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IntroductionDrinking is a lifestyle and social custom and has become an important public health problem worldwide. The public interest in alcohol consumption among college students is increasing due to its potential negative impact . For example, Ralph et al  analyzed alcohol consumption trends in 18-24 year old college students and found that the incidence of college students consuming alcohol over 5 standard cups in the past month has increased from 41.7% to 44.7% from 1998 to 2005 in United States. The incidence of drinking and driving increased from 26.5% to 28.9%, and the incidence of alcohol-related accidental death has increased from 1/100,000 to 3%. In recent years, the rate of drinking in college students is as high as 60% in China [3,4]. It is commonly known that alcohol consumption can cause a variety of problems, such as physical health problems, learning problems, psychological problems, and dangerous social behaviors, as well as leading to adverse consequences for individuals, families and society . Hazardous drinking is defined as a quantity or pattern of alcohol consumption that endangers health, but did not cause significant physical or mental damage . Harmful drinking is defined as alcohol consumption that results in physical or mental damage . A survey of pharmacy students at nine pharmacy schools in the U.S. demonstrated that over one-fourth of surveyed students exhibit signs of harmful alcohol use . Wallenstein et al study reported that nearly 34% of the surveyed college students participated in harmful or hazardous drinking . Pedrelli et al study in college students showed that worse depressive symptoms were associated with increased daily alcohol use and with greater risk for compulsive drinking . The problematic drinking situations and associated factors were also investigated in Chinese college students [3,4,10-12]. However, a search of literature published in English journals revealed only a few merged reports on alcohol consumption in Chinese college students. Also, no study addressed the association of impulsivity levels and risk factors with the hazardous and harmful alcohol consumption status in Chinese college students. In this study, the hazardous and harmful alcohol consumption status and risk factors were investigated in college students in Changsha city, Hunan province using a sample survey to provide directions for the intervention of problematic drinking among college students.Subjects and study methodsSubjectsSubjects were recruited from a college with 15 Departments in Changsha city, Hunan province using stratified, random cluster sampling and the subjects were ultimately stratified by grade. A total of 1015 students were recruited for survey from 12 classes containing freshman, sophomore, junior, and senior students. 907 valid questionnaires were obtained, including 317 boys, 590 girls, and 219 freshman, 182 sophomore, 374 junior, and 132 senior students.Study procedureWell-trained investigators explained the study purpose and content of questionnaires in the class. To keep confidentiality, communication between peers was prohibited during the survey. Approximately 25-30 min was given to finish the survey. The survey was conducted from February 30, 2013 - March 10, 2013.Study toolsSocial demographic characteristics, including gender, age, grade in school, major, ethnicity, family residence, whether the participant was an only-child, the average monthly living cost, smoking, family income, and parents' education level were collected using a general information questionnaire. Family, peers, and school environments including the attitude of parents to drinking, parents' alcohol consumption, peers' alcohol consumption, and peers' (friends / classmates) attitude to alcohol consumption, and so on were collected by a self-made questionnaire.Alcohol Use Disorders Identification Test (AUDIT)  is a scale for screening alcohol use disorders and recommended by WHO in 1989 after a trial in six countries. This scale has a high accuracy in identifying early risk of drinking and harmful drinking. The scale contains 10 items with item 1 to 3 measuring the amount of drinking and frequency, item 4 to 6 measuring alcohol dependency, and item 7 to 10 measuring various problems caused by alcohol. Total score was calculated and a limitation score was designed as hazardous drinking and harmful drinking. A previous study suggested a limitation score of 7.00 for hazardous drinking in Chinese population with a sensitivity and specificity of 99.17% and 90%, respectively . In this study, AUDIT score ≥7 was considered hazardous and harmful alcohol consumption, <7 as normal drinking, and 0 as non-drinking . Barratt Impulsiveness Scale, Chinese version (BIS-11)  contains 26 items using the 1 to 4 scoring system (almost no / never, occasionally, often, and almost always / always) and three dimensions: attentional, motor, and non-planning impulsiveness.Quality controlThe investigators were trained for the basic requirements of language for guiding field survey prior to the survey. A simulation of the survey process was conducted between two investigators. The survey was conducted in a classroom, questionnaires were filled by the students themselves on the spot, and collected face to face. Data were imputed in Epidata by two investigators independently and proofread. After exporting the data to SPSS, the logic correction was performed for each variable error to detect outliers.Data analysisData were analyzed using SPSS17.0. Descriptive analysis, Student’s t test, χ2 test, and unconditional logistic regression analysis were used. All tests in this study were two-sided at α = 0.05 level unless otherwise stated. Results Survey completion This study investigated 1015 college students in 12 classes containing freshman, sophomore, junior, and senior students. 108 students refused to participate in or did not complete the survey. 907 valid questionnaires were obtained with a valid response rate of 88.49% (907/1015). No significant differences in gender and grade structure were observed between excluded subjects and study samples (P> 0.05) (Table 1). Table 1. Comparison of general information between lost subjects and study subjects Variables Study subjects excluded subjects χ2 PSex 0.184 0.668 Male 317 40 Female 590 68Grade 0.734 0.865 Freshman 219 24 Sophomore 182 21 Junior 374 49 Senior 132 14 General information of participants Among 907 college students with valid surveys, 317 were male (35.0%) and 590 were female (65.0%) with a mean age of 20.55 ± 1.422 years. This population contained 813 Han Chinese (89.6%) and 94 (10.4%) ethnic minorities. Among 907 college students, 219 (24.1%) were freshman, 182 (20.1%) were sophomores, 374 (41.2%) were juniors, and 132 (14.6%) were seniors. 45 (5.0%) came from a single-parent family, 587 (64.%) from core family (two generations with parents and child or children), or 275 (30.3%) from expanded family (over two generations). Most fathers (42.0%) received middle school education followed by high school (29.9% ), college and above (16.0%), and elementary and below (12.1%) education. Most of mothers (46.3%) received middle school education followed by elementary and below (24.9%), high school (20.3%), and college and above (8.5%) education (Table 2).Table 2. Drinking situation in college students with different characteristics (n=907)Variables GroupsAUDIT=0AUDIT<7AUDIT≥7χ2P n（%）n（%）n（%） SexM60(18.9)184(58.0)73(23.1)98.663 0.000** F256(43.4）306(51.9)28(4.7) RaceHan289(35.5)436(53.6)88(10.9)2.0350.362 Minorities27(28.8)54(57.4)13(13.8) Age(year)≤20168(38.4)233(53.2)37(8.4)8.60.014* >20148(31.6)257(54.8)64(13.6) Gradefreshman72(32.9)129(58.9)18(8.2)4.0910.129 sophomore73(40.1)91(50.0)18(9.9) junior130(34.8)198(52.9)46(12.3) senior41(31.1)72(54.5)19(14.4) Family residencecity55(30.9)94(52.8)29(16.3)8.8430.012* town90(35.4)132(52.0)32(12.6) countryside171(36.0)264(55.6)40(8.4) Only childyes88(29.9)159(54.1)47(16.0)12.1860.002* no228(37.2)331(54.0)54(8.8) Average monthly livingexpenses (yuan)≤800168(39.2)232(54.1)29(6.8)29.7530.000** 801-1000123(33.0)207(55.5)43(11.5) >100025(23.8)51(48.6)29(27.6) Smokingyes8(11.4)29(41.4)33(47.1)102.3650.000** no308(36.8)461(55.1)68(8.1) Family structureone-parent family16(35.6)20(44.4)9(20.0)2.2720.321 core family206(35.1)316(53.8)65(11.1) extended family94(34.2)154(56.0)27(9.8) Father's educationelementary and below38(34.5)60(54.5)12(10.9)18.2930.000** middle school122(32.0)234(61.4)25(6.6) high school111(41.0)128(47.2)32(11.8) college and above45(31.0)68(46.9)32(22.1) Mother's educationelementary and below73(32.3)129(57.1)24(10.6)2.9190.232 middle school155(36.9)225(53.6)40(9.5) high school65(35.3)98(53.3)21(11.4) college and above23(29.9)38(49.4)16(20.8) Father's attitude to drinkingagree20(23.5)45(52.9)20(23.5)41.2930.000** neutral168(29.3)345(60.2)60(10.5) disagree128(51.4)100(40.2)21(8.4) Mother's attitude to drinkingagree5(14.3)25(71.4)5(14.3)40.3240.000** neutral137(27.6)293(59.1)66(13.3) disagree174(46.3)172(45.7)30(8.0) Father drinkingyes211(32.2)370(56.4)75(11.4)7.5320.023* no105(41.8)120(47.8)26(10.4) Mother drinkingyes57(27.4)128(61.5)23(11.1)7.0980.029* no259(37.1)362(51.8)78(11.2) Peers attitude to drinkingagree28(20.9)79(59.0)27(20.1)49.1510.000** neutral235(33.8)388(55.7)73(10.5) disagree53(68.8)23(29.9)1(1.3) Peers drinkingnever27(60.0)12(26.7)6(13.3) few179(42.8)212(50.7)27(6.5)61.3450.000** some93(29.5)188(59.7)34(10.8) much17(13.2)78(60.5)34(26.4) Family, peers and school environmental conditions Among the parents of 907 participants, 9.4% of fathers agreed with, 27.5% disagreed with, and 63.2% expressed a neutral attitude towards children's alcohol consumption, while 3.9% of mothers agreed, 41.5% disagreed, and 54.7% expressed a neutral attitude. However, 72.3% of fathers consumed alcohol, while 27.7% did not consume alcohol. 22.9% mothers consumed alcohol, but 77.1% did not consume alcohol. Among the participants' peers, 14.8% agreed with, 8.5% disagreed with, and 76.7% expressed a neutral attitude towards alcohol consumption in college. Among these peers, 5.0% never consumed, 46.1% consumed little, 34.7% consumed some, and 14.2% consumed a lot of alcohol (Table 2). Alcohol consumption in college students Among the 907 college students who completed the survey, 591 consumed alcohol, while 316 did not consume alcohol during the past year with an alcohol consumption rate of 65.2%. The range of AUDIT scores were 0 to 31. Among the 591 alcohol consumers, 101 (11.1%) had an AUDIT score ≥7 points and 490 (54.0%) had an AUDIT score <7 points. Table 2 presented the alcohol consumption situation in college students with different characteristics. Table 3. Comparison of impulsivity scores between students with different drinking status (n = 907)Variables AUDTT=0 score AUDTT<7 scores AUDTT≥7 scores χ2 P Average Average AverageImpulsiveness 437.3 443.4 557.8 13.443 0.001Impulsivity level The range of BIS-11 scores was 30 to 94 in the 907 participants with a mean score of 59 ± 8.320, a median score of 57, and a QR of 10 (P25 = 54, P75 = 64). The BIS scores of participants with different characteristics were presented in Table 3. Table 4. Ordinal regression analysis of hazardous and harmful drinking in college students (n = 907)VariablesGroupsbSbWald χ2PAOROR 95%CISexF0 1 M1.0490.16341.20102.8552.0733.934 Age (year)≤200 1 >200.3080.144.8350.0281.3611.0341.792 Average monthly livingexpenses (yuan)>10000.9270.24414.41402.5271.5664.078 801-10000.2450.1532.5530.111.2780.9461.726 ≤8000 1 Smokingno0 1 yes1.250.28719.00403.491.996.123 Mother's attitude to drinkingagree0.5710.4241.8180.1781.770.7724.061 neutral0.3640.1724.4820.0341.4391.0272.015 disagree0 1 Peers attitude to drinkingagree1.0510.358.9990.0032.8611.445.686 neutral1.0050.29411.7290.0012.7321.5374.858 disagree0 1 Peers drinkingmost1.0240.3877.0050.0082.7841.3045.939 some0.470.3521.7880.1811.60.8033.19 few0.1690.3440.2410.6231.1840.6032.327 never0 1 Impulsivity levelBIS score0.0220.0096.2080.0131.0221.0051.039 Analysis of risk factors and harmful drinking Univariate analysis showed that hazardous and harmful alcohol consumption were higher in men than in women (χ2 = 98.663, P <0.000). The incidence of hazardous and harmful alcohol consumption showed significant differences between participants of different age, family residence, only-child or not, different monthly living expenses, smoking or not, different father's education, parents' attitude to their children's alcohol consumption, alcohol consumption situation in parents, peers' attitudes to alcohol consumption in college, and alcohol consumption situation in peers (Table 2). The impulsivity score was statistically different in participants with different alcohol consumption situations (Table 3). A logistic regression analysis was conducted using a backward stepwise method, setting α = 0.05 in, α = 0.10 out and using hazardous and harmful alcohol consumption as the dependent variable (AUDIT = 0 point = 0, AUDIT <7 points = 1, AUDIT≥7 points = 2), and sex (X1), age (X2), family residence (X3), only-child (X4), the average monthly living expenses (X5), smoking (X6), father's education level (X7), father's alcohol consumption situation (X8), father's attitude towards children's alcohol consumption (X9), mother's alcohol consumption situation (X10), mother's attitude towards children's alcohol consumption (X11), peers' alcohol consumption situation (X12), peers' attitude to alcohol consumption in college (X13), and impulsivity score (X14) as independent variables (Table 4). Multivariate analysis showed that men, age older than 20 years, average monthly living expenses higher than 1000 yuan, smoking, mother's neutral attitude to children's alcohol consumption, peers' neutral attitude to alcohol consumption in college, most peers consuming alcohol, and high impulsivity level are risk factors of hazardous and harmful drinking (P <0.05). Under the control of other factors, the college students with a higher impulsive level are more likely to exhibit hazardous and harmful drinking behaviors (OR = 1.022,95% CI: 1.005-1.039). Discussion The hazardous and harmful consumption of alcohol have long been recognized as a danger to the physical and mental health of college students and can exhibit potential negative consequences to society. Recently, concerns about alcohol consumption among college students are increasing due to its high prevalence. This study demonstrated that 65.2% of college students consumed alcohol in the past year and over 11% of college students who consumed alcohol had an AUDIT score ≥7 points, suggesting hazardous or harmful drinking of alcohol. The rate of hazardous and harmful drinking in Chinese college students is lower than that reported in college students of western countries (25% to 34%) [7,8]. However, the incidence of hazardous and harmful drinking in Chinese college students is similar to that in rural residents (11.5%) in Hunan province . This study also found that sex, age, average monthly living expenses, smoking, mother's and peers' attitude to alcohol consumption, and high impulsivity scores are risk factors of hazardous and harmful drinking. This study suggests that hazardous and harmful drinking among college students should be taken into consideration seriously. This study showed that the incidence of hazardous and harmful alcohol consumption in males is much higher than that females, which is consistent with previous reports [14,15]. Family environment is widely accepted as an important factor that affects the growth of children and their behaviors in adulthood. Results in this study showed that family residence, father's education, parents' attitude to children's alcohol consumption, and alcohol consumption status in parents significantly affected the incidence of hazardous and harmful alcohol consumption in college students, suggesting that family environmental factors played an exemplary role in the drinking behavior of college students. In addition, being the only-child in the family is also a factor for high rate of hazardous and harmful drinking in college. This is because this special growing environment leads to poor psychological endurance, which is prone to eliciting drinking behavior . The finding that students with high monthly living expenses are also prone to hazardous and harmful drinking behavior may just reflect that a certain economic capacity is necessary for alcohol consumption . This study showed that peers' attitudes to alcohol consumption in college and alcohol consumption situations in peers affected the incidence of hazardous and harmful drinking behavior. In these students with hazardous and harmful drinking behaviors, their peers tend to have a supportive or neutral attitude, and a high rate to consume alcohol. This suggested that alcohol consumption in Chinese colleges may receive influences from peers [12, 16]. Besides the findings that the external factors affected the hazardous and harmful drinking behavior in college students, this study also found that the students' impulsivity level is significantly associated with the incidence of hazardous and harmful drinking behaviors. After control of other factors, a higher impulsivity level is an independent risk factor for hazardous and harmful drinking behaviors. High impulsivity levels promote adolescents' excessive drinking behaviors, but excessive drinking can in turn increase the impulsivity level of college students . Therefore, students' drinking behavior can be affected by many factors, including factors from family, peers, and impulsive personality traits. In conclusion, a variety of factors affect the drinking behaviors in college students. Family, school, and society could play a role in decreasing the incidence of hazardous and harmful drinking behavior in college students. The education on alcohol-related health and development of targeted interventions may reduce the harm of alcohol use on college students. References 1. English C, Rey JA, Schlesselman LS. Prevalence of hazardous alcohol use among pharmacy students at nine U.S. schools of pharmacy. Pharm Pract (Granada). 2011;9:162-168.2. Ralph WH, Wenxing Zha, Elissa RW. Magnitude of and Trends in Alcohol-Related Mortalityand Morbidity Among U.S. College Students Ages 18-24, 1998-2005. J. Stud. Alcohol Drugs. 2009;16:12-20.3. Ji CY, Hu PJ, Song Y. The epidemiology of alcohol consumption and misuse among Chinese college students. Alcohol Alcohol. 2012;47:464-472. 4. Chang J, Shrake E, Rhee S. Patterns of alcohol use and attitudes toward drinking among Chinese and Korean American college students. J Ethn Subst Abuse. 2008;7:341-356. 5. Marlon PM, Larissa IZ, David DB, Fleming MF.. Alcohol-induced memory blackouts as an indicator of injury risk among college drinkers. Injury Prevention. 2012;18:44-49.6. WHO Expert Committee, Problems related to alcohol consumption. WHO Technical Report Series 650. Geneva, Switzerland: World Health Organization. 1980.7. Sunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the alcohol use disorders identification test(AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction. 1993;88:791-804.8. Wallenstein GV, Pigeon S, Kopans B, Jacobs DG, Aseltine R. Results of National Alcohol Screening Day: college demographics, clinical characteristics, and comparison with online screening. J Am Coll Health. 2007;55:341-350.9. Pedrelli P, Farabaugh AH, Zisook S, Tucker D, Rooney K, Katz J, Clain AJ, Petersen TJ, Fava M. Gender, depressive symptoms and patterns of alcohol use among college students. Psychopathology. 2011;44:27-33. 10. Liping Yin, Fang Zhang, Shangrong He, Bokai Wang. A logistic regression analysis of college students drinking and related factors. Practical Chinese Medicine. 2007:2:23-25.11. Jin P. Drinking Survey Analysis in Nanjing College Students. Journal of Tropical Medicine. 2015;15:99-100.12. Zhou Q. Analysis of Drinking behavior and cognitive attitudes in college students. Huaihai Medicine. 2014;32:170-171.13. Wu Q, Zhou L, Xiao S. Hazardous and harmful drinking in rural residents of Liuyang. Chinese Journal of Drug Dependence. 2013:22:292-295.14. Luo X. Analysis of a college students' drinking behavior and related factors. China Journal of Pharmaceutical Economics. 2013;6:407-408.15. Wang C, Tong H, Li X. Analysis of Drinking Situation in College Students in Hehui city and its influencing factors. China School Health. 2015;36:699-701.16. Russell AB, Morton BS. Denise Haynie. Longitudinal Relationship Between Drinking with Peers, Descriptive Norms, and Adolescent Alcohol Use. Society for Prevention Research. 2014;15:497-505.17. Henges AL, Marczinski CA. Impulsivity and alcohol consumption in young social drinkers. Addictive Behaviors. 2012;37:217-220.
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