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The International Journal of the Addictions, 27( 12). 1389-1400, 1992
Alcohol-Related Problems Encountered by Japanese, Caucasians, and Japanese-Americans Takashi Izuno, M.D., 19' Michiko Miyakawa, M.D., 1 Tooru Tsunoda, M.D., Kiyoko M. Parrish, Ph.D., Hiroaki Kono, M.D., Motoi Ogata, M.D., 5 Thomas C. Harford, Ph.D., and Leland H. Towle, M.S. 'Department of Preventive Medicine and Public Health, School of Medicine, Keio University, Tokyo, Japan Department of Hygiene, School of Medicine, Kyorin University, Tokyo, Japan Department of Health Services, University of Washington,Seattle, Washington, USA The National Institute of Alcoholism, Kurihama National Hospital, Kanagawa, Japan School of Allied Health Profession, Sapporo Medical College, Hokkaido, Japan The National Institute on Alcohol Abuse and Alcoholism, Rockville, Maryland, USA
ABSTRACT Using population-based survey data, personal-problematic and socioproblematic factors were examined among Japanese in Japan, Japanese-Americans in Hawaii, and Japanese-Americans; Caucasians in California were analyzed as a control group. Caucasian males were more likely to exhibit drinking-related social problems, whereas Japanese males showed more personal-problematic symptoms. Japanese-American men, both in Hawaii and California, were least likely among the three ethnic groups to have personal-problematic symptoms and were more likely to have socioproblematic symptoms *To whom correspondence should be addressed at Department of Preventive Medicine and Public Health, School of Medicine, Keio University, 35 Shinanomachi Shinjuku, Tokyo 160, Japan. 1389
Copyright 01992 by Marcel Dekker, Inc
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than Japanese men. These differences might be explained by differences in the perception of social problems. Key words. Alcohol-related problems; Japanese; Japanese-American; Caucasian; Ethnicity
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INTRODUCTION Although the number of publications on alcohol-related problems have been increasing in recent years, few studies have dealt with cross-national and interethnic group comparisons (Kitano and Chi, 1989; Hong and Isralowitz, 1989). Because drinking is culture bound, cross-cultural surveys would contribute to a better understanding of drinking problems. In a previous study, factor analysis produced two factor patterns of alcohol-related problems among Japanese and Japanese-American men: personal-problematic factors and socioproblematic factors (Izuno et al., submitted for publication). In this study we focused on the differences in two types of alcohol-related problems in the populations of the United States and Japan stratified by drinking levels, ethnicity , and gender.
METHOD Questionnaires The survey questionnaire used in this study was based on a general population survey questionnaire developed by the World Health Organization (WHO) for a project concerned with community responses to alcohol-related problems (Ritson, 1985; Rootman and Moser, 1985) in such diverse countries as Zambia, Mexico, Scotland, and the United States. In 1986 the surveys asked respondents about their use of various kinds of alcoholic beverages. Data on the quantity and frequency of use of each beverage type were obtained for a 2-week period. Respondents were asked about the number of drinks of beer, sake, shochu, wine, and liquor they had consumed in the 2-week period preceding their most recent drink. The typical amount of each beverage consumed was multiplied by the reported frequency of drinking that beverage during the same 2-week period. The sum of absolute alcohol for all drinks consumed in the 2-week period was calculated for each respondent. For this study, current drinkers were defined as those who had a least one drink in the past year and whose average daily alcohol intake exceeded 0.0 mL. Other questions addressed the occurrence of some alcohol-related problems, allowing a comparison of problem rates for study groups. All interviewers were trained rigorously using standard training manuals and video tapes. Subjects were told to correlate the research on alcohol drink-
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ing behavior between Japan and the United States. The refusal rate was about
5 % in total. Ten alcohol-related problems that respondents reported during the
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preceding 12 months were grouped into two categories, as listed in Table 1. Answers to the questions were as follows: “never,” “yes, but not during the past year,” “less than once a month,” “one to three times a month,” “one to four times a week,” and “daily or almost daily”; for Questions 3, 4, and 5 to the socioproblematic group, the choices were “yes” or “no.”
Respondents
Japanese in Japan. Based on an area-stratified random rampling, 1,225 respondents (579 males and 646 females) were interviewed face-to-face in the Sapporo, Shizuoka, Osaka, and Kochi areas. Current drinkers comprised 518 males and 379 females. Japanese-Americans in Oahu, Hawaii. The majority of persons of Japanese ancestry in Hawaii live on the island of Oahu, making it possible to select areas in which 30% or more of the households are of Japanese ancestry. In such areas a list of telephone numbers was randomly generated. After screening for Americans of Japanese ancestry on the phone, trained bilingual interviewers conducted face-to-face interviews with 5 14 people of Japanese ancestry, of whom 271 were men and 243 were women. Current drinkers comprised 214 males and 161 females.
Table 1. Personal-Problematic and Socioproblematic Items of Alcohol-Related Problems Personal-Problematic Items 1. Have you wakened the next day not being able to remember some of the things you had done
while drinking? 2. Have you taken a drink first thing when you got up in the morning? 3. Have you had your hands shake a lot the morning after drinking? 4. Have you stayed intoxicated for several days at a time? 5 . Have you regularly had a drink instead of a meal? Socioproblematic Items 1. Have you been told to leave a place because of your drinking?
2. Have you gotten into a physical fight because of your drinking? 3. Thinking of your working life, has your drinking ever caused difficulties? 4. Did you ever lose your job as a result of your drinking? 5 . Have you ever had any difficulties with the police or other authorities where your drinking was involved?
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Japanese-Americans in Santa Clara County, California. In 1980, Japanese-Americans accounted for only 2 % of Santa Clara County’s population, and random-digit dialing would not have been cost-effective. Therefore, Japanese surnames were used as a sampling frame supplemented by membership directories, and telephone calls were made to screen Japanese-American households. Trained bilingual staff conducted a total of 5 16 face-to-face interviews with 302 males and 214 females. Current drinkers consisted of 245 males and 157 females. Caucasians in Santa Clara County, California. A comparison sample of Caucasians in Santa Clara was taken of individuals who were not Asian, African-American, Hispanic, or Native American. Computer-generated 7-digit phone numbers with the Santa Clara county area code were used to select respondents. Due to budget constraints, telephone interviews were conducted with an eligible person using a shorter version of the questionnaire. Although the number of questions had to be reduced to shorten the telephone interview, questions concerning alcohol-related problems were identical to those asked of the other population samples. The Caucasian sample contained 526 respondents, of whom 199 were male and 327 were female. Current drinkers comprised 172 males and 270 females. Statistical analysis was done using the SAS software package (1985) at the Parklawn Computer Center.
RESULTS Figure 1 shows the age distribution by sex in the four areas. Differences in age distribution were not significant. As shown in Table 2, Japanese males had 100
80
~-
0260 50 - 59
60
40 - 49
Percentage
W30-39 40
E 20 - 29 E c2O
20
0 Japan (males)
Japan (females)
Hawaii (males)
Hawaii California California (females) (males) (females)
Fig. 1. Age distribution at three areas.
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the highest percentage of personal-problematic items, such as “forgetful next day,” “drink in the morning,” and “drink instead of meal.” These percentages were about two times higher than those of Caucasians. Other items were represented by relatively low percentages for all four populations. Concerning socioproblematic items, in four items Caucasians had the highest percentage. Caucasians reported “troubles with police” four times more frequently than did Japanese. Table 3 presents alcohol-related problems among women. Female respondents reported much lower rates of alcohol-related problems than did their male counterparts. Nevertheless, Caucasian females reported more alcohol-related problems than Japanese and Japanese-American females. Table 4 shows the rate of male problem drinkers for the two categorized items by ethnic group and amount of ethanol intake. Table 5 shows the statistical testing on the frequency of male problem drinkers. Overall, Japanese males reported the highest rate of excess drinking problems, followed by Caucasian and Japanese-Americans in “light,” “heavy,” and “total” drinking categories. The percentage of Japanese in the “total” category was significantly higher than those of Japanese in Hawaii, Japanese in California, and Caucasians. The percentage of Caucasians in the “total” category was significantly higher than those of Japanese-Americans in Hawaii and California. There were no statistical differences between Japanese-Americans in Hawaii and those in California in any drinking category. The percentages of socioproblematic drinkers among Caucasian males in three drinking categories were the highest of four male
Table 2. Rate of Male Problem Drinkers on Each Item by Ethnic Group ( o h )
Japanese (Japan) 518
N
1. 2. 3. 4. 5.
Forgetful next day Drink in the morning Hands shake in A.M. Drunk for days Drink instead of meal
1. Told to leave 2. Gotten into fight
3. Difficulties 4 . Unemployment 5. Troubles with police
JapaneseAmerican (Hawaii) 2 I4
JapaneseAmerican (California) 245
Caucasian (California) 172
Personal-Problematic Items 27.6 (1431518) 7.0 (151214) 6.5 (161245) 12.9 (671518) 1.9 (41214) 1.2 (31245) 0.0 (01214) 0.8 (2/245) 2.1 (111518) 0.5 (11214) 0.8 (21245) 0.4 (21518) 1.2 (3/245) 5.8 (301518) 2.3 (5/214)
14.0 (241172) 5.8 (101172) 3.5 (61172) 4.1 (71172) 1.8 (31172)
Socioproblematic Items 0.4 (21518) 0.0 (01214) 0.0 (01245) 1.0 (51518) 0.9 (21214) 0.0 (01245) 3.7 (81214) 2.0 (51245) 3.1 (161518) 0.8 (41518) 0.0 (01214) 0.4 (11245) 4.2 (221518) 8.4 (181214) 9.8 (241245)
1.2 (21172) 4.1 (71172) 4.7 (81172) 0.0 (01172) 18.6 (321172)
Total 1149
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Table 3. Rate of Female Problem Drinkers on Each Item by Ethnic Group (YO) JapaneseAmerican (California) 157
Caucasian (California) 270
Personal-Problematic Items 4.7 (181379) 1.9 (31161) 3.2 (51157) 1.3 (5/379) 0.0 (01161) 0.6 (1/157) 0.5 (2/379) 0.6 (11161) 1.3 (2/157) 0.0 (0/379) 0.0 (0/161) 0.0 (0/157) 2.4 (9/379) 2.5 (4/161) 0.6 (1/157)
7.4 (20/270) 1.5 (4/270) 1.1 (3/270) 0.4 (11270) 1.5 (4/270)
Socioproblematic Items 0.0 (01379) 0.0 (01161) 0.0 (01157) 0.0 (0/379) 0.0 (01161) 0.0 (01157) 0.0 (01379) 0.6 (21161) 1.3 (2/157) 0.0 (0/379) 0.0 (0/161) 0.0 (01157) 1.1 (4/379) 1.2 (2/161) 0.6 (1/157)
0.0 (0/270) 1.9 (5/270) 3.7 (10/270) 0.0 (0/270) 1.9 (5/270)
Japanese (Japan) 379
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N
1. Forgetful next day
2. 3. 4. 5.
Drink in the morning Hands shake in A.M. Drunk for days Drink instead of meal
1. Told to leave
2. 3. 4. 5.
Gotten into fight Difficulties Unemployment Troubles with police
JapaneseAmerican (Hawaii) 161
Total 967
Table 4. Rate of Male Problem Drinkers on the Two Categorized Items by Ethnic Group and Volume of Ethanol Intake (YO)
N
Japanese (Japan) 379
JapaneseAmerican (Hawaii) 161
JapdneseAmerican (California) 157
Caucasian (California) 270
Lighta Moderateb Heavy' Total
10.1 (181178) 37.5 (63/168) 64.0 (1 10/172) 36.9 (191/518)
Personal-Problematic Items 2.7 (5/183) 4.1 (61147) 24.5 (12/49) 17.0 (8/47) 38.5 (5113) 40.0 (8/20) 10.3 (221214) 9.0 (22/245)
6.7 (7/105) 38.0 (19/50) 47.1 (8/17) 19.8 (34/172)
Lighta Moderateb Heavy' Total
2.8 (5/178) 6.0 (10/168) 17.0 (25/172) 7.7 (40/518)
8.2 (121147) 23.4 (11/47) 5.0 (1/20) 11.2 (24/214)
Socioproblematic Items 7.1 (13/183) 26.5 (13/49) 15.4 (2/13)
16.2 (17/105) 32.0 (16/50) 41.2 (7/17)
11.4 (28/245)
23.3 (40/172)
Total 967
'Light drinkers reported drinking less than 7 ounces (207 mL) in 2 weeks. bModerate drinkers reported drinking 7 ounces or more but less than 21 ounces (622 mL) in 2 weeks. Heavy drinkers reported drinking 21 ounces or more in 2 weeks.
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Table 5.
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Statistical Testing on the Frequency of Male Problem Drinkers on the Two Categorized Items by Ethnic Group and Volume of Ethanol Intakea JPN
JPN
JPN
HAW
HAW
vs
vs
vs
vs
vs
CAL vs
HAW
CAL
CAU
CAL
CAU
CAU
Personal-Problematic Items Lightb Moderate‘ Heavyd Total
Lightb Moderate‘ Heavyd Total
* * * ** * ** N.S. N.S.
** N.S.
N.S. N.S.
N.S. N.S.
N.S. N.S.
N.S. N.S.
N.S.
N.S.
N.S.
**
N.S. N.S.
N.S.
**
Socioproblematic Items ** N.S.
** N.S. N.S.
** * **
N.S. N.S. N.S. N.S.
**
**
*
*
N.S.
N.S. N.S.
** **
**
“JPN: Japanese in Japan ( N = 518). HAW: Japanese-Americans in Hawaii ( N = 214). CAL: Japanese-Americans in California ( N = 245). CAU: Caucasians in California ( N = 172). Light drinkers reported drinking less than 7 ounces (207 mL) in 2 weeks. cModerate drinkers reported drinking 7 ounces or more but less than 21 ounces (622 mL) in 2 weeks. Heavy drinkers reported drinking 21 ounces or more in 2 weeks. *Significant at p < .05 in x2 ratio. **Significant at p < .OI in x2 ratio.
groups, followed by Japanese and Japanese-Americans, except for the “heavy” drinking category. The percentages of Caucasians in all drinking categories were significantly higher than that of the Japanese. For females, the number of problem drinkers was so small that any result should be interpreted with caution. In the “total” class, Caucasian females had the highest percentage of personal-problematic drinkers, significantly higher than those of JapaneseAmericans in Hawaii and in California (Tables 6 and 7). Although the number of female drinkers in the “moderate” and “heavy” category was small, the percentage of Caucasian females was significantly higher than that of Japanese in all drinking classes. No significant differences were found between JapaneseAmerican females in Hawaii and those in California.
DISCUSSION Per capita alcohol consumption in Japan increased dramatically (about three times) in the post-World War I1 period and started to level off in the
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IZUNO ET AL.
Table 6. Rate of Female Problem Drinkers on the Two Categorized Items by Ethnic Group and Volume of Ethanol Intake (YO)
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N
Japanese (Japan) 379
JapaneseAmerican (Hawaii) 161
JapaneseAmerican (California) 157
Caucasian (California) 270
Total 967
Personal-Problematic Items Lighta Moderateb Heavy' Total
4.3 (141328) 16.2 (6137) 57.1 (8114) 7.4 (28/379)
0.7 (11141) 12.5 (2/16) 75.0 (3/4) 3.7 (6/161)
2.7 (4/148) 12.5 (1/8) 100.0 (1/1) 3.8 (6/157)
5.0 (11/222) 23.3 (10/43) 60.0 (3/5) 8.9 (241270)
Lighta Moderateb Heavy' Total
0.6 (21328) 0.0 (0/37) 14.3 (2114) 1 . 1 (4/379)
Socioproblematic Items 0.7 (11141) 0.7 (11148) 12.5 (2116) 0.0 ( O M ) 25.0 (114) 100.0 (1/1) 2.5 (4/161) 1.3 (2/157)
2.7 (61222) 14.0 (6/43) 80.0 (4/5) 5.9 (16/270)
"Light drinkers reported drinking less than 7 ounces (207 mL) in 2 weeks. bModerate drinkers reported drinking 7 ounces or more but less than 21 ounces (622 mL) in 2 weeks. ' Heavy drinkers reported drinking 2 1 ounces or more in 2 weeks.
1980s (Kono and Saito, 1977). The percentage of female current drinkers has risen sharply in recent years, suggesting that a change in drinking norms is taking place. An increase in the incidence of alcoholic liver disease is reported (Kono and Ikegami, 1980; Takeuchi et al., 1987). Nevertheless, few epidemiologic surveys on alcohol-related problems have been conducted. The authors found two factor patterns in alcohol-related problems from populationbased survey data (Izuno et al., submitted for publication). Heavy drinking is not only associated with a physical dependence syndrome but also with social problems, such as troubles with the police. Thus, the social impact of drinking needs to be considered. The reliability and validity of self-reported alcohol consumption have not been tested with cross-national surveys. However, current survey results are comparable to previous surveys. Both the percentages of drinkers and the amount of alcohol consumed by these samples were comparable to previous studies (Nukada, 1973; Pernanen, 1974; Malin et al., 1985/86).
Although the mode of interview for the Caucasian sample is different from that used for the other samples, the drinking patterns of Caucasians in this study are similar to those in a national drinking survey (Towle, 1988). This
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Table 7. Statistical Testing on the Frequency of Female Problem Drinkers on the Two Categorized ltems by Ethnic Group and Volume of Ethanol Intakea
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JPN vs HAW
Lightb
*
JPN
HAW vs CAL
HAW vs CAU
CAL vs CAU
Personal-Problematic Items N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S.
* N.S. N.S.
N.S. N.S. N.S.
N.S.
*
*
N.S. N.S. N.S.
N.S. N.S. N.S. N.S.
N.S. N.S. N.S
vs
CAL
Moderate' Heavyd Total
N.S. N.S. N.S.
Lightb Moderate'
N.S.
Heavyd Total
N.S.
*
N.S.
N.S.
N.S.
JPN vs CAU
N.S.
Socioproblematic ltems
*
N.S. N.S.
* * ** **
N.S.
*
*JPN: Japanese in Japan ( N = 379). HAW: Japanese-Americans in Hawaii ( N = 161). CAL: Japanese-Americans in California (N = 157). CAU: Caucasians in California ( N = 270). Light drinkers reported drinking less than 7 ounces (207 mL) in 2 weeks. Moderate drinkers reported drinking less than 7 ounces or more but less than 21 ounces (622 mL) in 2 weeks. Heavy drinkers reported drinking 2 I ounces or more in 2 weeks. *Significant at p < .05 in x2 ratio. **Significant at p < .01 in x2 ratio.
study shows that Japanese males appear to have more excess drinking problems than drinking-related social problems, whereas Caucasian males reported more social problems than excess drinking problems. There is an interesting relationship between the two types of alcohol-related problems and alcohol consumption. While personal-problematic symptoms appear to increase with greater alcohol consumption, this is not clearly the case for socioproblematic symptoms. Drinking norms among Japanese men are considered to be permissive, and drinking plays a more important role in doing business and socializing with friends and colleagues in Japan than it does in the United States (Kono and Ikegami, 1980). It is often said, but not documented, that Japanese society is tolerant of public inebriety. Thus, police in Japan may be less willing to arrest drunkards than would police in the United States. Similarly, Japanese employers may be more tolerant of drinking-related problems, whereas in the United States hang-
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overs or alcohol-related absenteeism is recognized as a sign of alcoholism and the individual may be referred to counseling. Observed differences in alcoholrelated social problems may stem from differences in perceptions of what constitutes a social problem. For cross-cultural studies, alcohol-related questions need further refinement. Ethnographic studies also need to be supplemented. JapaneseAmericans, regardless of the degree of assimilation, are judged by the societal norms of where they live. The threshold for drinking-related social problem is probably similar to that for United States Caucasians. The lengths of stay or use of the Japanese language at home among Issei (Japanese born in Japan who migrated to the United States) may serve as an indicator of assimilation. However, the number of Issei or Japanese-Americans who preferred Japanese for this interview was too small for further stratifications. No substantial differences were found among the four female groups concerning personal-problematic symptoms. This may be a reflection of low ethanol consumption among females and a small number of problem drinkers. However, the number of female drinkers is increasing not only in Japan but also in the United States and other industrialized societies (Higa et al., 1981). In the near future the number of alcohol-related problems among female drinkers may increase. Alcohol-related problems are a major public health concern in the United States and Japan. But as this study shows, there are considerable differences between Japan and the United States in the patterns of alcohol-related problems. Socioproblematic symptoms are much more noticeable to society than are personal-problematic symptoms (Voas and Williams, 1986). To summarize, alcohol-related personal problems are associated with the level of alcohol consumption, and alcohol-related social problems may be culture bound. Further research to grasp the consciousness of drinking is necessary to refine these issues.
ACKNOWLEDGMENTS The authors appreciate the assistance of Dr. Katsumasa Miyasato (Shizuoka), Dr. Yoshihiro Kosugi (Osaka), Dr. Hiroshi Suwaki (Kochi), and Mr. Walter Clark (United States) who conducted the surveys in each population sample.
REFERENCES HIGA, C., KUBOTA, A., and HADA, A. (1981). Sex differences in etiology and treatment of alcohol dependence. Arukom Kenkyu-to Yakubutsu lson (Jpn. J . Alcohol Drug Depend.) 16(1): S170-171.
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HONG, 0. T., and ISRALOWITZ, R. E. (1989). Cross-cultural study of alcohol behavior among Singapore college students. Br. J. Addict. 84(3): 3 19-32 1. IZUNO, T., TSUNODA, T., PARRISH, K. M., KONO, H., OGATA, M., HARFORD, T. C., and TOWLE, L. H. (submitted for publication). Factor analysis of alcohol-related problems among Japanese and Japanese Americans. J . Substance Abuse. KITANO, H., and CHI, I. (1989). Asian Americans and alcohol: The Chinese, Japanese, Koreans and Philippinos in Los Angeles. In D. L. Spiegler et al. (eds.), Alcohol Use among U.S. Erhnic Minorities [NIAAA Research Monograph 18, DHHS Publication (ADM) 89-14351, Washington, D.C.: U.S. Government Printing Office, pp. 373-382. KONO, H., and IKEGAMI, N. (1980). Profile of Policies and Programs for the Prevention of Alcohol Related Problems in Japan. Mimeographed report. KONO, H., SAITO, S., SHIMADA, K., and NAKAGAWA, J. (1977). Drinking Habits of the Japanese. Tokyo: Leisure Develop Center. MALIN, H., WILSON, R.,WILLIAMS, G . , and AITKEN, S. (1985/86). 1983 Alcohol/health practice supplement. Alcohol Health Res. World 10: 48-50. NUKADA, A. (1973). Epidemiology of alcoholism. In N. Kato, K. Ohara, and H. Kono (eds.), Alcoholism. Tokyo: Igaku Shoin, pp. 18-44 (in Japanese). PERNANEN, K. (1974). Validity of survey data on alcohol use. In R. J. Gibbins, Y. Israel, H. Kalant, R. E. Popham, W. Schmidt, and R. G. Smart, Research Advances in Alcohol and Drug Problems, Vol. 1. New York: Wiley, pp. 355-374. RITSON, E. B. (1985). Community Response to Alcohol-Related Problems (Public Health Paper 81). Geneva: World Health Organization. ROOTMAN, I . , and MOSER, J. (1985). Community Response to Alcohol-Related Problems: A World Health Organization Project Monograph [Alcohol, Drug Abuse, and Mental Health Administration. Publication (ADM) 85-13711. Washington, D.C.: U.S. Government Printing Office. SAS INSTITUTE, INC. (1985). SAS User’s Guide: Sraristics, 5th ed. Cary, North Carolina: SAS Institute. TAKEUCHI, J., OKUDAIRA, M., TAKADA, A , , OTA, Y., TSUJII, T., ITO, S., FUJISAWA, K., TANIGAWARA, K., and HASUMURA, Y. (1987). The incidence of alcoholic liver disease in Japan (1976- 1985). Nippon Shokakibyo Gakkai Zasshi (Jpn. J. Gastroenterology) 84(8): 1623- 1630. TOWLE, L. H. (1988). Japanese American drinking. Some results from the joint Japanese-U.S. alcohol epidemiology project. Alcohol Heaith Res. World 12(3): 216-223. VOAS, R. B., and WILLIAMS, A. F. (1986). Age differences of arrested and crash-involved drinking drivers. J. Stud. Alcohol 47(3): 244-248.
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THE AUTHOR Takashi Izuno, M.D., Department of Preventive Medicine and Public Health School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160, Japan, did his postgraduate work at the School of Medicine of Keio University. He has been a doctor of medical science since March 1989. His major experience and specialization is in occupational health and occupational epidemiology.
The International Journal of the Addictions, 27( 12). 1389-1400, 1992
Alcohol-Related Problems Encountered by Japanese, Caucasians, and Japanese-Americans Takashi Izuno, M.D., 19' Michiko Miyakawa, M.D., 1 Tooru Tsunoda, M.D., Kiyoko M. Parrish, Ph.D., Hiroaki Kono, M.D., Motoi Ogata, M.D., 5 Thomas C. Harford, Ph.D., and Leland H. Towle, M.S. 'Department of Preventive Medicine and Public Health, School of Medicine, Keio University, Tokyo, Japan Department of Hygiene, School of Medicine, Kyorin University, Tokyo, Japan Department of Health Services, University of Washington,Seattle, Washington, USA The National Institute of Alcoholism, Kurihama National Hospital, Kanagawa, Japan School of Allied Health Profession, Sapporo Medical College, Hokkaido, Japan The National Institute on Alcohol Abuse and Alcoholism, Rockville, Maryland, USA
ABSTRACT Using population-based survey data, personal-problematic and socioproblematic factors were examined among Japanese in Japan, Japanese-Americans in Hawaii, and Japanese-Americans; Caucasians in California were analyzed as a control group. Caucasian males were more likely to exhibit drinking-related social problems, whereas Japanese males showed more personal-problematic symptoms. Japanese-American men, both in Hawaii and California, were least likely among the three ethnic groups to have personal-problematic symptoms and were more likely to have socioproblematic symptoms *To whom correspondence should be addressed at Department of Preventive Medicine and Public Health, School of Medicine, Keio University, 35 Shinanomachi Shinjuku, Tokyo 160, Japan. 1389
Copyright 01992 by Marcel Dekker, Inc
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than Japanese men. These differences might be explained by differences in the perception of social problems. Key words. Alcohol-related problems; Japanese; Japanese-American; Caucasian; Ethnicity
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INTRODUCTION Although the number of publications on alcohol-related problems have been increasing in recent years, few studies have dealt with cross-national and interethnic group comparisons (Kitano and Chi, 1989; Hong and Isralowitz, 1989). Because drinking is culture bound, cross-cultural surveys would contribute to a better understanding of drinking problems. In a previous study, factor analysis produced two factor patterns of alcohol-related problems among Japanese and Japanese-American men: personal-problematic factors and socioproblematic factors (Izuno et al., submitted for publication). In this study we focused on the differences in two types of alcohol-related problems in the populations of the United States and Japan stratified by drinking levels, ethnicity , and gender.
METHOD Questionnaires The survey questionnaire used in this study was based on a general population survey questionnaire developed by the World Health Organization (WHO) for a project concerned with community responses to alcohol-related problems (Ritson, 1985; Rootman and Moser, 1985) in such diverse countries as Zambia, Mexico, Scotland, and the United States. In 1986 the surveys asked respondents about their use of various kinds of alcoholic beverages. Data on the quantity and frequency of use of each beverage type were obtained for a 2-week period. Respondents were asked about the number of drinks of beer, sake, shochu, wine, and liquor they had consumed in the 2-week period preceding their most recent drink. The typical amount of each beverage consumed was multiplied by the reported frequency of drinking that beverage during the same 2-week period. The sum of absolute alcohol for all drinks consumed in the 2-week period was calculated for each respondent. For this study, current drinkers were defined as those who had a least one drink in the past year and whose average daily alcohol intake exceeded 0.0 mL. Other questions addressed the occurrence of some alcohol-related problems, allowing a comparison of problem rates for study groups. All interviewers were trained rigorously using standard training manuals and video tapes. Subjects were told to correlate the research on alcohol drink-
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ing behavior between Japan and the United States. The refusal rate was about
5 % in total. Ten alcohol-related problems that respondents reported during the
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preceding 12 months were grouped into two categories, as listed in Table 1. Answers to the questions were as follows: “never,” “yes, but not during the past year,” “less than once a month,” “one to three times a month,” “one to four times a week,” and “daily or almost daily”; for Questions 3, 4, and 5 to the socioproblematic group, the choices were “yes” or “no.”
Respondents
Japanese in Japan. Based on an area-stratified random rampling, 1,225 respondents (579 males and 646 females) were interviewed face-to-face in the Sapporo, Shizuoka, Osaka, and Kochi areas. Current drinkers comprised 518 males and 379 females. Japanese-Americans in Oahu, Hawaii. The majority of persons of Japanese ancestry in Hawaii live on the island of Oahu, making it possible to select areas in which 30% or more of the households are of Japanese ancestry. In such areas a list of telephone numbers was randomly generated. After screening for Americans of Japanese ancestry on the phone, trained bilingual interviewers conducted face-to-face interviews with 5 14 people of Japanese ancestry, of whom 271 were men and 243 were women. Current drinkers comprised 214 males and 161 females.
Table 1. Personal-Problematic and Socioproblematic Items of Alcohol-Related Problems Personal-Problematic Items 1. Have you wakened the next day not being able to remember some of the things you had done
while drinking? 2. Have you taken a drink first thing when you got up in the morning? 3. Have you had your hands shake a lot the morning after drinking? 4. Have you stayed intoxicated for several days at a time? 5 . Have you regularly had a drink instead of a meal? Socioproblematic Items 1. Have you been told to leave a place because of your drinking?
2. Have you gotten into a physical fight because of your drinking? 3. Thinking of your working life, has your drinking ever caused difficulties? 4. Did you ever lose your job as a result of your drinking? 5 . Have you ever had any difficulties with the police or other authorities where your drinking was involved?
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Japanese-Americans in Santa Clara County, California. In 1980, Japanese-Americans accounted for only 2 % of Santa Clara County’s population, and random-digit dialing would not have been cost-effective. Therefore, Japanese surnames were used as a sampling frame supplemented by membership directories, and telephone calls were made to screen Japanese-American households. Trained bilingual staff conducted a total of 5 16 face-to-face interviews with 302 males and 214 females. Current drinkers consisted of 245 males and 157 females. Caucasians in Santa Clara County, California. A comparison sample of Caucasians in Santa Clara was taken of individuals who were not Asian, African-American, Hispanic, or Native American. Computer-generated 7-digit phone numbers with the Santa Clara county area code were used to select respondents. Due to budget constraints, telephone interviews were conducted with an eligible person using a shorter version of the questionnaire. Although the number of questions had to be reduced to shorten the telephone interview, questions concerning alcohol-related problems were identical to those asked of the other population samples. The Caucasian sample contained 526 respondents, of whom 199 were male and 327 were female. Current drinkers comprised 172 males and 270 females. Statistical analysis was done using the SAS software package (1985) at the Parklawn Computer Center.
RESULTS Figure 1 shows the age distribution by sex in the four areas. Differences in age distribution were not significant. As shown in Table 2, Japanese males had 100
80
~-
0260 50 - 59
60
40 - 49
Percentage
W30-39 40
E 20 - 29 E c2O
20
0 Japan (males)
Japan (females)
Hawaii (males)
Hawaii California California (females) (males) (females)
Fig. 1. Age distribution at three areas.
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the highest percentage of personal-problematic items, such as “forgetful next day,” “drink in the morning,” and “drink instead of meal.” These percentages were about two times higher than those of Caucasians. Other items were represented by relatively low percentages for all four populations. Concerning socioproblematic items, in four items Caucasians had the highest percentage. Caucasians reported “troubles with police” four times more frequently than did Japanese. Table 3 presents alcohol-related problems among women. Female respondents reported much lower rates of alcohol-related problems than did their male counterparts. Nevertheless, Caucasian females reported more alcohol-related problems than Japanese and Japanese-American females. Table 4 shows the rate of male problem drinkers for the two categorized items by ethnic group and amount of ethanol intake. Table 5 shows the statistical testing on the frequency of male problem drinkers. Overall, Japanese males reported the highest rate of excess drinking problems, followed by Caucasian and Japanese-Americans in “light,” “heavy,” and “total” drinking categories. The percentage of Japanese in the “total” category was significantly higher than those of Japanese in Hawaii, Japanese in California, and Caucasians. The percentage of Caucasians in the “total” category was significantly higher than those of Japanese-Americans in Hawaii and California. There were no statistical differences between Japanese-Americans in Hawaii and those in California in any drinking category. The percentages of socioproblematic drinkers among Caucasian males in three drinking categories were the highest of four male
Table 2. Rate of Male Problem Drinkers on Each Item by Ethnic Group ( o h )
Japanese (Japan) 518
N
1. 2. 3. 4. 5.
Forgetful next day Drink in the morning Hands shake in A.M. Drunk for days Drink instead of meal
1. Told to leave 2. Gotten into fight
3. Difficulties 4 . Unemployment 5. Troubles with police
JapaneseAmerican (Hawaii) 2 I4
JapaneseAmerican (California) 245
Caucasian (California) 172
Personal-Problematic Items 27.6 (1431518) 7.0 (151214) 6.5 (161245) 12.9 (671518) 1.9 (41214) 1.2 (31245) 0.0 (01214) 0.8 (2/245) 2.1 (111518) 0.5 (11214) 0.8 (21245) 0.4 (21518) 1.2 (3/245) 5.8 (301518) 2.3 (5/214)
14.0 (241172) 5.8 (101172) 3.5 (61172) 4.1 (71172) 1.8 (31172)
Socioproblematic Items 0.4 (21518) 0.0 (01214) 0.0 (01245) 1.0 (51518) 0.9 (21214) 0.0 (01245) 3.7 (81214) 2.0 (51245) 3.1 (161518) 0.8 (41518) 0.0 (01214) 0.4 (11245) 4.2 (221518) 8.4 (181214) 9.8 (241245)
1.2 (21172) 4.1 (71172) 4.7 (81172) 0.0 (01172) 18.6 (321172)
Total 1149
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Table 3. Rate of Female Problem Drinkers on Each Item by Ethnic Group (YO) JapaneseAmerican (California) 157
Caucasian (California) 270
Personal-Problematic Items 4.7 (181379) 1.9 (31161) 3.2 (51157) 1.3 (5/379) 0.0 (01161) 0.6 (1/157) 0.5 (2/379) 0.6 (11161) 1.3 (2/157) 0.0 (0/379) 0.0 (0/161) 0.0 (0/157) 2.4 (9/379) 2.5 (4/161) 0.6 (1/157)
7.4 (20/270) 1.5 (4/270) 1.1 (3/270) 0.4 (11270) 1.5 (4/270)
Socioproblematic Items 0.0 (01379) 0.0 (01161) 0.0 (01157) 0.0 (0/379) 0.0 (01161) 0.0 (01157) 0.0 (01379) 0.6 (21161) 1.3 (2/157) 0.0 (0/379) 0.0 (0/161) 0.0 (01157) 1.1 (4/379) 1.2 (2/161) 0.6 (1/157)
0.0 (0/270) 1.9 (5/270) 3.7 (10/270) 0.0 (0/270) 1.9 (5/270)
Japanese (Japan) 379
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N
1. Forgetful next day
2. 3. 4. 5.
Drink in the morning Hands shake in A.M. Drunk for days Drink instead of meal
1. Told to leave
2. 3. 4. 5.
Gotten into fight Difficulties Unemployment Troubles with police
JapaneseAmerican (Hawaii) 161
Total 967
Table 4. Rate of Male Problem Drinkers on the Two Categorized Items by Ethnic Group and Volume of Ethanol Intake (YO)
N
Japanese (Japan) 379
JapaneseAmerican (Hawaii) 161
JapdneseAmerican (California) 157
Caucasian (California) 270
Lighta Moderateb Heavy' Total
10.1 (181178) 37.5 (63/168) 64.0 (1 10/172) 36.9 (191/518)
Personal-Problematic Items 2.7 (5/183) 4.1 (61147) 24.5 (12/49) 17.0 (8/47) 38.5 (5113) 40.0 (8/20) 10.3 (221214) 9.0 (22/245)
6.7 (7/105) 38.0 (19/50) 47.1 (8/17) 19.8 (34/172)
Lighta Moderateb Heavy' Total
2.8 (5/178) 6.0 (10/168) 17.0 (25/172) 7.7 (40/518)
8.2 (121147) 23.4 (11/47) 5.0 (1/20) 11.2 (24/214)
Socioproblematic Items 7.1 (13/183) 26.5 (13/49) 15.4 (2/13)
16.2 (17/105) 32.0 (16/50) 41.2 (7/17)
11.4 (28/245)
23.3 (40/172)
Total 967
'Light drinkers reported drinking less than 7 ounces (207 mL) in 2 weeks. bModerate drinkers reported drinking 7 ounces or more but less than 21 ounces (622 mL) in 2 weeks. Heavy drinkers reported drinking 21 ounces or more in 2 weeks.
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Table 5.
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Statistical Testing on the Frequency of Male Problem Drinkers on the Two Categorized Items by Ethnic Group and Volume of Ethanol Intakea JPN
JPN
JPN
HAW
HAW
vs
vs
vs
vs
vs
CAL vs
HAW
CAL
CAU
CAL
CAU
CAU
Personal-Problematic Items Lightb Moderate‘ Heavyd Total
Lightb Moderate‘ Heavyd Total
* * * ** * ** N.S. N.S.
** N.S.
N.S. N.S.
N.S. N.S.
N.S. N.S.
N.S. N.S.
N.S.
N.S.
N.S.
**
N.S. N.S.
N.S.
**
Socioproblematic Items ** N.S.
** N.S. N.S.
** * **
N.S. N.S. N.S. N.S.
**
**
*
*
N.S.
N.S. N.S.
** **
**
“JPN: Japanese in Japan ( N = 518). HAW: Japanese-Americans in Hawaii ( N = 214). CAL: Japanese-Americans in California ( N = 245). CAU: Caucasians in California ( N = 172). Light drinkers reported drinking less than 7 ounces (207 mL) in 2 weeks. cModerate drinkers reported drinking 7 ounces or more but less than 21 ounces (622 mL) in 2 weeks. Heavy drinkers reported drinking 21 ounces or more in 2 weeks. *Significant at p < .05 in x2 ratio. **Significant at p < .OI in x2 ratio.
groups, followed by Japanese and Japanese-Americans, except for the “heavy” drinking category. The percentages of Caucasians in all drinking categories were significantly higher than that of the Japanese. For females, the number of problem drinkers was so small that any result should be interpreted with caution. In the “total” class, Caucasian females had the highest percentage of personal-problematic drinkers, significantly higher than those of JapaneseAmericans in Hawaii and in California (Tables 6 and 7). Although the number of female drinkers in the “moderate” and “heavy” category was small, the percentage of Caucasian females was significantly higher than that of Japanese in all drinking classes. No significant differences were found between JapaneseAmerican females in Hawaii and those in California.
DISCUSSION Per capita alcohol consumption in Japan increased dramatically (about three times) in the post-World War I1 period and started to level off in the
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Table 6. Rate of Female Problem Drinkers on the Two Categorized Items by Ethnic Group and Volume of Ethanol Intake (YO)
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N
Japanese (Japan) 379
JapaneseAmerican (Hawaii) 161
JapaneseAmerican (California) 157
Caucasian (California) 270
Total 967
Personal-Problematic Items Lighta Moderateb Heavy' Total
4.3 (141328) 16.2 (6137) 57.1 (8114) 7.4 (28/379)
0.7 (11141) 12.5 (2/16) 75.0 (3/4) 3.7 (6/161)
2.7 (4/148) 12.5 (1/8) 100.0 (1/1) 3.8 (6/157)
5.0 (11/222) 23.3 (10/43) 60.0 (3/5) 8.9 (241270)
Lighta Moderateb Heavy' Total
0.6 (21328) 0.0 (0/37) 14.3 (2114) 1 . 1 (4/379)
Socioproblematic Items 0.7 (11141) 0.7 (11148) 12.5 (2116) 0.0 ( O M ) 25.0 (114) 100.0 (1/1) 2.5 (4/161) 1.3 (2/157)
2.7 (61222) 14.0 (6/43) 80.0 (4/5) 5.9 (16/270)
"Light drinkers reported drinking less than 7 ounces (207 mL) in 2 weeks. bModerate drinkers reported drinking 7 ounces or more but less than 21 ounces (622 mL) in 2 weeks. ' Heavy drinkers reported drinking 2 1 ounces or more in 2 weeks.
1980s (Kono and Saito, 1977). The percentage of female current drinkers has risen sharply in recent years, suggesting that a change in drinking norms is taking place. An increase in the incidence of alcoholic liver disease is reported (Kono and Ikegami, 1980; Takeuchi et al., 1987). Nevertheless, few epidemiologic surveys on alcohol-related problems have been conducted. The authors found two factor patterns in alcohol-related problems from populationbased survey data (Izuno et al., submitted for publication). Heavy drinking is not only associated with a physical dependence syndrome but also with social problems, such as troubles with the police. Thus, the social impact of drinking needs to be considered. The reliability and validity of self-reported alcohol consumption have not been tested with cross-national surveys. However, current survey results are comparable to previous surveys. Both the percentages of drinkers and the amount of alcohol consumed by these samples were comparable to previous studies (Nukada, 1973; Pernanen, 1974; Malin et al., 1985/86).
Although the mode of interview for the Caucasian sample is different from that used for the other samples, the drinking patterns of Caucasians in this study are similar to those in a national drinking survey (Towle, 1988). This
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Table 7. Statistical Testing on the Frequency of Female Problem Drinkers on the Two Categorized ltems by Ethnic Group and Volume of Ethanol Intakea
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JPN vs HAW
Lightb
*
JPN
HAW vs CAL
HAW vs CAU
CAL vs CAU
Personal-Problematic Items N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S.
* N.S. N.S.
N.S. N.S. N.S.
N.S.
*
*
N.S. N.S. N.S.
N.S. N.S. N.S. N.S.
N.S. N.S. N.S
vs
CAL
Moderate' Heavyd Total
N.S. N.S. N.S.
Lightb Moderate'
N.S.
Heavyd Total
N.S.
*
N.S.
N.S.
N.S.
JPN vs CAU
N.S.
Socioproblematic ltems
*
N.S. N.S.
* * ** **
N.S.
*
*JPN: Japanese in Japan ( N = 379). HAW: Japanese-Americans in Hawaii ( N = 161). CAL: Japanese-Americans in California (N = 157). CAU: Caucasians in California ( N = 270). Light drinkers reported drinking less than 7 ounces (207 mL) in 2 weeks. Moderate drinkers reported drinking less than 7 ounces or more but less than 21 ounces (622 mL) in 2 weeks. Heavy drinkers reported drinking 2 I ounces or more in 2 weeks. *Significant at p < .05 in x2 ratio. **Significant at p < .01 in x2 ratio.
study shows that Japanese males appear to have more excess drinking problems than drinking-related social problems, whereas Caucasian males reported more social problems than excess drinking problems. There is an interesting relationship between the two types of alcohol-related problems and alcohol consumption. While personal-problematic symptoms appear to increase with greater alcohol consumption, this is not clearly the case for socioproblematic symptoms. Drinking norms among Japanese men are considered to be permissive, and drinking plays a more important role in doing business and socializing with friends and colleagues in Japan than it does in the United States (Kono and Ikegami, 1980). It is often said, but not documented, that Japanese society is tolerant of public inebriety. Thus, police in Japan may be less willing to arrest drunkards than would police in the United States. Similarly, Japanese employers may be more tolerant of drinking-related problems, whereas in the United States hang-
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overs or alcohol-related absenteeism is recognized as a sign of alcoholism and the individual may be referred to counseling. Observed differences in alcoholrelated social problems may stem from differences in perceptions of what constitutes a social problem. For cross-cultural studies, alcohol-related questions need further refinement. Ethnographic studies also need to be supplemented. JapaneseAmericans, regardless of the degree of assimilation, are judged by the societal norms of where they live. The threshold for drinking-related social problem is probably similar to that for United States Caucasians. The lengths of stay or use of the Japanese language at home among Issei (Japanese born in Japan who migrated to the United States) may serve as an indicator of assimilation. However, the number of Issei or Japanese-Americans who preferred Japanese for this interview was too small for further stratifications. No substantial differences were found among the four female groups concerning personal-problematic symptoms. This may be a reflection of low ethanol consumption among females and a small number of problem drinkers. However, the number of female drinkers is increasing not only in Japan but also in the United States and other industrialized societies (Higa et al., 1981). In the near future the number of alcohol-related problems among female drinkers may increase. Alcohol-related problems are a major public health concern in the United States and Japan. But as this study shows, there are considerable differences between Japan and the United States in the patterns of alcohol-related problems. Socioproblematic symptoms are much more noticeable to society than are personal-problematic symptoms (Voas and Williams, 1986). To summarize, alcohol-related personal problems are associated with the level of alcohol consumption, and alcohol-related social problems may be culture bound. Further research to grasp the consciousness of drinking is necessary to refine these issues.
ACKNOWLEDGMENTS The authors appreciate the assistance of Dr. Katsumasa Miyasato (Shizuoka), Dr. Yoshihiro Kosugi (Osaka), Dr. Hiroshi Suwaki (Kochi), and Mr. Walter Clark (United States) who conducted the surveys in each population sample.
REFERENCES HIGA, C., KUBOTA, A., and HADA, A. (1981). Sex differences in etiology and treatment of alcohol dependence. Arukom Kenkyu-to Yakubutsu lson (Jpn. J . Alcohol Drug Depend.) 16(1): S170-171.
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HONG, 0. T., and ISRALOWITZ, R. E. (1989). Cross-cultural study of alcohol behavior among Singapore college students. Br. J. Addict. 84(3): 3 19-32 1. IZUNO, T., TSUNODA, T., PARRISH, K. M., KONO, H., OGATA, M., HARFORD, T. C., and TOWLE, L. H. (submitted for publication). Factor analysis of alcohol-related problems among Japanese and Japanese Americans. J . Substance Abuse. KITANO, H., and CHI, I. (1989). Asian Americans and alcohol: The Chinese, Japanese, Koreans and Philippinos in Los Angeles. In D. L. Spiegler et al. (eds.), Alcohol Use among U.S. Erhnic Minorities [NIAAA Research Monograph 18, DHHS Publication (ADM) 89-14351, Washington, D.C.: U.S. Government Printing Office, pp. 373-382. KONO, H., and IKEGAMI, N. (1980). Profile of Policies and Programs for the Prevention of Alcohol Related Problems in Japan. Mimeographed report. KONO, H., SAITO, S., SHIMADA, K., and NAKAGAWA, J. (1977). Drinking Habits of the Japanese. Tokyo: Leisure Develop Center. MALIN, H., WILSON, R.,WILLIAMS, G . , and AITKEN, S. (1985/86). 1983 Alcohol/health practice supplement. Alcohol Health Res. World 10: 48-50. NUKADA, A. (1973). Epidemiology of alcoholism. In N. Kato, K. Ohara, and H. Kono (eds.), Alcoholism. Tokyo: Igaku Shoin, pp. 18-44 (in Japanese). PERNANEN, K. (1974). Validity of survey data on alcohol use. In R. J. Gibbins, Y. Israel, H. Kalant, R. E. Popham, W. Schmidt, and R. G. Smart, Research Advances in Alcohol and Drug Problems, Vol. 1. New York: Wiley, pp. 355-374. RITSON, E. B. (1985). Community Response to Alcohol-Related Problems (Public Health Paper 81). Geneva: World Health Organization. ROOTMAN, I . , and MOSER, J. (1985). Community Response to Alcohol-Related Problems: A World Health Organization Project Monograph [Alcohol, Drug Abuse, and Mental Health Administration. Publication (ADM) 85-13711. Washington, D.C.: U.S. Government Printing Office. SAS INSTITUTE, INC. (1985). SAS User’s Guide: Sraristics, 5th ed. Cary, North Carolina: SAS Institute. TAKEUCHI, J., OKUDAIRA, M., TAKADA, A , , OTA, Y., TSUJII, T., ITO, S., FUJISAWA, K., TANIGAWARA, K., and HASUMURA, Y. (1987). The incidence of alcoholic liver disease in Japan (1976- 1985). Nippon Shokakibyo Gakkai Zasshi (Jpn. J. Gastroenterology) 84(8): 1623- 1630. TOWLE, L. H. (1988). Japanese American drinking. Some results from the joint Japanese-U.S. alcohol epidemiology project. Alcohol Heaith Res. World 12(3): 216-223. VOAS, R. B., and WILLIAMS, A. F. (1986). Age differences of arrested and crash-involved drinking drivers. J. Stud. Alcohol 47(3): 244-248.
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THE AUTHOR Takashi Izuno, M.D., Department of Preventive Medicine and Public Health School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160, Japan, did his postgraduate work at the School of Medicine of Keio University. He has been a doctor of medical science since March 1989. His major experience and specialization is in occupational health and occupational epidemiology.
