Alcohol use among young adolescents in low-income ... - The Lancet

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Alcohol use among young adolescents in low-income and middle-income countries: a population-based study Chuanwei Ma, Pascal Bovet, Lili Yang, Min Zhao, Yajun Liang, Bo Xi

Summary

Background Alcohol use remains a major public health problem worldwide because of its harmful effects on physical and mental health. Few studies have used a standardised methodology to assess alcohol use among adolescents in low-income and middle-income countries (LMICs). In the present study, we aimed to compare the prevalence of alcohol use, drunkenness episodes, and drin king-related problems among young adolescents in LMICs. Methods For this population-based study, we used individual data from the Global School-based Student Health Surveys (GSHS) from between 2006 and 2013 in adolescents aged 12–15 years in LMICs. Data were collected using an anonymous self-reported questionnaire. This report is based on four questions assessing alcohol use, drunkenness episodes, alcohol-related drinking problems (ever had a hangover, felt sick, got into trouble with family or friends, missed school, or got into fights, as a result of drinking alcohol), and, in those who reported drinking, how alcohol was purchased. We calculated the overall and regional estimates using a meta-analysis with random-effects. Findings GSHS data from 57 countries, corresponding to a total of 139 649 young adolescents, were included in this study. The prevalence of the variables varied largely according to country and region. The overall prevalence of having at least one drink during the past 30 days was 25·0% (95% CI 19·3–30·7), and was higher among boys (27·5%, 21·9–33·2) than girls (22·5%, 18·8–26·2), and at age 14–15 years (29·0%, 23·1–34·8) than at age 12–13 years (18·9%, 15·3–22·5). The overall prevalence of having been drunk at least once during the lifetime was 17·9% (13·6–22·1); and was higher among boys (21·3%, 16·8–25·7) than girls (14·5%, 12·1–16·9), and at age 14–15 years (21·5%, 17·0–26·0) than at age 12–13 years (12·2%, 9·5–15·0). The overall prevalence of drinking-related problems was 10·6% (8·9–12·2), and was higher among boys (12·5%, 10·4–14·5) than girls (8·9%, 7·5–10·2), and at age 14–15 years (12·3%, 10·4–14·2) than at age 12–13 years (7·8%, 6·6–9·1). Among those reporting drinking, 27·8% (24·8–30·7) accessed alcohol from their friends, 23·2% (19·5–26·9) got it from family, 19·5% (17·5–21·6) bought it in a store, 9·1% (8·0–10·2) gave someone money to buy some, 2·8% (2·3–3·3) stole it, and 14·4% (12·2–16·5) got it by some other way. Interpretation Alcohol use, lifetime drunkenness, and alcohol-related problems were frequent among young adolescents in LMICs; however, with differences by country, region, sex, and age group. These findings emphasise the need for interventions to reduce alcohol use targeting young adolescents in LMICs with high prevalence of use and alcohol-related problems.

Lancet Child Adolesc Health 2018; 2: 415–29 Published Online April 30, 2018 http://dx.doi.org/10.1016/ S2352-4642(18)30112-3 See Comment page 382 Department of Epidemiology (C Ma MSc, L Yang MSc, Prof B Xi MD) and Department of Nutrition and Food Hygiene (M Zhao MD), School of Public Health, Shandong University, Jinan, China; Department of Health Care, Hubei Maternal and Child Health Hospital, Wuhan, China (C Ma); Institute of Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland (P Bovet MD); and Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden (Y Liang MD) Correspondence to: Prof Bo Xi, Department of Epidemiology, School of Public Health, Shandong University, Jinan 250012, China [email protected]

Funding Shandong University. Copyright © 2018 Elsevier Ltd. All rights reserved.

Introduction Alcohol is a psychoactive substance that has euphoric, intoxicating, and relaxing effects and can be addictive. Harmful use of alcohol is associated with several social, mental, and behavioural disorders, and it increases the risk of a broad range of diseases and mortality.1–3 Even lowlevel drinking can increase the risk of several diseases, including some cancers.4,5 In 2017, alcohol use accounted for 3·2 million deaths worldwide and it was the fourth largest cause of disability-adjusted years of life lost (after tobacco use, high blood pressure, and low birthweight).6 Adolescence is a vulnerable period in relation to adoption of harmful behaviours, including alcohol use, sexual-risk behaviours, physical inactivity, physical fighting, unhealthy diet, and tobacco use.7–9 In Europe, 57% of the adolescents aged 15–16 years were reported to www.thelancet.com/child-adolescent Vol 2 June 2018

consume alcohol at least once per month, and 70% experienced drunkenness at least once during their lifetime.10 In the USA, 11·5% of the adolescents aged 12–17 years reported consumption of alcohol at least once per month.11 Alcohol drinking at a young age has detrimental effects on physical and mental health (eg, alcohol poisoning, motor vehicle accidents, violence, and suicide) and it is a leading cause of deaths in this age range. Drinking during childhood also increases the risk of harmful alcohol use in adulthood.12–14 Alcohol use is associated with several drinking-related problems.15,16 Adolescents who have been drunk at least once in their lifetime are at increased risk of psychological distress.17 Although the overall consumption of alcohol at the population level is decreasing in some countries,10 alcohol use among adolescents remains an important 415

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Research in context Evidence before this study We searched PubMed and Scopus to identify publications on alcohol use in adolescents from low-income and middle-income countries (LMICs), published in any language between Jan 1, 2000, and Jan 9, 2018, using the keywords (“alcohol use” OR “alcohol consumption”) and (“adolescents” OR “youths”). Data were available for several countries or regions. We identified only two publications on global comparisons of prevalence of alcohol use in adolescents from LMICs. In 2014, a study based on Global School-based Student Health Surveys data from 2003 to 2008 reported that the overall prevalence of 30 day alcohol use ranged from 1·6% in Myanmar to 60·1% in Seychelles and drunkenness at least once in lifetime ranged from 2·5% in Indonesia to 53·1% in Seychelles in adolescents aged 13–15 years in 12 LMICs.

issue because adolescents often view alcohol consumption, including drunkenness, as a rite for transition into adulthood.18,19 Several factors are associated with the likelihood of youth drinking, including the availability and density of premises selling alcohol,20 policy restricting access to alcohol (eg, restricted sale hours, ban on sale to minors, etc),10,21 and social and cultural norms (eg, social tolerance for youth and adult drinking).22–25 Drinking patterns are also important to consider. For example, young people might engage in binge drinking, particularly when alcohol is purchased from commercial vendors and consumed outside of the family setting.24 Alcohol consumption and drinking patterns among adolescents have been extensively reported in highincome countries, but few studies have been done about alcohol use among adolescents in low-income and middle-income countries (LMICs).17 Furthermore, only a few studies used a standard instrument to assess these variables, which limits direct comparison between countries. In this study, we used data from the Global Schoolbased Student Heath Survey (GSHS) to assess the prevalence of alcohol use, the frequency of lifetime drunkenness and alcohol-related problems, and the sources of alcohol purchase in young adolescents in LMICs between 2006 and 2013.

Methods

Data sources For the CDC GSHS data see http://www.cdc.gov/gshs/ For the WHO GSHS data see http://www.who.int/ncds/ surveillance/gshs/en/

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In this population-based study, we used the most recent GSHS data (2006–13) publicly available on the websites of the US Centers for Disease Control and Prevention (CDC) and WHO. Methods and main findings of the GSHS are described on both the CDC and WHO websites. Briefly, the GSHS is a self-administered schoolbased survey developed by WHO and the CDC. The goal of the GSHS is to provide data on health behaviours

Added value of this study This study provides a timely update on drinking frequency in young adolescents in a large number of LMICs against which future trends can be compared. This study uses more recent data and covers more regions than previous studies. It also provides new information on the prevalence of alcohol-related problems and the main sources of alcohol beverages in young adolescents in LMICs. Implications of all the available evidence Alcohol use in young adolescents is an important issue in LMICs because of the high prevalence of alcohol use and alcohol-related problems. Our findings emphasise the need to strengthen alcohol control policy and programmes targeting young adolescents in most LMICs.

among adolescents aged 12–15 years using the same standardised procedures to help countries develop effective health programmes and policies. Surveys done before 2005 were not included in our analysis because this study focuses on recent data to enhance the comparability of the findings between countries. If a country had done more than one GSHS between 2006 and 2013, we analysed the last survey. The same standardised sampling strategy, study methodology, and questionnaire were used in all countries. Briefly, in each country, participants were selected using a two-stage cluster design to provide a nationally representative sample of young adolescents aged 12–15 years. All students in the selected school classes were included in the sampling frame. The GSHS questionnaire is made of ten modules of questions on different aspects of health including tobacco use, diet, physical activity, sexual behaviours, and alcohol use. Countries are free to select different modules when they do a national GSHS. However, when a module is included in a GSHS in a country, all core questions of the module must be used (there are generally less than seven core questions per module) and the wording of the questions cannot be altered (except for translation in the local language). The questionnaire is anonymous and it is self-administered to the students during a 40–45 min period in the classroom. Students record their responses on a computer-scannable answer sheet and data entry is done automatically at the US CDC using an automated optic character recognition procedure. The GSHS was approved by the Ministry of Education or a Health Research Ethics Committee in each participating country, or both. Participation was voluntary and verbal or written consent was obtained from all adolescents and their parents or guardians in each country. This study did not need ethics or institutional review board approval because it is based on the analysis of publicly available data. www.thelancet.com/child-adolescent Vol 2 June 2018

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Outcomes Drinking frequency was assessed among young adolescents using the question: “During the past 30 days, on how many days did you have at least one drink containing alcohol?”. The corresponding answers were “0 days”, “1 or 2 days”, “3–5 days”, “6–9 days”, “10–19 days”, “20–29 days”, or “all 30 days”. The questionnaire stated that one “drink” meant either one glass of wine, one bottle of beer, one small glass of liquor, or one mixed drink. The frequency of drunkenness episodes was assessed among young adolescents with the question: “During your life, how many times did you drink so much alcohol that you were really drunk?”. The corresponding answers were “0 times”, “1 or 2 times”, “3–9 times”, “10 or more times”. The question stated that a “drunkenness episode” meant staggering when walking, not being able to speak correctly, or throwing up. Occurrence of a drinking-related problem was assessed among young adolescents using the question: “During your life, how many times have you ever had a hangover, felt sick, got into trouble with your family or friends, missed school, or got into fights, as a result of drinking alcohol? ”. The corresponding answers were “0 times”, “1 or 2 times”, “3–9 times”, or “10 or more times”. Acquisition of alcohol beverages was assessed among young adolescents who reported drinking in the past 30 days using the question: “During the past 30 days, how did you usually get the alcohol you drank?”. The corresponding answers were “I bought it in a store, shop, or from a street vendor”, “I gave someone else money to buy it for me”, “I got it from my friends”, “I got it from my family”, “I stole it or got it without permission”, or “I got it some other way”.

Statistical analysis Estimates of frequency of the different variables were based on individual data in each survey. We calculated prevalence estimates and SEs according to sex, age group, country, and region (defined as the six WHO regions) based on the GSHS sampling weights and primary sample units, using the “Complex Samples” module in SPSS version 13.0. Prevalence estimates are presented with 95% CIs. We considered a difference between two prevalence estimates to be significant if the 95% CIs did not overlap, which corresponds to a conservative estimation of statistical difference. We calculated the pooled regional and overall estimates with 95% CIs in a meta-analysis with random-effects models using STATA version 11.0. This Article meets the requirements of the Guidelines for Accurate and Transparent Health Estimates Reporting.

Role of the funding source The funder of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full www.thelancet.com/child-adolescent Vol 2 June 2018

Survey year Response rate, n/N (%)

Boys, n (%)

Girls, n (%)

Africa Benin

2009

1063/1161 (91·6%)

667 (62·7%)

Ghana

2012

1231/1330 (92·6%)

617 (50·1%)

396 (37·3%) 614 (49·9%)

Malawi

2009

2087/2185 (95·5%)

967 (46·3%)

1120 (53·7%)

Mauritius

2011

3065/3131 (97·9%)

1390 (45·4%)

1675 (54·6%)

Namibia

2013

1828/1919 (95·3%)

755 (41·3%)

1073 (58·7%)

Seychelles

2007

930/1146 (81·2%)

421 (45·3%)

509 (54·7%)

Tanzania

2006

1630/1746 (93·4%)

794 (48·7%)

836 (51·3%)

America Anguilla

2009

651/696 (93·5%)

309 (47·5%)

342 (52·5%)

Antigua and Barbuda

2009

1148/1198 (95·8%)

532 (46·3%)

616 (53·7%)

Argentina

2012

20 142/21 324 (94·5%)

9398 (46·7%)

10744 (53·3%)

Bahamas

2013

1248/1304 (95·7%)

578 (46·3%)

670 (53·7%)

Barbados

2011

1432/1502 (95·3%)

658 (45·9%)

774 (54·1%)

Belize

2011

1540/1597 (96·4%)

721 (46·8%)

819 (53·2%)

Bolivia

2012

2654/2761 (96·1%)

1308 (49·3%)

1346 (50·7%)

British Virgin Islands

2009

1142/1191 (95·9%)

500 (43·8%)

642 (56·2%)

Cayman

2007

1001/1143 (87·6%)

469 (46·9%)

532 (53·1%)

Chile

2013

1289/1341 (96·1%)

631 (49%)

658 (51%)

Colombia

2007

7209/7963 (90·5%)

3131 (43·4%)

4078 (56·6%)

Costa Rica

2009

2217/2259 (98·1%)

1062 (47·9%)

1155 (52·1%)

Dominica

2009

1227/1308 (93·8%)

533 (43·4%)

694 (56·6%)

Ecuador

2007

3808/4508 (84·5%)

1802 (47·3%)

2006 (52·7%)

El Salvador

2013

1532/1600 (95·8%)

809 (52·8%)

723 (47·2%)

Grenada

2008

1105/1296 (85·3%)

464 (42%)

641 (58%)

Guatemala

2009

4293/4461 (96·2%)

1925 (44·8%)

2368 (55·2%)

Guyana

2010

1843/1958 (94·1%)

825 (44·8%)

1018 (55·2%)

Honduras

2012

1413/1474 (95·9%)

669 (47·3%)

744 (52·7%)

Jamaica

2010

1128/1196 (94·3%)

549 (48·7%)

579 (51·3%)

Montserrat

2008

140/161 (87·0%)

Peru

2010

2230/2350 (94·9%)

Saint Lucia

2007

940/1070 (87·9%)

387 (41·2%)

553 (58·8%)

Saint Vincent and Grenadines

2007

997/1184 (84·2%)

429 (43%)

568 (57%)

Suriname

2009

913/1043 (87·5%)

440 (48·2%)

473 (51·8%)

Trinidad and Tobago

2011

2223/2352 (94·5%)

1224 (55·1%)

999 (44·9%)

Uruguay

2012

2707/2855 (94·8%)

1280 (47·3%)

1427 (52·7%)

66 (47·1%)

74 (52·9%)

1087 (48·7%)

1143 (51·3%)

Eastern Mediterranean Lebanon

2011

1933/1981 (97·6%)

895 (46·3%)

1038 (53·7%)

Syria

2010

2916/2929 (99·6%)

1177 (40·4%)

1739 (59·6%)

Macedonia

2007

1362/1537 (88·6%)

660 (48·5%)

702 (51·5%)

Tajikistan

2006

7134/7457 (95·7%)

3476 (48·7%)

3658 (51·3%)

Europe

(Table 1 continues on next page)

access to all the data and had final responsibility for the decision to submit for publication.

Results Up to December, 2013, 94 countries had done at least one GSHS. Eight surveys done before 2005 were not included in our analysis because they were too old for global comparisons. GSHS data from 57 countries in the 417

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Survey year Response rate, n/N (%)

Boys, n (%)

Girls, n (%)

(Continued from previous page) Southeast Asia Indonesia

2007

2914/3014 (96·7%)

Malaysia

2012

16 082/16 248 (99%)

1350 (46·3%)

1564 (53·7%)

8200 (51%)

7882 (49%)

Maldives

2009

1870/1970 (94·9%)

808 (43·2%)

Myanmar

2007

2175/2227 (97·7%)

1033 (47·5%)

1142 (52·5%)

Thailand

2008

2414/2671 (90·4%)

1125 (46·6%)

1289 (53·4%)

Cambodia

2013

1768/1809 (97·7%)

775 (43·8%)

993 (56·2%)

Cook

2011

822/849 (96·8%)

401 (48·8%)

421 (51·2%)

Fiji

2010

1480/1491 (99·3%)

620 (41·9%)

860 (58·1%)

1062 (56·8%)

Western Pacific

Kiribati

2011

1283/1337 (96%)

527 (41·1%)

756 (58·9%)

Mongolia

2013

3635/3694 (98·4%)

1725 (47·5%)

1910 (52·5%)

Nauru

2011

326/361 (90·3%)

132 (40·5%)

194 (59·5%)

Niue

2010

80/82 (97·6%)

47 (58·8%)

33 (41·3%)

Philippines

2011

3755/3834 (97·9%)

1534 (40·9%)

2221 (59·1%)

Samoa

2011

1884/2153 (87·5%)

755 (40·1%)

1129 (59·9%)

Solomon

2011

843/904 (93·3%)

421 (49·9%)

422 (50·1%)

Tonga

2010

1854/1939 (95·6%)

830 (44·8%)

1024 (55·2%)

Tuvalu

2013

634/675 (93·9%)

301 (47·5%)

333 (52·5%)

Vanuatu

2011

816/844 (96·7%)

337 (41·3%)

479 (58·7%)

Vietnam

2013

1663/1742 (95·5%)

764 (45·9%)

899 (54·1%)

139 649/147 461 (94·7%)

65 290 (46·8%)

74 359 (53·2%)

All Total

NA

Response rate is for the first three alcohol questions. Data are for participants aged 12–15 years. NA=not applicable.

Table 1: Characteristics of the Global School-based Student Health Surveys by country, 2006–2013

See Online for appendix

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six WHO regions were included in this study: seven from Africa; 27 from America; two from the eastern Mediterranean; two from Europe; five from southeast Asia; and 14 from the western Pacific, corresponding to a total of 139 649 young adolescents (table 1). Overall response rates ranged from 81·2% (930 of 1146 contacted) in Seychelles to 99·6% (2916 of 2929) in Syria. Nearly all young adolescents who reported drinking in the past 30 days responded to the last question in each survey regarding acquisition of alcohol beverages. The sample size for the first three questions ranged from 80 (Niue) to 20 142 (Argentina), with a median sample size of 1540. The overall prevalence of alcohol use on at least 1 day during the past 30 days was 25·0% (95% CI 19·3–30·7), and was lowest in Tajikistan and highest in the Seychelles (table 2). The prevalence was 27·5% (21·9–33·2) in boys (lowest in Tajikistan and highest in the Seychelles) and 22·5% (18·8–26·2) in girls (lowest in Tajikistan and highest in Colombia). The prevalence was 18·9% (15·3–22·5) at the age of 12–13 years (lowest in Myanmar and highest in the Seychelles) and 29·0% (23·1–34·8) at the age of 14–15 years (lowest in Tajikistan and highest in the Seychelles). The prevalence exceeded 10% in 46 (81%) of the 57 included countries (table 2, figure). In 13 (23%) of the 57 countries, boys

used alcohol more frequently than girls. Adolescents aged 14–15 years tended to use alcohol more often than adolescents aged 12–13 years in most countries (31 of 57). The overall prevalence of alcohol use on at least 3 days during the past 30 days was 10·1% (95% CI 8·6–11·5), and was lowest in Tajikistan and highest in Jamaica (table 2; appendix). The prevalence was 12·0% (10·0–13·9) in boys (lowest in Tajikistan and highest in the Seychelles) and 8·3% (7·0–9·5) in girls (lowest in Indonesia and highest in Jamaica). The prevalence was 6·8% (5·8–7·8) at the age of 12–13 years (lowest in Vietnam and highest in Samoa), and 12·0% (10·3–13·7) at the age of 14–15 years (lowest in Tajikistan and highest in Argentina). The prevalence exceeded 10% in 26 (46%) of the 57 included countries. The overall prevalence of having been drunk at least once during the lifetime was 17·9% (95% CI 13·6–22·1), and was lowest in Tajikistan and highest in the Seychelles (table 3; appendix). The prevalence was 21·3% (16·8–25·7) in boys (lowest in Tajikistan and highest in the Seychelles) and 14·5% (12·1–16·9) in girls (lowest in Tajikistan and highest in the Seychelles). Boys were more likely to report drunkenness than girls in 23 of 56 countries (data on drunkenness were unavailable in Syria). The prevalence was 12·2% (9·5–15·0) at the age of 12–13 years (lowest in Myanmar and highest in the Seychelles) and 21·5% (17·0–26·0) at the age of 14–15 years (lowest in Tajikistan and highest in the Seychelles). The overall prevalence of drinking-related problems was 10·6% (95% CI 8·9–12·2), and was lowest in Cambodia and highest in Samoa (table 3; appendix). The prevalence was 12·5% (10·4–14·5) in boys (lowest in Cambodia and highest in Samoa) and 8·9% (7·5–10·2) in girls (lowest in Niue and highest in Samoa). The prevalence was 7·8% (6·6–9·1) at age 12–13 years (lowest in Niue and highest in Samoa) and 12·3% (10·4–14·2) at age 14–15 years (lowest in Cambodia and highest in Samoa). The prevalence was higher in boys than in girls, and higher at age 14–15 years than at age 12–13 years. The prevalence exceeded 10% in 28 (51%) of 55 countries (data were unavailable in Malawi and Syria). Overall, 27·8% (95% CI 24·8–30·7) of adolescents who reported drinking from 51 countries (data on alcohol acquisition were unavailable in Anguilla, Malawi, Guyana, Syria, Maldives, and Fiji) accessed alcohol from their friends, 19·5% (17·5–21·6) bought it in a store, 9·1% (8·0–10·2) gave someone money to buy it, 23·2% (19·5–26·9) got it from family, 2·8% (2·3–3·3) stole it, and 14·4% (12·2–16·5) got is in some other way (table 4; appendix). Boys tended to buy alcohol or give money to someone else to buy it more often than girls, whereas girls accessed alcohol from the family more often than boys (appendix). The percentage surveyed who stole alcohol, got alcohol from friends, or some other way did not differ significantly between boys and girls in most countries (appendix). www.thelancet.com/child-adolescent Vol 2 June 2018

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Drinking at least once during past 30 days

Drinking on ≥3 days during past 30 days

Total, % (95% CI)

Boys, % (95% CI)

Girls, % (95% CI)

12–13 years, % (95% CI)

14–15 years, % (95% CI)

Total, % (95% CI)

Boys, % (95% CI)

Girls, % (95% CI)

12–13 years, % (95% CI)

14–15 years, % (95% CI)

Benin

16·0 (12·6–20·1)

18·0 (13·5–23·5)

12·3 (9·0–16·6)

15·0 (10·5–21·0)

16·3 (12·7–20·6)

4·8 (3·5–6·5)

5·2 (3·6–7·4)

4·0 (2·3–7·0)

6·0 (3·7–9·6)

4·4 (3·1–6·3)

Ghana

14·5 (12·2–17·2)

17·1 (14·2–20·4)

12·0 (8·6–16·6)

15·1 (11·9–18·9)

14·2 (11·3–17·7)

6·8 (4·9–9·4)

8·0 (5·7–11·1)

5·6 (3·1–10·1)

6·3 (3·6–10·7)

7·1 (5·4–9·3)

Malawi

3·9 (1·7–8·4)

5·2 (2·4–10·8)

2·4 (0·9–6·5)

4·0 (2·2–7·1)

3·8 (1·4–9·7)

2·3 (0·8–6·3)

2·9 (1·1–7·3)

1·6 (0·5–5·6)

2·5 (1·1–5·6)

2·1 (0·6–7·1)

Mauritius

23·4 (19·7–27·7)

25·8 (19·9–32·6)

21·1 (16·3–26·9)

10·7 (7·7–14·6)

31·4 (27·3–35·8)

8·5 (7·0–10·4)

11·2 (8·7–14·3)

5·9 (4·3–8·1)

2·2 (1·2–4·2)

12·5 (10·7–14·5)

Namibia

23·0 (19·8–26·6)

26·0 (21·7–30·7)

20·8 (17·5–24·6)

15·3 (11·2–20·6)

26·1 (23·0–29·5)

8·6 (7·1–10·4)

10·6 (8·3–13·5)

7·1 (5·2–9·7)

5·2 (3·3–8·1)

10·0 (8·3–12·0)

Seychelles

57·0 (56·3–57·7)

59·6 (58·5–60·5)

54·6 (53·7–55·6)

47·8 (46·9–48·7)

64·9 (63·9–65·8)

23·5 (22·9–24·2)

31·3 (30·3–32·2)

16·5 (15·7–17·3)

21·4 (20·5–22·3)

25·4 (24·4–26·3)

Tanzania

5·3 (4·0–7·1)

6·0 (4·2–8·7)

4·7 (3·4–6·5)

5·4 (4·2–6·9)

5·2 (2·9–9·0)

1·4 (0·9–2·2)

1·2 (0·6–2·3)

1·7 (0·9–3·1)

1·7 (1·1–2·6)

0·8 (0·4–1·7)

Pooled estimates

20·5 (0–43·8)

22·5 (0–45·9)

18·3 (0–40·4)

16·2 (0–35·0)

23·1 (0–44·7)

8·0 (0–17·2)

10·1 (0–21·8)

6·1 (0·1–12·0)

6·5 (0–14·0)

8·9 (0·2–17·6)

I² (%)

99·9

99·8

99·9

99·8

99·8

99·8

99·7

99·1

99·4

99·7

Anguilla

41·3 (37·5–45·1)

40·5 (35·0–46·0)

42·1 (36·9–47·3)

33·3 (27·8–38·8)

47·3 (42·2–52·4)

17·1 (14·2–20·0)

21·0 (16·5–25·5)

13·5 (10·0–17·0)

12·2 (8·3–16·1)

20·7 (16·6–24·8)

Antigua and Barbuda

43·9 (39·5–48·5)

42·8 (37·2–48·6)

45·1 (39·5–50·9)

39·2 (32·9–45·9)

46·5 (41·6–51·6)

20·0 (16·9–23·4)

20·2 (16·4–24·6)

19·7 (15·7–24·6)

14·5 (11·3–18·4)

23·0 (19·1–27·4)

Argentina

48·1 (45·4–50·8)

47·3 (44·5–50·1)

48·8 (45·3–52·3)

33·0 (29·7–36·5)

55·2 (52·4–58·0)

23·5 (21·8–25·4)

25·0 (22·2–28·0)

22·2 (20·6–24·0)

13·7 (11·8–15·8)

28·2 (26·2–30·2)

Bahamas

27·1 (23·7–30·8)

28·4 (24·8–32·4)

25·9 (21·5–30·9)

22·1 (18·5–26·1)

32·6 (28·2–37·4)

11·0 (8·9–13·5)

12·7 (9·7–16·5)

9·4 (7·3–12·0)

7·6 (5·5–10·4)

14·6 (11·7–18·2)

Barbados

46·4 (43·4–49·5)

47·5 (42·9–52·2)

45·3 (41·3–49·4)

39·8 (35·4–44·4)

48·6 (44·8–52·3)

22·5 (19·5–25·7)

24·1 (20·1–28·6)

20·7 (17·1–25·0)

19·6 (15·8–24·0)

23·4 (19·8–27·4)

Belize

25·2 (22·6–28·1)

27·2 (23·6–31·1)

23·4 (19·9–27·3)

18·9 (16·1–22·1)

30·9 (27·4–34·7)

9·1 (7·5–11·0)

9·4 (7·5–11·7)

8·9 (6·6–11·8)

5·1 (3·7–7·1)

12·7 (10·5–15·3)

Bolivia

14·6 (12·1–17·5)

15·8 (12·3–20·0)

13·5 (10·9–16·6)

7·6 (6·1–9·5)

17·4 (14·3–21·0)

3·9 (3·1–5·1)

4·7 (3·2–6·8)

3·2 (2·4–4·2)

1·6 (0·9–2·8)

4·9 (3·8–6·2)


29·6 (27·0–32·2)

28·2 (24·3–32·1)

30·7 (27·1–34·3)

21·5 (18·0–25·0)

36·7 (32·8–40·6)

10·0 (8·2–11·8)

10·2 (7·5–12·9)

9·8 (7·4–12·2)

6·0 (4·0–8·0)

13·5 (10·8–16·2)

Cayman

36·5 (33·5–39·5)

38·4 (34·0–42·8)

34·8 (30·8–38·8)

28·6 (24·5–32·7)

43·1 (39·0–47·2)

16·6 (14·2–19·0)

19·8 (16·3–23·3)

13·7 (10·8–16·6)

13·7 (10·6–16·8)

19·1 (15·8–22·4)

Chile

24·9 (21·1–29·1)

23·5 (19·0–28·7)

26·3 (21·4–31·7)

15·1 (12·1–18·6)

31·3 (26·7–36·4)

11·5 (9·0–14·6)

13·6 (10·0–18·2)

9·5 (7·0–12·8)

4·2 (2·7–6·4)

16·3 (13·1–20·1)

Colombia

53·9 (50·8–57·1)

51·5 (47·8–55·2)

55·8 (52·0–59·5)

41·2 (37·4–45·1)

62·5 (59·0–65·9)

21·0 (18·4–23·8)

20·4 (18·2–22·8)

21·4 (18·0–25·2)

13·5 (12·0–15·3)

26·0 (22·7–29·5)

Costa Rica

23·2 (20·3–26·3)

23·1 (19·6–27·0)

23·3 (20·0–27·0)

16·0 (13·0–19·6)

26·9 (23·4–30·6)

8·1 (6·3–10·2)

8·8 (7·0–11·2)

7·3 (5·2–10·0)

5·5 (4·1–7·3)

9·4 (7·2–12·1)

Dominica

50·7 (46·5–55·0)

52·0 (46·8–57·2)

49·4 (43·8–55·0)

42·0 (37·0–47·3)

58·0 (53·3–62·5)

19·9 (17·2–22·8)

19·3 (15·8–23·4)

20·4 (16·8–24·5)

13·1 (10·3–16·4)

25·5 (22·5–28·9)

Ecuador

26·4 (24·0–28·8)

27·5 (24·4–30·8)

25·4 (22·5–28·4)

19·5 (17·1–22·2)

35·0 (31·7–38·4)

9·2 (7·9–10·7)

10·2 (8·2–12·6)

8·3 (6·8–10·2)

6·7 (5·1–8·7)

12·4 (10·7–14·4)

El Salvador

16·7 (13·9–19·9)

18·3 (15·0–22·1)

15·0 (11·9–18·7)

7·8 (5·1–11·6)

20·6 (17·7–23·9)

11·1 (9·0–13·6)

12·9 (10·4–15·9)

9·2 (6·8–12·3)

4·0 (2·1–7·6)

14·2 (12·0–16·7)

Grenada

43·2 (39·1–47·4)

46·8 (41·2–52·5)

40·5 (35·2–46·1)

33·6 (29·7–37·8)

50·0 (45·7–54·4)

17·1 (14·5–20·0)

22·5 (18·3–27·4)

13·1 (10·2–16·7)

10·8 (8·1–14·2)

21·6 (18·2–25·5)

Guatemala

16·2 (12·9–20·0)

18·1 (14·0–23·2)

14·0 (11·3–17·4)

11·8 (8·8–15·7)

18·2 (14·6–22·5)

5·1 (3·8–6·7)

5·9 (4·4–8·0)

4·2 (3·0–5·8)

3·7 (2·6–5·2)

5·8 (4·2–7·9)

Guyana

39·1 (35·5–42·8)

44·2 (39·2–49·4)

34·2 (30·6–38·0)

31·1 (25·8–37·0)

42·2 (38·8–45·7)

14·4 (12·3–16·8)

19·2 (16·1–22·8)

9·9 (8·1–12·2)

10·9 (7·7–15·2)

15·8 (13·4–18·6)

Honduras

14·8 (13·0–16·9)

12·6 (10·0–15·7)

16·8 (13·9–20·2)

11·6 (9·4–14·2)

17·7 (14·7–21·1)

5·2 (3·8–6·9)

3·7 (2·6–5·2)

6·4 (4·1–9·9)

4·6 (3·4–6·1)

5·7 (3·7–8·5)

Africa

America


www.thelancet.com/child-adolescent Vol 2 June 2018

419

Articles

Drinking at least once during past 30 days Total, % (95% CI)


Boys, % (95% CI)

Girls, % (95% CI)

12–13 years, % (95% CI)

14–15 years, % (95% CI)

Total, % (95% CI)

Boys, % (95% CI)

Girls, % (95% CI)

12–13 years, % (95% CI)

14–15 years, % (95% CI)

(Continued from previous page) Jamaica

52·4 (47·0–57·7)

57·9 (52·9–62·7)

46·8 (40·4–53·4)

44·3 (35·5–53·5)

53·8 (48·5–59·0)

26·5 (22·1–31·3)

30·1 (27·2–33·1)

22·8 (16·4–30·8)

19·7 (14·4–26·4)

27·7 (22·6–33·4)

Montserrat

33·6 (25·8–41·4)

37·9 (26·2–49·6)

29·7 (19·3–40·1)

23·6 (12·2–35·0)

40·0 (29·6–50·4)

10·0 (5·1–14·9)

13·6 (5·2–22·0)

6·8 (1·1–12·5)

3·6 (0·0–8·5)

14·1 (6·7–21·5)

Peru

27·0 (23·3–30·9)

28·3 (23·8–33·2)

25·6 (21·1–30·7)

20·8 (16·1–26·5)

29·0 (25·1–33·3)

6·9 (5·5–8·7)

7·8 (6·0–10·2)

6·0 (4·0–8·8)

5·1 (3·3–7·9)

7·5 (5·9–9·6)

Saint Lucia

52·5 (48·2–56·9)

55·4 (48·8–61·8)

50·3 (45·3–55·3)

44·2 (38·6–49·9)

58·1 (52·8–63·3)

20·3 (17·2–23·8)

22·5 (18·3–27·4)

18·5 (15·0–22·7)

15·0 (11·7–19·0)

23·8 (19·8–28·3)


48·9 (43·5–54·3)

50·9 (44·7–57·1)

47·4 (40·0–54·9)

38·7 (32·3–45·5)

60·7 (55·6–65·6)

20·6 (17·4–24·2)

25·0 (20·5–30·2)

17·2 (13·5–21·7)

15·9 (12·2–20·4)

26·0 (22·2–30·3)

Suriname

31·2 (26·8–35·9)

34·1 (29·3–39·3)

28·6 (23·3–34·6)

24·1 (17·7–32·0)

34·5 (29·9–39·4)

10·0 (8·1–12·3)

11·4 (8·9–14·5)

8·7 (6·6–11·5)

5·7 (3·1–10·4)

12·0 (9·9–14·5)

Trinidad and Tobago

31·5 (28·0–35·3)

33·3 (30·2–36·7)

29·7 (24·7–35·3)

18·9 (15·7–22·6)

41·9 (38·0–45·9)

13·3 (10·8–16·1)

15·2 (12·7–18·0)

11·4 (8·3–15·4)

6·9 (5·4–8·8)

18·5 (14·9–22·7)

Uruguay

45·1 (42·7–47·5)

47·1 (43·9–50·3)

43·4 (40·4–46·5)

26·2 (22·7–30·0)

52·1 (49·2–55·0)

20·2 (18·5–22·1)

22·1 (20·1–24·3)

18·6 (16·4–21·0)

10·6 (8·6–12·9)

23·8 (21·7–26·0)

Pooled estimates

34·9 (29·9–39·9)

36·1 (31·0–41·3)

33·7 (28·6–38·8)

26·2 (22·0–30·5)

40·4 (34·9–45·9)

14·1 (11·7–16·6)

15·9 (13·0–18·8)

12·5 (10·0–14·9)

9·1 (7·4–10·9)

17·2 (14·1–20·2)

I² (%)

98·4

97·6

97·6

97·2

98·1

97·4

96·9

96·6

94·3

97·3


28·5 (19·5–39·6)

36·9 (26·8–48·3)

21·2 (13·1–32·5)

27·1 (19·7–36·1)

29·5 (18·3–43·9)

13·0 (8·6–19·0)

19·1 (13·3–26·6)

7·7 (4·5–12·7)

9·7 (6·8–13·7)

15·3 (9·5–23·8)

Syria

7·2 (5·6–9·2)

10·8 (8·1–14·3)

3·3 (2·5–4·5)

6·3 (4·9–8·2)

7·9 (5·5–11·2)

2·4 (1·8–3·2)

3·6 (2·7–4·8)

1·2 (0·7–2·0)

2·2 (1·4–3·3)

2·6 (1·7–3·9)

Pooled estimates

17·2 (0–38·1)

23·3 (0–48·9)

11·6 (0–29·1)

16·3 (0–36·7)

17·7 (0–38·8)

7·4 (0–17·8)

11·0 (0–26·2)

4·1 (0–10·5)

5·8 (0–13·1)

8·4 (0–20·9)

I² (%)

93·9

95·0

92·4

95·8

90·2

93·8

95.1

90·3

94·4

91·8

Macedonia

34·6 (27·7–42·2)

40·1 (31·5–49·3)

29·0 (22·5–36·5)

23·5 (15·7–33·6)

41·4 (34·2–48·9)

15·0 (11·0–20·1)

18·1 (12·6–25·1)

11·8 (8·5–16·1)

10·2 (5·6–17·9)

17·9 (13·6–23·2)

Tajikistan

0·8 (0·4–1·3)

1·1 (0·6–1·9)

0·4 (0·2–0·7)

0·9 (0·4–1·9)

0·7 (0·4–1·3)

0·3 (0·1–0·7)

0·4 (0·2–0·9)

0·2 (0·1–0·5)

0·3 (0·1–1·3)

0·3 (0·1–0·6)

Pooled estimates

17·5 (0–50·6)

20·3 (0–58·5)

14·5 (0–42·5)

11·7 (0–33·9)

20·9 (0–60·8)

7·5 (0–21·9)

9·0 (0–26·3)

5·8 (0–17·2)

4·8 (0–14·4)

8·9 (0–26·2)

I² (%)

98·8

98·6

98·4

95·8

99·1

97·5

96·7

97·3

90·2

98·0

Indonesia

2·5 (1·7–3·6)

4·3 (2·9–6·4)

0·8 (0·4–1·7)

1·3 (0·7–2·3)

3·2 (2·2–4·7)

0·5 (0·3–1·1)

1·1 (0·5–2·2)

0·0 (0·0–0·3)

0·1 (0·0–0·5)

0·8 (0·4–1·6)

Malaysia

7·5 (6·4–8·7)

9·4 (7·9–11·0)

5·7 (4·7–6·9)

6·5 (5·5–7·6)

8·0 (6·8–9·5)

2·2 (1·8–2·7)

3·0 (2·4–3·7)

1·5 (1·1–2·1)

2·3 (1·7–3·1)

2·2 (1·7–2·8)

Maldives

4·9 (3·4–7·0)

7·3 (4·8–11·1)

2·7 (1·6–4·6)

5·6 (2·6–11·7)

4·8 (3·3–6·9)

3·6 (2·4–5·3)

5·4 (3·2–8·7)

2·0 (1·1–3·6)

4·2 (2·1–8·3)

3·5 (2·3–5·3)

Myanmar

0·9 (0·5–1·6)

1·3 (0·7–2·6)

0·4 (0·1–1·9)

0·4 (0·1–1·9)

1·2 (0·6–2·5)

0·4 (0·2–0·8)

0·5 (0·2–1·1)

0·2 (0·0–1·5)

0·1 (0·0–0·9)

0·5 (0·2–1·3)

Thailand

14·2 (12·2–16·5)

20·2 (17·1–23·6)

9·2 (7·5–11·3)

8·4 (6·6–10·6)

19·6 (16·5–23·1)

5·1 (4·0–6·5)

8·4 (6·5–10·8)

2·3 (1·6–3·4)

2·7 (2·0–3·8)

7·3 (5·6–9·5)

Pooled estimates

5·9 (2·2–9·6)

8·4 (3·1–13·7)

3·6 (1·2–6·1)

4·3 (1·4–7·1)

7·1 (3·1–11·0)

2·2 (1·0–3·4)

3·3 (1·5–5·1)

1·4 (0·4–2·5)

1·4 (0·6–2·2)

2·6 (1·2–4·0)

I² (%)

98·1

97·7

97·3

96·9

97·6

97·0

95·9

90·6

95·8

93·7

Cambodia

5·2 (4·2–6·5)

7·5 (5·7–9·8)

3·1 (2·1–4·4)

3·1 (1·9–5·1)

6·0 (4·6–7·8)

1·4 (0·9–2·1)

1·9 (1·1–3·3)

0·8 (0·4–1·7)

1·3 (0·5–3·4)

1·4 (0·9–2·1)

Cook

28·1 (25·0–31·2)

28·4 (24·0–32·8)

27·8 (23·5–32·1)

22·3 (18·0–26·6)

32·4 (28·3–36·5)

10·0 (8·0–12·0)

10·2 (7·3–13·1)

9·7 (7·0–12·4)

4·6 (2·4–6·8)

13·9 (10·8–17·0)

Europe

Southeast Asia

Western Pacific


420


Articles

Drinking at least once during past 30 days Total, % (95% CI)


Boys, % (95% CI)

Girls, % (95% CI)

12–13 years, % (95% CI)

14–15 years, % (95% CI)

Total, % (95% CI)

Boys, % (95% CI)

Girls, % (95% CI)

12–13 years, % (95% CI)

14–15 years, % (95% CI)

(Continued from previous page) Fiji

16·6 (14·4–19·1)

22·6 (18·9–26·8)

10·9 (8·3–14·3)

11·7 (7·9–16·9)

18·7 (16·4–21·3)

5·1 (3·6–7·2)

7·6 (4·8–11·9)

2·8 (1·8–4·2)

4·2 (2·6–6·8)

5·5 (3·8–8·0)

Kiribati

29·9 (25·9–34·1)

43·3 (36·8–50·2)

18·9 (15·2–23·3)

20·4 (15·3–26·6)

33·5 (29·1–38·2)

9·3 (7·7–11·1)

13·8 (11·2–16·9)

5·6 (3·9–7·9)

6·1 (3·9–9·3)

10·5 (8·8–12·6)

Mongolia

4·0 (3·1–5·1)

4·4 (3·2–6·0)

3·5 (2·6–4·8)

1·9 (1·3–2·7)

5·6 (4·2–7·5)

1·2 (0·8–1·7)

1·3 (0·9–1·9)

1·1 (0·6–2·1)

0·7 (0·4–1·2)

1·6 (1·0–2·6)

Nauru

20·9 (16·5–25·3)

26·5 (19·0–34·0)

17·0 (11·7–22·3)

16·3 (10·0–22·6)

24·1 (18·0–30·2)

11·3 (7·8–14·8)

15·2 (9·1–21·3)

8·8 (4·9–12·7)

9·6 (4·7–14·5)

12·6 (7·9–17·3)

Niue

16·2 (8·1–24·3)

23·4 (11·3–35·5)

6·1 (0–14·3)

4·8 (0–11·3)

28·9 (14·2–43·6)

7·5 (1·6–13·4)

10·6 (1·8–19·4)

3·0 (0·0–8·9)

2·4 (0·0–7·1)

13·2 (2·2–24·2)

Philippines

18·4 (15·3–21·8)

21·4 (17·4–26·0)

15·5 (12·0–19·7)

13·6 (9·4–19·3)

21·0 (17·7–24·7)

5·0 (3·6–6·7)

6·4 (4·5–9·1)

3·6 (2·4–5·2)

3·6 (1·7–7·5)

5·7 (4·2–7·7)

Samoa

34·0 (29·2–39·2)

43·4 (37·4–49·6)

25·6 (21·4–30·3)

35·5 (29·0–42·6)

33·5 (28·5–38·9)

24·1 (19·9–29·0)

31·2 (25·8–37·2)

17·8 (14·2–22·1)

24·9 (19·4–31·4)

23·9 (19·4–29·0)

Solomon

17·1 (12·9–22·3)

20·8 (14·6–28·8)

13·0 (9·0–18·4)

10·2 (5·2–19·1)

19·8 (15·7–24·5)

7·6 (4·9–11·5)

8·4 (4·9–14·1)

6·7 (4·0–11·0)

7·0 (3·4–13·9)

7·8 (5·1–11·8)

Tonga

16·2 (13·7–19·0)

14·9 (11·9–18·5)

17·5 (14·2–21·5)

13·0 (9·4–17·8)

17·4 (14·5–20·6)

7·0 (5·4–9·0)

6·7 (4·7–9·4)

7·3 (5·2–10·2)

5·5 (3·5–8·5)

7·6 (5·7–9·9)

Tuvalu

10·9 (8·5–13·3)

18·6 (14·2–23·0)

3·9 (1·8–6·0)

5·8 (3·4–8·2)

17·8 (13·3–22·3)

5·4 (3·6–7·2)

9·3 (6·0–12·6)

1·8 (0·4–3·2)

3·0 (1·2–4·8)

8·5 (5·2–11·8)

Vanuatu

7·3 (4·8–10·9)

9·2 (5·6–14·8)

5·4 (3·4–8·5)

4·4 (2·4–8·0)

10·5 (6·7–15·9)

1·9 (0·8–4·6)

2·8 (1·3–6·1)

1·1 (0·3–3·7)

1·7 (0·6–5·0)

2·2 (0·9–5·0)

Vietnam

15·5 (13·3–17·9)

21·7 (18·4–25·3)

10·2 (8·0–12·9)

15·8 (2·9–54·2)

15·5 (13·3–18·0)

4·1 (3·1–5·2)

6·8 (5·1–9·1)

1·7 (0·9–3·0)

Pooled estimates

17·0 (12·5–21·5)

21·6 (15·7–27·5)

12·6 (9·0–16·2)

12·1 (8·4–15·8)

19·9 (15·0–24·9)

6·7 (4·9–8·5)

8·8 (6·2–11·4)

4·5 (3·2–5·9)

4·8 (3·0–6·5)

7·6 (5·6–9·7)

I² (%)

98·0

97·4

96·4

95·6

97·2

96·4

95·5

92·7

90·7%

95·5%

Pooled estimates

25·0 (19·3–30·7)

27·5 (21·9–33·2)

22·5 (18·8–26·2)

18·9 (15·3–22·5)

29·0 (23·1–34·8)

10·1 (8·6–11·5)

12·0 (10·0–13·9)

8·3 (7·0–9·5)

6·8 (5·8–7·8)

12·0 (10·3–13·7)

I² (%)

99·8

99·6

99·7

99·5

99·8

99·4

99·1

98·5

98·3

99·1%

0

4·1 (3·2–5·3)

Total

The number of respondents for this question is given in table 1. We show estimates for two drinking frequencies: drinking on at least 1 day during the past 30 days (notably, this category also includes drinking as little as one sip once during the past 30 days) and drinking on at least 3 days during the past 30 days (considering that drinking on a higher number of days during the past 30 days can signal a more established drinking habit).

Table 2: Prevalence of alcohol use on at least 1 day or at least 3 days during the past 30 days among young adolescents by region, country, sex, and age group

Discussion We found that the prevalence of alcohol use during the past 30 days, lifetime drunkenness episodes, and lifetime alcohol-related problems were frequent in adolescents aged 12–15 years in 57 LMICs, although estimates largely differed between countries. The most common way for adolescent drinkers to obtain alcohol was from friends (27·8%) and family (23·2%) but a high proportion also reported getting alcohol from commercial outlets. Our findings on the drinking prevalence among young adolescents are generally consistent with previous studies. A previous study based on GSHS data from 12 LMICs showed that the prevalence of alcohol use in the past 30 days in adolescents aged 13–15 years varied largely, from 1·6% in Myanmar to 60·1% in the Seychelles.17 The prevalence of weekly alcohol use among adolescents aged 15–16 years in 40 North American and European countries varied from 10% in Switzerland to www.thelancet.com/child-adolescent Vol 2 June 2018

45% in Lithuania.26 The drinking patterns seen in this study (eg, magnitude of drinking frequency in a majority of LMICs and differences by sex and age) are generally similar to those reported in high-income countries. Our study in 57 LMICs also showed large differences in the prevalence of alcohol use across countries in young adolescents. These differences can relate to several factors, including differences in legal drinking age, cultural beliefs, social norms, and barriers in access to alcohol for adolescents.26 For example, prevalence of alcohol use is expected to be low in Islamic and other countries with alcohol prohibition based on religious or cultural grounds, with subsequent low availability of alcohol to young people. In this study, we found that the prevalence of alcohol use was indeed low in countries with large Muslim populations such as Syria (7·2%), Tajikistan (0·8%), Indonesia (2·5%), Malaysia (7·5%), and Maldives (4·9%). The prevalence might also be low 421

Articles

Boys

Girls

Total

Prevalence of alcohol use at least once (%) 10 40 20 50 30 60

Figure: Prevalence of alcohol use on at least 1 day during the past 30 days in young adolescents in 57 low-income and middle-income countries

in countries that effectively enforce policy on underage drinking (eg, ban on sales to youth) and in countries with low social acceptability of underage drinking. However, the prevalence of alcohol use might be underestimated in countries with strong legal or cultural barriers to alcohol drinking among youths because adolescents 422

might be reluctant to honestly admit their drinking habits and might under-report it, despite the fact that the questionnaire is anonymous. We defined outcomes in this study with low thresholds (eg, drinking once in the past 30 days, which can include drinking as little as one sip). With regards to prevalence www.thelancet.com/child-adolescent Vol 2 June 2018

Articles

Had been drunk at least once during lifetime

Had a drinking-related problem at least once during lifetime*

Total,% (95% CI)

Boys,% (95% CI)

Girls,% (95% CI)

12–13 years,% (95% CI)

14–15 years,% (95% CI)

Total,% (95% CI)

Boys,% (95% CI)

Girls,% (95% CI)

12–13 years,% (95% CI)

14–15 years,% (95% CI)

Benin

13·3 (9·8–17·8)

14·5 (9·9–20·7)

11·0 (7·6–15·8)

8·4 (5·4–12·8)

14·6 (10·6–19·7)

9·9 (7·3–13·1)

11·1 (7·5–16·1)

7·6 (5·3–10·7)

8·8 (4·8–15·9)

10·1 (7·7–13·3)

Ghana

9·6 (7·8–11·8)

11·3 (9·4–13·7)

7·9 (5·6–11·1)

8·7 (4·9–15·0)

10·1 (8·3–12·3)

9·1 (7·0–11·7)

10·3 (8·1–13·1)

7·9 (5·3–11·6)

9·0 (5·9–13·5)

9·1 (7·4–11·3)

Malawi

2·9 (1·2–6·6)

3·4 (1·5–7·6)

2·3 (0·9–6·1)

1·6 (0·7–3·7)

3·4 (1·3–8·4)

Mauritius

16·3 (12·8–20·5)

20·0 (15·2–25·9)

12·8 (8·7–18·6)

7·7 (5·2–11·3)

21·8 (17·6–26·5)

6·0 (4·5–7·9)

8·1 (6·1–10·7)

3·9 (2·4–6·3)

3·2 (2·0–5·0)

7·7 (5·9–10·0)

Namibia

21·1 (18·0–24·6)

26·6 (22·1–31·7)

17·1 (14·0–20·7)

13·6 (10·4–17·7)

24·2 (20·8–27·9)

10·5 (8·4–13·1)

13·1 (10·8–15·9)

8·6 (6·0–12·2)

9·2 (6·0–13·9)

11·0 (8·8–13·7)

Seychelles

48·0 (47·3–48·7)

52·8 (51·7–53·8)

43·8 (42·8–44·8)

40·8 (39·8–41·8)

54·2 (53·2–55·2)

19·2 (18·5–19·8)

25·8 (24·8–26·8)

13·3 (12·5–14·2)

16·5 (15·5–17·5)

21·5 (20·6–22·4)

Tanzania

2·5 (1·9–3·3)

3·0 (2·1–4·3)

2·0 (1·2–3·4)

1·7 (1·1–2·7)

4·5 (3·2–6·2)

11·5 (9·8–13·4)

12·7 (10·3–15·4)

10·4 (8·4–13·0)

11·4 (9·4–13·8)

11·6 (9·0–14·7)

Pooled estimates

16·2 (0–37·5)

18·8 (0–40·4)

13·9 (0–31·8)

11·8 (0–27·7)

19·0 (0–40·0)

11·1 (5·6–16·5)

13·6 (5·9–21·2)

8·7 (5·1–12·2)

9·7 (4·1–15·4)

11·9 (5·7–18·0)

I² (%)

100·0

99·9

99·8

99·9

99·9

98·5

98·6

94·7

97·6

98·5

Anguilla

26·0 (22·6–29·4)

30·1 (24·8–35·4)

22·3 (17·8–26·8)

20·0 (15·3–24·7)

30·4 (25·7–35·1)

12·2 (9·7–14·7)

12·5 (8·8–16·2)

11·9 (8·4–15·4)

7·7 (4·6–10·8)

15·6 (11·9–19·3)

Antigua and Barbuda

23·0 (20·0–26·3)

26·1 (21·8–30·8)

19·8 (16·4–23·7)

18·1 (13·4–24·0)

25·7 (22·4–29·3)

12·0 (9·3–15·2)

14·3 (10·7–18·9)

9·5 (6·9–13·0)

10·6 (7·1–15·6)

12·7 (9·8–16·3)

Argentina

27·3 (25·1–29·6)

28·2 (25·5–31·1)

26·5 (24·0–29·2)

14·3 (12·0–17·0)

33·5 (31·1–35·9)

19·3 (17·6–21·2)

18·8 (16·5–21·2)

19·8 (18·0–21·8)

11·7 (9·6–14·3)

22·9 (21·1–24·8)

Bahamas

19·9 (16·6–23·8)

23·2 (18·5–28·8)

17·0 (14·3–20·1)

16·3 (13·2–20·1)

23·9 (18·7–30·0)

10·4 (7·8–13·7)

13·7 (10·4–18·0)

7·4 (5·2–10·6)

8·7 (6·4–11·9)

12·2 (8·6–17·1)

Barbados

24·3 (21·2–27·8)

29·2 (25·0–33·7)

19·3 (15·9–23·4)

20·2 (16·4–24·7)

25·6 (21·8–29·7)

8·2 (6·7–10·0)

10·2 (7·7–13·3)

6·2 (4·3–8·9)

9·4 (6·5–13·5)

7·8 (6·2–9·8)

Belize

16·7 (14·4–19·4)

19·7 (16·2–23·6)

14·0 (11·5–16·9)

9·8 (7·6–12·5)

23·0 (19·4–27·0)

9·7 (8·0–11·7)

10·6 (8·4–13·3)

8·8 (6·8–11·3)

6·5 (5·1–8·3)

12·5 (9·8–15·9)

Bolivia

11·0 (9·1–13·4)

12·9 (10·1–16·2)

9·3 (7·2–11·8)

4·2 (2·8–6·2)

13·8 (11·0–17·0)

9·4 (7·9–11·2)

10·8 (8·3–13·8)

8·1 (6·6–9·9)

5·4 (3·9–7·3)

11·0 (9·1–13·2)


17·2 (15·0–19·4)

16·4 (13·1–19·7)

17·8 (14·8–20·8)

11·8 (9·1–14·5)

21·9 (18·6–25·2)

7·5 (5·9–9·1)

7·8 (5·4–10·2)

7·3 (5·3–9·3)

5·9 (3·9–7·9)

9·0 (6·6–11·4)

Cayman

25·5 (22·8–28·2)

26·2 (22·2–30·2)

24·9 (21·2–28·6)

18·4 (14·9–21·9)

31·5 (27·6–35·4)

17·2 (14·8–19·6)

18·9 (15·4–22·4)

15·8 (12·7–18·9)

11·3 (8·4–14·2)

22·3 (18·8–25·8)

Chile

15·1 (12·0–18·9)

14·8 (10·9–19·9)

15·4 (11·8–19·8)

7·7 (5·2–11·1)

20·0 (15·9–24·8)

6·8 (5·2–8·8)

7·6 (5·2–10·9)

6·0 (4·2–8·7)

4·7 (2·9–7·5)

8·2 (6·0–11·0)

Colombia

40·8 (37·4–44·4)

42·8 (38·6–47·0)

39·4 (35·2–43·7)

24·9 (21·6–28·6)

51·6 (47·9–55·2)

20·0 (17·7–22·6)

20·9 (18·6–23·5)

19·4 (16·0–23·2)

10·9 (9·2–12·9)

26·2 (23·2–29·4)

Costa Rica

15·7 (13·4–18·4)

15·7 (13·0–18·9)

15·7 (12·8–19·0)

9·0 (6·7–12·0)

19·1 (16·5–22·0)

5·9 (4·7–7·6)

6·7 (5·1–8·8)

5·2 (3·8–7·2)

3·2 (2·0–5·4)

7·3 (5·5–9·6)

Dominica

30·8 (27·1–34·6)

35·4 (30·4–40·8)

26·1 (22·3–30·2)

21·5 (18·3–25·2)

38·6 (34·3–43·1)

12·2 (9·8–15·1)

14·7 (11·1–19·2)

9·7 (7·5–12·6)

7·4 (4·9–11·1)

16·3 (13·2–19·9)

Ecuador

20·8 (18·8–23·0)

22·7 (19·8–25·9)

19·1 (17·0–21·4)

14·6 (12·7–16·8)

28·7 (25·5–32·1)

15·2 (13·6–17·0)

16·1 (13·8–18·7)

14·4 (12·6–16·5)

12·4 (10·4–14·6)

18·8 (16·5–21·4)

El Salvador

9·5 (7·6–11·9)

11·2 (8·5–14·7)

7·8 (5·8–10·5)

5·6 (3·6–8·6)

11·3 (8·9–14·2)

5·7 (4·0–8·2)

5·2 (3·4–7·9)

6·3 (4·3–9·1)

3·8 (2·4–6·0)

6·5 (4·4–9·6)

Grenada

25·8 (23·1–28·6)

33·2 (29·7–37·0)

20·4 (17·0–24·3)

18·1 (15·1–21·5)

31·3 (27·6–35·3)

14·1 (11·9–16·5)

16·4 (13·2–20·2)

12·4 (9·7–15·7)

9·3 (7·0–12·3)

17·5 (14·4–21·1)

Guatemala

10·9 (8·9–13·4)

12·9 (10·1–16·3)

8·8 (7·2–10·7)

5·7 (4·1–7·8)

13·5 (10·8–16·7)

5·4 (4·2–6·8)

5·6 (4·1–7·6)

5·1 (4·1–6·4)

3·3 (2·2–4·8)

6·4 (4·9–8·2)

Guyana

30·1 (26·5–34·0)

35·1 (30·2–40·3)

25·4 (22·3–28·8)

25·5 (21·8–29·5)

31·9 (27·9–36·2)

15·7 (13·1–18·7)

18·9 (15·0–23·6)

12·7 (10·2–15·6)

13·7 (10·4–17·8)

16·5 (13·6–19·8)

Africa

-

-

-

-

-

America



423

Articles

Had been drunk at least once during lifetime Total,% (95% CI)


Boys,% (95% CI)

Girls,% (95% CI)

12–13 years,% (95% CI)

14–15 years,% (95% CI)

Total,% (95% CI)

Boys,% (95% CI)

Girls,% (95% CI)

12–13 years,% (95% CI)

14–15 years,% (95% CI)

(Continued from previous page) Honduras

10·0 (8·6–11·5)

9·7 (7·6–12·4)

10·1 (7·4–13·7)

7·6 (5·7–10·1)

12·1 (10·1–14·4)

5·8 (4·4–7·4)

4·4 (2·8–7·0)

6·9 (4·8–9·7)

5·3 (4·1–6·8)

6·1 (4·2–8·8)

Jamaica

36·5 (29·1–44·6)

44·6 (37·7–51·7)

28·5 (20·5–38·1)

35·2 (22·9–49·9)

36·7 (29·6–44·5)

19·7 (13·3–28·2)

26·2 (19·3–34·5)

13·4 (7·4–23·1)

16·8 (9·2–28·6)

20·3 (13·4–29·4)

Montserrat

27·1 (19·7–34·5)

33·3 (21·9–44·7)

21·6 (12·2–31·0)

20·0 (9·4–30·6)

31·8 (21·8–41·8)

10·8 (5·7–15·9)

12·3 (4·3–20·3)

9·5 (2·8–16·2)

5·6 (0·0–11·7)

14·1 (6·7–21·5)

Peru

14·1 (11·7–16·8)

17·5 (14·2–21·3)

10·7 (8·1–14·1)

9·5 (6·8–13·2)

15·7 (13·1–18·6)

12·7 (11·0–14·6)

15·1 (12·8–17·7)

10·3 (8·3–12·6)

9·8 (7·4–13·0)

13·7 (11·8–15·7)

Saint Lucia

33·0 (29·2–37·2)

39·6 (34·1–45·5)

27·9 (23·1–33·3)

25·5 (21·4–30·2)

38·1 (32·5–43·9)

14·0 (11·4–17·2)

14·2 (10·4–19·1)

13·9 (10·9–17·4)

11·8 (8·4–16·2)

15·5 (12·1–19·7)

Saint Vincent 31·4 and Grenadines (27·4–35·8)

38·1 (32·7–43·9)

26·2 (21·5–31·6)

26·0 (20·6–32·3)

37·7 (32·6–43·0)

16·0 (13·8–18·6)

16·9 (13·3–21·3)

15·3 (12·3–18·9)

13·8 (11·3–16·8)

18·6 (15·1–22·6)

Suriname

14·9 (11·3–19·5)

21·2 (15·6–28·1)

9·4 (7·0–12·5)

9·9 (6·3–15·1)

17·3 (13·3–22·1)

5·1 (3·7–7·1)

7·8 (5·7–10·4)

2·9 (1·6–5·0)

3·7 (1·9–7·4)

5·8 (4·1–8·3)

Trinidad and Tobago

21·3 (18·1–24·8)

22·7 (19·8–25·8)

19·9 (15·2–25·6)

12·1 (9·6–15·3)

28·9 (25·0–33·2)

8·6 (7·0–10·4)

10·3 (8·2–12·8)

6·9 (4·9–9·5)

4·8 (3·3–6·9)

11·7 (9·3–14·5)

Uruguay

25·5 (23·6–27·4)

25·1 (23·0–27·3)

25·8 (23·1–28·7)

13·4 (11·0–16·2)

30·0 (27·7–32·3)

18·8 (17·2–20·5)

19·3 (17·1–21·7)

18·4 (15·9–21·3)

9·6 (7·7–11·9)

22·2 (20·2–24·4)

Pooled estimates

22·2 (19·1–25·3)

25·2 (21·7–28·7)

19·4 (16·5–22·3)

15·1 (12·6–17·5)

26·7 (22·8–30·5)

11·6 (9·8–13·5)

13·0 (10·9–15·1)

10·4 (8·6–12·2)

8·1 (6·8–9·4)

13·9 (11·5–16·2)

95·8

95·4

94·5

96·9

95·9

93·6

94·0

88·6

95·6

21·2 (14·5–29·9)

26·9 (19·9–35·4)

16·2 (9·6–26·1)

18·7 (13·6–25·0)

23·0 (14·0–35·5)

4·9 (3·5–6·9)

8·4 (5·8–12·2)

1·9 (1·3–3·0)

3·6 (2·2–5·8)

5·9 (3·8–9·0)

Macedonia

20·3 (15·9–25·6)

23·9 (18·3–30·7)

16·7 (12·6–21·7)

12·9 (8·4–19·3)

24·9 (19·6–31·2)

16·0 (13·3–19·1)

16·1 (12·2–20·9)

15·9 (13·4–18·8)

10·9 (8·0–14·8)

19·1 (15·8–23·0)

Tajikistan

0·9 (0·6–1·4)

1·3 (0·8–2·2)

0·4 (0·2–0·8)

1·0 (0·4–2·3)

0·9 (0·5–1·4)

1·6 (1·1–2·3)

1·9 (1·3–2·7)

1·3 (0·8–2·2)

1·5 (0·7–3·1)

1·6 (1·1–2·5)

Pooled estimates

10·4 (0–29·4)

12·4 (0–34·5)

8·4 (0–24·4)

6·7 (0–18·3)

12·7 (12·7–36·2)

8·7 (0–22·8)

8·8 (0–22·7)

8·5 (0–22·8)

6·1 (0–15·3)

10·3 (0–27·4)

98·0

98·0

94·7

98·5

98·9

97·5

99·0

96·3

98·9

I² (%)

97·0

Eastern Mediterranean Lebanon Europe

I² (%)

98·3

Southeast Asia Indonesia

2·2 (1·4–3·4)

4·0 (2·5–6·5)

0·4 (0·1–1·2)

1·0 (0·5–2·2)

2·8 (1·8–4·5)

1·6 (1·1–2·4)

2·2 (1·3–3·6)

1·1 (0·6–2·1)

1·1 (0·6–1·9)

2·0 (1·2–3·1)

Malaysia

4·9 (4·1–5·8)

6·9 (5·8–8·1)

3·0 (2·2–4·0)

3·8 (3·0–4·8)

5·5 (4·5–6·7)

2·6 (2·2–3·0)

3·3 (2·7–3·9)

1·8 (1·4–2·5)

2·0 (1·5–2·6)

2·9 (2·4–3·4)

Maldives

4·1 (2·9–5·9)

6·2 (4·0–9·5)

2·3 (1·4–3·8)

4·4 (2·0–9·6)

4·1 (2·9–5·7)

4·1 (2·7–6·3)

6·0 (3·6–9·9)

2·5 (1·3–4·4)

4·8 (2·3–9·9)

4·0 (2·6–6·1)

Myanmar

1·0 (0·6–1·7)

1·7 (1·0–3·0)

0·4 (0·1–1·1)

0·4 (0·1–1·1)

1·6 (0·9–2·9)

4·4 (3·5–5·6)

5·8 (4·3–7·9)

3·1 (2·1–4·5)

4·0 (2·7–5·8)

4·8 (3·8–6·1)

Thailand

15·8 (14·0–17·8)

21·0 (17·8–24·7)

11·4 (8·9–14·4)

8·6 (7·2–10·3)

22·4 (19·7–25·3)

7·4 (6·3–8·7)

11·6 (9·5–14·1)

3·9 (2·7–5·6)

5·2 (4·0–6·6)

9·5 (7·7–11·6)

Pooled estimates

5·5 (2·1–8·8)

7·7 (3·4–12·0)

2·8 (1·3–4·3)

3·5 (1·1–5·9)

7·1 (2·8–11·4)

4·0 (2·3–5·6)

5·6 (3·1–8·0)

2·4 (1·5–3·3)

3·2 (1·6–4·7)

4·5 (2·6–6·3)

97·0

96·1

97·0

98·0

95·3

93·2

76·1

91·3

92·6

I² (%)

98·3

Western Pacific Cambodia

4·3 (3·1–6·0)

6·2 (4·3–8·8)

2·6 (1·8–3·8)

3·0 (1·8–4·9)

4·8 (3·2–7·2)

1·4 (1·0–1·9)

1·2 (0·7–2·2)

1·5 (1·0–2·4)

0·9 (0·3–2·5)

1·5 (1·1–2·1)

Cook

22·2 (19·3–25·1)

22·9 (18·7–27·1)

21·6 (17·6–25·6)

12·6 (9·1–16·1)

29·4 (25·3–33·5)

16·6 (14·1–19·1)

16·7 (13·0–20·4)

16·6 (12·9–20·3)

13·2 (9·5–16·9)

19·2 (15·5–22·9)

Fiji

12·7 (10·8–14·8)

17·7 (15·0–20·7)

8·0 (5·9–10·6)

8·9 (6·5–12·1)

14·3 (11·9–17·2)

14·8 (11·9–18·2)

19·6 (15·3–24·9)

10·2 (8·4–12·4)

12·7 (9·1–17·5)

15·7 (12·0–20·3)

Kiribati

22·1 (18·3–26·3)

36·9 (30·3–44·1)

10·1 (7·4–13·6)

13·4 (9·6–18·3)

25·4 (20·8–30·7)

17·5 (14·9–20·5)

25·5 (21·1–30·4)

10·8 (7·9–14·6)

12·5 (8·6–17·7)

19·4 (16·7–22·5)


424


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Had been drunk at least once during lifetime Total,% (95% CI)


Boys,% (95% CI)

Girls,% (95% CI)

12–13 years,% (95% CI)

14–15 years,% (95% CI)

Total,% (95% CI)

Boys,% (95% CI)

Girls,% (95% CI)

12–13 years,% (95% CI)

14–15 years,% (95% CI)

(Continued from previous page) Mongolia

6·2 (5·0–7·7)

8·2 (6·4–10·4)

4·3 (3·2–5·8)

3·5 (2·5–4·8)

8·4 (6·6–10·6)

1·9 (1·5–2·5)

2·5 (1·9–3·3)

1·3 (0·8–2·1)

1·3 (0·8–2·0)

2·4 (1·8–3·3)

Nauru

18·3 (14·0–22·6)

24·2 (16·5–31·9)

14·6 (9·6–19·6)

12·4 (6·7–18·1)

22·4 (16·3–28·5)

16·7 (12·4–21·0)

20·7 (13·4–28·0)

14·0 (8·9–19·1)

11·3 (5·6–17·0)

20·5 (14·6–26·4)

Niue

17·9 (9·4–26·4)

27·7 (14·9–40·5)

3·2 (0–9·4)

4·8 (0·0–11·3)

33·3 (17·6–49·0)

7·7 (1·8–13·6)

13·0 (3·2–22·8)

Philippines

15·5 (13·1–18·1)

17·2 (14·7–20·1)

13·8 (10·5–18·0)

8·7 (6·5–11·6)

19·2 (16·4–22·4)

6·7 (5·4–8·4)

7·7 (5·8–10·1)

5·9 (4·3–7·9)

5·5 (3·7–8·2)

7·4 (5·9–9·2)

Samoa

36·2 (30·9–41·9)

48·2 (41·9–54·7)

26·1 (21·4–31·4)

35·6 (27·3–44·9)

36·4 (30·5–42·8)

33·1 (27·6–39·2)

42·5 (36·0–49·1)

25·2 (20·2–30·9)

34·6 (26·7–43·5)

32·7 (26·8–39·2)

Solomon

15·9 (11·8–21·2)

19·1 (12·9–27·3)

12·4 (8·9–17·2)

7·4 (3·7–14·0)

19·3 (15·2–24·2)

13·6 (9·5–19·2)

15·3 (9·7–23·1)

11·7 (7·9–17·0)

8·0 (3·9–15·8)

15·8 (11·6–21·1)

Tonga

14·5 (12·0–17·3)

14·0 (10·9–17·8)

14·9 (11·8–18·7)

11·1 (7·9–15·4)

15·7 (12·9–18·9)

12·2 (10·3–14·3)

11·3 (8·8–14·5)

13·0 (10·7–15·8)

8·0 (5·6–11·5)

13·7 (11·5–16·1)

Tuvalu

10·0 (7·6–12·4)

18·5 (14·0–23·0)

2·4 (0·7–4·1)

5·4 (3·0–7·8)

16·2 (11·7–20·7)

13·4 (10·5–16·3)

18·7 (13·8–23·6)

8·9 (5·6–12·2)

11·2 (7·7–14·7)

16·5 (11·6–21·4)

Vanuatu

6·1 (4·2–8·9)

8·0 (5·1–12·3)

4·4 (2·7–7·1)

4·0 (2·7–6·1)

8·5 (5·5–13·0)

3·4 (1·9–6·1)

4·5 (2·0–9·9)

2·4 (1·1–4·9)

2·4 (1·1–5·1)

4·5 (2·2–8·9)

Vietnam

13·0 (10·6–15·8)

18·5 (14·9–22·6)

8·3 (5·9–11·6)

10·6 (2·1–40·1)

13·0 (10·6–16·0)

4·7 (3·6–6·1)

6·8 (5·0–9·3)

2·9 (1·9–4·6)

5·2 (1·1–22·0)

4·7 (3·6–6·1)

Pooled estimates

15·0 (11·5–18·6)

19·9 (15·2–24·6)

10·2 (7·3–13·1)

8·9 (6·5–11·2)

18·2 (14·0–22·4)

11·2 (8·5–13·8)

14·1 (10·4–17·7)

9·0 (6·5–11·5)

8·6 (6·1–11·2)

12·9 (9·8–16·0)

95·6

95·1

89·6

95·3

98·1

97·2

96·6

94·4

97·6

21·3 (16·8–25·7)

14·5 (12·1–16·9)

12·2 (9·5–15·0)

21·5 (17·0–26·0)

10·6 (8·9–12·2)

12·5 (10·4–14·5)

8·9 (7·5–10·2)

7·8 (6·6–9·1)

12·3 (10·4–14·2)

99·5

99·5

99·2

99·6

98·9

98·3

97·5

96·5

98·6

I² (%)

96·4

0

0

16·2 (4·2–28·2)

Total Pooled estimates I² (%)

17·9 (13·6–22·1) 99·8

The number of respondents for this question is given in table 1. *Ever had a hangover, felt sick, got into trouble with family or friends, missed school, or got into fights, as a result of drinking alcohol.

Table 3: Prevalence of drunkenness episodes and drinking-related problems during lifetime among young adolescents by region, country, sex, and age group

of alcohol use, a low threshold might represent, in some cases, experimentation or rites of passage at an age when adolescents transition toward adulthood, whereas preva lence estimates based on a higher threshold might better signal a permanently established risk behaviour. In our study, the overall prevalence of alcohol use was 25% when based on drinking on at least 1 day during the past 30 days but 10% when based on drinking on at least 3 days. Further analysis assessing the variables on the basis of several thresholds might offer further insight, particularly if interpreted within a country’s specific cultural and social norms. We found that boys used alcohol more frequently than girls in many LMICs. Sex differences in alcohol prevalence have been reported in several LMICs27,28 and the prevalence of alcohol use was usually found to be higher in boys than in girls. However, a similar prevalence of alcohol use in boys and girls, as found in some high-income countries,29 might reflect social changes toward increasingly equal rights and conditions between boys and girls. The alcohol industry has been quick to build on this trend and subsequent market opportunities (eg, by portraying alcohol drinking by www.thelancet.com/child-adolescent Vol 2 June 2018

women in advertisements as a sign of emancipation, social integration, and success).30 We found an overall moderately high prevalence of both lifetime drunkenness episodes and lifetime drinkingrelated problems, but with large differences across countries. The previously published review of GSHS in 12 LMICs found that the prevalence of lifetime drunkenness ranged from 2·5% in Indonesia to 53·1% in the Seychelles in adolescents aged 13–15 years.17 As expected, the prevalence of these two outcomes was generally higher in countries with a high prevalence of alcohol use. In our study, both the prevalence of having been drunk and having had drinking-related problems was higher in boys than in girls, and in older than younger adolescents, in most countries. A higher prevalence of drunkenness in boys than girls has been reported in several countries (eg, Spain,16 the USA,31 Malaysia,32 and South Africa).33 A sex difference can be explained, at least in part, by an often larger alcohol consumption among boys than girls and a generally larger social tolerance for male than female drinking in many societies.34 With regard to age, the higher prevalence of having been drunk among older 425

Articles

Response rate, n/N (%)

Bought it in a store, Gave someone money % (95% CI) to buy, % (95% CI)

Got it from friends, % (95% CI)

Got it from family, % (95% CI)

Stole it, % (95% CI)

Some other way, % (95% CI)

Africa Benin

154/174 (88·5%)

17·1 (11·9–23·9)

6·0 (3·2–10·9)

32·4 (24·2–41·9)

33·8 (25·3–43·4)

6·1 (2·7–13·0)

4·7 (2·1–9·9)

Ghana

129/169 (76·3%)

23·4 (16·5–32·0)

15·0 (9·7–22·6)

26·7 (20·5–33·9)

20·3 (15·7–25·8)

5·8 (3·2–10·1)

8·8 (4·4–16·9)

Mauritius

607/728 (83·4%)

18·7 (13·7–25·0)

6·6 (4·7–9·4)

30·7 (25·6–36·3)

32·2 (25·1–40·2)

2·9 (1·7–4·7)

8·8 (6·2–12·4)

Namibia

364/424 (85·8%)

16·5 (12·7–21·1)

9·4 (7·0–12·6)

31·8 (26·3–37·9)

21·3 (16·7–26·9)

8·0 (5·6–11·2)

12·9 (9·9–16·7)

Seychelles

519/528 (98·3%)

12·5 (12·3–12·7)

6·9 (6·3–7·7)

15·8 (15·2–16·3)

36·1 (35·1–37·1)

2·5 (2·5–2·6)

26·2 (25·3–27·1)

Tanzania

82/83 (98·8%)

11·8 (5·8–22·4)

4·1 (0·8–17·5)

15·8 (8·1–28·6)

49·8 (39·0–60·7)

5·6 (2·7–11·3)

12·9 (7·5–21·5)

7·5 (5·8–9·1)

25·5 (17·4–33·6)

31·6 (23·8–39·3)

5·5 (3·1–7·8)

93·8

93·1

Pooled estimates

··

16·1 (12·7–19·5)

I² (%)

··

71·9

50·3

68·5

12·5 (3·1–21·8) 98·2

America Antigua and Barbuda

446/506 (88·1%)

19·0 (15·4–23·1)

5·5 (3·3–9·0)

16·5 (13·0–20·5)

38·0 (32·8–43·6)

5·2 (3·3–8·1)

Argentina

9265/10 063 (92·1%)

25·7 (23·3–28·2)

5·6 (4·8–6·5)

32·0 (29·9–34·2)

17·3 (15·6–19·2)

2·3 (1·5–3·5)

17·1 (15·5–18·8)

Bahamas

288/334 (86·2%)

11·0 (8·6–13·9)

9·1 (6·0–13·5)

21·3 (17·4–25·8)

37·1 (32·1–42·4)

6·3 (4·4–9·1)

15·2 (11·7–19·5)

Barbados

592/673 (88·0%)

11·0 (8·5–14·1)

6·1 (4·3–8·4)

22·0 (18·5–26·1)

41·0 (36·2–46·0)

3·8 (2·5–5·6)

16·1 (13·3–19·3)

Belize

365/394 (92·6%)

10·4 (7·9–13·6)

8·8 (6·3–12·3)

45·6 (41·2–50·1)

18·1 (14·6–22·2)

3·7 (2·2–6·3)

13·3 (10·2–17·2)

Bolivia

321/381 (84·3%)

28·7 (24·2–33·6)

11·7 (8·8–15·4)

36·3 (30·7–42·2)

7·3 (5·2–10·2)

0·4 (0·1–1·7)

15·7 (12·3–19·8)


306/338 (90·5%)

9·7 (6·6–12·8)

8·3 (5·4–11·2)

19·1 (15·0–23·2)

39·4 (34·3–44·5)

3·4 (1·5–5·3)

20·0 (15·8–24·2)

Cayman

361/365 (98·9%)

8·3 (5·5–11·1)

9·7 (6·6–12·8)

22·2 (17·9–26·5)

31·6 (26·8–36·4)

1·9 (0·5–3·3)

26·3 (21·8–30·8)

Chile

15·9 (12·2–20·4)

255/289 (88·2%)

15·6 (11·2–21·4)

8·1 (5·1–12·5)

28·9 (22·2–36·7)

27·6 (21·7–34·4)

2·5 (1·1–5·8)

17·2 (12·5–23·3)

Colombia

3677/3689 (99·7%)

15·7 (12·6–19·5)

6·8 (5·8–8·0)

36·0 (32·5–39·7)

17·8 (14·7–21·4)

1·2 (0·6–2·4)

22·5 (18·9–26·6)

Costa Rica

495/519 (95·4%)

11·4 (8·4–15·2)

17·7 (14·1–21·9)

30·5 (27·0–34·2)

20·2 (16·6–24·4)

2·1 (1·3–3·3)

18·2 (15·7–21·0)

Dominica

534/598 (89·3%)

16·9 (14·0–20·4)

7·9 (6·0–10·4)

29·6 (25·4–34·2)

27·0 (23·4–31·1)

5·9 (4·2–8·2)

12·6 (10·0–15·8)

Ecuador

1026/1047 (98·0%)

24·9 (21·6–28·4)

8·7 (6·6–11·4)

32·5 (28·7–36·7)

12·8 (10·6–15·4)

1·1 (0·7–1·9)

19·9 (17·4–22·7)

El Salvador

232/269 (86·2%)

14·0 (10·2–18·9)

12·3 (8·5–17·6)

38·1 (33·2–43·1)

9·7 (6·1–15·0)

1·8 (0·6–5·5)

24·1 (19·1–29·9)

Grenada

459/475 (96·6%)

18·6 (14·6–23·3)

9·5 (7·0–12·7)

23·2 (19·2–27·7)

29·6 (24·2–35·7)

0·5 (0·2–1·5)

18·7 (14·5–23·7)

Guatemala

663/755 (87·8%)

22·1 (17·1–27·9)

6·3 (4·9–8·2)

35·4 (30·6–40·5)

15·9 (11·8–21·1)

1·9 (1·0–3·3)

18·5 (15·3–22·1)

Honduras

181/211 (85·8%)

14·0 (10·0–19·4)

7·3 (4·0–12·8)

39·0 (31·5–47·0)

17·4 (12·5–23·7)

2·9 (1·6–5·5)

19·4 (14·2–25·9)

Jamaica

509/575 (88·5%)

33·2 (29·0–37·6)

10·2 (6·7–15·2)

25·2 (19·9–31·3)

20·8 (17·1–25·1)

1·5 (0·8–2·7)

4·3 (0–10·2)

26·1 (13·4–38·8)

43·5 (29·2–57·8)

2·2 (0–6·4)

Montserrat

46/47 (97·9%)

6·5 (0–13·6)

9·1 (6·2–13·3) 17·4 (6·4–28·4)

Peru

510/611 (83·5%)

18·8 (16·1–21·8)

11·9 (9·1–15·3)

34·0 (30·1–38·2)

16·1 (13·6–19·0)

2·3 (1·4–3·6)

17·0 (14·0–20·4)

Saint Lucia

489/494 (99·0%)

8·6 (6·1–12·0)

3·0 (1·8–5·1)

22·2 (18·5–26·5)

44·7 (39·8–49·6)

1·7 (0·9–3·3)

19·7 (16·1–23·9)


491/500 (98·2%)

16·5 (13·7–19·7)

5·9 (4·1–8·5)

27·6 (23·7–31·9)

32·3 (27·5–37·5)

1·3 (0·6–3·0)

16·3 (13·4–19·8) 29·8 (25·3–34·7)

Suriname

236/284 (83·1%)

13·7 (10·7–17·4)

3·3 (1·6–7·0)

14·2 (10·1–19·7)

32·8 (27·4–38·7)

6·1 (3·7–9·9)

Trinidad and Tobago

649/751 (86·4%)

10·9 (8·6–13·6)

6·1 (4·4–8·5)

16·6 (12·4–21·8)

42·0 (36·9–47·2)

7·1 (5·5–9·0)

17·3 (14·0–21·3)

1145/1245 (92·0%)

37·2 (34·0–40·5)

4·1 (2·6–6·3)

22·5 (19·6–25·8)

20·5 (18·3–22·9)

1·0 (0·6–1·5)

14·7 (12·1–17·8)

Uruguay Pooled estimates

··

16·9 (13·9–19·9)

I² (%)

··

95·1

7·6 (6·6–8·6) 80·2

27·8 (24·7–30·8)

26·0 (22·0–30·0)

92·3

96·5

2·5 (1·9–3·0) 84·4

17·8 (16·4–19·3) 77·2


431/484 (89·0%)

23·7 (18·5–29·8)

1·6 (0·8–3·4)

3·9 (2·0–7·3)

55·5 (48·4–62·3)

1·8 (0·8–3·9)

13·6 (8·3–21·4) 21·1 (16·0–27·2)

Europe Macedonia

483/494 (97·8%)

53·5 (46·7–60·1)

4·4 (2·9–6·6)

8·7 (5·9–12·8)

12·4 (8·4–17·9)

0

Tajikistan

42/43 (97·7%)

26·9 (14·1–45·3)

21·3 (13·7–31·6)

30·8 (12·9–57·4)

17·0 (9·5–28·5)

0

13·3 (9·1–17·5)

0

Pooled estimates

··

41·2 (15·2–67·2)

12·3 (0–28·8)

16·6 (0–37·3)

I² (%)

··

89·1

92·6

69·9

0

0

3·9 (1·0–14·6) 12·5 (0–29·4) 94·7 (Table 4 continues on next page)

than younger adolescents in our study is expected and consistent with other studies.35 We found that alcohol among youth was procured most often from friends or from the family. This finding reflects that these sources can escape age control more 426

easily than licensed commercial vendors. However, we found that youth also often purchased alcohol from commercial vendors, including in some countries with policy banning the sale of alcohol to youth (eg, Thailand) or in some countries in which alcohol availability is www.thelancet.com/child-adolescent Vol 2 June 2018

Articles

Response rate, n/N (%)

Bought it in a store, Gave someone money % (95% CI) to buy, % (95% CI)

Got it from friends, % (95% CI)

Got it from family, % (95% CI)

Stole it, % (95% CI)

Some other way, % (95% CI)

(Continued from previous page) Southeast Asia Indonesia

77/77 (100·0%)

18·9 (10·4–32·0)

12·4 (5·3–26·1)

40·9 (26·5–57·0)

13·0 (5·2–29·2)

0·7 (0·1–4·8)

Malaysia

875/1043 (83·9%)

27·6 (23·8–31·7)

6·1 (4·5–8·2)

18·5 (15·4–22·0)

36·6 (31·7–41·8)

1·8 (1·2–2·7)

14·2 (7·2–26·2) 9·4 (7·6–11·4)

Myanmar

23/23 (100·0%)

28·6 (13·5–50·9)

19·7 (8·1–40·7)

16·8 (6·4–37·4)

8·0 (4·5–13·7)

5·6 (0·8–31·5)

21·3 (7·3–48·0)

Thailand

345/345 (1 00·0%)

37·0 (32·4–41·9)

16·7 (12·7–21·7)

25·8 (21·8–30·4)

12·2 (8·2–17·8)

1·1 (0·4–2·8)

7·1 (4·8–10·5)

Pooled estimates

··

28·9 (21·2–36·6)

12·6 (4·9–20·2)

23·9 (16·7–31·0)

17·6 (3·4–31·7)

1·4 (0·8–2·0)

9·0 (6·5–11·5)

I² (%)

··

78·5

86·0

77·2

96·1

0

34·3

Western Pacific Cambodia

74/94 (78·7%)

51·5 (39·8–63·1)

9·8 (6·1–15·4)

12·0 (6·4–21·5)

20·2 (11·9–32·1)

0·9 (0·1–6·1)

5·6 (2·7–11·0)

Cook

193/231 (83·5%)

7·2 (3·9–10·5)

9·7 (5·9–13·5)

44·7 (38·4–51·0)

21·5 (16·3–26·7)

4·6 (1·9–7·3)

12·2 (8·0–16·4)

Kiribati

364/375 (97·1%)

10·6 (8·3–13·3)

29·9 (23·9–36·6)

45·4 (38·3–52·6)

2·0 (0·9–4·4)

5·8 (3·9–8·5)

6·4 (4·6–8·8)

Mongolia

112/140 (80·0%)

48·1 (39·4–56·9)

15·9 (11·0–22·4)

17·5 (12·7–23·7)

8·0 (4·5–13·8)

4·5 (2·6–7·6)

6·0 (3·2–11·0)

Nauru

48/68 (70·6%)

11·9 (3·6–20·2)

20·3 (10·0–30·6)

50·8 (38·0–63·6)

3·4 (0–8·0)

6·8 (0·4–13·2)

6·8 (0·4–13·2)

Niue

11/13 (84·6%)

8·3 (0–23·9)

8·3 (0–23·9)

50·0 (21·7–78·3)

16·7 (0–37·8)

8·3 (0–23·9)

8·3 (0–23·9) 8·8 (5·6–13·6)

Philippines

460/567 (81·1%)

24·8 (19·7–30·7)

12·8 (8·3–19·2)

38·1 (33·0–43·6)

14·0 (9·5–20·1)

1·4 (0·5–3·9)

Samoa

470/626 (75·1%)

24·4 (20·4–28·8)

24·4 (21·2–27·9)

18·1 (15·3–21·2)

16·3 (13·8–19·1)

9·8 (7·1–13·4)

7·0 (5·4–9·2)

Solomon

137/160 (85·6%)

21·1 (14·3–30·2)

20·0 (14·2–27·5)

43·4 (32·1–55·4)

5·3 (3·1–8·8)

1·6 (0·6–4·7)

8·5 (4·5–15·4)

Tonga

226/294 (76·9%)

13·5 (9·6–18·7)

12·6 (8·1–18·9)

45·9 (39·5–52·4)

11·9 (8·6–16·2)

5·8 (3·4–9·7)

10·3 (7·5–14·0)

Tuvalu

53/69 (76·8%)

22·6 (12·2–33·0)

12·9 (4·6–21·2)

41·9 (29·6–54·2)

8·1 (1·3–14·9)

6·5 (0·4–12·6)

8·1 (1·3–14·9)

Vanuatu

52/70 (74·3%)

24·8 (14·0–39·9)

5·4 (1·9–14·6)

50·1 (31·2–69·0)

15·6 (8·3–27·4)

1·2 (0·2–8·1)

2·8 (0·7–10·5)

Vietnam

229/250 (91·6%)

20·1 (15·3–26·1)

2·4 (1·1–5·0)

8·2 (4·9–13·3)

39·2 (31·8–47·1)

2·3 (0·9–5·7)

27·8 (22·6–33·8)

Pooled estimates

··

21·8 (15·9–27·6)

14·2 (8·8–19·6)

34·6 (25·8–43·5)

13·4 (8·6–18·3)

I² (%)

··

92·8

94·1

95·7

94·3

3·8 (2·4–5·3) 75·3

8·9 (6·4–11·4) 81·6

Total Pooled estimates I² (%)

30 101/34 587 (87·0%) ··

9·1 (8·0–10·2)

19·5 (17·5–21·6) 95·6

89·5

27·8 (24·8–30·7)

23·2 (19·5–26·9)

96·5

98·1

2·8 (2·3–3·3) 81·9

14·4 (12·2–16·5) 95·2

Table 4: Frequency of alcohol access among young adolescents who reported drinking in the past 30 days by region and country

restricted (eg, Malaysia). These findings could be related to poor enforcement of policy banning alcohol sales to minors, weak licensing system for outlets selling alcohol, or high density of shops selling alcohol (in countries in which alcohol is not restricted). For example, according to previous reports, youth in the Philippines36 and Australia37 often purchase alcohol from commercial outlets, possibly because of a high density of alcoholselling outlets and possibly because of high social acceptability of alcohol drinking. Adolescence is a crucial period with regard to the development of cognitive abilities and the internalisation of health risks toward their adult levels. In addition to increasing the risk of many diseases and unhealthy behaviours, alcohol use in adolescents is also associated with impaired development of the brain,38 including attention alterations, poor verbal learning, and decreased memory, which might carry on into adulthood.39 The findings of a substantial prevalence of alcohol use and alcohol-related problems in young adolescents in several LMICs emphasises the need to further develop and implement public policies and prevention programmes to curb alcohol use among adolescents. Several cost-effective measures are known and are formulated (eg, in appendix 3 www.thelancet.com/child-adolescent Vol 2 June 2018

of the WHO Global Plan of Action for the prevention and control of non-communicable diseases 2013–20,40 and in the WHO Global Strategy to Reduce Harmful Use of Alcohol). These measures include public health measures that reduce demand, such as excise tax increases on alcohol beverages and the ban or restriction on alcohol advertisement and promotion, as well as measures to regulate commercial and public availability of alcohol beverages (eg, reducing the numbers and types of shops authorised to sell alcohol beverages, restricting alcohol sale hours, and enforcing the ban on sales to minors). Interventions at the family level or in selected settings can also be helpful to reduce alcohol drinking among youth. Family-based measures such as face-to-face interventions and benevolent parental monitoring aimed at strengthening bonds between parents and adolescents can promote self-efficacy and resilience of youths with regards to alcohol consumption.41 Reduction of alcohol drinking at home can also reduce adolescent drinking.42 Programmes in high-income countries to increase knowledge and skills in addressing risk behaviours targeting parents, school nurses, teachers, paediatricians, social workers, and other key personnel have also been shown to help children become resilient to risk behaviours.43 427

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For the Global Burden of Diseases project see www.healthdata.org/gbd

428

Surveillance of drinking patterns at country level over time is necessary to guide national health policy. The Global Burden of Diseases project has been systematically collecting comprehensive health data from many sources in all countries for more than two decades, including from publicly available data such as those used in this study. Their estimates for risk factor frequency and associated disease burden, including for alcohol use, are based on statistical models,2 whereas estimates in this Article are based on, and limited to, actual survey findings. In 2013, WHO developed a global monitoring framework as part of the Global Action Plan for the prevention and control of non-communicable diseases (appendix). Three indicators (from a total of 25) assess alcohol use and related morbidity in the global population, including among adolescents.40 Countries are requested to regularly report levels of these indicators to monitor progress toward achievement of the targets set by the Global Action Plan, including a 10% reduction in harmful use of alcohol between 2010 and 2025.40 This global initiative is expected to stimulate systematic and standardised collection of data on alcohol use, including among adolescents in LMICs. Our study has several strengths. First, the sample was large (139 649 young adolescents aged 12–15 years) and arose from 57 LMICs in the six WHO regions. Second, a same standardised questionnaire was applied in all countries, allowing direct comparison between countries. However, several limitations should also be considered. First, the use of a self-reported questionnaire can be subject to recall bias and problems of understanding (some adolescents might have weak reading skills). Additionally, different cultural factors in countries can result in different levels of acceptability of alcohol, which can in turn affect self-reporting about alcohol use, a further potential bias in data across countries. Students might also have under-reported their alcohol use in some countries where alcohol drinking is strongly stigmatised. Second, overall and regional estimates must be interpreted with caution because of heterogeneity of results between countries. Third, estimates are representative at the country level, but we lack additional variables to perform subanalyses by setting (urban vs rural), social economic status, types of school (public vs private), or academic achievement. Fourth, the surveys were conducted between a fairly long period of time parison between countries (2006–13) and direct com should be made cautiously. However, most of the surveys (43 of 57) in the present study were conducted between a narrow time interval (2009–13). Fifth, the response rates to the surveys differed across countries, which might bias the results. Students who miss school (eg, nonparticipants in these surveys) might have higher risk behaviour levels.44 In conclusion, our study shows a moderately high prevalence of alcohol use, lifetime drunkenness, and alcohol-related problems in young adolescents in LMICs;

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