Priti Prabhughate¹, Sriyanchita Srinivasan², Vikram Ranga³, Katherine Fritz⁴,Mitzy Gafos⁵

1. International Center for Research on Women, C-59, South Extn Part II, New Delhi- 110049, India

2. International Centre for Research on Women, New Delhi, India

3. Centre for Sustainable Development, Suresh GyanVihar University, Jaipur, India

4. International Center for Research on Women, Washington DC, US

5. Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK

^*Corresponding author:PritiPrabhughate, International Center for Research on Women, C-59, South Extn Part II, New Delhi- 110049, India,Tel: +91 9999968828;

Abstract

Background:Evidence suggests a link between alcohol marketing, advertisements, and underage drinking. Despite India having prohibitive alcohol policies including a ban on advertising, there has been an increase in underage drinking.Purpose: We explore young peoples’ experiences of alcohol in Mumbai and their drinking behaviour. We also explore how young underage people are exposed to alcohol marketing and advertisements and how they access alcohol. Methods

We conducted a descriptive mixed methods study using Geographical Information System (GIS) mapping and participatory action research method called photovoice. Seven young people aged 18-24 participated in photovoice. Participants took photographs of their experiences of alcohol. The photographs informed the discussion at the photovoice workshops. We used GIS to map the proximity of alcohol outlets to educational institutions in Mumbai.Results: We found several interconnected factors that explain how young people perceive alcohol and how these factors contribute to the ‘normalization’ of alcohol. These include family influence, peer and media influence, gender norms, and access to alcohol. Despite being below the legal drinking age in the state, participants reported drinking underage. Using GIS we found that alcohol was available and accessible in proximity of colleges.Conclusion: This study highlights that despite restrictive alcohol policies, young people are exposed to alcohol marketing in multiple ways and is accessible and available to them. The consumption of alcohol is socially normalized and sanctioned through media, family and peer influences. It is necessary to reconsider current alcohol policies in India and design programs that address underage drinking.

Keywords: youth, photovoice, access to alcohol, drinking norms

Introduction

Excessive alcohol consumption among young people and the associated negative consequences are a growing public health concern globally. The harmful use of alcohol is the third leading risk factor for premature deaths and disabilities in the world with an estimated 2.5 million deaths in 2004, which included 320,000 15 to 29 years old [1]. The influence of alcohol marketing and advertising on young people’s drinking behavior is a matter of much debate. Evidence suggests associations between alcohol advertising, drinking behavior and a possible link between marketing and underage drinking [2]. In 2010, WHO recommended national policy interventions to restrict the marketing of alcoholic beverages especially to young people[1]. Of the 159 member countries who reported on alcohol marketing policies as part of the WHO Global status report on alcohol, 39.6% had no marketing restrictions, while 10.1% imposed total bans [3].

India has some of the most stringent alcohol policies, including a statement on prohibition in the constitutioni. However, alcohol policy is under the legislative power of individual states. India has high minimum legal ages of ranging from 18 to 25 years across states. In 2000, India became one of the few countries to ban advertising of alcoholic beveragesii. However, to circumvent the legislation there has been an increase in ‘Surrogate Advertising’ whereby alcohol companies advertise products such as non- alcoholic beverages, or sponsor events, under the same brand name. Surrogate advertising has been challenged in the courts with some cases being upheld [4].

Despite restrictive alcohol policies, the per capita consumption of alcohol in India increased by 55% from 1992 to 2012, accounting for the third highest increase in the world [5]. Although only 30% of the population in India consume alcohol, the fact that alcohol consumption has increased among the youth is of concern. In Karnataka, data show a drop in mean age of drinking initiation from 28-years to 20-years between the birth cohorts of1920–30 and 1980– 90 [6]. A study in Delhi, reported alcohol initiation among students from 13-years old and noted that alcohol consumption was higher among students from middle- income families [7]. In Goa, the proportion of adolescent boys who reported drinking alcohol increased from 19% to 74% among those born between 1956-60 and 1981-85[8]. In this study, adolescent drinking was associated with increased likelihood of experiencing lifetime alcohol dependence, hazardous or harmful alcohol use, alcohol related injuries and psychological distress. Evidence also suggests that half of all drinkers in India fall into the criteria of hazardous drinking, defined as binge drinking and solitary consumption to reach intoxication, and that a fifth of consumers are considered dependent drinkers [9].

This remarkable increase in alcohol consumption is often explained by the rapid economic and social changes that have occurred in India, influenced of globalization and economic liberalization [10]. Clearly, laws are proving inadequate and the prohibitive approach to alcohol restrictions means that there are few intervention programs targeted at underage or problem drinkers. There is an urgent need to review policies and design legislation and programs that promote health, prevent harm and addresses the social problems associated with the use of alcohol[11].To understand young people’s use of alcohol, it is important to examine structural factors including the influence of the media, social norms, marketing and accessibility of alcohol. We examine how young people access information about alcohol and how their perceptions and behavior are shaped. Drawing on the results, we make programmatic recommendations on revisiting alcohol education messages, alcohol education and prevention programs and suggest further areas for research.

Materials and Methods

We conducted a descriptive mixed methods study using a participatory action research method, photovoice, and Geographical Information System (GIS) mapping, as part of a multi-country study examining the associations between alcohol,

ⁱArticle 47: “The state shall regard the raising of the level of nutrition and standard of living of it’s People as among its primary duties and in particular, the state shall endeavor to bring about prohibition of the use except for medicinal purposes of intoxicating drinks and of drugs which are injurious to health.”

ⁱⁱ The Cable Television Network (Regulation) Amendment Act, 2011

iii According to the Bombay Prohibition Act 1949 (Part VI A Rule 70D) the minimum legal drinking age in Maharashtra is 25 years

health and sexual risk among young people. Using hand-held Global Positioning System (GPS) devices we mapped educational institutions (schools, colleges, vocational training institutes) and alcohol outlets (bars, restaurants selling alcohol, government liquor shops etc.) within a 500m radius of the institutions. Mapping was conducted in three regions of Mumbai: South Mumbai, West Mumbai and East Mumbai (Figure 1).

Figure 1.Liquor Cabinet at home. This picture was taken by a female participant of a liquor cabinet in her house to show how the presence of alcohol within the home reduces the taboo of drinking alcohol and can makeaccess to alcohol easy with parentalconsent.Caption by the participant: The Home is where the heart is…

The GPS locational data were downloaded and GIS analyses conducted, includingproximity/accessibility analysis, preparation of maps and exploratory data analyses, using Quantum GIS (QGIS) and R statistical software [12]. For accessibility analysis, three circular buffer zones were created around the institutions with varying distances (i.e. 100m, 300m and 500m) using Euclidean straight-line distances [13]. GPS coordinates of the venues were securely stored and not made visible on published maps.Photovoice is a participatory action research method that engages participants in documenting their world using photographic images that are interpreted with captions [14,15]. The photographic images are then used in focus group discussions, termed photo-dialogues, to stimulate dialogue on the issue of interest. Participants were recruited using convenience sampling by advertising the study in colleges in the mapped study area. Interested students were asked to contact the research team to find out more about the study and expectations of participants, which included willingness to take photographs, participate in three workshops, and in an advocacy event post completion of the project. Eighteen students expressed an interest in the study but only seven enrolled, attended all three photovoice workshops and completed their assignment. Respondents were aged 18-24 years old (four females and three males) which is below the prescribed minimum legal drinking ageⁱⁱⁱ in Mumbai.

We held three full-day workshops over weekends, using a manual that was developed for the training. In the first workshop, participants were taught basic photographic skills including how to use symbolism to express ideas and feelings and how to use silhouettes and shadows to protect anonymity. For homework, participants were asked to take photographs of alcohol adverts that they were exposed to in their daily lives, and capture images that presented how alcohol affects them and their communities. Over the course of the three photovoice workshops, students participated in group discussions and participatory exercises to share their understanding of alcohol consumption, what influences drinking among youth, the role of peers and peer socialization and their perception of alcohol availability, accessibility and norms around alcohol consumption among peers and in the media. The group discussions were recorded, translated and transcribed verbatim, and analyzed in Atlas-ti software using thematic analysis. Participants provided written consent. Identifiers were removed from allFGDtranscripts. Disposable cameras were used to avoid the uploading of images and participants were instructed not to photograph peoples’ faces, instead to use techniques of symbolism, shadows, and silhouettes. The study received ethical approval from local Institutional Review Board (IRB) as well as the International Center for Research on Women (ICRW) IRB.Although the study was initiated and designed by a research team, youth participants took ownership of the study and conducted photo-exhibits to engage with other young people on college campus.

Results

Datageneratedthroughphoto-dialoguesrevealedseveralinterconnectedfactorsthatexplainedhowyoungpeople perceive alcohol and how several factors work together in the lives of young people that contribute towards ‘normalizing’ alcohol consumption. The factors that emerged from the data included family influence, peer socialization, media influence and access toalcohol.

Family influence

Almost all participants reported either having witnessed at least one of their parents consuming alcohol, or alcohol being stored at home (Figure 1). Participants reported that the presence of alcohol at home made drinking alcohol socially appear a normal part of adulthood, as articulated by a respondent:“When your father drinks at home,- you see it as a natural thing, as such that one day when I grow up I too will consume alcohol as a grown up” (young male, 20). However, some participants also saw alcohol consumption by their parents, primarily fathers, as a means of coping with stress, financial worries and relationship issues at home.

Almost all participants revealed that their parents found it acceptable for their children to drink when they turned 18. Some parents offered their offspring their first drink to stop them from trying alcohol outside the home, as put by a participant:“Parents sometimes offer a drink to their children, so that they won’t go out and try to drink. They feel it is better that they drink in front of us (parents) instead of going out and doing things behind our backs. Sometimes it works sometimes it doesn’t.” (young male22). However, while observing alcohol in the household normalized drinking for most respondents, a couple said that the behavioral consequences witnessed among family members when drinking deterred them from consuming alcohol.

Peer influence

The influence of peer group socialisation emerged prominently from the discussions showing that peers influence alcohol consumption in several ways. Alcohol appeared to be an integral part of socialization among youth. All participants unanimously agreed that most their age start drinking with friends as a matter of ‘curiosity’ or ‘adventure’ (Figure 2).Participants reported that most of their socialization with friends took place in parties such as college ‘fresher’s or farewell parties organized by colleges. However, participants reported that such parties then extended to further clandestine socialization among students to include alcohol as shared by a respondent, “For example, if a farewell is organized by college then we organize an extended one after that. We publicize through poster, not about alcohol, but leave a WhatsApp number, there is a committee that gets all the messages and tells everyone how much to pay. Once college farewell is over, everyone knows where the party is in the evening. The college doesn’t even know about this.” (young male,24)

Even informal gatherings such as house parties, or sudden opportunities to privacy such as parents being away, could result in a night out. Consuming alcohol in the spirit of adventure and freedom was shared as a consistent feature of such informal gatherings. Participants also highlighted that alcohol consumption influences the formation of peer groups. For example, the discussion highlighted the notion of:‘ people who are drinkers are cool and the others are not’ (young male, 21).

Participants reported that non-drinkers, are labeled as boring or un cool, and may not be invited to events. Conversely, some participants felt that having a non-drinker in the group was an asset as they could “take care of everyone” by driving everyone home, resolving fights and cleaning up vomit.

Figure 2.This image was captured by a photovoice male participant to show alcohol as part of socialization with friends and how friends explore various drinks together out of curiosity and helps them have a good time.Caption by the participant: Good friend, good wine, good times.

Media influence in ‘normalisation’ of alcohol consumption

Discussions revealed that the participants were very active consumers of media. The media platforms used by the participants that were brought forth during the discussions were, Web series, and social media including YouTube and Facebook.It was apparent that participants watched web series as their primary source of entertainment as these featured issues that appealed to them like stories of self-discovery, rebellion, live-in relationships etc. Participants shared how consumption of alcohol was portrayed as a subtle but pivotal process of self-discovery. For example, a participant cited a popular web series in which,“fourfriendsaretryingtomakeitbigontheirown,theyhavequittheirjobsandarestrugglingtodowhat they really dream of. When you watch the web series alcohol is very much there in this story as if, if you want to do something big, alcohol helps you to think or that it is needed.” (young female,24)

Participants highlighted that some of the web series are sponsored by alcohol companies that advertise branded bottled water during the telecast. They pointed out how alcohol and drinking are portrayed positively in the media and negative consequences were rarely depicted. YouTube and Facebook were also discussed as platforms for alcohol adverts. The problem with YouTube as one participant puts is, “the fact that it was accessible to children and despite there being an age limit, it was very easy to surpass. Any person can make a video of themselves and upload it on YouTube and since there is no censorship on the content, it supplies an over abundance of information to the oath which they can filter as they deem fit” (young male,19).

Social media sites play a substantial role in shaping drinking culture as there are frequent representations of alcohol such as photographs and check-ins at bars, that provide young people with ways to document their night outs, and easy access to information on alcohol promotions such as “happy hours”, “ladies night out” as illustrated by a participant, (Figure 3). “It is very easy as your FaceBook is always logged in and you always get the notifications and sometimes when you use the chat or subscribe and you tick the notification, you get notified every time.” (young female,22)

Figure 3.Alcohol Promotions. In this image captured by a photovoice male participant, the person is capturing an image of an alcohol promotion that is offering buy one drink and get one free as a deal with a meal in a restaurant that looks fancy and a place students will visit for food and fun.Caption by the participant: Happines.

Gender Norms around alcohol consumption

Gender played an important role in the discussions in terms of both social and interpersonal gender norms. Gender differences were observed in the way female participants chose more discreet methods of purchasing alcohol which underscored their concern about safety and facing stigma for drinking. For example, female participants shared that, “Girls don’t go to a wine shop because they (shopkeepers) stare at you a lot and then they think that what is she doing over here and even if you manage to get it (alcohol bottle) I had experience where they began saying enjoy it baby and things like that.” (young female,24). Consequently, female

participants reported that, “women buy alcohol from some restaurants that also sells the bottle despite it beings lightly at higher rate. Girls prefer to go to those restaurants and buy that bottle because even if it more expensive she doesn’t get a lot of comments.” (young female,22). Conversely male participants bought their alcohol from ‘wine shops’ as the alcohol was cheaper. Female participants ’also preferred more discreet venues for drinking such as at a friend’s ’home or a big party where they felt ‘safe’ in a larger mixed sex group with friends. Males did not have any preferred venue of drinking as they could drink in a variety of places like bars, restaurants, or even in a park.

revealed gendered beliefs about alcohol consumption such as the notions of ‘stamina’ -understood as ability to hold a drink, outdo peers by drinking more and demonstrate increasing ability to tolerate alcohol to appear ‘cool’. Surprisingly female participants debunked the notion of the ability to hold a drink being a ‘masculine’ trait. They also shared that women drink and like to hold their drink, like men, but do so only in same sex groups and maintain restraint with mixed groups for issues of security, “No, no it is(drinking alcohol) the same as boys if a girl drinks a lot and nothing happens to her it becomes like a bit of competition between girls too, but then when a girl is with boys she might not risk heavy drinking. So amongst girls we too like to see who can hold it longer.” (young female21)

There were gender differences in participants’ behavior post consuming alcohol. Male participants reported ‘drunk texting’ their girlfriends. Male participants reported getting into physical and verbal fights with friends over girlfriends. Whereas the female participants reported getting into verbal fights only when in same-sex groups; they practiced more restraint when drinking in mixed sex groups out of their concern for security as they were aware of the risk of unintended, unsafe sexual encounters. In relation to interpersonal gender norms, both male and female participants pointed out that for women, boyfriends act as facilitators to drink with them for company. However, it was noted that once in a steady relationship, boyfriends act possessively and did not allow girlfriends to drink because he doesn’t like the idea of her drinking in a larger group.

Access to alcohol

Despite being below the legal drinking age in the state, all participants had experience of consuming alcohol. The discussions highlighted several ways in which alcohol was made readily accessible to young people.Participants pointed out various ways in which they could access alcohol including from venues near theircolleges and named several places where they or others in their college visited for a drink. Participants shared about other friends,“I know people who go drinking during college hours and come back to college and sit for lectures and slush and they take a nap in college before going home.” (young male 18).

Young people also accessed alcohol at events such as musical festivals which were sponsored by alcohol industry. The manner in which the music fests are advertised, made participants associate attending music fests with music, fun and an opportunity to drink alcohol, as poignantly expressed by a participant,“when people think about these festivals, they automatically link it to drinking and having a good time rather than the music”. (young male 23).

To further investigate this issue of access from a perspective of physical proximity, 20 educational institut- ions and 144 alcohol venues were mapped in East, West and South Mumbai area by a team of researchers. The physical accessibility ratio in Table 1 indicates the average number of liquor serving facilities to one college in a given buffer zone; e.g. a ratio of 1:2 in the 500m buffer zone indicates the rear eon average two liquor serving facilities per college. In all three regions there is accessibility of alcohol shops from some colleges within a 100m with the accessibility ratio ranging from 1:05 – 1:0.8. In the case of five colleges, liquor availability is within 50m, with the closest being 0.4m, meaning a liquor facility just outside the college. The average number of alcohol venues per college increases in the 300m radius to 1:1.4-1.32, and in the 500m radius to 1:3.3 – 1:5.4. Evidently, in all cases, there is EASY physical accessibility to liquor shops (Figure1).

Figure 1.Locations of educational institutions and liquor serving facilities.

Table 1. Alcohol accessibility measured by location of liquor selling venues in relation to educational institutions

Discussion

The results of this study highlight that several structural factors influence young peoples’ perceptions and behaviors around alcohol. Our finding that all participants had consumed alcohol underage, is consistent with prevalence data from other states in India [6,7]. Our study highlights two key findings underlie underage drinking: firstly, the high volume and location of alcohol outlets so close to schools and promotion of alcohol through event sponsorship; Secondly, normalization of alcohol as aspira- tional lifestyle in advertising, media messaging reinforced by peer and family influences.

It is evident from our GPS data that there are large numbers of alcohol outlets close to educational institutions, facilitating easy access for students. Consistent with another study in India, our findings suggest that the easy accessibility influences and facilitates underage alcohol initiation and consumption [16]. This study generates evidence of how surrogate advertising, alcohol marketing and media proliferate a positive imagery of alcohol to youth without any health warnings about alcohol consumption or counter messages to balance the one-sided perspective of alcohol as an important part of ‘self-discovery. This clearly shows that alcohol control measures in India need to regulate media content about alcohol messages, which is one of the recommendations outlined in the global strategy to reduce harmful use of alcohol by the WHO [1].

Finally, our findings also highlight the importance of social norms in influencing perceptions and behaviors around alcohol. It is clear from our study that under age alcohol consumption is normalized for this group of urban middle-class youth through family, peer, male-partner, and media influences. Other research has spoken to the role of peer pressure and social aspiration as factors underpinning underage alcohol consumption for youth in India [17]. Interestingly, while perceptions of alcohol consumption are clearly gendered, young women sensed their safety to be a concern and therefore limited their consumption of alcohol in the company of young men. Without addressing social norms that are promoting alcohol consumption as both normative and aspirational, the trend to increased underage and problem drinking will continue.

The main limitation of this study is the small sample size with only seven young people engaging in the photo voice participatory research method and therefore the findings cannot be generalized. However, the strength of this study is that this is one of the first studies to use the photo voice method to explore young peoples’ perceptions of alcohol. in fact, an important outcome of this project was that the participants organized photo-exhibitions in two colleges in Mumbai to talk to other young people about how alcohol affects their lives, questioned the messages embedded in alcohol promotion through the media and encouraged other young people to do the same.

This study provides some insight in to the perceptions of young people about alcohol, the influencing factors, and the role of social norms on alcohol consum- ption. Our study also highlights the importance of young peoples’ voices in the debate and the role that they can play in education go the r youth and challenging social norms that can be harmful for their generation.

Acknowledgements

This study was supported by the STRIVE research programme consortium, funded by UKaid from the Department for International Development. However, the views expressed do not necessarily reflect the department’s official policies.

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Received: December 05, 2019;
Accepted: January 15, 2019;
Published: January 20, 2019;

To cite this article : Prabhughate P, Srinivasan S, Gafos M. Normalizing Alcohol Consumption among Youth: Role of Peers, Media, and Access to Alcohol in Mumbai. Health Education and Public Health. 2020: 3:1.

© Prabhughate P. 2020.