Journal of Substance Use

ISSN: 1465-9891 (Print) 1475-9942 (Online) Journal homepage: http://www.tandfonline.com/loi/ijsu20

Pattern of alcohol use among problem alcohol

users in a community-based setting in India: A
cross-sectional study

Snehil Gupta, Rakesh Lal, Ravindra Rao, Ashwani Kumar Mishra & Atul
Ambekar

To cite this article: Snehil Gupta, Rakesh Lal, Ravindra Rao, Ashwani Kumar Mishra & Atul
Ambekar (2017): Pattern of alcohol use among problem alcohol users in a community-based setting
in India: A cross-sectional study, Journal of Substance Use, DOI: 10.1080/14659891.2017.1366557

To link to this article: http://dx.doi.org/10.1080/14659891.2017.1366557

Published online: 22 Sep 2017.

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 JOURNAL OF SUBSTANCE USE
https://doi.org/10.1080/14659891.2017.1366557

Pattern of alcohol use among problem alcohol users in a community-based setting

in India: A cross-sectional study
Snehil Gupta, Rakesh Lal, Ravindra Rao, Ashwani Kumar Mishra, and Atul Ambekar
Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India

ABSTRACT ARTICLE HISTORY

Introduction: Impact of alcohol on various adverse consequences is also determined by the pattern of Received 22 December 2016
consumption. Pattern of drinking from developing countries is an under-researched area. The present Revised 1 May 2017
study aims to assess the pattern of drinking among nontreatment-seeking problem alcohol users from Accepted 7 August 2017
an urban slum in a metropolitan city of North India. KEYWORDS
Methodology: Using a cross-sectional study design and employing the snowball method, 75 adult males Problem alcohol use; pattern
with problem alcohol use were recruited and interviewed using questionnaire and standard instruments. of alcohol use; heavy
Results: The median duration of alcohol consumption was 12 (7, 21) years, 90% were drinking daily, 64% episodic drinking;
were morning drinkers and 92% reported heavy episodic drinking (HED). Three-fourth participants were community; snowball
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in the high-risk category of alcohol use as assessed by WHO-ASSIST. One-third were spending 25–50% of method
their family income on alcohol. The most preferred alcohol beverage was country-made liquor (CML;
54.3%). Most alcohol users preferred drinking at home (58%), alone (67%), in evening or at night (80%).
Conclusion: Although many alcohol users consume alcohol in amounts much above the recommended
levels, with high rates of HED, they are not on treatment for alcohol-use disorder. Their pattern of
alcohol consumption is likely to place them at risk for alcohol-related harmful consequences.

Introduction fold higher mortality than their non-HED counterparts

(Plunk et al., 2014). HED is also associated with the poor
Alcohol is the third largest risk factor for disease and disability
prognosis of myocardial infarction (Mukamal et al., 2005).
globally. It is the leading risk factor for death mainly due to
Research has also shown that light-moderate drinkers had a
injuries, violence, and cardiovascular diseases among adults in
higher mortality rate when they reported an episode of heavy
the age group of 15–59 years (World Health Organization
drinking (Rehm et al., 2001). Alcohol-related negative con-
[WHO], 2011). Research studies on the adverse health impact of
sequences have also been associated with other alcohol-use
alcohol have traditionally focused on the volume of alcohol con-
patterns such as the type of alcoholic beverage consumed
sumed (Her & Rehm, 1998; Kessler et al., 1997; Rehm & Gmel,
(Vilamovska, Brown Taylor, & Bluthenthal, 2009), place of
2000). Although the average volume of consumption is associated
drinking (Ghosh, Samanta, & Mukherjee, 2012; Studer et al.,
with intoxication, the strength of association is not sufficient to
2015), and the time of drinking (Ghosh et al., 2012;
adequately predict the acute effects of alcohol in relation to injury,
Vilamovska et al., 2009).
health-related risks, and death (Naimi et al., 2003; Nazareth et al.,
A global status report on alcohol documents that although
2011; Rehm, Greenfield, & Rogers, 2001). Studies have shown that
India is a low-alcohol-consuming country, the prevalence of
the impact of an average volume of alcohol consumption on
HED among individuals aged 15 years or more is 1.7% while
mortality or morbidity is partly moderated by the way alcohol is
among drinkers it is 11%, placing it as a country with typically a
consumed (Mukamal, Maclure, Muller, & Mittleman, 2005; Plunk,
‘medium-risk’ pattern of alcohol consumption (WHO, 2011).
Syed-Mohammed, Cavazos-Rehg, Bierut, & Grucza, 2014; Rehm
Few studies have focused on assessing the pattern of alcohol
et al., 2001).
consumption among alcohol users in India (Benegal, 2005;
The pattern of alcohol use is characterized by considerable
Ghosh et al., 2012; Girish, Kavita, Gururaj, & Benegal, 2010;
variations. Particularly, heavy episodic drinking (HED) or
Pillai et al., 2013; Potukuchi & Rao, 2010; WHO, 2006). These
binge drinking has been gaining research attention in recent
studies are restricted to the south and eastern regions of the
years (Almeida-Filho et al., 2004; Dawson, Grant, Stinson, &
country and most have focused on only one aspect of drinking –
Chou, 2004; Greenfield et al., 2014; Kim et al., 2008; Midanik
HED. The few available studies on alcohol consumption pattern
& Clark, 1994; Naimi et al., 2003; Nazareth et al., 2011). HED
demonstrate different patterns of alcohol use across regions.
is commonly defined as ‘consumption of five or more drinks
Therefore, the present study was conducted with an aim to
within two hours in men or four or more drinks within two
assess the pattern of drinking among problem alcohol users in
hours in a female in a single occasion’ (NIAAA, 2004).
a community setting in North India.
Individuals with a history of HED were found to have two-

CONTACT Atul Ambekar atul.ambekar@gmail.com National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical
Sciences, New Delhi, India.
© 2017 Taylor & Francis Group, LLC
 2 S. GUPTA ET AL.
Methods
Study design
The present study employed a cross-sectional, observational
study design, conducted in an urban slum of a metropolitan
city of India. A slum is a compact settlement of at least 20
households with a collection of poorly built tenements, mostly
of temporary nature, crowded together usually with inade-
quate sanitary and drinking water facilities in unhygienic
conditions (Ministry of Housing and Urban Poverty
Alleviation National Buildings Organization, India, 2011).
Potential participants were recruited using snowball sampling
strategy. The initial seeds for the snowballing were recruited
with the help of patients receiving agonist maintenance treat-
ment for opioid dependence in a community drug treatment
clinic, situated in the locality where the study was conducted.
Additionally, help from field workers employed by a nongo-
vernmental organization working in the vicinity was solicited
to recruit initial seeds. After their interview, the seeds were
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requested to refer ‘similar’ individuals for the study.
Study participants
Data for the study was collected over a six-month period
(July–December 2014) with the following selection criteria:
males aged 18 years or more, not received treatment for
alcohol-related problem in the past three months, problem
alcohol use (defined as those with scores greater than 11 as
assessed by WHO-ASSIST) and residing in the community.
Those who reported the use of any other psychoactive sub-
stance (except tobacco) in the past three months, had medi-
cal/psychiatric illness preventing participation in the
interview, and unwilling/unable to provide written consent
were excluded from the study. After obtaining their written
consent, the participants were screened and, if found eligible,
were interviewed at a place of mutual convenience. Each
interview lasted for about 60 minutes. The study was
approved by the Ethics Committee of the authors’ institution.
Assessment tools
Alcohol, smoking, and substance involvement screening
test (WHO-ASSIST)
WHO-ASSIST is a screening tool developed by WHO (WHO
ASSIST working group, 2002) to be used in primary care and
community-based settings to identify those with substance-
use problems for referral to treatment. The instrument con-
sists of eight questions covering nine classes of psychoactive
substances. A total score is generated for each class of sub-
stance used over a lifetime as well as in last three months and
participants are, accordingly, classified as low risk, moderate
risk, and high risk for a particular class of substance. The
Hindi version of the instrument, which has been validated for
use in the Indian population, was used in the present study. In
this study, ASSIST was used to identify and include alcohol
users in the moderate- to high-risk category as well as to
exclude those who reported consuming any other substances
(except nicotine) in the past three months.
Semi-structured questionnaire
A semi-structured questionnaire, specifically designed for the
study, was used to collect socio-demographic data, alcohol-use
details (duration of alcohol use, age of onset of alcohol use,
presence of craving, withdrawal, daily drinking, morning
drinking, etc.), family history of substance use, and presence
of any psychiatric or medical complications. Other items
included drinking contexts like reasons to consume alcohol
(for relaxation, recreational purpose, on insistence of others,
etc.), usual timing of consumption (lunch, evening, night, or
throughout the day), usual place of drinking (home, outside
pub/bar, friend’s house, etc.), usual situation of drinking
(alone at home, going out with friends, marriage/festivals,
etc.), usual preferred company while drinking (with friends/
other acquaintance, wife/female friends, mostly alone), rela-
tionship of drinking with food (drinking with food or some-
thing to munch, before meal, after meal), any occasion of
consuming more than one alcohol beverage, diluting the
alcohol beverage before consumption and the frequency of
getting intoxicated after consuming alcohol.
Estimation of quantity of alcohol used
The quantity-frequency (QF) approach was employed to esti-
mate the quantity of alcohol consumed by the subject in the
past three months. The QF approach is a technique recom-
mended by WHO to be used in epidemiological studies to
assess drinking habits (WHO, 2000). The QF approach asks
for the overall frequency of drinking during a reference period
(e.g. three to four times/week, one to two time/week, two to
three times per month, once/month, or less than once/month)
and the usual number of drinks consumed on days when
drinking took place (number of standard drinks). Questions
can be extended to include beverage-specific questions and
also regarding the largest and usual dose of alcohol taken. In
the current study, we used the reference period as past three
months. Participants were initially asked to name all the
alcoholic beverages consumed in the past three months, fol-
lowed by the overall frequency of drinking for each beverage
consumed. Finally, the usual number of drinks consumed on
each drinking episode for each beverage was enquired. The
total amount of alcohol consumed in terms of standard drink
was estimated in this manner. Each subject was asked whether
he had any episode of HED in the past three months.
Statistical analysis
The data and statistical analysis were performed by licensed
SPSS 21.0 version software (IBM SPSS Statistics for Windows,
Version 21.0, Armonk, New York, USA). For continuous data,
mean (for variables that were less or moderately skewed) or
Median with Interquartile Range (IQR) (for characteristics
that were more skewed) were calculated. For categorical data
like sociodemographic, alcohol-related clinical details, and
drinking contexts, frequency distribution was calculated. The
quantity of alcohol consumed was derived by converting the
amount of alcohol consumed into number of standard drinks
(one standard drink = 10 g of absolute alcohol). From this, we
 JOURNAL OF SUBSTANCE USE 3

estimated the average quantity of alcohol (in gram) consumed Table 1. Socio-demographic characteristics and alcohol-use-related details#.
by an individual subject per day. Frequency distribution of Variables Categories Values (n, %)
HED was also calculated. Marital status Married and staying 50 (67.0)
together
Unmarried 17 (23.0)
Widower 4 (5.0)
Results Separated 3 (4.0)
Divorce 1 (1.3)
A total of 87 participants were screened, out of which 12 were Education Illiterate 8 (10.0)
excluded (seven had concomitant cannabis use, three had Primary school 15 (19.0)
High school 38 (48.0)
ASSIST scores less than 11, one had sought treatment in the Higher secondary 8 (10.0)
past three months, and one resided more than 5 km away school
from the area and could not come for subsequent interview). Graduate 4 (5.0)
Post-graduate 2 (3.0)
A total of 75 participants were finally included in the study. Occupation Unskilled worker 22 (29.3)
Skilled worker 23 (30.7)
Businessman 18 (24.0)
Socio-demographic characteristics and alcohol-use- Administrators 1 (1.3)
Professionals 4 (5.3)
related details Other 7 (9.3)
Employment status Currently employed 48 (66.0)
The mean age of study participants was 36.78years. Two-thirds full time
(67%, n = 50) of the participants were married. Half of the Currently employed 11 (15.0)
part time
participants (48%, n = 38) completed 10 years of education.
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Currently unemployed 16 (20.3)

About one-third of the participants (33%, n = 23) were skilled Religion Hindu 66 (88.0)
workers and almost an equal number were unskilled workers. Muslim 9 (12.0)
Family history of substance use Yes 50 (67.0)
Two-third (n = 48) of the participants were currently full-time No 25 (33.0)
employed. The detailed socio-demographic characteristics of the Alcohol 46 (61.0)
Opioids 6 (8.0)
participants are provided in Table 1. Cannabis 6 (8.0)
The mean age of onset of alcohol use was 21.5 (6.9) years Inhalant 1 (1.3)
and the median duration of alcohol use was 21 (7, 21) years. A Major source of income to Self 60 (80.0)
procure alcohol Family members 14 (18.7)
substantial, 92% (n = 71), number of participants reported in Lone/credit 13 (17.3)
their lifetime they have ever drank daily and 64% (n = 45) Other 4 (5.3)
Proportion of family income <25% 39 (52.0)
reported morning drinking. The mean age of onset of daily spent on alcohol 25–50% 24 (32.0)
drinking was 26.6 (9.3) years, whereas the age of onset of 50–75% 6 (8.0)
craving, withdrawal, and of morning drinking was 30 (10.2) >75% 6 (8.0)
#
years, 34 (10.4) years, and 31.1 (7.5) years, respectively. Two- The sum for some variables is more than 100% because participants could give
multiple responses within the same category
thirds of the participants (n = 50) belonged to a family with a
history of substance use. About 5% (n = 4) of the participants
reported alcohol-related medical complications, mostly in the
form of alcohol liver disease. For 80% (n = 60) of the parti- 125 g (70, 241). The median time taken to finish the usual
cipants, a major source of income for the procurement of amount of alcohol was 20 minutes (10, 50). About 92%
alcohol was their own income. In the last three months, (n = 69) of the participants had at least one episode of HED
about one-third of the participants (n = 26, 35%) reported in the reference period.
that they experienced mugging, loss of money, or theft when
they were intoxicated with alcohol. About half of the partici-
Pattern of alcohol use
pants (n = 39) reported that the expenses on their alcohol use
amounted to less than 25% of their family income, while one- The reason for alcohol consumption for 60% (n = 45) of the
third (n = 24) reported the expenses on their alcohol use was participants was ‘for relaxation’ or to ‘relieve tension’ while 40%
25–50% of the family income (Table 1). (n = 30) reported alcohol use for recreational purpose. The usual
timing of drinking in 40% of the participants was evening
(n = 31) and about the equal proportion of participants reported
Quantity and frequency of alcohol use over the past three
night as the usual timing for drinking (n = 30). About 24% of the
months
participants (n = 18) consumed alcohol throughout the day.
About 85% (n = 64) of the participants reported drinking Drinking while ‘relaxing at home’ was the usual situation for
alcohol daily in the past three-month period. The most pre- 50% (n = 41) of the respondents. The contexts cited for deciding
ferred alcoholic beverage was country-made liquor (CML) to drink were equally (36%, n = 26) for being ‘angry, sad,
(54%, n = 41), followed by whiskey (41%, n = 31). About frustrated’ and for ‘feeling tired’. ‘Home’ was the most common
89% of the participants used their most preferred beverage place of consuming alcohol (59%, n = 44), followed by consum-
three to four times a week or more, while the use of the ing in ‘open, just outside liquor shop’ (43%, n = 32). More than
second most preferred beverage with the same frequency two-third (68%, n = 51) of the participants reported consuming
was 22% (n = 11). The median amount of alcohol consump- alcohol mostly alone (Table 2). The median number of sips
tion on a typical drinking day was 80 g (60, 120), whereas the required to consume about 180 ml of their preferred beverage
maximum amount of alcohol consumption was a median of was four (3, 7).
 4 S. GUPTA ET AL.

Table 2. Pattern of alcohol use (context/situation of drinking) #

over the past Table 3. Pattern of alcohol use (style of drinking, social aspect, intoxication) over
three months (n = 75). the past three months (n = 75).
Variables Categories Values (n, %) Variables Categories Values (n, %)
Reason to consume Social assertiveness 6 (8.0) Relationship of drinking with food Light snacks/ 57 (76.0)
alcohol Recreation 30 (40.0) (more than one response something to munch
Relaxation/to relieve tension 45 (60.0) possible) Prefer to finish 10 (13.3)
On insistence of others 10 (13.0) drinking before I eat
Sexual pleasure 3 (4.0) Drinking along/after 6 (8.0)
Others 17 (23.6) with meals
Decision to drink in Feeling happy 26 (34.7) Doesn’t matter 7 (9.3)
context of Feeling sad/angry/irritated/ 27 (36.0) Close people who drink (more Neighbor mostly 21 (28.0)
frustrated than one response possible) people in locality
Wanting to relax 17 (23.0) Coworkers 25 (33.3)
Feeling very tired 27 (36.0) Friends 53 (33.3)
Meeting friends 20 (26.3) Others (relatives) 2 (2.7)
No particular reason 16 (21.3) Intoxication related to drinking ‘Get drunk whenever 6 (8.0)
Having quarrel with spouse/ 14 (18.7) (more than one response drink’
parents possible) ‘Get drunk some of 42 (56.0)
Miscellaneous 23 (29.9) the time when drink’
Usual time of Morning 6 (8.0) ‘Never get drunk’ 27 (36.0)
consumption Lunch time 6 (8.0)
Evening 31 (41.3)
Night 31 (41.3)
Throughout the day 18 (24.0)
Usual situation/context of Going out with friends 27 (36.0)
These out-of-treatment participants were recruited into the
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drinking Festivals/marriages 2 (2.6)

Relaxing at home 41 (54.7) study using the snowball technique, and their cross-sectional
Others* 20 (26.7)
Usual place of Pub, bar, or restaurant 9 (12.0)
assessment included severity, pattern, quantity, and frequency
consumption Just outside liquor shops in 32 (42.7) of alcohol use.
the open The participants in the study had a long history of alcohol
Street (crowded place) 13 (17.3)
Lonely place 23 (30.7) use with the presence of features of physical dependence such
At home 44 (58.7) as withdrawals as well as features of psychological dependence
At place of work 24 (33.3) such as craving for more than a decade. About one-fourth also
Miscellaneous 26 (35.9)
Preferred company while Friends/other acquaintances 24 (32.0) showed salience of drinking in terms of drinking throughout
drinking Wife/female friends - the day. Many participants also spent a sizeable proportion of
Mostly my own 51 (68.0)
#
their family income on alcohol use. Yet, all the subjects were
The sum for some variables is more than 100% because participants could give
multiple responses within the same category nontreatment seekers. This draws attention to the fact that
*Includes workplace, outside home, in illicit home-turned liquor shop there are significant numbers of alcohol users in the commu-
nity who are problem alcohol users, yet do not seek treatment
for their alcohol-use problem. As per the last national survey
Style of drinking, social aspect of drinking and on the extent, pattern, and trends of substance-use disorders
intoxication in India, although there are about 60 million alcohol users, the
number of dependent alcohol users was about 10 million
About 76% (n = 57) of the respondents would have light (Ray, 2004). However, the addiction treatment services are
snacks or something to munch along with alcohol. About woefully short (Charlson, Baxter, Cheng, Shidhaye, &
50.7% (n = 38) of the participants consumed more than one Whiteford, 2016; WHO, 2008). There is, hence, an urgent
alcohol beverage on a single occasion, and almost all (n = 74) need to expand treatment services for people suffering from
respondents would dilute their alcohol with water or soda. substance-use disorders, including problem alcohol users.
About 56% of the respondents reported that they were intoxi- The amount of alcohol being used by the participants was
cated ‘some of the time’ after consuming alcohol in the past way above the maximum recommended levels, as the median
three months (Table 3). amount of alcohol consumed in a typical day was about 80 g.
Additionally, it took the participants less than 30 minutes to
consume their quantity of alcohol. Not surprisingly, almost
Severity of alcohol use
all (92%) of the participants reported having HED while
About three-fourth (77%, n = 58) of the participants had more than half of the participants reported being intoxicated
ASSIST score in the ‘high-risk’ range and less than one-fourth due to alcohol. Studies have shown that the complications
(23%, n = 17) had score in the ‘moderate-risk’ range in due to alcohol use are not only due to the total amount
ASSIST. None of the participants was in the ‘low-risk’ cate- consumed, but also due to HED (Dawson et al., 2004;
gory, as this was one of the exclusion criteria. Greenfield et al., 2014; Kim et al., 2008; Midanik et al.,
2003; Nazareth et al., 2011). The total amount consumed is
linked to the long-term risk of dependence and morbidity
Discussion
and mortality in the participants themselves while HED is
The present study was conducted to assess the details of additionally linked to short-term risks related to the general
pattern of drinking among male residents of a slum who public. This includes events such as drunken driving, road
consumed alcohol in a ‘moderate’ or ‘high risk’ manner. traffic accidents, violence etc., (WHO, 2014). Our study

participants appear to be at risk of both the short-term and
long-term complications due to alcohol use, although sur-
prisingly a small minority reported features suggestive of
liver diseases. More than three-fourth participants in our
study had ASSIST scores in the ‘high-risk’ category, which
corresponds to alcohol dependence (WHO ASSIST Working
Group, 2002).
While some findings on the pattern of drinking are similar to
studies conducted from other regions of India, some other find-
ings are unique to our study population. Thus, the finding that
majority preferred drinking alone was reported by other studies
from India (Benegal, 2005; Ghosh et al., 2012); reason for drink-
ing to feel intoxicated and the consumption of different types of
beverages in a drinking occasion (Benegal, 2005) are other
commonalities. However, in comparison, more participants in
our study preferred CML compared with another study
(Benegal, 2005) where Indian-made foreign liquor (IMFL)
(IMFL is the official term used in India to refer all types of
hard spirits manufactured in the country other than indigenous
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alcoholic beverages such as fenny, toddy, arrack, and others) was
found to be the most preferred beverage, and ‘home’ as being the
most common place of drinking while another Indian study
reported the most common place of drinking to be outside
liquor shops (Girish et al., 2010). This underscores the need to
conduct studies in different regions, as understanding the regio-
nal patterns of drinking would have implications for developing
relevant interventions. Understanding alcohol-use pattern in a
given population is important as it has bearing on the conse-
quences associated with alcohol use. Alcohol-related complica-
tions have been seen to be associated with the type of alcohol
beverage, place of consumption, manner of drinking, and other
drinking-associated attributes such as mixing drinks, consuming
food along with drinks, etc.(Benegal, 2005; Brien, Ronksley,
Turner, Mukamal, & Ghali, 2011; Ghosh et al., 2012; Studer
et al., 2015; Vilamovska et al., 2009).
Among the limitations, the sample was of convenience
recruited through snowballing. Snowballing helped in reaching
out to the nontreatment-seeking population, since participants
further referred people like them (i.e. people who drank in
heavy amounts and likely to be dependent), and the sample
obtained in our study cannot be representative of all alcohol
users in the moderate- or high-risk category. Nevertheless, the
study provides a useful understanding on the pattern of alcohol
use among a subset of moderate- and high-risk, nontreatment-
seeking alcohol users from an urban slum in North India.
Conclusion
Among men drinking in a moderate- or high-risk pattern, a size-
able proportion has high rates of HED and yet they are non-
recipient of treatment. They demonstrate some distinct pattern
of alcohol consumption, which is likely to place them at risk of
various adverse acute and long-term consequences of alcohol use.
Disclosure of potential conflicts of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the article.
JOURNAL OF SUBSTANCE USE 5
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