Prevalence in population-based studies

Nationally representative and well-designed multi-center population surveys are lacking in India. Several researchers have examined the prevalence of alcohol use in different parts of the country over time. Caution has to be exercised in interpreting findings and extrapolations from these individual studies as findings are likely to be influenced by sample size, techniques of sampling, survey areas (urban / rural) screening instruments, definition of alcohol use, case ascertainment and statistical analysis. While well- designed studies are few, small sample studies have limitations, as local consumption patterns cannot be generalized to the larger national level. Reporting fallacies of survey respondents and methodological issues among individual studies also limit their usefullness. These factors need to be considered in estimating per capita consumption levels.

Different studies have used different terminologies to classify alcohol users. Examples include:

 never users,

 recovered users,

 current users and dependent users,

 hazardous and harmful users,

 past and current drinkers,

 users and nonusers

The prevalence has varied in different parts of the country and is influenced by macro and micro level factors. At the macro level, the influencing factors include a) availability factors like production and affordability influenced by taxation policies of local state governments; b) promotion and advertising by the media; c) the extent of local brewing practices, distribution and availability of alcohol; d) the density and timing of outlets; e) enforcement by local excise and police, and several others. At the micro level, influencing factors include a) population characteristics; b) availability of alcohol; c) urban rural characteristics; d) socio- economic status; e) local values and cultures; and f) the extent of restraint imposed by the society on permissible levels of drinking. Many studies have been undertaken in India (Table 4a - 4d), few of which are highlighted below.

 Examining alcohol use in a rural community in Vellore, John et al observed that 35% reported alcohol use in the past year with 14% drinking regularly (John et al, 2009).

 Reporting from urban slums of Sambalpur,

Orissa, Sarang et al (2008) observed that 15% of survey respondents (n =502 adolescents) consumed alcohol, and was commonly influenced by family status and peer pressure.

 Anand et al (2007), in a survey of 2564 persons from urban slums of Faridabad district, observed that 26% of men consumed alcohol in the past year and the number of cases increased with age.

 The overall prevalence in Arunachal Pradesh was 30% as reported by Chaturvedi et al (2003). Studies from the northern part of India during a one-year period have revealed the prevalence

of alcohol use to be between 25 and 40%.

 Gupta et al (2003) from Mumbai noticed that the current alcohol use was 19% and history of past use was reported by 5% of respondents,

while 76% of the individuals had never used alcohol.

 In Goa, based on AUDIT Scores, nearly 60% were users of alcohol, broadly influenced by the local Table 4a: Studies of Alcohol use in India (nationally representative)

Author Year of Place Urban/Rural Sample Screening Crude Rate Remarks survey Size instrument (%)

NFHS 3 2005-06 All India 1,98,754 Household survey M: 32.0; F: 2.2 Alcohol use as part of questionnaire morbidity and health NHSDA 2000-01 All India 40,697 Household survey 21.4 Substance use including (Ray 2004a) questionnaire alcohol in males NFHS 2 1998-99 All India 4,86,011 Household survey M: 17 F: 2 Alcohol as life style

questionnaire indicator IIPS and 2003 In Assam, Karnataka, 9,994 Study specific Total 9.1M: Multi stage stratified WHO, 2006 Maharashtra, Rajasthan, Questionnaire 16.6; F:1.2 random sample to

Uttar Pradesh and assess health systems

West Bengal performace

Table 4b: Studies of Alcohol use in India - States / Region representative

Author Year Place Urban/ Sample Screening Crude Rate Remarks Rural Size instrument (%)

Benegal et al 2008 Andaman Island 18,018 AUDIT M: 34.7; F: 6.3 Substance use and population

Nicobar

Chavan et al, 2007 Chandigarh Union 2,992 ICD 10 criteria 6.7 Alcohol dependence Territory

Bengal et al 2005 Karnataka 5 districts 2,979 Study specific M: 33.2; F: 5.8 Alcohol and gender questionnaire + specific issues

AUDIT

Chaturvedi et al 2003 North east 3 States 1,831 NK 12.5 Pilot study in

India NE regions

Benegal et al 2003 Karnataka 3 districts 21,276 Study specific 15.3 Unrecorded alcohol questionnaire consumption

Table 4c: Studies of Alcohol use in India - Combined populations (urban, rural, etc.,)

Author Year Place Urban/ Sample Screening Crude Rate Remarks Rural Size instrument (%)

Gururaj et al 2006a Bangalore Combined 28507 Study specific 13 Alcohol users in population questionnaire Urban, Rural, Town

and Slum population Gururaj, et al 2004a Bangalore Combined 10168 Structured 9 Alcohol users in

population questionnaire Urban, Rural, Town and Slum population Varma et al 1980 Punjab Combined 1,031 Structured 23.7 Urban and rural

population questionnaire

Dube and 1971 Uttar Rural 16,275 2 Stage 2.3 Alcohol and

Handa Pradesh interview drug abuse

Thacore et al 1975 Lucknow Combined 2,696 prepared schedule 19 Urban and rural population habitual excessive

Table 4d: Studies of Alcohol use in India-(geographically defined populations)

Author Year Place Urban/ Sample Screening Crude Rate Remarks Rural Size instrument (%)

Anand et al 2008 Haryana Urban 2,589 WHO steps M: 28.9 Alcohol and approach tobacco users Chaturvedi and 2004 Arunachal Urban 5,135 Pretested 30.0 Substance abuse Mahantha Pradesh questionnaire

Gupta et al 2003 Mumbai Urban 50,220 Structured 18.8 Alcohol users questionnaire

Meena et.al 2002 Rohtak Urban 1,42,000 WHO 19.8 Alcohol users questionnaire

Mohan et al 2002b Delhi Urban 10,312 Structured 5.9 Alcohol users questionnaire

Sharma and

Singh 2001 Goa Urban 4,022 RPES 1.0 Alcohol dependence Mohan et al 2001a Delhi Urban 6,004 DSM III R 12.6 Dependent drug users Hazarika et al 2000 Bandardewa, Urban 312 NA 36.5 Alcohol Users

Assam

Murthy et al 1998 Bangalore Urban 5,633 – – Alcohol use in slum Ghulam et al 1996 Madhya Urban – – 37.0 Alcohol users

Pradesh

Zulfikarali 1994 – Urban 254 SAQA 16.7 Alcohol users and Vankar

Premarajan 1993 Pondicherry Urban 1,115 IPSS 34.5 Alcohol dependence et al

Ponnudrai et al 1991 Madras Urban 2,334 MAST 16.7 Suffering from alcoholism Singh et al 1988a Uttar Urban 1,806 Structured 10.4 Alcohol users

Pradesh questionnaire

Lal and Singh 1978 Punjab Urban 6,699 QFI 29.3 Adult alcohol users Verghese et al 1973 Vellore Urban 2,904 Mental health 4.8 Chronic alcoholism

item sheet

John et al 2009 Vellore Rural 345 AUDIT 46.7 Hazardous alcohol drinkers Sethi and 1979 Lucknow Rural 2,415 Semi structured 21.4 Drug abusers

Trivedi interview

Nandi et al 1975 West Rural 1,060 3 schedules 0.94 Bengal

Elnagar et al 1971 West Rural 1,383 3 stage survey 13.0 Alcohol and drug

Bengal Addiction

Gopinath 1968 Bangalore Rural 423 Survey 2.36 Alcoholism questionnaire

culture and easy availability of alcohol. Only 31% were abstinent in the past year. The prevalence of hazardous drinking using a cut-off of 8 on the AUDIT in the total population was 20.1% and among users, which increased to 31% in individuals aged ≥15years (Silva et al, 2003).

 In Rohtak city, Meena et al (2002) observed the prevalence to be 20%.

 In southern India, the prevalence of current alcohol use has varied between 33 and 50% with a higher prevalence among those with lower levels of education and income levels (Chakravarthy, 1990).

 Hazarika et al (2000) from Bandardewa in

Assam observed the current prevalence of alcohol use to be 36.5%.

 Singh et al (1998a) from Moradabad city

reported prevalence of alcohol use to be 10% in a sample of 1806 respondents.

 Ghulam et al (1996) in Raipur, Madhya

Pradesh observed never users of alcohol to be 71% and current users to be 26.5%. The overall prevalence of alcohol use was 37% for current users and 39% for ever users, with 20% being dependent users.

A series of population-based studies undertaken by NIMHANS in recent years have documented the prevalence of alcohol in different settings.

 In the study of health behaviors among 10,168 individuals from four different strata of Bangalore City, it was observed that though the reported prevalence of alcohol use was 9% in the age group of 15–60 years, the focused group discussion at the community level revealed the problem to be 2–3 times higher (Gururaj et al, 2004a)

 In a recent survey of 28,507 individuals

regarding socio-economic impact of alcohol in 4 different populations (urban, slum, periurban (town) and rural areas), 32% of

males in 15–60 years were alcohol abusers, varying between 29% in rural areas and 39% in urban areas (Gururaj et al, 2006a).

 In the GENACIS study, covering a total of 2,981 respondents (1,517 males and 1,464 females) across 5 districts of Karnataka including eight urban and rural sampling areas, 5.9% of all female respondents (n=87) reported drinking alcohol at least once in the last 12 months compared to alcohol use in 32.7% of all male respondents (n=496) (Benegal et al, 2005)

 In a survey covering 5,200 families comprising 21,276 individuals (14,364 adults with 7,445 males and 6919females) from 5 districts of Karnataka, the prevalence of alcohol use in the past 12 months was 15.3% (28.4% in males and 1.2% in females). The overall prevalence varied between 20 and 30%, among men in ≥10 years in different centers (Benegal et al, 2003).

In summary, it can be concluded that nearly one third (30 - 35%) of adult males and 5% of adult females are regular users of alcohol.

5.7. Hospital-based studies

Alcohol consumption and use has been examined in hospital settings, both with reference to hospital emergencies and specific health problems (examined in greater detail under the section on health consequences and drinking of this report). The use of alcohol among hospitalized subjects has been examined in 3 ways: (i) among general hospital registrations, (ii) in emergency care settings and (iii) among those with specific health problems like cardiovascular diseases, road traffic injuries, suicides, cerebrovascular accidents and other conditions. In emergency care settings, alcohol involvement has been observed for acute health care problems, mainly for injuries, violence and stroke

apart from other conditions like psychiatric problems. Studies among hospitalized subjects have included a smaller sample but the involvement of alcohol has been examined in greater detail. Generally, hospital-based studies on consumption patterns are not true reflections; either of the use and abuse nor prevalence, as they only measure consequences of alcohol use. Viewed indirectly, the hospitalization rates among alcohol users reflect the seriousness of the problem in communities.

 Studies on road traffic injuries have estimated the involvement of alcohol to vary from 20–30% (Gururaj, 2004a), while studies on suicide indicate the involvement to be 30–40%; detailed psychological autopsy studies have supported the involvement of alcohol in 45% of cases in one of the studies (Gururaj and Isaac, 2001a and 2001b).

 Among a series of hospitalized subjects for injuries in a public health care setting, the association with alcohol was 16 % (Gururaj, 2004a and 2004b), further indicating the greater association with violence.

 Two of the recent studies on stroke at NIMHANS have revealed the association of alcohol to be 20–25% (Nagaraja et al, 2000 and Nagaraja et al, 2005).

 Narwane et al (1998) in Mumbai reported that 317 of the 327 men admitted for liver diseases admitted to regular alcohol intake and 239 men had evidence of liver disease.

 Among 127 cases of an autopsy study in Delhi, nearly 18% had evidence of alcohol in the viscera (Sahadev et al, 1994).

 Problem drinking among male inpatients has varied from 14–24% among Indian population. Sampath et al, from a study in a general hospital in Kolar, observed that 28% of hospital admissions had life-time use of alcohol and 26% were current alcohol users, with 18%

scoring >8 on AUDIT scores. A total of 37% fulfilled criteria for alcohol dependence as per DSM IV criteria (Sampath et al, 2007).

 Nearly 1 out of 3 patients above 25 years entering the emergency room has been due to acute or chronic effects of alcohol (Poulose and Srinivasan, 2009).

 The Emergency Management Research Institute (108 ambulance service), during August 1st 2007-July 31st 2008 in Gujarat and Andhra Pradesh recorded 40,541 behavioral emergencies of which alcohol intoxication (3%) was the third commonest emergency (Saddichha et al, 2009).