This is one of the largest studies of the prevalence and patterns of alcohol consumption in China. In this study, drinking alcohol was much more frequent in men than women and there was striking regional variation in drinking patterns as well as in the types of alcohol consumed, reflecting the level of geographical, economic and cultural diversity present within China. A clustering of lifestyle behaviours associated with alcohol drinking was also observed, with weekly drinkers more likely to smoke and drink tea regularly. Most people drank with meals, largely reflecting traditional Chinese customs; however, heavy episodic drinking was common among younger people, perhaps reflecting a tendency towards more Western drinking styles. Although the study was not designed to be nationally representative, these results provide unique and reliable information about drinking habits in China at a time of rapid economic and social change, when there is a growing risk of alcohol-related health problems.
The overall findings in our study are broadly consistent with those from a nationally representative study of 220 000 men in China, conducted in 1990–91, where the prevalence of regular drinking was also 33%, and heavy consumption was more frequent in rural areas.13
A more recent nationally representative survey of 50 000 adults in 2007 reported 56% of men and 15% of women drinking alcohol in the past year.14
In a survey conducted in 2001 among 25 000 adults from five provinces, 75% of men and 39% of women reported drinking alcohol at least once in the past year,6
and in a similar survey conducted 6 years earlier, the rates were 84% in men and 29% in women.5
Other studies conducted in particular regions of China have reported the prevalence of drinking ranging from 58 to 90% for men and 12 to 55% for women.19–21
Although the overall prevalence and frequency of alcohol drinking in this Chinese population is lower than that typically seen in many Western populations,4
the regional variation observed is probably much more extreme. This is consistent with the substantial regional variation in alcohol drinking reported in a survey of 69 rural counties in China in 1989, in which the prevalence of ever regular drinking (at least three times a week for more than 6 months) in men varied from 3% to 82% across study sites.22
In common with previous reports from China and elsewhere,23
drinking prevalence and consumption levels in our study were much higher among men than women.
A major characteristic of alcohol drinking in China is the widespread consumption of strong spirits in many parts of the country, particularly in the inland rural regions. In the study of 220 000 Chinese men, of whom three-quarters were from rural regions,13
93% were strong spirit drinkers, which was comparable with some of the rural regions in our study. In our study population, over 80% of alcohol consumed was from spirits and 10% from beer. WHO recently reported that 57% of per capita alcohol consumption in China was from spirits and 34% from beer.4
These differences could be due to the much younger population of adults aged 15 years or above or the different regions surveyed in the WHO report. In the 2001 survey of 25 000 adults in five provinces, which had a large proportion of young people aged below 30 years from urban areas, beer was the most popular drink in their study population, followed by strong spirits.6
In our study population aged 30–79 years, beer drinking was most frequent among the younger drinkers, and was highest in Harbin and Qingdao, two northern cities which are famous for their beer production. Weaker spirits and traditional rice wine were relatively favoured in the more prosperous coastal and southern areas in our study, and consumption of grape wine was generally very low in all areas.
Smoking and alcohol consumption were highly correlated, as has been observed previously in China and elsewhere.24,25
This must be considered when assessing the health affects of alcohol, although adjustment for smoking did not substantially affect the correlations between alcohol and baseline health characteristics in our study. Drinking alcohol was also associated with tea drinking (mainly green tea), which may have some benefits for health.26,27
Whereas weekly drinking was most common among men living in urban areas, the heaviest drinkers tended to live in rural areas and have poorer education—patterns fairly consistent with other studies in China.20,28
People with high socioeconomic status (e.g. greater education or income) were more likely than others to be occasional drinkers or, if weekly drinkers, to consume less, which may in turn represent a grouping of lifestyle and socioeconomic factors potentially advantageous to health.29
Apart from the total amount consumed, patterns of consumption are also likely to influence the health effects of alcohol.7
Heavy drinking episodes (or ‘binge drinking’) may be particularly harmful to health and also increase the risk of injury and other immediate adverse consequences.18
Binge drinking among adolescents and young people has been rising in many Western populations, causing significant public health concern,30
and in this adult population both weekly and occasional binge drinking were higher among younger people. A similar trend was also reported in a survey of 10 000 Chinese adults in Hong Kong,31
and a survey of 54 000 adolescents in 18 provincial capitals in China found 30% started to drink before the age of 13 years, and 10% reported at least one episode of binge drinking.32
Conversely, drinking alcohol with meals, which is thought to be less harmful to health,33
is a common custom in China and was seen widely in the present study.
As expected, ex-weekly drinkers and those who had reduced their intake were more likely to have poor health status. This is particularly relevant to the appropriate control of reverse causality when assessing the prospective association of alcohol drinking with disease risks in the future.29
Also as expected, a proportion of the population experienced flushing and dizziness in response to alcohol, symptoms of a deficiency in alcohol-metabolizing enzymes which is common in East Asian populations, and may modify the health effects of drinking alcohol.17,34
The observed association between blood pressure and alcohol consumption, a phenomenon widely reported in many populations, is of a similar magnitude to that reported in other studies i.e. an increase of approximately 2 mmHg systolic blood pressure per 20 g alcohol consumed each day,35
which provides an important measure of validation for the self-reported alcohol measures collected in the present study.
To conclude, this large survey found that drinking alcohol remains a predominantly male phenomenon in Chinese adults, although for both men and women there is large heterogeneity in the prevalence and patterns of drinking by area, age, socioeconomic status and other lifestyle behaviours. The wide diversity of alcohol exposures in China creates particular challenges as well as opportunities for evaluating the health effects of alcohol consumption. Large prospective studies like the CKB with a range of measures for alcohol (as well as for other lifestyle and environmental factors), done in many different parts of China, will help to improve our understanding of the effects of alcohol on a wide range of fatal and non-fatal conditions in this country.