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PREVALENCE AND PATTERNS OF ALCOHOL USE

AMONG COLLEGE STUDENTS: COMPARING


SCENARIO IN ARUNACHAL PRADESH AND KERALA

Dr Tumge Loyi

Dissertation submitted in partial fulfillment of the requirements


for the award of the degree of Master of Public Health

Achutha Menon Centre for Health Science Studies


Sree Chitra Tirunal Institute for Medical Sciences and Technology
Thiruvananthapuram, Kerala
October 2009

1
ACKNOWLEDGEMENTS

Foremost, I would like to express my sincere gratitude to my guide Dr. Biju


Soman, Associate Professor, AMCHSS for his supervision, advice and guidance
throughout the time of research and writing of this thesis.

I thank Dr. K. R. Thanakappan, Professor and Head of AMCHSS and faculty


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

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

Collective and individual acknowledgements are also owed to my colleagues, all


MPH/DPH 2008 students, PhD scholars, Project staff for their help and support. Many
thanks go in particular to Dr. Indrani and Dr.Madhu for their help and constant
encouragement.

I cannot end without thanking my family, in particular Maen, on whose constant


support and love I have relied throughout the duration of the study.

2
Certificate

This is to certify that the work embodied in this dissertation entitled Prevalence and

patterns of alcohol use among college students: Comparing scenario in Arunachal

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

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

Master of Public Health under my guidance and supervision.

Guide

Dr. Biju Soman MBBS, MD, MPH


Associate Professor

Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology

Thiruvananthapuram
October 2009

3
DECLARATION

I hereby declare that the work embodied in this dissertation e ntitled

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

Arunachal Pradesh and Kerala is the result of original research and has not been

submitted for award of any degree/diploma in any other university or institution.

Dr. Tumge Loyi

Achutha Menon Centre for Health Science Studies


Sree Chitra Tirunal Institute for Medical Sciences and Technology

Thiruvananthapuram

October 2009

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TABLE OF CONTENTS

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

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

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

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

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

REFERENCES 62

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

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

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

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Abstract

Background

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

Objectives

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

Methodology

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

Results

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

Conclusions

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

8
Chapter 1

Review of Literature

1.1 Introduction.

Alcohol has been defined in the Websters dictionary as any of a series of volatile

hydroxyl compounds that are made from hydrocarbons by distillation. In common usage,

"alcohol" often refers simply to ethanol or "grain alcohol", which may be produced by

fermentation of fruits or grains with yeast and is one of the oldest a nd most widely used

recreational drugs in the world, typically taken in the form of an alcoholic beverage.

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

Alcohol is a psychoactive substance which has an effect on people in many ways. It

mainly acts on central nervous system but it also affects almost all other body organs and

systems. Alcoholic beverages contain ethyl alcohol (ethanol), produced as a result of the

fermentation of starch which includes grains (beer), vegetables (vodka) and fruits (wine).

Ethyl alcohol has no taste and is a colorless liquid. Each alcoholic beverage is different in

taste and the way it looks, due to the presence of other substances which are added

deliberately or accidentally. The manufacturing process also gives a distinct flavor and

color to the alcoholic beverage. Alcohol is absorbed directly into the bloodstream through

the walls of the stomach and the small intestine, and is then quickly distributed all over

the body. All alcohol that is consumed enters the bloodstream and then goes to the brain.

It takes only a few minutes for alcohol to reach the brain and begin to act. Liver is the

main organ which metabolize alcohol, and on an average it takes about one hour for the

liver to completely digest a standard alcoholic drink. 2

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1.2 History

Alcohol has been consumed by humanity since time immemorial. 3 In every

ancient civilization there is evidence of use of alcoholic beverages. It has been consumed

in various forms and under various circumstances and for various reasons. In India too,

alcoholic beverages seem to have been around since the Indus Valley civilization. These

people not only fermented, but also distilled alcoholic beverages. An important thing to

note here is that during this period itself the harmful effects of alcohol were identified and

the ancient Vedas strictly prohibited its use.

In the Rig Veda it is mentioned that alcohol be strictly prohibited for Brahmins

and students. The Sutras could serve it to guests or when a bride first enters her husbands

house. The warrior class of Kshatriyas and the trading community of Vaishyas could take

alcohol brewed from honey, mahua flowers or jaggery, but not from those made by

distillation of fermented grains. Alcoholic beverages in those days were usually from

fermented grains, flowers and fruits. Another variety was from the exudates of spathes of

coconut or palmyra trees. These exudates were fermented to yield alcoholic beverages.

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

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

(Indian Made Foreign Liquor) in Kanpur in 1805. Following this, many more distilleries

came up. This led to an appreciable increase in consumption. By the time India gained her

Independence, the makers of the Constitution of India included the prohibition of

intoxicating drinks under the Directive Principles. 4

1.3 Curre nt scenario

Global alcohol consumption has increased in recent decades, with most or all of this

increase occurring in developing countries. 3 Both average volume of alcohol consumption

and patterns of drinking vary dramatically between sub-regions. Average volume of

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

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

Myanmar and Nepal). Alcohol causes 3.2 percent of deaths (1.8 million) and 4.0 percent

of DALYs (58.3 million). Within sub-regions, the proportion of disease burden


3
attributable to alcohol is greatest in the Americas and Europe.

Table 1.1 Annual per capita consumption of alcohol per adult 15 years of age and
over
Region Consumption Range Percentage of population
(liters) covered
Africa 03.9 0.02 - 07.72 76.7
America 16.2 1.66 - 14.03 99.9
Eastern 00.4 0.05 - 10.00 90.4
Mediterranean
European 10.5 0.85 - 15.12 99.9
South-East Asian 01.7 0.04 - 08.64 98.4
West Pacific 04.8 0.34 - 18.39 99.9
Source: Global Status Report on Alcohol, WHO 2004

South-East Asian societies are in a state of rapid transition. Traditional societies

are gradually adopting modern lifestyles, giving rise to new problems. The alcohol

industry is huge in the region. It is estimated that there are over 600 factories, 1582

distributors and thousands of retail outlets involved in alcohol production and retailing.

Over 4 million people are involved with the industry. 5

Although India is regarded as a traditional dry country, it is the dominant

producer of alcohol in the South-East Asia region (65 percent) and contributes to about 7

percent of the total alcohol beverage imports into the region. More than two thirds of the

total beverage alcohol consumption within the region is in India. There has been a steady

increase in the production of alcohol in the country, with the production doubling from

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

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

11
consumption. This is coupled with the initiation age decreasing on an alarmingly. The

recorded market and consumption levels are still very low as compared to the global

standard. The illicit market consumption is far more than legal sales. 4

Country liquor is a distilled alcoholic beverage made from locally available cheap

raw material such as sugarcane, rice, palm, coconut and cheap grains, with alcohol

content between 25-45 percent. Common varieties of country liquor are arrack, desi

sharab and toddy. Illicit liquor is mostly produced in small production units with raw

materials similar to that used for country liquor. With no legal quality control checks on

them, alcohol concentration of illicit liquor varies (up to 56 percent). Adulteration is quite

frequent, industrial methylated spirit being a common adulterant, which occasionally

causes incidents like hooch tragedies. Cheaper than licensed country liquor, illicit liquor

is popular among the poorer sections of the population. In many parts of India, illicit

production of liquor and its marketing is a cottage industry with each village having one

or two units operating illegally.6

Toddy is an alcoholic drink made by fermenting the sap of coconut or palm. It is white

and sweet with a characteristic flavor. It has between 4-6 percent alcohol and has a shelf

life of about 24 hours.7, 8


Toddy is popular among the lower socioeconomic groups in

south India. Besides these, home production for self-consumption is also common in

some parts of India. Toddy is brewed all along the coast. Besides toddy, home

fermentation and distillation is also common in several tribal areas in the country,

especially the north-eastern region of the country.

The area of Arunachal Pradesh boasts a rice wine called Apong (Poka). Rice beers like

handia and chhung are also popular in the hills and the tribal belts. Distillates, however,

are also common - from arrack to desi to the mahua used in the tribal belts. Toddy and

12
the rice brews are not considered very damaging to the health being natural brews. Jack-

fruit wine is an alcoholic beverage made by ethnic groups in the eastern hilly areas of

India. As its name suggests, it is produced from the pulp of jack- fruit (Artocarpus

heterophyllus). Ripe fruit is peeled and the skin discarded. The seeds are removed and the

pulp soaked in water. Using bamboo baskets, the pulp is ground to extract the juice,

which is collected in earthenware pots. A little water is added to the pots along with

fermented wine of a previous batch. This acts as the inoculums. The pots are covered with

banana leaves and allowed to ferment at 18 to 30C for about one week. The liquid is then

decanted and drunk. During fermentation, the pH of the wine reaches a value of 3.5 to

3.8, suggesting that an acidic fermentation takes place at the sa me time as the alcoholic

fermentation. Final alcohol content is about 7 percent to 8 percent within a fortnight. 8

1.4 Curre nt patterns & trends of alcohol use in India

The prevalence of alcohol use is still low in India as compared to other countries. Though

consumption is low, patterns of alcohol consumption vary widely through the country.

Punjab, Andhra Pradesh, Goa and the north-eastern states have a much higher proportion

of male alcohol consumers than the rest of the country. Women tend to drink more in the

states of Arunachal Pradesh, Assam and Sikkim in north-east; Madhya Pradesh,

Chhattisgarh, Orissa and Andhra Pradesh in central and east India; and Goa in the west,

compared to other states.9 The unrecorded consumption and expenditure on alcohol still

remains high in India.5

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

India, satisfy the criteria for hazardous drinking. The people who indulge in hazardous

drinking follow a pattern. They drink alone; drink predominantly IMFL and drink more

than five standard drinks per occasion. Alcohol use is strongly associated with

expectations of disinhibition and violence, especially among men, which 'legitimizes'

13
male drunkenness and violence. Patterns of alcohol consumption are probably more

important than per capita levels of alcohol use in predicting whether people will

experience problems with their drinking, making them better indices of the likelihood of

harm in the population.4

Studies done on the inhabitants of Arunachal Pradesh have shown that the

prevalence of alcohol use varies. A study done by Chaturvedi et al showed it to be 30

percent.10 Another study showed it to be 50 percent. 11 This same study showed that

prevalence of alcohol consumption was 64.2 percent among males and 34.7 percent

among females. It also found that most of the alcohol users consumed local home

beverages, and only very few consumed IMFL (Whisky/Rum/Brandy/Gin). The NFHS 3

found the prevalence of alcohol consumption among men in Arunachal Pradesh to be 61.1

percent and among women to be 33.6 percent. 9

In the case of Kerala, it has been mentioned that the per capita alcohol consumption is

highest in India.4 The NFHS 3 data shows the prevalence rates among men in Kerala to

be 45.2 percent and 0.7 percent among women.9

1.4.1 Drinking trend among youth

The age of initiation to alcohol is going down. Different states have different legal

minimum age limits for alcohol consumption, with the lowest being 18 years in

Karnataka and Kerala and the highest at 25 years in Delhi; Maharashtra has permissible

age for beer and wine as 21 years and 25 years for spirits. There is increasing lobbying

by the alcohol industry for reduction in the permissible age. Young people, especially

teenagers, are more sensitive to alcohol use because their bodies and brains are still

developing. Studies and findings around the world are conclusively underscoring the

dangers of early alcohol use resulting in a much higher risk of dependence and abuse, but

14
the legal age in India for serving alcohol is seldom checked. In India, the young are being

lured towards alcohol use. They are impressionable, want to be seen as fun, hip, cool &

belonging to their peer groups and friend circles. Alcohol also provides an excuse to

behave in an uncontrolled manner. In a setup like India, alcohol consumption takes place

without the knowledge of parents and family. 4

1.4.2 Drinking trends among women

The little information that exists about patterns of consumption in India indicates that

women consumers can have an equally explosive pattern of alcohol consumption as men.

Traditionally, their numbers have been lower but persuasive marketing and advancing

urban lifestyles can make a significant change in this and they make another popular

target group. A recent study in Karnataka reported no major difference between the

amounts of alcohol drunk by men or women on any typical drinking occasion. The

frequency of use varies between men and women, with men drinking more frequently

than women. It might be noted that while almost 70 percent of the male drinkers drink

daily or almost daily, 55 percent of women drinkers also drink at the same frequency.

This can hardly be termed infrequent drinking.

1.5 Impact of alcohol on health

It has been estimated by WHO that worldwide there are about 2 billion people who
3
consume alcoholic beverages. Of these 76.3 million have diagnosable alcohol use

disorders. Globally, alcohol causes 3.2 percent of all deaths (1.8 million deaths) and 4

percent of Disability- Adjusted Life Years (58.3 million DALYs). This proportion is much

higher in males (5.6 percent deaths and 6.5 percent of DALYs) than females (0.6 percent

deaths and 1.3 percent DALYs).

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Besides the direct effects of intoxication and addiction, alcohol is estimated to cause

about 20-30 percent of each of the following worldwide: esophageal cancer, liver cancer,

and cirrhosis of the liver, homicide, epilepsy, and motor vehicle accidents. For males in

European region, 50-75 percent of drownings, esophagus cancer, epilepsy, unintentional

injuries, homicide, motor vehicle crashes and cirrhosis of the liver are attributed to

alcohol.3, 12

In a study conducted in Bangalore, India, alcohol users reported more health problems

than the non-users. The alcohol- users were found to be at approximately three times at

higher risk of suffering from a health problem as compared to non-users.13

Alcohol affects almost every organ of the body. It can cause an endless list of negative

health outcomes. Few of them are given here. Heartburn, nausea and gastritis,

malabsorption syndromes, worsens complications of diabetes, anemia, reduced sexual

capacity, increased risk of seizures, addiction and alcohol dependence, depression,

anxiety, suicide and other psychiatric symptoms, abuse of other substances including

tobacco, fatty liver, alcoholic hepatitis and cirrhosis, alcoholic pancreatitis, cardio-

vascular effects include: poor blood pressure control, increased cerebral hemorrhage and

strokes, cardiomegaly, cardiac failure, and arrhythmias, reduced immunity and increased

susceptibility to infections, damages to the musculo-skeletal system, impaired sleep and

memory, polyneuropathy, delirium tremens, Wernickes encephalopathy and Korsakoffs

syndrome and hallucinations.12, 14, 15


And especially for female users of alcoholic

beverages, it has been proved that alcohol negatively affects the fetus leading to Fetal
16, 17
Alcohol Syndrome. One study has even reported that alcohol use can be considered a

risk factor for periodontitis.18 It has been reported time and again that alcohol leads to

high-risk sexual behaviors. Alcohol consumption acts as a disinhibitor to high-risk sexual

behavior. This might include wrong choice of partners, non use of condoms and also

16
having multiple partners.19-22 Alcohol is so harmful to the body that there is a list of

diseases named solely upon alcohol. These are: 23, 24 Alcohol abuse, Alcoholic gastritis,

Alcoholic psychoses, Alcoholic liver cirrhosis, Alcoholic polyneuropathy, Alcoholic

cardiomyopathy, Alcohol-dependence syndrome, excess blood alcohol and Ethanol and

methanol toxicity.

1.6 Positive effects of alcohol:

Though there is much harm caused by consumption of alcoholic beverages, there are

some documented positive effects too. The well known case is that of the protective effect

of alcohol on Coronary Heart disease and Cerebrovascular diseases. Alcohol reduces the

risk of Coronary and Cerebrovascular diseases by inhibiting formation of atheroma and

decreasing rate of blood coagulation. 25, 26


A study even showed that alcohol has a

protective effect on hearing loss.27

1.7 Social impact of alcohol

Alcohol consumption is linked to many harmful consequences for the individual drinker,

the drinkers immediate environment and society as a whole. Such social consequences as

traffic accidents, workplace-related problems, family and domestic problems, and

interpersonal violence have been receiving more public or research attention in recent

years. Social consequences affect individuals other than the drinker, for examp le,

passengers involved in traffic casualties, or family members affected by failure to fulfill

social role obligations, or incidences of violence in the family.

17
1.7.1 Alcohol consumption and the workplace

Heavy drinking at the workplace may potentially lower productivity. Sickness absence

associated with harmful use of alcohol and alcohol dependence entails a substantial cost

to employees and social security systems. There is ample evidence that people with

alcohol dependence and problem drinkers have higher rates of sickness absence than

other employees.28 A number of studies have demonstrated an association between heavy

drinking or alcohol abuse and unemployment. Here, a causal association may go in either

direction, heavy drinking may lead to unemployment, but loss of work may also result in

increased drinking, which may become heavy drinking. Alcohol may also lead to trauma

at the workplace, especially in job profiles that involves machinery. 29

1.7.2 Alcohol consumption and the family

It is well established that drinking can severely impair the individuals functioning in

various social roles. Alcohol misuse is associated with many negative consequences both

for the drinkers partner as well as the children. Maternal alcohol consumption during

pregnancy can result in fetal alcohol syndrome in children, and parental drinking is

correlated with child abuse and impacts a childs environment in social, psychological

and economic ways.30 Drinking can impair performance as a parent, as a spouse or

partner, and as a contributor to household functioning. There are also other aspects of

drinking which may impair functioning as a family member. In many societies, drinking

may be carried out primarily outside the family and the home. In this circumstance, time

spent while drinking often competes with the time needed to carry on family life.

Drinking also costs money and can impact upon resources particularly of a poor family,

leaving other family members destitute. Also, it is worth noting that events occurring

when drunk can also have lasting consequences, through home accidents and family

18
violence.24 The effects of men's drinking on other members of the family is often

particularly on women in their roles as mothers or wives of drinkers. The risks include

violence, HIV infection, and an increased burden in their role of economic providers.

1.7.3 Alcohol and poverty

The economic consequences of expenditures on alcohol are significant especially in areas

with high poverty. Besides money spent on alcohol, a heavy drinker also suffers other

adverse economic effects. These include lowered wages (because of missed work and

decreased efficiency on the job), lost employment opportunities, increased medical

expenses for illness and accidents, legal cost of drink-related offences, and decreased

eligibility for loans.24

1.7.4 Alcohol and domestic violence

Research has found that alcohol is present in a substantial number of domestic violence

accidents. The most common pattern is drinking by both offender and victim. Alcohol has

been shown to be a significant risk factor for husband-to-wife violence. Drinking

frequently has been associated with intra-family violence. Studies based on interviews

with abused wives tend to report higher proportions of alcohol involvement than do

general population studies or police samples. Regarding partner violence, research

evidence indicates that it is more strongly associated with heavy drinking. 24

1.8 Economic impact of alcohol

It is a well established fact that the use of alcohol entails a large number of adverse
24
economic consequences. This could be in differing areas such as physical and mental

health, traffic safety, violence, and labor productivity. But these are difficult to measure.

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

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

use.

1.9 Rational for the study:

Consumption of alcoholic beverages is a public health problem. It not only harms the

person who consumes it but also harms the family and the society in general. In an

attempt to generate more income, governments in many countries are promoting the sale

of alcohol containing drinks. But it has been found the expenditure for the treatment of

problems resulting due to consumption of alcohol is more than the income generated. 13

Over the years, the age of drinking has been reducing. More and more people have started

having alcohol at younger ages. The college setting is an ideal place for initiation into the

world of alcohol. The students are away from the watchful eyes of elders. They are young

and want to try out any new thing. They are under pressure from friends to be like rest of

the students. College students are at that phase of life when they start taking independe nt

decisions.

Several studies that have been conducted elsewhere have tried to quantify the problem of

alcohol use among the college students. They have looked into the patterns and beliefs
31 32
related to alcohol use among college students. These patterns and beliefs vary in the

different region among different population groups. In India researchers have tried to

address the issue of drinking among college students, but they are very few in number.

Also, there is paucity of data on any attempt to understand the difference in patterns and

beliefs among different population groups in India.

The state of Arunachal Pradesh is in the extreme east of the country. The inhabitants of

this region are mostly tribal. Consumption of alcohol is a part of the day to day life of

these people. Consumption of alcohol is culturally accepted in most parts of Arunachal

20
Pradesh. The few studies which have been carried out in the state rank Arunachal Pradesh

on top with respect to prevalence of alcohol use in India. 9, 11 These studies also show that

the prevalence of alcohol among women of Arunachal Pradesh is highest in India. On the

other hand, the state of Kerala has very low acceptance to alcohol use. This is in direct

contrast to the practice in Arunachal Pradesh. But eve n with this low acceptance of

alcohol use in the society in Kerala, it has the highest rates of per capita consumption of

alcohol in the country. It is evident that there are differences in the patterns and beliefs

with regard to alcohol use in this two states.

For this reason an attempt was needed to study the prevalence, patterns and beliefs of

alcohol use in these two states and compare the findings.

1.10 Objectives of the study:

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

of Arunachal Pradesh and Kerala.

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

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

of Arunachal Pradesh and Kerala.

21
Chapter 2

Methodology

2.1 Study type:

It is a descriptive study. A self administered questionnaire survey was done among

college students of Arunachal Pradesh and Kerala using a common pre-tested

questionnaire survey tool to assess and compare prevalence and pattern of alcohol use

among them.

2.2 Study setting:

West Siang district in Arunachal Pradesh and Trivandrum district in Kerala were selected

for the study. The main reason for selection of these districts is logical convenience, but

the fact that these districts are fairly representative of the respective states with respect to

the question under study also contributed in their selection. In both the states the study

was conducted in non-professional colleges. This was because there was only one college

in West Siang district of Arunachal Pradesh, and the colleges in Kerala were selected to

match with this college. Five colleges were selected from Kerala.

2.3 Study population:

The age group of students in Arunachal Pradesh was from 18-26 years and that in Kerala

was from 18-30 years. All the students of the selected colleges who were 18 years and

above were considered eligible for the study.

2.4 Time frame:

Data was collected done between June 2009 and August 2009.

22
2.5 Sample size:

Sample size was calculated based on the prevalence of use of alcohol in the general

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

In Arunachal Pradesh it was reported by the NFHS 3 that the prevalence of use of alcohol

among men was 61.1 percent.9 Assuming that the rates were lower among the student

population, the prevalence rate of 50 percent was taken for the students. The sample size

was calculated as,

N=Z2 *PQ/D2

Where,

N=sample size

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

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

Q= 1-P,

In this case Q= 1-50

= 0.5

D= precision factor (this is the difference between the assumed prevalence and lowest

expected prevalence.) The lowest expected prevalence was taken as 44 percent.

Therefore, D= 0.50-0.44

=0.06

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

23
The final calculated sample size was,

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

=400

In Kerala also the prevalence of alcohol use among men was obtained from NFHS 3 and

it was 45.2 percent.9 Assuming that the prevalence rate was lower in the college going

students, it was considered to be 30 percent. The worst acceptable prevalence was taken

as 26 percent, and hence the precision factor as 0.04. A design effect factor of 1.5 was

also considered. Using the same formula as for Arunachal Pradesh, the sample size was

calculated as,

N=Z2 *PQ/D2

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

= 758,

This value was rounded off to 800.

Final sample size in Arunachal Pradesh = 400

Final sample size in Kerala = 800

2.6 Sample selection proce dures:

In Arunachal Pradesh:

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

A list of all class divisions in the college was made. By simple random sampling from

this list, the class divisions were selected for distribution of the questionnaires.

24
In Kerala:

First of all a list of all non-professional colleges in Trivandrum district was made. By

means of lottery method five colleges were selected from this list. Among these selected

colleges, a list of all class divisions was made. By simple random sampling from this list,

the class divisions wee selected for the distribution of the questionnaires.

2.7 Data collection:

Data was collected by the primary investigator. The tool used was a self administered

questionnaire in English. (Annexure 1) It was pre-tested among a group of 15 students

prior to actual data collection. It was anonymous so as to decrease any inhibition and

extract maximum response from the respondents. This questionnaire was in English for

easy understanding and also to maintain inter-state similarity. Data collection was

conducted in the class-rooms. A standard drinks table was also provided along with the

questionnaire. (Annexure 2) This table contained a list of alcoholic beverages, the amount

of alcohol that constitutes a standard drink for each type of alcohol, the alcoholic contents

of each type of alcohol and also the normal method of packaging. This table was given so

that there might be uniformity in answering what a standard drink constitutes.

Permission was taken from the respective head of the institution of the selected

colleges prior to data collection. A day was fixed for the distribution of the questionnaire

which was decided based on a mutually convenient date and time for the respondents as

well as the investigator. On the day of the data collection, the investigator gave a briefing

on the questionnaire and the respondents were told the procedure of filling up of the

questionnaire. The questionnaires were to be filled in the classroom itself and not to be

filled outside or to be taken to their residences. Besides this, the participants were also

requested not to disturb others during the filling up of the questionnaire. The students

25
were requested to answer honestly without any fear or shyness. They were informed that

they need not give their names in the questionnaire. They were also informed that their

privacy and the confidentiality of the information provided would be strictly maintained.

They were also requested to answer the questionnaire by themselves and not to discuss

among themselves. In case of any doubt, they could ask the investigator, who was

available in the classroom.

Following this briefing, the consent forms were distributed. (Annexure 3) When the

consent forms were filled and returned, the questionnaire was distributed among the

students. It was taken care that no elders or teachers were around when the students were

filling up the questionnaire. After the questionnaire was filled, it was collected by the

investigator. The respondents were verbally thanked for their participation.

2.8 Data analysis:

Primary data was collected and entered in Epidata software version 3.1. This was then

imported to SPSS for windows version 17.0 to carry out further analysis. Data cleaning

was performed, and some questionnaires which were incompletely filled for important

variables were cleaned out. Univariate analysis was done to study the sample

characteristics (baseline characteristics of the study sample was assessed using descriptive

statistics). Bivariate analysis of the independent variables with respect to the dependent

variables (Alcohol use and Problem drinking) was done using non parametric Chi square

test of significance. For all the tests, p value of <0.05 was considered for statistical

significance. Variables that had significant outcome in the bivariate analysis were

considered for multivariate analysis. Multivariate analysis was done on these variables for

adjustment of possible interaction and confounding factors to arrive at a final model.

26
2.9 Study variables:

The study variables on use of alcohol have been adopted from the Global school-based

student health survey (GSHS) which is a school-based survey conducted primarily among
33
students aged 13-15 years. These variables have been specially developed for

classroom based surveys. The GSHS uses a standardized scientific sample selection

process, core questionnaire modules, core-expanded questions, and country-specific

questions that are combined to form a self-administered questionnaire which can be

administered during one regular class period. Some questions on drinking pattern were

adopted from the AUDIT questionnaire for alcohol. 34 The AUDIT questionnaire is

generally used for detection of alcohol related drinking problems among adults; here it

was adapted for use among college going students. 35, 36

2.9.1 Dependent variables:

Alcohol use was a dependent variable. Any person who had ever taken alcohol was

considered to be a user of alcohol. This included only those individuals who had taken

alcohol more than a sip.

Proble m drinking was another dependent variable. Problem drinking was estimated

from the CAGE questionnaire. The CAGE questionnaire was developed by Dr. John

Ewing. CAGE is an internationally used assessment instrument for identifying problems

with alcohol. 'CAGE' is an acronym formed from the italicized letters in the questionnaire

(cut-annoyed- guilty-eye).

CAGE is considered a validated screening technique, with one study determining

that CAGE test scores >=2 had good sensitivity and specificity for the identification of

problem drinkers.36-39

27
The CAGE Questionnaire for alcohol:

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

have problem drinking. By combining the answers for the four questions, a new variab le

CAGE was derived.

2.9.2 Independent variables:

Age: Age was collected by asking the respondents to give their age in completed years as

a continuous variable. No attempt was made to divide the age into age groups because the

expected range was very small.

Sex: It is known that use of alcohol varies between the sexes. Studies which have been

done elsewhere have time and again proved that the use of alcohol is more among males

than among females.32, 40, 41

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

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

Muslim. Others option was provided for people who belonged to a religion other than

the ones mentioned.

28
Pocket money: This variable was measured in INR and was initially collected by having

six groups with a width of 500 each starting from Less than 500 up to more than 2500.

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

1000 and more than 1000, considering the low number of cases in the higher pocket

money groups. The access to higher amount of pocket money is a direct indicator of the

ability to spend more, and studies have proved this. 42, 43

Residence: Residence meant the place of present residence of the respondent. This

variable was included in the demographic variable, but apart from this it was included to

see if there was any relation with place of stay and use of alcohol.

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

Extended and Joint. Nuclear family was defined as a family which had the parents and the

children. Extended family was a family which had the parents, children and the

grandparents. Joint family was defined as a family that had the parents, children,

grandparents and uncle and aunties.

Age at first drink: Respondents who reported that they had consumed alcohol had to

inform about their age when they first tried alcohol. This was a continuous variable and

option was given to report the age in years. If in case the respondent knew from their

parents or elders that they had taken alcohol before one year of age, they could report it in

months. This was done primarily because; use of alcohol is a part of the cultural practice

of the inhabitants of Arunachal Pradesh. They frequently give home made rice beer to

their children.

Place where alcohol was first tried: The alcohol using respondents also had to report the

place where they first tried alcohol. This could be their home, friends home, hostel,

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

beach or streets.

Reason behind trying alcohol: To capture the various reasons under which an individual

might first try alcohol, the relevant occasions were included.

Type of alcohol tried first: A list of alcoholic beverages was given from which the

respondents could choose.

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

on the use of alcohol on the children.

Variables on patterns of alcohol use: This included a set of questions such as the usual

place of consumption, the people with whom alcohol was usually consumed, usual

amount and maximum amount of standard drinks that were consumed and usual type of

alcohol taken.

Alcohol use among siblings: The purpose of this variable was to see if there was any

relation between alcohol use by siblings and alcohol use by the respondents.

Discussion about harm of using alcohol in the home: The respondents had to answer if

there was any discussion about the negative effects of alcohol at home and if they were

told that alcohol consumption was bad.

Discussion about harm of using alcohol in schools/colleges: Similarly, the respondents

had to answer if there was any education or discussion in the ir classes about the harm of

alcohol use.

30
Harm that is caused by drinking once or twice a year or several times a week: These

two sets of questions intended to look into the knowledge of the respondents regarding

the use of alcohol and its negative impacts.

Usual amount of alcohol that is needed to make a person drunk: The aim of this

variable was to check the beliefs and perceptions of the respondents. In absence of better

measures, this was taken as an indirect measurement of the amount the respondent would

need to become drunk.

Tobacco use practices: People use tobacco. This use of tobacco might be in relation to

alcohol. It is known that people tend to take more tobacco products while they are

consuming alcohol. Options were included for tobacco products that are smoked and also

for smoke less tobacco. Further, it was asked if they take more of these products while

consuming alcohol.

2.10 Ethical considerations:

The primary consent to conduct the study was obtained from the head of the institute of

the concerned colleges. The students were then invited to participate in the study which

was conducted in their class rooms. Written informed consent was taken from the

respondents at the beginning of the study.

Any participant whose age was less than 18 years was not considered for the study. Any

student who wished not to participate in the study was permitted to do so. Also, anyone

willing to discontinue filling the questionnaire midway was permitted to discontinue with

the process.

31
2.11 Definitions:

Some terms were used in the study which needs further elaboration. There are different

types of alcohol that is used in different places around the world. In India, the types of

alcohol can be divided into locally brewed and the IMFL (Indian Made foreign liquor).

The common types of locally brewed alcoholic beverages in Arunachal Pradesh are poka,

nyongin and raksi. Poka and nyongin fermented from rice while raksi is a distilled

variety. In Kerala the locally prepared alcoholic beverages are toddy and arrack. Toddy is

a fermented alcoholic beverage prepared from tender coconut palm while arrack is

distilled variety. The volume by volume pure alcohol content of these local alcoholic

beverages varies from 4-14 percent. Arrack is an exception and its alcoholic content may

go up to 50 percent. With regard to the IMFLs, these are foreign brands that are brewed

and distilled in India. The most common IMFLs are Brandy, Whisky, Rum and Vodka.

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

alcohol content.

Alcoholic beverage and its alcohol content.


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

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

32
2.12 Spectrum of alcohol use

Alcohol use, as the term implies, is the consumption of alcohol. It does not indicate the

amount used or the extent of harm from use. 44 Alcohol use usually starts as a social

phenomenon. Many communities consider the occasional use of alcohol, for recreational

purposes or on social occasions, as normal and acceptable. There is little awareness

that even the occasional or social use of alcohol does carry a risk of road traffic injuries or

industrial accidents. Intoxication from occasional use can lead to violence or socially

inappropriate or embarrassing behavior.

Harmful use

A pattern of alcohol consumption that causes damage to health. 45 The damage may be

physical (as in cases of hepatitis from prolonged use of alcohol) or mental (e.g. episodes

of depressive disorder secondary to heavy consumption of alcohol).

Harmful use of alcohol is a pattern of use which causes damage to an individuals

health.44 Harmful use is not necessarily linked to drinking too much alcohol or drinking

alcohol every day. Harmful drinking is usually related to the circumstances of drinking

alcohol. Many patterns of consumption of alcohol can be considered as harmful use of

alcohol, for example, drinking alcohol and driving which can lead to road traffic injuries,

binge drinking (drinking too much alcohol at one time) sometimes indulged in by

teenagers, pay-day drinking when a person drinks heavily on the day he gets his salary, or

pregnant women drinking alcohol.

Hazardous use

Hazardous use is a pattern of alcohol consumption carrying with it a risk of harmful

consequences to the drinker.44 The damage may be to healthphysical, or mental, or they

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

abuse.

Alcohol abuse, also called problem drinking, is a pattern of excessive drinking that

result in adverse health and social consequences to the drinker, and often to those around

the drinker. People with an alcohol abuse problem may show the following

characteristics:

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

aspects of their lives.

Experience some problems associated with their alcohol use.

Get complaints about their alcohol use.

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

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

available.

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

Gulp drinks, become intoxicated intentionally.

Drink alone or in secret.

Dependence syndrome

A cluster of behavioral, cognitive, and physiological phenomena that develop after

repeated alcohol use and that typically include a strong desire, difficulties in controlling

its use, persisting in its use despite harmful consequences, a higher priority given to

alcohol use than to other activities and obligations, increased tolerance, and sometimes a

physical withdrawal state. 45

34
There are four main symptoms. These are:

Craving: A strong need, or compulsion to drink.

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

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

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

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

Binge drinking:

Binge drinking is defined as the consumption of 5 or more standard alcoholic drinks on

one occasion. 44

Standard drink:

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

One standard drink may consist of:

Spirit..30 ml

Wine...120 ml

Beer.285ml

35
Chapter 3

Results

3.1 Sex distribution of the study population:

Table 3.1 Sex distribution:


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

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

Arunachal Pradesh and 90 in Kerala). Since a design effect of 1.5 was considered during

the sample size calculation, the final figures are well within the range. Hence the validity

of the study findings was not affected. Although there was no non response per se during

the study, there were some incomplete or partially filled forms. These forms were not

considered for further analysis.

In Kerala, the male representation was 40 percent. To confirm that this was a true

representation of the male female distribution among the selected colleges, the male

female percentage was checked from the enrolment registers in these colleges where data

was collected. It was found that the percentage of males was 39.36 percent.

3.2 Religion:

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

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

36
population in other religions was very less. In Kerala, the followers of Hindu religion

formed 68 percent, Christians 26 percent and Muslim 6 percent.

3.3 Monthly pocket money allowance of the respondents:

Table 3.2 Monthly pocket money allowance

State INR Frequency (%)


Arunachal <500 152 (41.8)
Pradesh 501-1000 99 (27.3)
>1001 113 (31.0)
Kerala <500 618 (84.8)
501-1000 83 (11.4)
>1001 28 (3.8)

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

3.4 Residence

Table 3.3 Residence


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

Most of the Arunachal Pradesh students resided in hostels. This might have been beca use

of the fact that there was only one college in the West Siang district and students from all

over district came to study here. These students had to stay in hostels. The students in

Kerala mostly resided at their respective houses.

37
This finding of residence might explain why the students in Arunachal Pradesh had more

pocket money than the students of Kerala. Since the students of Arunachal Pradesh stayed

away from home, they had to have some money for their day to day expenditure.

3.5 Type of family:

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

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

family (88.9 percent).

3.6 Alcohol use:

Table 3.4 Alcohol use


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

It was also observed that 81.2 percent of males and 38.6 percent of females were ever

users of alcohol in Arunachal Pradesh. Same was 46.1 percent in males and 5.9 percent

among females in Kerala.

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

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

Arunachal Pradesh when compared to Kerala.

3.7 Place where the first drink of alcohol was taken:

In Arunachal Pradesh, 70.6 percent reported that they were in their homes when they had

their first drink of alcohol. The other place was at friends home (15.6 percent). The

students of Kerala reported having their first drink at a public place (35.8 percent), at a

38
friends home (33.2 percent) and at home (23.8 percent). In both of the states, very few

students mentioned the hostel as a place of first drink.

3.8 Reason for trying alcohol for the first time:

The main reason stated in Arunachal Pradesh as the reason behind trying alcohol for the

first time was family occasion (47.6 percent), followed by religious occasion (26.4

percent). The students of Kerala reported that pressure from friends (31.1 percent) was

the main reason for trying alcohol for the first time.

3.9 Type of alcohol that was first tried:

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

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

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

first by 32.7 percent of the respondents.

3.10 With whom the first alcoholic drink was taken:

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

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

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

with family members (24.5 percent).

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

In Arunachal 68.1 percent reported that the alcohol was obtained from home. About 24

percent reported that they obtained it from friends. In Kerala 30.9 percent said they got it

from friends which was closely followed by liquor shop (30.2 percent). Home was also

reported as a source by 22.4 percent respondents.

39
3.12 Usual place of drinking alcohol:

The favorite place in Arunachal Pradesh was home (44.9 percent), then a public

place (31.9 percent) followed by friends home (15.7 percent). Any public place was the

usual place of drinking in Kerala (41.9 percent), followed by friends home (36.3 percent)

and home (16.1 percent)

3.13 Usual type of alcohol taken:

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

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

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

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

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

Pradesh usually consumed home made alcoholic beverage, consumed with family

members and in the house during family or religious occasions. We may interpret from

these findings that the consumption of alcohol is culturally accepted in Arunachal

Pradesh. In case of Kerala, the trend is that the students tried to be away from the family

members while consuming alcohol, which lead to interpret that consumption of alcohol is

not culturally accepted in Kerala.

3.14 Frequency of getting drunk in the past 30 days:

Table 3.5 Frequency of getting drunk in the past 30 days


State Frequency Percent
Arunachal No 82 39.6
Pradesh Yes 125 50.4
Missing* 145
Kerala No 83 57.6
Yes 61 42.4
Missing* 559
*Missing are those who did not answer the respective fields.

40
3.15 Any trouble caused by drinking in the last 30 days:

Table 3.6 Any trouble caused by drinking in the last 30 days:


State Frequency Percent
Arunachal No 135 64.9
Pradesh Yes 73 35.1
Missing* 144
Kerala No 112 78.9
Yes 30 21.1
Missing* 561
*Missing are those who did not answer the respective fields.

3.16 Monthly expenditure on alcohol:

Table 3.7 Monthly expenditure on alcohol:


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

3.17 Managing money for alcohol:


In Arunachal Pradesh, 47.4 percent replied that they manage money from their pocket

money, 33.5 percent said they get it free at home. In Kerala, 36.1 percent said they

manage money from their pocket money, 18.9 percent said they borrowed from friends,

16.4 percent said they pool money among friends.

41
3.18 Alcohol use among parents:

Table 3.8 Alcohol use among parents:


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

It was also observed that in Arunachal Pradesh, the parental drinking was 32.4 percent

among father or male guardians, 4.5 percent among mother or female guardians and 28.4

percent reported that both their parents consumed alcohol. In Kerala, the use of alcohol

among father or male guardian was 30.2 percent. There were no reports of maternal or

female guardian using alcohol. Only 0.6 percent reported that both of their parents drink.

3.19 Alcohol use among siblings:

Table 3.9 Alcohol use among siblings:


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

42
3.20 Discussion in the family about harmful effect of alcohol:

Table 3.10 Discussion in the family about harmful effect of alcohol:


State Frequency Percent
Arunachal No 78 22.2
Pradesh Yes 273 77.8
Missing* 1
Kerala No 219 31.6
Yes 473 68.4
Missing* 11
*Missing are those who did not answer the respective fields.

3.21 Discussion in the institute about harmful effect of alcohol:

Table 3.11Discussion in the institute about harmful effect of alcohol:


State Frequency Percent
Arunachal No 102 34.1
Pradesh Yes 197 65.9
Missing* 53
Kerala No 140 21.8
Yes 503 78.2
Missing* 60
*Missing are those who did not answer the respective fields

3.22 Perceived reasons for drinking by othe rs:


The respondents in Arunachal Pradesh thought that people drink alcohol because its fun

(28 percent), because culture permits (23.3 percent), to forget sorrows (13.6) and because

friends drink (12.1 percent). The students in Kerala reported it was because friends drink

(22.8 percent), because it relaxes (15.6 percent) and 14.4 percent said people drank so as

to forget sorrows and the same percentage of respondents said people drink to have fun.

43
3.23 Perceived risk if alcohol was consumed once or twice in a year:

Sixty one percent in Arunachal Pradesh and 49 percent in Kerala said that there was no

risk. Others reported that consuming alcohol once or twice in a year is great risk, 12.8

percent in Arunachal Pradesh and 15.5 percent in Kerala.

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

It was perceived by 24.1 percent of students in Arunachal Pradesh that consuming alcohol

several times in a week is of no risk, while 52.2 percent said it was a great risk. In Kerala,

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

3.25 Type of alcohol that is safest:

The students in Arunachal Pradesh considered Poka to be safest (56.1 percent), this was

followed by beer (28.2 percent). A few considered wine to be safest (10.3 percent). IMFL

came at 3.5 percent. The students of Kerala considered beer to be safest (47.6 percent),

followed by wine (48.9 percent). The local drink toddy was considered safe by 5.6

percent. Only 5.1 percent thought IMFL to be safe.

3.26 Perceived health benefit of alcohol consumption:

Table 3.12 Perceived health benefit of alcohol consumption:


State Frequency Percent

Arunachal No positive health benefit 240 70.2


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

44
3.27 Prevalence of drinking problem:

Drinking problem was assessed by the CAGE questionnaire.

Table 3.13 Problem drinking


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

3.28 Prevalence of smoking:

The prevalence of smoking in the Arunachal Pradesh population was 29.3 percent and

that in Kerala was 9.9 percent. It was reported by 17.6 percent in Arunachal Pradesh and

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

3.29 Prevalence of use of non-smoke tobacco:

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

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

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

3.30 Bivariate Analysis Results:

Simple chi square analysis was done to examine whether prevalence of alcohol use was

influenced by any of the above mentioned factors. This analysis was further divided as

follows. The factors related to the prevalence of alcohol use among students in both the

States-Arunachal Pradesh and Kerala (combined) were analyzed first followed by those

factors related to alcohol use among students in both the States independently.

45
3.30.1 Combined analysis for association with alcohol use:

Table 3.14 Association with alcohol use


Variables Does not Use alcohol OR of use of 2 p
use alcohol (%) alcohol (95% value
(%) confidence
interval)
Residence Home 546(73.1) 209(26.9) 1 0.001
Hostel 136 (45.0) 166 (55.0) 3.32(2.51-4.38)
Use of alcohol by No 369 (78.3) 102 (21.7) 1 0.001
parents Yes 4.17(3.13-5.60)
207 (46.4) 239 (53.6)

Use of alcohol by No 573 (77.4) 167 (22.6) 1 0.001


siblings Yes 62 (27.2) 166 (72.8) 9.18(6.54-12.90)

Relation of pocket <500 537 (72.3) 206 (27.7) OR* 0.001


money (in INR) 90(51.1) 86 (49.0)
501-1000
>1001 60 (44.1) 76 (60.0)

Discussion about harm No 185 (62.3) 112 (37.7) 1 0.282


of alcohol in family Yes 491 (65.8) 255 (34.2) 0.85 (0.65-1.13)

Discussion about harm No 130 (53.7) 112 (46.3) 1 0.001


of alcohol in Yes 486 (69.4) 214 (30.6) 0.51(0.38-0.70)
school/college
*
OR-Odds ratio not calculated

Combined analysis of both the States shows that use of alcohol was significantly higher

among those students whose parents also used alcohol. Similarly, use of alcohol was

significantly higher among those students whose siblings also used alcohol. As pocket

money increases the use of alcohol also increases.

Use of alcohol was higher among those students who did not have any discussion in the

family about the harm of alcohol but it did not show any statistical significance.

Use of alcohol was significantly higher among those students who did not have any

discussion in the institute about the harm of alcohol.

46
3.30.2 Separate analysis for association with alcohol use:

Table 3.15 Separate bivaritate analysis with alcohol use


Use of alcohol by parents
State Does not Use OR of use of 2 p value
use alcohol alcohol alcohol (95%
(%) (%) confidence
interval)
Arunachal No 41(53.2) 36(46.8) 1
Pradesh Yes 66(28.7) 164(71.3) 2.83(1.66-4.81) 0.001
Kerala No 328(83.2) 66(16.8) 1
Yes 141(65.3) 78(34.7) 2.64(1.79-3.88) 0.001
Use of alcohol by siblings
Arunachal No 78(54.2) 66(45.8) 1
Pradesh Yes 38(28.8) 122(76.2) 3.79(2.32-6.19) 0.001
Kerala No 495(83.1) 101(16.9) 1
Yes 24(35.3) 44(64.7) 8.98(5.22-15.44) 0.001
Discussion about harm of alcohol in family
Arunachal No 33(42.3) 45(57.7) 1
Pradesh Yes 105(38.5) 168(61.5) 1.17(0.70-1.95) 0.540
Kerala No 152(69.4) 67(30.6) 1
Yes 386(81.6) 87(18.4) 0.51(0.35-0.74) 0.001
Discussion about harm of alcohol in school/college
Arunachal No 36(35.3) 66(64.7) 1
Pradesh Yes 82(41.6) 115(58.4) 0.76(0.46-1.25) 0.288
Kerala No 94(67.1) 46(32.9) 1
Yes 404(80.3) 99(19.7) 0.50(0.33-0.75) 0.001
Relation of pocket money ( in INR)
Arunachal <500 54 (36.7) 93(63.3) OR*
Pradesh 501-1000 40(41.7) 56(58.3) 0.669
>1001 45(41.3) 64(58.7)
Kerala <500 483(81.0) 113(19.0)
501-1000 50(62.5) 30(37.5) 0.001
>1001 15(55.6) 12(44.4)
*
OR-Odds ratio not calculated

47
In both States use of alcohol was significantly higher among those students whose parents

also used alcohol. Similarly in both States use of alcohol was significantly higher among

those students whose siblings also used alcohol.

In Arunachal Pradesh use of alcohol was significantly higher among those who had a

discussion in the family about the harm of alcohol though it was not statistically

significant. In Kerala use of alcohol was significantly higher among those students who

did not have any discussion in the family about the harm of alcohol.

In Arunachal Pradesh use of alcohol was significantly higher among those who had a

discussion in the institute about the harm of alcohol though it was not statistically

significant. In Kerala use of alcohol was significantly higher among those students who

did not have any discussion in the institute about the harm of alcohol.

In Arunachal Pradesh it is seen that as pocket money increases the use of alcohol also

increases but it is not statistically significant. In Kerala as pocket money increases the use

of alcohol decreases and it is statistically significant.

48
3.30.3 Combined analysis for association with proble m drinking (CAGE)

Table 3.16 Combined analysis with problem drinking


No drinking Drinking OR of use of 2 p value
problem (%) problem (%) alcohol (95%
confidence
interval)
Use of alcohol No 411 (90.7) 42 (9.3) 1 0.001
by parents Yes 323 (74.8) 109 (25.2) 3.30(2.24-4.85)

Use of alcohol No 641 (89.0) 79 (11.0) 1 0.001


by siblings Yes 145 (67.8) 69 (32.2) 3.86 (2.66-5.59)

Monthly <500 111 (50.7) 118 (49.3) 1 0.041


expenditure on
alcoholic 500 24 (36.4) 42 (63.6) 1.80 (1.02-3.71)
drinks

Discussion No 245 (87.0) 37 (13.1) 1 0.091


about harm of
alcohol in Yes 599 (82.5) 127 (17.5) 1.40 (0.94-2.08)
family

Discussion No 187 (80.6) 45 (19.4) 1 0.103


about harm of
alcohol in Yes 579 (85.1) 101 (15.0) 0.72 (0.50-1.06)
school/college

Parents drinking had a significant effect on drinking problem of the child. Students whose

siblings drink had higher percent of drinking problem compared to the students whose

siblings didnt drink.

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

Drinking problem was more among students whose family did not have any discussion on

harm of alcohol use, but it was not statistically significant.

49
Drinking problem was more among students who did not have any discussion on harm of

alcohol use in their institution, but it was not statistically significant.

3.31 Separate analysis for association with problem drinking (CAGE)

3.17 Separate analysis with proble m drinking


Use of alcohol by parents
State No drinking Drinking OR of use of alcohol 2 p
problem (%) problem (%) (95% confidence value
interval)
Arunachal No 50(69.4) 22(30.6) 1
Pradesh Yes 141(63.8) 80(36.2) 1.28(0.72-2.28) 0.383
Kerala No 361(94.8) 20(5.2) 1
Yes 182(86.3) 29(13.7) 2.87(1.58-5.22) 0.001
Use of alcohol by siblings
Arunachal No 97 (70.3) 41(29.7) 1
Pradesh Yes 96(63.2) 56(36.8) 1.4(.844-2.25) 0.199
Kerala No 544(93.5) 38(6.5) 1
Yes 49(79.0) 13(21.0) 3.79(1.89-7.60) 0.001
Monthly expenditure on alcoholic drinks
Arunachal <500 62(47.7) 68(52.3) 1
Pradesh 500 15(29.4) 36(70.6) 2.18(1.09-4.37) 0.025
Kerala <500 49(55.1) 40(44.9) 1
500 9(60.0) 6(40.0) .83(.27-2.52) 0.721
Discussion about harm of alcohol in family
Arunachal No 59(83.1) 12(16.9) 1
Pradesh Yes 168(63.4) 97(36.6) 2.83(1.45-5.54) 0.002
Kerala No 186 (88.2) 25(11.8) 1
Yes 431 (93.5) 30(6.5) 0.51(0.29-0.90) 0.019
Discussion about harm of alcohol in school/college
Arunachal No 75(77.3) 22(22.7) 1
Pradesh Yes 116(61.1) 74(38.9) 2.17(1.24-3.79) 0.006
Kerala No 112(83.0) 23(17.0) 1
Yes 463(95.5) 27(5.5) 0.28(0.15-0.51) 0.001

50
In Arunachal Pradesh parents drinking did not have much effect on drinking problem of

the child whereas in Kerala the parents drinking had a significant effect on drinking

problem of the child. Students whose siblings drink had higher percent of drinking

problem in both Arunachal Pradesh and Kerala compared to the students whose siblings

didnt drink, though it was not statistically significant in Arunachal Pradesh.

As monthly expenditure increases drinking problem decreases significantly among the

students in Arunachal Pradesh whereas in Kerala as monthly expenditure increases

drinking problem also increases among the students but it is not statistically significant.

In Arunachal Pradesh drinking problem was significantly associated with those who had a

discussion in the family about the harm of alcohol. In Kerala the drinking problem was

significantly associated with those who did not have family discussion on the harm of

alcohol.

In Arunachal Pradesh drinking problem was significantly associated with those who had a

discussion in the institute about the harm of alcohol. In Kerala the drinking problem was

significantly associated with those who did not have any discussion on the harm of

alcohol in the institute.

51
3.32 Binary logistic regressions with ever alcohol

3.18 Regression with Ever use of alcohol


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

In Arunachal Pradesh, three variables -pocket money, alcohol use by parents and alcohol

use by siblings were found to be significantly associated with alcohol use by students.

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

money of <Rs 500,i.e students with pocket money of Rs 500-1000 drink less alcohol as

compared to students with <Rs 500 as pocket money. Students whose parents drank

alcohol were two times more likely to use alcohol themselves as compared to their

counterparts. Students whose siblings drank alcohol were three times more likely to use

alcohol as compared to their counterparts.

52
In Kerala, four variables pocket money, alcohol use by parents, alcohol use b y siblings

and discussion in family about harm of alcohol were found to be significantly associated

with alcohol use by students. Students who had Rs 500- 1000 as pocket money per month

are three times more likely to use alcohol than those who had Rs 500 per month.

Likewise, students who had Rs 1000 or above are also three times more likely of using

alcohol than those who had Rs 500 per month. Students whose parents drank alcohol

were two times more likely to use alcohol themselves as compared to their counterparts.

Students whose siblings drank alcohol were seven times more likely to use alcohol as

compared to their counterparts. Discussion in family about the harm of alcohol was a

protective exposure, that is, if there was discussion in the family about harm of alcohol

the use of alcohol among students was low.

53
Chapter 4

Discussion

The objective of this study was to assess and compare prevalence and pattern of alcohol

use and problem drinking among students of selected colleges in Arunachal P radesh and

Kerala.

4.1 Prevalence and patterns

The prevalence of use of alcohol was very high in Arunachal Pradesh (60.5

percent). This is in conformation with the findings of NFHS 3 which found the

prevalence to be 61.1 percent among the males of Arunachal Pradesh.9 The prevalence

rate among males in Arunachal Pradesh was 81.5 percent and that among females was

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

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

Kerala the rates were 46.1 percent among males, 5.4 percent among females and

combined it was 22 percent. The rates in the male population is in agreement to the NFHS

3 data which states the prevalence to be 45.2 percent. 9 The findings are similar to finding

by Jinez et al and Ruth et al who said that male sex was associated with higher risk of

drug and alcohol use.46, 47

Seventy percent of students in Arunachal Pradesh reported that they had their first drink

at home. This reflects the fact that consumption of alcohol is socially accepted in

Arunachal Pradesh and hence they start at home. In Kerala since alcohol use is not part of

the social customs and its use is not accepted in the society, most of the students reported

that they had their first drink at a public area (35.8 percent) and at a friends house (33.2

percent).

54
The main reason for consuming alcohol for the first time was stated in Arunachal Pradesh

as family occasion (47.6 percent), which was followed by religious occasion (26.4

percent). In Arunachal Pradesh, no ceremony, celebration or festival is complete without

the serving of locally brewed Poka. This is reflected in the reasons stated for initiation to

alcohol. The students of Kerala on the other hand, reported that pressure from friends

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

Hamilton et al who reported that drinking among peers was associated with higher odds

of ever using alcohol.48 It was found in Mexico also by Jinez et al that peer pressure is a

risk factor for drug and alcohol use among youngsters. 46 A Thai study added that besides

peer pressure, the desire to participate in social life led to trying alcohol. 49

There was time when every house in certain d istricts of Arunachal Pradesh fermented rice

to brew Poka. This was before IMFL was introduced into the state in the 1990s. Still

now many continue to locally produce this beverage. It is easily available and served

frequently at home. And this was the reason why 75.5 percent of the respondents of

Arunachal reported Poka as the first drink tried. Deswal et al has reported the use of local
11
alcoholic beverage to be 53.3 percent in Arunachal Pradesh. In Kerala, 57 percent of

the students reported that the first type of drink tried was beer. This might be because of

the perception that beer is safer than the other variety of alcoholic beverages. It might also

be because beer comes in bottles from where it can be easily consumed.

From the discussions done above it may be assumed that the usual place of drinking

might be the home among the respondents of Arunachal Pradesh. And this is true because

it was reported by 44.9 percent of participants that they usually consume alcohol at home.

Any public place was the usual place of drinking in Kerala (41.9 percent), followed by

friends home (36.3 percent). Since drinking in home is not possible, the youngsters tend

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

beach or park.

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

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

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

(26.9 percent). Wine was reported by 13.1 percent respondents. It might be noted that

beer was popular in both the states. The study done by Khosla et al too indicated that
42
47.3 percent preferred beer. This finding might be because of the belief that beer is

safe, also because it is sold at cheaper rates and because of the bottling. Beer in India is

sold in a sealed bottle. It can be directly consumed from the bottle. There is no need to

have another bottle and glass to carry and mix water, as is the case with IMFLs. Also,

beer is sold chilled. India being a hot country, a chilled drink is always welcome.

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

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

33.5 percent said they get it free at home. In Kerala, 36.1 percent said they manage

money from their pocket money, 18.9 percent said they borrowed from friends, 16.4

percent said they pool money among friends. In both the states majority used pocket

money to buy alcohol. Availability of pocket money has been indicated in other states too

as a reason to using abusive substances. Khosla et al did a study among college students

in Punjab and found that those with access to pocket mo ney were four times more likely

to use alcohol when compared to their counterparts. 42 Mohan et al in Kerala also had

findings that relate substance use to pocket money. 42, 43 Access to pocket money was also

associated with problem drinking among the study population. (Table 3.14 and 3.15)

56
Another finding was the statistically significant association between alcohol use by

parents and alcohol use by the respondents. In both the states, if the parents consumed

alcohol, there was almost three times greater chance of alcohol use by the respondents.

Chaung et al from Taipei reported that parental drinking was influenced the drinking

among young adults.50 Latendresse et al too found that parental drinking was associated

adolescent alcohol use.51 Similar association was seen between alcohol use by siblings

and alcohol use by respondents. If siblings consumed alcohol there four times greater risk

of respondents using alcohol in Arunachal Pradesh, while in Kerala, if siblings consumed

alcohol there was nine times greater risk that the respondent used alcohol. This finding is

substantiated by the study done by Poelen et al which showed a strong association

between drinking by friends and siblings and drinking among adolescents and young

adults.52

Parenting plays an important part in monitoring the behavior of the adolescents. 51 The

finding of our study confirms that a discussion in the family about the harm of alcohol

does affect the alcohol use among respondents. In Kerala, a statistically significant

protective effect was found between parental advices and drinking among the students. A

discussion in the family was associated with lower number of respondents consuming

alcohol. In Arunachal Pradesh, it was found that if there was a discussion in the family

about the harm alcohol causes, more number of respondents consumed alcohol. This is

contrary to the popular belief that if there is proper education about the harmful

substances, the children avoided these substances. The explanation might be that the

young adults were already using alcohol and therefore there was a discussion that they

should stop consuming alcohol. However, this relation was not statistically significant. A

parents positive reinforcing role is very important in molding the childs behavior with

regard to harmful substances.53

57
Besides home, proper education about harm of alcohol could also be imparted at schools

and colleges. In both the states it was found that such a discussion was protective. If the

students were informed about the harm of alcohol, then fewer students consumed alcohol.

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

significant in Kerala.

4.2 Socio de mographic characteristics

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

Kerala majority resided at home (89.9 percent). There being only one college in the whole

of West Siang district, students from throughout the district come to this college. This has

led to students residing in hostels provided by the colle ge as well as the nearby locals. In

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

Moreover, the transport facility is very good. So even if the college is far away from the

home, students prefer to go to college from home. An analysis to find the relation

between residence and alcohol consumption is important because previous studies have

found that place of residence is related to use of alcohol. A study in Massachusetts, USA

done by Harford et al reported that those students staying in single gender dormitories

were more likely to indulge in drinking when compared to those living off campus with

parents.54 In our study too we find that the use of alcohol is more among hostel residing

students than those residing in their own homes.(Table 3.14) This finding is statistically

significant when we look into the combined population of Arunachal Pradesh and Kerala.

When we analyze them separately this relation is not statistically significant as 90 percent

of the students in Kerala were staying at home. (Table 3.3)

58
4.3 Strengths of the study

The study used a tool that was adapted from the World Health Organizations Global

School-based Health Survey (GSHS).33 The prevalence of problem drinking was assessed

by using the CAGE questionnaire which is an established standard. Some of the variables

on drinking pattern were adopted from the AUDIT questionnaire. The AUDIT

questionnaire too has been widely used and it has been recommended by Kokotailo et al

that this can be used among college students.35

A standard drinks table was distributed along with the questionnaire. (Annexure 2) This

table informed about what constitutes a standard drink. Use of this table decreased the

chance of inter-respondent difference in reporting the questions related to amount of

drinks.

To our knowledge no authentic studies have been undertaken till to date in finding the

prevalence and patterns of alcohol use among college students of Arunachal Pradesh.

Also, no attempt has been made to compare the alcohol related prevalence, patterns and

beliefs in between these two states.

A single investigator did the study in both the places, using the same standard too. So a

chance of investigator bias is very less.

4.4 Limitations of the study

In this survey, we were depending on the statement of subjects for their and their parents

drinking pattern. We have not used any objective criteria like blood biochemical

investigation to ascertain their drinking pattern. However use of standardized tools like

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

59
It was observed in the study that drinking is a socially accepted behavior in Arunachal

Pradesh whereas, it is not in Kerala. This could have differently affected the way

students in the states have responded to the questions. Being a self administered

questionnaire survey, there was no way to ascertain that the answers given by the

respondents were genuine.

4.5 Conclusion

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

Arunachal Pradesh the use of alcohol was mostly in the family setup, this highlights the

fact that consumption of alcohol is culturally accepted in Arunachal Pradesh.

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

Also, alcohol use by siblings was related to the use of alcohol by the respondents. The

relation between use of alcohol by siblings and use of alcohol by respondents was

stronger in Kerala than in Arunachal Pradesh. Peer pressure plays a n important role in

shaping the patterns related to alcohol use.

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

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

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

the respondents.

Overall place of initiation to alcohol was either home or a friends home. The students

usually prefer the home or a friends home for drinking. The place of proc urement of

alcoholic beverages was also either home or a friends home. For all these own home

was the first option for Arunachal Pradesh whereas friends home was for Kerala.

60
Large number of students managed money for alcohol from their pocket money. Also, the

amount of pocket money had an incremental relationship with alcohol use and problem

drinking and this relationship is even statistically significant in Kerala.

Family support is an important factor that moulds the way people perceive alcohol. It is

important to inform the younger generation about the ill effects of alcohol before its too

late. This information, if imparted through schools and colleges will also be very effective

in decreasing the harm of alcohol.

4.6 Recommendations and policy implications of the study

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

It is important to have culturally specific and contextualized interventions and health

education methods against alcoholism. Intervention in Arunachal Pradesh should address

the social drinking pattern, home brewing of alcoholic beverages and the tender age of

initiation at first drink. In Kerala it should focus on preventing youngsters from catching

the habit of alcohol use, proper guidance by parents and emphasis on reducing parental

and sibling alcohol use.

Proper health education system should be developed not only for the younger generation,

but also for the adults and parents. Parents should maintain strong positive influence on

alcohol and other addictive substance use. The schools and colleges should give emphasis

on students who are staying away from home.

Student should be given proper guidance on money management skills. Such skills should

be given especially to those youngsters who are staying away from family.

A policy is needed which might look into altering the packaging of beer bottles. It should

be emphasized that alcohol is not safe in any form, including beer.

61
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66
ANNEXURE 1

PREVALENCE AND PATTERNS OF ALCOHOL USE AMONG COLLEGE STUDENTS:


COMPARING SCENARIO IN ARUNACHAL PRADESH AND KERALA.

QUESTIONNAIRE

Form number:

Date of data collection:

2009

Sl no. Question Response Code


General information
1. State 1. Arunachal Pradesh gi01
2. Kerala

2. College gi02

3. Year of study 1. 1st year gi03


2. 2nd year
3. 3rd year
4. Age (in completed years) gi04

5. Sex 1. Male gi05


2. Female

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

7. Average monthly family income gi07


(in Rupees) Rs__________________

8. How much pocket money do you 1. Less than 500 gi08


get per month? (in Rupees) 2. 501-1000
3. 1001-1500
4. 1501-2000
5. 2001-2500
6. More than 2500

67
9. Present residence 1. Home gi09
2. Hostel
3. Rented house
4. Relative's place
5. Others(please specify)_____________

10. Type of family 1. Nuclear gi10


2. Extended
3. Joint

Prevalence and pattern

11. Have you ever taken alcohol? 1. Yes pp01


(if NO, then please go to question 2. No
no. 26)

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

13. Where were you when you had 1. At home pp03


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

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

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

68
16. Who all were there when you first Family members pp06
tried alcohol? Friends
Strangers
Nobody

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

18. Where do you usually drink At home pp08


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

19. What do you usually drink? Beer Toddy pp09


Wine Arrack
Whisky Poka
Rum Nyongin
Brandy Raksi
Vodka Some other type (please
Gin specify)
____________

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

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

69
22. During the past 30 days, how many 1. Never pp12
times did you drink so much 2. 1 or 2 times
alcohol that you got really drunk? 3. 3 to 9 times
4. 10 or more times

23. During the past 30 days, how many 1. Never pp13


times did you have a hangover, feel 2. 1 or 2 times
sick, get into trouble with your 3. 3 to 9 times
family or friends, miss school, or 4. 10 or more times
get into fights as a result of
drinking alcohol?

24. What is your monthly expenditure 1. Less than 500 pp14


on alcoholic drinks? (in Rupees) 2. 501-1000
3. 1001-1500
4. 1501-2000
5. 2001-2500
6. More than 2500

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

Factors related to friends

26. How many of your friends consume 1. None ffr01


alcohol? 2. A few (2 out of 5)
3. Some (3 out of 5)
4. Most (4 out of 5)
5. All (5 out of 5)

27. How frequently do your friends get 1. Never ffr02


drunk? 2. Rarely (once in a month)
3. Sometimes (once in a week)
4. Most of the time (almost daily)
5. Always

28. If one of your best friends offered 1. Definitely not ffr03


you a drink of alcohol, would you 2. Probably not
drink it? 3. Probably yes
4. Definitely yes

70
29. With whom do you usually drink 1. With my friends ffr04
alcohol? 2. With my family
3. With anyone who is ready to give me
company
4. I usually drink alone
5. Not applicable

30. How frequently do you consume 1. Never ffr05


alcohol with your friends? 2. Sometimes
3. Most of the time
4. Always

Factors related to family

31. Which of your parents or guardians 1. Neither ffm01


drink alcohol? 2. My father or male guardian
3. My mother or female guardian
4. Both
5. I do not know

32. Do any of your siblings (brothers or 1. Yes ffm02


sisters) drink alcohol? 2. No
3. I do not know

33. Has anyone in your family 1. Yes ffm03


discussed with you about the 2. No
harmful effect of drinking alcohol?

34. Were you ever taught in your 1. Yes ffm04


school/ college about the harmful 2. No
effects of using alcohol? 3. I do not know

35. Do any of your parents/guardians 1. Yes ffm05


know that you drink alcohol? 2. No
3. I dont know
4. Not applicable

36. How often do you drink alcohol at 1. Never ffm06


home? 2. Sometimes
3. Most of the time
4. Always
5. Not applicable

71
Beliefs and perceptions

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

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

39. How much do you think people 1. No risk bp03


harm themselves if they drink 2. Slight risk
alcohol once or twice a year? 3. Moderate risk
4. Great risk
5. I dont know

40. How much do you think people 1. No risk bp04


harm themselves if they drink 2. Slight risk
alcohol several times a week? 3. Moderate risk
4. Great risk
5. I dont know

41. What kind of drink do you think is 1. Beer 8. Toddy bp05


safest? 2. Wine 9. Arrack
3. Whisky 10. Poka
4. Rum 11. Nyongin
5. Brandy 12. Raksi
6. Vodka 13. Some other type
7. Gin (please specify)
______________

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

72
The CAGE Questionnaire for alcohol

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

44. Have people annoyed you by 1. Yes cq02


criticizing your drinking? 2. No

45. Have you felt bad or guilty about 1. Yes cq03


your drinking? 2. No

46. Have you ever had a drink first 1. Yes cq04


thing in the morning to steady your 2. No
nerves or get rid of a hangover
(eye-opener)?

Tobacco use practices while drinking.

47. Do you smoke any tobacco 1. Yes tp01


products? (such as beedi, cigarettes, 2. No
cigars or pipes etc)

48. Do you smoke or smoke more than 1. Yes tp02


usual while drinking? 2. No

49. Do you use any smokeless tobacco? 1. Yes tp03


(such as snuff, chewing tobacco, 2. No
betel with tobacco etc)

50. Do you use, or use more than usual 1. Yes tp04


smokeless tobacco when you drink? 2. No

73
ANNEXURE 2

Standard drinks table (approximates)

Name of beverage One Standard Alcohol content Packing


Drink (%)
Beer 285 ml 4-8 650 ml

Wine 120 ml 10-22 750 ml

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

Toddy 5-10 Bottles, jugs, mugs,


Poka 200 ml bamboo containers
Nyongin

Arrack 25 ml 50-60 Packets and bottles

One standard drink contains approximately 10 grams of absolute alcohol.

74
ANNEXURE 3

Informed consent

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

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

Consent statement

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

Signature of the participant Date:

Name: Place:

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

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


email loyi@sctimst.ac.in.

2. Dr. Anoop Kumar Thekkuveettil (I.E.C member secretary SCTIMST): Phone number
0471-2520256/7 or email anoop@sctimst.ac.in.

75