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Measuring and preventing alcohol use and related harm among young people in Asian countries: a thematic review
© The Author(s) 2018
Received: 29 October 2017
Accepted: 28 March 2018
Published: 9 May 2018
The paper reviews alcohol consumption patterns and alcohol-related social and health issues among 15–29-year old young people in Asian countries, and discusses strategies for preventing and controlling alcohol use and related harms.
We searched Google Scholar, PubMed, and Web of Science for reports, reviews and journal articles published in English between 1st Jan 1990 and 31st August 2016.
Forty-one reports, reviews and journal papers were identified and included in the final review. The current drinking levels and prevalence among young people are markedly different between eight included Asian countries, ranging from 4.2% in Malaysia to 49.3% in China. In a majority of the selected Asian countries, over 15% of total deaths among young men and 6% among young women aged 15–29 years are attributable to alcohol use. Alcohol use among young people is associated with a number of harms, including stress, family violence, injuries, suicide, and sexual and other risky behaviours. Alcohol policies, such as controlling sales, social supply and marketing, setting up/raising a legal drinking age, adding health warning labels on alcohol containers, and developing a surveillance system to monitor drinking pattern and risky drinking behaviour, could be potential means to reduce harmful use of alcohol and related harm among young people in Asia.
The review reveals that drinking patterns and behaviours vary across eight selected Asian countries due to culture, policies and regional variations. The research evidence holds substantial policy implications for harm reduction on alcohol drinking among young people in Asian countries -- especially for China, which has almost no alcohol control policies at present.
Alcohol is a psychoactive substance with dependence-producing properties. Alcohol use is one of the leading risk factors for disease, disability and death among young and middle-aged men and women in many countries, associated with more than 200 diseases and injury conditions and with 2.3 million deaths attributed to it globally in 2015 [1, 2].
Asia is the fastest growing alcohol market, accounting for over 30% of global alcohol sales in 2014, with an estimated overall 176% growth from 2000 to 2019; China and India are leading the growth with rates of 382% and 1245% respectively . Alcohol companies focus on youth drinking because they want to establish drinking habits that will be carried on and even expanded in middle age. Furthermore, binge drinking is more common among young people compared with older age groups [4, 5], and young persons are being targeted by alcohol marketers through the development of new products and sophisticated marketing techniques . Motivations to drink in young people, which have been extensively studied [7, 8], commonly include to obtain social rewards such as camaraderie and approval, to enhance positive mood or wellbeing, to cope with negative emotions, and to avoid social rejection . Nowadays, the internet and other social media have substantially extended the range of peer engagement, and gaining greater respect from peers is a major reason why youth is a risk period for alcohol use and abuse .
Although harmful use of alcohol among young people has been widely discussed in western countries , little attention has been paid in Asian countries. A recent World Health Organization (WHO) report highlighted the increasing adverse effects of alcohol use particularly on young people compared to older adults in still-developing Asian countries , pointing out that alcohol use among this group deserves special attention due to their biological and psychological vulnerability . The present study reviews alcohol consumption patterns and related health and social issues among young people in Asian countries, defining young people as those aged 15–29. Strategies for prevention and control of alcohol-related harms are discussed and assessed in terms of their potential contribution to future policies to reduce harmful use of alcohol among young people in Asia.
We conducted a comprehensive thematic review of PubMed, Web of Science and Google Scholar for reports, reviews and journal articles published in English between 1st Jan 1990 and 31st August 2016, with search terms pertaining to “alcohol use or alcohol consumption or drinking”, “current drinking or risky drinking or risk alcohol use or risky alcohol consumption” “young people or youth or adolescent or adolescence” “health outcome or social outcome or harm” and “Asia or Asian countries”. The full search method of the review is elaborated in the Appendix.
The 2014/15 Survey of Drug Use among Students in Hong Kong and National Family Health Survey 2005–06 (NFHS-3) in India were used in this review as sources of the prevalence of current drinking among young people in Hong Kong and India. The GSHS is a longitudinal survey conducted in many countries, and the results from the latest survey in selected Asian countries were abstracted. We also reported some results from the 2015 Global Burden of Disease Study’s modelled estimates of number of deaths and percentage of total death attributable to alcohol use among young men and women aged 15–29 years in the eight Asian countries .
The measures -- of current drinking (in the past 30 days) or risky or heavy episodic drinking (60 g or more of alcohol consumed in a single drinking occasion in the last 12 months) or alcohol’s health or social harms among young people aged 15–29 years -- were abstracted from the reviewed studies. The Oxford 2011 Levels of evidence developed by the Oxford Centre for Evidence-Based Medicine  was used to assess the quality of studies in the thematic review.
Prevalence and patterns of drinking among young people in Asian countries
Prevalence of drinking and per capita alcohol consumption
Heavy and risky drinking was common among young people, and those under age 35 had the highest levels of risky drinking practices in a study in Mongolia . Among school students aged 12–17 in China, 11.4% of males and 5.1% of females had binge drinking at least once a month . In South Korea, 7.9% of young males and 7.3% of young females had drunk heavily on 1–2 days in the past 30 days, while 1.6% of males and 0.9% of females had drunk heavily on more than 5 days in the past 30 days . About 27% of teenagers aged 13–17 years and 26% of young adults aged 18–29 years had engaged in risky drinking in Malaysia . In high schools in Japan, 3.0% of students were frequent drinkers (drank alcohol 10 days or more in the past month) . In Thailand, very high-risk drinking (drinking more than 100 g for males and 60 g for females per day) was reported by 8.1% of boys and 1.8% of girls aged 12–19 years, and 16.6% of males and 4.6% of females aged 20–24 years. In a rural district in northern Vietnam, 35% of young people (18–24 years) were excessive drinkers, with 1.9% binge drinkers and 11.8% problem drinkers as measured by their AUDIT score . In India, 59% and 21% of males and females aged 18–34 years drank heavily (over 60 g alcohol) in a single drinking occasion in the last 12 months, while the heavy episodic drinking rate was still higher in Japan -- 76% among young males and 45% among young females .
Alcohol-related harm among young people in Asia
Adolescents and young people are typically more vulnerable to alcohol-related harm from a given volume of alcohol than other age groups [23–25]. Drinking and heavy drinking are also associated with a variety of social and health harms among young people in Asia, and may be instrumental in the occurrence of the harm. A summary of detailed studies of the relation of drinking to health and social harms among young people from survey studies in eight Asian countries is presented in Tables 4 and 5 in the Appendix. Heavy drinking was found to be significantly associated with suicidal ideation, suicidal attempts and, self-distress in many Asian countries . HIV risk behaviours have been found to be strongly linked with binge drinking and its frequency among rural adolescents in Vietnam . Effective measures to prevent binge drinking are thus essential to HIV prevention, especially among youth aged 18–20 years [26, 27]. Students who started drinking at age 12 or younger, and at 13 or 14 years, were significantly more likely to be currently smoking, currently drinking, engaging in heavy smoking and heavy drinking than students who began drinking at age 15 or older. Studies from Western countries suggest that before 14 years of age, early onset of alcohol use was a predictor of impaired health status because it was associated with increased risk for alcohol dependence and abuse at later ages, alcohol-related motor vehicle crashes, and other unintentional injuries [27–35]. Adolescents who have used alcohol were more likely to have used other substances, and to have engaged in sexual behaviours and fights , while young people with current alcohol consumption were more likely to have poor academic performance, family conflict or social problems .
Number and percentage of deaths attributable to alcohol use among males and females aged 15–29 years in selected Asian countries in 2015 (data from the Global Burden of Disease Study 2015 )
Strategies for prevention and control
Comparison of “WHO’s five best buys” alcohol policy interventions among eight Asia countries in 2014 
Policies and interventions
Restrict access to retailed alcohol
Minimum drinking age
21 or higher in most states
Restrictions for on−/off-premise sales
✘ / ✘
✘ / ✘
✘ / ✘
✔ / ✘
✔ / ✔
✔ / ✔
✘ / ✘
✔ / ✔
✘ / ✘
✘ / ✘
✔ / ✔
✔ / ✔
✘ / ✘
Raise taxes/prices on alcohol
Alcohol excise or tax
Legally binding alcohol sales promotion / sponsorship
✔ / ✔
✘ / ✘
✘ / ✘
✘ / ✘
✔ / ✘
✔ / ✔
✘ / ✘
Enforce bans on alcohol advertising
Advertising / product placement
✘ / ✘
✔ / ✔
✔ / ✔
✔ / ✘
✔ / ✔
✔ / ✘
✔ / ✔
✔ / ✔
Enforce drink driving laws
RBT / BAC level
✔ / 0.02
✔ / 0.03
✘ / 0.03
✘ / 0.05
✔ / 0.08
✔ / 0.05
✘ / 0.05
✘ / 0.00
Offer brief advice for hazardous drinking
Number of standard drinks
Alcohol content displayed on containers
Health warning labels on advertisements / container
✘ / ✘
✔ / ✔
✘ / ✘
✘ / ✔
✘ / ✘
✘ / ✘
✔ / ✔
✘ / ✘
The majority of Indian states have set their minimum ages at 21 years or higher , resulting in relatively low prevalence of alcohol drinking among young people . In contrast, there is a substantially higher prevalence of alcohol consumption among young people aged 16–29 years in China (see Table 3), which is the only country among the eight Asian countries in Table 1 without a law for a minimum legal drinking age. Compared with six other Asian countries, Mongolia is the only country which has a national alcohol monopoly and there are state level alcohol monopolies in some Indian states [40, 43]. Government monopolies for the sale of alcohol could reduce alcohol consumption and related harm among young people, and such a system allows for more limits on the number of liquor stores and the trading hours and days than the private sale system [44, 45]. Nevertheless, restricting availability may have much less effect in countries where one third of the alcohol drunk is informally produced and sold outside any government control or regulation. For example, unrecorded alcohol consumption per capita in India was estimated at 2.2 l in 2010, while recorded alcohol consumption was 4.3 l .
Increasing alcohol prices delays the start of drinking, slows young people’s progression towards drinking large amounts, and reduces young people’s heavy and risky drinking behaviour [46, 47]. Table 2 shows that alcohol tax policies exist in all selected Asian countries. A study in Vietnam found increasing the price and reducing the availability of alcohol are potential means to reduce alcohol use among young people . The taxation system in Thailand, ‘Two-Chosen-One’ (2C1), combines specific taxation (as a function of the alcohol content) and ad valorem taxation (as a function of the price); the higher one will be chosen when taxes are calculated according to the two alternatives, which it is argued results in a great potential to reduce simultaneously alcohol consumption and prevent drinking initiation among young people .
Alcohol is often supplied to adolescents and young adults by their parents, care-givers and peer friends. In China and South Korea, adolescents were often introduced to alcohol at home or friend’s home via a taste from their parents’ liquors during family gatherings or special celebration events [8, 50]. Protective parenting practices and disapproving caregiver’s attitudes towards youthful alcohol use can deter alcohol use among young people . Social supply of alcohol to adolescents should be regulated via legislation, as early drinking leads to higher alcohol dependence in later life. Asian countries can learn from the social supply laws in Australia, which provide that supplying alcohol to a minor is illegal .
Evidence from longitudinal studies suggests that initiation of youth drinking and of riskier patterns of youth drinking are affected by exposure to alcohol advertising in social media, or in the form of movie content or of alcohol-branded merchandise , and similar associations were found in Taiwan, China . The effects of exposure to alcohol advertising seem to be cumulative; young people are likely to continue increasing their consumption as they move into their mid-20s in markets with a greater amount of alcohol advertising . Some Asian countries (such as China, Thailand and Vietnam) have implemented a partial ban of alcohol advertising in some media. Others have not had any alcohol advertising regulations (e.g. Japan and Laos). Alcohol companies are sponsors of major music and sports events where youth are heavily involved, sponsoring the International Music Summit in China, the Japanese team in the Olympics, Thai football teams and World Cup soccer . In contrast, direct alcohol advertising is not permitted in the broadcast media or on billboards in Malaysia, except in the state of Sabah; this reduces exposure to alcohol advertisements and may prevent alcohol-related harms among young people . Bans or restrictions on alcohol advertising and sponsorship have been called for by public health researchers and bodies, because in some Asian countries (e.g., China and Japan), alcohol brands promote their products using sport and movie stars or successful business men, which shapes young people’s drinking attitude and behaviour.
School-, family- and community-based interventions have been found effective in reducing harmful use of alcohol among young people [58–60]. However, most of these interventions have been carried out in western developed countries. High quality interventions that target on youth drinking and other risky behaviours are recommended to be applied and evaluated in low- and middle-income countries, particularly in Asia.
It is worth noting that a number of Asian studies on youth drinking, harms and alcohol policies were published in local (non-English) languages and were unable to be captured in this study. Another limit is that some of the findings used in the discussions of strategies for prevention come from non-Asian countries.
Harmful use of alcohol has been one of the global public health challenges among young people in the last decade, particularly in Asian countries. Over 70% of the total population of the earth lives in Asia, and Asian developing countries such as India, China, Thailand and Vietnam have been targeted by global alcohol corporations as emerging alcohol markets in recent decades. Alcohol imports in the developing Asian countries, such as Thailand and China, have been increasing significantly, facilitated by free trade agreements coming into effect in recent years [61, 62]. The potential adverse public health effects from alcohol, tobacco and other drugs need to be taken into account in negotiating new international trading agreements involving Asian countries. More attention should be paid to the potential adverse effects of limiting governments’ ability to control the alcohol market in increasing rates of alcohol problems, particularly among youth and young adults. To the best of our knowledge, there are as yet no formal studies of the social and economic costs of harmful use of alcohol among young people in Asian countries.
This review suggest that more coherent and focused research efforts are urgently needed on youth drinking and its problems in Asia, where drinking is rising so rapidly. Public health research and policymaking needs to catch up with the alcohol industry’s realisation that what happens in a youth cohort strongly affects their market for the next half-century. Studies on social and economic harm and cost of drinking among young people in Asia could be a good step forward, incorporating both population surveys and health, police and welfare register data. A recent collaborative project  (Alcohol’s Harm to Other in five Asian countries) funded by the WHO and Thai Health Promotion Foundation may help to fill this research gap.
Prevention of the health and social issues related to youth drinking will be a major goal for public health in Asian countries that follow WHO strategies to prevent non-communicable diseases and road-traffic injuries by reducing harmful alcohol use within the national context [64, 65]. Establishing or improving national monitoring and surveillance systems to inform alcohol policy in Asian countries could be the first step. But what is needed beyond this is a multi-level approach that integrates policy actions (e.g., sales, social supply and marketing), regulations (e.g., drinking age laws), health education (e.g., media campaigns and health warning labels), and effective health system responses (brief intervention, and alcohol abuse and dependence treatment). This is an urgent mission for public health action in all Asian nations. The review has particular policy implications for the Chinese government and health authorities in tackling the toll of death and disease among young people, given that China at present has almost no alcohol control policies.
This study was funded by the China Medical Board to Xiaojun Xiang (Global Health Project 13–132) and by the National Nature Science Foundation of China to Xiaojun Xiang (81571306). H.J’s work was partially funded by the China Studies Research Centre and La Trobe Asia, La Trobe University.
Availability of data and materials
All data generated or analysed during this study are included in this published article (and its supplementary information files).
All authors contributed equally in this paper. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
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