Background
Alcohol is a psychoactive substance that can produce addiction and dependence [
1]. Chronic alcohol use is associated with a myriad of negative health outcomes, including damage to the central nervous system [
1]. Alcohol use is causally associated with more than 200 diseases and injuries and is a major contributor to mortality globally [
1]. The WHO global status report on alcohol and health reported that 3 million deaths and millions of disabilities are caused by alcohol consumption each year, which constitutes over 5.3% of deaths worldwide [
2]. However, drinking behavior remains very common, especially in China. In 2015–2016, the prevalence of alcohol use in China, defined as the percentage of people who have drunk alcohol in the past 12 months, was 43.7% among adults 18 years of age and older. Prevalence is higher among adult men (64.5%) than adult women (23.1%) [
3].
Multiple factors are associated with alcohol consumption, including biological [
4], sociocultural [
5], and psychological factors [
6,
7]. For example, genetics appears to play a critical role in alcohol dependence and consumption. Polymorphisms in Alcohol Dehydrogenase Genes, specifically, can lead to an increased risk of alcohol dependence [
8‐
10]. Ecological Systems Theory posits that people’ s behavior is influenced by nested ecological systems, including microsystem, mesosystem, exosystem, and macrosystem. Macrosystems, which refer to as the culture, subculture, and social environment, are of particular interest [
11]. The macrosystem in China, where there is a strong historical influence of Confucian culture, may figure prominently in Chinese alcohol use, particularly among men. The Confucian culture emphasizes developing and maintaining social bonds via gift exchange, which is seen as a social norm [
5,
12,
13]. Chinese consumers spend more money on alcohol when purchasing alcohol as a gift, compared to when it is purchased for their own use. This may reflect a desire for people to be perceived favorably among their peers [
14]. This idea is further supported by findings that gifting alcohol serves as a mechanism to maintain good relationships with elders and promote camaraderie among peers, [
15] especially in higher social classes [
16]. Gender ideals are also associated with alcohol use, where men who consumed alcohol are seen as full of masculine charm and loyalty [
15,
17]. While global per capita alcohol consumption rose from 5.5 L in 2005 to 6.4 L in 2016, per capita alcohol consumption in China rose to an even greater extent, from 4.1 L in 2005 to 7.2 L in 2016. This increasing rate of per capita alcohol consumption may indicate a great challenge for alcohol control in China [
1].
Identifying factors associated with alcohol gifting behavior in China may inform future interventions. However, there is little published literature on this topic. One of the few existing studies showed that spending more money on wine gifting in China is associated with younger age and higher education [
18]. Top reasons for consuming wine included business, while a top reason for purchasing wine was gifting. It should be noted, however, that these relationships often vary by region [
18]. Although this study offers some insight into correlates with demographic factors, the influence of the social environment should also be considered. Social Capital Theory predicts that individuals with strong social capital inherently have access to more supportive resources and have a higher capacity to utilize them [
19,
20]. Higher social capital can result in the spread of health information, such as information about the harms of drinking, via social networks, which can influence health-related behaviors [
21]. According to Social Capital Theory and Behavioral Accessibility Theory, alcohol gifting as a norm may further increase contact with and consumption of alcohol for both non-drinkers and drinkers attempting to quit.
It is also important to consider the potential adverse consequences of alcohol exchange in addition to factors and characteristics associated with alcohol gifting. Given the hypothesis proposed by previous empirical research [
22], gifting alcohol may be associated with alcohol use. However, there is a lack of evidence-based studies that quantitatively identify the relationship between alcohol gifting behavior and potential hazardous behavioral outcomes, such as alcohol drinking and tobacco smoking in China. Although there is no research on this relationship in China, there have been studies assessing this relationship in other countries. Reviews from the U.S. identified a significantly higher risk for alcohol misuse among those who use tobacco [
23]. Nationally representative data from the U.S.-based Add Health Survey also found a high prevalence of polysubstance use behavior, including the use of alcohol, marijuana, and cigarettes among adolescents in 2008 [
24]. Polysubstance use of alcohol and tobacco is particularly concerning because they enhance the effects of each other, a reaction that tobacco and alcohol companies have exploited to promote sales [
23].
The purpose of this study is to investigate the prevalence and correlates of alcohol gifting, including associations with social capital. We additionally aim to explore whether alcohol gifting is associated with alcohol or tobacco consumption in China. We employ quantitative analysis on a large sample at the regional/provincial level to inform evidence-based alcohol control practices relevant to China's alcohol gifting culture.
Discussion
Research on alcohol has generally only focused on its use or overuse as a psychoactive substance [
3,
35], meaning there are few studies on the behavior of alcohol gifting. In this study, two provinces in southern and northern China were selected to explore alcohol gifting, associated factors, and behavioral outcomes. We also distinguished between actively offering and passively receiving alcohol gifts. This study showed that nearly half of the participants had received alcohol, and nearly one-third had offered alcohol, suggesting that alcohol gifting is common in China.
There are some differences in alcohol gifting across sociodemographic characteristics. Our research showed that men were more likely to offer and receive alcohol than women. We posit two potential explanations for this difference. One, there are sex differences in drinking alcohol behavior in China, where drinking frequency in men is higher than in women [
3,
35]. This higher drinking frequency in men might explain why alcohol gifting is more common among men. Two, compared to women, men are more likely to participate in social interaction where alcohol consumption is normative in the Chinese socio-cultural context, especially on business occasions.
In addition, the study also suggests that married people have higher odds of receiving alcohol. Consistent with this finding, a previous study of Chinese drinking behaviors showed that being married is associated with more alcohol consumption [
36]. We hypothesize that married people may be more invested in maintaining interpersonal relationships than those who aren’t married, especially on special holidays when alcohol gifting is common. Married people may have more social and family ties that are accompanied by gift-giving expectations, and therefore may be more likely to receive alcohol as a gift. Moreover, Chinese society emphasizes filial respect, and gift-giving is a way for the younger generation to show respect for the elder generation. As married people are generally more mature and have higher status within the family hierarchy, they may be more likely to receive gifts such as alcohol.
The finding that participants with a high level of social participation were more likely to give and receive alcohol is consistent with the role that alcohol plays in Chinese culture, where alcohol consumption is commonly involved in social interaction. Chinese people traditionally consider drinking an important tool of social contact and emotional expression. Alcohol often accompanies business meetings, social activities, weddings, funerals, holidays, and other special celebrations [
37]. Gift giving can reduce uncertainty while producing positive emotions, social cohesion, and commitment [
38]. Feelings of obligatory reciprocity often accompany gift-giving, even when altruistic motives are also present [
39]. As consequence, those who have received alcohol may feel obligated to reciprocate after receiving an alcohol gift by offering the gift-giver help, strong emotional ties, etc. While social participation was found to be significantly associated with offering alcohol, we did not find a significant relationship with cognitive social capital and social network. Social Exchange Theory holds that all human behaviors are exchange behaviors, and gift-giving is also a social exchange behavior [
40]. In other words, the cognitive perception of social capital and the extent of social network might not promote the occurrence of gifting behaviors. Perhaps gift-giving behavior can only be promoted through social engagement, where there is real interaction with people in the context of social participation.
The behaviors of offering and receiving alcohol were also related to family annual income. Higher annual household income indicates higher economic status. It was previously illustrated that individuals of higher economic status are more likely to offer expensive wines to demonstrate their prestige and high social standing [
41]. Our results offer additional support for the relationship between higher SES and alcohol gifting.
This study found that compared with Guangdong, the southern coastal area in China, the phenomenon of alcohol offering and receiving is more common in Shaanxi, an inland city in northwest China. This may be partially explained by the regional differences in drinking prevalence. According to a study on regional differences in alcohol consumption in China, the prevalence of regular drinking in the northern region is higher than prevalence in the central-southern region [
42]. It is possible that northerners perceive drinking as an effective way to cope with cold weather, and northern culture emphasizes hospitality with frequent gatherings and exhortation to drink [
43]. In addition, Guangdong has higher economic and cultural development than Shaanxi due to the advantages of economic reform and being a coastal area which has more foreign trade activities with the outside. This higher level of economic development may be associated with receiving more information about the harms of drinking, leading to more concern about its effects on health and avoidance of alcohol [
44]. This difference may also be related to the cultural differences of gifting between the North and the South.
Drinking status was also found to be strongly associated with giving and receiving alcohol. Behavioral Susceptibility Theory posits that behavior will gradually increase when that behavior is convenient [
45]. Drinkers are more likely to approve of drinking than non-drinkers and may have more regular, convenient access to alcohol. Drinkers may therefore be more inclined to choose alcohol as gifts.
In another study in China, smoking outcomes were associated with cigarette gifting behaviors [
22]. Notably, a similar relationship was found in the current study, where gifting alcohol was significantly associated with not only drinking, but also smoking. Many studies have demonstrated that tobacco and alcohol were complementary products, and co-use is common [
46‐
49]. Drinkers are also more likely to smoke cigarettes than nondrinkers [
50]. These findings may indicate that receiving alcohol as a gift may facilitate the consumption of addictive substances including tobacco and alcohol.
With regards to policy implications, the result of the current study can be used to inform prevention and intervention. First, alcohol gifting is associated with higher odds of current drinking and current smoking. Previous studies have suggested that limiting alcohol advertising is an effective intervention to control drinking [
51,
52]. While it might be difficult to ban all alcohol advertising, restrictions could be pursued that restricts advertising from using gifting themes and imagery. Interventions that teach people how to refuse alcohol as gifts and suggest alternative gifts could also be pursued. Such interventions should be targeted at specific populations that have higher odds of alcohol gifting, for example, people who are male, married, currently drink alcohol, reside in the northern region, have larger social networks and more social participation, and people with higher economic status. Finally, given the differences in alcohol giving in North and South, local alcohol gifting culture should receive attention when formulating policies and interventions programs, particularly in the northern region.
Limitations
Some limitations should be considered. First, the cross-sectional design prohibits causal associations. Additionally, self-reported questionnaires are vulnerable to recall bias and social desirability bias. Second, selection bias might misrepresent the prevalence of alcohol offering and receiving because the sample only included the household heads whose children were college students. Moreover, results may not generalize to the entire country, and the selected provinces might reflect north–south cultural differences due to their geographical and economic characteristics.
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