Spatial distribution of alcohol consumption
The state and district- wise comparison of alcohol consumption prevalence in men and women recorded by NFHS-4 is shown in Fig. 1. On an average, only 1.2% of women in India consume alcohol, whereas the national average for men is 29.2%. Alcohol consumption of both men and women is high in NE and Eastern states of India. In addition, alcohol consumption in men is high in South and North India. In men, high consuming alcohol states are Arunachal Pradesh, Tripura, Telangana, Chattisgarh, Manipur, Sikkim, Mizoram and Tamil Nadu where > 45% of men consume alcohol. Alcohol prevalence among women is high in all NE states and Telangana.
The district-wise distribution of alcohol consumption in India shows that excluding a few isolated districts of Gujarat, Rajasthan and, Jammu and Kashmir, all the districts of India have alcohol prevalence in excess of 10% in men (Fig. 1B and Supplementary File 1). Alcohol use is very high (> 50%) in NE India and Eastern peninsular states, especially Telangana and Chattisgarh. In some districts of Arunachal Pradesh (Anjaw and Upper Siang) the prevalence is 100%. Except for NE, Telangana, and border districts in Jharkhand, Chhattisgarh and Odisha, the alcohol consumption among women in all the other districts is quite low (< 2%). However, many districts in Arunachal Pradesh exceed 30%, and the highest prevalence of alcohol consumption in women (53.2%) was observed in Alirajpur district of Madhya Pradesh (Fig. 1A and Supplementary File 1).
In India, both men and women, consume different types of alcoholic beverages such as tadi madi, country liquor, hard liquor (spirit), beer, wine or other alcoholic beverages, and the state-wise distribution is given in Fig. 1C. In all the states, more than one type of alcohol are consumed, and overall, there is no single dominant alcoholic beverage in India. However, hard liquor with high alcohol content is highly consumed in Mizoram, Tamil Nadu, Meghalaya, Nagaland and Kerala. The proportion of Tadi madi / country liquor is higher in the tribal dominated states of Tripura, Chhattisgarh, Jharkhand, Assam, Odisha and Madhya Pradesh. Compared to men, women in these states mostly prefer tadi madi / country liquor. Beer and wine constitute the largest proportion of alcohol consumed in the small states (Sikkim and Goa) and UT (Andaman and Nicobar, Daman and Diu, Dadra and Nagar, and Puducherry).
Hot Spots Of Alcohol Consumption
We employed Getis-Ord Gi* statistic to identify statistically significant spatial clusters of alcohol prevalence among men and women. To form a statistically significant hot spot, the district with high prevalence should be surrounded by districts with high prevalence. Based on z-scores and p-values, hot spots of alcohol consumption for men and women are shown with 99%, 95% and 90% confidence intervals (Fig. 2A, 2B and Supplementary Table 1). There are three significant alcohol hot spots in India. NE states form the first and prominent hot spot of alcohol consumption in India for both men and women. Due to lack of data from the neighboring districts, some of the border districts in the NE hot spot are excluded from the results. However, individual consumption rates of those districts are high, and hence we consider the entire NE region as a hot spot. The second hot spot is formed primarily by the districts of Chhattisgarh, Odisha, Jharkhand and Telangana states of the Eastern peninsular region. This hot spot is more pronounced in men, and also extends to the western districts of Madhya Pradesh and North-Eastern districts of Andhra Pradesh. In women, the second hot spot is split into two - the districts in the borders of Jharkhand, Chattisgarh and Odisha form one cluster, and the second cluster is formed by Telangana (excluding the Northern districts), and the Southern districts of Jharkhand. Most of the districts in NE and Eastern peninsular hot spots (Jharkhand, Chhattisgarh and Odisha) have high proportion of Scheduled Tribes (ST) (> 75%). The bifurcation of the women’s alcohol hot spot in the Eastern peninsular region coincides with the distribution of the ST women population (Fig. 2A).
The third hot spot is formed by the districts of Tamil Nadu and South Kerala, and is seen only in men. Tamil Nadu is a cold spot for women. The cold spots cover majority of the districts in Western and Northern India, excluding the states of Punjab, Himachal Pradesh and Uttarkhand, where alcohol consumption is moderately high.
Even though the consumption of alcohol is very high in NE, population density in this region, especially in Arunachal Pradesh and Tripura is very low compare to the rest of India. In order to identify vulnerable districts / states in terms of population density and high alcohol prevalence, scatter plot analysis was carried with the district-level consumption in men (%) and men density (per sq.km) (Fig. 2C). The analysis shows that among the three hot spots, the districts of Tamil Nadu, Telangana and Assam are highly vulnerable. In the high risk metro districts of Chennai (Tamil Nadu), Hyderabad (Telangana) and Kolkata (West Bengal), the men density exceeds 10,000 per sq.km and alcohol consumption rate is more than 40%.
Sdi Affecting Alcohol Consumption In Indian Men And Women
The prevalence of alcohol consumption among men and women aged 15–49 years by different SDI and adjusted odds ratios (aOR) are given in Table 1. The socio-demographic profile of the respondents aged 15–49 years is given in the Supplementary Table 2.
Table 1
Prevalence of alcohol use among survey participants age 15–49 years by socio- economic characteristics, India, NFHS-4
Socio-Economic Characteristics | Alcohol Men | Alcohol Women |
Prevalence n (%) | 95% CI | Adjusted Odds Ratio (aOR) | 95% CI | Prevalence n (%) | 95% CI | Adjusted Odds Ratio (aOR) | 95% CI |
Place of Residence |
Rural | 18827(29.5) | 28.9–30.1 | 0.85** | 0.79–0.92 | 6920(1.5) | 1.4–1.6 | 1.01 | 0.75–1.36 |
Urban | 11339(28.7) | 27.4–29.9 | Reference (1.0) | Reference (1.0) | 1717(0.7) | 0.6–0.8 | Reference (1.0) | Reference (1.0) |
Age |
15–24 | 5686(16.1) | 15.4–16.8 | 0.65** | 0.60–0.72 | 1516(0.6) | 0.6–0.7 | 0.61** | 0.48–0.74 |
25–39 | 15865(35.6) | 34.7–36.5 | 1.11** | 1.04–1.18 | 3992(1.3) | 1.2–1.4 | 0.81* | 0.68–0.96 |
40–49 | 8614(36.7) | 35.7–37.7 | Reference (1.0) | Reference (1.0) | 3128(2.1) | 1.9–2.2 | Reference (1.0) | Reference (1.0) |
Region |
North | 3433(23.1) | 22.2–24.1 | 0.31** | 0.28–0.34 | 171(0.2) | 0.1–0.2 | 0.08** | 0.03–0.22 |
Central | 6149(27.4) | 26.5–28.2 | 0.3** | 0.27–0.33 | 1566(1.0) | 0.9–1.1 | 0.28** | 0.21–0.37 |
East | 6117(31.7) | 30.0–33.5 | 0.41** | 0.36–0.46 | 1911(1.2) | 1.1–1.3 | 0.29** | 0.21–0.39 |
North- East | 1376(40.5) | 38.4–42.6 | 0.6** | 0.53–0.68 | 1561(6.9) | 6.4–7.5 | 2.05** | 1.44–2.92 |
West | 3246(17.0) | 15.5–18.5 | 0.16** | 0.14–0.18 | 277(0.3) | 0.2–0.4 | 0.08** | 0.05–0.14 |
South | 9842(40.6) | 39.1–42.1 | Reference (1.0) | Reference (1.0) | 2887(1.8) | 1.6–2.0 | Reference (1.0) | Reference (1.0) |
Educational Level |
No Education | 4876(39.9) | 38.5–41.3 | 1.13* | 1.02–1.26 | 5074(2.6) | 2.5–2.8 | 1.83** | 1.19–2.82 |
Primary | 4537(36.6) | 35.2–38.0 | 1.05 | 0.94–1.17 | 970(1.1) | 1.0–1.2 | 0.97 | 0.61–1.54 |
Secondary | 16337(27.1) | 26.4–27.8 | 0.97 | 0.89–1.05 | 1977(0.6) | 0.5–0.7 | 0.79 | 0.53–1.18 |
Higher | 4415(24.0) | 22.7–25.2 | Reference (1.0) | Reference (1.0) | 615(0.7) | 0.6–0.8 | Reference (1.0) | Reference (1.0) |
Religion |
Hindu | 26585(31.6) | 30.9–32.2 | 0.48** | 0.41–0.58 | 7323(1.3) | 1.2–1.4 | 0.36** | 0.27–0.48 |
Muslim | 1561(11.3) | 10.2–12.5 | 0.11** | 0.09–0.14 | 137(0.1) | 0.1–0.2 | 0.06** | 0.02–0.15 |
Christian | 973(42.8) | 39.6–46.0 | 0.53** | 0.42–0.66 | 668(4.0) | 3.5–4.6 | 0.25** | 0.16–0.41 |
Others | 1046(33.4) | 30.8–36.2 | Reference (1.0) | Reference (1.0) | 508(2.2) | 2.0–2.5 | Reference (1.0) | Reference (1.0) |
Social Category |
Others | 5188(21.6) | 20.4–22.8 | 0.88** | 0.81–0.96 | 754(0.5) | 0.4–0.6 | 1.5* | 1.07–2.11 |
Schedule Caste | 7442(36.3) | 35.1–37.6 | 1.22** | 1.13–1.31 | 1251(0.9) | 0.8–1.0 | 1.02 | 0.77–1.36 |
Schedule Tribe | 3775(41.3) | 39.7–43.0 | 1.67** | 1.53–1.82 | 4145(6.5) | 6.1–6.9 | 5.99** | 4.71–7.63 |
Other Backward Classes | 12872(28.5) | 27.7–29.4 | Reference (1.0) | Reference (1.0) | 2229(0.7) | 0.7–0.8 | Reference (1.0) | Reference (1.0) |
Wealth Index |
Poorest | 5387(35.4) | 34.2–36.6 | 0.95 | 0.85–1.06 | 3596(2.9) | 2.8–3.1 | 1.75** | 1.24–2.48 |
Poorer | 5796(29.9) | 28.8–31.0 | 0.83** | 0.75–0.92 | 1931(1.4) | 1.3–1.5 | 0.93 | 0.65–1.34 |
Middle | 6623(30.0) | 29.0 -31.1 | 0.88* | 0.80–0.97 | 1367(1.0) | 0.9–1.1 | 0.8 | 0.55–1.17 |
Richer | 6376(27.8) | 26.6–29.0 | 0.87** | 0.79–0.96 | 829(0.6) | 0.5–0.6 | 0.84 | 0.57–1.24 |
Richest | 5982(25.1) | 23.8–26.5 | Reference (1.0) | Reference (1.0) | 911(0.6) | 0.5–0.7 | Reference (1.0) | Reference (1.0) |
Marital Status |
Never Married | 7406(18.7) | 17.9–19.5 | 0.82 | 0.66–1.03 | 1035(0.7) | 0.6–0.7 | 1.05 | 0.73–1.52 |
Married | 22242(35.6) | 34.8–36.3 | 0.89 | 0.72–1.14 | 6765(1.3) | 1.3–1.4 | 0.8 | 0.62–1.04 |
Others | 517(40.4) | 35.9–45.1 | Reference (1.0) | Reference (1.0) | 837(2.9) | 2.5–3.2 | Reference (1.0) | Reference (1.0) |
Occupation |
Not Working | 3322(13.9) | 13.2–14.7 | 0.49** | 0.44–0.53 | 607(0.7) | 0.6–0.8 | 0.55** | 0.44–0.69 |
Professional / Managerial | 1801(27.1) | 25.2–29.2 | 0.73** | 0.63–0.83 | 43(1.2) | 0.6–2.4 | 0.72 | 0.38–1.36 |
Clerical / Sales / Services | 6236(32.8) | 31.3–34.3 | 0.92 | 0.84–1.01 | 123(1.9) | 1.2–3.1 | 0.86 | 0.58–1.27 |
Agricultural | 8607(32.2) | 31.2–33.1 | 0.69** | 0.64–0.73 | 535(3.0) | 2.6–3.5 | 1 | 0.79–1.27 |
Skilled / Unskilled Manual | 10148(37.7) | 36.5–38.8 | Reference (1.0) | Reference (1.0) | 185(2.4) | 2.0–3.0 | Reference (1.0) | Reference (1.0) |
CI- Confidence Interval |
** P < 0.01; |
* P < 0.05; |
South Indian men (aOR: 1), and NE men (aOR: 0.6) and women (aOR: 2.5) consume more alcohol. The place of residence (urban or rural) does not influence the consumption pattern in both men and women. Alcohol consumption among women increases with age, and is higher in women greater than 40 years (aOR: 0.61, 0.81 and 1.0 respectively for 15–24, 25–39 and > 40 years). Alcohol use is higher in men > 25 years. Married women consume less alcohol, while married and divorced / separated men consume more alcohol than never married.
Women from the poorest wealth index (aOR: 1.75), and uneducated background (aOR: 1.83) have high prevalence of alcohol consumption compared to the richest and highly educated. When occupation was analyzed in women, manual laborers (aOR: 1.0) and agricultural workers (aOR: 1.0) consumed more alcohol than other class of workers, while in men, no such association were observed.
Among the SDI, religion and social category had the greatest influence on alcohol use. Compared to other religions, Muslim men (aOR: 0.11) and women (aOR: 0.06) consume less alcohol. Among the different social categories in men, scheduled tribes (aOR: 1.67) and scheduled castes (aOR: 1.22) have higher alcohol prevalence. Compared to the Other Backward Castes (OBC), ST women have six times higher odds of consuming alcohol.