Alcohol and alcohol-related harm in China: policy changes needed

Abstract

In China, alcohol consumption is increasing faster than anywhere else in the world. A steady increase in alcohol production has also been observed in the country, together with a rise in alcohol-related harm. Despite these trends, China’s policies on the sale and consumption of alcoholic beverages are weak compared with those of other countries in Asia. Weakest of all are its policies on taxation, drink driving laws, alcohol sale to minors and marketing licenses. The authors of this descriptive paper draw attention to the urgent need for public health professionals and government officials in China to prioritize population surveillance, research and interventions designed to reduce alcohol use disorders. They describe China’s current alcohol policies and recent trends in alcohol-related harm and highlight the need for health officials to conduct a thorough policy review from a public health perspective, using as a model the World Health Organization’s global strategy to reduce the harmful use of alcohol.

Introduction

In China, alcohol consumption is increasing faster than other parts of the world. Data from recent decades show a steady increase in alcohol production and consumption and in rates of alcohol-related conditions.^1,2 These dramatic increases, noted after the 1980s, stem from China’s fast economic development and the parallel rise in average income level.

Drinking alcoholic beverages has been traditionally accepted in China during major social events, such as the spring festival, wedding ceremonies and birthday parties. However, the rapid growth in the Chinese economy has been accompanied by noticeable changes in the drinking behaviour of the Chinese population. Furthermore, alcohol is now commonly consumed to relieve stress, facilitate social interaction and foster good relations between supervisors and employees, since these often eat out together after work or hold business meetings over dinner.^1,2

In this article, we first review recent trends in alcohol-related harm in China, primarily alcohol use disorders, and then describe the policies in place to mitigate alcohol-related harm. We finish with a set of recommended policy changes that could help contain the rapid increase in alcohol-related harm currently observed in the country.

Drinking and drinking patterns

A recent national survey of drinking in China revealed that 55.6% of the men and 15.0% of the women were current drinkers.³ Among respondents who endorsed alcohol consumption, 62.7% of the men and 51.0% of the women reported excessive drinking, 26.3% and 7.8%, respectively, reported frequent drinking, and 57.3% and 26.6%, respectively, reported binge drinking. These figures show that China has experienced dramatic increases in the consumption of alcoholic beverages since the late 1970s and even the 1990s.⁴ High-risk drinking behaviour has reached epidemic proportions in China.³

The Chinese population consumes a wide range of alcoholic beverages. The production of most alcoholic beverages has increased steadily since 2004 (Fig. 1), to the point that China is now one of the largest beer-producing countries in the world.⁵ Wine production and consumption have also increased substantially. The average annual consumption of alcohol among Chinese people 15 years of age or older has increased progressively, from 0.4 litres of pure alcohol in 1952 to 2.5 litres at the end of the Cultural Revolution in 1978,¹ to 4.9 litres in 2009. Furthermore, a substantial amount of unrecorded alcohol is also produced and consumed in China, so that the data in Fig. 1 only reflect the alcohol production officially recorded by the government.

Fig. 1.

Average annual national production of alcoholic beverages and average annual per capita consumption of alcohol in China, 2000–2011

^a Per capita annual consumption of pure alcohol (litres).

In many places, especially in socially and economically disadvantaged areas, alcoholic beverages whose production goes unrecorded account for a considerable proportion of the alcohol consumed. As shown in Table 1, approximately 1.7 (30%) of the 5.9 litres of pure alcohol consumed in China in 2000 were unrecorded. Many cases involving the illegal, unrecorded manufacture and sale of alcoholic beverages have been unreported, some of which have resulted in mass poisoning and death. The sale and use of illegally manufactured liquor are almost impossible to regulate and must be eradicated. Morbidity and mortality from poisoning with methanol and other contaminants are a major public health concern.

Table 1. Alcohol use disorder (AUD) prevalence and alcohol control policy in China and its neighbouring countries, 2003–2005.

	China	India	Japan	Republic of Korea	Malaysia	Mongolia	Myanmar	Philippines	Russian Federation	Thailand	Viet Nam
AUDa prevalence (%) in people aged ≥ 15 years
Males	6.9	3.47	2.25	13.10	3.74	5.95	1.62	7.95	16.29	10.18	4.13
Females	0.22	0.42	0.13	0.41	0.42	0.20	0.05	0.95	2.58	0.99	0.14
Per capita average alcohol consumption (litres) in people aged ≥ 15 years
Recorded/unrecorded	4.2/1.7b	0.6/2.0	7.8/0.2	11.8/3.0	0.5/0.3	1.2/2.0	0.1/0.5	4.4/2.0	11.0/4.7	6.4/0.7	1.1/2.7
Excise tax on:	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA
Beer	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA
Wine	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA
Spirits
National legal minimum age for off-premise sales of:
Beer	No	Subnational	20	19	18	18	18	18	18	20	No
Wine	No	Subnational	20	19	18	18	18	18	18	20	18
Spirits	No	Subnational	20	19	18	18	18	18	18	20	18
National legal minimum age for on-premise sales of:
Beer	No	Subnational	20	19	18	21	18	18	18	20	No
Wine	No	Subnational	20	19	18	21	18	18	18	20	18
Spirits	No	Subnational	20	19	18	21	18	18	18	20	18
Restrictions for on-premise sale of alcoholic beverages:
Time	No	Yes	No	No	Yes	Yes	Yes	Yes	Yes	Yes	NA
Location	No	Yes	No	No	No	Yes	Yes	Yes	Yes	Yes	NA
Restrictions for off-premise sale of alcoholic beverages:
Time	No	Yes	No	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Location	No	Yes	No	No	Yes	Yes	Yes	No	Yes	No	NA
National maximum legal blood alcohol concentration while driving, mg per 100 ml	0.02	0.03	0.03	0.05	0.08	0.05	0.07	–c	0.03	0.05	ZT
Legally binding regulations on:
Alcohol advertising	Yes	Yes	No	Yes	Yes	Yes	Yes	No	NA	Yes	Yes
Alcohol product placement	No	Yes	No	No	Yes	Yes	Yes	No	NA	Yes	NA
Legally binding regulations on:
Alcohol sponsorship	No	Yes	No	No	Yes	Yes	Yes	No	NA	Yes	NA
Alcohol sales promotion	No	Yes	No	No	Yes	Yes	Yes	No	NA	Yes	Yes

NA, not available; ZT, zero tolerance.

^a AUDs comprise not only the diagnostic categories “harmful use of alcohol” and “alcohol dependence”, but also alcohol-related psychoses.⁶

^b Estimated from data collected in 2000. Based on the Global status report on alcohol and health.⁶

^c No limit established.

Alcohol-related harm

Alcohol-related harm has not been systematically studied in China because reliable data are not available. Alcohol use disorders (AUDs), which encompass harmful patterns of drinking, such as alcohol dependence and abuse, have grown to become a frequent problem linked to disturbances in mental and physical health and in social functioning in China. According to recent World Health Organization (WHO) estimates, rates of AUD in China are 6.9% and 0.2% among men and women, respectively.⁶

According to a review by Hao et al.,¹ the average rate of AUD in China increased from 0.455% (in Chongqing, a former city in Sichuan province, now a municipality with a population of approximately 29 million in 2010) in the mid-1980s to 3.428% (in a national population sample) in the mid-1990s. In a study involving four Chinese provinces, Phillips et al. found that the lifetime prevalence rate of AUDs was 9.0% in 2001–2005.⁷ It is difficult to ascertain to what extent differences in diagnosis, survey methods and reporting have contributed to the dramatic increase in the prevalence of AUD in China. Nonetheless, such a rise has paralleled equally dramatic increases in commercial alcohol production and changes in Chinese society’s alcohol consumption habits.

The sex ratio in the rates of alcohol abuse and dependence in China is particularly interesting. Alcohol dependence exists when a person craves alcohol, develops a tolerance for it and is unable to refrain from drinking despite experiencing harmful consequences, such as liver damage or depression.⁸ On the basis of the above-mentioned studies, the male to female ratio in the rate of alcohol dependence is approximately 33:1,⁹ significantly higher than in developed countries. In Chinese culture, women are discouraged from drinking alcohol and from using illicit substances, but the current sex differential is likely to diminish in the future in the face of rising income levels and increased marketing.¹⁰

Studies have also suggested that the pattern of AUDs in urban populations in China is now quite similar to that seen in high-income countries. The pattern is still different in rural areas, where about 50 to 60% of the Chinese population lives. Urban surveys in China have repeatedly shown a significantly higher prevalence of alcohol dependence than rural surveys and a higher prevalence of AUDs among older males.^11–13 Surveys that have included both urban and rural regions have revealed the prevalence of alcohol dependence to be higher than that of alcohol abuse.⁹ These findings highlight the need for treatment resources, especially in rural areas.

As in many other countries, in China excessive drinking has shown an association not just with health-related harm, but also with social harm, specifically traffic accidents,¹⁴ crime and child abuse,¹⁵ domestic violence^16,17 and injuries of all types, including work-related injuries.¹⁸ However, the data are very sparse and most studies are based on case analysis or small clinical samples. This points to the need for better epidemiological surveillance of alcohol use indicators in China’s general population.

A public health approach to policy

Given the dramatic increase in alcohol production and consumption and of alcohol-related harm in China over the past 30 years, national alcohol policy in the country needs to be reviewed to improve policy coordination and enforcement, alcohol-related research, population surveillance and treatment services for people with AUDs. A review conducted by the authors, whose results are presented in Table 1, shows that many aspects of alcohol policy are weaker in China than in its neighbouring countries. New policies are needed in areas such as taxation, drink driving laws, alcohol sales to minors, marketing controls, licensing and regulation of availability of alcohol. For example, China has no enforceable legal drinking age and does not regulate when or where alcoholic products are sold.

Weak alcohol policies create conditions conducive to increased alcohol consumption and alcohol-related problems.¹⁰ China is pressed to conduct a thorough review of its alcohol policies from a public health perspective. To guide this effort, we recommend that China’s government officials follow WHO’s Global strategy to reduce the harmful use of alcohol¹⁹ as a model for the planning and implementation of a public health approach to alcohol control. Many of the interventions in the strategy are universal measures intended to reduce the affordability, availability and accessibility of alcohol.²⁰ Given the broad reach, these measures are expected to have a large public health impact, especially if the informal market and illegal production of alcoholic beverages can be controlled. When universal measures are combined with interventions targeted at high-risk populations, such as adolescents (age restrictions), automobile operators (drink driving regulations), alcoholics (treatment and support) and hazardous drinkers (brief interventions in primary health care), the combined effect is likely to be substantial.

In the following sections, we describe how key aspects of WHO’s global strategy apply to China and what additional measures are required to implement it. Of note, some policies have already been adopted in China and data regarding their effectiveness are available. Others, however, need to be assessed in the future for possible adjustments.

Strengthening taxation

Taxation on the sale of alcoholic drinks is one of the world’s most cost-effective and widely adopted alcohol control policies.^10,20 Taxation in China has not been used to improve public health. In 2001, the government wanted to increase revenues from the sale of liquor and adopted new tax policies. It also limited to 20% the proportion of sales revenues that could be used for advertising and imposed different taxes on liquor made from potatoes and grain. Although the government’s intention was to increase liquor revenues, liquor production decreased sharply from 2001 to 2004 (Fig. 1). In 2006 the government discontinued differential taxation for potato and grain liquor. This was followed by dramatic increases in alcohol consumption (Fig. 1).

Legislation on drink driving

China has made some progress in this area, but the increase in the number of automobiles and in traffic congestion has created a need for more and better policies. Criminal law has been amended to impose harsher punishments for drink driving (i.e. driving with a blood alcohol concentration of 0.02 mg to 0.08 mg of alcohol per 100 ml of blood). Drunk drivers (those with > 0.08 mg per 100 ml of blood) will have their license revoked when caught and cannot apply for a new license for 5 years. Preliminary data show that these measures are proving remarkably effective in reducing drinking and drunk driving in larger cities. However, they have to be more consistently enforced in other parts of the country, especially in medium-sized and small cities. Measures based on deterrence rather than punishment, such as random breath tests, are rarely used, yet studies have shown that they are more effective than punitive measures.^10,20

Age restrictions and marketing controls

Regulations on the administration of alcohol sales were issued by China’s Ministry of Commerce in 2005 and went into effect in 2006. Their purpose was to ban the sale of alcoholic beverages to minors, but the penalties for violations are not specified.

More than 15 years ago China also issued an advertising regulation on alcoholic beverages (1995), but its enforcement has been weak. Violations are commonplace, alcohol commercials are still aired during prime time television programmes and misleading and sensational advertising content is common.²¹ The most effective policy to prevent the exposure of vulnerable population groups, especially children and young adults, to aggressive marketing practices is a complete ban on alcohol marketing rather than the self-regulation codes promoted by the alcohol industry.¹⁰

Scaling up treatment programmes

Few treatment programmes are available in China for people with AUDs. Although some psychiatric hospitals in China have special addiction units for the treatment of patients with alcohol-related mental disorders, most of these units, which were established in the 1990s, are in major cities. Patients with AUDs rarely seek psychiatric help until they have developed serious psychiatric symptoms (hallucinations, delusions, suicidal ideation/attempts). Community-based treatment and rehabilitative programmes are urgently needed. Only a small proportion of patients can get psychiatric services in China, and only a few of the medications for the prevention of relapses that are used in developed countries are available in China. Those that are have not been officially approved for use in alcohol dependence because effectiveness studies have had small samples. Furthermore, China has few qualified primary health-care workers trained in the diagnosis and treatment of alcohol-related disorders, which makes it difficult to establish community-based specialized treatment programmes. Alternatively, medical services in general hospitals, such as gastroenterology departments, could provide treatment facilities for people with alcohol use disorders.

Drinking among government employees

Drinking among government employees, (e.g. civil servants, officials, even policemen), especially during working hours, has drawn considerable public attention in China. Several studies have shown that alcohol-related liver diseases are among the most common disorders found on regular physical examination among government employees,²² 20.3 to 34.9% of whom have been found to have fatty liver disease.^22–24 This has caused much public criticism because the public perceives it as being linked to corruption, abuse of power and bureaucratic inefficiency. In response to public disapproval, some local governments have begun to enforce a policy banning any drinking during working hours. However, a nation-wide effort is needed for such a policy to be successful. More comprehensive policies will have to be implemented as well. China’s most influential newspaper, People’s Daily, recently published a series of articles highlighting this problem.²⁵

More research and surveillance

Some reports on various aspects of alcohol-related harm in China have been published,^17,26,27 but data are missing in many critical areas, such as the impact of alcohol consumption on health, families, work performance and absenteeism, crime and health resource utilization. The effects of alcohol consumption on health can take many forms, including gastrointestinal ulcers, liver damage, peripheral neuropathy and suicidal tendencies. Many indicators of alcohol production and consumption and of the harms produced by drinking are not up to date and fail to reflect the changes in drinking behaviour and in alcohol production observed in China over the last decade. The lack of data is a major obstacle to the development of services, programmes and policies.

No officially approved medication for alcohol dependence exists in China other than benzodiazepines for acute withdrawal. Hence, well designed clinical effectiveness trials involving traditional Chinese medicines and drugs already widely used in developed countries, such as naltrexone, topiramate and acamprosate, are needed. To fund research on alcohol-related harm, develop prevention and treatment programmes and monitor and enforce the implementation of policies surrounding the production, sale and use of alcoholic beverages, the Chinese Government could follow the example of Thailand and set aside a certain proportion (at least 0.5–1%) of the revenues gained from alcohol taxation.²⁸

Social marketing to support policy and treatment

Although alcohol-related harm in China has increased greatly in recent years, Chinese society does not yet view alcohol dependence as a treatable psychiatric condition.²⁹ The level of awareness surrounding the problem is low and myths about AUDs abound. A recent survey showed that 41.9% of a sample of people living in rural China was not aware that alcoholism was a health problem, whereas 75.6% of urban residents were aware of this.³⁰ Of those interviewed in rural and urban areas, 32.1% and 41.4% believed, respectively, that alcoholism requires no treatment. A recent study in Beijing revealed that only 2.4% of the people with alcohol dependence received treatment and that only 1.4% of those treated sought treatment from mental health professionals.³¹ Other studies conducted in China have shown that early intervention is effective in problem drinkers recruited from both clinical³² and community settings.³³ Professionals and the general public need to be educated about the effectiveness of alcohol treatment services.

Public information campaigns emphasizing that alcohol dependence is a treatable medical disorder have proven successful in some countries. Historically the demand for the treatment of hypertension, diabetes and depression has increased substantially after public educational campaigns and there is reason to expect the same result after a public campaign on the treatment of alcohol dependence. Regional governments in China should set aside funds for the construction of treatment facilities for patients with alcohol-related disorders. All physicians should be taught about basic screening and brief interventions for AUDs. In the meantime, more public awareness activities should be conducted, especially in areas where alcohol dependence and its harms constitute serious problems. Deeply-rooted myths about drinking – e.g. “drinking is good for health”, “friendship can be measured by how much you drink”, “drinking is essential in business affairs”, “alcohol heightens sexual performance”, etc. – need to be debunked. Articles written by experts and medical journalists would reach more people and be more effective if they were published in the popular press. Public campaigns need to be tailored to local cultures and target different populations. For example, the Chinese Government is implementing a campaign that seeks to integrate health education into primary health care. The campaign covers many general topics, such as cigarette smoking, alcohol drinking, diet and exercise. If the campaign succeeds in increasing public awareness surrounding alcohol abuse, it should be extended to the general population.

Government commitment and coordination

Few things can be accomplished in China without the direct involvement and support of the central government. Unlike the use of tobacco and illicit drugs, alcohol use has received scant attention from Chinese policy-makers and public health officials. Some of them even argue that the alcohol industry is an important driver of national economic growth.³⁴ To date, the government has focused on cracking down on the production of counterfeit alcohol products and on protecting the integrity of well-known brands, as well as on taxation of alcoholic beverages as a way to boost economic development. While such efforts are important, additional attention must be paid to alcoholic beverages that are legally produced and to the hazards resulting from their use. Besides paying relatively little attention to alcohol policy, China’s government agencies for alcohol regulation are poorly coordinated. Several ministries share responsibility for different aspects of alcohol policy and no national supervisory or coordinating body exists.

As prescribed by WHO’s Global strategy to reduce the harmful use of alcohol, China should establish an inter-ministerial office as a coordinating agency for overseeing legislative initiatives and policy-making, enforcing laws surrounding alcohol production, trade, sales and distribution, and monitoring health resource allocation for the treatment of individuals with alcohol dependence. We urge the Chinese government to prioritize this agenda at inter-ministerial joint meetings on mental health to improve awareness of the harms produced by alcohol dependence and reach consensus regarding appropriate policy. At these joint meetings, a national action plan for the control of alcohol-related harm control under the auspices of China’s state council (cabinet) should be developed, as was done for the control of illicit drug use, to ensure that multiple stakeholders, including provincial and municipal governments, participate in the plan and provide access to the resources needed to implement programmes. Because the interests of producers and marketers of alcoholic beverages are clearly incompatible with these health-oriented measures, it is important not to include such vested interest groups in collaborative actions among health and welfare workers.¹⁹

Conclusion

The expansion of alcohol production and consumption in China over recent decades has been followed by a predictable increase in both acute and chronic problems resulting from alcohol use, and the increase is likely to accelerate in the future. China urgently needs to develop a comprehensive national alcohol policy based on the experience of other countries and on WHO recommendations.¹⁹ It can do so by adopting measures aimed at controlling overall alcohol consumption (a population-based approach) as well as measures intended to reduce risky behaviours (a high-risk approach). The restriction of alcohol advertisement, taxation of alcoholic beverages, the setting of a legal age for drinking and policies against drink driving will have a significant impact on the frequency of alcohol-related problems.^20,35

The substantial economic and political reforms currently taking place in China are aimed at striking a balance between economic development and public health and between short-term and long-term alcohol control strategies. For this effort to succeed, a public health focus must be adopted now, along with long-term alcohol control policies. Both will eventually pay off politically and economically. In this process, China could benefit from the experiences of other Asian countries, such as the Republic of Korea and Thailand, that have implemented WHO’s global strategy to reduce the harmful use of alcohol.