reporting the prevalence of alcohol-referencing music and/or investigating its association with drinking behavior were included. Pooled prevalence with 95% confidence intervals (CIs) were computed using a random effects model. Of 1007 articles identified, 26 met inclusion criteria and 23 studies comprising 12,224 songs were eligible for meta-analysis. The overall pooled prevalence of alcohol references in music (including lyrics and videos) was 24.0% (95% CI: 19.0%-29.0%). The pooled prevalence was 22.0% (95% CI: 16.0%-29.0%) for only lyrics, 25.0% (95% CI: 18.0%-33.0%) for only the visual elements of music videos, and 29.0% (95% CI: 21.0%-38.0%) for both the lyrical content and the visual components. Only three studies assessed the relationship between listening to music with alcohol references and drinking behavior, and all three reported a positive association. Whereas almost a quarter of all songs included references to alcohol, public health preventive measures are needed to reduce alcohol exposure from music. Future research is needed to understand fully the effect of music with alcohol references on drinking behavior.

Keywords: alcohol; drinking behavior; music; systematic review.

© 2024 The Authors. Alcohol, Clinical and Experimental Research published by Wiley Periodicals LLC on behalf of Research Society on Alcohol.

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(March 2002 Supplement)

Journal of studies on alcohol  supplement.

Journal of Studies on Alcohol College Drinking, What It Is, and What To Do about It: A Review of the State of the Science

National Advisory Council on Alcohol Abuse and Alcoholism Task Force on College Drinking

Special Editors:  Mark S. Goldman, Ph.D., Gayle M. Boyd, Ph.D., Vivian Faden, Ph.D.

Supplement No:  14 Printed Date:  March 2002

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Panel 1 - contexts and consequences, studying college alcohol use: widening the lens, sharpening the focus.

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ABSTRACT Objective:  The study was designed to assess current trends in studying, and emerging approaches to furthering understanding of, college drinking. Method:  A literature review was conducted of findings and methods highlighting conceptual and methodological issues that need to be addressed. Results: Most studies address clinical, developmental and psychological variables and are conducted at single points in time on single campuses. Factors affecting college alcohol use and methods of studying them are discussed. Conclusions:  Most current studies of college drinking do not address the influence of the college and its alcohol environment. Our understanding of college drinking can be improved by expanding the scope of issues studied and choosing appropriate research designs. ( J. Stud. Alcohol,  Supplement No. 14: 14-22, 2002)

George W. Dowdall, Ph.D., Professor, Department of Sociology, St. Joseph’s University, and Henry Wechsler, Ph.D., Lecturer and Director of College Alcohol Studies, Department of Health and Social Behavior, Harvard School of Public Health

Epidemiology of Alcohol and Other Drug Use among American College Students

ABSTRACT Objective:  This article provides information on the extent of alcohol use and other drug use among American college students. Method:  Five different sources of data are examined for estimating recent levels of alcohol (and other drug) use among college students: Harvard School of Public Health College Alcohol Study (CAS), the Core Institute (CORE), Monitoring the Future (MTF), National College Health Risk Behavior Survey (NCHRBS) and National Household Survey on Drug Abuse (NHSDA). Results:  Alcohol use rates are very high among college students. Approximately two of five American college students were heavy drinkers, defined as having had five or more drinks in a row in the past 2 weeks. Alcohol use is higher among male than female students. White students are highest in heavy drinking, black students are lowest and Hispanic students are intermediate. Use of alcohol—but not cigarettes, marijuana and cocaine—is higher among college students than among noncollege age-mates. Longitudinal data show that, while in high school, students who go on to attend college have lower rates of heavy drinking than do those who will not attend college. Both groups increase their heavy drinking after high school graduation, but the college students increase distinctly more and actually surpass their nonstudent age-mates. Trend data from 1980 to 1999 show some slight improvement in recent years. Conclusions:  Despite improvements in the past 20 years, colleges need to do more to reduce heavy alcohol use among students. ( J. Stud. Alcohol , Supplement No. 14: 23- 39, 2002)

Patrick M. O’Malley, Ph.D., Senior Research Scientist, Institute for Social Research, University of Michigan, and Lloyd D. Johnston, Ph.D., Distinguished Research Scientist, Institute for Social Research, University of Michigan

Student Factors: Understanding Individual Variation in College Drinking

ABSTRACT Objective:  Research on individual differences in drinking rates and associated problems among college students is reviewed. Method:  Studies are included if completed within U.S. college and university samples and found in published scientific literature as identified by several searches of national databases. Results:  The resulting review suggests first that the extant literature is large and varied in quality, as most studies use questionnaire responses from samples of convenience in cross-sectional designs. Evidence from studies of college samples does consistently suggest that alcohol is consumed for several different purposes for different psychological effects in different contexts. A pattern of impulsivity/sensation seeking is strongly related to increased drinking among students. This pattern is supported by research into personality, drinking motives, alcohol expectancies and drinking contexts. A second pattern of drinking associated with negative emotional states is also documented. Some long-term consequences of this second pattern have been described. Social processes appear especially important for drinking in many college venues and may contribute to individual differences in drinking more than enduring personality differences. Conclusions:  Future research efforts should test interactive and mediating models of multiple risk factors and address developmental processes. ( J. Stud. Alcohol,  Supplement No. 14: 40-53, 2002)

John S. Baer, Ph.D., Research Associate Professor, Department of Psychology, University of Washington, and Coordinator of Education, Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System

A Developmental Perspective on Alcohol Use and Heavy Drinking during Adolescence and the Transition to Young Adulthood

ABSTRACT Objective:  This article offers a developmental perspective on college drinking by focusing on broad developmental themes during adolescence and the transition to young adulthood. Method:  A literature review was conducted. Results:  The transition to college involves major individual and contextual change in every domain of life; at the same time, heavy drinking and associated problems increase during this transition. A developmental contextual perspective encourages the examination of alcohol use and heavy drinking in relation to normative developmental tasks and transitions and in the context of students' changing lives, focusing on interindividual variation in the course and consequences of drinking and on a wide range of proximal and distal influences. Links between developmental transitions and alcohol use and other health risks are discussed in light of five conceptual models: Overload, Developmental Mismatch, Increased Heterogeneity, Transition Catalyst and Heightened Vulnerability to Chance Events. We review normative developmental transitions of adolescence and young adulthood, focusing on the domains of physical and cognitive development, identity, affiliation and achievement. Conclusions: As shown in a selective review of empirical studies, these transitions offer important vantage points for examining increasing (and decreasing) alcohol and other drug use during adolescence and young adulthood. We conclude with a consideration of research and intervention implications. ( J. Stud. Alcohol,  Supplement No. 14: 54-70, 2002)

John E. Schulenberg, Ph.D., Senior Research Scientist, Institute for Social Research, Professor, Department of Psychology, and Research Scientist, Center for Human Growth and Development, University of Michigan, and Jennifer L. Maggs, Ph.D., Associate Professor, Family Studies and Human Development, University of Arizona

The Adolescent Brain and the College Drinker: Biological Basis of Propensity to Use and Misuse Alcohol

ABSTRACT Objective:  This article reviews the literature on adolescent brain development and considers the impact of these neural alterations on the propensity to use and misuse alcohol. Method:  Neural, behavioral and hormonal characteristics of adolescents across a variety of species were examined, along with a review of the ontogeny of ethanol responsiveness, tolerance development and stress/alcohol interactions. Results:  The adolescent brain is a brain in transition. Prominent among the brain regions undergoing developmental change during adolescence in a variety of species are the prefrontal cortex and other forebrain dopamine projection regions, stressor-sensitive areas that form part of the neural circuitry modulating the motivational value of alcohol and other reinforcing stimuli. Along with these characteristic brain features, adolescents also exhibit increased stressor responsivity and an altered sensitivity to a variety of ethanol effects. Findings are mixed to date as to whether exposure to ethanol during this time of rapid brain development alters neurocognitive function and later propensity for problematic ethanol use. Conclusions:  Developmental transformations of the adolescent brain may have been evolutionarily advantageous in promoting behavioral adaptations to avoid inbreeding and to facilitate the transition to independence. These brain transformations may also alter sensitivity of adolescents to a number of alcohol effects, leading perhaps in some cases to higher intakes to attain reinforcing effects. These features of the adolescent brain may also increase the sensitivity of adolescents to stressors, further escalating their propensity to initiate alcohol use. Additional investigations are needed to resolve whether ethanol use during adolescence disrupts maturational processes in ethanol-sensitive brain regions. ( J. Stud. Alcohol,  Supplement No. 14: 71-81, 2002)

College Factors That Influence Drinking

ABSTRACT Objective:  The purpose of this article is to examine the aspects of collegiate environments, rather than student characteristics, that influence drinking. Unfortunately, the existing literature is scant on this topic. Method:  A literature review of articles primarily published within the last 10 years, along with some earlier "landmark" studies of collegiate drinking in the United States, was conducted to determine institutional factors that influence the consumption of alcohol. In addition, a demonstration analysis of Core Alcohol and Drug Survey research findings was conducted to further elucidate the issues. Results:  Several factors have been shown to relate to drinking: (1) organizational property variables of campuses, including affiliations (historically black institutions, women's institutions), presence of a Greek system, athletics and 2- or 4-year designation; (2) physical and behavioral property variables of campuses, including type of residence, institution size, location and quantity of heavy episodic drinking; and (3) campus community property variables, including pricing and availability and outlet density. Studies, however, tend to look at individual variables one at a time rather than in combination (multivariate analyses). Some new analyses, using Core Alcohol and Drug Survey data sets, are presented as examples of promising approaches to future research. Conclusions:  Given the complexities of campus environments, it continues to be a challenge to the field to firmly establish the most compelling institutional and environmental factors relating to high-risk collegiate drinking. ( J. Stud. Alcohol , Supplement No. 14: 82-90, 2002)

Cheryl A. Presley, Ph.D., Director, Student Health Programs and Assistant to the Vice Chancellor for Student Affairs for Research, Executive Director, Core Institute, Southern Illinois University; Philip W. Meilman, Ph.D., Director, Counseling and Psychological Services, Courtesy Professor of Human Development, Associate Professor of Psychology in Clinical Psychiatry, Cornell University; and Jami S. Leichliter, Ph.D., Behavioral Scientist, Division of STD Prevention, Centers for Disease Control and Preventiony

Surveying the Damage: A Review of Research on Consequences of Alcohol Misuse in College Populations

ABSTRACT This article provides a review and synthesis of professional research literature on the types, extent and patterns of negative consequences produced by student's misuse of alcohol in college populations based on survey research conducted during the last two decades. Considerable evidence is available documenting a wide range of damage by some student's drinking done to themselves as well as to other individuals, although some types of consequences remain speculative. Damage and costs to institutions are likely to be substantial, but this claim remains largely an inference based on current studies. Drinking by males compared with that of females produces more consequences for self and others that involve public deviance, whereas female's drinking contributes equally with males to consequences that are personal and relatively private. Research on racial/ethnic background, time trends and developmental stages reveals patterns in student data on consequences of drinking, but these data are very limited in the literature. Evidence suggests there is only a modest correlation between student's self-perception of having a drinking problem and the many negative consequences of drinking that are reported.  (J. Stud. Alcohol,  Supplement No. 14: 91-100, 2002)

H. Wesley Perkins, Ph.D., Professor of Sociology, Department of Anthropology and Sociology, Hobart and William Smith Colleges

Alcohol Use and Risky Sexual Behavior Among College Students and Youth: Evaluating the Evidence

ABSTRACT Objective:  To evaluate the empirical associations between alcohol use and risky sex at two levels of analysis. Global associations test whether individuals who engage in one behavior are more likely to engage in the other, whereas event-specific associations test whether the likelihood of engaging in one behavior on a given occasion varies as a function of engaging in the other on that same occasion. Method:  Studies examining the association between drinking and risky sex in samples of college students and youth were reviewed. Those published in the past 10 years and using event-level methodology or random sampling were emphasized. Results:  Findings were generally consistent across levels of analysis, but differed across types of risky behaviors. Drinking was strongly related to the decision to have sex and to indiscriminate forms of risky sex (e.g., having multiple or casual sex partners), but was inconsistently related to protective behaviors (e.g., condom use). Moreover, the links among alcohol use, the decision to have sex and indiscriminate behaviors were found in both between-persons and within-persons analyses, suggesting that these relationships cannot be adequately explained by stable individual differences between people who do and do not drink. Analysis of event characteristics showed that drinking was more strongly associated with decreased protective behaviors among younger individuals, on first intercourse experiences and for events that occurred on average longer ago. Conclusions: Future efforts aimed at reducing alcohol use in potentially sexual situations may decrease some forms of risky sex, but are less likely to affect protective behaviors directly. ( J. Stud. Alcohol , Supplement No. 14: 101-117, 2002)

M. Lynne Cooper, Ph.D., Professor of Psychology, Department of Psychology, University of Missouri at Columbia

Alcohol-Related Sexual Assault: A Common Problem Among College Students

ABSTRACT Objective:  This article summarizes research on the role of alcohol in college students' sexual assault experiences. Sexual assault is extremely common among college students. At least half of these sexual assaults involve alcohol consumption by the perpetrator, the victim or both. Method:  Two research literatures were reviewed: the sexual assault literature and the literature that examines alcohol's effects on aggressive and sexual behavior. Results:  Research suggests that alcohol consumption by the perpetrator and/or the victim increases the likelihood of acquaintance sexual assault occurring through multiple pathways. Alcohol's psychological, cognitive and motor effects contribute to sexual assault. Conclusions:  Although existing research addresses some important questions, there are many gaps. Methodological limitations of past research are noted, and suggestions are made for future research. In addition, recommendations are made for college prevention programs and policy initiatives. ( J. Stud. Alcohol,  Supplement No. 14: 118-128, 2002)

Antonia Abbey, Ph.D., Associate Professor, Department of Community Medicine, Wayne State University

Alcohol-Related Aggression during the College Years: Theories, Risk Factors, and Policy Implications

ABSTRACT Objective:  The purpose of this article is to present an overview of the research literature on alcohol-related aggression with a focus on college students. Method:  Data from both survey studies and experimental laboratory investigations conducted on college students are reviewed. Various methodological approaches to studying the alcoholaggression relation, and their associated limitations, are then presented and discussed. Results:  The literature indicates that alcohol consumption facilitates aggressive behavior and increases the risk of being the victim of a violent act, particularly in heavy drinkers. Results from these studies are then placed into a context by reviewing 12 influential theories of aggression and alcohol-related aggression. On the basis of these theories and empirical data, a preliminary risk profile is presented to help identify which factors are likely to be important in predicting who will and who will not become aggressive after drinking alcohol. Conclusions:  Although much research is still needed to elucidate the intricate causes of alcohol-related aggression, current prevention efforts might focus on modifying key risk factors such as poor cognitive functioning and inaccurate expectations about the effects of alcohol. Other prevention efforts directed specifically at college students might focus on helping them to identify risky situations that might facilitate the expression of intoxicated aggression. ( J. Stud. Alcohol , Supplement No. 14: 129-139, 2002)

Peter R. Giancola, Ph.D., Assistant Professor of Psychology, University of Kentucky

Today's First-Year Students and Alcohol  (Not part of Supplement) M. Lee Upcraft, Ph.D., Senior Scientist, Center for the Study of Higher Education, Professor Emeritus of Higher Education and Assistant Vice President Emeritus for Student Affairs, The Pennsylvania State University

So What Is an Administrator to Do?  (Not part of Supplement) Susan Murphy, Ph.D., Vice President, Student and Academic Services, Cornell University


A Typology for Campus-Based Alcohol Prevention: Moving toward Environmental Management Strategies

ABSTRACT Objective:  This article outlines a typology of programs and policies for preventing and treating campus-based alcohol-related problems, reviews recent case studies showing the promise of campusbased environmental management strategies and reports findings from a national survey of U.S. colleges and universities about available resources for pursuing environmentally focused prevention. Method:  The typology is grounded in a social ecological framework, which recognizes that health-related behaviors are affected through multiple levels of influence: intrapersonal (individual) factors, interpersonal (group) processes, institutional factors, community factors and public policy. The survey on prevention resources and activities was mailed to senior administrators responsible for their school's institutional response to substance use problems. The study sample was an equal probability sample of 365 2- and 4-year U.S. campuses. The response rate was 76.9%. Results:  Recent case studies suggest the value of environmentally focused alcohol prevention approaches on campus, but more rigorous research is needed to establish their effectiveness. The administrators' survey showed that most U.S. colleges have not yet installed the basic infrastructure required for developing, implementing and evaluating environmental management strategies. Conclusions:  The typology of campus-based prevention options can be used to categorize current efforts and to inform strategic planning of multilevel interventions. Additional colleges and universities should establish a permanent campus task force that reports directly to the president, participate actively in a campus-community coalition that seeks to change the availability of alcohol in the local community and join a state-level association that speaks out on state and federal policy issues. ( J. Stud. Alcohol,  Supplement No. 14: 140-147, 2002)

William DeJong, Ph.D., Professor, Boston University School of Public Health, and Director, U.S. Department of Education's Higher Education Center for Alcohol and Other Drug Prevention, and Linda Langford, Sc.D., Associate Director of Evaluation and Assessment, U.S. Department of Education's Higher Education Center for Alcohol and Other Drug Prevention

Identification, Prevention, and Treatment: A Review of Individual-Focused Strategies to Reduce Problematic Alcohol Consumption by College Students

ABSTRACT Objective:  The purpose of this article is to review and assess the existing body of literature on individually focused prevention and treatment approaches for college student drinking. Method:  Studies that evaluate the overall efficacy of an approach by measuring behavioral outcomes such as reductions in alcohol use and associated negative consequences were included. All studies discussed utilized at least one outcome measure focused on behavioral change and included a control or comparison condition; however, not all trials were randomized. Results:  Consistent with the results of previous reviews, little evidence exists for the utility of educational or awareness programs. Cognitive-behavioral skills-based interventions and brief motivational feedback (including mailed graphic feedback) have consistently yielded greater support for their efficacy than have informational interventions. Conclusions:  There is mixed support for values clarification and normative reeducation approaches. Much of the research suffers from serious methodological limitations. The evidence from this review suggests that campuses would best serve the student population by implementing brief, motivational or skills-based interventions, targeting high-risk students identified either through brief screening in health care centers or other campus settings or through membership in an identified risk group (e.g., freshmen, Greek organization members, athletes, mandated students). More research is needed to determine effective strategies for identifying, recruiting and retaining students in efficacious individually focused prevention services, and research on mandated student prevention services is an urgent priority. Integration between campus policies and individually oriented prevention approaches is recommended. ( J. Stud. Alcohol,  Supplement No. 14: 148-163, 2002)

Mary Larimer, Ph.D., Assistant Professor of Psychiatry and Behavioral Sciences, Adjunct Assistant Professor of Psychology, Associate Director, Addictive Behaviors Research Center, University of Washington, and Jessica M. Cronce, B.S., Research Coordinator, Addictive Behaviors Research Center, Department of Psychology, University of Washington

Social Norms and the Prevention of Alcohol Misuse in Collegiate Contexts

ABSTRACT Objective:  This article provides a review of conceptual and empirical studies on the role of social norms in college student alcohol use and in prevention strategies to counter misuse. The normative influences of various constituencies serving as reference groups for students are examined as possible factors influencing students' drinking behavior. Method:  A review of English language studies was conducted. Results:  Parental norms have only modest impact on students once they enter college beyond the residual effects of previously instilled drinking attitudes and religious traditions. Faculty could theoretically provide a positive influence on student drinking behavior, but there is little evidence in the literature that faculty norms and expectations about avoiding alcohol misuse are effectively communicated to students. Although the norms of resident advisers (RAs) should ideally provide a restraint on student alcohol misuse, the positive influence of RAs is limited by their negotiated compromises with students whom they oversee and by their misperceptions of student norms. Research reveals student peer norms to be the strongest influence on students' personal drinking behavior, with the more socially integrated students typically drinking most heavily. The widespread prevalence among students of dramatic misperceptions of peer norms regarding drinking attitudes and behaviors is also a consistent finding. Permissiveness and problem behaviors among peers are overestimated, even in environments where problem drinking rates are relatively high in actuality. These misperceived norms, in turn, have a significant negative effect promoting and exacerbating problem drinking. Conclusions:  Interventions to reduce these misperceptions have revealed a substantial positive effect in several pilot studies and campus experiments. ( J. Stud. Alcohol,  Supplement No. 14: 164- 172, 2002)

Alcohol Advertising and Youth

ABSTRACT Objective:  The question addressed in this review is whether aggregate alcohol advertising increases alcohol consumption among college students. Both the level of alcohol-related problems on college campuses and the level of alcohol advertising are high. Some researchers have concluded that the cultural myths and symbols used in alcohol advertisements have powerful meanings for college students and affect intentions to drink. There is, however, very little empirical evidence that alcohol advertising has any effect on actual alcohol consumption. Method:  The methods used in this review include a theoretical framework for evaluating the effects of advertising. This theory suggests that the marginal effect of advertising diminishes at high levels of advertising. Many prior empirical studies measured the effect of advertising at high levels of advertising and found no effect. Those studies that measure advertising at lower, more disaggregated levels have found an effect on consumption. Results:  The results of this review suggest that advertising does increase consumption. However, advertising cannot be reduced with limited bans, which are likely to result in substitution to other available media. Comprehensive bans on all forms of advertising and promotion can eliminate options for substitution and be potentially more effective in reducing consumption. In addition, there is an increasing body of literature that suggests that alcohol counteradvertising is effective in reducing the alcohol consumption of teenagers and young adults. Conclusions:  These findings indicate that increased counteradvertising, rather than new advertising bans, appears to be the better choice for public policy. It is doubtful that the comprehensive advertising bans required to reduce advertising would ever receive much public support. New limited bans on alcohol advertising might also result in less alcohol counteradvertising. An important topic for future research is to identify the counteradvertising themes that are most effective with youth. ( J. Stud. Alcohol,  Supplement No. 14: 173-181, 2002)

Henry Saffer, Ph.D., Professor of Economics, Kean University, and Research Associate, National Bureau of Economic Research

The Role of Mass Media Campaigns in Reducing High-Risk Drinking among College Students

ABSTRACT Objective:  This article categorizes and describes current media campaigns to reduce college student drinking, reviews key principles of campaign design and outlines recommendations for future campaigns. Method:  The article describes three types of media campaigns on student drinking: information, social norms marketing, and advocacy. Key principles of campaign design are derived from work in commercial marketing, advertising, and public relations and from evaluations of past public health campaigns. Results:  Information campaigns on the dangers of high-risk drinking are common, but none has been rigorously evaluated. Quasi-experimental studies suggest that social norms marketing campaigns, which correct misperceptions of campus drinking norms, may be effective, but more rigorous research is needed. As of this writing, only one major media campaign has focused on policy advocacy to reduce college student drinking, but it is still being evaluated. Lessons for campaign design are organized as a series of steps for campaign development, implementation and assessment: launch a strategic planning process, select a strategic objective, select the target audience, develop a staged approach, define the key promise, avoid fear appeals, select the right message source, select a mix of media channels, maximize media exposure, conduct formative research, and conduct process and outcome evaluations. Conclusions:  Future campaigns should integrate information, social norms marketing, and advocacy approaches to create a climate of support for institutional, community and policy changes that will alter the environment in which students make decisions about their alcohol consumption. ( J. Stud. Alcohol,  Supplement No. 14: 182-192, 2002)

William DeJong, Ph.D., Professor, Boston University School of Public Health, and Director, U.S. Department of Education's Higher Education Center for Alcohol and Other Drug Prevention

Environmental Policies to Reduce College Drinking: Options and Research Findings

ABSTRACT Objective:  The goal of this article is to provide an overview of environmental strategies that may reduce college drinking. Drinking behavior is influenced by many environmental factors, including messages in the media, community norms and attitudes, public and institutional policies and practices and economic factors. College student drinking may be influenced by environmental factors on and off campus. Method:  A comprehensive search of MEDLINE, ETOH, Current Contents and Social Science Abstracts databases was conducted to identify research studies evaluating effects of environmental strategies on college and general populations. Results:  The identified environmental strategies fall into four categories: (1) increasing compliance with minimum legal drinking age laws, (2) reducing consumption and risky alcohol use, (3) decreasing specific types of alcohol-related problems and (4) deemphasizing the role of alcohol on campus and promoting academics and citizenship. Although the extant research indicates that many environmental strategies are promising for reducing alcohol-related problems among the general population, few of these strategies have been evaluated for effects on the college population. Conclusions:  Further research is needed to evaluate effects of alcohol control policies on alcohol consumption and its related problems among college students. ( J. Stud. Alcohol,  Supplement No. 14: 193-205, 2002)

Traci L. Toomey, Ph.D., Assistant Professor, School of Public Health, Division of Epidemiology, University of Minnesota, and Alexander C. Wagenaar, Ph.D., Professor and Director, Alcohol Epidemiology Program, School of Public Health, Division of Epidemiology, University of Minnesota

Effects of Minimum Drinking Age Laws: Review and Analyses of the Literature from 1960 to 2000

ABSTRACT Objective:  The goal of this article is to review critically the extant minimum legal drinking age (MLDA) research literature and summarize the current state of knowledge regarding the effectiveness of this policy. Method:  Comprehensive searches of four databases were conducted to identify empirical studies of the MLDA published from 1960 to 1999. Three variables were coded for each study regarding methodological quality: (1) sampling design, (2) study design and (3) presence or absence of comparison group. Results:  We identified 241 empirical analyses of the MLDA. Fifty-six percent of the analyses met our criteria for high methodological quality. Of the 33 higher quality studies of MLDA and alcohol consumption, 11 (33%) found an inverse relationship; only 1 found the opposite. Similarly, of the 79 higher quality analyses of MLDA and traffic crashes, 46 (58%) found a higher MLDA related to decreased traffic crashes; none found the opposite. Eight of the 23 analyses of other problems found a higher MLDA associated with reduced problems; none found the opposite. Only 6 of the 64 college-specific studies (9%) were of high quality; none found a significant relationship between the MLDA and outcome measures. Conclusions:  The preponderance of evidence indicates there is an inverse relationship between the MLDA and two outcome measures: alcohol consumption and traffic crashes. The quality of the studies of specific populations such as college students is poor, preventing any conclusions that the effects of MLDA might differ for such special populations. ( J. Stud. Alcohol,  Supplement No. 14: 206-225, 2002)

Alexander C. Wagenaar, Ph.D., Professor and Director, Alcohol Epidemiology Program, School of Public Health, Division of Epidemiology, University of Minnesota, and Traci L. Toomey, Ph.D., Assistant Professor, School of Public Health, Division of Epidemiology, University of Minnesota

Comprehensive Community Interventions to Promote Health: Implications for College-Age Drinking Problems

ABSTRACT Objective:  This article reviews comprehensive community interventions that sought to reduce (1) cardiovascular disease risks; (2) smoking; (3) alcohol use disorders, alcohol-related injury and illicit drug use; or (4) sexual risk taking that could lead to HIV infection, sexually transmitted disease and pregnancy. Method:  Comprehensive community programs typically involve multiple city government agencies as well as private citizens and organizations and use multiple intervention strategies such as school-based and public education programs, media advocacy, community organizing, environmental policy changes and heightened enforcement of existing policies. This review focused on English-language papers published over the past several decades. Results:  Some programs in each of the four problem areas achieved their behavioral and health goals. The most consistent benefits were found in programs targeting behaviors with immediate health consequences such as alcohol misuse or sexual risk taking. Results were less consistent when consequences of targeted behaviors were more distant in time such as cardiovascular risks and smoking. Also, programs that targeted youth to prevent them from starting new health-compromising behaviors tended to be more successful than programs aimed at modifying preexisting habits among adults. Programs that combined environmental and institutional policy change with theory-based education programs were the most likely to be successful. Finally, programs tailored to local conditions by the communities themselves tended to achieve more behavior change than programs imported from the outside. Conclusions: Comprehensive community intervention approaches may have considerable potential to reduce college-age drinking problems, especially given the success of these programs in reducing alcohol-related problems and in preventing health-compromising behaviors among youth. ( J. Stud. Alcohol,  Supplement No. 14: 226-240, 2002)

Ralph Hingson, Sc.D., Professor and Chair, Social and Behavioral Sciences Department, Boston University School of Public Health, and Jonathan Howland, Ph.D., M.P.H., Professor and Chair, Social and Behavioral Sciences Department, Boston University School of Public Health

The Role of Evaluation in Prevention of College Student Drinking Problems  (Not part of Supplement) Robert F. Saltz, Ph.D., Associate Director and Senior Research Scientist, Prevention Research Center, Berkeley, CA

View from the President's Office: The Leadership of Change  (Not part of Supplement) Joy R. Mara, M.A., Mara Communications


The Student Perspective on College Drinking  (Not part of Supplement) Peggy Eastman, Author and Journalist

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  • Research article
  • Open access
  • Published: 30 April 2019

Analysis of the alcohol drinking behavior and influencing factors among emerging adults and young adults: a cross-sectional study in Wuhan, China

  • Wanrong Lu 1 ,
  • Jingdong Xu 2 ,
  • Anne Winifred Taylor 3 ,
  • Bridgette Maree Bewick 4 ,
  • Zhen Fu 1 ,
  • Nanjin Wu 1 ,
  • Ling Qian 5 &
  • Ping Yin   ORCID: orcid.org/0000-0003-0869-3772 1  

BMC Public Health volume  19 , Article number:  458 ( 2019 ) Cite this article

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The relationship between alcohol use in adolescents and young adults and outcomes has not been widely researched in China. The aim of the current study was to understand the current status of drinking behavior of Chinese youth transitioning into adulthood.

The cross-sectional study included 1634 participants between 18 and 34 years of age. The participants were randomly chosen from 13 administrative districts in Wuhan, and invited to complete a questionnaire. Univariate analysis was performed to describe the demographic distribution of alcohol consumption and the association with drinking status. Stepwise Logistic regression analysis was undertaken analyzing the factors influencing the drinking behaviors. The data were weighted to the population in Wuhan and analyzed using SAS version 9.3.

For our sample of emerging and young Chinese adults the prevalence of drinking alcohol was 45.84%. The non-drinkers predominated, accounting for 54.16% and light drinkers accounted for 42.94%, while moderate and heavy drinkers were in the minority (2.90%). The earlier the age of first alcohol drinking or the age of first being intoxicated, the greater the likelihood of being a moderate or heavy drinker. People with high emerging adulthood were more likely to have moderate or heavy drinking behaviors. The logistic regression analysis indicated that heavy drinkers were more likely to not be married and to be classified as high emerging adulthood.


Our findings suggested that the drinking pattern should be further evaluated over time to explore the ways in which social and cultural factors shape the drinking route of this age group. Effective drinking behavior prevention and interventions and appropriate guidance should be formulated to establish an appropriate attitude towards drinking alcohol and develop a drinking behavior which is conducive to physical and mental health between this particular demographic.

Peer Review reports

According to the World Health Organisation’s 2014 estimate, 5.1% of the global disease and injury burden can be attributed to drinking alcohol [ 1 ]. In recent years, the analysis of international trends and investigations into the determinants of substance use has revealed alcohol consumption as one of the substances typically used and abused by adolescents and young adults [ 2 , 3 , 4 ]. Heavy drinking has largely been a phenomenon of emerging and young adulthood [ 5 , 6 ], which places individuals at risk for adverse health and social effects [ 7 , 8 , 9 ]. It is believed this vulnerability is in part due to the dramatic life changes in relationships, employment, accommodation and roles of the individual as they transition into adulthood [ 10 , 11 ]. Harmful drinking behaviors in young years have been associated with greater risk of severe psychiatric and other drinking problems in adults [ 12 ]. Reducing high risk drinking patterns remain a major public health challenge [ 13 ].

In China, drinking alcohol is a widely accepted cultural tradition, especially during rituals, festivals, social gatherings, commercial occasions and special activities [ 14 ]. Based on the estimates of the Chinese National Bureau of Statistics, alcohol production and consumption in China has seen a sharp growth in recent decades [ 15 , 16 ]. The acceleration in growth is the highest internationally [ 17 ]. There is an inseparable relationship between alcohol consumption growth and the Chinese cultural context [ 18 , 19 ].

Compared with other countries, early research on alcohol in China focused on the etiology of adults, mainly containing the physiological and clinical analysis. In recent years, investigations have begun to pay closer attention to alcohol-related health harm (e.g. mortality, chronic disease, cancer) [ 17 , 20 , 21 , 22 ] and social problems (e.g. drunk driving, drunk crime, injuries) [ 23 , 24 , 25 ]. A local and national literature examining drinking behaviors and drinking motivations associated with alcohol consumption in China is emerging [ 26 , 27 , 28 ]. These studies have chiefly focused on adults, even the studies investigating younger drinkers have concentrated on adolescent or student populations [ 29 , 30 ]. There remains a relative paucity of studies on drinking prevalence, drinking behaviors and its related factors in China [ 31 ]. It is extremely rare for alcohol studies to concentrate attention on emerging and young adults groups in China. Accordingly, our research is of significance as the first attempt to explore the current status of drinking behaviors of emerging and young adults under the specific social and cultural background in China.

Within the literature no one age is identified as the exact point of transition into adulthood. Within the literature there is broad agreement that the point of transition occurs somewhere between late adolescence and the age of more than 30 [ 32 , 33 , 34 ]. Given this background the current study defined emerging and young adulthood as being between 18 to 34 years old. The outcomes of the current study will inform the development of prevention and early-intervention programs for emerging and young adults in China.

The data were derived from a trans-national population-based survey covering four cities (Moscow, Ilorin, Wuhan, Montevideo) in four countries. In the current paper, the Wuhan data was used to investigate the drinking behavior among emerging adults and young adults (18–34 years old) under a specific social and cultural background in China. The method part refers to the published papers by Anne and Bridgette [ 35 ].

Ethics approval and consent to participate

This study received ethical review and approval from the Hubei Provincial CDC (Hubei Provincial Society for Health Promotion and Cigarette-smoking Control, HBPHP & CCS-2014-01). Before further investigation, the interviewers conducted household confirmation, informed consent, and investigation management issues. The interviewers must introduce the content and purpose of the survey according to specific introductions and obtain verbal informed consent from all participants. Participants could terminate the interview at any time, or choose not to answer any question. Confidentiality of information was assured. Approval for the research was obtained by community leaders, appropriate government officials and other important related personnel. Households with alcohol and substance abuse could be referred to recognized hospitals/caregivers for proper management.

Data source and participants

Wuhan is the capital of Hubei Province, and at the time of the survey it had a population of approximately 9.8 million and a geographical area of about 8467 km 2 . Wuhan was pragmatically selected as a research site based on its diversity. Wuhan is divided into 13 administrative regions, and the multi-stage random sampling was performed across each region. The sample size of each administrative district was proportional to the population size. Communities were randomly selected in each administrative district, followed by random household selection. In each randomly selected household, the person with the most recent birthday, aged between 18 and 34 years, who lived in Wuhan for at least six months, was eligible and was invited to participate in the study. Prior to the main survey, 33 pilot interviews were conducted. The pilot assessed participants’ understanding of the questions and length of the interview.

Data collection lasted for 186 days (2014.10.25–2015.04.29). Door-knocking interviews were conducted in Chinese and the Wuhan local dialect by the interviewers who were local college students with specialized training. The data was obtained through face-to-face interviews, which is better for mutual understanding between interviewee and interviewer. Interviewers read out the questions and recorded via paper-and-pencil. Interviews were conducted in an environment where respondents felt most comfortable and where their privacy was respected. The average interview time was 15 min. In total 1675 individuals were approached and 1675 participants agreed to be interviewed. After screening 1646 were identified as eligible to be interviewed. Of these 1642 interviews were completed. Two interviews were excluded due to insufficient completion of demographic information; demographic information is necessary for weighting. A further six cases were excluded due to incomplete drinking information. A total of 1634 questionnaires were included in the current analysis. The response rate was therefore 99.3%.

Drinking questionnaire

Main alcohol questions included: (1) Have you ever consumed alcohol (excluding sips). (2) How old were you the first time you had a drink of an alcoholic beverage (excluding sips)? (3) How old were you the first time you got drunk? (4) During the past 12 months, how often did you drink beer, wine, spirits (e.g. vodka, gin, whisky, brandy), huangjiu or any other alcoholic beverage, even in small amounts? (5) During the past 12 months, how many alcoholic drinks did you have on a typical day when you drank alcohol? (6) In the past 12 months, how often have you ever gotten drunk? (Drunk refers to walking unsteadily, blurred vision, slurred speech, nausea, vomiting or any other symptoms)? (7) Drinking alcohol may impose various effects on people. When you are drinking, on what extent of the following statement may fit your situation (Always, usually, sometimes, seldom, never)? The effects including positive and negative effects, such as feel happy, feel relaxed, become aggressive toward other people, and so on.

Overall quantity-frequency (i.e. usual frequency of drinking by usual number of drinks consumed per drinking occasion) was calculated by multiplying the responses to the above two questions (how much and how many) with 25 or more drinks (coded as 25), 19–24 drinks (coded as 21.5), 16–18 drinks (coded as 17), 12–15 drinks (coded as 13.5), 9–11 drinks (coded as 10), 7–8 drinks (coded as 7.5), 5–6 drinks (coded as 5.5), 3–4 drinks (coded as 3.5), 2 drinks (coded as 2), 1 drink (coded as 1) and less than 1 full drink (coded as 0.5). The annual number of drinks was calculated by multiplying the responses to the question on how many days did you drink alcohol with the response from how many drinks did you have. The variables were recorded into four drinking status groups: 0 drinks = Abstainers; > 0 but less than 365 drinks/year = Light drinkers; 365–729 drinks/year = Moderate drinkers; 730 or more drinks/year = Heavy drinkers. No distinction was made between lifetime abstainers and former drinkers with alcohol consumption assessed during the past 12 months only. These four groups were collapsed into two groups of non-drinkers and current drinkers. ‘Non-drinkers’ referred to those who have never drunk before (‘Lifetime abstainers’) and those who have not drunk in the past 12 months (‘Former drinkers’). ‘Current drinkers’ referred to those who have either drunk more than half a cup of alcohol at least once in the past 12 months or those who have drunk any quantity of alcohol at least twice in the past 12 months.

Pure alcohol intake (grams per day) was calculated by multiplying the responses to questions about how often and how much—and then the units were converted (the calculation was made according to the standard glass of specific alcoholic beverages, 1 ml alcohol = 0.789 g). Respondents were provided with visual references to beverage specific drink sizes in order to facilitate reporting of number of drinks in standard sizes.

The interview also included an assessment of emerging adulthood which included the following three statements: a) I have reached adulthood. b) I am financially independent of my parents. c) I am emotionally independent of my parents. Questions were answered on a five-point Likert scale: 5 = strongly agree; 4 = agree; 3 = neither agree nor disagree; 2 = disagree; 1 = strongly disagree. Responses were totaled with 3–11 points indicating low emerging adulthood, 12–13 points indicating medium emerging adulthood, and 14–15 points indicating high emerging adulthood. The emerging adulthood statements were based on the work of Arnett and Padilla-Walker [ 36 ] and adapted to fit common assumptions within China. Scores were reversed so that lower emerging adulthood scores indicated lower emerging adulthood.

Statistical analysis

In this study, the data were ranked weighted as per the stratified target population information provided by Hubei Provincial Institute for Health Education in 2014 by Administrative District, age, gender and selection probability. The weight value distribution range was 0.285–4.300. The aim was to minimize bias and ensure that samples were representative; the weighted demographics of the sample were consistent with the local demographics.

The data base was built with EpiData version 3.1, and the logical verification and statistical analysis of the data were carried out using the 9.3 version of the SAS statistical analysis package. Demographic characteristics included age, sex, marital status, education level, current student status and employment status. Group comparison of categorical data was using CMH- χ 2 test. The rank test was used for group comparison of grade data. Simple univariate analysis was performed to describe the demographic distribution of alcohol consumption and the association analysis of drinking status. Stepwise Logistic regression analysis was undertaken analyzing the factors influencing the drinking status among the population between 18 and 34 years of age in Wuhan, controlling for the socio-demographic characteristics and adult tendency. In addition, the relationship between emerging adulthood and drinking behavior was assessed. The significance was set at p  < 0.05.

The demographic and emerging adulthood distribution of alcohol consumption

A total of 1634 people were included in the current analysis. Of these 749 (45.8%) were current drinkers. Chi-square statistics were calculated to assess the drinking distribution difference between different demographic characteristics and emerging adulthood (Table  1 ). Significant differences were observed in the drinking distribution between different marital status, current student status and emerging adulthood. The proportion of married people drinking was lower than those not married ( χ 2  = 10.14, p  = 0.0015); Students had a higher proportion of drinking than non-students ( χ 2  = 5.09, p  = 0.0240); People with high emerging adulthood had a higher proportion of drinking ( χ 2  = 10.09, p  = 0.0064). Figure  1 displays the current drinking proportion for the three age groups. Although not significant, younger females (18–24 years) were more likely to drink than males.

figure 1

The proportion of current alcohol drinkers by age group

  • Drinking behavior

Participants were divided into four categories: non-drinkers, light drinkers, moderate drinkers and heavy drinkers. The non-drinkers predominated, accounting for 54.2% of the population, followed by light drinkers (42.9%), moderate drinkers (1.7%) and heavy drinkers (1.2%). The drinking status between different demographic characteristics and emerging adulthood are shown in Table  2 . It revealed a statistically significant difference between drinking status and marital status, current student status, as well as emerging adulthood. Non-students had a higher proportion of moderate or heavy drinkers ( χ 2  = 4.24, p  = 0.0395); People who were not married had a higher proportion of heavy drinkers ( χ 2  = 7.22, p  = 0.0072); People with high emerging adulthood had a higher proportion of heavy drinkers ( χ 2  = 7.36, p  = 0.0067).

The results of the rank test (Table  3 ) indicated that males with an early first drinking age (z = 2.49, p  = 0.0129) or a first drunk age (z = 2.46, p  = 0.0138) before 15 years of age, had a higher proportion of moderate or heavy drinkers than that after the age of 15; No significant relationship was observed for females (small cell sizes). Overall, the earlier the first drinking age, the higher the level of current drinking (z = 2.57, p  = 0.0101). When exploring the relationship between drunkenness and negative effects among current drinkers, the incidence of intoxication was 33.6% for those who linked drinking with negative effects, while for people who did not consider drinking with negative effects, the incidence of intoxication was 18.7%, a difference of 15.0% (95% CI (0.081–0.205), p  < 0.0001).

Drinking behaviors and emerging adulthood

Stepwise regression methodology was used to determine the model for demographic characteristics and drinking status; age, marital status and emerging adulthood were positively related to drinking status (Table  4 ). There was a significant difference in marital status ( p  < 0.0001) and higher emerging adulthood ( p  = 0.0030), with heavy drinkers more likely to be people not married, and with higher emerging adulthood.

Figure  2 , (a) demonstrates the daily average alcohol intake and the highest alcohol intake significantly increased as emerging adulthood scores increased. The result of rank correlation analysis showed the correlation coefficient of emerging adulthood and the alcohol intake (grams per day) was 0.56 ( p  = 0.0897). The correlation coefficient of emerging adulthood and the highest alcohol intake (grams per time) was 0.76 ( p  = 0.0111). Similarly, in the Fig.  2 (b), drinking frequency, the highest drinking frequency and the frequency of being drunk significantly decreased as adult tendency scores decreased. The correlation coefficient of emerging adulthood and the drinking frequency was 0.70 ( p  = 0.0165). The correlation coefficient of emerging adulthood and the highest drinking frequency was 0.52 ( p  = 0.1276). The correlation coefficient of emerging adulthood and frequency of being drunk was 0.52 ( p  = 0.1221). Figure 2 , (c) showing that the alcohol consumption of beer was significantly higher than other types of alcoholic beverages, followed by white spirits, wine and huangjiu. The annual alcohol consumption of four types of alcoholic beverages (beer, wine, white spirits and huangjiu) showed a upward trend with the increasing emerging adulthood scores.

figure 2

The relationship between alcohol grams ( a ), drinking/drunk frequency ( b ), and four alcoholic beverages’ consumption ( c ) with emerging adulthood scores (For current drinkers)

This is the first study aimed at evaluating the drinking behaviors and its related factors among emerging and young adults in China. The current study suggests that the majority of people aged 18–34 years living in Wuhan who consume alcohol could be considered ‘light drinkers’. Although the incidence of heavy drinking is not high among this population when extrapolated to the number of individuals across China, this represents a substantial challenge for public health. In addition, we cannot predict whether light or moderate drinkers will engage in dangerous drinking behaviors in the future. Public health prevention and intervention efforts in China should strengthen and develop an appropriate attitude towards drinking alcohol. There is also a need to develop effective interventions for the relatively few, but substantial in number, heavier drinkers in order to minimize the costs associated with problematic drinking behavior.

The influence of gender on drinking behavior has been demonstrated in many studies. Some alcohol studies reported that males were more likely to consume alcohol than females, and females were more likely to be abstainers [ 37 , 38 , 39 ]. In our gender analysis, females had a slightly higher current drinking proportion than males (2.82% higher). This finding may be related to recent changes in economic and social status resulting in females developing a stronger independent consciousness, increasing levels of employment, and increasing social activities and communication opportunities. Other studies have highlighted that male excesses are no longer apparent along with the appearance of “narrowing of the gender gap” in particular time periods, geographical settings, age groups and drinking patterns [ 40 , 41 , 42 , 43 ]. Consistent with the findings that males had higher drinking frequency and exceeded females in rates of heavy drinking behavior in other studies, we found males had a higher proportion of moderate or heavy drinkers [ 17 ]. In addition, the results revealed students were more likely to report being consumers of alcohol, this is consistent with surveys from other countries [ 44 , 45 ].

Previous studies have noted a first drinking age of 15 years or earlier was at elevated risk for alcohol abuse and dependence [ 46 , 47 ]. The earlier the first drinking age, the probability of subsequently developing heavy drinking patterns and resultant health damage was markedly increased [ 48 , 49 ]. Our results also indicated that, whether male or female, a first drinking age before 15 had a greater potential risk of engaging in heavy drinking when compared to people who started later than 15. Those who started drinking before 15 years of age were also more likely to be moderate or heavy drinkers. Publish research confirms that age of reporting first being drunk is related to the negative effects of drinking [ 50 ]. Early-onset drunkenness is associated with an increased risk of developing alcohol use disorder and signaled excess mortality risk [ 51 ]. Consistent with these earlier reports, our results showed that the younger the age of first drunkenness, the greater the likelihood of becoming a moderate or heavy drinker. Those who had ever been intoxicated were more likely to associate drinking with negative effects. Premature drinkers or premature drunks have been found to be more impulsive and adventurous, more extreme and poorly controlled, and report the occurrence of health problems and other risks in later life [ 47 , 52 , 53 ].

The current results concerning emerging adulthood found an association between emerging adulthood and drinking behaviors. Heavy drinkers were more likely to be people with higher emerging adulthood. Furthermore, people with higher emerging adulthood usually had more extreme drinking alcohol behavior with higher frequency. Previous studies suggested that young adults reduce risk drinking behavior to more moderate levels of alcohol use when adult roles and responsibilities are taken on [ 54 , 55 , 56 ]. Our results suggested an increase of alcohol use in those with higher emerging adulthood. This apparent contradiction between our study and the published literature may be the result of differences in culture between China and other countries. As emerging adults mature, they encounter more responsibility and play new roles. For current Chinese drinkers it can be difficult to avoid consuming alcohol, especially during social activities where there is a felt pressure to drink [ 57 ]. Greater social pressure and more drinking occasions can be related to trends in drinking motives, drinking opportunities and drinking behaviors.

Our research also indicated a link between the alcohol consumption of the four types of alcoholic beverages (beer, wine, white spirits and huangjiu) and emerging adulthood scores, which have shown that among the four most common types of alcoholic beverages in China, the annual alcohol consumption of beer was significantly highest, which supported the fact that China is one of the largest beer consuming countries in the world [ 58 ].

Study limitations include the fact that the study was cross-sectional, which restricts our assessments of the temporal relationships of the associations. The data was limited to one city and the results were not nationally representative. Concerns around the length of the structured interview and lack of availability of a validated brief assessment of ‘emerging adulthood’ meant the current study created a measure based on the work of Arnett and Padilla-Walker [ 36 ]. The study would have been strengthened had a standardized, validated, brief-assessment of emerging adulthood been available. Our definition of a heavy drinker precludes those who drink very occasionally but who on these occasions drink very heavily. Future research should aim to understand this important group of individuals. Study strengths include focusing on emerging adults and young adults aged between 18 to 34 years old, a large and targeted sample is conducive to formulating effective prevention and intervention. Probability-based random sampling methodology (stratified, clustered, systematic) was adopted to ensure the random selection of population. The data were weighted, ensuring findings were representative of the broader urban population. In addition, this self-report method can incorporate all alcohol consumption levels under the circumstance that many official statistics often do not record the alcohol consumption.

The research focused on the alcohol drinking behaviors of this particular age group, and the findings of the present study strongly supported the significant impact of social and cultural background and age-specific characteristics on the drinking behaviors. For China,, China-specific influences together with assessment of adulthood level are important considerations when developing effective drinking interventions for emerging and young adults. Internationally, this country-specific study increases the understanding of Chinese drinking characteristics and provides valuable reference for international alcohol-related surveys.


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The authors wish to thank the International Alliance for Responsible Drinking (IARD), the National Science Foundation of China (No. 81573262) and the Fundamental Research Funds for the Central Universities, HUST (No. 2016YXZD042) for providing support towards the study. And we express sincerely gratitude to thank Professor Ping Yin, Ling Qian, Alfred Bamiso Makanjuola and Valentina Vasilievna Kirzhanova for their contributions. The authors also would like to thank all research participants for their generous assistance and cooperation.

Including travel and reasonable expenses, this work was funded by the International Alliance for Responsible Drinking (IARD), the National Science Foundation of China (No. 81573262). A not-for-profit organization supported by major producers of alcoholic beverages ( http://iard.org ). This work was also supported by the China Health Education Center and ‘the Fundamental Research Funds for the Central Universities’, HUST Department of Epidemiology and Health Statistics, School of Public Health Tongji Medical College (No. 2016YXZD042). The funders had no role in the analysis, data interpretation and writing of this manuscript. The corresponding author was the only one to have full access to all the data and had final responsibility for the decision to submit for publication. The work product, findings, viewpoints, and conclusions presented here are solely those of the named authors and do not necessarily represent those of IARD or its sponsoring companies.

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We did not get consent to share data obtained from the questionnaire and key informant interviews. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Wanrong Lu, Zhen Fu, Nanjin Wu & Ping Yin

Hubei Institute for Health Education, Zhuodao Quan Road No.6, Hongshan District, Wuhan, 430079, China

Jingdong Xu

Population Research & Outcome Studies, Discipline of Medicine, The University of Adelaide, SAHMRI, North Terrace, Adelaide, 5006, Australia

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All authors contributed to the study. PY, LQ, AWT and BMB conceptualized and designed the study, and supervised the survey. PY, LQ, JX carried out the questionnaire survey. WL performed the statistical analyses and wrote an initial draft of the paper. ZF and NW performed data and statistical analysis results checking. PY, LQ, AWT, and BMB supervised and guided the writing of the manuscript. All authors have provided comments on drafts and contributed to the writing of the manuscript. All authors have read and approved the final manuscript.

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From the Hubei Provincial CDC (Hubei Provincial Society for Health Promotion & Cigarette-smoking Control, HBPHP & CCS-2014-01), this study received ethical review and approval, ethics committee approval for verbal consent was also included. The interviewers must introduce the content and purpose of the survey according to specific introductions. For all the participants, the verbal informed consent to participate in the study was obtained before the interview started. The abbreviation of the content is as follows: the interviewer’s name and working institute, the purpose of this investigation and the randomly selected of the participants for inclusion in our study, the main information will be collected and the time will take to complete the survey. Finally tell the participants that his decision whether or not to participate in this research is completely voluntary. Should he decide to participate, his responses will be kept completely confidential. If any questions make him uncomfortable, we can skip them. He is also free to end the interview at any time. Then ask the participant if he will agree to participate in our study. All methods in the study were performed in accordance with relevant guidelines and regulations.

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BMB, as keynote speaker/expert adviser, has received reimbursement of travel expenses and/or time from Anheuser-Busch, Noctis, and the International Centre for Alcohol Policies. BMB has been in receipt of a research grant provided by the European Research Advisory Board (ERAB) and is currently a recipient of a research grant provided by the International Alliance for Responsible Drinking (IARD). BMB has received reimbursement of reasonable expenses incurred as a member of the independent Research Advisory Board for the European Foundation for Alcohol Research. These projects/activities did not influence the current work. The other authors declare that they have no competing interest other than those mentioned in the acknowledgment section.

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Lu, W., Xu, J., Taylor, A.W. et al. Analysis of the alcohol drinking behavior and influencing factors among emerging adults and young adults: a cross-sectional study in Wuhan, China. BMC Public Health 19 , 458 (2019). https://doi.org/10.1186/s12889-019-6831-0

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