Ascending Pattern of Alcohol Use and Underage Drinking in Asia: A Commentary on the Article by Assanangkornchai

Ascending Pattern of Alcohol Use and Underage Drinking in Asia: A Commentary on the Article by Assanangkornchai

and Vichitkunakorn (2020)

Kristiana Siste and Lee Thung Sen

A

CCORDING TO A 2018 World Health Organization (WHO) report, nearly half (43%) of the world’s popu- lation (15 years and older) had consumed alcohol within the last 12 months. The report, based on data until 2016, revealed that 26.5% of 15- to 19-year-olds and 40.7% of 20- to 24-year-olds had consumed alcohol. In Southeast Asia, 21.1 and 34.3% of 15- to 19- and 20- to 24-year-olds, respec- tively, had reduced their drinking habits. This was in sharp contrast to the global trend whereby there was a marked decline in individuals’ drinking habits within the same period in the American and European regions (World Health Orga- nization, 2018). Although the percentage of people consum- ing alcohol remains relatively the same, the volume of alcohol consumed per capita (APC) has increased by 34% in the Southeast Asian region during the same period, while the European region witnessed a decrease of 12% (Manthey et al., 2019). There is, however, substantial variability in the proportion of adolescent (13 to 17 years old) population consuming alcohol across geographical boundaries. Notably, 4.4% of adolescents in Indonesia consumed alcohol, while it was 23.0% in Thailand. Assanangkornchai and Vichitku- nakorn (2020) illustrate a temporal picture of Thai youths’

drinking behavior by analyzing 4 national cross-sectional surveys. Their results provide compelling evidence on the changing patterns of problematic alcohol consumption from 2007 to 2017. Unlike the regional trend, this study describes the increasing alcohol consumption in the past year prevalent among Thai youth (15- to 24-year-olds) from 2007 to 2014, especially among female youth. This necessitated identifying country-specific trends of alcohol consumption among the young population (Assanangkornchai and Vichitkunakorn, 2020).

Assanangkornchai and Vichitkunakorn attributed the trend of increased alcohol consumption among female Thais

to the marketing of appealing and flavorful products, such as alcopops, directed at young women (Sargent and Babor, 2020). A similar trend could be observed across the region, as evident in Vietnam. Concurrently, the decreasing stigmati- zation of women and their increasing independence are believed to contribute to the narrowing gap between men and women’s drinking habits (Manthey et al., 2019; World Health Organization, 2018). The pattern is particularly wor- risome, as vulnerability to alcohol consumption is still under- estimated in women (World Health Organization, 2018).

With the increased prevalence of suicidal intention/attempts among female compared to male students in Southeast Asia (Southeast Asia Regional Office and World Health Organi- zation [SEARO], 2017a), women could be subjected to alco- hol consumption-related harm. In addition, Thailand reported the third-highest APC in the region and the highest percentage (10.7%) of adolescents with problems arising due to alcohol consumption (SEARO, 2017a, 2017b). According to the International Classification of Diseases, Tenth Revi- sion (ICD-10), alcohol use is classified mainly within the paradigm of alcohol dependence syndrome and includes harmful alcohol use (hazardous use in ICD-11), intoxication, and withdrawal (Saunders et al., 2019). Although not cate- gorically a disease, harmful alcohol use is a mental disorder with detrimental consequences. It has a predominant causal linkage with over 40 diseases and injuries as outlined in the ICD-10 (Rehm et al., 2017) and more than 200 health condi- tions (World Health Organization, 2018). It is also responsi- ble for 5.3% of worldwide mortality, which is greater than the mortality associated with tuberculosis, HIV/AIDS, or diabetes (World Health Organization, 2018).

Critically, the authors illuminate the effect of changing times (subject’s year of birth and study era) on alcohol con- sumption. They noted an increasing tendency for early initia- tion (<20 years old) in a more recent national survey, with about 1-tenth of respondents admitting that they consumed alcohol before reaching the legal age (20 years old) as per Thai regulations. Their data provided initial evidence of increased underage drinking and potential association with the younger generation (Assanangkornchai and Vichitku- nakorn, 2020). A review evaluating the sensitive period of adolescent-onset drinking found no defined stage (early vs.

middle vs. late) was more subjected to risk. Instead, alcohol From the Department of Psychiatry, Faculty of Medicine, Universitas

Indonesia–Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.

Received for publication October 18, 2020; accepted January 17, 2021.

Correspondence: Kristiana Siste, Department of Psychiatry, Faculty of Medicine, Universitas Indonesia – Cipto Mangunkusumo General Hospital, Jakarta, Indonesia; E-mail: ksiste@yahoo.com

©2021 by the Research Society on Alcoholism.

DOI: 10.1111/acer.14556

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ALCOHOLISM: CLINICAL ANDEXPERIMENTALRESEARCH Vol. 45, No. 3

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drinking before the age of 21 presented a comparable corre- lation between problematic use and chronicity at any stage (Guttmannova et al., 2011). Delaying the age of one’s first drink would not be the solution for preventing an individ- ual’s dependence on alcohol in later life. This could be con- cluded based on several cohort studies among Western youth (Maimaris and McCambridge, 2014). Other variables, such as events during the first drink, subsequent drinking patterns, and psychological resilience, greatly contribute to the risk of developing dependence. However, preventing early alcohol consumption remains a vital issue because of its close associ- ation with morbidity and mortality among youth and its impact on neurocognitive performance during adulthood.

Moreover, the early onset of weekly consumption predicted poor neuropsychological function, particularly within the domains of cognitive inhibition and working memory (Nguyen-Louie et al., 2017). This is consistent with the find- ings of structural and functional brain deficits in adolescents due to varying levels of alcohol ingestion. These deficits included altered prefrontal cortex (PFC) gray matter volume, diminished anisotropic diffusion of white matter pathways across the corpus callosum, corona radiata, limbic, brain- stem, and cortical projections, and hypoactivation in hip- pocampus and PFC during task-based functional magnetic resonance imaging. Importantly, the impairment of PFC in adolescents, which is responsible for cognitive control, is pre- dictive of the progression to alcohol abuse (Hammond et al., 2014).

Youths show a preference for heavy episodic (≥60 g of pure alcohol on at least 1 occasion in the past month) or binge drinking (4 standard drinks in females and 5 standard drinks in males over 2 hours; World Health Organization, 2018). This exposes them to a heightened risk of harm from alcohol intoxication. In particular, the PFC matures much later than other regions that control reward and emotions (Giedd et al., 1999). This predisposes adolescents to impul- sivity, reduced error processing, and greater reward sensitiv- ity, thereby leading to problematic use (Stautz and Cooper, 2013). Collectively, these risks can culminate in the early onset of alcohol consumption, which induces a range of adverse physiological (e.g., hippocampal asymmetry and liver dysfunction), psychological (e.g., cross-substance addic- tion, depression, and suicide attempts), and social effects, such as academic difficulties, delinquency, and risky sexual practices (Ryan et al., 2019). It has been documented that genetic factors are responsible for almost half the risk in terms of alcohol use disorder, and environmental determi- nants account for the remainder. Although the latter is believed to be the primary factor influencing initial alcohol consumption and subsequent abuse, the former are consid- ered pivotal to the development of addiction or dependence (Ryan et al., 2019). Environmental factors include peer influ- ence through behavioral modeling and social conformity (Wang and Chen, 2018). A study involving multiple low- and middle-income countries revealed that adolescent individuals acquire drinking habits mainly through peers (27.8%) and

parents (23.2%). Strikingly, almost 20% of adolescents report being able to purchase alcoholic beverages at a store (Ma et al., 2018).

The driving forces behind the global rise of APC are the increased consumption in low- and lower-middle-income countries (Manthey et al., 2019). Within South and Southeast Asia, India, Indonesia, and Thailand are predicted to be the major contributors to this growth (World Health Organiza- tion, 2018). This growth trend is forecasted to persist until 2030 and is predicted to exceed consumption levels in high-in- come countries, such as those in Europe (Manthey et al., 2019). Therefore, it is important that regional stakeholders focus on preventive strategies specifically designed to take into account regional and national socio-cultural factors. Societal attributes play a pivotal role in determining alcohol consump- tion or even initiation, as illustrated in the studies by Assanangkornchai and Vichitkunakorn (2020). The authors noticed a significant decline in alcohol consumption and initi- ation in 2017, after peaking in 2014. This coincided with the year-long mourning of the death of the Thai king. Similar studies must be undertaken to analyze populations in the Asian continent, particularly in Southeast Asia, as Asian studies on underage drinking, and its longitudinal risks are rare and usually cross-sectional (Wang and Chen, 2018).

Additionally, many countries within the region have deep familial traditions and variables regarding parental influences on exposure, attitudes, and normative beliefs about alcohol consumption, which shape the drinking culture within society (Wang and Chen, 2018). For instance, countries such as China, with its historic drinking culture, have a more positive attitude toward alcohol consumption. Naturally, there is a higher prevalence of drinking (Jiang et al., 2017) in China than in Indonesia, a predominantly Muslim country that strongly abhors alcohol consumption. Another environmental factor that is currently relevant, as mentioned by Assanangkornchai and Vichitkunakorn, is the move of alcohol marketing strate- gies to online platforms, such as social media.

Studies conducted in Southeast Asia have not focused on the influence of digital advertising for alcohol (Wang and Chen, 2018). Thus, although several Asian countries have implemented a complete ban (e.g., Indonesia and Malaysia) or a partial ban (e.g., Thailand and Vietnam) on conven- tional advertising of alcohol, no country in the region has extensively regulated the digital marketing of alcohol (Jiang et al., 2017). A recent systematic review by Sargent and Babor (2020) pointed out the causality between alcohol mar- keting and underage drinking. Overall, exposure to adver- tisements had a moderate effect on the initiation of alcohol use among young people, an effect observed across heteroge- neous groups of individuals. The correlation extends to online marketing of alcohol, with which there is a similarly modest positive association with escalated binge or haz- ardous alcohol consumption among youth. The facets of dig- ital interaction that are conclusively associated with effects on drinking are the sharing, liking, and downloading alco- hol-related marketing content (Sargent and Babor, 2020).

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Alcohol advertisements act as real-world reward cues, which elicit activation within reward neural pathways, such as the ventral striatum, ventral tegmental area, and nucleus accum- bens (Courtney et al., 2020). As discussed, these areas develop earlier in adolescence than regions that process cog- nitive control. Socially, adolescents also display a proclivity toward risk-taking behavior, especially in the presence of peers. Together, these neurobiological and psychosocial risk factors increase adolescents’ vulnerability to alcohol con- sumption cues. Further, it has been shown that branding and framing of marketing content, affiliating it with positive logos (e.g., university or sports team emblems), and catering to adolescents’ expectations play a large role in modulating their alcohol uptake and abuse. The risk is especially con- cerning when 1 considers the cumulative impact of years of exposure on an average middle-school student, who is exposed to 2 to 4 alcohol advertisements per day (Courtney et al., 2020).

Asia is a growing market for the alcohol industry, which employs aggressive online marketing strategies with a pri- mary focus on youth (Jiang et al., 2017). In combating alco- hol commercials on social media, the Finnish government in 2015 restricted interactive digital advertising of alcohol that targeted Finnish individuals. Other nations in the region fol- lowed this approach (World Health Organization, 2018).

However, the social media ban does not protect conventional alcohol marketing via online platforms and personal social media accounts. In a follow-up study in 2017, it was observed that the number of alcohol-related posts declined and were rarely shared, with alcohol companies failing to establish online communities. Nonetheless, the initiative had been criticized as it stopped short of being stringent enough, as 40% of alcohol producers did not apply age limits to their advertising, thereby leaving it accessible to minors (Kauppila et al., 2019). A modified and more rigorous initiative could be adopted within the Asian region to keep up with the alco- hol industry’s growing digital marketing efforts. The Internet has introduced numerous marketing opportunities and increased the availability of alcohol to minors. There are less stringent detection and deterrence systems for online alcohol sales’ that infringe on regulations, even in high-income coun- tries. A recent Australian study found that less than half of online retailers required the buyer to submit their birth year and three-quarters of the retailers were willing to deliver alcohol products that require no physical identification con- firmation (Colbert et al., 2020). A similar, if not more severe, situation is shared across Asian countries as alcoholic bever- ages are available through virtual marketplaces with fewer controls. Furthermore, nearly half of the alcohol sales within the region are unrecorded, that is, manufactured, distributed, and sold outside of legal channels (Ma et al., 2018; SEARO, 2017a). These increase minors’ accessibility to alcoholic bev- erages (Jiang et al., 2017).

Overall, Assanangkornchai and Vichitkunakorn highlight preliminary data on greater prevalence of underage alcohol drinking over the decade of 2007–2017. This foundational

study should prompt stakeholders to invest in research on the alcohol consumption habits of the region’s adolescents and youth. This must include research both at the basic and programmatic levels. The alcohol industry is poised to expe- rience future exponential growth by riding the online market- ing wave. In response, increased research on the online marketing of alcohol in Asia and effective preventive mea- sures for underage alcohol initiation and misuse for Asian adolescents, youth, and women are needed. There is a vast gap in understanding the cultural and geographical differ- ences between Asian and Western regions regarding the lon- gitudinal effects stemming from the early onset of alcohol consumption. In this regard, the exportation of internation- ally verified trials into local evidence-informed programs by adding contextual modifications would be a practical option to bypass the financial and temporal burden. Data should be the cornerstone of policymaking that guides the implementa- tion of prevention and treatment programs. Governments should review their regulations, incentivize national research, and ensure that adolescents are safeguarded and allowed to develop to their fullest potential, being equipped with requi- site skills to make positive life choices.

CONFLICT OF INTEREST The authors have none to report.

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