Alcohol and other substance use in a cross-cultural perspective.

Abstract

In 1969, MacAndrew and Edgerton published their book Drunken Comportment 1 and with it made a substantial contribution to cultural studies on alcohol. Their argument was that the behavioural effects of alcohol differ greatly from society to society, and they thereby put forth the argument that the effects of alcohol (and one could extend it to use of other substances) are culturally as well as pharmacologically determined. Since the publication of this seminal work, there has been a growing interest among researchers in understanding cultural diversity and how it relates to alcohol and other substance use, which in turn has generated a demand for cross-cultural comparative research studies. While it is well-established nowadays that alcohol and other substance use is shaped by the interplay of psychosocial factors and cultural characteristics, empirical evidence is still rare. This is regrettable since cultural exchange has increased tremendously over the last decades due to globalisation and proliferation of worldwide use of social media. Scholars recently argued 2 that ‘further empirical work in diverse contexts is needed to better understand drinking cultures, their interactions and their entanglement with other factors’ (p. 280). The authors further emphasise that there is a particular need for research outside European and Anglophone countries that explore the micro- and macro-level characteristics of drinking cultures. The current Special Issue features a series of cross-cultural studies that deal with person-specific factors, but place them within the wider cultural contexts in which use usually takes place. Among person-specific determinants, drinking motives, defined as the final decision to drink or not, are particularly important because they are proximal factors for engaging in drinking. Constituting a final pathway to alcohol use, drinking motives tend to reflect more distal influences such as personality characteristics or cultural aspects 3, 4. However, the paper by MacKinnon et al. 5 reveals a high cross-cultural consistency in drinking motives; not only was the classification of drinking motives largely invariant but also the rank order of endorsing a certain kind of motives (social > enhancement > coping > conformity) was identical across young adults from the 10 countries. A similar result was found concerning the association between drinking motives, alcohol use and adverse consequences in the paper by Wicki et al. 6, which includes adolescents from 10 different countries. Further evidence on the robustness and stability of drinking motives comes from a unique study that compared Brazilians who immigrated to the UK 2–11 years ago with Brazilians residing in Brazil 7. The results revealed that the former had a higher percentage of binge drinking than the latter but that there was no difference in drinking motives. It appears that, living in another culture for several years, people tend to adapt their drinking behaviour to the alcohol consumption norms of their host country. However, the cognitive driving forces such as drinking motives appear to be relatively resistant to cultural change and perhaps are more deeply rooted in the culture of origin. This circumstance may also explain why, on the one hand, the classification of drinking motives, their rank order and the links to alcohol-use patterns and alcohol-related consequences are stable across cultures while, on the other hand, cultures differ in how strongly certain motives were endorsed. Young adults from what MacKinnon et al. 5 classify as individualistic countries (Switzerland, Hungary, Canada, Netherlands, UK and Ireland, USA) more strongly endorsed positive reinforcement motives (social and enhancement, i.e. drinking together with others and to get drunk) than their counterparts from collectivistic countries (Portugal, Mexico, Brazil, Spain). The same was found by Wicki et al. in their study 6 among adolescents from northern Europe (Denmark, Estonia, Finland, Ireland, Scotland and Wales) compared to their counterparts from middle and southern Europe (Belgium, Portugal, Slovakia and Switzerland). In a previous study, we even demonstrated that the kind of drinking motives endorsed mediate the link between cultural differences and adolescent alcohol use 4. Taken together, it appears that psychological driving forces behind alcohol consumption are universal across countries, that is, the kind of drinking motives in terms of the classification and ranking is similar among young people around the globe. However, although in all countries most young people drink to have more fun, particularly when being together with others (positive reinforcement), in some countries this is more pronounced than in others and can partly explain why young people in individualistic or northern countries drink more frequently and heavily. Similar cross-cultural differences were found for pre-drinking defined as consuming alcohol in private before going out. Labhart et al. 8 reported that, although pre-drinking was practiced in all 25 countries included in the study, it was most common in English-speaking and Nordic countries. Since pre-drinking often also involves aspects of social and enhancement drinking, these cross-cultural differences are consistent with the differences in positive reinforcement motives reported in the previous paragraph 5, 6. In addition, this study indicates that a country's drinking culture (measured by how prevalent binge drinking was in each country) and alcohol policy (here, the ratio between on- and off-premise prices) affect common individual practices, such as pre-drinking 8. Another example of person-specific determinants is the impact that parents and peers exert, for which considerable cross-cultural consistency was found in a previous Special Issue focussing on young adolescents 9. The evidence reported here by Creemers et al. 10 adds to this, showing that the associations of parental permissiveness and affiliation with alcohol-using peers with adolescent and young adult alcohol use generalise across cultures, in this case to both native and immigrant youth in the Netherlands. This was the case although immigrant youth generally reported less alcohol consumption, perceived lower parental permission to use alcohol and had lower proportions of alcohol-using friends compared to their native Dutch counterparts. That immigrant youth tend to drink alcohol less frequently than their native counterparts was also found in a large study among 13- to 15-year-olds in 23 receiving countries coming from over 130 origin countries 11. The authors argue that this is due to the cultural norms and values on alcohol consumption in the country of origin, which tend to be—at least among first generation immigrants—more important determinants of immigrant adolescent alcohol consumption than those in the receiving country. However, one immigrant subculture may adapt more easily than another to the culture of the receiving country. Saw et al 12 found that most of the factors associated with asserting the preference for smoke-free environments (e.g. not wanting to be exposed to tobacco smoke at home, the workplace or other locations) were relatively similar between Korean and Chinese-American non-smokers living in the USA. In direct comparisons, however, Korean-Americans were found to be more likely to assert preference for smoke-free environments than Chinese-Americans, even after controlling for various individual, family and community factors. At first glance, this result may simply reflect greater presence of smoking in Korean-American than in Chinese-American households. At second glance, however, keeping the original language and traditional values had a much stronger impact on assertiveness about smoke-free environments among Korean-Americans than Chinese-Americans. In other words, anti-smoking attitudes tend to depend on how strongly the category of immigrant remains connected with the culture of origin. However, keeping the original language and traditional values is not always protective. When the language and the values of the country of origin clash with those of the receiving country, cultural conflicts and stress often occur, along with identity confusion, feelings of rejection and a lack of sense of belonging, as illustrated in the qualitative interviews of Canfield et al. 7. Barsties et al. 11 also argue that the high rates of drunkenness found among immigrant youth can be a sign of immigration-related difficulties and stressors, which may also be part and parcel of a disadvantageous socio-economic situation. Another form of cultural demarcation is related to socio-economic status. Studies included in this Special Issue indicate that growing up in wealthy rather than poor families puts adolescents at risk for binge drinking. Comparing two countries with similar levels of income inequality, Sentenac et al. 13 found that, among French but not among Canadian adolescents, drunkenness was more likely when considering oneself as better off than most others in the same school and when coming from a more wealthy family. Investigating 32 European countries, Gomes de Matos et al. 14 also found that drunkenness was more likely among adolescents from wealthier families but lower when parents were highly educated. Thus, it appears that the protection that higher education may offer is undermined by the higher income highly educated parents tend to have. Socio-economic disparities in youth drinking were more pronounced in poorer countries and in those with high income inequality. It appears that a low socio-economic position at the individual level makes less of a difference if one lives in a less-poor country where there is wide access to education 14. Another indication that personal affluence matters more than education emerged from the study of Luczak et al. 15. Among male adult drinkers in Mauritius, the researchers found that the higher risk of hazardous drinking among men of Tamil origin compared to other men of Hindu origin was associated with occupational but not educational differences. Being Muslim was not associated with abstinence or any drinking pattern. It appears that occupation or the values shared in a subculture explain differences in drinking patterns rather than education or religion per se. Further insights in this respect come from the study by Sznitman et al. 16 that found Israeli Arabs reported feeling drunk at higher levels of breath alcohol concentration as compared to Israeli Jews. The authors argued that the taboo of alcohol consumption in the Arab culture may make it more difficult for Arabs than for Jews to acknowledge the effects alcohol has on them. Interestingly, the differences remain present when comparing only Arab Christians and Jews. This suggests that cultural factors beyond the Muslim culture and religion explain the differences in perceived drunkenness. Taken together, the studies in this Special Issue advance the knowledge on how (mainly) alcohol consumption is shaped by individual and cultural factors. The cross-cultural stability in the impact of person-specific factors indicates that, in every country or cultural setting, someone drinks more frequently and/or hazardously when endorsing particular drinking motives, engaging in pre-drinking, having permissive parents and affiliating with alcohol-using peers. Nevertheless, how strongly these person-specific factors are endorsed or how frequently they occur is likely to be different from one cultural setting to another. Preventive action targeting positive reinforcement drinking (i.e. drinking for social and enhancement motives) are needed, particularly in individualistic and in northern European countries. Provision of alternative sources of stimulation, altering expectancies of the enhancing effects of alcohol, focussing on social influences and promoting safer drinking environments are promising approaches in this respect 4. The included studies further show that immigrants are at particular risk for the development of alcohol use from either abstinence or moderate use into more harmful patterns. Most immigrants come from developing countries where binge drinking is less common. Thus, integration often means that they adopt the more frequent and heavy consumption patterns that are the norm in the countries they are immigrating to. On top of that comes the potential clash of the language and values between the origin and the receiving country. The resulting cultural conflicts and stress tend to further fuel binge drinking. It appears that approaches are urgently needed that facilitate integration in the receiving country, such as the promotion of special schools focusing on language apprenticeship and communication of cultural values and customs. However, these approaches should also integrate efforts to prevent the assimilation of the more harmful habits that are often common in the receiving countries—or even the norm in certain settings. The reported evidence from adolescent samples 13, 14 and from men in east Africa 15 clearly indicates that affordability of alcohol plays a role in the occurrence of binge drinking. This points to the importance of price increases by means of taxation, which was repeatedly shown to be among the most effective alcohol-related public health policy measures 17, 18. The evidence emerging from this Special Issue makes a substantial contribution to our understanding of cross-cultural consistency (in terms of person-specific factors) and diversity (in terms of socio-economic disparities or immigrants' connectedness with the culture of origin, for example). However, research from other areas such as violence, social media use or marketing is required to get a more complete picture. Moreover, we need more evidence from other populations than the ones included in this Special Issue, particularly from older adults and clinical samples. The former is essential because this is a period of life when cultural differences in drinking tend to become even more pronounced than among young people 19. The latter is crucial to better understand to what degree intervention and treatment efforts can be readily applied from one culture to another. In addition, it would be desirable to have cross-cultural comparative longitudinal studies, which follow, for example, immigrants from different countries of origin before their immigration into their adaptation process in the different receiving countries. This would allow studying changes in alcohol and other substance use and in disentangling the impact that the personal factors (e.g. stress resistance) of the immigrant have from the impacts of cultural values and traditions in the country of origin and the facilities for acculturation in the receiving country, for example. The authors would like to thank Prof. Paul Dietze and Prof. Robin Room for their helpful comments to improve this work. None declared.