Underage drinking, group identity and access to alcohol: a qualitative study of Chinese youths

Abstract

Despite substantial research into underage youth’s source of alcohol, few studies have examined how they go about obtaining alcohol through various means. This study explored the nature of alcohol access by Chinese adolescents and how their own perceptions around alcohol availability influence them to source alcohol in particular ways. This research involved focus groups with 111 young people aged 14–17 in Hong Kong, China. A grounded theory analysis was conducted using NVivo 10. While participants perceived ease of obtaining alcohol from retail outlets, proxy purchasing through friendship group members was reported as routine experience primarily to avoid potential embarrassment of being turned away. Convincing vendors that they were of legal drinking age was the convention used most commonly by Chinese teen drinkers. Participants expressed resentment toward adults who were willing to supply minors with alcohol. Nevertheless, this feeling of disappointment did not alter the ways they sourced alcohol. Access activities embodied a symbol of group identity in the collectivist Chinese culture. Results suggest that greater consideration should be given to understanding the complex interplay between alcohol access and community experience within peers. The perceived importance of face saving in Chinese culture may provide avenues for preventing youth access to alcohol.

Introduction

There is growing evidence that alcohol availability is positively associated with underage drinking, i.e. the easier alcohol is to obtain, the more alcohol is consumed. Research into youth and alcohol suggests that supply factors invariably appeared to be an important predictor of underage alcohol use. For example, increasing the minimum drinking age and enforcement of underage sales contribute to reduction in underage alcohol consumption while parental provision of alcohol and home alcohol accessibility are associated with increase in the trajectories of young adolescent alcohol use and intentions [1–5].

The aim of this study is to explore how Chinese underage youth in Hong Kong source alcohol and what specific conventions or practices are involved in the method of sourcing they use. Hong Kong is the most westernized and urbanized city in China. The prevalence of alcohol drinking (past 30 days) in Hong Kong Chinese youth was 24% in 2012, which was lower than that in Western countries (e.g. 39% in US, 65% UK) [6, 7]. While many countries and jurisdictions in the West have used legislative measures to restrict underage youth’s access to commercial sources, Hong Kong put a strong emphasis on laissez-faire capitalism when it comes to regulating alcohol access by minors—off-premise alcohol sales to persons aged below 18 years are exclusively subject to industry voluntary codes of conduct. In addition to this legal loophole, in Chinese culture, alcohol drinking is commonly characterized by the coming together of friends and relatives for celebrations, during which adolescents are often encouraged to try drinking [8–10]. This implies that social sources such as family, friends and social networks are also an important means of accessing alcohol for Chinese underage young people.

Studies examining alcohol availability suggest that underage youth obtain alcohol from a variety of sources and that avenues for acquiring alcohol broaden as youths progress to drink more alcohol [2, 11–13]. As restrictions increase, young people were found to develop complex approaches for acquiring alcohol through alternative sources [14, 15]. Despite the evidence, the majority of studies on youth alcohol access consist of quantitative research on the sources of alcohol for young people. Little is known about how they go about obtaining alcohol through various means and the tactics they employ to ensure success in the acquisition of alcohol [16]. In addition, the literature has mainly focused on adolescents in the Western societies, rendering little insight into comprehending alcohol access behaviors of Chinese adolescents who consume less alcohol than their Western counterparts.

This study used qualitative methods to understand the nature of alcohol access by Chinese adolescents and how their own perceptions around alcohol availability influence them to source alcohol in particular ways. By doing so, this study sought to enrich our understanding of Chinese adolescents’ alcohol access behaviors and inform the development of pertinent approaches and measures for reducing the underage young people’s alcohol access. The use of qualitative method enabled a more in-depth understanding of Chinese adolescents’ alcohol access behaviors and the context in which access activities take place. This qualitative exploration thus serves to complement the breadth of understanding afforded by the existing quantitative studies. In addition, this study contributes to the literature on youth alcohol access behaviors across different social, economic, cultural and regulatory environments.

Materials and methods

Sampling and recruitment

To recruit a diverse range of adolescents, the research team contacted 44 secondary schools in 3 geographical areas of Hong Kong. Thirteen schools (29.5%) agreed to participate. The main reason given for non-participation was there being too many surveys interrupting normal teaching activities. We distributed a one-page screening questionnaire on drinking behavior (e.g. age of one’s first drink; use of alcohol in the past 30 days, 1 year and one’s lifetime; age; gender; grade) to one randomly selected class in each of four grades (grades 3–6) per school. Written consent from parents was gained prior to the questionnaire distribution. At the end of the questionnaire, students were asked to leave their contact details if they were willing to participate in the focus group discussion. Out of 2744 questionnaires distributed, 2271 questionnaires (82.7%) were returned and 538 students (23.7%) provided their contact details. It is unclear why the majority of students refused to participate, but it could be that students were uncomfortable providing personal information to the research team. While the one-page screening questionnaire was used to check the eligibility (adolescents aged between 14 and 17 years) and interest for interview participation, we purposively selected participants of different age, gender, geographical location and drinking status (both drinkers and non-drinkers were included) to maximize the diversity of perspectives and experience. A total of 131 students were contacted by our research staff and 111 students (84.7%) agreed to participate in the focus group discussion. Reasons for refusal included being too busy or unavailable, feeling uncomfortable and lost interest in study participation.

Focus groups

We used focus groups to enable adolescents to discuss alcohol access activities within their sub-cultural context. The final decision on sample size was based on evidence that data saturation had been reached. Data saturation was achieved when the themes generated during the concurrent analysis were not augmented by further interviews. Data collection was finalized with 22 focus groups. Group sizes varied from three to seven (Table I). Focus groups were formed in terms of participants’ similar characteristics and circumstances (i.e. gender, school and year at school) so that participants felt more at ease at discussion. Written informed consent from parents and participants were collected before each session commenced. A topic guide was developed to ensure that all topics of interest were covered but at the same time allowed for flexibility should participants raise new topics of relevance. Confidentiality of all personal information was emphasized. The focus groups typically lasted 90 min or less, and were conducted by two moderators with one taking detailed observational notes. All interviews except two (undertaken in a youth community center) were conducted in a classroom of the participants’ schools. School staff or teachers were not present during the data collection.

Table I.

Focus group composition

Number of focus group (n = 22)	Number of participants (n = 111)	Age range	Sex
1	4	17	Girls only
2	6	16–17	Girls only
3	6	15–17	Girls only
4	6	16–17	Girls only
5	5	15–17	Girls only
6	6	15–17	Girls only
7	5	17	Girls only
8	3	15–17	Girls only
9	5	14–16	Girls only
10	3	15–16	Boys only
11	5	15–17	Boys only
12	6	15–18	Boys only
13	7	13–17	Boys only
14	6	16–18	Boys only
15	4	15–16	Boys only
16	4	17	Boys only
17	5	16–17	Boys only
18	5	16–17	Boys only
19	5	16–17	Mixed
20	6	15–18	Mixed
21	6	15–16	Mixed
22	3	15	Mixed

Data analysis

All interviews were audio-recorded and transcribed verbatim. The transcripts were analyzed thematically based upon grounded theory [17]. The search for themes began by reading and immersing within a single transcript to note preliminary interpretations. A list of emerging themes and the relationships that they have with each other allowed them to be grouped together as master themes. A code was assigned to each theme using NVivo 10 software. The list of emerging themes was then compared with those generated through the remaining transcripts. This process allowed themes and explanations to arise inductively from the data. Two authors each independently coded a sub-set of data and compared coding. Consensus was reached through discussion and iterative review of codes and categories. This involved a process of constant comparison between and within categories, and refining and recoding of the text till an array of interlinking themes was elicited. All codes were then reviewed together by the research team to ensure that common themes reflected a shared understanding among participants of the phenomena under investigation. Ethics approval was granted by the Institutional Review Board of the University of Hong Kong.

Results

About half of the participants were female and 80% reported to have tried more than a sip of alcohol in their lifetime. The average age for first alcohol use was 13.1 years. More than half of the participants had experience of alcohol use in the past 1 year whereas 34% of them drank alcohol in the past 1 month (Table II).

Table II.

Demographic and drinking characteristics of participants

	Number of participants (%)
Gender
Male	56 (50.5)
Female	55 (49.5)
Age
≤14	3 (2.7)
15	33 (29.7)
16	26 (23.4)
≥17	47 (44.2)
Grade
≤S3	13 (13.5)
S4	51 (45.9)
S5	39 (35.1)
S6	6 (5.4)
Drinking status
Lifetime	90 (81.1)
During the last 12 months	63 (56.8)
During the last 30 days	38 (34.2)
Age of first alcohol use	13.09 ± 1.95

Drinking as a social activity

Before we set out to explore how adolescents go about obtaining alcohol, it is useful to get a picture of how Chinese teenage drinking in Hong Kong takes place. For many of our participants, drinking is usually undertaken in the company with peers at special occasions such as friends’ birthdays, school breaks and Lunar New Year festivals. This occasional alcohol drinking was established as the key facilitator of group bonding and thus consumption was seen as integral to the experience of peer interactions. Since alcohol drinking was primarily about having fun with peers, consumption was more likely to be in public spaces and commercial venues with many participants citing streets, parks and local food stalls where they regularly frequented. Whereas decisions on how much to drink differed across groups depending on normative expectations surrounding the perceived intoxicated states, the pursuit of drunkenness was seen as inappropriate by the majority of our participants [10]. We identified several recurring and prominent themes regarding the sources of alcohol and access strategies amongst Chinese underage youths.

Finding ways to access alcohol

Adolescents in this study used several routes to access alcohol. These routes appear to be related to their age, how frequently they drink, parents’ views about their drinking and the type of licensed premises in the neighborhood. The most commonly reported source was buying alcohol directly from retail outlets. Such attempts often involved small independent family owned shops and grocers than larger outlets that were perceived to more strictly enforce the store policy on sales of alcohol to minors. Participants had common knowledge about the relative ease of access from small shops and it appeared that even non-drinkers were aware of which shops allowed underage drinkers to purchase alcohol.

• “You know where to go after a while. You can find a small grocery store in your neighborhood. They won’t ask for your ID.” (female, 16 years old, non-drinker)

On-premise establishments were equally seen as an important source of alcohol where access to alcohol was mostly guaranteed. Attempts were facilitated by the apparent complicity with the attendants who were not even willing to check ID. Discussions also indicated that young people quickly acquired knowledge as to which outlets and premises were easier to obtain alcohol through word of mouth.

• “Everyone knows which restaurants…There is this all-you-can-eat Chinese hot pot restaurant. We can take beer anytime from the fridge in there.” (female, 16 years old)

• “We went to the Japanese buffet restaurant a few weeks ago. All you can drink Sake [Japanese rice wine] came with our dinner. They didn’t ask a thing.” (female, 17 years old)

Buying through others was another important alcohol source for Chinese adolescents, especially when drinking outdoors. What emerged distinct from our data was that no participants relied on complete strangers to act as their agents. Thus proxy purchasing through opportunistic encounters was not a visible practice among our participants. Instead, peers of legal drinking age in a mixed aged group or more commonly older looking members of the group purchased alcohol for everyone using funds contributed by all members. They used this method because they wanted to avoid potential embarrassment of being turned away.

• “There are always some friends who look mature in a group. They usually get alcohol for everyone.” (male, 17 years old)

• “I am not afraid of drinking but I am afraid of buying actually. I would be embarrassed if somebody says no. So usually purchasing is done by one of my friends.” (female 16 years old)

Typically, the proxy purchasers belonged to the same friendship network and no monetary gains or profiting were reportedly involved. Occasional drinkers appeared to use proxy purchase more often since they tended to be younger and would therefore find it less problematic to acquire alcohol from friends.

A less commonly reported source was the family home. Many participants stated that their parents limited the context in which children could consume alcohol such as Chinese reunion dinner at the eve of Spring Festival or having relatives over for a visit. Among some, there was a tacit acceptance that children could drink outside of the home as long as drinking did not take place on a regular basis and that the amount of alcohol was limited (e.g. a can of beer). However, participants commonly noted that parents would not supply their children and children’s friends with alcohol. This means that drinking with a group of friends within their own homes while parents are present was not an option for many of our participants.

Sourcing alcohol from home was more common among younger participants who began to experiment with alcohol, and access to alcohol was associated with family members who were drinkers and the amount of alcohol stored in the home. A recurring observation was that participants simply took alcoholic beverages purchased by parents—typically without them knowing—but this would only be possible if there were many different beverages around. Commonly, alcohol was kept unlocked in locations easily accessible to youths in the home. Participants reported having little concern about being caught since parents would not notice unless significant quantities of alcohol went missing.

• “I can find some alcohol around the house all the time. I drank a can of beer after my parents were asleep. My dad is OK with me drinking but I decided not to tell him.”(male, 15 years old)

• “My dad usually buys a twelve pack of beer and they are in the refrigerator. I took one but he never noticed.”(male, 14 years old)

Perceived accessibility to alcohol

Running through the accounts of participants was the perceived ease of obtaining alcoholic beverages from both retail outlets and on-premise establishments. It was commonly felt that proof of age was unnecessary.

• “If you have money, you can get it. If you don’t have money, you can’t (laughs).” (male, 17 years old)

• “They might ask your age at some large supermarket chains. But if you say you’re 18, they wouldn’t bother to ask you to show your ID.”(female, 17 years old)

Buying alcohol was not only easy but also involved little risk since there were no negative consequences for trying. Some participants, more prominently regular drinkers, reported to have attempted to make purchases at many varied venues since they had not been challenged even after the service being denied. This indicates that purchasing skills and confidence evolved over time as adolescents became more experienced consumers.

By and large, participants were not knowledgeable about the specifics of the laws that target underage drinking. No one in the study was aware of the absence of legislative measures pertaining to off-premise alcohol sales to minors. There was a mixed perception as to whether legislative changes would reduce youth access to alcohol: whereas some had skepticism over the effect of changing the law on their ability to access alcohol, others felt that sanctions and law enforcement could limit the underage young people’s drinking behavior. Non-drinkers were more likely to give a positive response to the legislative changes.

• “Even if there is a prohibition against selling alcohol to those underage people, it doesn’t matter because some people will know where to go and get served.” (male, 17 years old)

• “Well, if it[law] is changed one day, I think it will make a difference because people of my age are going to be worried about getting caught.” (female, 16 years old, non-drinker)

Following the protocol: tactics employed to ensure success

Despite the perceived ease of alcohol access, nearly all participants believed that it is ‘illegal’ for underage persons to purchase alcohol from commercial sources. Thus, potential negative consequences of acquiring alcohol (e.g. sanctions after being caught) were felt to be avoided as far as possible. Our participants described various yet sophisticated tactics to which they resorted when in shops or on-premises to secure purchases.

Convincing vendors that they were of legal drinking age, such as removing items of school uniform and saying that they had forgotten to carry ID, was the tactic used most commonly by teen Chinese drinkers. Other tactics included avoiding premises that posted signs on responsible alcohol sales, saying that they were buying for parents, or choosing alcohol products with lower alcohol content. However, participants consistently maintained that most of the time, ID was not even asked for. Many reported that they were rarely confronted with vendors asking for their age or ID even in larger outlets.

• “It is pretty easy if you are not wearing a school uniform. You can walk into a supermarket and buy the whole pack.” (female, 15 years old)

• “The lower the alcohol content is, the easier you will get the drink. If the alcohol content is high, like Chinese rice wine, you’re less likely to get it.” (male, 16 years old)

• “When hanging out with a group of friends, there is one who is old enough [to purchase]. When ID is requested in a restaurant, we can show his ID.” (male, 17 years old)

• “Try to avoid places that put up a big sign that alcohol is not sold to customers under the age of 18. Don’t bother to go inside.” (male, 15 years old)

Intriguingly, appearance, not the actual age, was commonly perceived to be the single most important factor behind their success.

• “It entirely depends on your look. My face looks fairly mature. I can buy alcohol for my group of friends… I acted like I was of the age and always got what I wanted without being asked for ID.” (male, 16 years old)

Participants were highly aware of which stores would serve them and how to get served. They used certain practices to facilitate sales from vendors such as entering shops when there were no other customers present. Another reported tactic was to attempt to build a relationship with the retailers. A small minority of participants reported to purchase alcohol from certain vendors (most commonly small corner shops) so as to avoid the risk of refusal.

• “A friend of mine knows the owner of this shop. She gets alcohol only from that shop. It’s like showing respect for your sensitivity because they know each other.” (female, 16 years old, non-drinker)

Perceptions toward vendors

While the purchases occurred through mutual benefits, running through the accounts of participants was a critical recognition of business priorities among vendors. Discussions suggested that adult complicity is an intricate issue. While participants described ‘reciprocal gains’ between sellers and buyers, they spoke in pejorative terms about people who willingly aided underage young people’s access to alcohol. Some young drinkers portrayed shop vendors who sold alcohol to them as “dishonest” and “bad”. It was also commonly viewed that vendors would sell or serve alcohol without question because their motives were primarily driven by the need for profit.

• “For the shops, economic benefit is their priority. That is, the more beer they sell, the more money they earn.” (male, 17 years old)

• “They know that we are underage but they are not bothered. They are selling because they just want the money from you.” (female, 17 years old)

Discussion

This study is the first to explore how alcohol is accessed by Chinese adolescents and what strategies they used to secure success in the acquisition of alcohol. The focus group method in this study allowed us to validate participants’ views and experiences through challenging and confirming accounts generated from within the group, and thus yielded a keen insight into the nature of alcohol access by Chinese adolescents. However, findings from this study should be considered in light of several limitations. While we recruited a diverse range of participants in terms of geographical location, age, gender and drinking status in order to garner different opinions and practices concerning alcohol access, it was not possible to explore in depth the views and experiences of certain groups. For example, adolescents living in disadvantaged communities might have perceived the extent of alcohol accessibility in a different way. We did not provide a gender-specific account of alcohol access although no distinct gender difference was observed in terms of the preferences for sourcing alcohol and access tactics. In addition, while the focus group enabled us to observe social interactions and group dynamics, peers in the group might have influenced comments and thus some participants might have felt intimidated in sharing experiences regarding alcohol acquisition. It remains also possible that non-drinkers were reluctant to express their views on underage alcohol access behavior, which might have led to a biased picture. The voluntary nature of participation impacted recruitment rates, which may have created selection bias. Those students who did choose to participate in the focus group may feel more strongly, one way and another, than those who did not respond to our invitation to participate in the study. Despite these limitations, several important themes emerged from the study with particular relevance to policy development for reducing alcohol access to underage youth.

Our findings suggest that there appears to be a strongly positive and what other researchers portrayed as “intoxigenic” environment conducive to encouraging underage drinking [18]. Many participants acknowledged the visibility of alcohol access and this was most commonly mentioned in relation to purchases from small independent shops. Our participants not only knew where to obtain alcohol but also how to go about getting them. The inclusion of non-drinkers in the study gave a clear indication that this knowledge was prevalent regardless of drinking status and that peer networks may facilitate the diffusion of access skills and information. We also noted that Chinese adolescents did not rely on “shoulder tapping” (where a minor asks an adult to purchase alcohol outside a licensed premise), a common access strategy identified by studies in other countries [19, 20]. It could be that our participants perceived direct purchase of alcohol from commercial sources easy and that other sources of supply such as home access and purchases made via friends were readily available. Research indicates that higher visibility or awareness of alcohol sources is likely to increase youths’ opportunities to consume alcohol [11, 12]. It is therefore important to address the visibility of access activities that entrenches a sense of ease around alcohol access [20]. Tackling the visibility of access requires action across all areas of policymaking and society, and may be successful where there is consensus about prohibiting underage acquisition of alcohol.

There emerged a picture of access activities having an important unifying function within a peer group. Chinese underage drinkers appeared to progress from home access when they experimented drinking to commercial sources as they gradually learned how to maneuver certain situations or deal with vendors. The act of purchasing was a shared group activity with some older-looking members being able to purchase alcohol, which can then be shared with their peers and friends. We also found that more committed young drinkers ventured to different venues to obtain alcohol even as others in the group felt apprehensive about trying. While these young people became a point-of-access, peer profiting (peers being paid to buy alcohol), as has been observed elsewhere [21], seemed neither salient nor acceptable among our participants. This indicates that the way in which alcohol is accessed by young Chinese adolescents is not simply part of their drinking repertoire, it also embodies a symbol of group identity and connection with others in the collectivist nature of Chinese culture. Chinese culture is characterized by a close-knit and harmonious social unit in which everyday life is undertaken with peers [22]. It became evident that for our participants, accessing alcohol together with and for friendship group was a collaborative process, thereby upholding camaraderie and endorsing social harmony. The complex interplay between alcohol access and community experience within peers underlines that tackling cultural drivers of alcohol will require actions further and more difficult than simply regulating the commercial availability of alcohol to young people.

Findings from this study provide much needed empirical support for enacting legislation that prohibits off-premise alcohol sales to minors. Given the common reliance on commercial sources for obtaining alcohol, it is questionable whether self-regulatory codes currently in use would suffice to regulate how alcohol is sold to underage youth in Hong Kong. As noted in other studies [23, 24], we observed some vendors being complicit in the establishment of routines to enable adolescents to continue to buy alcohol. Thus, intervention on adult complicity is required through greater investment in policing underage sales. Sustained retail interventions such as the age of sale legislation, server training, compliance check programs and graduated penalty scheme would effectively curtail adult complicity [5, 11, 23]. At the same time, what is striking and potentially significant about the accounts of participants is that while there was general resentment and discontent toward adults who were willing to supply minors with alcohol, this feeling of disappointment did not seem to alter the ways they sourced alcohol. This suggests that simply diminishing the expectations of adult complicity may not be sufficient to remove the motivation for acquiring alcohol as young Chinese adolescents might circumvent the restrictions by relying on other modes of access. Research in China documented that ‘face saving’ is a core tenet of social interaction in Chinese culture [25]. The act of saving face involves crafting a desirable image and enhancing feelings of one’s reputation or that of others in everyday affairs, while public criticisms and open confrontation are viewed as causing a loss of face. The perceived importance of upholding face and the risk of losing face in Chinese culture may provide avenues for preventing youth access to alcohol. For example, there may be value in community action initiatives that aim to foster awareness of expected behaviors and increase informal social sanctions (i.e. disapproval and embarrassment) associated with underage youth acquisition of alcohol [26, 27]. Intervention efforts designed to strengthen the collective efficacy of community (e.g. neighborhood monitoring and communication) could make the task of obtaining alcohol more ‘costly’ for the Chinese underage drinkers [27]. Such efforts would benefit from parallel social marketing campaigns that seek to incorporate the notion of face-saving and informal controls.

The accessibility through the family home merits more consideration. The family home has been seriously neglected in the movement to restrict youth access to alcohol. Our study showed that younger Chinese adolescents obtained alcohol from their home with little knowledge or approval from their parents. Direct furnishing of alcohol from parents to adolescents for drinking with peers in the family home, a practice observed elsewhere [28, 29], was not common among our participants. Yet, by providing unguarded access to alcohol at home and having permissive attitudes regarding underage drinking, parents might contribute to the notion that underage drinking is acceptable. It is therefore important that parents set consistent and enforced alcohol-specific rules, monitor supplies and communicate with their children about the consequences of alcohol consumption. There is also a need to encourage greater involvement of parents in alcohol education in schools and communities to ensure that the same key message about alcohol is reinforced. The impact of parental supervision and communication on underage alcohol use is well documented [28, 30]. Thus, more work is needed to identify the most effective ways to assist parents with these efforts.

In conclusion, this study sheds light on the specific access behaviors among Chinese adolescents in the context of particular social and regulatory environments. Findings underscore that health education alone may not be sufficient to limit youth access to alcohol in an environment where alcohol is readily available, not merely in the absence of legal tools but through the proliferation of available opportunities being offered to underage young people to partake in drinking [31–33]. Interventions that aim to restrict access should take into account of social factors, such as alcohol acquisition being a symbol of groups’ identities, which perhaps represent one of the most important influences on underage alcohol access. To be effective, policies must be grounded in Chinese adolescents’ lived experiences and acknowledge the importance of their own perspectives.

Funding

This study was supported by Health and Medical Research Fund [Grant Number 10111091] from the Food and Health Bureau, Hong Kong Government and Small Project Fund [Grant Number 104002034] from the University of Hong Kong.

Conflict of interest statement

None declared.