A Multiprong Approach to Curb Underage Drinking: Addressing a Centuries-Old Practice in China

Unlike tobacco and illicit drug use, alcohol use has garnered limited attention from policymakers and public health officials in China.¹ Epidemiological studies conducted since 1980 have revealed a consistent increase in alcohol consumption and incidence of alcohol-related issues in China, which they attribute to China’s rapid economic growth and the concurrent elevation of average income levels.^1,2 Such trends are reflected in underage drinking. A meta-analysis indicates that 50.7% of Chinese youths aged 12 to 18 years have had at least one alcoholic drink in their life, and 24.3% consumed alcohol in the past month.³ Male youths have higher prevalence rates of drinking than do female youths for all drinking practices except weekly drinking and past month drunkenness.³

STRENGTHENING ADVERTISING REGULATIONS

The study by Ji et al. (p. 814) in this issue of AJPH underscores different proalcohol advertising channels in China and advances the knowledge of the association between advertising exposure and underage drinking in China. Their findings echo the calls for tightening alcohol advertising regulations, including strengthening alcohol-related policy enforcement and regulating digital advertising, given the increasingly sophisticated marketing strategies adopted by alcohol companies.^1,2 The use of advertising that appeals to youths, coupled with “corporate social responsibility” strategies designed to enhance a company’s public image by highlighting its involvement in philanthropic endeavors in China, mask the harms related to alcohol consumption and obscure the profit-making intentions behind marketing efforts.¹ As commercial advertising often associates alcohol consumption with glamour, excitement, popularity, sophistication, and social status, it is imperative to not only implement stricter regulations and policies on alcohol advertising but also orchestrate campaigns that challenge these positive portrayals and offer accurate information about the consequences of alcohol consumption and underage drinking.

REASONS FOR A HOLISTIC APPROACH

Although the study by Ji et al. centers on alcohol advertising, tackling underage drinking in China requires a holistic approach. Relying solely on interventions targeting alcohol advertising is insufficient for several reasons. First, although alcohol advertising is linked to underage drinking, results from a recent systematic review show that the evidence to conclude that alcohol marketing bans effectively reduce alcohol consumption is insufficient.⁴ Although this result does not suggest that restrictions on alcohol advertising are futile, concentrating on advertising alone may not achieve the broader public health goals of preventing minors from initiating and continuing alcohol consumption.

Second, alcohol advertising reflects and reinforces broader sociocultural norms and values related to drinking. Alcohol consumption has been rooted in Chinese culture for centuries. As widely documented in folk and classic literature and poetry that continue to be revered and recited today, drinking is a communal activity that takes place within the social fabric of family, work, and other social networks¹ and is often regarded as a form of cultural engagement, aesthetic pleasure, and intellectual enrichment, which is distinguished from overindulgence and misuse.⁵ Research in China also suggests that drinking is associated with affective, creative, and embodied experiences among young people.⁶ A coordinated and comprehensive approach is needed to shift positive attitudes toward drinking among the public, and among young people in particular, with the aim of ultimately influencing drinking practices and behaviors.

Lastly, although China has endorsed SAFER, an initiative launched by the World Health Organization (https://www.who.int/initiatives/SAFER), with the aims of restricting alcohol availability, implementing measures to combat drunk driving, improving access to screening and treatment, enforcing restrictions on alcohol advertising and sponsorship, and enhancing taxation policies, SAFER strategies have not been fully implemented in China.⁷ In addition, SAFER objectives appear comprehensive, but they lack a youth focus, potentially limiting the impact on deterring young people from drinking.

FROM A YOUTH DEVELOPMENT PERSPECTIVE

Effective strategies to curb underage drinking in China would integrate a youth development perspective that considers the etiology from multiple levels, accounts for gender differences, and understands the constant interplay between youths and their environments, such as families, school, peers, and the community, all within the broader sociocultural context. To counter the injunctive norms associated with drinking, public health campaigns that underscore the alcohol-related harms and risks should begin early through the schools and in education; these campaigns could demystify alcohol consumption and empower young people to start understanding the consequences of drinking and making informed decisions about their health and well-being. Given gender differences in drinking patterns and progression, such campaigns should integrate gender-specific messages and address gender norms associated with drinking.

In addition, because parents and caregivers play a vital role in preventing underage drinking and because strong parent–child bonding and communication can buffer the effects of peer pressure and social influences, it is important to prioritize parent education on alcohol, support parents in improving their attitudes toward responsible drinking, foster parental monitoring, and promote effective parent–child communication on alcohol consumption. These efforts at the family level can be particularly relevant to males, as positive parenting is associated with reduced drinking among younger Chinese adolescent boys.⁸

Furthermore, considering the stark provincial-level disparities in alcohol consumption in China as indicated by surveillance data,⁹ it is vital to engage community stakeholders such as local authorities, health care providers, educators, community agencies, and youth organizations to assess and address local needs. This collaborative approach is essential for developing tailored strategies appropriate for the regional context, including effective regulation of outdoor advertising and local television commercials, which are prevalent proalcohol advertising methods in China, as suggested by Ji et al. Other strategies to consider include adding health warning messages to labels or advertisements to allow youths to make informed decisions, as well as specifying penalties for alcohol sales to minors and reinforcing policies and regulations related to underage drinking in China to curtail the availability of alcohol to youth.

Devising underage drinking prevention strategies in China would be incomplete without incorporating digital technology. Often referred to as the “technosystem,” digital technology has become a pervasive force that transcends the traditional social structures of family, school, and community.¹⁰ The prevalence rate of 96.8% of Internet use among Chinese adolescents in 2021 signifies a near-universal adoption of digital technology. Moreover, the rural–urban digital divide in China has diminished because of the surge in e-learning platforms during the COVID-19 pandemic.¹¹ Digital technology provides scalable platforms for substance use prevention in school and family settings and facilitates the integration of interactive and personalized content. The current evidence suggests that digital approaches to underage drinking are effective.¹²

Drinking is a social act ingrained in cultural practices and traditions, and commercial advertising taps into these deeply rooted cultural norms to promote drinking. Ji et al. provide valuable findings on the prevalence of exposure to alcohol advertising among adolescents in China and the association between exposure and alcohol consumption. Their study results demonstrate the need for increased scrutiny of and restrictions on proalcohol advertising targeting young people. Importantly, addressing underage drinking in China necessitates a systematic, multipronged approach that includes engaging multiple stakeholders and platforms to resocialize young people about alcohol and the consequences of alcohol use.