I think it's quite a public school thing to say- the word 'Booze-meister'. I've never actually had the opportunity to hear anyone in real life use it but I think it's fair to say I've had enough experience working and communicating with people who are more fortunate than me in terms of socio-demographic status at a younger age. Booze-meister is just one of them. There are many more posh terms making reference to a wide array of activities undertaken by the upper-middle class who seek their education from independent schools across the country, such as drug use, with cannabis smoking being quite a hobby. It is wrong to construe it as a mere 'out-of-touch' activity that is only coherent in public school circles. In fact, universities have long been clouded by such trends that these become the stereotypes of 'the uni life' etched on sixth-formers' minds. Many of the older generation also tend to stereotype younger people as avid drinkers (alcohol). While there is some truth to it, things are changing, according to a recent study done by UCL. [1] Researchers have found that non-drinking seems to be the new 'cool' - a new trend that reverses the old. It seems that the likes of JB from Fresh Meat (Channel 4 drama series) are no longer representative of this generation of young people. Let's take a look at what the paper says. Then, we can delve deeper in the issues associated with its findings.
Just as a disclaimer, I've never been particularly immersed in any drinking culture, if there is one in the first place. The occasions where I have voluntarily consumed alcohol are fewer than the times I get praised by a professor (well...) so that's that.
Study Introduction
The study, published in 2018, is a retrospective (meaning that it garners data from a central source, in this case the Health Survey for England data for the time period 2005-2015) descriptive study, where the trends and behaviours of drinking (alcohol) of young people (defined as those falling in the 16-24 years age bracket). It does not delve deep in the reasons behind and recommends the execution of qualitative studies to explore the attitudes behind drinking. Cultural reasons are suggested - although the study has lighted up that in the past, non-drinking is stigmatised, it seems that the non-drinking culture amongst young people has emerged as the new 'cool' and taken root. Two big notes before reading the data are that (1) everything mentioned only applies to England, not other parts of the UK. So, if you're Scottish and are wondering why your observations are inconsistent with the results of the study - well, you're not in the right place at all; (2) all factors stated in the study, such as mental health status, employment status and BMI, are all correlates. Correlation is not equivalent to causation in medicine, since two factors can be correlated but one is not the cause of the other. For example, increased non-drinking amongst those who are in full-time employment can be due to many reasons. The fact that they're in full-time employment does not necessarily cause the phenomenon.
Variables, Data and Discussion
The following factors are included in the study:
- Sociodemographic Factors: Ethnicity (broad, not broken down to separate categories, just white and non-white; I guess this is because of simplicity); Gender (assuming it means birth gender); Whether in Full-time Education or not; Employment Status; Household Socioeconomic Status; Urban Location, Geography (North versus South in England);
- Health Behaviours and Parameters: Mental Health Status (dichotomised, not graded for the purposes of simplicity; where good mental health is defined as scoring Zero [0] on the questionnaires; anything equal to or above 1 indicates impaired mental health), Exercise Habits, Diet (defined as the quantity of fruit/vegetable consumption), Smoking Behaviour (dichotomised: yes or no);
With regard to these factors, the study wishes to explore several correlations:
(1) Whether these factors are related to (not causation) non-drinking behaviour in the 16-24 years population;
(2) Describing the trend of non-drinking and the 'type' of non-drinker, e.g. life abstainers (never having tried alcohol), previous drinkers (those who drank but got it out of their systems), occasional drinkers;
(3) Have the chances of being a non-drinker increased for any subgroup over time?
(4) The correlation between increased non-drinking proportion in the young population, and the changes in mean consumption and heavy episodic drinking over time. Here, two parameters are devised- not drinking in the last week, and drinking on the heaviest drinking day (the first one is dichotomised into affirmative/negative, and the second one, segregated into three different categories: within limits, above limits and binge).
For all of those worried about the limits, a definition is provided: =< 4 units for men and 3 units for women, daily.
So, what are the results?
In consideration of previous studies, it has been established that non-drinking behaviour is associated with lower education status, lower income, unemployment and lower socio-economic status. However, while results still lend credence to part of it, the general trend is changing. There is a general increase in the percentage of non-drinkers, especially life-abstainers (rising from 9% in 2005 to 17% in 2015). There is an increase in the percentage of the young population (in general) that has not engaged in drinking for the past week (35% in 2005 risen to 50% in 2015). This figure includes young people who identify as drinkers. Even on the day where the heaviest drinking takes place, the percentage of the drinking population that has gone 'above limit' is substantially lower (43% in 2005 to 28% in 2015). The percentage of binge drinkers has dropped for around 10%.
In terms of sociodemographic features and health behaviours, the following trends are deduced:
More non-drinkers belong to the sub-bracket 16-17 years, as compared to the sub-bracket 18-24 years; This can be attributed partly to the fact that it is illegal to sell alcohol to minors (aka individuals under the age of 18) in England;
The percentage of non-drinkers remains stable and much higher in people of non-white ethnicity (54% in 2005, risen above 60% from 2012 to 2015); however, the percentage of non-drinkers in the white population (of the sample) has risen considerably (43% from 2005 to 2015);
There are higher percentages in non-drinkers in the North, urban dwellers and those residing in towns/villages;
Although those residing in the most deprived regions still accommodate a larger percentage of non-drinkers than those living in least deprived regions, the percentage rise of non-drinkers of those living in least deprived regions is significantly greater (81% as compared to 42%);
Those classified as 'intermediate' in terms of household social class have the highest percentage of non-drinkers. They also have the greatest percentage rise of non-drinkers;
Those in full-time education accommodate more non-drinkers than those otherwise;
A higher faction of the unemployed population do not drink (38% as compared to 18% in 2015) but the percentage rise of non-drinkers in the employed population is more significant (100% as compared to 46%);
Higher percentages of non-drinkers are also recorded in the following subgroups by health determinants: normal/underweight individuals, better mental health and those without long-standing illnesses.
This suggests a shift in the paradigm of understanding. Traditionally, as from the data garnered, we can naturally infer that, since alcohol consumption entails greater costs, those who are of lower socio-economic status are more prone to not drink. This observation can, however, be confounded by factors such as the presence of psychiatric illnesses precipitated by strong environmental factors, such as depression and schizophrenia. The data presented above shows that the tide is changing. Although old factors continue to be relevant, as exemplified by the fact that the unemployed and residents of the most deprived regions still accommodate the highest percentages of non-drinkers, more individuals from the other subgroups indicative of better well-being* opt not to drink. It is a lifestyle choice rather than, necessarily, a coerced habit due to impoverishment.
However, the data should also be read with caution. Although I cannot pretend not to be pedantic, the dataset is not entirely complete. This rings true for the collection of data for mental health status for certain years. Moreover, as the registry only provides annual data, comparisons and trends might not be as fine as one might have expected. We may be able to derive a broad trend occurring in the past ten years, but not month-on-month or quarter-on-quarter alterations. I know this study is meant to be read as an overview. However, I need to point out that many parameters are dichotomised, such as ethnicity, residence in deprived region and mental health status. Sub-analyses can be performed to reflect changes in the proportion of the non-drinking population in more subgroups.
Postulations
There are many factors underlying this. Although not explicitly elaborated or extrapolated by the study, I think it can be due to the shifting attitudes towards health. Rather than focusing on the 'chicness' of participating in the drinking culture, many are more informed about health consequences, especially due to the rise of mass media and the proliferation of channels to obtain health information. For instance, Cochrane Reviews and NICE Guidelines, both being the key sources of health information and best medical practices in England, host a series of social media platforms for promoting core health messages. There is also a stronger emphasis on longevity and alternative hobbies. Conroy has written an article elaborating on the various changes which may have taken place in the communication and socialisation of the younger population. [2] This includes the rise of alcohol-free accommodation (university accommodation for instance; I've once stayed in a student flat in Ireland. Alcohol is expressly prohibited; long story short, I did NOT learn this the hard way), the changing locations of socialisation and the exertion of peer pressure. Socialisation shifts from traditional locations such as pubs and clubs to cafes and university spaces, where alcohol is banned. This might be due to the increase in international students, where some of these students originate from countries which are less liberal than the West when it comes to alcohol and drugs. Increased mixing between local and international students may have contributed, in my opinion, the decreased peer pressure regarding drinking in social occasions. Due to COVID, socialisation online is also more preponderant than ever. Face-to-face communication is stunted by long periods of COVID restrictions, while bars and pubs are closed during lockdown. Many, even if such venues are open, refuse to meet each other in these places, in fear of infection. I, for one, simply have to decline invitations to crowded areas (if you count that one sympathetic female friend who wants to check in with me over a drink...). Due to the rise of social media and feminism, we can also cheer at the fact that there are more sources in promotion of ways as to how young people can protect themselves from sexual assault. Not trying to stereotype certain places, but whenever one is in a location where alcohol is never far from reach, intoxication and inebriation are never distant possibilities. Young people nowadays are equipped with tougher shields of knowledge to protect themselves from being taken advantage.
There is also considerable discussion of movements such as 'Dry January.' [3] Dry January, a movement that I haven't quite heard of prior to reading relevant articles, has first started as a fundraising event in promulgation of the ramifications of prolonged intoxication. As we all know, chronic alcohol consumption can lead to myriads of devastating issues, including liver disease, obesity and mental health issues (funnily enough, as we'll explore later, it is rather difficult to untangle the complex relationship between substance abuse, alcohol dependency and recognised psychiatric conditions, including depression and borderline personality disorder). Dry January basically requires participants to abstain from drinking for a whole month. However, while such movements mean well and come from a fairly good place (judging by the motive), we cannot be blind-sighted by its purported benefits. Indeed, there are two main modes of self-control: moderation and abstinence, with the latter adopted as well when the former fails. [4] Abstinence over 2 days per week is recommended. [3] However, abstinence over such a long period of time entails two core issues: (a) the abstinence period is likely to be shortened and overcome with the desire to drink and the emergence of withdrawal symptoms, (b) the rebound effect is greater. More importantly, it delivers the wrong message. Moderation and abstinence are long-term goals and practices. Alcohol misuse can be approached by a cornucopia of ways, including cognitive behavioural therapy (CBT), 12-step facilitation therapy (as devised by Alcoholics Anonymous) and family therapy. However, not one method stands alone. They complement each other and just like alcoholic dependence, setting things straight means you must be in for the long haul. To say that everything will magically disappear after a month of abstinence is simply fairy dust.
Withdrawal
To understand withdrawal effects, we first need to know the mechanism of action of alcohol itself. Alcohol, or more commonly, ethanol (alcohol is the blanket term covering all manners of chemicals with the functional group -OH; ethanol is the most common form, with two carbon atoms), acts by binding towards different receptors in the brain. The brain is a gigantic trove of neurones**. Neurones are responsible for transmitting messages between each other, similar to telephone calls or an email. Electric messages dart from one point to another rapidly. For instance, if I want to order my foot to move, this command arises from my prefrontal cortex. It then gets transmitted to the motor cortex and heads downwards, all the way to the designated foot through the spinal cord and the peripheral nerves branched out from it. Neurones don't always stimulate each other. Sometimes, they inhibit each other. That's a good thing, since it makes sure that an equilibrium is achieved. Neuronal communication is performed by the 'meeting' - the point of which is called a synapse, where neurotransmitters (specific chemicals) are released from the synaptic terminal, to be received by the receptors on the other side (also known as the post-synaptic neurone). The stimulation or inhibition of the communication is determined by the type of neurotransmitter. Some, like serotonin, dopamine and glutamate, serve to stimulate. Others, like GABA and glycine, serve to inhibit.
Diagram showing a synaptic terminal (extracted from: http://antranik.org/synaptic-transmission-by-somatic-motorneurons/)
A key issue here is the role of alcohol. Alcohol, through a lot of mechanisms including the stimulation of GABA receptors and glycine receptors and the dampening of NMDA receptors (stimulatory normally), decreases neurotransmission. Brain function cannot be performed normally. Moreover, voltage-gated calcium channels, which help facilitate neurotransmission (the communication between different neurones) are adversely affected by alcohol. This leads to the impaired consciousness, memory and executive functions that alcohol consumption entails. As alcohol exerts its effects as well on the cerebellum, one also finds difficulty in balancing. [5-6]
Withdrawal effects arise when the body is not having what it's used to having. It's like a toddler who's always treated to three ice creams a day suddenly being told that he can't have any on a particular day. The body gets furious and irritated. Patients with alcoholic dependence exhibit withdrawal symptoms which are totally opposite to the effects of alcohol. It's similar to over-compensation (we all know that one person who drives such a big car to work). Giving an example, patients with alcoholism lasting for a month, if forced to abstain, are likely to experience a phenomenon called Delirium Tremens in the following few days. It is an acute syndrome whose symptoms are defined by the triad of disorientation, mental confusion and tremors. Hallucinations are also present. Many patients also experience common withdrawal symptoms reminiscent of the activation of the fight-or-flight mechanism, including sweating, insomnia, anxiety and restlessness. More than five per cent of patients also experience seizures due to the increase in electric currents traversing the brain parenchyma. As time goes by, alcohol diminishes the body's reserve of a little something called Vitamin B. More specifically, it's Vitamin B1 or Thiamine. Thiamine is crucial for the normal functioning of neurones: metabolising glucose and other forms of carbohydrates and amino acids (the subunit of proteins), the production of the protective coating of neurones (myelin sheath), neurotransmission and so forth - basic housekeeping. When thiamine is in short supply after weeks and weeks of alcoholic consumption, things start to go wrong. Brain diseases such as Wernicke's Encephalopathy and Korsakoff Psychosis (where there is a memory impairment; one of my professors ardently compared patients with this condition with medical students, where when one doesn't remember a particular fact or facet of knowledge, one makes it up!***) occur. Wernicke's Encephalopathy entails many issues, such as movement problems (ataxia) and eye problems (vertical nystagmus -> eye weirdly going up acutely, then chronically down [9]). Such withdrawal symptoms are very likely to deter one from accomplishing that so-called 'period of challenge' in Dry January. [7-8]
Diagram showing the symptoms of Thiamine Deficiency (there are four categories under this: Wernicke's Encephalopathy, usually due to alcoholic dependence, Wet Beriberi - high-output heart failure, Shoshin Beriberi - low-output heart failure, and Dry Beriberi - peripheral neuropathy) (extracted from: https://www.rnpedia.com/nursing-notes/psychiatric-nursing-notes/wernickes-encephalopathy/)
Alcohol use is a fascinating area of research. The UCL study highlights the current trends of drinking behaviour in the younger population. Needless to say, we must not be complacent. Public health programmes should be made accessible and available for individuals regardless of age. Such efforts should be fortified, increasing outreach and support especially during COVID lockdowns, where being restricted to one's home certainly entails considerable detriment to one's mental wellbeing. Withdrawal symptoms are serious and can be an impediment towards abstinence. As with alcohol dependence, fixing the issue requires one to be fully devoted in the long-term. The key to moderation and abstinence is taking slow but sure steps. If you're at any point struggling with a drinking problem, you can contact Alcoholics Anonymous on their helpline: 0800 9177650 or drop them a line via help@aamail.org. Of course, don't hesitate to share your issues with your family and friends. Or, if you are experiencing related mental health issues, do check out the page (on this website) Medics' Mental Health.
*Here, I define those with better well-being as those who: (1) have better mental health, (2) are normal/underweight, (3) are classified as of higher socio-economic class and reside in the least deprived regions; (4) are employed or in full-time education.
**This is a reminder of the neurone-neuron debate; in UK English, it's always been 'neurone'. However, in the US and the scientific world, 'neuron' is the preferred term. Actually, I've learnt the latter initially from New Scientist (I really love that magazine).
***This is delicately summarised by the word 'confabulation'. And no, I never have that said to me.
[1] Fat LN, Shelton N, Cable N. (2018). Investigating the growing trend of nondrinking
among young people; analysis of repeated cross-sectional surveys in England 2005–2015. BMC Public Health. 18:1090. doi: https://doi.org/10.1186/s12889-018-5995-3.
[2] Conroy D. (2020). Why young people are drinking less – and what older drinkers can learn from them. The Conversation. Retrieved 29 November 2020, from https://theconversation.com/why-young-people-are-drinking-less-and-what-older-drinkers-can-learn-from-them-133020.
[3] Hamilton I. (2016). Dry January: is it worth giving up alcohol for a month?. The Conversation. Retrieved 29 November 2020, from https://theconversation.com/dry-january-is-it-worth-giving-up-alcohol-for-a-month-51956.
[4] Alcohol misuse - Treatment. NHS. (2020). Retrieved 29 November 2020, from https://www.nhs.uk/conditions/alcohol-misuse/treatment/.
[5] Davies M. (2003). The role of GABAA receptors in mediating the effects of alcohol in the central nervous system. Journal of psychiatry & neuroscience : JPN, 28(4), 263–274.
[6] Enoch MA (2008). The role of GABA(A) receptors in the development of alcoholism. Pharmacology, biochemistry, and behavior, 90(1), 95–104. https://doi.org/10.1016/j.pbb.2008.03.007.
[7] Trevisan LA, Boutros N, Petrakis IL, Krystal JH. (1998). Complications of alcohol withdrawal: pathophysiological insights. Alcohol health and research world, 22(1), 61–66.
[8] Thomson AD, Marshall EJ. (2006). The natural history and pathophysiology of Wernicke's Encephalopathy and Korsakoff's Psychosis. Alcohol Alcohol. 41(2):151-8.
[9] Kattah JC, McClelland C, Zee DS. (2019). Vertical nystagmus in Wernicke's encephalopathy: pathogenesis and role of central processing of information from the otoliths. Journal of neurology, 266(Suppl 1), 139–145. https://doi.org/10.1007/s00415-019-09326-9.
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