Prevalence and Patterns of Alcohol Usage Among College Students

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
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

Thiruvananthapuram
October 2009
4
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
5
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
6
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
7
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
9
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).
15
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:

Pradesh Yes 73 35.1
Missing* 144
Kerala No 112 78.9
Yes 30 21.1
Missing* 561
3.16 Monthly expenditure on alcohol:
Table 3.7 Monthly expenditure on alcohol:

Arunachal Pradesh <500 141 72.7
>500 53 27.3
Missing* 158
Kerala <500 94 84.7
>500 17 15.3
Missing* 592
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:

Arunachal Pradesh No 77 25.1
Yes 230 74.9
Missing* 45
Kerala No 394 64.6
Yes 216 35.4
Missing* 93
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:

Missing* 48
Kerala No 596 89.8
Yes 68 10.2
Missing* 39
42
3.20 Discussion in the family about harmful effect of alcohol:
Table 3.10 Discussion in the family about harmful effect of alcohol:

Missing* 1
Kerala No 219 31.6
Yes 473 68.4
Missing* 11
3.21 Discussion in the institute about harmful effect of alcohol:
Table 3.11Discussion in the institute about harmful effect of alcohol:

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:

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

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
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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http://www.indiana.edu/~engs/articles/gender90.htm (accessed 17th Oct 2009)
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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

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PREVALENCE AND PATTERNS OF ALCOHOL USE

AMONG COLLEGE STUDENTS: COMPARING

Dissertation submitted in partial fulfillment of the requirements

Achutha Menon Centre for Health Science Studies

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

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

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

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

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

Master of Public Health under my guidance and supervision.

Dr. Biju Soman MBBS, MD, MPH

Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology

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

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

Dr. Tumge Loyi

Achutha Menon Centre for Health Science Studies

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

liver to completely digest a standard alcoholic drink. 2

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

the ancient Vedas strictly prohibited its use.

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

intoxicating drinks under the Directive Principles. 4

1.3 Curre nt scenario

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

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

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

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

Over 4 million people are involved with the industry. 5

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

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

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

or two units operating illegally.6

life of about 24 hours.7, 8

especially the north-eastern region of the country.

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

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

remains high in India.5

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

harm in the population.4

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

percent and among women to be 33.6 percent. 9

be 45.2 percent and 0.7 percent among women.9

1.4.1 Drinking trend among youth

without the knowledge of parents and family. 4

1.4.2 Drinking trends among women

This can hardly be termed infrequent drinking.

1.5 Impact of alcohol on health

deaths and 1.3 percent DALYs).

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

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

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

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

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

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

Alcoholic psychoses, Alcoholic liver cirrhosis, Alcoholic polyneuropathy, Alcoholic

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

1.6 Positive effects of alcohol:

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

N= [(1.962 0.500.50)/ 0.062 ]*1.5

= [(1.962 0.300.70)/ 0.04]*1.5