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China: alcohol today

2005; Wiley; Volume: 100; Issue: 6 Linguagem: Inglês

10.1111/j.1360-0443.2005.01036.x

1360-0443

Wei Hao, Hanhui Chen, Zhonghua Su,

Metabolomics and Mass Spectrometry Studies

China is a vast country, containing 22% of the world's population. Over recent decades there has been evidence of a striking increase in alcohol consumption and related problems in that country, with the potential for a major impact on health. As one of the oldest brewing countries in the world, there are many legends and tales that center on this theme in China. Research shows that the origin of alcohol in China was from the Shen Nong period of the New Stone Age (approximately 7000 years ago). Legend also tells that Du Kang, living in the Xia Dynasty (2100 BC−1600 BC), invented alcohol. Today some Chinese still use his name to indicate alcohol. Based on the oracle inscriptions from the late Shang Dynasty (1200–1046 BC), the earlier texts from China, at least three beverages were distinguished: chang (a herbal wine), li (probably a sweet, low-alcoholic rice or millet beverage), and Jiu (a fully fermented and filtered rice or millet beverage or 'wine', with an alcoholic content of probably 10–15% by weight) (McGovern et al. 2004). During the period of the Xia-Shang Age (1700 BC), the invention of alcohol yeast resulted in an increase in quality. With the reform of storage techniques, many famous brands of alcohol were produced in China, such as Moutai (135 BC). However, newly published research indicated that the Chinese were consuming fermented beverages—possibly wine—as far back as 9000 years ago. A study, using modern techniques to analyse ceramics (from Jiahu, Henan Province) dated about 7000 BC, showed chemicals that matched residues from modern rice and rice wine, grape wine, grape tannins and ancient and modern herbs. The most straightforward interpretation of this data is that the Jiahu vessels contained a consistently processed beverage made from rice, honey and fruit (McGovern et al. 2004). Archaeologists found that the earliest bronze distillery in China was built during the Eastern Han Dynasty (25–220 AD), but documentary records detailing liquor distilling techniques began during the Yuan Dynasty (1206–1368 AD) (Xu 2004). At the end of the 18th and the early 19th centuries beer, brandy, whisky, and vodka were introduced to China (Hao & Young 2000; Cochrane et al. 2003). China is known as a country in which alcohol is an important aspect of the culture. The Chinese have continually regarded alcohol as the representation of happiness and the embodiment of auspiciousness. Alcohol plays an important role in traditional Chinese medicine. It is also associated with the arts and poetry: the famous Chinese poet Li Bai is known as the 'Saint of Alcohol'. At the same time, Chinese people regard alcohol as one of the 'Four Vices' or disasters. This double view of alcohol is reflected in China's history. Drinking is socially accepted and plays a significant part in major events of daily life such as the New Year Festival, wedding ceremonies, birthday parties and so on. Ritual drinking for special events, such as thanking God, ancestors, heaven and earth, still exists in some areas. While several customs remain, there are noticeable changes in the drinking behavior of the Chinese. The Chinese business world is becoming highly competitive, and drinking is seen as a necessary behavior for success. Drinking is seen as easing tension and facilitating social exchange among Chinese businessmen. Furthermore, alcohol is also believed to help to maintain good relations between supervisors and employees and among colleagues (Cochrane et al. 2003; Hao & Young 2000). Generally speaking, people in the north tend to have heavier drinking habits than ones in the south of China. Chinese cultural norms encourage social drinking and discourage solitary drinking. Despite the custom of toasting (urging one another to drink, and being made to drink as a forfeit at a banquet) and the drinking game known as 'wager', Chinese drinkers tend to remind themselves not to drink too much when with friends. Most social drinking takes place with a meal (Hao & Young 2000). Early Chinese literature includes many references to the control of alcohol. Dynasties are said to have fallen as a result of overindulgence in alcohol by kings. Historical records clearly suggest that, at different times, governments have acknowledged alcohol-related problems and have used policies to prevent these problems and increase government income. For example, the Emperor Yu (2205–2198 BC) imposed an alcohol tax to reduce consumption while during the Han Dynasty (220–206 BC) a variety of laws were passed to control consumption. During the Wei regime (220–246 AD) infringement of the government's alcohol monopoly was punishable by death, a measure intended in part to prevent public health problems from alcohol use (Newman 2003). A wide range of alcoholic beverages is consumed in contemporary China (Table 1). These include 'strong' distilled liquor (about 54% V/V ethanol), 'less strong' liquor (32–44% ethanol), wine and yellow rice wine (12–18% ethanol) and beer (4–6% ethanol). Rice wine is produced from rice or millet, with ethanol content usually15–16%. Additionally, medicinal liquor is produced which includes traditional herbs and is used to improve general health and treat a variety of ailments including arthritis and sexual performance problems such as impotence (Hao & Young 2000). The amount of alcoholic beverages produced and consumed in China is increasing steadily and China is now the second largest beer-producing country in the world (World Drink Trends 1996; Hao & Young 2000). In 2001 the sale of beer accounted for 73.1% of total beverage alcohol sales in China, with spirits at 26%. However, spirits still constitute the major alcohol consumption, with more than four times the amount of ethanol consumed as spirits than as beer in 2001 (China Statistic Bureau 2003). Wine, especially red wine is becoming more popular because of its supposed health-improving effects. Taxation on imported liquors (brandy and whisky) was cut in 1995 from 150% to 80% and the volume of sales has doubled in the last decade but the consumption of these imported liquors is limited. A 2001 World Health Organization (WHO) sponsored survey of 24,992 subjects (male 56%, female 44%, mean age 40.1 ± 15.6) in China, showed an annual absolute ethanol consumption of 4.5 litres among adults aged 15 years and older (Hao et al. 2003). In this survey, sampling took place in five sites in the city of Chengdu (CD) and its adjacent rural area in Sichuan Province; the city of Yanji (YJ) and its adjacent rural area in Jilin Province; the city of Fuyang (FY) and its adjacent rural area in Anhui Province; the city of Jinan (JN) and its adjacent rural area in Shandong Province and the city of Hengyang (HY) and its adjacent rural area in Hunan Province. In all five areas, blocks in cities and villages in rural areas were selected with a probability proportionate to size from the primary units, which were selected randomly (Hao et al. 2003). Based on WHO data the per capita alcohol consumption in pure alcohol for adults in China in 1970 was 1.03 litres, and rose to 5.17 litres in 1996 (WHO 1999). This was still low compared with industrialized countries: by comparison European alcohol consumption was 8.6 litres per capita in 2001(WHO 2001). Analysing these numbers is difficult. Some 70–80% of China's population lives in rural areas and an even larger percentage could be considered poor. Their ability to purchase alcohol is limited. In the report by Hao et al. (2003) the 3-month use rate of the unrecorded alcohol beverages (mainly home-brewed beverages, also including counterfeited alcohol beverages, that is unscrupulous merchant-produced illicit alcohol beverages marketed as famous brands) was 7.1% among all the respondents, the most frequent types of unrecorded alcohol beverages being rice wine and paddy wine. The proportion of unrecorded alcohol beverages accounted for 14.9% of total alcohol consumption, and those in CD and HY sites (in southern areas) were 25.5% and 29.9% of each site's consumption, while the other three sites accounted for less than 1% each. It is very hard to predict when China's alcohol consumption may reach a plateau, and where the plateau will be. The biological, cultural and economic factors should be considered in the prediction. Over 10% of Chinese are estimated to respond to a small amount of alcohol with a 'flushing' reaction, due to a variant of the enzyme aldehyde dehydrogenase, and this restricts the consumption of alcohol by some Chinese people. However, Korean and Japanese people, who may share a similar physiological makeup with Chinese people, do drink a lot of alcohol (WHO 1999). It is social and cultural factors that drive the level of consumption of alcohol. There are some social and cultural factors that may encourage moderate drinking in China: traditional Chinese values and philosophies emphasize 'moderation', and 'moral drinking'; Chinese traditionally drink alcohol only when eating, and they are against solitary drinking; and poor economic conditions restrict some people's use of alcohol. However, as China continues to open up to the West and becomes richer, these economic and traditional cultural constraints against alcohol abuse will be severely tested. The continuing increase of alcohol consumption in China is inevitable. In the above WHO sponsored study of the general population aged 15 and above, the proportion of 3-month drinking rates in the study was 63.8%, 18.3% and 43.8%, for males, females and the total sample, respectively, and that of 1-year drinking rates was 74.9%, 38.8% and 59.0%, respectively. Both the 3-month and the 1-year drinking rates were higher in males than in females (P < 0.0001). Both 3-month and 1-year drinking rates increased with age, reached a peak at 41–50 years old in males and 36–40 years old in females and then declined. A majority (76.7%) of female drinkers and 33.8% of male drinkers had alcoholic beverages once a week or less, while 26.1% of male drinkers and only 5.4% of female drinkers drank at least once a day (Hao et al. 2003). In men, distilled spirit is the primary beverage of choice, accounting for more than one third of all drinks consumed. Women report consuming more wine and beer than other beverages (Cochrane et al. 2003). Drinking behavior in young people should be given more attention in China. A survey (n = 1650) conducted in three middle schools in Shijingshan district, Beijing, showed that life-time drinking rates were 48.3% and 37.0% for boy and girl juniors students, respectively, and 72.8% and 56.3% for boy and girl senior students, respectively. 12.2% admitted that they had experienced drunkenness in the last year (Xing et al. 2002). Luo et al. (2003) conducted a survey in 115 middle, high or technical schools in Shanghai (n = 9308). The results showed that 45.7% of these students had consumed alcoholic beverages in the past and 17.8% drank alcohol (5.2% had been drunk) in the 30 days preceding the survey. Some studies have targeted people with specific occupations, such as steel workers and mine workers (heavy physical labourers). A report showed that daily drinking rates were 63.8% for steel workers (n = 242; male, 82.2%; female 17.8%), with an average of 88 g/day in pure alcohol (Lu et al. 1999). Alcohol-related harm has not been systematically studied and reviewed in China. It was conservatively estimated by WHO in 1990 that in China alcohol was responsible for 114,000 deaths, 2.118 million years of life lost and 4.854 million 'disability adjusted' years of life lost with a 2.3% disease burden (WHO 2002). In the earliest reported field survey of mental morbidity in China, Shen et al. surveyed 38,136 persons aged 15 and over from 12,000 households in 12 regions in the early 1980s (Hao & Young 2000; Cochrane 2003). Only six cases (0.016%) could be diagnosed as alcohol dependent according to ICD-9 criteria. Since then China has undergone rapid social and economic change. In the above five site study, the prevalence of current alcohol dependence was 6.5% in men and 0.2% in women (3.87% overall), and the 1-year morbidity from gastritis/ulcers in the whole sample was 7.9%, which associated non-linearly to alcohol intake, while heart disease and cerebral infarction/cerebral haemorrhage showed U-shaped curve relationships (Hao et al. 2003). Some other epidemiological surveys show the trends (Hao & Young 2000) (Table 2). It is difficult to ascertain to what extent differences in diagnosis rate, survey methodology, and reporting have impacted on this apparent dramatic increase in the prevalence of alcohol dependence. Nonetheless the rise in prevalence of alcohol dependence has paralleled similarly dramatic increases in commercial alcohol production (see above), and other considerable changes within Chinese society. While alcohol is an integral part of Chinese culture, policy making has not been fully responsive to the rate of increase of consumption and related problems. Alcohol-related diseases are not major subjects for undergraduate and postgraduate education and training in China. Population based prevention has not been developed, and early intervention techniques have not been routinely implemented because of lack of expertise and public awareness. Health services' response to alcohol-related harm has traditionally focused on treatment of complications with little focus on the underlying alcohol use disorder (Hao 1995). No publications can be found on harm reduction or prevention programs. There are few published reports of current treatment methods for alcohol dependence in China. Facilities have been established for treatment of substance abuse, but they are very few and there are no specific alcohol treatment centers (Hao & Young 2000; Cochrane 2003). Home detoxification has been relatively unexplored, and self-help organizations similar to Alcoholics Anonymous exist only in certain regions. Only one multicenter study on efficacy of naltrexone in reduction of relapse is being conducted. Drink-driving is responsible for a lot of deaths in China (in 2001 the number of traffic accident cases in China were over 100 000 and 1/3 were related to drink-driving, Zhang et al. 2004). The Chinese government has issued a new version of the 'Traffic Safety Law', which took effect from 1 May 2004. The related punishments include life-long license suspension and imprisonment. However, the criteria for drink driving and related procedures are not clarified (Zhang et al. 2004). Another important issue has not been addressed at present: China has not got a comprehensive public health policy on alcohol. Access to alcohol has few restrictions and controls. There is no limit to the age at which it can be bought or consumed, and alcohol is freely available in supermarkets and other shops. Even though the State Industry and Commerce Bureau issued an official document regarding 'The Regulations of Alcohol Advertising on Media' on 17 November 1995 which was implemented from 1 January 1996 (State Industry & Commerce Bureau 1996), there is still much alcohol advertising that disobeys the regulations. The content of advertisements include associating drinking with social success, daring, toughness, bravado, stimulation and relaxing, and suggest that alcohol can enhance health and sexual performance (herb alcohol beverages). A further problem is that there is no agency taking a lead on alcohol policy or legislation. Many government sectors are involved in the regulation of alcoholic beverages, such as: State Administration for Industry and Commerce for quality and advertising, the Ministry of Commerce regarding the regulation of the trade in liquor, State Administration of Taxation for tax, General Administration of Quality Supervision, Inspection and Quarantine and State Food and Drug Administration for quality control and State of Grain Administration for the materials of alcohol production and so on. Considering the time lag between alcohol use and alcohol-related chronic harm, it is likely alcohol-related disorders will increase even if alcohol consumption does not continue to increase in China over the coming years and so the burden of ill health related to alcohol use will grow. China should develop an alcohol policy to improve public health based on the experiences of other countries. The policy should be a harm reduction strategy, whose aim is to reduce health damage and stabilize the consumption of alcohol. This can be achieved through measures aimed at controlling overall alcohol consumption (a population-based approach), and specific measures targeted towards risk behaviors (a high-risk approach). Measures such as public awareness education, advertising restrictions, taxation, a minimum drinking age, and drink driving penalties would have a significant impact on alcohol-related problems. China is now experiencing economic and political reform and the government needs to achieve a balance between economic development and public health, and between short and long-term strategies. At the present stage, economic development is the focus of public and government attention. Although alcohol and alcohol-related problems is one of the concerns of professionals, there appears to be a lack of attention being paid to alcohol policy and legislation in China from the public and the government. Today there are no laws regulating the purchase, consumption, or selling of alcohol, and alcohol use appears to be controlled by culture, tradition, social pressure and the economy. With economic development, westernization, and globalization, the availability of different brands of alcohol has created a special appeal that is cosmopolitan and western, especially for young people. The development of brew pubs has also attracted young people and increased competition has led to lower prices. It will be a challenge to mount a population-based alcohol policy in China in the future. This work was supported by the National Basic Program of China (2003CB515400) and the National Nature Sciences Foundation (30370522).