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5 Alcohol consumption Bob Erens and Johanna Laiho
Alcohol misuse contributes to a wide range of health and social problems, including high blood pressure, cirrhosis of the liver, accidents, and anti-social behaviour including crime and domestic violence. Epidemiological studies have suggested that heavy drinking constitutes a severe risk for cardiovascular disease, but that low levels of consumption can have a protective effect against coronary heart disease (CHD) mortality.1,2 Alcohol is a significant component of the diet in Britain as in many other countries. However, there are large variations between minority ethnic groups, some of which are in part due to cultural and religious differences. While there has been little research on alcohol consumption (or other health-related behaviours) among minority ethnic groups in England, previous evidence suggests that consumption levels tend to be lower among most such groups than in the general population.3 Since its inception in 1991, the Health Survey has included a set of questions on alcohol consumption, with the principal questions addressed to adults being the same as those used in the General Household Survey (GHS).4 These questions were designed to provide an estimate of average weekly consumption. Until late 1995, advice about sensible drinking had been expressed in terms of weekly consumption levels (with men advised not to exceed 21 units per week, and women 14 units).5 At the end of 1995, following the recommendations of an inter-departmental Working Group, advice on sensible drinking was revised so that it is now commonly expressed in terms of daily, rather than weekly, consumption.6 It also reflects evidence that moderate consumption may be beneficial for certain groups of the population. Current advice about sensible drinking is that:
The main series of questions in the Health Survey and in the GHS had been designed to estimate average weekly consumption rather than daily drinking patterns. Since 1997, there have been additional questions which provide some information on daily consumption by asking about drinking in the week before the interview. The results given in this chapter include weekly consumption estimates and show the proportion of men and women exceeding the weekly levels advised before 1996, as these are still the most widely used figures in public health. In addition, the chapter also reports some findings from the new questions on daily consumption. This chapter contains sections on weekly consumption (Sections 5.2 and 5.3), usual frequency of drinking (Section 5.4) and drinking in the past week (Section 5.5). Minority ethnic groups differ from each other and from the general population in their age structures, and for comparative purposes it is possible to remove the effects of age differences by age standardisation. This has been done on each table for a selection of key figures. In general, however, comparisons of alcohol consumption between groups are not much affected by age standardisation, and in this chapter the observed, rather than the standardised, figures are principally reported. 5.2 Measuring weekly consumption Informants aged 16 and over, after preliminary questions on whether they drank alcohol at all, were asked how often during the past 12 months they had drunk each of six different types of alcoholic drink: normal beer/lager/cider/shandy; strong beer/lager/cider; sherry and martini; spirits and liqueurs; wine; and alcoholic soft drinks. From the responses, the average number of days a week the informant had drunk each type of drink was estimated. A follow-up question asked how much of each drink type they had usually drunk on each occasion. These responses were then converted into units of alcohol and multiplied by the average number of drinking days per week to provide an estimate of weekly amounts consumed.7 The module of questions on drinking in 1999 was the same as the one used in the 1998 Health Survey, which incorporated a number of changes from previous years.8 It is well known that surveys tend to underestimate alcohol consumption for a number of reasons, including problems of memory and the difficulties involved in assigning an average estimate to an activity that varies from day-to-day. Also, because the questions relate to 'usual' behaviour, responses are unlikely to reflect occasions of heavier drinking. These problems may be amplified among particular minority ethnic groups which discourage or prohibit alcohol consumption (for example, among Muslims), and where general social norms could result in some under-reporting - for example, in households where several people may be present during the interview, or when the interviewer is of the same ethnicity as the informant. Despite these problems, survey estimates still provide useful comparisons of the consumption patterns of different population groups and enable comparisons over time. 5.3.1 Usual weekly consumption by minority ethnic group Table 5.1 shows consumption bands with estimated overall mean consumption. There were very large differences between minority ethnic groups, both in terms of the likelihood of drinking and in amounts consumed. Men's usual weekly consumption Among men, 7% of the general population said they did not drink alcohol: 4% were ex-drinkers and 3% had never drunk alcohol. The proportion of non-drinkers among minority ethnic groups ranged from 5% among Irish men to 91% and 96% respectively among Pakistani and Bangladeshi men. Among these two (almost entirely Muslim) groups, the great majority said they had never drunk alcohol (86% and 92% respectively). A relatively high proportion of Indian (33%) and Chinese (30%) men were non-drinkers. Most of these (26% and 24% respectively) had never drunk alcohol. 13% of Black Caribbean men were non-drinkers, a much lower proportion than for Indian and Chinese men but still about double the proportion for the general population. 7% had never drunk alcohol and 6% were ex-drinkers. About one in three men in the general population (30%) drank over
21 units of alcohol a week. The proportion of men exceeding 21 units
a week was, in all minority ethnic groups except the Irish (34%), well
below the 30% for the general population: 18% for Black Caribbeans,
14% Indians, 3% Chinese, 2% Pakistanis and 1% Bangladeshis. As the inset
table shows, the lower levels of drinking found among these minority
ethnic groups remained after taking account of age differences between
them, the standardised risk ratios being significantly lower than 1,
except for the Irish (which at 1.13 was higher than the general population,
but not significantly so).
Similar patterns were found for estimated mean weekly units. Compared
with the 17.5 mean weekly units consumed by men in the general population,
Irish men consumed a significantly higher amount (20.4 units). But men
in all other minority ethnic groups had much lower levels of consumption:
11.5 weekly units for Black Caribbeans, 8.6 units for Indians, 4.2 units
for Chinese, 1.7 units for Pakistanis, and 1.5 units for Bangladeshis.
(The denominator for these means is all men in each group, not drinkers
only.) Women's usual weekly consumption Among all minority ethnic groups, women had higher levels of abstinence and lower levels of consumption than men. Overall, 12% of women in the general population were non-drinkers (7% had never drunk, 6% were ex-drinkers). Among women from minority ethnic groups, the proportion of non-drinkers was: 10% among the Irish, 18% Black Caribbean, 41% Chinese, 64% Indian, 97% Pakistani, and 99% Bangladeshi. Among (the mainly Muslim) Pakistani and Bangladeshi women, only a very small minority reported that they had ever drunk alcohol (only 5% and 2% respectively). A majority of Indian women also reported never having drunk alcohol (60%, which is over twice as many as the 26% of Indian men who had never drunk). Overall, women were about half as likely as men to exceed the (previously)
recommended weekly limit: 16% of women in the general population drank
more than 14 units of alcohol a week, compared with 30% of men drinking
more than 21 units a week. Except for Irish women (at 19%), the proportion
of women from the other minority ethnic groups exceeding this limit
was much lower than in the general population. Among Black Caribbean
and Chinese women, the proportions were 9% and 4% respectively, while
very few women from the South Asian minority ethnic groups exceeded
this amount.
Similarly, while Irish women had higher mean weekly consumption levels
(8.5 units) than the general population (7.2 units), women from all
other minority ethnic groups had much lower average weekly consumption
levels (ranging from 4.3 units among Black Caribbean women to virtually
zero among Bangladeshi women). Variations in alcohol consumption by age In the general population, weekly alcohol consumption levels decreased with age, both in terms of exceeding the (previously) recommended levels of 21 (men)/14 (women) units and in mean consumption. Among both sexes, mean weekly consumption for those aged 55 and over was about half the level for those aged 16-34. Many of the minority ethnic groups (with exceptions such as Black Caribbean and Indian men) showed a similar tendency for alcohol consumption to decrease with age. In general, the tendency was more marked among women than among men, so that differences in consumption between the sexes appeared to be reducing in successive generations. Among Pakistani and Bangladeshi groups (particularly women), consumption
levels were too low to detect differences by age. 5.3.2 Socio-economic variations in usual weekly consumption Alcohol consumption among women in the general population was higher in non-manual than manual social classes. This tendency was also found among Irish and to a lesser extent Chinese and Indian women, but not among women from the other minority ethnic groups. After age standardisation, these social class differences were no longer significant for women from any minority ethnic group. Alcohol consumption patterns among men did not show much difference
between non-manual and manual social classes, either in the general
population or within minority ethnic groups. Patterns of consumption in the general population varied more with
household income than with social class. Among both men and women, the
general population's consumption increased as equivalised household
income increased. After age standardisation, similar patterns to the
general population were found among the following minority ethnic groups
(although the small sample bases make it difficult to confirm the findings):
Black Caribbean men; Indian men and women; Chinese and Irish women. 5.4 Usual frequency of drinking Informants were asked on how many days a week they usually had any kind of alcoholic drink. Responses are shown in Table 5.5 by minority ethnic group. As noted in Section 5.4.1, 7% of men and 12% of women in the general population were ex-drinkers or had never drunk alcohol. A further 4% of men and 8% of women were very occasional drinkers, saying they drank alcohol only once or twice a year. At the other end of the scale, about one in five men (18%) and one in ten women (11%) reported drinking almost every day, two in five (43%) men and one in four (27%) women drank on three or more days a week, and nearly three in four men (74%) and over half (56%) of women drank at least once a week. Among the minority ethnic groups, only the Irish drank alcohol as
frequently as the general population: 18% of Irish men and 10% of Irish
women drank almost every day, and 45% and 29% respectively drank on
three or more days a week. All other minority ethnic groups, among both
sexes, reported drinking less frequently. For example, the proportion
of men drinking on three or more days a week was 28% Black Caribbean,
25% Indian, 16% Chinese, 2% Pakistani and 1% Bangladeshi. The equivalent
figures for women were 12%, 5%, 8%, and 1% (with no Bangladeshi women
in the sample drinking on more than three days a week). Among the general population, informants aged 55 and over were more likely to be at the extremes of the distribution for frequency of drinking: on the one hand, they were more likely than the younger age categories not to drink at all or to drink only very occasionally (less than once every two months); on the other hand, they were the most likely to report drinking almost every day. The proportion drinking at least once every couple of months appeared to vary by age within minority ethnic groups (except for Pakistanis and Bangladeshis where the small number of drinkers makes it difficult to draw conclusions) in much the same way as in the general population. The tendency in the general population for the proportion drinking
on most days to increase with increasing age was also found among Irish
men (13% at age 16-34 and 26% at age 55 and over) and Irish women (6%
and 15% respectively). The pattern was similar for Black Caribbean men
(6% at 16-34 and 16% at 55 and over) and Indian men (4% and 15% respectively),
but not for any of the other minority ethnic groups. Informants were asked if they had drunk alcohol in the last seven days. Those who had were asked the number of days on which they drank and, if on more than one, whether they had drunk the same amount on each day or more on one day than others. If they had drunk more on one day than others, they were asked how much they drank on their heaviest day. If they drank the same amount on more than one day, they were asked about the most recent of those days. If they drank on only one day, they were asked about their consumption on that day. In each case, informants were asked for the details of amounts drunk for each type of drink (similar to the questions on average weekly consumption), which were then converted to the number of units of alcohol consumed. The proportion who had not had any alcohol during the last seven days
was 23% for men and 38% for women in the general population. It was
slightly lower among Irish men and women (21% and 34% respectively),
but after standardisation for age the difference was barely significant
among men and not significant among women. For all other groups, the
proportion of past week abstainers was much higher than in the general
population, being highest among Bangladeshis (98% for men and 99% for
women) and Pakistanis (95% men and 98% women), followed by Chinese (61%
and 71% respectively), Indians (54% and 85%) and Black Caribbeans (37%
and 50%). In all groups, women were more likely than men not to have
had any alcoholic drink in the past week. The difference was greatest
among Indians. The number of days in the past week when alcohol was consumed
by Irish men and women did not differ significantly from the number
reported by the general population. The mean number of days in the general
population was 2.7 for men and 1.8 for women, compared with 2.9 and
1.9 respectively for Irish men and women. Next highest means were for
Black Caribbeans (1.9 and 1.1 respectively) and Chinese (1.1 and 0.6
respectively). The mean was 0.1 or less for Bangladeshis and Pakistanis. In Table 5.8 alcohol consumption in the past week is presented by
age. The proportion drinking at least once during the last week was
lower for people aged 55 and over than for people aged 16-54 in all
minority ethnic groups (except Pakistani and Bangladeshi), for both
men and women. However, the proportion drinking on all days during the
last week was highest for men aged 55 and over in all minority ethnic
groups (except Pakistani and Bangladeshi). Among women this pattern
is not seen. Table 5.9 shows the estimated amounts of alcohol consumed on the heaviest drinking day in the past week (except for Bangladeshi and Pakistani informants, for whom the number drinking in the past week was too small for quantities to be analysed). The proportion of men drinking 4 or more units of alcohol on their heaviest drinking day was 59% in the general population, and higher (74%) among Irish men. Among other groups it was 50% for Indian men, 43% for Black Caribbean men and 21% for Chinese men. These differences between the minority ethnic groups and the general population were statistically significant after standardisation for age. The proportion of women drinking 3 or more units of alcohol on their heaviest day followed a similar pattern. For the general population it was 47%, rising to 56% among Irish women. It was 36% among Indian women, 35% among Black Caribbean women and 30% among Chinese women. As for men, these differences were significant after taking account of age. Looking at even higher levels of consumption on the heaviest drinking
day (8 units for men and 6 for women), the differences between minority
ethnic groups and the general population become more marked for men,
less marked for women.
References and notes 1 Maclure M. Demonstration of deductive meta-analysis: ethanol intake and risk of myocardial infarction. Epidemiol Rev 1993; 15:328-51. 2 Rimm EG, Giovannucci FL, Willett WC, Colditz GA, Ascherio A, Rosner B, Stampfer MJ. Prospective study of alcohol consumption and risk of coronary heart disease in men. Lancet 1991; 338:464-68. 3 Smaje, C. Health, 'race' and ethnicity. (p.49) The King's Fund Institute, London, 1995. 4 It should be noted that the different context for the two surveys could affect responses: the General Household Survey (GHS) is a general purpose survey, and is not specifically concerned with health. The most recently published GHS report dealing with alcohol consumption is that for 1998: Bridgwood A, Lilly R, Thomas M, Bacon J, Sykes W, Morris S. Living in Britain: results from the 1998 General Household Survey. The Stationery Office, London, 2000. 5 A 'unit of alcohol' is 8 gms of ethanol, and is the amount contained in half a pint of ordinary beer or lager, or in a small glass of wine, or in a measure of spirits. 6 Sensible Drinking: The Report of an Inter-Departmental Working Group, Department of Health, December 1995. 7 The method for calculating quantities of alcohol consumption among adults (aged 16 and over) was as follows. For informants aged 16 and 17, details on alcohol consumption were collected as part of a special self-completion smoking and drinking questionnaire. For those aged 18 or over, the information was collected as part of the face-to-face interview, except in a small number of cases, limited to age 18-25, where the interviewer felt that responses might be unduly affected by the presence of other household members - in these cases, the 16/17 self-completion questionnaire was given to informants to complete. The method of estimating consumption follows that used
in previous Health Surveys in the series. For six types of alcoholic
drink (normal strength beer/lager/cider/shandy, strong beer/lager/cider,
spirits/liqueurs, fortified wines, wine and alcoholic soft drinks),
informants were asked about how often they had drunk each one in the
past twelve months, and how much they had usually drunk on any one day.
The amount given to the latter question was converted into units of
alcohol, with a unit equal to half a pint of normal beer/lager/cider/shandy,
a single measure of spirits, one glass of wine, one small glass of fortified
wine, or one glass of alcoholic soft drink. A half pint of strong beer/lager/cider
was equal to 1.5 units. The number of units was then multiplied by the
frequency to give an estimate of weekly consumption of each type of
drink. The frequency multipliers were:
The separate consumption figures for each type of drink were rounded to two decimal places and then added together to give an overall weekly consumption figure. The results were then banded, using the same bands as in previous reports. The bandings for men are as follows: 1 Under 1 unit (less than or equal to 0.50 units) 2 1-10 units (over 0.50 units, but less than or equal to 10.00 units) 3 Over 10-21 units (over 10.00 units, but less than or equal to 21.00 units) 4 Over 21-35 units (over 21.00 units, but less than or equal to 35.00 units) 5 Over 35-50 units (over 35.00 units, but less than or equal to 50.00 units) 6 Over 50 (over 50.00 units) The bands for women are similarly defined, but with breaks at 7, 14, 21 and 35 units, instead of 10, 21, 35 and 50. 8 The 1998 Health Survey was the first year that a distinction was made between normal (alcoholic strength less than 6%) and strong (6% or more) beer, lager and cider. A separate question on shandy, which had been asked in previous years, was dropped, and shandy was included with normal strength beer. A question on alcoholic lemonades, colas and fruit drinks was added to the adult interview for the first time, having previously been included in the self-completion booklets for those aged 13-17. Also, 1998 was the first year to include a section of questions on drinking behaviour over the seven days before the interview. 5.1 Estimated usual weekly alcohol consumption level, by minority ethnic group 5.2 Estimated usual weekly alcohol consumption level, by age within minority ethnic group 5.3 Estimated usual weekly alcohol consumption level, by social class of head of household within minority ethnic group 5.4 Estimated usual weekly alcohol consumption level, by equivalised household income tertile within minority ethnic group 5.5 Reported frequency of drinking alcohol, by minority ethnic group 5.6 Reported frequency of drinking alcohol, by age within minority ethnic group 5.7 Number of days on which alcohol consumed in the past week, by minority ethnic group 5.8 Number of days on which alcohol consumed in the past week, by age within minority ethnic group 5.9 Estimated alcohol consumption on heaviest drinking day in the past week, by minority ethnic group
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