Author: Akau B.Z.
INTRODUCTION
Alcohol consumption, a prevalent aspect of social and cultural practices worldwide, often carries diverse drinking patterns. These patterns, vital in understanding individual behaviors and societal impacts, are assessed through various indicators to gauge the level and potential risks associated with alcohol intake. Drinking patterns refer to the frequency, quantity, and circumstances surrounding alcohol consumption, as well as age and gender differences.
The quantity and pace of an individual's alcohol intake affect the amount of alcohol that enters the brain and the degree of impairment that person experiences. Targeting risk groups for specific behaviors requires understanding the differences in drinking patterns. Like a standard drink, drinking patterns and definitions vary from country to country.
The amount of alcohol consumed can be determined using several indicators. These measurements include the proportion of the population in a country or region that currently drinks or abstains, the amount of pure alcohol consumed annually per person in liters, and the amount of pure alcohol consumed daily per person in grams. The latter two are the most important and commonly used indicators. Another crucial indicator for determining alcohol consumption is blood alcohol concentration.
CATEGORIES OF DRINKING PATTERNS
1. Light Drinking Having three (3) drinks or less per week on average over the previous year is considered light drinking, according to the Centers for Disease Control and Prevention (CDC). Physicians defined light drinking as the consumption of 1.2 drinks per day for both genders. Light drinking has no harmful effects under most conditions. Some studies have shown that light drinking is associated with some health benefits for diabetes mellitus, coronary heart disease, and ischemic stroke. For instance, Gill et al., in a case-control study, reported that the risk of stroke was significantly less in light drinkers (those consuming 10–90 g of pure alcohol per week) as compared with non-drinkers but was four-fold higher in heavy drinkers (those consuming 300g per week).
2. Moderate
Drinking
Having more than three drinks per week but not more than fourteen (14) for men or seven (7) drinks for women is considered moderate drinking, according to the Centers for Disease Control and Prevention (CDC). Physicians define moderate drinking as the consumption of 2.2 drinks per day. The American dietary guidelines describe moderate drinking as the consumption of 1 drink per day for women and up to 2 drinks per day for men. Research has demonstrated that average alcohol consumption can reduce the risk of atherosclerosis, diabetes, ischemic stroke, coronary heart disease, and osteoporosis in postmenopausal women. The definition of moderate drinking is subjective; it may not apply equally to everyone or under all circumstances. Research findings have shown that long-term, light-to-moderate drinking increases the risk of cancer.
3. Low-Risk Drinking
Women should not consume more than three drinks in a single day or more than seven drinks in a week, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA). For men, it is defined as having no more than four drinks per day and no more than fourteen per week. Only 2 out of every 100 people who drink within these limits fit the criteria for alcohol use disorders, according to NIAAA research (AUD). Rehm et al. defined low-risk drinking as the consumption of 2.6–40 g of pure alcohol per day for men and 2.6–20 g per day for women. Even within these limits, people can have problems if they drink quickly or if they have other health issues.
4. Heavy Drinking or High-risk Drinking
This drinking pattern refers to regular alcohol consumption that significantly risks your health. People who engage in this type of drinking are known as heavy, problem, or high-risk drinkers. Drinking more alcohol than is advised daily (e.g., three drinks per day), occasionally (e.g., five drinks at least once a week), or both are commonly referred to as excessive drinking. Such persistent patterns of drinking may result in acute or chronic health and social consequences for the drinker. Heavy drinking is defined as having more than seven drinks for women and more than fourteen for men per week, according to the Centers for Disease Control and Prevention (CDC). Experts define heavy drinking as a harmful drinking pattern in which alcohol is consumed more than 14 units a week for women or 15 units for men. This is the equivalent of consuming more than six pints of regular-strength beer (4% ABV) or seven medium-sized glasses (175 ml) of wine (12% ABV) during a week. Frequent heavy drinking is associated with chronic gastritis, gastrointestinal bleeding, pancreatitis, and esophageal varices.
5. Heavy Episodic Drinking (HED)
HED, also known as binge drinking, refers to drinking occasionally at a level where there is a high risk of intoxication and acute consequences. Those that belong to this category are called heavy, episodic drinkers, or binge drinkers. The World Health Organization defines high alcohol consumption disorder (HED) as consuming five or more drinks in one sitting at least once a week. However, it can also mean consuming 60 grams or more of pure alcohol one or more times. Sixty (60) grams of pure ethanol are equal to six (6) standard alcoholic drinks. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines binge drinking as a pattern of drinking that increases blood alcohol content (BAC) to 0.08 grams per deciliter (0.08%) or higher. In roughly two hours, this equates to four drinks or more for women and five drinks or more for men. In Nigeria, the term "binge drinking" refers to the practice of men consuming more than four calabashes of low-concentration or one to two calabashes of high-concentration drinks in a single sitting. It is more than three calabashes for low-concentration and one calabash for high-concentration alcoholic beverages in women. Binge drinking is associated with acute intoxication, alcohol poisoning, suicide, unintentional injuries, cardiovascular diseases, risky sexual behaviors, neurocognitive impairment, traffic collisions, sexually transmitted infections, and antisocial behaviors.
INDICATORS FOR MEASURING LEVELS OF ALCOHOL CONSUMPTION
1. Current Drinkers
The percentage of people in all age groups who have consumed alcohol in the past 12 months
2. Former drinkers
The percentage of people who have consumed alcohol in their lifetime but have not drunk alcohol in the previous 12 months
3. Lifetime drinkers
The combination of both former and current drinkers, i.e., the prevalence of all the drinkers
4. Abstainers
Abstainers are those who have not consumed alcohol in the past 12 months. They can be lifetime abstainers (people who have never consumed alcohol before), former drinkers, or current abstainers (those who have previously consumed alcohol but who have not done so in the previous 12-month period). Past 12-month abstainers refer to both former drinkers and lifetime abstainers.
5. Total Alcohol Per Capita Consumption (APC)
The total documented plus undocumented alcohol per person consumption in liters of pure alcohol over a calendar year, with visitor consumption taken into account. Abstention rates have a significant impact on APC consumption. High abstention rates increase APC consumption. This is because a country or region's APC consumption decreases when the number of drinkers decreases. APC consumption has two components: recorded and unrecorded alcohol consumption. The term "recorded alcohol" describes alcoholic drinks that are consumed and noted in government statistics, like taxation scales.
Unrecorded alcohol has no record in official statistics on alcohol taxation or scales in the country where it is consumed. It is usually produced, distributed, and sold outside the formal channels under government control. Unrecorded alcohol includes consumption of homemade or informally made alcohol, smuggled alcohol, surrogate alcohol, tourist consumption (alcohol intended for industrial or medical uses), beverages with alcohol content below the legal definition of alcohol, and alcohol obtained from cross-border shopping. Most homemade alcoholic drinks are fermented beverages made from fruits, grains, rice, sorghum, millet, or other traditional ingredients enjoyed at home or in communal settings.
6. Grams of Pure Ethanol per Day
The most widely used indicator of alcohol consumption is this one. Countries that have established regulations for daily alcohol consumption limits use them to reduce the risk of illness and injury.
g/day = APC x 1000 x 0.793 / 365 days.
For safety and intervention in low-risk drinking, WHO adopted a guideline for defining a standard drink as any drink containing 10g of pure alcohol. Both men and women are advised not to exceed two standard drinks per day (i.e., 20g per day). The definition of a legal drink varies across countries, ranging from 8 to 20 grams. For instance, a standard drink in the UK and US contains 8 and 14 grams of pure alcohol, respectively. However, not every nation has a standard drink that is unique to it; Nigeria is one of those nations. Many Nigerian studies rely on the WHO standard drink definition. In many Nigerian studies, the WHO standard drink guideline is often expressed in units, such that men consume no more than 15 units of pure alcohol per week and women no more than 14 units. That means each person should not have more than two units (20g) of pure alcohol per day. The percentage of alcohol by volume (ABV) can be used to calculate the unit of alcohol in the following way:
The volume of alcohol (ml) × % of alcohol per 1000.53
Men should have no more than nine calabashes of locally brewed alcohol per week, and women should have no more than seven calabashes of low-alcohol beverages such as palm wine, burukutu, and pito. Men should not consume more than four calabashes per week of high-concentration drinks (such as Ogogoro and Kaikai), and women should not consume more than three calabashes per week.
7. Blood Alcohol Concentration (BAC)
Blood alcohol concentration (BAC) refers to the milligrams of alcohol per 100 millimeters of blood. It is most commonly expressed using percentages. For instance, having a BAC of 0.10 means that the person has 1 part alcohol per 1,000 parts blood. The acceptable BAC limit by the WHO global strategy is 0.02% to 0.05%. However, this varies in most countries, ranging from 0.01% to 0.08%. Physiological changes appear as a function of BAC. For instance, BAC levels of 0.02% to 0.09% will cause mood changes (such as euphoria, increased social ability, talkativeness, and a more expansive personality), loss of inhibition, and impaired coordination, and BAC levels of 0.1% to 0.19% will cause lack of coordination, defective judgment, and difficulty walking and standing steadily. BAC of 0.2% to 0.29% will cause ataxia, primary motor impairment, and nausea; BAC of 0.3%–0.39% will cause sedation, marked decreased responsiveness to environmental stimuli, and partial amnesia (blackout); and BAC of 0.4% and above will cause alcohol poisoning, coma, and risk of death (the lethal dose for 50% of people).
8. CAGE Questionnaire
The CAGE questionnaire is a widely used screening tool designed to identify potential alcohol-related problems or alcohol use disorders. Its name is an acronym derived from its four key questions: cut down, annoyed, guilty, and eye-opener. Developed in 1984 by Dr. John Ewing, this questionnaire provides a simple yet effective means of assessing an individual's relationship with alcohol and the potential for alcohol abuse or dependence.
Cut Down: "Have you ever felt you should cut down on your drinking?" This question aims to determine if the individual has ever considered or felt the need to reduce their alcohol consumption
Annoyed: "Have people annoyed you by criticizing your drinking?" It assesses whether others' perceptions or criticisms about the person's drinking behavior have been a source of irritation or annoyance.
Guilty: "Have you ever felt guilty about drinking?" This question probes into feelings of remorse, guilt, or regret related to alcohol consumption.
Eye-opener: "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?" This question targets whether the person resorts to alcohol in the morning as a coping mechanism or to alleviate the effects of a hangover.
The CAGE questionnaire is the first screening instrument designed to help clinicians, counselors, and other healthcare professionals rapidly ascertain a person's patterns of alcohol consumption and potential issues related to alcohol abuse. Each "yes" response to a question is assigned one point, leading to a total score ranging from 0 to 4. Higher scores indicate a greater likelihood of alcohol-related problems or dependence. When two or more "yes" answers are received, it usually denotes that additional testing or assistance is required. The questionnaire prompts discussions between healthcare professionals and individuals about their drinking behavior, enabling a non-confrontational approach to addressing potential alcohol-related concerns. Early identification through the CAGE questionnaire allows for timely intervention, potentially preventing the escalation of alcohol-related problems and facilitating access to appropriate support or treatment.
9. Alcohol Use Disorders Identification Test (AUDIT)
The World Health Organization (WHO) created the comprehensive screening tool known as the Alcohol Use Disorders Identification Test (AUDIT) to evaluate a person's patterns of alcohol consumption, associated behaviors, and potential alcohol use disorders. It comprises ten questions that cover various aspects of alcohol use, providing a more in-depth evaluation compared to more straightforward screening tools like the CAGE questionnaire.
Questions 1-3 evaluate consumption patterns of alcohol.
These questions focus on the frequency and quantity of alcohol consumed. They inquire about the frequency of drinking, the amount consumed on a single occasion, and the frequency of consuming six or more drinks at a time (binge drinking).
Questions 4-6 evaluate the signs of dependence
These questions delve into dependence symptoms, including a sense of guilt or remorse after drinking, the inability to stop drinking once started, and the need for a drink in the morning to get going (eye-opener).
Questions 7–10 assess harmful alcohol use and behavior.
These questions assess the occurrence of problems associated with alcohol consumption, such as neglecting responsibilities, experiencing blackouts or memory lapses, getting injured due to drinking, or facing criticism due to alcohol use.
Each question in the AUDIT is scored on a scale ranging from 0 to 4 points, with the total score being the sum of all responses. The maximum possible score is 40.
0–7: This typically indicates low-risk alcohol use.
8–15: Suggests hazardous or harmful drinking patterns.
16–19: Indicates the possibility of alcohol dependence and the need for further evaluation.
20 and above: highly indicative of alcohol dependence or severe problems related to alcohol.
The AUDIT is used as a screening tool by healthcare professionals, counselors, and in clinical settings to identify individuals at risk of alcohol-related problems. A higher score prompts further evaluation, intervention, or referral to specialized services for alcohol use disorders. It assists in developing tailored treatment plans by providing insights into an individual's specific alcohol consumption patterns, behaviors, and the severity of their alcohol-related issues. The AUDIT can be used at different points in time to monitor changes in alcohol consumption and related behaviors throughout treatment or intervention.
CONCLUSION
Alcohol has been an integral part of human culture for centuries, serving as a social lubricant, a celebratory element, and sometimes a coping mechanism. Understanding drinking patterns and utilizing appropriate indicators to measure alcohol consumption are essential steps in addressing alcohol-related issues. Early identification and intervention can significantly reduce the risks associated with excessive drinking and mitigate its negative impacts on individuals and society as a whole. Encouraging responsible drinking practices, promoting awareness, and providing support for those struggling with alcohol misuse are crucial aspects of fostering a healthier relationship with alcohol.
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