1
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
Medical Academy
Beka Khurtsidze
Alcohol consumption in school-aged children: a comparison between
Lithuania and Georgia
Master Thesis
(Public Health, Preventive Medicine)
Student: Beka Khurtsidze Supervisor: Dr. Mindaugas Štelemėkas
(Signature)... (Signature)...
Date: Date:
2
Table of Contents
1. Abbreviations ... 3
2. Introduction ... 4
3. Aim and Objectives of the study: ... 6
4. Literature Review ... 7
4.1. Alcohol consumption in school-aged children: ... 7
4.2. Global strategy to reduce the harmful use of alcohol ... 10
4.3. Prevention measures related to alcohol use reduction implemented in Lithuania: ... 11
4.4. Alcohol consumption: ... 11
4.5. Alcohol-attributable Mortality: ... 13
5. Research Methodology ... 16
6. Results ... 19
6.1 The review of the situation in Georgia: ... 19
6.2 The review of the situation in Lithuania ... 24
6.3 A comparison of the current situation in Lithuania and Georgia... 31
7. Discussion ... 38
8. Conclusions ... 41
9. Practical recommendations ... 42
3
1. Abbreviations
WHO–World Health Organization
HBSC–Health Behaviour in School-aged Children
NCDC–National Centre for Disease Control
AAM–Alcohol Attributable Mortality
GBD–Global Burden of Disease
CVD–Cardio Vascular Disease
HCV–Hepatitis C Virus
DALY–Disability Adjusted Life Years
U.S. –United States
4
2. Introduction
Alcohol consumption has very deep roots in the ancient and modern cultures of many countries and regions across the globe. Its effects often go beyond the celebratory and gregarious to include
undesirable health, social and economic outcomes. Almost all societies that consume alcohol show
related health and social problems. The marketing globalization and production industrialization have increased the amount of global consumption of alcohol and alcohol-related harms by itself. Alcohol also is responsible for 3.8% of all global deaths and 4.6% of global disability-adjusted life years (DALY), and costs related with its use in high-income and middle-income countries are over
1% of gross domestic product (GDP) [1].
The actuality of the problem: Adolescent’s health care is a big challenge for developing
countries. Georgia and Lithuania are one of those developing countries, and both of them are facing the transition from Soviet culture. The absence of adolescent-friendly healthcare services influence negatively adolescents and youths health and increases the burden of adolescent’s mortality and morbidity in the country. This Study is focused on alcohol consumption in school-aged children in Lithuania and Georgia because the problem is very relevant in both countries. In Georgia, it is related to winemaking tradition. According to the World Health Organization(WHO), 2010 survey[2] Georgia was consuming 8.1 liters of pure alcohol per capita, Lithuania 13.61. The same study has defined that Lithuania was on the 3rd (from 191 countries) place by consuming alcohol and Georgia on 67th.
This is the first study which is comparing alcohol consumption in school-aged children in Georgia and Lithuania. Results of this study by comparing Georgian and Lithuanian data defined to be very different from what WHO has researched in 2010 for the whole population. So the survey is saying a piece of new information on how significantly different is compared data, which can be used in preventive measures for reducing alcohol consumption in both countries and especially in Georgia. Also, it can be used for increased education about the harmful use of alcohol for children at an early age.
In this survey, the most recent alcohol-related data from 2018 were analyzed, from WHO collaborated cross-national study, Health Behavior in School-Aged Children (HBSC)[3]. HBSC study in Georgia is the first and only source of information on adolescent health in the country, providing national, international and local data to stakeholders. National wide surveys conducted the first time in 2018 by the National Center for Disease Control and Public Health of Georgia. The
5 author of this study has personally received the data from NCDC Georgia. The data from Georgia was personally handed from the preventive medicine department of NCDC Georgia. Lithuanian data was provided from the Lithuanian University of Health Sciences and approved by the ethics committee.
The novelty of the problem: The research of Alcohol consumption in school-aged children: a
comparison of Lithuania and Georgia was conducted for the first time and can be used by students, teachers and medical personnel in both countries
Practical use: The survey is saying a piece of new information on how significantly different is
compared data, which can be used in preventive measures for reducing alcohol consumption in both countries and especially in Georgia. Also, it can be for increased education about the harmful use of alcohol for children at an early age.
Personal input: The author of this study has made the formalities of the work (Bioethics
permission), analyzed the literature and methodologies of Health Behavior in School-aged Children, and also received HBSC data from the National Center of Disease Control (NCDC) Georgia. Analyzed Georgian and Lithuanian data and summarized the findings.
6
3. Aim and Objectives of the study:
Aim:
To analyze alcohol consumption related situation among school-aged children in Lithuania and Georgia
Objectives:
1. To review the alcohol consumption situation in school-aged children in Georgia
2. To review the alcohol consumption situation in school-aged children in Lithuania
7
4. Literature Review
Alcohol consumption is a major problem worldwide, Lithuania and Georgia are not exceptions, and these two countries are facing a current problem for a long time. Alcohol consumption is associated with the risk of many harmful health conditions such as injuries, violence, alcohol poisoning, chronic diseases, cancers, reproductive health, etc. [4]. Future generation’s health and their rights are challenges for developing countries. Structural and functional changes in adolescents impact their behavior and emotion. Georgia and Lithuania are one of these developing countries and both of them are facing a post-soviet transition. The absence of adolescent-friendly healthcare services influence negatively adolescents’ health and increase the burden of adolescents mortality and morbidity in the country. Alcohol consumption in school-aged children is a big problem in the selected countries. According to World Health Organization(WHO), 2010 survey[2] Georgia was consuming 8.1(Beer 1.40/Wine 3.81/Spirits 2.89) liters of pure alcohol per capita, Lithuania 13.61 (Beer 5.93/Wine 0.99/Spirits 5.05/Other 1.65). These numbers have significantly changed in past years only in Georgia and in 2016 it became 7.44(Beer 1.37/Wine 3.20/Spirits 2.86/ other 0.01) in Lithuania Situation was the same. The same study has defined that Lithuania was on the 3rd place (from 191 countries) and Georgia on 67th. The volume of Alcohol-related mortality is huge worldwide, in 2012 3.3 million (5.9% of all deaths) people died from harmful use of alcohol in the entire world[5]. By this determinant, Lithuania is on 7th place (from 181 countries) with a high rate
of 8.26 and Georgia on 146th with a low rate of 0.56[6].
4.1. Alcohol consumption in school-aged children:
The very first survey of Health behavior in school-aged children(HBSC)[3] worldwide was conducted in 1993/1994 years[7], and it already included a questionnaire about alcohol consumption. The harm and impact of alcohol consumption in school children were already big at that time. Lithuania already was a part of the HBSC family from the very beginning and the survey for these years. The survey defined that by questioning category "students who have been really drunk two or more times" Denmark was on the first place in 15-year-old children, the smallest number of drinkers in all aging categories was in Greenland. In Lithuania, the highest amount of consumers was in 11 years old children. The next survey of HBSC followed in 1997/1998[8] where the situation didn't seem to change significantly. Some countries have changed the places but the
8 overall situation seemed to remain the same. In the years 2001/2002 [9] situation of Lithuanian youth by consuming alcohol got worse. Regardless the fact that a lot of countries joined HBSC family at this year Lithuania anyway was in the leading list of students who were drunk two or more times in a lifetime, especially in 11 years category and the number of boys was enormously big here compare to girls. In 2005/2006[10] by the category 15-year-olds who report first drunkenness at age 13 or younger Lithuania was on the second place from 40 participant countries. Which seems to be very alarming information. In the next four years in the 2009/2010[11] survey, the situation got even worse for Lithuania and at the same category as in the previous survey it now took the first place, and at the questions 13 and 15-year-olds who have been drunk at least twice, Lithuania was on second places. The situation remained the same for 2013/2014[12]round and Lithuania still was leading the list of 15-year-old children which reported first drunkenness at age 13 or younger
Inequalities were found In Scotland in adolescent alcohol use by urban/rurality and the neighborhood social conditions[13]. Neighborhood social cohesion related to having ever drunk. An urban-to-rural gradient was found with non-urban adolescents exhibiting higher odds of having ever drunk. Among drinkers, those living in accessible small towns had higher odds of weekly drinking and drunkenness compared to urban areas. Higher odds of drunkenness were also found in remote rural areas. Those residing in the least deprived areas had lower odds of weekly drinking.[14]
In 2008 about 15 children daily in Scotland under the age of 17 were arriving at the hospital emergency departments drunk and in need of treatment[15]. The extent of the problem has been shown in an audit carried out at all 21 emergency departments in Scotland for over six weeks. It defined that 648 children under the age of 17 needed help for the impacts of drinking alcohol, including 15 aged under 12 and one as young as eight. They had consumed an average of 13 units of alcohol—the equivalent of six pints of lager—in the 24 hours before attendance.
The 2011 survey in Germany defined some connections between ethnicity and alcohol consumption
in school-aged children[16]. Children who live in a rural area have fewer alternatives for engaging
in interesting routine activities than children who live in big cities. This might be the biggest reason for the alcohol consumption situation in a rural area. The expectations about the drinking behavior of children who had certain cultural, traditional or religious backgrounds (migrant children who had Russian background were drinking more than migrant children from Arabic or Islamic countries)
9 were only partly proved. Possibly, German permission to alcohol consumption plays some role in the degree of acculturation.
Lifetime consumption for alcohol differed significantly between rural (93.7%) and urban areas (86.6% large cities; 89.1% smaller cities) with a higher number of consumption in rural areas. The same results appaired for a 12-month prevalence of alcohol consumption. 57.3% of the rural, 45.9% of the urban children were drinking in the 4 weeks prior to the survey. Students with a migration background of the former Soviet Union showed mainly drinking behavior similar to that of German adolescents. Children with Turkish backgrounds were drinking in the last 4 weeks less frequently than children with German roots. (23.6% vs. 57.4%). However, in those children who consumed alcohol in the last 4 weeks, alcohol consumption is very prominent across cultural backgrounds.
A very recent study in 21019[17] defined new shreds of evidence of a connection between alcohol consumption and disrupted brain functional organization in youth. These children have been drinking from young ages and highlighted negative feedback. Alcohol is the most popular substance in children; it has a major influence on the brain and personality of young people, which has to be considered for future preventive measures. It will reduce the prevalence of alcohol-related adverse outcomes.
From 16 to 20 years of age period, late adolescence is a time of expanded and fast transition in particularly every sphere of life working. It is also a period of continued neurologic, intellectual, and social maturation. These evolutional changes and background set the stage for late adolescents’ increasing connection with alcohol. Increased freedom, reduced parental monitoring, and greater involvement with peers all create the opportunity for psychological growth; they also create a context for the rise of problem drinking. An alarming number of late adolescents, especially those who are out of high school, engage regularly in hazardous drinking. Although these problematic drinking practices are wide-spread among late adolescents, they are not universal. Adolescents with a history of behavioral problems and a family history of alcoholism seem especially prone to engaging in problem drinking. A study in 2009 defined that[18] although problem drinking may represent a transient phase in the lives of many adolescents, for others it can have profound and life-altering effects. Adolescence is now recognized as a period of continued neurologic development, and the adolescent brain may be especially vulnerable to the neurotoxic effects of alcohol, especially given the typical ways in which youths drink. Problem drinking in late adolescence is directly linked to an increased risk of an AUD in early adulthood. Less clear is how problem
10 drinking influences other life outcomes, including risk for mental health problems and social achievement. Although there have been some notable successes, most efforts to treat and/or to prevent adolescent drinking have had limited success. This may be because many of the interventions have been modeled on those used with adults, rather than being tailored to the unique cognitive and social context of late adolescence.
4.2. Global strategy to reduce the harmful use of alcohol(Resolution of the Sixty-third World
Health Assembly (May 2010)[19] is following 5 objectives which are:
1. raised global awareness of the magnitude and nature of the health, social and economic problems caused by harmful use of alcohol, and increased commitment by governments to act to address the harmful use of alcohol
2. strengthen the knowledge base on the magnitude and determinants of alcohol-related harm and on effective interventions to reduce and prevent such harm
3. increased technical support to, and enhanced capacity of, Member States for preventing the harmful use of alcohol and managing alcohol-use disorders and associated health conditions
4. strengthen partnerships and better coordination among stakeholders and increased mobilization of resources required for appropriate and concerted action to prevent the harmful use of alcohol[20]
5. Improved systems for monitoring and surveillance at different levels, and more effective dissemination and application of information for advocacy, policy development, and evaluation purposes. [21]
Dry law- also known as the noble experiment is the bright example of how alcohol consumption can't be prevented. Prohibition in the United States was the government's attempt to outlaw the production sale and shipment of alcohol and intoxicating alcoholic beverages across the country. Prohibition of alcohol brought nothing good to the U.S. and soon everything went out of the control, it only brought smugglers, the black market which fell under the control of gangsters like Al Capone and Bugs Moran, homemade undrinkable poisonous alcohol and a lot of violence.
Between all the homemade solutions tens of thousands were poisoned or killed during Prohibition.[22]
11
4.3. Prevention measures related to alcohol use reduction implemented in Lithuania[23,24]:
• Lithuania applies a licensing system for alcoholic beverages (licenses for import, admission, and export of alcoholic beverages, also licenses for production, retail trade and wholesale of alcoholic beverages are issued).
• Prohibition of home-made alcoholic beverages (except for cases of personal use when alcoholic beverages of natural fermentation are produced not exceeding 18 percent of alcohol concentration, and for beer - 9,5 percent;
• Definition of sites for alcohol sale establishing places where trade in alcoholic beverages is allowed and prohibited;
• The setting of the minimum age to buy alcoholic beverages granting the sellers the right to request a document certifying the person's age, and prohibiting persons younger than 18 years of age to use or possess alcoholic beverages,
• Prohibition to sell alcoholic beverages to intoxicated persons establishing that sellers must ensure unavailability for intoxicated persons to acquire alcoholic beverages;
• Alcohol beverages sale prohibition at night time (8 p.m. – 8 a.m.)
• Reduction of alcohol use through taxation: Increase of Excise duty on alcohol • Prohibition to sell alcohol on September 1.
• Prohibition to use, have and transport alcoholic beverages in open packaging in the passenger compartment of automobiles; [25]
• Organization of narcological supervision including treatment interventions for alcohol-dependent persons and providing restrictions of action in the cases of dependence;
• Advertising of alcoholic beverages is limited in the radio and TV programs during the daytime. Advertising of alcohol allowed only at night time on TV.
• Prohibition to keep open bottles, cans with alcohol inside the vehicles
4.4. Alcohol consumption:
A lot of surveys have already proved that alcohol consumption has a harmful influence on health. Health risk factor caused by consuming alcohol we can divide into two parts:
• Short-term Health risks[26]
12
4.4.1. Short-term Health Risks:
A time series analysis in Australia proved the relation between alcohol consumption and fatal injuries. Results defined that the association between alcohol consumption per capita and fatal injuries were statistically significant. An increase in per capita alcohol consumption of 1L was accompanied by an increase in traffic mortality of 0.5 among females and 3.4 among males per 100,000 inhabitants[27].[28]
Alcohol boozing seems to be a very important factor in homicide rates. A lot of people drink, often and to excess, without violent consequences. So the role of alcohol may vary according to the social situation and cultural context[29]. Parker and Rebhun[30] called this “selective disinhibition" and argued about the relationship between alcohol consumption and violence was mediated by situational characteristics. Parker found evidence for the relationship between alcohol and violence in the U.S. and argued that consuming alcohol is a situational factor that may serve to turn a run-of-the-mill confrontation into a homicide event[31]. The experimental research of Taylor[32] similarly suggested that alcohol consumption leads to aggression, but only when some kind of competition is involved in the interpersonal interaction.[33]
Methyl and Ethyl alcohol poisoning are still responsible for high morbidity and mortality rates. The retrospective study which examined ethyl and methyl alcohol poisoning related deaths in Ankara, Turkey studied 10,720 medico-legal autopsy cases between 2001-2011 [34].[35] The results of the survey say that the deaths due to methanol and ethanol poisoning were 74 (0.69% of all medico-legal autopsies performed) and of these 35(47.3%) were methanol poisoning and 39(52.7%) were ethanol poisoning. The majority of the cases were male (N=67, 90.5%) with a mean age of 44.9 ±
10.9 years. The age group of 35-49 years was mostly affected.[36]
4.4.2. Long-term Health Risks:
A lot of studies had already proved that alcohol has a negative effect on the cardiovascular system, But Tomas A. Pearson[37] and Paul E. Ronksley[38] argued about the positive effect of alcohol on CVS. Their surveys proved that alcohol can not only bring harm but also bring a cardioprotective effect. The secret is only in doses and it is different for males and females. Dose-response analysis revealed that the lowest risk of coronary heart disease mortality occurred with 1–2 drinks a day, but for stroke mortality, it occurred with ≤1 drink per day. There was also a proved relationship between alcohol consumption and disease as Insomnia, and other sleep disorders also with the neuropathological disease[39,40].
Marissa B.'s study about the Prevalence of alcohol dependence among U.S. adult drinkers[41] defined that from 2009 to 2011, the prevalence of previous-year drinking among adults was 70 %.
13 When evaluated by education, the prevalence of binge drinking was significantly higher among those with some college education than among those with other levels of education. By drinking patterns, the prevalence of alcohol dependence was 10.2% among excessive drinkers, 10.5% among binge drinkers, and 1.3% among non-binge drinkers. The prevalence of alcohol dependence was significantly higher among excessive drinkers and binge drinkers than among non-binge drinkers across all sociodemographic groups[42]. The study also found that about 9 of 10 adult excessive drinkers did not meet the diagnostic criteria for alcohol dependence. About 90% of excessively drinking adults reported binge drinking, and the prevalence of alcohol dependence was similar among excessive drinkers and binge drinkers.[43]
Alcohol depended people/Chronic alcoholics have a high incidence of hepatitis C virus (HCV)[44] which may be due, in part, to the action of alcohol on the cellular immune response to epitopes that reside on viral structural and non-structural proteins. The natural history of HCV infection is influenced by genetic and environmental factors of which chronic alcohol use is an independent risk factor for cirrhosis in HCV infected individuals[45]. Alcohol synergistically enhances the progression of liver disease and the risk for liver cancer caused by hepatitis C virus (HCV). [46]
4.5. Alcohol-attributable Mortality:
Alcohol-attributable Mortality (AAM) can be caused by several reasons, and in some countries, the volume of AAM is still growing and annually becoming more. From all cases/surveys what I have studied majority in AAM are a man.
AAM in France in 2009[47]: out of 535,000 deaths in 2009, 49,000 were related to alcohol. 12,500
among women and 36,500 among men, which is 5 and 13% from total deaths. Causes of AAM among both genders are so:
Men: cancer 11,197, oral cavity 951, liver 1,850, breast 0, ischemic heart disease 938, alcoholic liver disease 3543.
Women: cancer 4,003, oral cavity 178, liver 201, breast 2,199, ischemic heart disease -529, alcoholic liver disease 1,317.
AAM in the U.S. in 2005 [48]: For people aged 15 to 64 years, alcohol was responsible for
for55,974 deaths in 2005 representing 9.0% of all deaths in that age range. This number can be broken down by sex into 46,461 representing 12.0% of all deaths of men, and 9,513 representing 4.1% of all deaths of women.
14
Most of the deaths attributable to alcohol were due to injuries, with 36,622 such deaths (33,485 for men; 3,137 for women). In terms of the number of deaths attributable to alcohol, the net effect was highest for the older age groups, peaking in the age range of45 to 54 years; however, this was dependent on the cause of death, with people in younger age categories experiencing much more mortality attributable to injuries than was experienced by people in older age groups.
AAM in Switzerland in 2011[49]: Overall in 2011, 1,600 individuals (95% confidence intervals-CI:
1,472 – 1,728) died due to alcohol between 15 and 74 years, almost three times more men than women(419 women and 1,181 men). This corresponds to a rate of 13.8 women and 38.8 men per 100,000.
Overall, based on net estimates, 8.7% of all deaths in the age group of 15 to 74 years were due to alcohol consumption.[50]
The single most important cause of death due to alcohol among men was an alcoholic liver disease, followed by self-inflicted injuries. For women, alcoholic liver disease was the single most important cause, followed by breast cancers. Overall, in broader categories, most alcohol-attributable deaths were due to injuries (522 deaths), cancers (473 deaths) and digestive diseases (440 deaths).
In younger ages, alcohol-attributable deaths mainly stem from injuries, whereas with increasing age, digestive diseases (predominantly liver disease) and cancers gain increasing importance. Among women, breast cancer alone accounts for about one-quarter of all alcohol-attributable deaths.
In the figure below is described Alcohol Attributable mortality in Lithuania and Georgia according to the causes for 2014[51]:
15
Fig. 1. Distribution of AAM by disease in Lithuania and Georgia
0 500 1000 1500 2000 2500 3000 3500 4000 Lithuania Georgia
Standardized mortality from alcohol-attributable disease and injury categories in 2014 (overall age-standardized rate and rate of
alcohol-attributable causes of death per million)
Liver Chirosis (LIT 197.1/ Geo 203.9) Cancer (Lit 1156.2/ Geo 945.8) CVD (Lit 2411.5/ Geo 3681.7) Injuries (Lit 729.9/ Geo 438.8)
16
5. Research Methodology
Type of research.
This is inductive, quantitative study, data for the present study were derived from the Georgian and Lithuanian version of the 2018 survey of Health Behavior among School-aged Children (HBSC), which is conducted every four-year (cross-sectional research study) in collaboration with the World Health Organization (WHO) Regional Office for Europe. The study addresses young people’s health and well-being, health behavior, and social context. The HBSC study used cluster sampling (school or classes) method.
Organization of research
In Georgia, 140 secondary public and private schools were asked to participate in the study from the list provided by the Ministry of Education and Science (2321 total secondary schools) and about 87% (123 schools) took part. The main reason for school non-response was due to the lack of free time. According to the HBSC survey methodology, the following age groups were involved in the study: 11, 13, 15-year-old adolescents (5th, 7th, 9th grades), from the rural and urban settings. The response rate among pupils was high about 87% of students participated in the study. Response rates were higher among 11 and 13 years old than among 15 years old adolescents. The main reason for pupil non-response was illness, unexplained absence or due to their parents' refusal to sign the informed concept. The study was done in the Georgian Language.
Lithuania researched 4191 children from 64 schools with a response rate of 80.5%; sampling was performed using a stratified randomization method.
Data collection:
The self-filled questionnaire was applied as a method of data collection. The questionnaire was developed based on the HBSC mandatory and optional modules, translated and adapted to the Georgian language. Data was collected with the active participation of interviewers from NCDC from in the selected schools and selected grades from 6 May till 25 of 8 June 2018. The author of this study has made the formalities of the work (Bioethics permission), analyzed the literature and methodologies of HBSC, and also received HBSC data from the National Center of Disease Control (NCDC) Georgia. Analyzed Georgian and Lithuanian data and summarized the findings.
17
Researched contingent/ respondents
The study population was young students of public and private schools, aged 11, 13 and 15 years. From Georgia, 2435 children participated in alcohol consumption related questionnaires from which 1266 were male and 1169 female. From Lithuania, 4174 students took a part in a survey from which 2050 were girls and 2124 boys. These age groups were selected due to important stages of development occurring these years. The school-based survey was administered at a national level in both countries
Sample of research and its formation method
Self-administrated questionnaires were completed in the classroom during the spring semester of 2018. In our survey, 12 questions were picked from each country database. As far as valuing groups were not matching each other in the countries, it was necessary to recode the valuing information and here is provided question and answers + their meanings in SPSS values
From Georgia: 1. Are you Male or Female? 1=“Male “/ 2= „Female“2. How many times have you drunk alcohol in your lifetime? 3. How many times have you drunk alcohol in the last 30 days? 4. How many times have you been drunk for a lifetime? 5. How many times have you been drunk for the last 30 days? For the questions 2-5 answers are 1= „0"/2= „1-2"/3= „3-5"/4= „6-9"/5= „10-19"/6= „20-39"/7= „40+". 6. At what age did you drink beer the first time? 7. At what age did you drink cider the first time? 8. At what age did you drink wine the first time? 9. At what age did you drink alcopops the first time? 10. At what age did you drink spirits the first time? 11. At what age did you get drunk the first time? For questions 6-11 answers + SPSS values are 1= never/2= „9 years old or less"/3= „10 years old"/4= „11 years old"/5= „12 years old"/6= „13 years old"/7= „14 years old"/8= „15 years old"/9= „16 years old". 12. How difficult do you find to get wine? 1= „impossible"/2= „very difficult"/3= „fairly difficult"/4= „fairly easy"/5= „very easy"/6= „don‘t know"
Lithuanian questionnaire: 1. Are you a girl or a boy? 1=“Male“/ 2= „Female“2. On how many times (if any) have you drunk alcohol? (In your lifetime) 3. On how many times (if any) have you drunk alcohol? (In the last 30 days) for the questions 2 and 3 answers are 1= „0“/2= „1-2“/3= „3-5“/4= „6-9“/5= „10-19“/6= „20-29“/7= „30+“. 4-10. at present, how often do you drink anything alcoholic, such as beer, wine or spirits like…? Try to include even those times when you only drink a small amount (Beer/Wine/Spirits, Liquor/ Alcopops/ Spirits and other strong drinks/ Champagne/ Any other drink that contains alcohol). For questions 4-10 answers + SPSS values are 1=”every day”/2=”every week”/3=”every month”/4=”rarely”/5=”never” 11. Have you ever had so much
18 alcohol that you were really drunk? (In your lifetime) 12. Have you ever had so much alcohol that you were really drunk? (In the last 30 days). For 11 and 12 answers are 1=”No, never”/2=”Once”/ 3=”2-3 times”/4=”4-10 times”/5=”More than 10 times”
Methods of data analysis
For analyzing data from Georgia and Lithuania (In I and II objectives to review the situation in Georgia and Lithuania), there was used IBM SPSS 25 and Microsoft word Excel 2007. For comparison of countries and defining square, For comparison of countries and defining chi-square, data was encoded into different variables and united as one data source, values were changed it was used Openepi web software and SPSS together. Categorical variables were shown in numbers and percentages. P-value <0.05 was accepted as significant. For comparison of country groups, there were used, chi-square tests and two-sided z tests.
Research ethics:
From the Lithuanian side to get the HBSC data, It was received permission from the bioethical committee of Lithuanian University of Health Sciences. As far the HBSC survey is first and only conducted information about adolescent’s health, it was done on the national level by NCDC Georgia, so we have received the permission directly from the National Center for Disease Control and Public Health of Georgia, from the head of the Department of Preventive Medicine.
19
6. Results
6.1 The review of the situation in Georgia:
When asking Georgian children “At what age did you drink beer first time?
In total 2393 children answered this question, from which 1245 were boys and 1148girls. From the total amount of children beer has never tried 492(20.6%) of them and 1901 has tried it.
In answering category "Never" girls were more than boys almost 3 times, the opposite situation was for the answer "9 years old or less"
(χ² =151.383; df-8; p<0.005)
Fig. 2. Distribution of respondents who has drunk beer in Georgia by gender
When asking Georgian children “At what age did you drink alcopops the first time?
In total 2300 children answered this question, from which 1116 were girls and 1184 boys. From the total amount of children, alcopops have never tried 1125(51.1%) of them and 1175 has tried it. The majority of both genders have never tried alcopops before
20 (χ² =90.804; df-8; p<0.005)
Fig. 3. Distribution of respondents who has drunk alcopops in Georgia by gender
When asking Georgian children “At what age did you drink wine first time?
In total 2366 children answered this question, from which 1223 were boys and 1143 girls. From the total amount of children wine has never tried 348(14.7%) of them and 2018 has tried it.
The majority of both genders have drunk wine before 9 years, also in this age boys are significantly drinking more.
21 (χ² =83.776; df-8; p<0.005)
Fig. 4. Distribution of respondents who has drunk wine in Georgia by gender
Related to such a big number of wine drinkers one additional question was analyzed “how difficult do you find to get wine? “ was analyzed.
In total 2374 children answered this question, from which 1232 were boys and 1142 girls. From the total amount of children, 925(39.0%) thinks that it is fairly easy to get wine.
22 (χ² =65.431; df-8; p<0.005)
Fig. 5. Distribution of respondents who finds difficult to get wine in Georgia by gender
When asking Georgian children “At what age did you drink spirits the first time?
In total 2337 children answered this question, from which 1207 were boys and 1130 girls. From the total amount of children, spirits have never tried 797(34.1%) of them and 1540 has tried it.
In the answering category "14 years old" amount of children is almost the same (χ² =65.431; df-8; p<0.005)
23 Fig. 6. Distribution of respondents who has drunk spirits in Georgia by gender
When asking Georgian children “At what age did you get drunk for the first time?
In total 2352 children answered this question, from which 1220 were boys and 1132 girls. From the total amount of children 993(42.2%) of them have never been drunk before and 1359 the opposite. But in the aging category of 15 and 16 amount of boys and girls are almost the same.
24 Fig. 7. Distribution of respondents who have been drunk in Georgia by gender
6.2 The review of the situation in Lithuania
When asking Lithuanian children “At present, how often do you drink beer? Try to include even those times when you only drink a small amount“?
In total 4130 children answered this question, from which 2100 were boys and 2030 girls. From both genders, 3211(77.7%)children answered they never drink beer.
In answer categories: every day, every week and every month boys were almost 3 times more than girls.
25 Fig. 8. Distribution of respondents who has drunk beer in Lithuania by gender.
When asking Lithuanian children “At present, how often do you drink wine? Try to include even those times when you only drink a small amount“?
In total 4126 children answered this question, from which 2035 were girls and 2091 boys. From both genders, 3478(84,3%) children answered they never drink wine.
In answer category: "every week" amount of 14-year-old boys and girls were absolutely similar. (χ² =33.153; df-4; p<0.005)
26 Fig. 9. Distribution of respondents who has drunk wine in Lithuania by gender.
When asking Lithuanian children “At present, how often do you drink spirits/liquor? Try to include even those times when you only drink a small amount“?
In total 4066 children answered this question, from which 2005 were girls and 2061 boys. From both genders, 3671(90.3%) children answered they never drink spirits/liquor.
27 Fig. 10. Distribution of respondents who has drunk spirits/liquor in Lithuania by gender.
When asking Lithuanian children “At present, how often do you drink alcopops? Try to include even those times when you only drink a small amount"?
In total 4127 children answered this question, from which 2091 were boys and 2036 girls. From both genders, 3004(72.8%) children answered they never drink alcopops.
But an interesting fact is that girls have been drinking more alcopops than boys in every answering category.
28 (χ² =31.455; df-4; p<0.005)
Fig. 11. Distribution of respondents who has drunk alcopops in Lithuania by gender.
When asking Lithuanian children “At present, how often do you drink spirits and other strong drinks? Try to include even those times when you only drink a small amount“?
In total 4127 children answered this question, from which 2094 were boys and 2033 girls. From both genders, 3546(85.9%) children answered they never drink spirits and other strong drinks. The number of children in both genders was very close to each other in every category, when answering this question.
29 (χ² =30.885; df-4; p<0.005)
Fig. 12. Distribution of respondents who has drunk spirits and other strong drinks Lithuania by gender.
When asking Lithuanian children “At present, how often do you drink champagne? Try to include even those times when you only drink a small amount“?
In total 4126 children answered this question, from which 2032 were girls and 2094 boys. From both genders, 2558(62.0%) children answered they never drink champagne.
30 (χ² =72.442; df-8; p<0.005)
Fig. 13. Distribution of respondents who has drunk champagne in Lithuania by gender.
When asking Lithuanian children “At present, how often do you drink other strong drinks? Try to include even those times when you only drink a small amount“?
In total 4124 children answered this question, from which 2092 were boys and 2032 girls. From both genders, 3386(82.1%) children answered they never drink other strong drinks.
31 (χ² =15.894; df-4; p<0.005)
Fig. 14. Distribution of respondents who has drunk other alcoholic drinks in Lithuania by gender.
6.3 A comparison of the current situation in Lithuania and Georgia
Table. 1. Distribution of respondents aged 11, 13 and 15 by gender in Lithuania and Georgia
Gender Lithuania Georgia Total
Boys 1266 (51.99 %) 2124 (50.89 %) 3390 (51.29 %) Girls 1169 (48.01 %) 2050 (49.11 %) 3219 (48.71 %) Total 2435 (100.0 %) 4174 (100.0 %) 6609 (100.0 %)
6.3.1. A comparison of how many times did respondents drink alcohol in lifetime/last 30 days in Lithuania and Georgia using IBM SPSS
32 In the figure below is illustrated alcohol consumption in Lifetime Lithuania and Georgia. By uniting the data in total 6465(100%) respondents were analyzed from which 4113(63.62%) children were from Lithuania and 2352(36.38%) from Georgia. An interesting fact is that more than 35 % of Lithuanian children have never tried alcohol in a lifetime while in Georgia it was a little bit more than 5 %. In Georgia, the biggest percentage of children answered that they have drunk alcohol in a lifetime more than 40 times while less than 3% of children in Lithuania gave this answer.
(χ² =1711.999; df-6; p<0.005)
Fig. 15. Distribution of respondents by the amount of alcohol drunk in a lifetime in Lithuania and Georgia.
In the table below is shown how significantly different is the situation in countries by consuming alcohol in Lifetime. The biggest difference is in the „Never drinkers" category. In Lithuania, more than half answered they have never tried alcohol where the number of children was a little bit more than 15 %.
33 Table. 2. Distribution of respondents by the significance of the difference between countries by consuming alcohol in a lifetime
Lithuania Georgia Total
Alcohol: Lifetime Never 2308a
(56.1%) 360b (15.3%) 2668 (41,3%) 1-2 times 899a (21.9%) 301b (12.8%) 1200 (18,6%) 3-5 times 319a (7.8%) 312b (13.3%) 631 (9,8%) 6-9 times 181a (4.4%) 283b (12.0%) 464 (7,2%) 10-19 times 145a (3.5%) 339b (14.4%) 484 (7,5%) 20-39 times 72a (1.8%) 254b (10.8%) 326 (5,0%) 40+ times 189a (4.6%) 503b (21.4%) 692 (10,7%) Total 4113 (100.0%) 2352 (100.0%) 6465 (100.0%)
In the figure below is illustrated alcohol consumption in the last 30 days in Lithuania and Georgia. By uniting the data in total 6484(100%) respondents were analyzed from which 4104(63.29%) children were from Lithuania and 2380(36.71%) from Georgia. An interesting fact is that more than 35 % of Lithuanian children have never tried alcohol in a lifetime. In Georgia, the biggest percentage of children answered that they have drunk alcohol in a lifetime more than 40 times.
34 (χ² =563.843; df-6; p<0.005)
Fig. 16. Distribution of respondents by the amount of alcohol drunk in the last 30 days in Lithuania and Georgia.
In the table below is shown how the significantly different situation is in countries when school children were asked about alcohol consumption during the last 30 days. The biggest difference is in the „Never drinkers" category where more than 80 % of respondents from Lithuania have not drunk alcohol while in Georgia less than 60 %.
35 Table. 3. Distribution of respondents by the significance of the difference between countries by consuming alcohol in the last 30 days.
Lithuania Georgia Total
Alcohol: Last 30 days Never 3407a (83.0%) 1358b (57.1%) 4765 (73.5%) 1-2 times 456a (11.1%) 598b (25.1%) 1054 (16.3%) 3-5 times 119a (2.9%) 236b (9.9%) 355 (5.5%) 6-9 times 44a (1.1%) 91b (3.8%) 135 (2.1%) 10-19 times 32a (0.8%) 62b (2.6%) 94 (1.4%) 20-39 times 4a (0.1%) 17b (0.7%) 21 (0.3%) 40+ times 42a (1.0%) 18b (0.8%) 692 (0.9%) Total 4104 (100.0%) 2380 (100.0%) 6484 (100.0%)
6.3.2. A comparison of how many times did respondents get drunk in lifetime/last 30 days in Lithuania and Georgia using Openepi
Table. 4. Distribution of respondents by the number of children who have been drunk in a Lifetime and Last 30 days in Georgia
Georgia
(How many times have you been drunk for a lifetime and last 30 days?)
0 1-2 3-5 6-9 10-19 20-39 40+ total Lifetime? 1336 (57.4%) 630 (27.1%) 204 (8.8%) 74 (3.2%) 45 (1.9%) 24 (1.0%) 15 (0.6%) 2328 (100%) Last 30 days? 2128 (89.6%) 192 (8.1%) 29 (1.2%) 10 (0.4%) 5 (0.2%) 9 (0.4%) 1 (0.0%) 2374 (100%)
36 Table. 5. Distribution of respondents by the number of children who have been drunk in a Lifetime and Last 30 days in Lithuania
Lithuania
(How many times have you been drunk for a lifetime and last 30 days?)
0 Once 2-3 times 4-10 times 10 + times total Lifetime? 3083 (74.8%) 456 (11.1%) 274 (6.7%) 143 (12.0%) 163 (14.4%) 4119 (100%) Last 30 days? 3696 (90.3%) 232 (5.7%) 91 (2.2%) 28 (0.7%) 45 (1.1%) 4092 (100%)
According to the collected data Number of children who have been drunk in a lifetime in Lithuania was more than 70 % while in Georgia it was almost 60 %. The number of children who weren't drunk for the last 30 days in Lithuania was a little bit more than 90% while in Georgia this number was almost the same.
Table. 6. Distribution of respondents who have been drunk in a Lifetime in Lithuania and Georgia, Openepi analysis.
Analysis for the question Been Drunk: Lifetime
Georgia Lithuania Total
Never 1336 (57.4%) 3083 (74.8%) 4419 (68.54%) Ever 992 (42.6%) 1036 (25.2%) 2028 (31.46%) Total 2328 (100%) 4119 (100%) 6447 (100%)
By analyzing data groups were divided into two categories for both genders: 1. Who has never been drunk (Never) 2 Who has been drunk (Ever)
In Georgia, the number of respondents who have been drunk (minimum one time and more) in a lifetime was more than 40 % while this number in Lithuania was a little bit more than 25 %.
37 Table. 7. Distribution of respondents who have been drunk in the last 30 days in Lithuania and Georgia, Openepi analysis.
Analysis for the question Been Drunk: last 30 days
Georgia Lithuania Total
Never 2128 (89.6%) 3696 (90.3%) 5824 (90.07%) Ever 246 (10.4%) 396 (9.7%) 642 (9.93%) Total 2374 (100%) 4092 (100%) 6466 (100%)
By analyzing data, groups were divided into two categories for both genders: 1. Who has not been drunk in the last 30 days (Never) 2 Who has been drunk in the last 30 days (Ever)
In Georgia, the number of respondents who have been drunk (minimum one time and more) in the last 30 days was a little bit more than 10 % while this number in Lithuania was almost the same. This is the only compared data where is no significant difference.
38
7. Discussion
HBSC study is a WHO collaborative cross-national survey that focuses on school children aged 11,13 and 15 years and is doing research every four years. This is the first HBSC study made in Georgia while Lithuania is part of the research network since the very beginning (1993/1994). The HBSC study is one and only source of information about adolescent's health in Georgia, and for now, it is made on a national level by the NCDC Georgia. By comparing Georgian and Lithuanian alcohol consumption related data, our study is saying a piece of a new word and is making visible what is the current situation in both countries, how alcohol consumption habits differ. It also once again proves the theory that in Georgia consumption of wine is high. The reason for this fact is the Georgian traditions of winemaking and feasts. for example, the culture of alcopop drinking is totally unknown in Georgia.
While analyzing Georgian data for I objective, the first noticeable fact that was interesting is in the question „at what age did you drink cider for the first time"? Answers were empty, that is in our opinion because cider is absolutely not a popular drink in Georgia and not only children but even the elderly drink it rarely. The second very important and alarming thing that was noticed was the consumption of wine (Fig. 4.) where the number of children who had drunk it before 9 years was enormously big, especially the number of boys. They were almost twice more than girls and the difference between them was statistically significant.
The author of this study thinks this is related to Georgian winemaking traditions. Almost in every family in Georgia, wine can be found because of why Georgian children have easy access to wine (Fig. 5.). And traditional Georgian feast which is called „supra" is accepting the drinking of alcohol and especially wine in very high amounts. Children see everything this and their relationship with alcohol and in particular with wine is getting loyal.
While analyzing Lithuanian data for II objective, champagne (Fig. 13) „rare drinker" girls defined to be almost on 10% more than boys and the difference between them was statistically significant, but not only this fact was interesting in this table but also the frequency of drinking champagne and those who had never tried it was less than other alcoholic drinks. Another thing to notice what we expected to get while analyzing is an alcopop girl „rare drinkers" (Fig. 11) was more than boys and the difference was statistically significant.
While comparing data in objective III, it was observed that in almost every comparable category Georgian children were consuming more alcohol than Lithuanians.
39 By comparing to a previous HBSC survey 1993-2014[3,7–12] situation in Lithuania seems changed slightly better. Overall alcohol consumption reduced in Lithuania in the last 4 years; maybe it is because of preventive measures which were used in the last period. It is very hard to say how the situation changed in Georgia because there is no such survey which was done before.
The biggest advantage of the HBSC study in Georgia was that it was the first time to conduct it. Georgia is a part of the HBSC family for the last 3 rounds and the last 2 rounds with the status of observer. But there were a few influential disadvantages while doing the research, and the working process could be better without them.
In the process of doing I and II objectives which were to review the situation in Georgia and Lithuania, it had to be used different questioning categories. Georgia was used „at what age did you drink beer, wine, etc. the first time?" and for Lithuania, „how often do you drink beer, wine, etc.?". This is because the HBSC survey has some obligatory questions which were used for the III objective (comparison) and it has some country specified questions that are added by the researchers depended on the interests. So, in this case, we had to use very different data for I and II objective, of course, it still describes the situation in the countries but it would be better to have the similar data for the visualization and quick understanding of objectives and viewers own comparison of objectives.
In III objective there were HBSC obligatory questions compared which had to match perfectly but we had to change values grouping because in this data differed. Also, the Georgian survey asked, „How many times did you drink alcohol for lifetime/last 30 days?" And Lithuanian survey asked, „How many days did you drink alcohol for lifetime/last 30 days? “. Maybe there were some translations mismatches are perceived differently due to cultural differences in two countries, as we already know for both separate HBSC survey questions that were translated in national languages. We used Openepi for two more questions about how many times respondents have been drunk in their Lifetime/Last 30 days. Openepi was used because of the difference in answering categories. In Georgian data sorting of answers was: 0; 1-2; 3-5; 6-9; 10-19; 20-39; 40+, while in Lithuania on the same questions sorting of answers was : 0; once; 2-3; 4-10; 10+.
Also besides these challenges, it may be debated whether there are enough questions for a sole comparison only in alcohol thematic questions, but as HBSC study is a broad study, the health-related comparison between the two countries may be much wider in terms of many health-health-related aspects. For the narrow alcohol-related comparison, the number of questions about alcohol consumption in the Lithuanian survey was quite low, while the Georgian questionnaire in this
40 particular field was very diverse. Maybe this was because of the number of questioned Lithuanian students was almost twice more than the number of Georgian students.
This is the first study which is comparing alcohol consumption in school-aged children in Georgia and Lithuania. So the survey is saying a piece of new information on how significantly different is compared data, which can be used in preventive measures for reducing alcohol consumption in both countries and especially in Georgia. Also, it can be for increased education about the harmful use of alcohol for children at an early age.
41
8. Conclusions
1. When reviewing alcohol consumption situation in Georgia, by asking children at what age did they drink various alcoholic drinks, it was defined a very alarming percentage (26.5%) of children who had drunk wine at least once in a lifetime before 9 years. When analyzing the data about the difficulties to obtain alcohol (wine in particular) the results were not very encouraging, more than 35% of really young (9 years old or less) children had indicated fairly easy to get wine and 31.5% found it very easy.
2. When reviewing alcohol consumption situation in Lithuania, by asking children how often did they drink different alcoholic drinks? Research defined a very promising number of children who weren't drinking alcohol, compared to every previous HBSC study. But still, there are high percentages in champagne consumers that have to be changed and decreased by preventive measures and educational activities.
3. When comparing Lithuanian and Georgian data, there were Areas where significant differences have been found. The biggest difference was found by comparing data of alcohol consumption in Lifetime, children who have never tried alcohol in Georgia were less on 30% compared to Lithuanian youth. In almost all cases surveyed Georgian children remained to drink more than Lithuanian pupils.
42
9. Practical recommendations
According to the results defined, we can recommend increasing the awareness of family, local community and society itself.
As children in Georgia find wine easily accessible it is better to strengthen control from parents and at family level hide alcohol from children, on governmental level laws about selling alcohol with ID cards should be controlled strictly. Also because of the Georgian traditional feasts, children are getting more loyal to alcohol and in our opinion, it is better to control it by not making it visible for children how parents drink alcohol in high amounts.
43
10. References
1. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. The Lancet. 2009;373:2223–33.
2. GHO | By category | Recorded alcohol per capita consumption, from 2010 - Updated May 2018 [Internet]. WHO. [cited 2018 May 27]. Available from:
http://apps.who.int/gho/data/node.main.A1039?lang=en
3. HBSC [Internet]. [cited 2019 May 17]. Available from: http://www.hbsc.org/about/index.html 4. CDC - Fact Sheets-Alcohol Use And Health - Alcohol [Internet]. 2018 [cited 2018 May 28]. Available from: https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm
5. Alcohol [Internet]. World Health Organ. [cited 2018 May 27]. Available from: http://www.who.int/news-room/fact-sheets/detail/alcohol
6. ALCOHOL DEATH RATE BY COUNTRY [Internet]. World Life Expect. [cited 2018 May 27]. Available from: http://www.worldlifeexpectancy.com/cause-of-death/alcohol/by-country/
7. King AJC, editor. The health of youth: a cross-national survey. Copenhagen, Denmark: WHO Regional Office for Europe; 1996.
8. Health and health behavior among young people. :134.
9. Currie C, World Health Organization, editors. Young people’s health in context: Health
Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen, Denmark: World Health Organization, Regional Office for Europe; 2004.
10. Currie C, Weltgesundheitsorganisation, editors. Inequalities in young people’s health: HBSC international report from the 2005/2006 survey. Copenhagen: WHO; 2008.
11. World Health Organization, Regional Office for Europe. Social determinants of health and well-being among young people: health behavior in school-aged (HBSC) children: international report from the 2009/2010 survey [Internet]. Copenhagen, Denmark: World Health Organization, Regional Office for Europe; 2012 [cited 2019 May 17]. Available from:
http://www.euro.who.int/__data/assets/pdf_file/0003/163857/Social-determinants-of-health-and-well-being-among-young-people.pdf
12. Inchley J, Currie D, Young T, Samdal O, Torsheim T, Augustson L, et al., editors. Growing up unequal: gender and socioeconomic differences in young people’s health and well-being: Health
44 Behaviour in School-Aged Children (HBSC) Study: international report from the 2013/2014
survey. Copenhagen, Denmark: World Health Organization Regional Office for Europe; 2016. 13. The neighborhood social environment and alcohol use among urban and rural Scottish adolescents | SpringerLink [Internet]. [cited 2019 May 19]. Available from:
https://link.springer.com/article/10.1007%2Fs00038-018-1181-8#Abs1
14. Treno AJ, Ponicki WR, Remer LG, Gruenewald PJ. Alcohol Outlets, Youth Drinking, and Self-Reported Ease of Access to Alcohol: A Constraints and Opportunities Approach. Alcohol Clin Exp Res. 2008;32:1372–9.
15. Fifteen children a day attend Scottish emergency departments as a result of drinking alcohol | The BMJ [Internet]. [cited 2019 May 19]. Available from:
https://www.bmj.com/content/336/7652/1036.3.extract
16. Alcohol consumption and binge drinking in adolescents: comparison of different migration backgrounds and rural vs. urban residence - a representative study | BMC Public Health | Full Text [Internet]. [cited 2019 May 19]. Available from:
https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-11-84
17. Ruan H, Zhou Y, Luo Q, Robert GH, Desrivières S, Quinlan EB, et al. Adolescent binge drinking disrupts normal trajectories of brain functional organization and personality maturation. NeuroImage Clin [Internet]. 2019 [cited 2019 May 22];22. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6451196/
18. Brown SA, McGue M, Maggs J, Schulenberg J, Hingson R, Swartzwelder S, et al. A
Developmental Perspective on Alcohol and Youths 16 to 20 Years of Age. Pediatrics. 2008;121: S290–310.
19. World Health Organization, editor. Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization; 2010.
20. Madureira-Lima J, Galea S. Alcohol control policies and alcohol consumption: an international comparison of 167 countries. J Epidemiol Community Health. 2018;72:54–60.
21. Anderson P, Chisholm D, Fuhr DC. Effectiveness and cost-effectiveness of policies and programs to reduce the harm caused by alcohol. The Lancet. 2009;373:2234–46.
22. The Noble Experiment [Internet]. Prohib. 1920sbr Br Br Br. [cited 2018 Jun 10]. Available from: http://prohibition101.weebly.com/the-noble-experiment.html
23. ev_20090217_co05_en.pdf [Internet]. [cited 2018 Jun 10]. Available from:
http://ec.europa.eu/health/archive/ph_determinants/life_style/alcohol/documents/ev_20090217_co0 5_en.pdf
45 24. World Health Organization, Regional Office for Europe. European action plan to reduce the harmful use of alcohol 2012-2020 [Internet]. Copenhagen: WHO Regional Office for Europe; 2012 [cited 2018 Jun 10]. Available from: http://ranzetta.typepad.com/files/european-action-plan-to-reduce-the-harmful-use-of-alcohol-20122020.pdf
25. Wagenaar AC, Langley JD. Alcohol licensing system changes and alcohol consumption: introduction of wine into New Zealand grocery stores. Addiction. 1995;90:773–83.
26. Jung Y, Namkoong K. Chapter 7 - Alcohol: intoxication and poisoning – diagnosis and treatment. In: Sullivan EV, Pfefferbaum A, editors. Handb Clin Neurol [Internet]. Elsevier; 2014 [cited 2019 May 22]. p. 115–21. Available from:
http://www.sciencedirect.com/science/article/pii/B9780444626196000070
27. Jiang H, Livingston M, Room R. Alcohol Consumption and Fatal Injuries in Australia Before and After Major Traffic Safety Initiatives: A Time Series Analysis. Alcohol Clin Exp Res. 39:175– 83.
28. Scribner RA, MacKinnon DP, Dwyer JH. Alcohol outlet density and motor vehicle crashes in Los Angeles County cities. J Stud Alcohol. 1994;55:447–53.
29. Marshall M, Tropic T. Beliefs, Behaviors, & Alcoholic Beverages: A Cross-cultural Survey. University of Michigan Press; 1979.
30. Parker RN. Alcohol and Homicide: A Deadly Combination of Two American Traditions. SUNY Press; 1997.
31. PARKER RN. Bringing “Booze” Back In: The Relationship Between Alcohol and Homicide. J Res Crime Delinquency. 1995;32:3–38.
32. Experimental Investigation of Alcohol-Induced Aggression in Humans - ProQuest [Internet]. [cited 2018 May 28]. Available from:
https://search.proquest.com/openview/61882dfa53129e36e96308bc82d294ac/1?pq-origsite=gscholar&cbl=2031130
33. Trolldal B. An investigation of the effect of privatization of retail sales of alcohol on consumption and traffic accidents in Alberta, Canada. Addiction. 2005;100:662–71.
34. Fatal ethyl and methyl alcohol-related poisoning in Ankara: A retrospective analysis of 10,720 cases between 2001 and 2011- ClinicalKey [Internet]. [cited 2018 Jun 1]. Available from:
https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S1752928X12001370?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS1 752928X12001370%3Fshowall%3Dtrue&referrer=https:%2F%2Fwww.ncbi.nlm.nih.gov%2F
46 35. Freisthler B, Weiss RE. Using Bayesian Space-Time Models to Understand the Substance Use Environment and Risk for Being Referred to Child Protective Services. Subst Use Misuse.
2008;43:239–51.
36. Wagenaar AC, Holder HD. Changes in alcohol consumption resulting from the elimination of retail wine monopolies: results from five U.S. states. J Stud Alcohol. 1995;56:566–72.
37. Pearson TA. Alcohol and Heart Disease. Circulation. 1996;94:3023–5.
38. Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol
consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. BMJ. 2011;342:d671–d671.
39. Chakravorty S, Chaudhary NS, Brower KJ. Alcohol Dependence and Its Relationship With Insomnia and Other Sleep Disorders. Alcohol Clin Exp Res. 2016;40:2271–82.
40. de la Monte SM, Kril JJ. Human alcohol-related neuropathology. Acta Neuropathol (Berl). 2014;127:71–90.
41. Esser MB. Prevalence of Alcohol Dependence Among US Adult Drinkers, 2009–2011. Prev Chronic Dis [Internet]. 2014 [cited 2018 May 30];11. Available from:
https://www.cdc.gov/pcd/issues/2014/14_0329.htm
42. Treno AJ, Ponicki WR, Stockwell T, Macdonald S, Gruenewald PJ, Zhao J, et al. Alcohol Outlet Densities and Alcohol Price: The British Columbia Experiment in the Partial Privatization of Alcohol Sales Off-Premise. Alcohol Clin Exp Res. 2013;37:854–9.
43. Changes in per capita alcohol sales during the partial privatization of British Columbia’s retail alcohol monopoly 2003–2008: a multi‐level local area analysis - Stockwell - 2009 - Addiction - Wiley Online Library [Internet]. [cited 2019 May 20]. Available from:
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1360-0443.2009.02658.x 44. Hepatitis C and Alcohol. 2003;27:8.
45. Szabo G, Wands JR, Eken A, Osna NA, Weinman SA, Machida K, et al. Alcohol and Hepatitis C Virus –Interactions in Immune Dysfunctions and Liver Damage. Alcohol Clin Exp Res.
2010;34:1675–86.
46. Trolldal B. The Privatization of Wine Sales in Quebec in 1978 and 1983 to 1984. Alcohol Clin Exp Res. 2005;29:410–6.
47. Guérin S, Laplanche A, Dunant A, Hill C. Alcohol-attributable mortality in France. Eur J Public Health. 2013;23:588–93.
47 48. Shield KD, Gmel G, Kehoe-Chan T, Dawson DA, Grant BF, Rehm J. Mortality and Potential Years of Life Lost Attributable to Alcohol Consumption by Race and Sex in the United States in 2005. PLOS ONE. 2013;8:e51923.
49. Marmet S, Rehm J, Gmel G, Frick H, Gmel G. Alcohol-attributable mortality in Switzerland in 2011--age-specific causes of death and impact of heavy versus non-heavy drinking. Swiss Med Wkly. 2014;144:w13947.
50. Wu T, Morgan TR, Klein AS, Volk ML, Saab S, Sundaram V. Controversies in Early Liver Transplantation for Severe Alcoholic Hepatitis. Ann Hepatol. 2018;17:759–68.
51. Shield KD, Rylett M, Rehm J, World Health Organization, Regional Office for Europe. Public health successes and missed opportunities: trends in alcohol consumption and attributable mortality in the WHO European Region, 1990-2014. Copenhagen: World Health Organization, Regional Office for Europe; 2016.
