This meta-analysis provided an estimate of Chinese undergraduate university student drinking rates in the last 30 days of 66.8% for male university students and 31.7% for female university students. As expected, the estimated drinking rate is higher for males than for females. While many papers on alcohol use by university students have been published, this is the first to present an estimate of last 30 day drinking rates based on surveys of Mainland China undergraduate university students, published in English or Chinese, and describing male and female alcohol use separately. The results reflect the best estimate of last-30-day alcohol use by Chinese undergraduate university students.
This estimate for university students’ alcohol use is higher than WHO’s estimates of per capita drinking in the previous year for persons 15 years and older in China: 58.4% male, 28.9% females [1, 2]. We will refrain from offering explanations of why university undergraduate student drinking rates appear to be higher than adult per capita drinking rates. That question is beyond the scope of this analysis.
This estimate for university students’ alcohol use is also higher than the last 30 day drinking rates estimated for high school students: 36.5% males and 22.2% females attending regular high schools, and 44.7% males and 28.8% females attending vocational high schools [10]. The significant differences between high school drinking rates and the university student drinking rates could be a direct result of the way Chinese high school students focus on preparation for the university entrance examination (known as the gaokao).
Studies of Chinese high school students’ drinking have found that vocational high school students report higher drinking rates than regular high school students [10]. One of the main differences between the two types of high school students is that regular high school students are preparing for the gaokao, while the vocational high school students typically are not. Preparation for the gaokao is rigorous and begins before the last year of high school. Students pressure themselves to a strict discipline of study, reinforced and supervised by parents and teachers. There is little time for any recreational activities. By comparison the vocational high school students have more discretionary time to be involved in activities that include alcohol. Once high school students have finished the gaokao and have been accepted to universities, they are under much less pressure and have more freedom to engage in activities that could include alcohol. In this manner the gaokao may be protective for high school students by delaying their drinking until they enter university. There are likely other individual-specific explanations for these rates that have not been identified and studied.
The university student drinking rates need to be interpreted in the context of Chinese university life and Chinese alcohol culture. China is a relationship society, meaning the social structure is based first on relationships. Actions that build, maintain and protect relationships are important, and sharing alcohol is an important part of this process. Alcohol use in moderation is considered good for health, it is a part of meals, ceremonies and celebrations, and it is an important part of Chinese medicine. It is legal for university students to purchase and consume alcohol. Chinese universities, with the exception of the newest campuses, are walled compounds with everything inside the walls that students need: housing, recreational facilities, food services, health services, educational services, post offices, small shops and banks. During the week there is little need to leave the campus. On weekends students will often go off-campus with friends to eat a lunch or dinner at local restaurants. Eating with friends is a typical occasion for drinking alcohol, usually beer. In this context, the last-30-day rates reported here are not surprising and do not necessarily represent high risk drinking.
The moderator analysis showed that the heterogeneity observed affected the results, and the significant I 2 suggests caution in interpreting these results. Nine moderator variables were examined in the meta regression, and three of the moderators should be considered in interpreting these results: whether the survey stated a definition of drinking, whether the questionnaire was based on YRBS or was investigator developed, and the geographic region where the data were collected.
Definition of drinking
A clearly stated definition of drinking as having “at least one cup” of an alcohol beverage (yes vs. no) was associated with the logit drinking rates of male and female university students. Surveys with stated definitions of drinking reported lower drinking rates compared to surveys without definitions (Table 4). This finding is similar to one reported in an earlier meta-analysis of high school student drinking rates [10]. In published studies of Chinese alcohol use, surveys have used drinking self-report for the past week, past 30 days, past 3 months, past 6 months, past year, and lifetime. Even in surveys that specify the past 30 days, alcohol questions differ on the basis of quantity. Some questions ask if a respondent has drunk alcohol at least once, including one sip, some questions specify at least one cup. Specificity has its value in quantifying a behavior, but it is also possible that specificity overlooks important drinking patterns that deserve attention. There is a need for a standardized definition of alcohol drinking to improve the accuracy of estimating drinking rates [9]. This standardized definition needs to be based on a careful observation of actual student drinking behaviors within Chinese alcohol culture.
Questionnaire development
Logit drinking rates for males were related to whether or not the questionnaire was developed by the investigator or based on YRBS. Studies that used YRBS-based questionnaires reported higher drinking rates for males compared to studies using investigator-developed questionnaires. There was no significant difference in female last-30-day drinking based on type of questionnaire (Table 4). We believe men’s drinking tends to be more nuanced, with drinking varying according to traditional, established protocols regarding appropriate drinking for the time, place, occasion, and companions. In China, women drinking in public is relatively new. That is not to say that women did not drink on many occasions out of public view, often only in the company of other women; however, these occasions tended to be traditional functions like rites of passage, lunar festivals, and other special ceremonies where drinking occurred as part of the ceremony. Now there is a wider acceptance of women drinking in public, an awareness of more female drinking, and an acknowledgement of female-only drinking occasions. The relative newness of acceptability of female drinking may mean its repertoire is limited and either type of questionnaire captures the behavior equally well. Men’s drinking behavior, while superficially standardized, because it is so widespread and so integrated into daily life may be better captured by investigator-developed questionnaires than by the more standardized (restricted) YRBS-type alcohol use questions.
The most likely variations in questionnaire development that affect these differences relate to 1) how alcohol is defined, 2) how quantity is measured, and 3) how frequency is measured, and 4) the way Western questions are translated into Chinese.
Definition of “alcohol”
In the West, alcohol questionnaires are generally organized around three types of alcohol: beer, wine, and spirits. In China, the classification of alcohol types is more complicated: there are more types of beverage alcohol and there is no widely accepted understanding of a standard drink. Beer is comparable, with beer strength and packaging being fairly similar in China and the West. In China “wine” can mean fruit wines (often imported, Western-style strength and packaging), but it also refers to traditional wines such as huangjiu (yellow wine, common in the Shanghai area) or low strength rice wines and porridges. Distilled spirits are popularly classified by the grains used to make them and by their strength (high-strength spirits and low-strength spirits, with about 40% alcohol-by-volume being the threshold). Locally-made varieties of unlabeled, unrecorded spirits are legal, inexpensive and readily available, especially in rural areas [17]. Medicinal spirits (distilled spirits compounded with plant and animal ingredients) are part of Chinese traditional medicinal. In addition, there is little understanding of how much wine is used in traditional Chinese cooking, and whether the cooking methods ensure that the alcohol is fully reduced before the food is eaten. To accommodate this wider range of beverage alcohols, some large surveys of Chinese alcohol use have included questions on as many as five beverage alcohol categories (but not medicinal spirits) [3, 18].
Quantity
Alcohol survey questions ask if a respondent has drunk alcohol at least once “including one sip,” some questions specify “at least one cup.” There is an absence of a widely accepted understanding of a “standard drink” both in terms of the drinking cup size and the beverage container size. Beer is sold in reasonably uniform-sized containers, ranging from 300 ml to 1 L, so survey data on beer consumption can probably provide useful information on quantity. Fruit wine (especially imported wine) is often in standard bottles and served in wine glasses; however, wine currently makes up less than 3% of alcohol consumed in China [2]. Spirits are sold in containers of varied sizes. Spirits are often served in cups, glasses and bowls of different sizes and shapes that are frequently topped up by others in the drinking group, making it difficult to estimate quantity consumed. Even a simple survey question defining alcohol as “more than one cup” can be interpreted many ways. In terms of trying to estimate alcohol consumption in terms of liters of pure alcohol, it should be noted that Chinese spirits come in a wide range of strengths.
Translating survey questions
Translating Western alcohol survey questions is challenging, and the accuracy of the translation directly affects the validity of the data collected. There are many Chinese words for different types of alcohol. In everyday conversation “wine” (jiu, 酒) is used as a generic term for all types of alcohol. Beer is sometimes not thought of, by survey respondents, as a form of alcohol. Because alcohol use, even by very young people, is an unremarkable event, especially at festivals, unless carefully specified in the questionnaire many drinking events may be overlooked by respondents when answering questions about alcohol use.
These wide-ranging concerns about questionnaire development may explain the differences in rates reported in studies that used investigator-developed questionnaires and studies that used YRBS-based questionnaires.
Geographic Region
The moderator geographic region (east vs. central, east vs. west) was associated with the logit drinking rates for male university students. Surveys of students at central China universities reported higher drinking rates. Surveys of students at eastern China universities reported lower drinking rates, and surveys in western China reported drinking rates in between.
A meta-analysis of studies of high school student alcohol use also found higher drinking rates were reported from surveys of west China adolescents. That meta-analysis of high school surveys found surveys from central China reported lower drinking rates, and surveys from eastern China were in between [10]. Neither the meta-analysis of high school drinking studies [10] or this meta-analysis of university drinking studies showed any significant north–south differences.
Because high schools enroll local adolescents, we expected to find some geographic differences that reflected regional differences in alcohol use. Universities, on the other hand, especially the more prestigious universities, serve students from all parts of the country, so accounting for differences due to the geographic region of the survey is more difficult.
The very suggestion of drinking rates varying at universities in different regions of the country begs exploration, as does the effect of geographic region on male drinking but not on female drinking. Geographic differences in drinking rates in a country as large and diverse as China calls into question the usefulness of national drinking rate estimates in alcohol policy development.
Limitations
Many technical issues, not assessed in this analysis, could have affected the results. Survey research is relatively new in China and surveys of populations like university students are often conducted by well-meaning investigators with little experience. We have no information on the conditions under which the data were gathered, how confidentiality was assured, how any assurance of anonymity was interpreted or the methods used for data collection. We have no information on how the samples were identified and how individuals who completed surveys were recruited. We have no information on the times of the year the surveys were conducted. Timing could have affected survey results if data were collected within 30 days of significant festivals, rites of passage and other significant events in which alcohol is a traditional part. The diversity of the students in the samples represented in these papers may not have been truly representative of the Chinese university student population. We know little about data management and analysis techniques used in the studies included in this analysis.