Time Trends: A Ten Years Comparison (2005/2006-2015/2016) of Alcohol Misuse During First Year in Medical School

RAZVAN MIHAI HORHAT1#, RADU-VASILE BAGIU2#, BRIGITHA VLAICU2, DELIA HUTANU3, DELIA IOANA HORHAT2*, LUMINITA NICA1, DANIELA IACOB4, SMARANDA ARGHIRESCU2*, IULIA-CRISTINA BAGIU2 1Victor Babes University of Medicine and Pharmacy Timisoara, Faculty of Dental Medicine, 2 Eftimie Murgu Sq., 300041, Timisoara, Romania 2Victor Babes University of Medicine and Pharmacy, Faculty of General Medicine, 2 Eftimie Murgu Sq., 300041, Timisoara, Romania 3West University of Timisoara, Faculty of Chemistry, Biology Geography, 4 Vasile Parvan Blvd., 300223, Timisoara Romania 4Victor Babes University of Medicine and Pharmacy, Department of Neonatology, 2 Eftimie Murgu Sq., 300041, Timisoara, Romania

The purpose of the present study was to explore time-trends (2005/2006-2015/2016) of alcohol misuse in first year medical students and types of alcohol preferred by young adults in the same medical school. The study compared two cross-sectional cohorts of medical students (2005/2006: 365 females and 249 males; 2005/2016: 336 females and 123 males) from Timisoara, Romania, using the same questionnaire in both investigations. The analysis was conducted measuring gender and cohort effect on frequency of alcohol use patterns during the last month and the type of alcohol used preferred. Girls have increased with a small effect size both the number of days consuming at least one portion of alcohol and the number of days with binge drinking between evaluations, reducing the gap between boys and girls, seen in 2005/2006 evaluation. In multivariate models, though beer consumption has decreased (OR=0.6) between evaluations, wine (OR=3.6) and spirits (OR=1.6) consumption has increased. Beer and spirits are the type of alcohol used by young people for binge drinking. Interventions to reduce misuse of alcohol in general population or specific to university students need to be carefully tailored to the shifting patterns of alcohol consumption, which are gender specific.
Keywords: Alcohol misuse; Type of alcohol; Binge drinking; Intoxication; Medical students .
The term misuse of alcohol is defined by frequent patterns of consume and high volume of consumption, both of which determine the impact of alcohol consumption on acute and chronic health problems. According to WHO, the European Region, especially the Eastern Europe has the highest proportion morbidity and premature death in the world due to misuse of alcohol. The trends of alcohol consumption per capita in the European Region have recorded a negative trend from 11.9 liters of pure alcohol in 2003-2005 to 10.9 liters of pure alcohol in 2008-2010. For Romania, in the same time frame the per capita alcohol consumption has increased from 12.8 to 14.4 L [1].
Following adolescence, the period of emerging young adulthood is characterized by gaining more independence and exploring various life possibilities [2]. For emerging young adults, especially the first year students, this period represents an abrupt transition to a more independent life with a change in role and setting [3,4]. Several studies have reported for this age an increase of several health risk behaviors, including alcohol abuse and subsequent alcoholrelated problems, such as injuries, crimes [5][6][7], STDs, unplanned pregnancies, behavioral problems [8] and dependency, co-use of other drugs.
The purpose of the present study was to explore timetrends (2005/2006-2015/2016) of alcohol use and misuse in first year medical students and types of alcohol preferred by young adults.

Experimental part Material and Methods Subjects
This sample compared two cross-sectional cohorts from 2005/2006 and 2015/2016. Participants were selected from the students attending the first year of Victor Babes University of Medicine and Pharmacy Timisoara, that included the following specializations:General Medicine, Dentistry, Nurses and Midwifes. All participants were over 18 years of age at the time of the evaluation, with an age range of 18 -25 years and median of 20 for the 2006 cohort and an age range of 18 -26 years and median of 21 years for the 2016 cohort. In both occasions students were included in the cohort after expressing their free will to participate. The research was carried out in compliance with Helsinki Declaration.

Questionnaire
A 126-item questionnaire was developed in 2004 to investigate health-risk behaviors of young adults, as part of the grant The evaluation of risk behavior dimension in high school students and young people from vocational schools and universities in Timis County (CORT 2004), carried out between 2003-2006, CNCSIS code 1167, attained at Victor Babes University of Medicine and Pharmacy Timisoara. Some of the questionnaire items were modified from other instruments, including the Youth Risk Behavior Survey (YRBS) [9] and European School Survey Project on Alcohol and Other Drugs (ESPAD) [10]. In 2004 a pilot test was conducted to establish the validity and reliability of the instrument. This study received the University's Ethic Committee approval on both occasions.
The questionnaire was administered in both evaluations 2005/2006 and 2015/2016 in a regular classroom/ laboratory/clinical setting and took students 60 min to complete. No filter questions were used. By doing this, comparable amounts of time are required to complete the questionnaire, regardless of risk behavior status and students cannot detect the risk behaviors of their colleagues simply by looking at the pattern of the responses. Only students present the day of the survey were eligible for participation.
Trained public health residents and undergraduate students conducted the survey. The data collectors read aloud scripts that explained the survey procedures. Anonymity was guaranteed and students were reassured that the information obtained would be used only for general assessment of the situation in the county.
The present paper used questions related to patterns of alcohol consumption during last 30 days: at least one portion and binge drinking, and types of alcohol preferred to consume. Between evaluations, boys did not significantly modify the proportion of days with at least one portion of alcohol, but for girls, the number of days had increased between evaluations: U=51783.5, z=-3.56, p<0.001, r=0.14, with a small effect size (table 1).

Practices binge drinking during last month
Regarding binge drinking, for 2006, 35.1% (87) of men and 8.9% (36) of women admit they consumed at least in one occasion 5 or more portions of alcohol. For 2016 the percentages of students practicing binge drinking are 31% (50) for men and 16% (53) for women. In both evaluations, boys binge drank in significantly more days than the girls, with a medium effect size in 2005/2006: U=33340.5, z=-7.85, p<0.001, r=0.32, and a small to medium effect size for 2015/2016 sample: U=14925, z=-5.86, p<0.001, r=0.27.
Also for binge drinking in boys group no significant differences were found between evaluations regarding the number of days during last month when they drank more than 5 portions of alcohol in an occasions, p=0.157, but girls significantly increased the number of days with binge drinking U=56565, z=-2.51, p=0.012, r=0.09, with a small effect size (

Predictions
Direct logistic regression was performed in order to assess the impact of gender, group and pattern of alcohol consume during last month on the likelihood that the respondents would answer that they prefer to consume beer, vine or spirits.
Each of the models was applied separately for each type of preferred alcoholic drink. Each model For beer the full model containing all predictors was statistically significant, χ 2 (6, N=1074)=305.9, p<0.001, indicating that the model was able to distinguish between respondents who had beer as their favorite alcoholic drink or not. The model as a whole explained between 25.1% and 34.4% of the variance of having beer as their favorite alcoholic drink or not, and correctly classified 75.4% of cases. All six predictors made a unique contribution to the model. The strongest predictor of having beer as favorite alcoholic beverage was the daily consumption of at least one portion of alcohol in more than 5 days during last month, as compared who students who did not consume at least one portion of alcohol during last month,which recorded a OR=7.6. Students who drank in 1 to 5 days at least one portion of alcohol had 5 times more chances to like beer (table 4).
Students who practiced binge drinking in more than 6 days during last month, as compared to those who did not practice binge drinking at all, had an OR=5.1 and students who practiced binge drinking in 1 to 5 days during last month had an OR=2.3. Boys were 2.2 times more likely to preferred beer, as compared to girls. The sample 2015/2016 had an OR=0.604 meaning that the sample in 2015/2016 consumed significantly less beer than the sample from 2005/2006 For wine the full model containing all predictors was statistically significant, χ 2 (6, N=1074)=221.2, p<0.001, indicating that the model was able to distinguish between respondents who had wine as their favorite alcoholic drink or not. The model as a whole explained between 18.8% and 25.3% of the variance of having wine as their favorite alcoholic drink or not, and correctly classified 71.8% of cases. Only three predictors made a unique contribution to the model. The strongest predictor of having wine as favorite alcoholic beverage was the daily consumption of at least one portion of alcohol in 1 to 5 days during last month, as compared who students which did not drink alcohol at least one portion, which recorded a OR=7.8. Students who drank in more than 6 days at least one portion of alcohol had 7.3 times more chances to like wine. The group of 2015/2016 was 1.6 times more likely to consume wine, compared to group investigated in 2005/ 2006. For gender, the OR=0.706 indicating that women are more likely than men to prefer wine.
The frequency of binge drinking did not contribute to the model (table 5).
For spirits, the full model containing all predictors was statistically significant, χ 2 (6, N=1074)=181.4, p<0.001, indicating that the model was able to distinguish between respondents who had wine as their favorite alcoholic drink or not. The model as a whole explained between 15.7% and 28.0% of the variance of having wine as their favorite alcoholic drink or not, and correctly classified 86.6% of cases. All 6 predictors made a unique contribution to the model. The strongest predictor of having spirits as favorite alcoholic beverage was the frequency of binge drinking of more than 6 days during last month, which recorded an OR=5.8. The frequency of binge drinking of 1 to 5 days had an OR=3.77. Students enrolled in 2015/2016 were 3.6 more likely than the students evaluated in 2005/2006 and men were 1.9 times than women to drink spirits.
Students who drank in more than 6 days at least one portion of alcohol had 3.5 times more chances to like spirits. Daily consumption of at least one portion of alcohol in 1 to 5 days during last month, as compared who students which did not have any day during last month when they consumed one portion of alcohol, recorded an OR=2.4 (table 6).
The prevalence of use of alcohol, defined as the consume at a least a portion of alcohol during last month for 2005/ 2006 sample of 66.9% for men and 38.5% for women and for 2015/2016 sample of 69.9% for men and 52.0% for women. This study has found that, in men, 35% in 2005/ 2006 and 41% in 2015/2016 practiced binge drinking, while in women 9.9% in 2005/2006 and 16% in 2015/2016 had this pattern of consumption.In men, the number of days during last month with at least one portion of alcohol and the number of days with binge drinking was kept relatively constant between evaluations, but women have increased both the number of days in which consumed at least a portion of alcohol and in which binge drank, with a small effect size, reducing the gap between men and women. WHO recommend at most 20 g of alcohol per day for man and 10 g of alcohol for women, but not in all days, and in the absence of binge drinking [1]. Most beneficial health effect related to coronary artery disease [11], cardiovascular and overall mortality [12] were seen in elderly moderate drinkers. For internalizing disorders such as depression or anxiety, in young people [13], or for breast cancer in women [14] no beneficial effects were observed even in low doses of alcohol. Instead heavy drinking was associated in several cohorts with increase mortality and morbidity, and according to WHO the percentage of alcohol-attributable deaths among men amount to 7.6 % of all global deaths compared to 4.0 % of all deaths among women [1]. In both evaluations, for men beer remains top favorite alcoholic drink, followed by wine, and then spirits, while for women wine is top favorite alcoholic drink, followed by beer and spirits. The proportions of each type of alcohol have changed as follows: while beer consumption maintained constant for both genders, wine and spirits have increased their quotation as favorite in 2015/2016 evaluation.The prediction model for beer indicated that the consumer was male, which consumed it in at least as portion throughout the last month, but also used it for binge drinking, with a predilection of belonging to 2005/2006 evaluation. In prediction model for wine significant contributors were feminine gender, and 2015/2016 evaluation, and moderate consumption. Binge drinking patterns did not contribute significantly to prediction of wine   as favorite drink. For spirits, the user profile is of masculine gender, with membership in 2015/2016 evaluation, binge drinker, but also moderate consumer.
So the pattern of consumption related to type of alcohol has shifted: in 2005/2006 beer was used for binge drinking, while in 2015/2016 the odds ratio for spirits have increased. Most probably spirits are consumed hidden in fixed drinks such as alcopop or mixed with energy drinks, which contain high amounts of sugar and hide the strong taste of this type of alcoholic drink.
A recent review [15] of 62 studies has shown that young people who consumed mixes of alcohol-energy drinks have drank more alcohol and experienced more alcohol-related harm than other users.
Beneficial effect of wine and beer is due to non-alcoholic compounds, manly polyphenols, found in higher quantities in wine, compared to beer. In a review, Arranz et al [16] have pointed out that regular and moderate wine and beer consumption is associated with decreased incidence of cardiovascular disease (CVD), hypertension, diabetes, and certain types of cancer, including colon, basal cell, ovarian, and prostate carcinoma, the effect being lower for beer. Recent study [17] showed a beneficial effect in moderate beer consumption for major chronic conditions and some benefit against cardiovascular disease. Other authors [18] have shown a reduction of the endothelial dysfunction associated with cardiovascular risk factors by nonalcoholic beer components.
On the other hand, spirits have the lowest amount of polyphenols of all alcoholic beverages.

Conclusions
The present study gives a unique overview of the changing trends in type and patterns of use and misuse of alcohol in medical students from western Romania, over one decade. The prevalence of use of alcohol, defined as the consume at a least a portion of alcohol during last month for 2005/2006 sample of 66.9% for men and 38.5% for women and for 2015/2016 sample of 69.9% for men and 52.0% for women. This study has found that, in men, 35% in 2005/2006 and 41% in 2015/2016 practiced binge drinking, while in women 9.9% in 2005/2006 and 16% in 2015/2016 had this pattern of consumption.In men, the number of days during last month with at least one portion of alcohol and the number of days with binge drinking was kept relatively constant between evaluations, but women have increased both the number of days in which consumed at least a portion of alcohol and in which binge drank, with a small effect size, reducing the gap between men and women.
In both evaluations, for men beer remains top favorite alcoholic drink, followed by wine, and then spirits, while for women wine is top favorite alcoholic drink, followed by beer and spirits. The proportions of each type of alcohol have changed as follows: while beer consumption maintained constant for both genders, wine and spirits have increased their quotation as favorite in 2015/2016 evaluation.