Abstract
Objective:
The growing costs to the community of excessive alcohol consumption have resulted in pressure for governments and non-governmental organisations (NGOs) to develop strategies to address this problem, but they do so in a highly constrained resource environment. To provide evidence of health education approaches that may be effective across multiple drinker segments, and hence be relevant to a large number of drinkers, this study investigated the alcohol-related issues that are most salient to adult drinkers at different life stages.
Method:
Ten focus groups were conducted with 82 drinkers aged 18–65 years in Perth, Western Australia.
Results:
Sixteen categories of concerns were identified that related to three main themes of social, health and logistical issues. The youngest drinkers nominated the largest number of issues and older drinkers the least, although there were certain issues, such as concerns relating to role modelling and product quality, that became of increasing relevance with age.
Conclusion:
Study findings provide insights for those seeking to develop strategies to address alcohol-related harm at the population level.
Introduction
Alcohol consumption now represents one of the primary causes of illness, injury and death in industrialised countries (World Health Organization [WHO], 2007). Government policies to date have emphasised harm minimisation by focusing on issues such as youth binge drinking (i.e. heavy episodic drinking) and drink driving. In Australia, binge drinking campaigns targeting young people have highlighted the potential physical injury and negative social consequences associated with excessive alcohol consumption (Van Gemert et al., 2011). Public education relating to drink driving has involved communicating the maximum number of standard drinks that should be consumed per drinking session to stay ‘under the limit’, and ensuring that the number of standard drinks within an alcohol container is clearly labelled (Commonwealth of Australia, 2010). Non-governmental organisations (NGOs) are also active in this space, both in terms of running their own public education campaigns and lobbying governments to enact relevant regulation and take a more proactive stance in advising drinkers of the dangers associated with excessive alcohol consumption (e.g. Winstanley et al., 2011).
A core assumption behind the harm-minimisation approaches used to date is that ‘moderate’ consumption is unproblematic and may even be therapeutic (Goldberg et al., 1994). This viewpoint is widely shared in the community, with 90% of men and 81% of women reporting the belief that they can drink alcohol every day for many years without adverse health effects (Australian Institute of Health and Welfare [AIHW], 2005). However, a growing body of evidence demonstrates that alcohol consumption at any level may be detrimental (Rehm et al., 2009). The range of health problems that have been associated with alcohol includes cardiovascular disease, hypertension, liver disease, diabetes, cancer, foetal abnormalities and mental health problems (National Health and Medical Research Council [NHMRC], 2009; Testino et al., 2013). This growing evidence base provides the impetus and justification for greater efforts to educate the public about alcohol-related harms and how to minimise or avoid them.
The policy emphasis to date on youth binge drinking and drink driving has meant that formative research to inform alcohol education programmes has been primarily focused on these issues. The recent heightened appreciation of the alcohol-disease link brings the need for further formative research that examines attitudes and behaviours among the broader community to inform population-level education programmes. Accordingly, the aim of this study was to explore the issues relating to alcohol consumption that are most salient to different drinker segments to inform efforts to advise the Australian public that ‘Every drinking occasion contributes to the lifetime risk of harm from alcohol’ (NHMRC, 2009: 36). The increasingly constrained financial environment for health promotion activities necessitates the identification of approaches that are as effective as possible among as many drinkers as possible. By understanding which issues are especially salient for different drinker segments, governments and NGOs can focus their efforts on those strategies that are likely to cost-effectively deliver the greatest benefit across the community.
Previous research has tracked alcohol consumption across time and between cohorts to establish levels and patterns of use. This work has found a consistent trend of increasing alcohol intake up until the early 20s, after which time there is a substantial reduction in consumption (Johnson et al., 1998; Patrick et al., 2011). In addition to drinking more, young people tend to engage more frequently than their older counterparts in heavy episodic (binge) drinking behaviours (Kerr et al., 2009). Other trends are greater consumption among men than women and higher levels of consumption among more recent cohorts relative to previous cohorts (Degenhardt et al., 2008; Kerr et al., 2009; Wilsnack et al., 2000). Reflecting the identified importance of age as a segmentation variable in drinking behaviours, Patrick and colleagues (Patrick et al., 2011; Patrick and Schulenberg, 2011) have highlighted the need for research that explores the interplay of maturation processes and alcohol-related beliefs and behaviours to facilitate intervention design. This study provides insight into this issue by qualitatively exploring the most salient alcohol-related issues for Australian drinkers during their adult years to identify those alcohol-related factors that remain important across the lifespan and those that wax and wane according to stage of life.
Methods
A multi-stage recruitment strategy was employed to access Western Australian drinkers of different ages. Most participants were accessed via two social research agencies that used random digit dialling and existing databases to contact potential participants. These agencies have access to a broad range of Western Australians who vary according to demographic characteristics. This ensured wide variation in the drinking behaviours and socioeconomic backgrounds of participants. In addition, a notice was placed on a university listserv to attract some of the younger participants. During recruitment, current drinkers aged 18 years and older were invited to take part in focus groups on the general topic of alcohol consumption. Ethical clearance for the study was received from the University of Western Australia Human Research Ethics Research Committee (approval number RA/4/1/5158). Informed consent was obtained in writing from all participants, who were assured of confidentiality through the use of de-identification during transcription.
In total, 10 focus groups were held in Perth, Western Australia, with an average of eight participants per group. The sample comprised 82 drinkers ranging in age from 18 to 64 years, about half of whom were men (n = 40) and half were women (n = 42). The groups were stratified by gender and by age (18–21 years [four groups], 22–30 [two groups], 31–45 [two groups], 46–64 [two groups]) to permit factors relating to these demographic variables to be explored. Australians aged 18–21 years are typically young singles either undertaking college education or commencing full-time employment (Australian Bureau of Statistics [ABS], 2010). As noted above, many members of this segment exhibit levels and patterns of alcohol consumption that may place them at heightened risk of short- and long-term harm (AIHW, 2011). Reflecting this situation, twice as many groups were conducted with members of this age group. The next three life stages were selected on the basis of family and career status. The median age of first-time mothers and fathers in Australia is 31 and 34 years, respectively (ABS, 2011), and hence those in the 22–30 years age group are unlikely to have families, those in the 31–45 years age group are likely to have young families and those aged 46–64 years tend to have older children or be ‘empty nesters’. These age ranges also reflect changes in career status, progressing through career establishment, stabilisation and maintenance stages, respectively (Morrow and McElroy, 1987).
The focus groups were moderated using a semi-structured approach (Fontana and Frey, 1994). In the first instance, participants were asked to discuss their perceptions of the role of alcohol in Australian society. These conversations naturally evolved into participants providing more detailed accounts of how they used alcohol in their own lives. As various positive and negative aspects of drinking were raised, these were probed in more detail to provide insight into alcohol-related beliefs, concerns and behaviours. This semi-structured approach facilitated wide-ranging conversations where issues or concerns of particular relevance to each group were raised and subsequently explored in detail. The average duration of the groups was 74 minutes.
All groups were audio-recorded, and the recordings transcribed verbatim. The transcripts were imported into NVivo10 for coding and analysis. In line with the approach advocated by Strauss and Corbin (1990), a coding hierarchy was developed using issues that emerged during the interviews (in vivo codes) and concepts that feature in the alcohol literature (theoretical codes).
NVivo’s matrix query function facilitated the interrogation of the coded data to identify which issues resonated most strongly with different groups of participants. On the basis of the matrix query results, an importance score on a scale from 0 to 10 notional ‘points’ was allocated to each identified issue. This score reflected the frequency and intensity of discussion, with account taken of the larger number of participants in the youngest age group. Given the qualitative nature of the data, the allocated importance scores cannot be considered directly proportional or representative of the broader Australian population. Instead, they constitute a device for depicting the salience of various issues to different groups of drinkers and are thus useful in the context of indicating which issues appeared to be relatively more important to different participants. By illustrating points of similarity and differentiation, the scores provide insight into how alcohol-related issues and concerns may vary across adult life, and hence, how public education programmes could potentially cater for alcohol-related issues at different life stages.
During the coding process, high levels of consistency were identified across different groups relating to the important role of alcohol in Australian culture, both historically and in contemporary life. In particular, alcohol was commonly described as a desirable and necessary element of social gatherings, especially those involving celebrations and rites of passage. However, there were distinct differences in issues raised by drinkers in different age and gender groups. These differences became the focus of the analysis, as outlined below.
Findings
Table 1 provides a representation of the apparent relative importance of the various issues by age group and an indication of whether these trends were consistent by gender. The issues raised by the focus group participants fell into 16 categories, which were generally related to three higher-level themes: social (8 categories), health (5) and logistical (3). Reflecting the trend for alcohol intake to progressively decrease across the adult years, the youngest age group had the highest level of representation across the categories and the oldest age group had the lowest. However, some issues appeared to become more relevant in later years, as described below.
Issue relevance scores. a
Estimated importance rating out of possible notional score of 10 reflecting the frequency and intensity of discussion.
Social issues
The eight issues that were classified as social were as follows: (1) the effects of peer pressure on consumption decisions, (2) being cognisant of parents’ attitudes to alcohol consumption, (3) drinking to overcome social inhibition, (4) concerns about appearing unattractive to others while intoxicated, (5) consuming substantial quantities of alcohol at friends’ homes prior to going out (pre-drinking), (6) requiring reasons to give to others as ‘legitimate’ excuses for abstinence or light consumption, (7) acknowledging responsibilities as role models to others and (8) being able to demonstrate an appreciation of the relative quality of different alcoholic beverages.
Those in the youngest age group were considerably more likely than older participants to discuss the effects on their drinking of peer pressure and their need to reduce their inhibitions in social situations:
You want to be seen to fit in with the crowd.
Yeah, (drinking is) a pretty good thing to do socially. (Focus group men, 18–21 years)
(The best thing about drinking is) being able to talk to anyone, I think. You know, having a conversation with everyone, whether you know them or not, you can just socialise. (Woman, 18–21 years)
People always try to get a bit of alcohol under their belt so you get more confidence when you’re out, a bit louder, a bit more confident around girls and stuff.
Yeah, not as shy. (Focus group men, 18–21 years)
Many of the participants in this age group referred to the ways their parents had attempted to control their alcohol consumption behaviours when they were below the legal drinking age. A small number, mainly woman, noted that their parents had tried to prevent them from drinking entirely, but most reported that their parents had attempted to constrain their consumption by providing them with limited quantities of alcohol and asking them to refrain from obtaining more through other means. The overall message assimilated by these participants appeared to be that moderate drinking is acceptable for young people and condoned by their seniors: My parents always would drop me at the party. They bought me two drinks and said, ‘We know we’ve bought them for you and don’t take them off anyone else’. (Woman, 18–21 years) Your parents, when you’re younger, they buy you stuff and you only get kind of drunk. And that’s instead of going behind their backs. (Man, 18–21 years)
Those aged 22–30 years frequently discussed the process of ‘pre-drinking’, which often involved consuming large quantities of alcohol prior to attending commercial entertainment venues such as public bars and nightclubs. They described their pre-drinking behaviour in the context of their desire to participate in numerous social activities each week and the need to manage the high costs of alcoholic beverages available in venues popular with their age group. Purchasing alcohol from retail stores and ‘pre-drinking’ at someone’s home provided them with the opportunity to maximise their time with their peers while reducing their total expenditure on alcohol. This seemed particularly important to the women, some of whom also noted that the pouring of drinks during a pre-drinking session was more generous than in commercial settings, resulting in larger servings of alcohol and faster inebriation: The drinks are so expensive, so you need to be ‘on your way’. (Woman, 22–30 years) When I’m at pres (pre-drinking sessions), we always self-pour and it’s horrible (laughing) … we’ll pour our own spirits, so I don’t know how many standard drinks is in a drink. (Woman, 22–30 years)
Many of those in the 31–45 years age group expressed concerns that reflected their status as parents of young children. They were almost the only study participants to reference their positions as role models for children and younger people, and they were more likely than those in other age groups to articulate a desire for acceptable excuses they could give to other people to reduce the pressure to engage in heavy drinking episodes. This age range appeared to be a period of reassessing drinking behaviour and attempting to pull back: It’s not good for your kids as role models if you’re always passed out on the lounge every night. (Man, 31–45 years) I know people do Dry July and at least have that excuse to say, ‘Oh no, I’m doing Dry July’. And they’ll say, ‘Good on you’, because they’re raising money for charity. That seems to be an acceptable excuse for not drinking. (Woman, 31–45 years)
By comparison, those in the oldest age group exhibited fewer concerns relating to the social aspects of alcohol consumption, with the exception of product quality. Some of those in this age group, and to a lesser extent those in the previous age group, appeared keen to differentiate themselves from younger drinkers on the basis of their preference for more upmarket products. This was especially apparent among some of the men: I think your tastebuds do actually change as you get older … I used to drink a lot of cask wine, and it was okay. But since I’ve started drinking so called ‘better wines’, you know, bottled wines, there’s very few casks that I’d be able to enjoy now. (Man, 46–64 years)
Health-related issues
The five health-related issues that were discussed in the focus groups were as follows: (1) the ongoing need in the early years of drinking to monitor physiological responses to alcohol, (2) a general concern with the health consequences of alcohol consumption, (3) concerns relating to physical safety, (4) a desire to lose or manage weight by reducing the amount of energy consumed as alcohol and (5) the perceived health benefits of moderate amounts of alcohol.
As was the case with the identified social issues, there was a clear difference in the salience of different health issues for members of the various age groups. Concerns relating to the ability to cope with the physical effects of alcohol were only expressed by members of the younger two age groups, and especially men aged 18–21 years who frequently discussed the tendency to rely on vomiting as the signal that they had reached their tolerance limit: A lot of stuff at our age is reactionary, so we wait until we throw up and then we’ll take a step back. (Man, 18–21 years) You don’t feel proud (about vomiting), but then, like what my buddy says, ‘Like at least now you know your limits, so next time you won’t get there’. (Man, 18–21 years)
Numerous general and specific health conditions were raised as potential adverse health consequences of excessive alcohol consumption. Younger participants focused on the potential effects of alcohol on the growing brain and the increased likelihood of engaging in unprotected sex: I think about all the brain cells I’m killing, and I kind of think I don’t want to lose any more of these. (Woman, 18–21 years) (When I was drunk) I had sex with a random Russian girl, and it was without protection, so it was pretty dangerous. (Man, 22–30 years)
Older participants were more likely to mention health problems such as cancer, impaired cognitive functioning and car accidents. For some older drinkers, health concerns had prompted them to discuss their drinking with their doctors and take action to reduce their overall consumption: I discussed it with my doctor some time back that two days a week, one week it might be three, the next it might be one, but roughly two days a week are alcohol-free days. (Man, 46–64 years)
Safety concerns were most prevalent among those aged 22–30 years, especially women. These participants had been drinking long enough to directly experience alcohol-related harms or to witness harms suffered by others. They were at a life stage where they were drinking frequently and heavily, often in public venues, and were thus vulnerable to dangers resulting from their own and others’ intoxication. Specific examples of safety concerns discussed by the focus group participants included blackouts, falls, verbal abuse from other drinkers and, in one case, the death of a friend in a boating accident: I’ve had really bad experiences overseas when my friends have been really drunk and been missing for a couple of hours. I’ve only ever a couple of times got to that point where I just don’t even remember, because I always try to keep a stable head because you never know what’s going to happen. (Woman, 22–30 years) A friend of ours was drinking and he fell off the boat and he got chopped up by the motor … I think that the fact that it’s someone you know, it will just affect you more, just having those real life accidents. You can look at them and go, ‘Well, I don’t want that to happen to me, therefore I’m not going to do what that person did’. (Man, 18–21 years)
Both men and women made reference to the calorific content of alcohol and its role in weight management. For some, the desire to control or decrease their weight was adequate to stimulate a reduction in consumption: I actually got a huge shock, I was 40 something. I said to my personal trainer that I’m not losing weight, I’m dieting, I’m exercising. She said, ‘Well, how much are you drinking?’, and I said, ‘Just the usual’. She said, ‘Well, you know, it’s your alcohol’. I’m much wiser now, it makes a huge difference. (Woman, 46–64 years)
Some of the participants in the two older age groups, and especially men, expressed the belief that alcohol can be therapeutic in moderate quantities. Red wine in particular was mentioned as being capable of providing health benefits: We’re told that a glass of red wine a day is good for your heart. (Man, 31–45 years)
Red wine has good antioxidants in it.
Good for the blood. (Focus group women, 31–45 years)
Logistical issues
The three identified logistical issues were as follows: (1) the limiting effect of cost, (2) negotiating supply constraints and (3) managing intake rates to avoid being caught drunk driving. While gender differences were apparent in the social and health issues discussed above, the identified logistical issues appeared to affect women and men equally.
Cost and supply issues were discussed most frequently by those who had recently come of drinking age. For these drinkers, their progression to adult status required both different behaviours (e.g. carrying ID cards to show to alcohol retailers) and different mental processes (e.g. budgeting and prioritising expenditure): The other day I left my ID at home and Dad just drove me up to go to the bottle shop because I’d had a few drinks. He (shop attendant) wouldn’t serve me and I was like, ‘Okay, my Dad will buy it’, and he was like, ‘No, I can’t serve either of you’. So then we had to drive home, get my ID and come back, and he was just like, ‘Oh, you are 18’, and I was like, ‘Yeah I told you it was just at home’. It was just annoying. (Woman, 18–21 years) When you turn 18, usually your parents have cut you off by then and you’ve got your own income. So you’re more wary about spending money on alcohol because you think, ‘Oh, I can spend this money on something else’. (Man, 18–21 years)
The participants explained that such issues became less salient over time, with supply no longer being a problem once they were obviously of legal age and budgeting becoming less critical as their incomes increased and they developed alcohol purchase routines. By comparison, drink driving considerations remained relevant for all the age groups, albeit with an apparent drop in importance among those aged 21–30 years. This may have been the result of the tendency for members of this age group to do much of their socialising in commercial venues located in central business or entertainment districts, where both public transport and taxis are in easier supply. By comparison, younger and older drinkers were more likely to report drinking at other people’s homes, thus necessitating consideration of transport options prior to going out: I just pack my swag in my car and you’re good to go. You just sleep in your car overnight and drive home in the morning. (Man, 18–21 years) I will only have a glass of wine. Being a single person, if I’m going out I will only have a glass of wine followed by water, so I’m drinking less because I’ve got to drive home. (Woman, 46–64 years)
Discussion
Increasing appreciation of the short- and long-term harms associated with alcohol use has resulted in a greater emphasis on understanding the factors influencing alcohol consumption to inform the development of appropriate interventions (Patrick et al., 2011; Patrick and Schulenberg, 2011). However, due to the focus of most previous work on very young drinkers, there remains a gap in the evidence base in terms of a comprehensive understanding of alcohol-related issues of relevance across different age segments of drinkers (Gilson et al., 2013; Patrick et al., 2011). By generating data relating to a broader range of relevant factors that may affect alcohol-related beliefs and behaviours throughout the life course, this study provides initial insight into the complex and changing dynamics that are at play as people move between life stages. This information has the potential to be of assistance to those attempting to develop interventions that include components relevant to different segments of drinkers.
The limited previous work that has investigated alcohol-related issues in non-youth samples has tended to use quantitative scales that demarcate drinking motivations into categories such as social needs, coping needs and enhancement needs (e.g. Doyle et al., 2011; Gilson et al., 2013). While useful in providing insight into the psychological processes that influence the desire to drink, these results do not tell the full story of the multitude of factors that impact on individuals when making alcohol-related decisions. To begin to provide a more comprehensive account, this study used a qualitative, exploratory approach to identify and explicate the broad range of alcohol-related factors that are salient to adult drinkers at different life stages.
Sixteen categories of issues were identified, which were encompassed within the broader themes of social, health and logistical concerns. The dominance of the social theme (8 of the 16 identified categories), and especially the well-acknowledged role of alcohol as a key component of social events and celebrations, is consistent with literature documenting the ‘social life’ of alcohol (Douglas, 1987). Similarly, the higher relevance of most of these social issues to younger drinkers is consistent with previous research that has emphasised the social significance of alcohol as a component of the rite of passage to adulthood (Piacentini et al., 2012) and the importance of peers in influencing youth alcohol consumption (Neve et al., 2000; Umberson et al., 2010). The identified health and logistical issues were more likely to constitute barriers to consumption than motivators, and as such have been less recognised in previous work that has focused on factors that encourage and facilitate consumption.
For the purposes of this study, these barriers are important as they constitute potential means of discouraging consumption across various segments of drinkers. In particular, the findings suggest that emphasising the more recently identified health risks of which drinkers may be unaware and taking measures to reduce the affordability of alcohol could be effective with drinkers across multiple segments. The former would involve public education that reaches multiple drinker segments. The latter would require policy changes, such as a minimum pricing approach that has been recently considered and acknowledged as likely to be effective in curbing consumption, but ultimately rejected in the face of strenuous industry opposition in both Australia and the United Kingdom (Chalmers et al., 2013). This multi-level approach involving both policy change and public education is recognised as being necessary for complex health problems such as those relating to alcohol-related harms (Robinson and Baggott, 1985).
Most issues appeared to reduce in importance with age, with those participants in the youngest age group discussing a greater range of issues and concerns than those in older age groups. Of note was the tendency for the youngest drinkers to reference their parents in terms of attitudes to and provision of alcohol. Despite these drinkers having reached the age at which they can legally purchase their own alcohol products, the lessons learned from listening to and observing their parents appear to have traction beyond the childhood years. This supports previous research that has stressed the importance of parents in influencing their children’s alcohol-related beliefs and behaviours (Danielsson et al., 2011; Laghi et al., 2013; Mares et al., 2013; Pasch et al., 2010) and highlights the importance of targeting parents as a key audience in education campaigns designed to address youth drinking. It also supports the need for secondary supply laws to be consistently applied across Australia to communicate the important role of older people in minimising minors’ exposure to alcohol. Currently, some states have such legislation while others do not.
The findings suggest possible explanations for consumption trends identified in previous research. For example, higher levels of alcohol intake among men relative to women are well documented (Degenhardt et al., 2008) and have been attributed to a combination of biological and social factors, including women’s greater physical vulnerability (Wilsnack et al., 2000). Findings from this study support this interpretation, with women being more likely to discuss their compromised safety while intoxicated. By comparison, the men in this study were more likely to focus on positive outcomes such as reductions in social inhibition, the ability to distinguish themselves through their product selections and the perceived health benefits of some forms of alcohol. However, the present findings relating to the higher salience of peer pressure and pre-drinking among women suggest that the trend towards increasing alcohol consumption among women (Degenhardt et al., 2008; Kerr et al., 2009) will continue, with likely adverse health consequences for current and future cohorts. In addition, it appears that peer pressure can remain a force to be reckoned within the later years, rather than being a problem experienced mainly by the young. This suggests that interventions that provide drinkers with strategies to handle pressure to drink may be useful to drinkers in general. Such an approach is already being considered to assist pregnant women to abstain from alcohol while socialising (France et al., 2014) and may be usefully adapted to also relate to a broader range of drinkers.
The selection of a cross-sectional approach for this study provided access to those issues that were salient for members of different age groups at a particular point in time, thereby recognising the importance of life stage to drinking behaviours (Umberson et al., 2010). However, this approach did not allow an analysis of changes in alcohol-related issues over time within cohorts. Other limitations included the restriction of data collection to one state within one country and the exclusion of underage drinkers and those aged 65 years and older. Future studies could be designed to address these limitations by taking a longitudinal approach to track changes both across and within cohorts, adopting a cross-cultural approach and/or including a broader age spectrum. Also, the qualitative approach and use of focus groups as the data collection method serve to limit the generalisability of the findings. Future research that employs representative samples is required to assess the extent to which these findings reflect the broader population of Australian adult drinkers. Finally, there are likely to be differences in the importance of various alcohol-related issues according to other variables, such as ethnicity and socioeconomic status. Future research could more comprehensively explore the relevance of such variables and the implications for health promotion strategies designed to reduce high current levels of alcohol-related harm.
Footnotes
Funding
This study was partially funded by the Western Australian Health Promotion Foundation (Healthway), research grant #20338.