Familial alcohol supply, adolescent drinking and early alcohol onset in 45 low and middle income countries

Highlights

• There is large variation between LMICs in prevalence of familial alcohol supply.

• Prevalence of familial supply ranged from 0.1% in Tajikistan to 23.8% in St Lucia.

• There is also large variation in prevalence of adolescent alcohol use.

• Prevalence of familial alcohol supply is associated with adolescent alcohol use.

Abstract

Aims

This study estimated the extent of familial alcohol supply in 45 low and middle income countries (LMIC), and examined the country-level effects of familial alcohol supply on adolescents’ alcohol use.

Method

We used data from 45 LMICs that participated in the Global School-Based Student Health Survey (GSHS) between 2003 and 2013 (n = 139,840). The weighted prevalence of familial alcohol supply in each country was estimated. Multilevel binary and ordinal logistic regression analyses were used to examine the country-level effect of familial alcohol supply on early onset of alcohol use (first alcohol before 12), past 30-day alcohol use, lifetime drunkenness and alcohol-related social problems.

Results

There were large variations between LMICs in the prevalence of familial alcohol supply and pattern of adolescent alcohol use. The prevalence of familial supply ranged from 0.1% in Tajikistan to 23.8% in St Lucia. It was estimated that a one percentage change in prevalence of familial alcohol supply was associated with 10%, 12% and 12% change in the odds of lifetime drunkenness (OR = 1.10, 95% CI = [1.04, 1.16]), early onset of alcohol use (OR = 1.12, 95% CI = [1.07, 1.08]) and more frequent drinking in the past month (OR = 1.12, 95% CI = [1.04, 1.20]).

Conclusion

There were large variations in the prevalence of familial alcohol supply and adolescent alcohol use among LMICs. Adolescents in countries with higher prevalence of familial alcohol supply were more likely to start using alcohol at an earlier age, to have used alcohol in the past 30 days and experience intoxication.

Introduction

Alcohol use is one of the major preventable contributors to global burden of disease (Rehm et al., 2009; Rehm et al., 2010; World Health Organization, 2014). It was identified as one of the most prominent risk factors for non-communicable diseases in the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases (UN General Assembly, 2012). The 66th World Health Assembly set a target of reducing alcohol-related burden of disease by 10% by 2025 (UN General Assembly, 2012).

Traditionally, consumption in high income countries (HICs) has been higher than in low and middle income countries (LMICs). However, this consumption gap is likely to narrow with the increasing globalization of alcohol production and sophisticated marketing campaigns by the alcohol industry in LMIC (Alcohol and Public Policy Group, 2010). Consumption in many HICs, such as the United States, Canada and Australia, has stabilized or declined while consumption in LMICs such as China and India has been increasing (World Health Organization, 2014).

Our understanding of alcohol use is largely based on research in HICs. This body of research has shown that alcohol use is commonly initiated during adolescence (Johnston, O'Malley, Bachman, & Schulenberg, 2013) and that early onset of alcohol use is strongly associated with future alcohol misuse (Hingson, Heeren, & Winter, 2006), making adolescence an important window for prevention and intervention in HICs.

Many countries have a minimum legal purchasing age (MLPA) for alcohol. Adolescents below the MLPA in these countries are not able to legally purchase alcohol themselves but often obtain alcohol from peers or family members (White & Bariola, 2012). In some HICs, many parents see alcohol use as a rite of passage in adolescence and use harm minimization as the rationale for supplying their children with alcohol. For example, a study on Australian parents who gave their children alcohol found that many of these parents believed that they could teach their children to drink responsibly and provide a safe place to drink by giving their children alcohol (Allan, Clifford, Ball, Alston, & Meister, 2012). Current evidence suggests otherwise. Studies show that parental supply of alcohol is associated with higher risks of adolescent alcohol use (Mattick et al., 2017), heavy episodic drinking and alcohol-related problems (Kaynak, Winters, Cacciola, Kirby, & Arria, 2014; Mattick et al., 2018). This emerging body of research on familial alcohol supply and adolescent alcohol use is based upon studies done in HICs, and it is unclear if similar results would be found among young people in LMICs. This is an important limitation because adolescent drinking in LMICs is a global public health priority since LMICs comprise 87% of the world’s adolescent population (United Nations Population Division, 2015).

Most research on parental and/or familial alcohol supply focuses on the individual level effect of supply. This body of research has primarily examined the effect of the supply of alcohol by parents to their own children on their children’s alcohol use and alcohol-related harm. However, parental supply of alcohol may also have an impact on the broader community in addition to the influence each parent may exercise on their own children’s alcohol consumption (Chan, Leung, Connor, Hall, & Kelly, 2017). For example, parents who supply alcohol to their children can influence the alcohol-related attitudes and behaviors of other parents (Gilligan, Thompson, Bourke, Kypri, & Stockwell, 2014). When parents see other parents as having favorable attitudes towards supplying alcohol to children, they may relax their own attitudes toward underage drinking and be more likely to supply alcohol to their own children (Gilligan et al., 2014). A high level of parental supply to underage drinkers also heightens the perception that underage drinking is socially condoned (Gilligan, Kypri, Johnson, Lynagh, & Love, 2012). In addition, supplying alcohol to youngsters, regardless whether it is given by parents to their own children, reduces barriers to alcohol access (Jones, Andrews, & Berry, 2016). Hence, communities with a high level of parental alcohol supply can perpetuate a social environment that encourages more parents to give alcohol to their own children, increasing the contextual risks of adolescent alcohol misuse.

The first aim of this study was to investigate country-level contextual effects of familial alcohol supply on adolescents' alcohol use by examining the effects of the overall prevalence of familial alcohol supply in each country on adolescent alcohol use.

The second aim was to estimate the extent of familial alcohol supply in LMICs. The majority of research on familial alcohol supply and adolescent alcohol use has been done in high income countries and research on the contextual effect of familial alcohol supply is even more limited within these countries. Given that familial alcohol supply is potentially a modifiable risk factor for future alcohol misuse, it is important to understand the prevalence of familial alcohol supply in LMICs, and its impact on adolescent drinking behaviors.