bs_bs_banner
R E V I E W
Drug and Alcohol Review (March 2016), 35, 196 – 205 DOI: 10.1111/dar.12250
Alcohol use among immigrants in Ontario, Canada BRANKA AGIC1, ROBERT E. MANN2, ANDREW TUCK3, ANCA IALOMITEANU3, SUSAN BONDY4, LAURA SIMICH5 & GABRIELA ILIE6 1
Centre for Addiction and Mental Health, Toronto, Canada, Centre for 2Addiction and Mental Health, Toronto, Canada, Centre for 3Addiction and Mental Health, Toronto, Canada, Dalla Lana School 4 of Public Health, University of Toronto, Toronto, Canada, 5Center on Immigration and Justice, Vera Institute of Justice, New York, USA, and 6Neurosurgery Department, St. Michael’s Hospital, Toronto, Canada
Abstract Introduction and Aims. This study examined prevalence of alcohol consumption among immigrants and the Canadianborn populations of Ontario by ethnic origin, and the association between ethnicity, country of birth, age at arrival, length of residence in Canada and drinking measures. Design and Methods. Data were derived from the Centre for Addiction and Mental Health (CAMH) Monitor, a cross-sectional survey of Ontario adults, conducted between January 2005 and December 2010 (n = 13 557). Results. The prevalence of alcohol consumption and risk drinking was generally lower among foreignborn than Canadian-born respondents, but significant variations across ethnic groups were found. In general, foreign-born respondents of European descent reported higher rates of alcohol use and risk drinking than foreign-born respondents from other ethnic groups.We also observed that ethnicity effects varied by whether or not respondents were born in Canada, and by the age at which they arrived in Canada. Discussion and Conclusions. While previous studies generally found an increase in immigrants’ alcohol consumption with years in Canada, our data suggest that longer duration of residence may have either positive or negative effects on immigrants’ alcohol use, depending on the country of origin/traditional drinking pattern. More research is needed to explore determinants of alcohol use and risk drinking among immigrants and to identify those groups at highest risk.[Agic B, Mann RE, Tuck A, Ialomiteanu A, Bondy S, Simich L, Ilie G. Drug Alcohol Rev 2016;35:196 –205] Key words: alcohol, risk drinking, immigrants, ethnicity, Canada.
Introduction Although immigrants represent over 20% of Canada’s population, there is little data on the epidemiology of alcohol use among specific immigrant groups. While immigrants to Western countries, particularly recent arrivals, generally report lower rates of alcohol consumption and related problems than the host population, substantial variations exist in alcohol use according to ethnic group and country of origin [1–6]. Findings from the United Kingdom show that immigrants born in parts of Asia, Africa, the West Indies and the Middle East had lower alcohol consumption and alcohol-related mortality than the British-born population, while alcohol-related mortality was particularly high in men born in Ireland, Scotland and India [7–9].
Immigrants from Islamic countries to Germany and Norway reported lower levels of alcohol use than the native population. Yet, other groups such as Albanian immigrants to Italy and Hispanic immigrants to Spain reported more drinking or drinking levels similar to that of the host population [10,11]. US data reveals that immigrants from Asian countries reported the lowest rates of alcohol abuse, followed closely by immigrants of African origin [2,12]. Length of residence in the host country plays an important role in shaping immigrants’ patterns of alcohol use [12–14]. There is a general expectation that the health behaviours of immigrants eventually ‘migrate’ or mimic patterns observed among host country members. Past research using the Canadian Community Health Survey data found that alcohol use
Branka Agic MD, PhD, Manager, Robert E. Mann PhD, Senior Scientist, Andrew Tuck MA, Research Coordinator, Anca Ialomiteanu MA, Research Coordinator, Susan Bondy PhD, Associate Professor, Laura Simich PhD, Research Director, Gabriela Ilie PhD, Research Fellow. Correspondence to Dr Branka Agic, Health Equity Office, Centre for Addiction and Mental Health (CAMH), 2013-33 Russell Street, Toronto, ON M5S 2S1, Canada. Tel: 416 535 8501 ext. 34526; Fax: 416 979 4284; E-mail: [email protected] Received 19 May 2014; accepted for publication 4 January 2015. © 2015 Australasian Professional Society on Alcohol and other Drugs
Alcohol use among immigrants in Ontario, Canada
among immigrant men increased with years of residence, and for those from Europe and the United States, reached the levels of the Canadian-born population after having been in Canada for 10–20 years. For immigrants from other regions, including long-term immigrants, the incidence of alcohol consumption appeared to remain low [3,14]. In the United Kingdom, the observed rates of problem drinking in Sikh immigrants were higher than the rates found in the Sikh population in South Asia. Similar patterns have been observed among Hispanic immigrants in the United States, whose prevalence of alcohol-related health problems has more than doubled over the past ten years [15,16]. The role of age at arrival to host country in predicting health risks has been examined in a number of studies of chronic disease in immigrants [17–20]. Findings generally show that younger age at migration predicted higher risks of alcohol use and risk drinking during adulthood [14,21,22]. The reported rates of alcohol use and related problems among immigrants may represent an underestimation of the real figures. Immigrants, in particular recent arrivals not fluent in the official language, are often missed in population surveys [23,24]. In addition, immigrants may be hesitant to report alcohol misuse due to social stigma or fear of revocation of visa and deportation [1,12]. Reaching a better understanding of drinking patterns in different immigrant populations, and how they change over time, is important for the development of effective alcohol polices and prevention and treatment programs [12].This study aims to enhance understanding of alcohol use among immigrants to Ontario, Canada. Using data from the Centre for Addiction and Mental Health (CAMH) Monitor survey, we examined (i) the prevalence of alcohol use and risk drinking in foreign-born and Canadian-born populations by ethnic origin, (ii) average self-reported volume of alcohol consumed per year by different ethnic groups, and (iii) the associations among ethnicity, country of birth, length of residence and drinking measures.
197
versity using Computer Assisted Telephone Interview procedures with a response rate between 53 and 67%. The survey population is based on adult telephone subscribers residing in Ontario who were capable of completing the interview in English. The CAMH Monitor sample is representative for Ontarians aged 18 and older and data estimates are based on the weighted sample size [25,26]. Measures The major outcomes of interest were drinking status, risk drinking and quantity/volume of alcohol consumed. We defined four alcohol-related measures as follows: 1. ‘Lifetime drinker’ was coded 1 if the respondent reported being a past twelve month drinker or a former drinker and coded 0 if the respondent reported being a lifetime abstainer (never drank). 2. ‘Current drinker’ was coded 1 if the respondent used any alcohol in the past twelve months and coded 0 if the respondent did not use alcohol in the past twelve months. 3. ‘Risk drinking’ was defined by the presence of at least one of the following three problem indicators: a. Exceeding Canada’s Low Risk Drinking Guidelines (LRDG) [27] defined as a weekly consumption of 16 or more standard drinks1 for men or 11 or more standard drinks for women, or exceeding a daily consumption of 2 drinks for women and 3 drinks for men in any given day over the past week. b. Consuming five or more drinks at least once a month (‘binge drinking’) during the twelve months before the survey (considered an indicator of ‘risky single occasion drinking’). c. Reporting hazardous or harmful drinking as indicated by a score of 8 or more out of 40 on the AUDIT2 [28,29] screener. All risk drinking indicators refer to the past twelve months. Respondents were coded as risk drinkers if they had at least one of the three problem indicators (coded 1; all others coded 0).
Methods Survey design This study is based on data derived from the CAMH Monitor, a regionally stratified telephone-based survey of Ontario adults (18 years and older) conducted between January 2005 and December 2010. The CAMH Monitor is a cross-sectional survey designed to serve as the primary vehicle for monitoring substance use and mental health problems among Ontario adults. The Monitor is conducted by CAMH and administered by the Institute of Social Research at York Uni-
4. The quantity/volume of alcohol consumed is estimated based on the reported number of standard drinks consumed in the past twelve months. 1 According to Canada’s Low Risk Drinking Guidelines (LRDG), a standard drink is the equivalent to 341 ml (12 oz.) bottle of 5% alcohol beer, cider or cooler, 142 ml (5 oz.) glass of 12% alcohol wine or 43 ml (1.5 oz.) serving of 40% distilled alcohol. 2 The 10 AUDIT items focus on drinking frequency, volume, heavy consumption and frequency of various disruptive experiences due to alcohol to assess hazardous and harmful drinking). A score of 8 or more on the AUDIT is generally accepted as an indication of problem drinking.
© 2015 Australasian Professional Society on Alcohol and other Drugs
198
B. Agic et al.
The independent variables include ethnicity, country of birth, age at arrival and length of residence in Canada. Participants were allocated to an ethnic group using a CAMH Monitor question about family origin, ‘To what ethnic or cultural group did you or your ancestors belong on first coming to this continent?’ Country of birth refers to a country in which a person was born (Canada/Other). Foreign-born respondents were categorised according to their years of residence in Canada (≤5, 6–10, 11–20 or 21+ years). Age at arrival was calculated by subtracting the year of arrival from the year of birth. Respondents were grouped into two categories: those who arrived in Canada before the age of 19 and those who arrived at 19 or older. Canadianborn respondents were dummy coded to zero age at arrival and grouped with immigrants who arrived under the age of 19 for the purposes of logistic regression model 1. Data analysis Sample characteristics. A total of 13 557 respondents were included in the sample considered in the study; 26.8% of the weighted sample were immigrants and 73.2% of them were born in Canada. The Monitor’s ancestry question allowed respondents to report one or two ancestry groups. Between 2005 and 2010, 73% of the participants reported one ethnic origin while 27% of the participants reported two ethnic origins. None of the double ancestry groups had a sufficient number to be included in the analysis as a separate group. Respondents who reported two ancestry groups were assigned to an ethnic group based on their first choice/ primary group identified. To assure sufficient statistical power and meaningful group comparisons, the Monitor’s 44 ethnic ancestry origins were collapsed into 12 main ethnic categories: Canadian, East Asian, South East Asian, South Asian, Caribbean, African, Middle Eastern, East European, South European, North European, Central West European and Others3 [30]. Based on a priori calculations of the sample size per group needed to detect an odds ratio of 2.0 and above in a logistic regression, only groups with weighted sample sizes of 131 and above were included in these analyses. Groups whose weighted sample size was less than 131 (African and Middle Eastern) and the ‘Others’ group were not included. To accommodate the complex survey data, variances were estimated using Taylor linearisation available in 3 Aboriginal peoples were not included in this study. Indigenous peoples are recognised as having unique social, cultural, economic and political characteristics and historical continuity with precolonial and/or pre-settler societies. According to a common definition, they are ‘the descendants of those who inhabited a country or a geographical region at the time when people of different cultures or ethnic origins arrived’.
© 2015 Australasian Professional Society on Alcohol and other Drugs
the Complex Samples module in SPSS v20.0 (SPSS Inc., Chicago, IL, USA) [31–33]. The final analyses were based on a design with six strata (region), and 11 647 adults. Descriptive statistics were used to estimate prevalence of alcohol use and risk drinking in foreign-born and Canadian-born respondents by ethnic group. Simple prevalence estimates for each of the outcomes of interest (proportion of each group that are lifetime, current and risk drinkers) were calculated. Subsequently, effects of ethnicity (with the sole origin Canadian group serving as the referent group), place of birth and age at arrival in Canada on alcohol measures were assessed using logistic regression analyses. Four logistic regression analyses were performed to test the difference in the rates among ethnic groups. Model 1 tested whether ethnicity was a significant predictor of lifetime, current and risk drinking, controlling for place of birth and age at arrival. Model 2 included only Canadianborn respondents to test the ethnicity effect on alcohol use measures. Models 3 and 4 examined the effects of age at migration and ethnicity on alcohol use measures among foreign-born respondents. Models 2–4 were included to assess whether the nature of ethnicity effects differed depending on whether respondents were born in Canada, arrived at Canada under 19 years of age or arrived at Canada at age 19 or older. To assess overall consumption among different ethnic groups, average volume of alcohol consumed per year by each ethnic group was examined with general linear model. Finally, we explored whether ethnocultural drinking patterns affected the nature of change in drinking measures over time in Canada. To do this, we collapsed ethnic groups into high and low consuming groups based on their average total alcohol consumed per year and used logistic regression tests to examine the association between length of residence in Canada and drinking measures.
Results Rates of self-reported alcohol use differed between immigrants and Canadian-born respondents and among immigrants from different ethnic groups by age at arrival to Canada (before or after the age of 19). Place of birth (Canada/Other) was significantly associated with risk drinking for all but two ethnic groups, East Asian and North European. Place of birth was significantly associated with lifetime drinking for Canadians, South Asians, East Europeans and South Europeans. The association with current drinking was significant for all of the ethnic groups except East Asians, South East Asians and North Europeans.
Alcohol use among immigrants in Ontario, Canada
The prevalence of alcohol use and risk drinking was generally lower among foreign-born than Canadianborn respondents, with variations across ethnic groups. This difference was larger among respondents from the Asian and Caribbean ethnic groups. The largest, more than fourfold difference between foreign-born and Canadian-born respondents, was observed in the rate of self-reported risk drinking in the Caribbean (11.9 vs. 51.2%) followed by the South East Asian (7.8 vs. 30.9%) group. Relative to other groups, reported prevalence of lifetime, past year and risk drinking was lower among foreign-born respondents than the Canadian and European groups. The East European group had the highest proportion of foreign-born respondents who reported risk drinking (28.6%), while the South East Asian group had the lowest (7.8%). For immigrants, the rates of lifetime, current and risk drinking were generally higher among immigrants who arrived in Canada before the age of 19, with the exception of the Canadian and Caribbean group (Table 1). The largest, almost 20-fold difference in the rate of self-reported risk drinking was observed among the foreign-born South East Asians (26.9 vs. 1.6%). In the logistic regression analyses (Table 2), after controlling for place of birth and age at arrival to Canada, we found ethnicity to be a significant predictor of lifetime, current and risk drinking. Model 1 shows that, relative to the Canadian group, the odds of risk drinking were significantly lower for the South East Asian [odds ratio (OR) = 0.51, 95% confidence interval (CI) 0.32–0.74)] group, and significantly higher for the East European (OR = 1.46, 95% CI 1.13–1.88) group when compared with their Canadian counterparts. Model 2 shows that among Canadian-born respondents, the odds of lifetime drinking were significantly lower among South Asians (OR = 0.14, 95% CI 0.03– 0.20) and East Asians (OR = 0.33, 95% CI 0.11–0.98) compared with those who identified as Canadian. Compared with the Canadian group, East Europeans (OR = 1.34, 95% CI 1.02–1.17) were significantly more likely to be risk drinkers. Model 3 indicates that among immigrants who arrived in Canada under the age of 19, East Europeans (OR = 4.82, 95% CI 1.57–14.83), Central West Europeans (OR = 3.35, 95% CI 1.19–9.49), South Europeans (OR = 3.85, 95% CI 1.47–10.99) and North Europeans (OR = 5.36, 95% CI 1.15–24.92) had significantly higher odds of risk drinking relative to the Canadian group. While the odds were not significantly different for the other ethnic groups, we observe that they all had higher odds of risk drinking than the Canadian group.
199
Model 4 shows that among immigrants who arrived after the age of 19, the odds of risk drinking were significantly lower for South East Asians (OR = 0.10, 95% CI 0.01–0.92), relative to those who self-identified as Canadians. The estimated average volume of alcohol consumed for the entire sample was 180.26 standard drinks per year. As seen in Table 3, the observed average volume of alcohol consumed was significantly different across ethnic groups (Wald F [8,11 240] = 79.10, P < .001). The analyses show that between groups, the average volume of alcohol was significantly lower for the respondents from the East Asian (M = 65.89, SE 8.69), South East Asian (M = 32.11, SE 9.41), South Asian (M = 44.75, SE 6.27) and Caribbean (M = 78.47, SE 18.90) groups compared with Canadians (M = 210.44, SE 16.18), East Europeans (M = 183.71, SE 13.16), Central-West Europeans (M = 203.85, SE 5.12), South Europeans (M = 174.73, SE 9.73) and North Europeans (M = 211.57, SE 28.36). There were no significant differences in average volume of consumption between the Canadian and the four European groups. These results suggested that these nine groups could be grouped into two homogenous subsets based on the average volume of alcohol consumed in a year: (i) high consumption ethnic groups (HCEG: Canadian, East European, Central-West European, North European and South European) and (ii) low consumption ethnic groups (LCEG: Asian East, Asian South East, Asian South and Caribbean). We observed significant associations in the percentage of foreign-born respondents reporting lifetime drinking for LCEG, and risk drinking for HCEG with length of residency in Canada (≤5 years, 6–10 years, 11–20 years and >20 years; Table 4). Among foreignborn respondents in the HCEG, the percentage of respondents who reported lifetime, current and risk drinking was highest amongst recent immigrants (≤5 years in Canada) and tended to decrease among immigrants who have lived in Canada for longer periods of time. The proportion of lifetime and current drinkers tended to increase again among those here more than twenty years, but was still lower than among recent immigrants. The proportion of risk drinkers appeared to rise among respondents who have lived in Canada 11–20 years (29.7%) but then fell again among immigrants who have lived in Canada over twenty years. Among LCEGs, the proportion of foreign-born respondents who reported lifetime and current drinking increased as length of residence in Canada increased, with the highest proportion observed among immigrants who have lived in Canada 20+ years. The proportion of respondents reporting risk drinking also increased as length of residence increased, with the greatest percentage observed among those who have © 2015 Australasian Professional Society on Alcohol and other Drugs
200
B. Agic et al.
Table 1. Alcohol use and drinking measures by ethnicity and country of birth (Canada/other who arrived before 19 years old/other who arrived 19 years old and older), Ontarians aged 18 and older, CAMH Monitor
Ethnic group
Sample (total n = 11647)
Lifetime drinkers
Current drinkers
Risk drinkers
Unweighted n (weighted n)
% (95% CI)
% (95% CI)
% (95% CI)
95.9 (93.8–97.3) 97.7 (96.3–98.5) 81.9 (59.8–93.2) 84.1 (66.0–93.5) *** 89.0 (84.4–92.4) 93.3 (84.1–97.3) 93.0 (84.3–97.1) 84.2 (76.3–89.9) N.S. 66.0 (53.5–76.6) 85.2 (42.8–97.8) 63.9 (30.8–87.6) 60.4 (45.1–73.9) N.S. 59.7 (53.7–65.6) 77.1 (60.6–88.0) 53.8 (40.1–67.0) 56.6 (49.3–63.6) * 90.3 (81.8–95.1) 100 79.8 (57.0–92.2) 89.0 (75.8–95.5) N.S. 96.7 (94.8–97.8) 97.8 (95.9–98.8) 98.7 (95.8–99.6) 90.1 (81.7–94.9) *** 96.5 (95.9–96.9) 96.6 (96.1–97.1) 96.8 (94.5–98.1) 94.1 (91.0–96.1) * 95.5 (94.2–96.5) 96.6 (95.4–97.5) 94.6 (88.6–97.5) 85.1 (76.8–90.8) *** 97.2 (92.2–99.1) 97.8 (91.8–99.5) 89.1 (57.5–98.0) 100 N.S.
80.6 (77.2–83.6) 82.9 (79.6–85.8) 57.1 (39.2–73.3) 69.3 (51.3–82.8) ** 67.1 (60.5–73.1) 72.6 (57.7–83.7) 73.5 (60.2–83.6) 60.2 (51.2–68.6) N.S. 51.9 (39.7–63.8) 75.6 (39.7–93.6) 58.5 (27.8–83.9) 42.0 (28.0–57.3) N.S. 45.4 (39.5–51.3) 65.9 (49.7–79.0) 46.4 (33.3–59.9) 38.9 (32.2–46.2) ** 75.9 (65.4–83.9) 91.9 (76.8–97.5) 70.8 (49.3–85.8) 66.2 (49.0–79.9) * 84.8 (81.6–87.5) 87.8 (84.3–90.6) 85.1 (74.7–916) 72.1 (62.3–80.1) ** 84.2 (83.2–85.1) 84.5 (83.4–85.5) 84.7 (80.6–882) 79.7 (75.5–83.4) *. 84.3 (82.3–86.2) 85.9 (83.8–87.7) 82.3 (74.4–88.2) 71.4 (61.7–79.4) ** 91.0 (86.2–94.3) 90.5 (85.0–94.1) 87.5 (58.2–97.2) 98.1 (87.1–99.7) N.S.
31.4 (27.7–35.5) 34.1 (30.1–38.5) 10.0 (3.9–23.2) 14.3 (5.4–32.7) ** 22.1 (16.6–28.8) 28.0 (16.0–44.2) 26.1 (15.7–40.3) 16.3 (10.4–24.6) N.S. 12.2 (5.9–23.4) 30.9 (11.4–60.8) 26.9 (7.9–61.3) 1.6 (0.2–10.6) ** 11.6 (8.3–15.9) 20.8 (11.5–34.7) 17.5 (9.3–30.5) 6.7 (4.0–10.9) ** 27.2 (18.0–38.9) 51.2 (30.1–71.9) 14.4 (4.1–39.9) 14.4 (6.0–30.7) ** 37.3 (33.3–41.4) 41.0 (36.2–46.0) 34.7 (24.3–46.8) 23.4 (15.7–33.3) * 34.3 (32.9–35.6) 35.9 (34.5–37.4) 27.0 (22.1–32.6) 20.0 (16.3–24.3) *** 33.2 (30.4–36.0) 35.1 (32.1–38.3) 29.8 (22.0–39.2) 16.8 (10.7–25.4) ** 35.1 (27.4–43.7) 38.4 (29.5–48.1) 37.2 (15.5–65.7) 6.9 (2.0–21.0) *
Canadian
899 (841) 806 (738) 48 (47) 45 (57)
East Asian
273 (424) 64 (101) 72 (125) 137 (198)
South East Asian
South Asian
Caribbean
East European
85 (132) 14 (26) 12 (26) 59 (80) 352 (616) 58 (112) 77 (128) 217 (376) 98 (140) 28 (46) 29 (36) 41 (58) 834 (863) 593 (596) 114 (125) 127 (142)
Central-West European
6977 (6382) 6057 (5538) 533 (377) 498 (466)
South European
1791 (1688) 1503 (1366) 173 (191) 115 (131)
North European
216 (163) 174 (130) 21 (15) 21 (17)
Total Born in Canada Age at arrival
R E V I E W
Drug and Alcohol Review (March 2016), 35, 196 – 205 DOI: 10.1111/dar.12250
Alcohol use among immigrants in Ontario, Canada BRANKA AGIC1, ROBERT E. MANN2, ANDREW TUCK3, ANCA IALOMITEANU3, SUSAN BONDY4, LAURA SIMICH5 & GABRIELA ILIE6 1
Centre for Addiction and Mental Health, Toronto, Canada, Centre for 2Addiction and Mental Health, Toronto, Canada, Centre for 3Addiction and Mental Health, Toronto, Canada, Dalla Lana School 4 of Public Health, University of Toronto, Toronto, Canada, 5Center on Immigration and Justice, Vera Institute of Justice, New York, USA, and 6Neurosurgery Department, St. Michael’s Hospital, Toronto, Canada
Abstract Introduction and Aims. This study examined prevalence of alcohol consumption among immigrants and the Canadianborn populations of Ontario by ethnic origin, and the association between ethnicity, country of birth, age at arrival, length of residence in Canada and drinking measures. Design and Methods. Data were derived from the Centre for Addiction and Mental Health (CAMH) Monitor, a cross-sectional survey of Ontario adults, conducted between January 2005 and December 2010 (n = 13 557). Results. The prevalence of alcohol consumption and risk drinking was generally lower among foreignborn than Canadian-born respondents, but significant variations across ethnic groups were found. In general, foreign-born respondents of European descent reported higher rates of alcohol use and risk drinking than foreign-born respondents from other ethnic groups.We also observed that ethnicity effects varied by whether or not respondents were born in Canada, and by the age at which they arrived in Canada. Discussion and Conclusions. While previous studies generally found an increase in immigrants’ alcohol consumption with years in Canada, our data suggest that longer duration of residence may have either positive or negative effects on immigrants’ alcohol use, depending on the country of origin/traditional drinking pattern. More research is needed to explore determinants of alcohol use and risk drinking among immigrants and to identify those groups at highest risk.[Agic B, Mann RE, Tuck A, Ialomiteanu A, Bondy S, Simich L, Ilie G. Drug Alcohol Rev 2016;35:196 –205] Key words: alcohol, risk drinking, immigrants, ethnicity, Canada.
Introduction Although immigrants represent over 20% of Canada’s population, there is little data on the epidemiology of alcohol use among specific immigrant groups. While immigrants to Western countries, particularly recent arrivals, generally report lower rates of alcohol consumption and related problems than the host population, substantial variations exist in alcohol use according to ethnic group and country of origin [1–6]. Findings from the United Kingdom show that immigrants born in parts of Asia, Africa, the West Indies and the Middle East had lower alcohol consumption and alcohol-related mortality than the British-born population, while alcohol-related mortality was particularly high in men born in Ireland, Scotland and India [7–9].
Immigrants from Islamic countries to Germany and Norway reported lower levels of alcohol use than the native population. Yet, other groups such as Albanian immigrants to Italy and Hispanic immigrants to Spain reported more drinking or drinking levels similar to that of the host population [10,11]. US data reveals that immigrants from Asian countries reported the lowest rates of alcohol abuse, followed closely by immigrants of African origin [2,12]. Length of residence in the host country plays an important role in shaping immigrants’ patterns of alcohol use [12–14]. There is a general expectation that the health behaviours of immigrants eventually ‘migrate’ or mimic patterns observed among host country members. Past research using the Canadian Community Health Survey data found that alcohol use
Branka Agic MD, PhD, Manager, Robert E. Mann PhD, Senior Scientist, Andrew Tuck MA, Research Coordinator, Anca Ialomiteanu MA, Research Coordinator, Susan Bondy PhD, Associate Professor, Laura Simich PhD, Research Director, Gabriela Ilie PhD, Research Fellow. Correspondence to Dr Branka Agic, Health Equity Office, Centre for Addiction and Mental Health (CAMH), 2013-33 Russell Street, Toronto, ON M5S 2S1, Canada. Tel: 416 535 8501 ext. 34526; Fax: 416 979 4284; E-mail: [email protected] Received 19 May 2014; accepted for publication 4 January 2015. © 2015 Australasian Professional Society on Alcohol and other Drugs
Alcohol use among immigrants in Ontario, Canada
among immigrant men increased with years of residence, and for those from Europe and the United States, reached the levels of the Canadian-born population after having been in Canada for 10–20 years. For immigrants from other regions, including long-term immigrants, the incidence of alcohol consumption appeared to remain low [3,14]. In the United Kingdom, the observed rates of problem drinking in Sikh immigrants were higher than the rates found in the Sikh population in South Asia. Similar patterns have been observed among Hispanic immigrants in the United States, whose prevalence of alcohol-related health problems has more than doubled over the past ten years [15,16]. The role of age at arrival to host country in predicting health risks has been examined in a number of studies of chronic disease in immigrants [17–20]. Findings generally show that younger age at migration predicted higher risks of alcohol use and risk drinking during adulthood [14,21,22]. The reported rates of alcohol use and related problems among immigrants may represent an underestimation of the real figures. Immigrants, in particular recent arrivals not fluent in the official language, are often missed in population surveys [23,24]. In addition, immigrants may be hesitant to report alcohol misuse due to social stigma or fear of revocation of visa and deportation [1,12]. Reaching a better understanding of drinking patterns in different immigrant populations, and how they change over time, is important for the development of effective alcohol polices and prevention and treatment programs [12].This study aims to enhance understanding of alcohol use among immigrants to Ontario, Canada. Using data from the Centre for Addiction and Mental Health (CAMH) Monitor survey, we examined (i) the prevalence of alcohol use and risk drinking in foreign-born and Canadian-born populations by ethnic origin, (ii) average self-reported volume of alcohol consumed per year by different ethnic groups, and (iii) the associations among ethnicity, country of birth, length of residence and drinking measures.
197
versity using Computer Assisted Telephone Interview procedures with a response rate between 53 and 67%. The survey population is based on adult telephone subscribers residing in Ontario who were capable of completing the interview in English. The CAMH Monitor sample is representative for Ontarians aged 18 and older and data estimates are based on the weighted sample size [25,26]. Measures The major outcomes of interest were drinking status, risk drinking and quantity/volume of alcohol consumed. We defined four alcohol-related measures as follows: 1. ‘Lifetime drinker’ was coded 1 if the respondent reported being a past twelve month drinker or a former drinker and coded 0 if the respondent reported being a lifetime abstainer (never drank). 2. ‘Current drinker’ was coded 1 if the respondent used any alcohol in the past twelve months and coded 0 if the respondent did not use alcohol in the past twelve months. 3. ‘Risk drinking’ was defined by the presence of at least one of the following three problem indicators: a. Exceeding Canada’s Low Risk Drinking Guidelines (LRDG) [27] defined as a weekly consumption of 16 or more standard drinks1 for men or 11 or more standard drinks for women, or exceeding a daily consumption of 2 drinks for women and 3 drinks for men in any given day over the past week. b. Consuming five or more drinks at least once a month (‘binge drinking’) during the twelve months before the survey (considered an indicator of ‘risky single occasion drinking’). c. Reporting hazardous or harmful drinking as indicated by a score of 8 or more out of 40 on the AUDIT2 [28,29] screener. All risk drinking indicators refer to the past twelve months. Respondents were coded as risk drinkers if they had at least one of the three problem indicators (coded 1; all others coded 0).
Methods Survey design This study is based on data derived from the CAMH Monitor, a regionally stratified telephone-based survey of Ontario adults (18 years and older) conducted between January 2005 and December 2010. The CAMH Monitor is a cross-sectional survey designed to serve as the primary vehicle for monitoring substance use and mental health problems among Ontario adults. The Monitor is conducted by CAMH and administered by the Institute of Social Research at York Uni-
4. The quantity/volume of alcohol consumed is estimated based on the reported number of standard drinks consumed in the past twelve months. 1 According to Canada’s Low Risk Drinking Guidelines (LRDG), a standard drink is the equivalent to 341 ml (12 oz.) bottle of 5% alcohol beer, cider or cooler, 142 ml (5 oz.) glass of 12% alcohol wine or 43 ml (1.5 oz.) serving of 40% distilled alcohol. 2 The 10 AUDIT items focus on drinking frequency, volume, heavy consumption and frequency of various disruptive experiences due to alcohol to assess hazardous and harmful drinking). A score of 8 or more on the AUDIT is generally accepted as an indication of problem drinking.
© 2015 Australasian Professional Society on Alcohol and other Drugs
198
B. Agic et al.
The independent variables include ethnicity, country of birth, age at arrival and length of residence in Canada. Participants were allocated to an ethnic group using a CAMH Monitor question about family origin, ‘To what ethnic or cultural group did you or your ancestors belong on first coming to this continent?’ Country of birth refers to a country in which a person was born (Canada/Other). Foreign-born respondents were categorised according to their years of residence in Canada (≤5, 6–10, 11–20 or 21+ years). Age at arrival was calculated by subtracting the year of arrival from the year of birth. Respondents were grouped into two categories: those who arrived in Canada before the age of 19 and those who arrived at 19 or older. Canadianborn respondents were dummy coded to zero age at arrival and grouped with immigrants who arrived under the age of 19 for the purposes of logistic regression model 1. Data analysis Sample characteristics. A total of 13 557 respondents were included in the sample considered in the study; 26.8% of the weighted sample were immigrants and 73.2% of them were born in Canada. The Monitor’s ancestry question allowed respondents to report one or two ancestry groups. Between 2005 and 2010, 73% of the participants reported one ethnic origin while 27% of the participants reported two ethnic origins. None of the double ancestry groups had a sufficient number to be included in the analysis as a separate group. Respondents who reported two ancestry groups were assigned to an ethnic group based on their first choice/ primary group identified. To assure sufficient statistical power and meaningful group comparisons, the Monitor’s 44 ethnic ancestry origins were collapsed into 12 main ethnic categories: Canadian, East Asian, South East Asian, South Asian, Caribbean, African, Middle Eastern, East European, South European, North European, Central West European and Others3 [30]. Based on a priori calculations of the sample size per group needed to detect an odds ratio of 2.0 and above in a logistic regression, only groups with weighted sample sizes of 131 and above were included in these analyses. Groups whose weighted sample size was less than 131 (African and Middle Eastern) and the ‘Others’ group were not included. To accommodate the complex survey data, variances were estimated using Taylor linearisation available in 3 Aboriginal peoples were not included in this study. Indigenous peoples are recognised as having unique social, cultural, economic and political characteristics and historical continuity with precolonial and/or pre-settler societies. According to a common definition, they are ‘the descendants of those who inhabited a country or a geographical region at the time when people of different cultures or ethnic origins arrived’.
© 2015 Australasian Professional Society on Alcohol and other Drugs
the Complex Samples module in SPSS v20.0 (SPSS Inc., Chicago, IL, USA) [31–33]. The final analyses were based on a design with six strata (region), and 11 647 adults. Descriptive statistics were used to estimate prevalence of alcohol use and risk drinking in foreign-born and Canadian-born respondents by ethnic group. Simple prevalence estimates for each of the outcomes of interest (proportion of each group that are lifetime, current and risk drinkers) were calculated. Subsequently, effects of ethnicity (with the sole origin Canadian group serving as the referent group), place of birth and age at arrival in Canada on alcohol measures were assessed using logistic regression analyses. Four logistic regression analyses were performed to test the difference in the rates among ethnic groups. Model 1 tested whether ethnicity was a significant predictor of lifetime, current and risk drinking, controlling for place of birth and age at arrival. Model 2 included only Canadianborn respondents to test the ethnicity effect on alcohol use measures. Models 3 and 4 examined the effects of age at migration and ethnicity on alcohol use measures among foreign-born respondents. Models 2–4 were included to assess whether the nature of ethnicity effects differed depending on whether respondents were born in Canada, arrived at Canada under 19 years of age or arrived at Canada at age 19 or older. To assess overall consumption among different ethnic groups, average volume of alcohol consumed per year by each ethnic group was examined with general linear model. Finally, we explored whether ethnocultural drinking patterns affected the nature of change in drinking measures over time in Canada. To do this, we collapsed ethnic groups into high and low consuming groups based on their average total alcohol consumed per year and used logistic regression tests to examine the association between length of residence in Canada and drinking measures.
Results Rates of self-reported alcohol use differed between immigrants and Canadian-born respondents and among immigrants from different ethnic groups by age at arrival to Canada (before or after the age of 19). Place of birth (Canada/Other) was significantly associated with risk drinking for all but two ethnic groups, East Asian and North European. Place of birth was significantly associated with lifetime drinking for Canadians, South Asians, East Europeans and South Europeans. The association with current drinking was significant for all of the ethnic groups except East Asians, South East Asians and North Europeans.
Alcohol use among immigrants in Ontario, Canada
The prevalence of alcohol use and risk drinking was generally lower among foreign-born than Canadianborn respondents, with variations across ethnic groups. This difference was larger among respondents from the Asian and Caribbean ethnic groups. The largest, more than fourfold difference between foreign-born and Canadian-born respondents, was observed in the rate of self-reported risk drinking in the Caribbean (11.9 vs. 51.2%) followed by the South East Asian (7.8 vs. 30.9%) group. Relative to other groups, reported prevalence of lifetime, past year and risk drinking was lower among foreign-born respondents than the Canadian and European groups. The East European group had the highest proportion of foreign-born respondents who reported risk drinking (28.6%), while the South East Asian group had the lowest (7.8%). For immigrants, the rates of lifetime, current and risk drinking were generally higher among immigrants who arrived in Canada before the age of 19, with the exception of the Canadian and Caribbean group (Table 1). The largest, almost 20-fold difference in the rate of self-reported risk drinking was observed among the foreign-born South East Asians (26.9 vs. 1.6%). In the logistic regression analyses (Table 2), after controlling for place of birth and age at arrival to Canada, we found ethnicity to be a significant predictor of lifetime, current and risk drinking. Model 1 shows that, relative to the Canadian group, the odds of risk drinking were significantly lower for the South East Asian [odds ratio (OR) = 0.51, 95% confidence interval (CI) 0.32–0.74)] group, and significantly higher for the East European (OR = 1.46, 95% CI 1.13–1.88) group when compared with their Canadian counterparts. Model 2 shows that among Canadian-born respondents, the odds of lifetime drinking were significantly lower among South Asians (OR = 0.14, 95% CI 0.03– 0.20) and East Asians (OR = 0.33, 95% CI 0.11–0.98) compared with those who identified as Canadian. Compared with the Canadian group, East Europeans (OR = 1.34, 95% CI 1.02–1.17) were significantly more likely to be risk drinkers. Model 3 indicates that among immigrants who arrived in Canada under the age of 19, East Europeans (OR = 4.82, 95% CI 1.57–14.83), Central West Europeans (OR = 3.35, 95% CI 1.19–9.49), South Europeans (OR = 3.85, 95% CI 1.47–10.99) and North Europeans (OR = 5.36, 95% CI 1.15–24.92) had significantly higher odds of risk drinking relative to the Canadian group. While the odds were not significantly different for the other ethnic groups, we observe that they all had higher odds of risk drinking than the Canadian group.
199
Model 4 shows that among immigrants who arrived after the age of 19, the odds of risk drinking were significantly lower for South East Asians (OR = 0.10, 95% CI 0.01–0.92), relative to those who self-identified as Canadians. The estimated average volume of alcohol consumed for the entire sample was 180.26 standard drinks per year. As seen in Table 3, the observed average volume of alcohol consumed was significantly different across ethnic groups (Wald F [8,11 240] = 79.10, P < .001). The analyses show that between groups, the average volume of alcohol was significantly lower for the respondents from the East Asian (M = 65.89, SE 8.69), South East Asian (M = 32.11, SE 9.41), South Asian (M = 44.75, SE 6.27) and Caribbean (M = 78.47, SE 18.90) groups compared with Canadians (M = 210.44, SE 16.18), East Europeans (M = 183.71, SE 13.16), Central-West Europeans (M = 203.85, SE 5.12), South Europeans (M = 174.73, SE 9.73) and North Europeans (M = 211.57, SE 28.36). There were no significant differences in average volume of consumption between the Canadian and the four European groups. These results suggested that these nine groups could be grouped into two homogenous subsets based on the average volume of alcohol consumed in a year: (i) high consumption ethnic groups (HCEG: Canadian, East European, Central-West European, North European and South European) and (ii) low consumption ethnic groups (LCEG: Asian East, Asian South East, Asian South and Caribbean). We observed significant associations in the percentage of foreign-born respondents reporting lifetime drinking for LCEG, and risk drinking for HCEG with length of residency in Canada (≤5 years, 6–10 years, 11–20 years and >20 years; Table 4). Among foreignborn respondents in the HCEG, the percentage of respondents who reported lifetime, current and risk drinking was highest amongst recent immigrants (≤5 years in Canada) and tended to decrease among immigrants who have lived in Canada for longer periods of time. The proportion of lifetime and current drinkers tended to increase again among those here more than twenty years, but was still lower than among recent immigrants. The proportion of risk drinkers appeared to rise among respondents who have lived in Canada 11–20 years (29.7%) but then fell again among immigrants who have lived in Canada over twenty years. Among LCEGs, the proportion of foreign-born respondents who reported lifetime and current drinking increased as length of residence in Canada increased, with the highest proportion observed among immigrants who have lived in Canada 20+ years. The proportion of respondents reporting risk drinking also increased as length of residence increased, with the greatest percentage observed among those who have © 2015 Australasian Professional Society on Alcohol and other Drugs
200
B. Agic et al.
Table 1. Alcohol use and drinking measures by ethnicity and country of birth (Canada/other who arrived before 19 years old/other who arrived 19 years old and older), Ontarians aged 18 and older, CAMH Monitor
Ethnic group
Sample (total n = 11647)
Lifetime drinkers
Current drinkers
Risk drinkers
Unweighted n (weighted n)
% (95% CI)
% (95% CI)
% (95% CI)
95.9 (93.8–97.3) 97.7 (96.3–98.5) 81.9 (59.8–93.2) 84.1 (66.0–93.5) *** 89.0 (84.4–92.4) 93.3 (84.1–97.3) 93.0 (84.3–97.1) 84.2 (76.3–89.9) N.S. 66.0 (53.5–76.6) 85.2 (42.8–97.8) 63.9 (30.8–87.6) 60.4 (45.1–73.9) N.S. 59.7 (53.7–65.6) 77.1 (60.6–88.0) 53.8 (40.1–67.0) 56.6 (49.3–63.6) * 90.3 (81.8–95.1) 100 79.8 (57.0–92.2) 89.0 (75.8–95.5) N.S. 96.7 (94.8–97.8) 97.8 (95.9–98.8) 98.7 (95.8–99.6) 90.1 (81.7–94.9) *** 96.5 (95.9–96.9) 96.6 (96.1–97.1) 96.8 (94.5–98.1) 94.1 (91.0–96.1) * 95.5 (94.2–96.5) 96.6 (95.4–97.5) 94.6 (88.6–97.5) 85.1 (76.8–90.8) *** 97.2 (92.2–99.1) 97.8 (91.8–99.5) 89.1 (57.5–98.0) 100 N.S.
80.6 (77.2–83.6) 82.9 (79.6–85.8) 57.1 (39.2–73.3) 69.3 (51.3–82.8) ** 67.1 (60.5–73.1) 72.6 (57.7–83.7) 73.5 (60.2–83.6) 60.2 (51.2–68.6) N.S. 51.9 (39.7–63.8) 75.6 (39.7–93.6) 58.5 (27.8–83.9) 42.0 (28.0–57.3) N.S. 45.4 (39.5–51.3) 65.9 (49.7–79.0) 46.4 (33.3–59.9) 38.9 (32.2–46.2) ** 75.9 (65.4–83.9) 91.9 (76.8–97.5) 70.8 (49.3–85.8) 66.2 (49.0–79.9) * 84.8 (81.6–87.5) 87.8 (84.3–90.6) 85.1 (74.7–916) 72.1 (62.3–80.1) ** 84.2 (83.2–85.1) 84.5 (83.4–85.5) 84.7 (80.6–882) 79.7 (75.5–83.4) *. 84.3 (82.3–86.2) 85.9 (83.8–87.7) 82.3 (74.4–88.2) 71.4 (61.7–79.4) ** 91.0 (86.2–94.3) 90.5 (85.0–94.1) 87.5 (58.2–97.2) 98.1 (87.1–99.7) N.S.
31.4 (27.7–35.5) 34.1 (30.1–38.5) 10.0 (3.9–23.2) 14.3 (5.4–32.7) ** 22.1 (16.6–28.8) 28.0 (16.0–44.2) 26.1 (15.7–40.3) 16.3 (10.4–24.6) N.S. 12.2 (5.9–23.4) 30.9 (11.4–60.8) 26.9 (7.9–61.3) 1.6 (0.2–10.6) ** 11.6 (8.3–15.9) 20.8 (11.5–34.7) 17.5 (9.3–30.5) 6.7 (4.0–10.9) ** 27.2 (18.0–38.9) 51.2 (30.1–71.9) 14.4 (4.1–39.9) 14.4 (6.0–30.7) ** 37.3 (33.3–41.4) 41.0 (36.2–46.0) 34.7 (24.3–46.8) 23.4 (15.7–33.3) * 34.3 (32.9–35.6) 35.9 (34.5–37.4) 27.0 (22.1–32.6) 20.0 (16.3–24.3) *** 33.2 (30.4–36.0) 35.1 (32.1–38.3) 29.8 (22.0–39.2) 16.8 (10.7–25.4) ** 35.1 (27.4–43.7) 38.4 (29.5–48.1) 37.2 (15.5–65.7) 6.9 (2.0–21.0) *
Canadian
899 (841) 806 (738) 48 (47) 45 (57)
East Asian
273 (424) 64 (101) 72 (125) 137 (198)
South East Asian
South Asian
Caribbean
East European
85 (132) 14 (26) 12 (26) 59 (80) 352 (616) 58 (112) 77 (128) 217 (376) 98 (140) 28 (46) 29 (36) 41 (58) 834 (863) 593 (596) 114 (125) 127 (142)
Central-West European
6977 (6382) 6057 (5538) 533 (377) 498 (466)
South European
1791 (1688) 1503 (1366) 173 (191) 115 (131)
North European
216 (163) 174 (130) 21 (15) 21 (17)
Total Born in Canada Age at arrival
