Social inequalities in alcohol consumption in the Czech Republic: a multilevel analysis

ARTICLE IN PRESS Health & Place 16 (2010) 590–597 Contents lists available at ScienceDirect Health & Place journal homepage: www.elsevier.com/locate/healthplace Social inequalities in alcohol consumption in the Czech Republic: A multilevel analysis Dagmara Dzúrová a,1, Jana Spilková a,n, Hynek Pikhart b,2 a b Charles University in Prague, Faculty of Science, Department of Social Geography and Regional Development, Albertov 6, 128 43 Prague 2, Czech Republic University College London, Department of Epidemiology and Public Health, 1-19 Torrington Place, London WC1E 6BT, UK a r t i c l e in f o a b s t r a c t Article history: Received 12 June 2009 Received in revised form 13 January 2010 Accepted 16 January 2010 Czech Republic traditionally ranks among the countries with the highest alcohol, consumption. This paper examines both risk and protective factors for frequent of alcohol, consumption in the Czech population using multilevel analysis. Risk factors were measured at the, individual level and at the area level. The individual-level data were obtained from a survey for a, sample of 3526 respondents aged 18–64 years. The area-level data were obtained from the Czech, Statistical Office. The group most inclinable to risk alcohol consumption and binge drinking are mainly, men, who live as single, with low education and also unemployed. Only the variable for divorce rate, showed statistical significance at both levels, thus the individual and the aggregated one. No cross-level interactions were found to be statistically significant. & 2010 Elsevier Ltd. All rights reserved. Keywords: Alcohol consumption Binge drinking Czech Republic Multilevel analysis 1. Introduction The Czech Republic is a country with a high level of alcohol production and consumption. Beer and drinking alcohol are considered an important part of Czech culture, society and history, and the beer industry is seen as part of the national heritage. According to the Czech Statistical Office, every Czech citizen consumes more than 10 litres of pure ethanol annually. In 2006, Czechs drank on average about 160 litres of beer and 17 litres of wine per person. The consumption of pure alcohol per capita in the Czech Republic has gradually increased since 1930, with a drop between 1985 and 1990 (Fig. 1). This decrease is assumed to be the effect of the implementation of a limited version of Gorbachev’s antialcohol campaign in Russia, of which its primary aim was to prevent the use of alcohol in the work place. In the transformation period after the ‘‘Velvet Revolution’’ of 1989, restrictive policies towards drinking habits were revoked and in the market economy, alcoholic beverages became readily available even more so than before. Kubička et al. (1998) explored the possible relationship between the political changes in the Czech Republic n Corresponding author. Tel.: + 420 221 951 388; fax.: + 420 224 920 657. E-mail addresses: dzurova@natur.cuni.cz (D. Dzúrová), spilkova@natur.cuni.cz (J. Spilková), h.pikhart@ucl.ac.uk (H. Pikhart). 1 Tel.: + 420 221 951 390; fax: + 420 224 920 657. 2 Tel: + 44 20 7679 1906; fax: + 44 20 7813 0280. 1353-8292/$ - see front matter & 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2010.01.004 and the drinking behaviour of Czech men. According to their study, mean alcohol consumption decreased by 26% between 1983 and 1988 as a consequence of the Gorbachev-inspired antialcohol campaign, and increased again by 16% between 1988 and 1993. The percentage of heavy drinkers fell from 33% in 1983 to 23% in 1988 and then went up again to 28% in 1993. Men’s attitudes to drinking did not change significantly during the 10-year period covered by their study. Alcohol consumption has seen increased momentum in the last 20 years, and has been accompanied by significant changes in the alcohol-consuming population. These changes are characterised by a higher consumption of alcohol among women and, above all, an alarming increase of alcohol consumption among young people. In 1993, the Czech government approved a complex strategy for the prevention of drug related problems, but a suitable antidrug policy is still a matter of public and political debate. The most effective policies seem to be a reduction of the range of beverages available, reducing the access to and availability of alcohol, imposing restrictions on the advertising of alcohol and higher taxation. All possible regulatory measures are frequently discussed in the mass media. The offer of professional assistance to individuals suffering from alcohol-related problems is an integral part of the health care system and related activities are also emerging within the NGO sector. Nevertheless, according to the CIDI (Composite International Diagnostic Interview) survey, almost 24% of all Czech adult men and 11% of adult women can be identified as at-risk alcohol drinkers (Dzúrová et al., 2000). Although the Czech Republic joined the European Action Plan on Alcohol for 2000–2005 aiming to reduce and prevent the harm ARTICLE IN PRESS D. Dzúrová et al. / Health & Place 16 (2010) 590–597 2004; Kubička, 2006), or on individual or social determinants of alcohol use (Kubička and Kožený, 1988; Kubička et al., 1993; Kubička et al., 1995; Kubička, Csémy, Duplinský, Kožený, Kubička, 2007), rather than on the multifactorial character of alcohol abuse. Only very few papers have focused on these complex relationships (Bobak et al., 2005). In this context, the aim of this paper is to assess socioeconomic inequalities in alcohol consumption in Czech society and to apply the multilevel modelling approach as a method that allows us to evaluate the role of small-area and individual-level determinants of alcohol abuse in the Czech population. In more detail, we tested the following hypotheses: litres per capita 17 16 15 Czech Rep 14 EU 13 (i) Individual socio-economic characteristics affect the drinking behaviour of study respondents. (ii) Area-level socio-economic characteristics independently affect individual drinking behaviours whereby people living in more disadvantaged areas exhibit more risky health behaviours than people living in less disadvantaged areas. (iii) Area-level characteristics affect the drinking behaviours of privileged and underprivileged individuals differentially (presence of cross-level interaction). 12 11 10 1980 591 1983 1986 1989 1992 1995 1998 2001 2004 Fig. 1. Consumption of pure ethanol in the Czech Republic and EU15, age 15 + (litres per capita). Note: Data on alcohol consumption in EU15 relate to the 15 member states of the EU prior to 1 May 2004. 2. Data and methods caused by alcohol, almost one quarter of men and a smaller but increasing proportion of women consume alcohol in quantities that are highly risky for their health. Heavy alcohol consumption is thought to be one of the major causes of ill health in Central and Eastern Europe (Varvasovsky et al., 1997; Nemtsov, 2001), possibly because binge drinking is relatively common in the region (Bobak et al., 2004). Alcohol dependence is also closely related to the social and economic environment. During the post-communist transformation period, the political changes also brought about life style changes that included higher alcohol consumption, drug use and cigarette smoking in many countries of Central and Eastern Europe. Consequently, deaths linked to alcohol use have risen steeply (WHO, 2009). The fact that traditionally Czech society is rather tolerant towards the regular drinking of alcohol, as well as to excessive drinking, also plays an unfavourable role. Moreover, the price of alcohol is relatively low compared to Western Europe, and alcohol is thus easily affordable for all socio-economic strata of society. Recently, there has been an increasing interest in small area and community effects on health behaviours (including alcohol consumption) (Pasch et al., 2009; Picket and Pearl, 2001; Cummins et al., 2007; Duncan et al., 1993; Karvonen and Rimpela, 1996). Various contributions have sought a possible solution to a general discussion on the importance of individual and area-level risk factors through multilevel analysis, a method that has recently been applied in several studies in health-related research (Duncan et al., 1996; Twigg et al., 2002; Twigg and Moon, 2002; Monden et al., 2006; Fukuda et al., 2005). Multilevel analysis has shown itself to be a useful tool in alcohol-related research (Marchand et al., 2003; Jefferis et al., 2007). All over the world it seems that alcohol consumption and its health and social consequences are considered important social issues. Despite the importance of these issues for Czech society, the number of scientific studies on alcohol, alcoholism and its consequences in the Czech Republic is limited, and the available studies mostly only focus on descriptive research (Csémy et al., The ‘‘Sample study of the health status and life style of the population of the Czech Republic’’ was conducted by the Institute of Health Information and Statistics of the Czech Republic (IHIS CR) in collaboration with the INRES–SONES public opinion research agency. Data were collected via face-to-face interviews based on the EMCDDA (European Monitoring Centre for Drugs and Drug Addiction) questionnaire. Cluster sampling was used for sample selection. A total of 235 electoral wards were randomly selected in the country. In each selected electoral ward, data were collected from 15 randomly chosen individuals (with the exception of one ward where data from 16 individuals were collected). As there were two or more wards selected in some municipalities, 161 municipalities were represented in the final study. The smallest analytic unit for this analysis is the municipality. In total, the study covers 161 municipalities with more than 4.23 million inhabitants in different municipality size categories, the smallest municipality having 96 inhabitants (15 respondents) and the largest 1.17 million inhabitants (Prague: 405 respondents). The sample of respondents corresponds to the Czech population structure in terms of regional, sex and age divisions. Small deviations were found in the distribution by marital status, education and economic activity. The sample included 3526 persons, aged 18–64 years at the time of the survey. The response rate was 68.2%. The questions focused on self-rated health, longterm illness, mental health and substance abuse-related behaviours (smoking, drinking alcohol, drug use). Basic demographic and socio-economic data were also collected (such as education, marital status, occupational status). 2.1. Study population 2.2. Measures of alcohol consumption and problem drinking The two outcome measures of drinking behaviour used in this paper were frequency of alcohol consumption and binge drinking. The frequency of alcohol consumption (termed ‘‘frequency’’ in the article) was estimated by a question: ‘‘How often do you usually drink alcohol?’’ Respondents selected one answer from the following five options: (i) four times a week and more, (ii) two ARTICLE IN PRESS 592 D. Dzúrová et al. / Health & Place 16 (2010) 590–597 to three times a week, (iii) two to four times a month, (iv) once a month or less often and (v) abstainers. A binary variable, drinking at least twice a week, was constructed combining answers (i) and (ii) to the original question as a positive answer, and (iii)–(v) as a negative answer. Binge drinking (termed ‘‘binge’’ in the article) was investigated by a question: ‘‘How often do you drink 5 or more glasses of alcohol on one occasion?’’ Response categories were: every day, once a week or more, once a month or more, less than once a month, or never. A binary variable was created with those binging at least once a week marked as binge drinkers and the remaining respondents as non-binge drinkers. 2.3. Individual-level variables A range of demographic, socio-economic and health-related covariates were used as potential explanatory variables. As demographic and socio-economic variables we used gender (men and women), age (18–29, 30–39, 40–49, 50–64 years old), marital status (married/cohabitating, single, divorced, widowed), education (four categories based on the highest education level achieved: university degree, secondary, vocational, primary or less), and economic activity (employed/self-employed, pensioners, students, housewife/maternal leave, unemployed and others). Three variables were used to control for the health status: selfrated health (5-point scale ranging from excellent to poor), longstanding illness (yes, no) and emotional disorders (yes, no). 2.4. Area-level variables The small-area contextual variables described the socioeconomic dimensions of the municipalities where the respondents resided. Data from the 2001 Census, obtained from the Czech Statistical Office, was used. The individuals surveyed were linked with the Census database, and subjects were assigned an ID number of the municipalities. Using this area ID number, the survey subjects were linked with 161 municipalities and 5 characteristics were derived from the Census:      proportion proportion proportion proportion proportion of of of of of people with university education, divorced people, people reporting no religious attachment, people with nationality other than Czech, and unemployed people. 2.5. Statistical analysis Firstly, the crude relationships between the independent and dependent variables were assessed by cross-tabulations. Random intercept logistic regression comprising two levels (individual and small-area level) in multilevel regression analysis was applied. In this way, the modelling strategy accounts for the hierarchical structure of the data set. First, both individual-level socioeconomic characteristics and area-level measures were assessed with respect to their effect on the odds of individual frequency of alcohol consumption. Then, other individual-level indicators (used as proxy measures of individuals’ physical and psychological health) were included into the model to control for potential confounding. Finally, one by one, area-level characteristics were added into the model with all individual-level characteristics present. The additional models were tested for potential individual-level interactions and cross-level interactions between area and individual-level variables. Data were analysed using Stata 10 software (Stata Corp., College Station, USA). Table 1 Consumption of alcohol (frequency and binge drinking) in study sample by gender, N= 3526 individuals Frequency of drinking 4 times and more per week 2–3 times per week 2–4 times per month 1 times per month Abstainer Males (N = 1766) Females (N = 1760) Total (N = 3526) Count % Count % Count % 273 431 513 437 112 15.5 24.4 29.0 24.7 6.3 3.4 10.1 27.2 45.7 13.6 333 608 992 1241 352 9.4 17.2 28.1 35.2 10.0 on single occasion) 3.5 11 0.6 19.9 81 4.6 18.0 145 8.2 31.7 467 26.5 27.0 1056 60.0 72 432 463 1026 1533 2.0 12.3 13.1 29.1 43.5 Binge of drinking (at least 5 glasses Every day 61 1 time per week or more 351 1 time per month or more 318 Less than 1 time per month 559 Never 477 60 177 479 804 240 3. Results Descriptive characteristics of the study population are shown in Table 1 and Table 2, area-based variables are described in Table 3. Table 1 shows the consumption of alcohol in the study sample by gender. The gender distribution of the sample was almost equal (1766 men and 1760 women). Some 15.5% of men drink more than four times a week, while the same is true for only 3.4% of women. Men tend to binge drink more frequently than women with almost one fifth of respondents reporting binge drinking at least once every week. However, there are 27% of men and 60% of women who never binge drink. The study population and its risk behaviour described by demographic characteristics are presented in Table 2. The majority of respondents were married (52.6%) or single (27.9%) More than half of the respondents had an education level lower than secondary education and more than one fifth (23.2%) had only completed primary education. Almost a quarter of respondents in the 18–29 age group consume alcohol two or more times a week. The highest proportion of frequent drinkers is among the 40–49-year olds (approximately 30%). Concerning the marital status of the respondents, we found that divorced and nevermarried people drink more than married and widowed persons, which is also true for binge drinking, where the relation to marital status becomes even more pronounced. The proportion of frequent drinkers decreases as the level of education rises (19.9% among those with primary education or less compared to 8.5% among those with university education). As regards economic activity, the people who consume alcohol the most frequently are those who are unemployed (36%). The frequent consumption of alcohol is reported even more by ‘‘others’’, but this group is only small (N= 18) and may therefore be affected by specific individuals. As regards the binge drinking episodes in Table 2, more men tend to binge drink than women (23.3% men and 5.2% women). The highest proportion of binge drinking was reported by young people between 18 and 29 years. In relation to marital status, the groups more prone to binge drinking are single and divorced individuals (17.9% and 17.7%, respectively). A tendency to binge drinking is almost 100% negatively related to the level of education: 31.5% of the people with only a basic level of education binge drink, while 28.2% of the people with vocational training and only 22.1% of the people with secondary education and 22.9% of those with university education do so. ARTICLE IN PRESS D. Dzúrová et al. / Health & Place 16 (2010) 590–597 593 Table 2 Association between alcohol drinking and socio-demographic variables (unadjusted odds ratio). Variable N Frequent drinking (drinking alcohol twice a week or more) Binge drinking (drinking at least 5 glasses per occasion at least once a week) % Unadj.OR 95% CI % Unadj.OR 95% CI Gender Men Women 1766 1760 39.9 13.5 1 0.22 0.18–0.26 23.3 5.2 1 0.16 0.13–0.21 Age 18–29 30–39 40–49 50–64 1012 739 730 1045 25.6 26.1 30.3 25.6 1 1.01 1.27 1.01 0.81–1.27 1.02–1.58 0.82–1.24 15.5 14.7 15.5 12.0 1 0.92 0.99 0.73 0.70–1.21 0.76–1.30 0.55–0.93 Marital status Married/cohabiting Single Divorced Widowed 1849 980 497 192 25.7 28.5 31.0 15.6 1 1.16 1.31 0.53 0.97–1.38 1.04–1.64 0.35–0.80 12.2 17.9 17.7 7.3 1 1.60 1.57 0.53 1.28–2.00 1.18–2.08 0.30–0.93 Education Primary Vocational Secondary University 819 1325 936 446 19.9 15.5 10.4 8.5 1 0.85 0.61 0.63 0.70–1.04 0.49–0.76 0.48–0.83 31.5 28.2 22.1 22.9 1 0.73 0.44 0.34 0.58–0.92 0.33–0.58 0.23–0.51 Economic activity Employed/self-employed Pensioner Student Housewife/maternal leave Unemployed Other Total 2346 453 252 136 321 18 3526 28.6 18.8 19.0 11.8 36.1 50.0 26.7 1 0.57 0.57 0.32 1.48 2.45 0.44–0.74 0.40–0.79 0.19–0.55 1.14–1.91 0.93–6.46 14.8 9.6 12.3 1.5 24.3 33.3 14.3 1 0.54 0.85 0.09 1.95 2.53 0.38–0.77 0.57–1.27 0.02–0.36 1.45–2.63 0.88–7.23 Table 3 Area-level characteristics. Municipality population o2000 2000–19,999 20,000–99,999 100,000–499,999 1,000,000 + Total Number (%) 59 64 33 4 1 (36.6) (39.8) (20.5) (2.5) (0.6) 161 Average/median (SD) University education Divorced Without religion With non-Czech nationality Unemployed 5.6/5.3 7.1/6.9 56.6/58.5 4.9/4.1 8.4/7.9 (2.9) (2.5) (16.5) (3.3) (3.9) The relationship between economic activity and binge drinking copies the pattern of the relationship between economic activity and frequent drinking, with most binge drinkers among the unemployed people (24.3%), followed by employed and selfemployed individuals (14.8%) and students (12.3%). Table 3 shows the basic statistical information from the municipalities studied. The study included 59 municipalities with less than 2000 inhabitants, 64 municipalities with 2–20,000 inhabitants, 33 municipalities with 20–100,000 inhabitants, four cities with 100–500,000 inhabitants and the capital city of Prague with more than one million inhabitants (the category of cities between 500,000 and 1 million inhabitants is missing because there is no city of this size in the country). Figs. 2 and 3 demonstrate the geographic distribution of the frequency of drinking and binge drinking in the Czech Republic according to settlement category. Each municipality in the survey is marked and the colour of the mark shows the intensity of this phenomenon while the shape indicates the size of the settlement. In terms of the frequency of drinking, a slightly higher figure of frequent alcohol consumption is seen in the north-east of the Czech Republic (municipalities with a larger population). This area is characterized by a high unemployment rate since mines and heavy industry plants were shut down or downsized in the post-communist era. Lower figures of frequent alcohol consumption are found in the south-west of the country (municipalities with a smaller population). The pattern is the same for binge drinking, with higher numbers in the north-east of the country and lower in the south-west. Table 4 shows the effects of the main individual-level socioeconomic characteristics on frequency and binge drinking after adjustment for all characteristics in the table and self-rated health, long-standing illness, mental health. Models 1 and 3 in Table 4 show the results from the individual-level models adjusted mutually for all five individual socio-demographic characteristics and three health-related variables used to control for potential confounding (self-reported health, long-time illness and emotional disorders). Both models show a reduction of social and demographic differences in frequency of alcohol use and binge drinking among older people. The influence of gender, marital status and education remain statistically significant. With respect to economic activity, the lower frequency of drinking among pensioners and students and the highest binge drinking frequency among unemployed individuals remains significant. Models 2 and 4 in Table 4 show the adjusted odds ratios from the models using all eight individual characteristics and five ARTICLE IN PRESS 594 D. Dzúrová et al. / Health & Place 16 (2010) 590–597 Fig. 2. Frequency of alcohol consumption/drinking alcohol in 161 municipalities and community size. Fig. 3. Binge drinking by 161 municipalities and community size. area-level variables. Two variables (divorce rate and religiosity) remain statistically significant for frequency of drinking. Divorce was an important variable at both individual and small area levels. Alcohol is consumed more often not only by divorced persons, but also by people living in municipalities with a higher divorce rate. As regards religiosity and its significant result in the model, it could be attributed to lower social stability in those areas with lower religiosity, however, these odds ratios are only small and religion does not seem to be the most important factor to take into account when considering problem drinking. Finally, no cross-level interactions were found to be statistically significant in this data set (results not shown in the tables). 4. Discussion The multilevel analysis suggests that the groups most prone to high risk alcohol consumption are men, single persons and people with low education (similarly Tomkins et al., 2007; Forcier, 1988; Montgomery et al., 1998; Kopp and Réthelyi, 2004; Zagozdzon et al., 2009; Virtanen et al., 2008). These groups seem to be even ARTICLE IN PRESS D. Dzúrová et al. / Health & Place 16 (2010) 590–597 595 Table 4 Multilevel logistic regression (adjusted odds ratios and 95% confidence intervals) of drinking alcohol and binge drinking at least twice a week, N= 3525 individuals nested within N= 161 areas. Variable MODEL 1: Frequency MODEL 3: Binge Adj. OR 95% CI p Adj. OR 95% CI p Individual-level variables Gender Men Women 1 0.22 0.18–0.27 o 0.001 1 0.18 0.14–0.23 o0.001 Age 18–29 30–39 40–49 50–64 P for liner trend of OR 1 1.00 1.34 1.26 0.06 0.74–1.34 0.97–1.84 0.90–1.77 0.97 0.08 0.17 0.79–1.65 0.84–1.89 0.73–1.70 0.48 0.26 0.62 Marital status Married/cohabiting Single Divorced Widowed 1 1.28 1.33 0.7 0.97–1.70 1.04–1.70 0.44–1.10 0.08 0.02 0.12 1.02–2.03 1.12–2.08 0.37–1.35 0.04 0.007 0.29 Education Primary Vocational Secondary University P for liner trend of OR 1 0.79 0.65 0.61 o 0.001 0.63–0.98 0.51–0.84 0.45–0.83 0.03 0.001 0.002 0.55–0.94 0.37–0.68 0.24–0.55 0.01 o0.001 o0.001 Economic activity Employed/self-employed Pensioner Student Housewife/maternal leave Unemployed Other 1 0.58 0.53 0.83 1.33 2.43 0.42–0.81 0.35–0.80 0.47–1.47 0.99–1.77 0.86–6.88 0.001 0.002 0.52 0.06 0.09 0.42–1.01 0.43–1.17 0.06–1.07 1.14–2.25 0.80–7.70 0.06 0.18 0.06 0.007 0.11 Area-level variables MODEL 2: Frequency 1 1.14 1.26 1.11 0.65 1 1.43 1.53 0.71 1 0.72 0.50 0.36 o 0.001 1 0.65 0.71 0.25 1.60 2.49 MODEL 4: Binge Adj. OR 95% CI p Adj. OR 95% CI p % university 1% increase 0.986 0.943–1.03 0.40 1.026 0.971–1.024 0.36 % divorced % without religion % non-Czech nationality % unemployed Community size 1% increase 1% increase 1% increase 1% increase o2000 2000–19,999 20,000–99,999 100,000–499,999 1,000,000 + 1.059 1.010 1.038 1.019 1 1.09 1.17 1.13 1.43 0.39 1.003–1.119 1.002–1.019 0.995–1.083 0.984–1.054 0.04 0.02 0.08 0.3 0.972–1.118 0.997–1.019 0.952–1.063 0.996–1085 0.25 0.15 0.84 0.07 0.79–1.50 0.80–1.69 0.55–2.35 0.39–5.28 0.61 0.42 0.74 0.59 1.042 1.008 1.006 1.04 1 1.42 1.33 1.92 1.45 0.11 0.94–2.13 0.83–2.12 0.79–4.66 0.30–7.04 0.009 0.23 0.15 0.65 P for linear trend of OR more at risk when it comes to binge drinking: single people and unemployed persons in particular showed significantly higher odds ratios for binge drinking. We need, however, to be cautious when interpreting these results because the cross-sectional design of the study does not allow for making any causal inferences on the association between social and demographic indicators and alcohol drinking outcomes. Although it is likely that a certain number of participants from low socio-economic groups and from groups with more risky alcohol-related behaviour did not respond, we believe that the response rate was so high that the outcome of the study was not biased by nonresponsive participants. However, we err on the side of caution when it comes to generalising our interpretations and conclusions for the whole population of the country. From the geographical point of view, these risk groups exist more often in socially disadvantaged areas of the Czech Republic, characterized by high unemployment, low social stability and various socio-pathological phenomena. Again, it is however unclear whether single unemployed men tend to congregate in more socially disadvantaged areas or whether areas are more socially disadvantaged because they have a high concentration of single unemployed men. As earlier studies (Dzúrová et al., 2000) demonstrate, the population in these regions is more prone to mental disorders (diagnosis: alcohol dependence syndrome). Furthermore, another geographic analysis suggested that sucidal behaviour is also more widespread in these areas (Dzúrová et al., 2006). The observed determinants of risky alcohol consumption appear to be related to the area characteristics in terms of the social and ecological environment rather than to the size and make up of the municipality population. The religiosity of the municipality population and the family situation in the area showed that these factors have a significant influence on the risk behaviour of individuals. What is more, the divorce rate was statistically significant with regard to the frequency of alcohol consumption at both the individual and the aggregated level. Despite the fact that the results show the risk of problem drinking increases along with the increase of the size of the municipality, ARTICLE IN PRESS 596 D. Dzúrová et al. / Health & Place 16 (2010) 590–597 these results are statistically not significant; they may easily be the effect of a more accentuated influence of geographical location (horizontal location) rather than of the position in the settlement system (vertical location). Risk behaviour according to the size of place of residence has also been studied by Kubička (2007), who focused on the population of Prague. He used two 10-year follow-up studies of representative samples for his analysis. The sample was comprised of 777 men and 582 women from Prague. The results of his study clearly indicated that for both sexes, both psychological and social risk factors were important. Nevertheless, for men, the most prevalent factors were social ones, such as group drinking and acceptance of the social function of alcohol, whereas for women psychological factors were more important, namely the reduction of anxiety and tension when using alcohol. These outcomes are in accordance with the results of this study, which prove that the larger the city, the more frequently drinking and binge drinking occur; this is especially true for men drinking on social occasions. Excessive alcohol consumption and smoking is often described as ‘‘the syndrome of East European societies’’ (Kopp, 2000; Kopp and Réthelyi, 2004). Overall, according to the development of alcohol and tobacco consumption, the Czech Republic clearly resembles other post-communist countries rather than the EU15 countries. The fact that males begin drinking with friends in midadolescence and regularly spend time in pubs with friends by the age of 18 is especially alarming (Hall, 2003). It is also in flat contradiction to what is considered proper or acceptable behaviour in the European Union, which the Czech Republic aspires to belong to not only administratively, but also culturally. To sum up, the general tolerance to drinking alcohol in Czech society and adolescent alcohol misuse should be issues at the top of the anti-alcohol agenda in the near future. 5. Concluding remarks Czech society is very tolerant towards alcohol consumption and Czechs are among the highest consumers of alcohol in the developed world as measured by the consumption of alcoholic drinks per capita. What is more, beer is considered not only a national beverage in the Czech Republic, but according to many surveys it is also one of the main attractions for foreign visitors to the Czech Republic. This is due to its low price and also due to many attractions related to beer, favoured by tourists, such as beer festivals, beer spas, etc. Despite all the policy efforts, legal measures and their stronger enforcement, there has been an obvious upward trend in the alcohol consumption of the Czech population since 1993, with only slight signs of a change after 2000. While this paper did not directly address policy issues, we may speculate about some possible steps that could be taken in order to reduce alcohol-related problems. At the aggregate level, it can be assumed that one of the most effective strategies to lower alcohol consumption would be to raise the taxes and prices of alcoholic beverages, which would subsequently make it more difficult for individuals in socially disadvantaged groups to be engaged in frequent or binge drinking. Another important factor is related to age restrictions insofar as how it relates to alcohol consumption. Although our data suggest that frequent drinking is less common among young individuals, there are still many cases of law violations reported in the media such as selling alcohol to under-aged individuals in shops and pubs, alcohol at work, alcohol use when driving, etc.). The regulation or prohibition of advertising alcohol and tobacco is undoubtedly also a significant measure that could be taken. Nonetheless, the real way to combat alcohol abuse is through the engagement of physicians in prevention and early intervention. For young people, education on healthy lifestyles must be supported at the level of schools as well as community and recreational organizations and clubs providing leisure-time activities, but the main responsibility lies in the hands of parents, who should set a good example to their teenage children. However, the fact that problematic risk behaviours and risk groups of the population are concentrated in disadvantaged areas appears to be even more disturbing for the Czech Republic. In this respect, the anti-alcohol campaigns and policies seem to be ineffective. The health problems tend to accumulate and interact with other social and psychological issues in these areas, creating spatial niches of higher mortality, risk behaviour, problematic drinking, mental disorders, various socio-pathological phenomena and social instability. Alcohol abusers in these disadvantaged areas should be approached with different anti-alcohol policy tools such as complex psycho-social counselling focussed on the social situation of the individual as an underlying cause of their risk behaviour. Acknowledgements The authors would like to thank the Fogarty International Centre which provided support for the preparation of this paper. 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