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Journal of Addictive Diseases

ISSN: 1055-0887 (Print) 1545-0848 (Online) Journal homepage: http://www.tandfonline.com/loi/wjad20

Prevalence and Correlates of Alcohol Abuseand Dependence in Lebanon: Results from theLebanese Epidemiologic Survey on Alcohol (LESA)

Jean-Claude Yazbek MD, Ramzi Haddad MD, Rami Bou Khalil MD, Sani HlaisMD, Grace Abi Rizk MD, Jihane Rohayem MD & Sami Richa MD, PhD

To cite this article: Jean-Claude Yazbek MD, Ramzi Haddad MD, Rami Bou Khalil MD, SaniHlais MD, Grace Abi Rizk MD, Jihane Rohayem MD & Sami Richa MD, PhD (2014) Prevalenceand Correlates of Alcohol Abuse and Dependence in Lebanon: Results from the LebaneseEpidemiologic Survey on Alcohol (LESA), Journal of Addictive Diseases, 33:3, 221-233, DOI:10.1080/10550887.2014.950026

To link to this article: http://dx.doi.org/10.1080/10550887.2014.950026

Accepted author version posted online: 12Aug 2014.Published online: 12 Aug 2014.

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PREVALENCE AND CORRELATES OF ALCOHOL ABUSE AND DEPENDENCEIN LEBANON: RESULTS FROM THE LEBANESE EPIDEMIOLOGIC SURVEYON ALCOHOL (LESA)

Jean-Claude Yazbek, MD1, Ramzi Haddad, MD2, Rami Bou Khalil, MD2, Sani Hlais, MD3,Grace Abi Rizk, MD3, Jihane Rohayem, MD2, Sami Richa, MD, PhD2

1Department of Psychiatry, Lebanese American University, Beirut, Lebanon2Department of Psychiatry, Saint Joseph University, Beirut, Lebanon3Department of Family Medicine, Saint Joseph University, Beirut, Lebanon

The current article aimed to determine the 12-month prevalence and correlates of DSM-IValcohol abuse and dependence in a nationally representative sample of Lebanese adults. Onethousand participants collaborated in face-to-face interviews in 2011. Prevalence of 12-monthalcohol dependence was 5%, with a higher risk for those who were men, unmarried, theyoungest adults (aged between 18 and 34 years old), students, participants with a liberaloccupation, participants with a low income, participants with a positive family history of alcoholmisuse, and smokers. Prevalence of 12-month alcohol abuse was 6.2%, with a higher risk forthose who were men, students, employees, and Druze and Christians compared to Muslims.Current alcohol abuse and dependence were found to be very highly prevalent in Lebanon.

KEYWORDS. Alcohol abuse and dependence, epidemiology, public health in Lebanon, AlcoholUse Disorder Identification Test (AUDIT), Mini-International Neuropsychiatric Interview (MINI)

INTRODUCTION

Alcoholic beverages havebeenubiquitously con-sumed by human beings since the beginning oftimes.1,2 The use of this substance has not ceasedto evoke various emotions and reactions becauseit is socially associated with pleasure despite hav-ing thepotential to inducea stateof addiction thatcan become harmful to the drinker and his or hersurroundings.3 Alcohol use disorders (“alcohol-ism”) refer to alcohol abuse and alcohol depen-dence. These aremaladaptive patterns of alcoholconsumption causing many problems that resultin significant impairment or distress.4,5 Alcoholuse disorders are among the most common psy-chiatric conditions in the Western countries.3,6

They are of special concern to psychiatrists notonly because they are widespread and frequent,butalsobecausetheyimposemajor lossesonindi-viduals,aswellasonsocietiesat large.7–19

Information regarding the epidemiology ofalcohol is crucial for the elaboration of etiologi-cal hypotheses that could lead to the discoveryof biopsychosocial causes of alcoholism. Inaddition, up-to-date descriptive epidemiologicwork is considered important for informing thepublic health system of treatment needs andprevention requirements.3,6,20 Several wide-scale psychiatric epidemiologic surveys havealready been undertaken in various countriesespecially since the 1970s.6–8,10,13,16,20-32

Nonetheless, not all of the studies have specifi-cally focused on the disorders related to alcoholuse and they did not use the same diagnosticcriteria, methods, or screening tools.6,33 Majorstudies based in the United States, Europe,and Lebanon comprise the landmarkEpidemiologic Catchment Area survey,25,26 theNational Comorbidity Survey Replication (NCS-R),22,27–30 the National Epidemiologic Survey

Address correspondence to Rami Bou Khalil, MD, Department of Psychiatry, Saint Joseph University, Hotel Dieu de France hospital,Achrafieh, P.O. Box: 166830, Beirut, Lebanon. E-mail: ramiboukhalil@hotmail.com

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Journal of Addictive Diseases, 33:221–233, 2014

Copyright� Taylor & Francis Group, LLC

ISSN: 1055-0887 print / 1545-0848 online

DOI: 10.1080/10550887.2014.950026

on Alcohol and Related Conditions (NESARC),6

the European Study of the Epidemiology ofMental Disorders (ESEMeD),7,31 and the Leba-nese Evaluation of the Burden of Ailments andNeeds Of the Nation (LEBANON)32 (Table 1).Concerning the 12-month prevalence rates, therate of alcohol abuse ranged from 0.7%(ESEMeD)7,31 to 4.7% (NESARC)6 and the rateof alcohol dependence ranged from 0.3%(ESEMeD and LEBANON)7,31,32 to 3.8%(NESARC).6 Prior to the NCS-R (which wasbased on DSM-IV criteria), other studies hadreported the prevalence rates for alcohol usedisorders based on older versions of the DSM(such as DSM-III-R) and their results had fallenwithin the following ranges: current prevalencewas 1.0% to 4.7% for alcohol abuse and 3.0%to 7.2% for alcohol dependence.10,16,21–23 Fur-thermore, based on DSM-IV criteria, somestudies (other than the NESARC) have alsoreported a wide range of percentages as fol-lows: current prevalence of alcohol abuse was1.9% to 4.3% and of alcohol dependence 3.6%to 4.4%.8,13,20,24

No psychiatric epidemiologic study has beenperformed in the Arab world. Moreover, nonationally representative study that specificallytackles the issue of alcohol use disorders—in theirprevalence and their correlates—has beenundertaken in Lebanon.32 Because alcohol couldindeed constitute a major public health issue andbecause many aspects of its epidemiology are stillobscure in the region, we have chosen to launcha nationwide epidemiologic study in Lebanon

that we have called the Lebanese EpidemiologicSurvey on Alcohol (LESA).

METHODS

LESA has been designed to fulfill multiple objec-tives related to the prevalence of alcohol usedisorders and the various correlates suspectedof being associated with such diseases. Thestudy has been funded by the research depart-ment of the Saint Joseph University of Beirutafter being approved by the Ethics Committeeof the University.

Sample

A large nationwide cross-sectional survey hasbeen performed throughout the month of April2011 on a representative sample of the Leba-nese general population aged between 18 and64 years. The nationally representative samplewas based on proportional probability sam-pling, where the cluster was taken into consid-eration and the primary sampling unit wasconsidered as a bloc of households. The inter-viewees were non-institutionalized adults lack-ing cognitive or physical impairements thatmight alter the quality of their participation.The sampling and surveying procedures werecarried out by Statistics Lebanon, a Lebanesefirm specializing in this kind of endeavor.The face-to-face interviews were all launchedafter insuring appropriate informed consent for

TABLE 1. Prevalence (%) of Alcohol Use Disorders According to Large-Scale Surveys

12-month prevalence Lifetime prevalence

Name ofthe study Location Time

Number ofparticipants (N)

Alcoholabuse

Alcoholdependence

Any alcoholuse disorder

Alcoholabuse

Alcoholdependence

Any alcoholuse disorder

ECA USA Late 1970searly 1980s

20,291 6-monthrateD 1.9

6-monthrate D 2.8

6-monthrate D 4.8

5.6 7.9 13.5

NCS-R USA 2001–2003 9,282 3.1 1.3 4.4 13.2 5.4 18.6NESARC USA 2001–2002 43,093 4.7 3.8 8.5 17.8 12.5 30.3ESEMeD Europe 2001–2003 21,425 0.7 0.3 1.0 4.1 1.1 5.2LEBANON Lebanon 2002–2003 2,857 1.2 0.3 1.5 — — —

Notes: Prevalence refers to the prevalence rate of the disorder and is given in percentage (%).ECA D Epidemiologic Catchment Area survey; NCS-R D National Comorbidity Survey Replication; NESARC D National Epidemiologic

Survey on Alcohol and Related Conditions; ESEMeD D European Study of the Epidemiology of Mental Disorders; LEBANON D LebaneseEvaluation of the Burden of Ailments and Needs Of the Nation

222 J.-C. YAZBEK ET AL.

participation. To estimate the sample size, thefollowing formula has been used:34

ND Z2£ P£ .1¡ P/d2

;

where N D the sample size, Z D the statisticcoefficient for a classical confidence interval of95% (Z D 1.96), P D the estimated prevalenceof the alcohol-disease, as a ratio (proportion),and d D the precision.

Ten trained interviewers who formed twoteams performed the fieldwork. In total, theyapproached 1265 individuals, among whom265 (20.95% of 1265) refused to participate.The total sample comprised 1000 respondents,which was approximately equivalent to the tar-get sample size of 1009. The response rate was79.05%.

The Screening Test: The Alcohol UseDisorder Identification Test (AUDIT)

The AUDIT has been developed by researchersappointed by the World Health Organization asa brief screening instrument for hazardous andharmful alcohol consumption.35–38 The classi-cal cutoff score used to identify an alcohol-related problem is eight.36,38,39 Authors havefound that a cutoff value of eight yieldedsensitivities that were generally in the mid0.90s.36,38,39 Specificities across countries andacross criteria averaged in the 0.80s.36,38,39 Inaddition, Babor et al.36 affirmed that theAUDIT can be used by non-health professionalswith appropriate instructions. The Arabic Ver-sion of the AUDITwas the first of its kind to beproposed and used in simple conventional Ara-bic language. Only one translation of theAUDIT had been performed in the Arab world(in Dubai).40 However, the aforementionnedtranslation cannot be used outside its country oforigin because it was done in a country-specificdialect that is not understandable in the otherArab-speaking regions.

The Arabic AUDIT that was used in theLESA study had been produced in a systematicway. First, a translation into Arabic by an experttranslator from Saint Joseph University was

performed, together in coordination with abilingual alcohol-expert psychiatrist; second, areverse translation of this first Arabic draft wasworked through by another independent pro-fessional translator; third, a board of four bilin-gual psychiatrist-experts worked on theresolution of eventual divergences between thetwo forms of the translated test; fourth, a finalreview resulted in the last version of the ArabicAUDIT.

The Diagnostic Tool: The Alcohol-RelatedPart of theMini-InternationalNeuropsychiatric Interview (MINI)

The MINI is a short, structured diagnostic inter-view that was developed in 1990.41 It uses deci-sion tree logic to assess the major Axis Ipsychiatric disorders described in both DSM-IVand the 10th edition of the InternationalClassification of Diseases (ICD-10). The MINIturned out to be a short, handy, and accurateevaluation tool for use in clinical trials andin epidemiological studies.41–47 Nevertheless,the only Arabic version of the MINI found inthe literature is in Moroccan dialect and is notunderstandable by other Arabic-speaking popu-lations.48 Accordingly, the four steps in translat-ing the MINI were the same as the ones usedfor the AUDIT.

Statistics

Upon accomplishment of the data entry, theresults were cross-tabbed and then analyzed(using SPSS software) (Version 19.0. Armonk,NY: IBM Corp.) in two ways. The first way per-tained to descriptive statistics: prevalence esti-mates were calculated and expressed inpercentages with standard errors (SEs). The sec-ond way of analysis was related to inferentialstatistics. For the purpose of inferential statisticalanalysis, sociodemographic and other similarcharacteristics were considered independentvariables. The statistical significance of eachindependent variable to the predictive modelwas determined by Wald Chi-square (x2) statis-tics. Tests like analysis of variance (ANOVA),Student’s t-test, Pearson correlation, and odds

LEBANESE EPIDEMIOLOGIC SURVEY ON ALCOHOL 223

ratio (with 95% confidence intervals [95% CIs])computation were also used where pertinent.Statistical significance was judged as P < 0.05(95% level of significance). Also by means ofinferential analysis, calculation of sensitivity andspecificity (with CIs) for the Arabic AUDIT testwas produced.

RESULTS

Sociodemographic and Other PertinentCharacteristics of the Respondents

The characteristics of the sampled populationare presented in Table 2.

Results of the MINI Interview

According to the MINI, the 12-month preva-lence of alcohol dependence was 5.00%(CI D 3.65%, 6.35%), alcohol abuse was 6.20%(CI D 4.71%, 7.69%), and alcohol use disorderswas 11.20% (standard error [SE] D 0.997).Odds ratios (ORs) of alcohol dependence were

TABLE 2. Sociodemographic and Other Pertinent Characteristicsof the Respondents

Characteristics ofalcohol respondents

% SE Totalnumber

GenderMale 67.9 1.48 679Female 32.1 1.48 321

Age, in years18–34 45.5 1.57 45535–49 30.2 1.45 30250–64 24.3 1.36 243Mean 38.01 (95% CI D 37.14–38.88)

Marital statusSingle 39.1 1.54 391Married 58.5 1.56 585Widowed 1.1 0.33 11Divorced 1.3 0.36 13

OccupationLiberal 46.7 1.58 467Employee 33.5 1.49 335Unemployed or house wife 12 1.03 120Student without any job 4.9 0.68 49Student with a job 2.9 0.53 29

Academic levelNone 2.3 0.47 23Primary schooling 19.3 1.25 193Complementary schooling 34.2 1.5 342Secondary schooling 22.5 1.32 225Technical formation 7.3 0.82 73University 14.4 1.11 144

ReligionChristian 38.7 1.54 387Muslim 54.4 1.58 544Druze 6.9 0.8 69

Familial monthly income, in $<$500 3.2 0.56 32$500–$1000 37.6 1.53 376$1000–$3000 50.8 1.58 508>$3000 8.4 0.88 84

Having a family member thoughtto suffer from alcohol problemYes 8.2 0.87 82No 91.8 0.87 918

SmokingYes 60.5 1.55 605No 39.5 1.55 395

Physical exerciseNot at all 35.7 1.52 357Occasionally 36 1.52 360Often 10.7 0.98 107Daily 17.6 1.20 176

Exposure to war-relatedtraumatic eventsYes 76.0 1.35 760No 24.0 1.35 240

Geographical locationBeirut 10.0 0.95 100Mount Lebanon 35.3 1.51 353North 20.3 1.27 203

TABLE 2. Sociodemographic and Other Pertinent Characteristicsof the Respondents (Continued)

Characteristics ofalcohol respondents

% SE Totalnumber

South 20.8 1.28 208Bekaa 13.6 1.08 136

Usual place of drinkingAt home and alone 13.6 1.08 91At home with other drinkers 35.3 1.51 237At other people’s home 4.9 0.68 33In restaurants 40.8 1.55 274In other public places such aspubs, bars, or discotheques

5.4 0.71 36

Seeking help to stop drinkingYes 0.9 0.30 6No 99.1 0.30 665

Number of persons in the householdMean D 4.513 » 5Mode D 4.00; Std. Deviation D 1.96; MinimumD 1.00;

Maximum D 16.00Number of rooms in the houseMean D 4.125 » 4Mode D 3; Std. Deviation D 1.57; MinimumD 1;

MaximumD 12Age at first drinking, in yearsMean D 19.51Mode D 20.00; Std. Deviation D 5.23; MinimumD 10.00;

Maximum D 60.00

(Continued)

224 J.-C. YAZBEK ET AL.

significantly greater among men compared withwomen; among participants aged between 18and 34 years as compared with participantsaged between 50 and 64 years; among singleparticipants as compared with married ones;among participants without any job as com-pared with unemployed participants or house-wives; among participants with a liberaloccupation (i.e., lawyers, medical doctors, self-employed engineers, freelancers, singers, busi-nessmen or traders who work on their own,etc.) as compared with those unemployed orhousewives; among participants with a familyincome of $500 to $1000 as compared withthose whose family income is greater than$3000 per month; among participants with apositive family history of alcohol use disorder;and among smokers. ORs of alcohol abusewere greater among men; among students(with or without a job), employees, or partici-pants with a liberal occupation when eachsubgroup was compared to the subgroup of un-employed participants or housewives; amongparticipants belonging to Druze confession ascompared to participants belonging to Islam;and finally among Christian participants com-pared to participants Muslim (Tables 3 and 4).

DISCUSSION

According to LESA, 11.2% of Lebanese adultsexperienced alcohol use disorders in the prior12 months (abuse: 6.2%; dependence: 5%) in2011. LESA estimates were considerably higherthan the prevalence estimates from the LEBA-NON study.32 The latter survey had found a1.5% prevalence of alcohol use disorders(abuse: 1.2%; dependence: 0.3%). The authorshad highlighted their strong beliefs that theirestimates were lower than the true prevalencerates of the population.32 LESA estimates werealso considerably higher than the Europeanprevalence figures reported by the ESEMeD(alcohol use disorders: 1%; abuse: 0.7%;dependence: 0.3%). Nonetheless, the ESEMeDinvestigators had also said that their results wereprobably conservative.7,31 The LESA resultswere closest to the ones of the NESARC study,

where the prevalence of alcohol use disorderswas 8.5% (abuse: 4.7%; dependence: 3.8%).NESARC reported that the results of previousstudies in the United States were probablyunderestimates of true rates and that theirresults, despite the relatively higher figures,were also probably underestimates because thebulk of the encountered biases tended to pullestimates downward (eg, sampling bias).6 Nosolid conclusions can be drawn by comparingLESA results with all of these studies done in differ-ent countries and time frames. Many differencesrelated to sampling methods, age ranges, diagnos-tic systems, measuring tools, cultural variations,and time frames are present among thesevarious surveys.6–8,10,13,16,22,23,25,28,31,32,49–51

LESA results appeared similar to some of thosestudies, although similarities with previous studiescannot be over interpreted. When it comes to thecorrelates and possible risk factors for alcohol dis-orders, several variables have been identified.

Consistent with previous studies, men wereat greater risk of alcohol use disorders thanwomen.6–8,52 However, ORs were very highcompared with those found in other studies.The OR for alcohol use disorders was 11.82(NESARC’s ORs concerning different alcoholdisorders were between 2 and 3),6 the OR forabuse was 5.79, and that for dependence wastoo high to be calculated because the preva-lence of dependence among Lebanese womenwas found to be zero. The latter result was cer-tainly a major underestimation that came fromvarious reasons, such as the under-representa-tion of women among respondents and the cul-tural or religious norms and values that renderwomen less at ease in reporting embarrassing orprohibited behaviors (e.g., alcohol consump-tion is “religiously prohibited” in Islam).

Consistent with previous studies, a trend forincreased risk for alcohol use disorders withdecreasing age has been made evident in theLESA.6–8 Nonetheless, the increased risk wasstatistically significant only for dependence(and any alcohol use disorder) and only whencomparing the 18 to 34 years subgroup to the50–64 years subgroup. Single participants wereat higher risks of experiencing dependencecompared with married participants. This was

LEBANESE EPIDEMIOLOGIC SURVEY ON ALCOHOL 225

TABLE 3. 12-Month Prevalence of DSM-IV Alcohol Use Disorders According to Different Characteristics of the Respondents

Alcohol use disorder(n D 112)

Alcohol dependence(n D 50)

Alcohol abuse(n D 62)

Characteristics of the Respondents % SE % SE % SE

Total 11.2 0.997 5 0.689 6.2 0.763Gendera

Male 15.76 1.152 7.36 0.826 8.39 0.877Female 1.56 0.392 0 0 1.56 0.392P-value of the trend test (Chi-square) 0.000*** 0.0000*** 0.000***

Age, years18–34 13.41 1.078 6.59 0.785 6.81 0.79735–49 10.93 0.987 4.3 0.641 6.62 0.78650–64 7.41 0.828 2.88 0.529 4.53 0.658P-value of the trend test (ANOVA) 0.056 0.081 0.142

Marital statusSingle 13.04 1.065 6.65 0.788 6.39 0.773Married 10.26 0.96 3.93 0.614 6.32 0.769P-value of the trend test 0.179 0.057 0.161Widowed 0 0 0 0 0 0Divorced 7.69 0.843 7.69 0.843 0 0

Occupationa

Liberal 14.78 1.122 6.64 0.787 8.14 0.865Employee 7.76 0.846 3.28 0.563 4.48 0.654Unemployed or house wife 2.5 0.494 1.67 0.405 0.83 0.287Student without any job 20.41 1.275 10.2 0.957 10.2 0.957Student with a job 13.79 1.09 3.45 0.577 10.34 0.963P-value of the trend test 0.001* 0.129 0.010*

Academic levela

None 4.35 0.645 4.35 0.645 0.00 0.000Primary schooling 13.47 1.08 6.74 0.793 6.74 0.793Complementary schooling 14.04 1.099 7.89 0.852 6.14 0.759Secondary schooling 10.67 0.976 1.78 0.418 8.89 0.9Technical formation 6.85 0.799 5.48 0.72 1.37 0.368University 5.56 0.725 0.69 0.262 4.86 0.68P-value of the trend test 0.001* 0.001* 0.010*

Religiona

Christian 12.92 1.061 4.91 0.683 8.01 0.858Muslim 9.38 0.922 5.51 0.722 3.86 0.609Druze 15.94 1.158 1.45 0.378 14.49 1.113P-value of the trend test 0.104 0.343 0.002*

Family monthly income<$500 9.38 0.922 3.13 0.551 6.25 0.765$500–$1000 10.37 0.964 6.12 0.758 4.26 0.639$1000–$3000 11.81 1.021 4.72 0.671 7.09 0.812>$3000 11.9 1.024 2.38 0.482 9.52 0.928P-value of the trend test 0.752 0.375 0.187

Having a family member thought to suffer from alcohol problemsa

Yes 20.73 1.28 14.63 1.12 6.1 0.76No 10.35 0.96 4.14 0.63 6.21 0.76P-value of the trend test 0.004* 0.000*** 0.000***

Smokinga

Yes 14.38 1.11 7.27 0.82 7.11 0.81No 6.33 0.77 1.52 0.39 4.81 0.68P-value of the trend test 0.000*** 0.000*** 0.000***

Physical exerciseNot at all 12.89 1.06 5.32 0.71 7.56 0.84Occasionally 10.00 0.95 3.89 0.61 6.11 0.76Often 7.48 0.83 3.74 0.60 3.74 0.60

(Continued on next page)

226 J.-C. YAZBEK ET AL.

in concordance with the literature, whereunmarried individuals were consistently moreat risk for alcohol disorders than married indi-vidual.6–8

Dissimilarities with previous surveys wereevident for occupation and associated risk foralcohol disorders. LESA reported a lower riskfor alcohol disorders among unemployedadults, whereas previous international studieshad repeatedly shown that unemployment wasa risk factor for alcohol use disorders.7,8 Adultswith a job were at a higher risk of alcohol abuseand of any alcohol use disorder. Students with-out any job and adults with a liberal occupationdisplayed higher odds of dependence thanunemployed adults. In the literature, being astudent had sometimes been presented as a riskfactor for alcohol use disorder (e.g., the Austra-lian survey).8 However, the results concerningthe lower rate of alcohol disorders among theunemployed were unique to the LESA study. Apossible explanation is that in this part of the

world unemployed adults are often taken careof by their families. Furthermore, Lebaneseadults who state they have a liberal occupationdo not always mean that they are currently hav-ing regular and sufficient income.

Religion and confession continue to play asignificant role in the way the Lebanese popula-tion identify its norms, values, and behaviors. Ahigher risk for abuse (and for any alcohol usedisorder) was observed among Druze andChristians when each subgroup was comparedto Muslims. However, no difference was notedwhen it came to dependence. The religious fac-tor was not studied in the before-mentionedlarge epidemiological surveys in relation toalcohol use. Nonetheless, a study done by But-ton et al.53 in 2010 showed that religiosityappears to moderate the genetic effects onproblem alcohol use during adolescence butnot during early adulthood. It appeared to theresearchers that the decreased genetic variancefor alcohol misuse in adolescence may be due

TABLE 3. 12-Month Prevalence of DSM-IV Alcohol Use Disorders According to Different Characteristics of the Respondents (Continued)

Alcohol use disorder(n D 112)

Alcohol dependence(n D 50)

Alcohol abuse(n D 62)

Characteristics of the Respondents % SE % SE % SE

Daily 12.50 1.05 7.39 0.83 5.11 0.70P-value of the trend test 0.343 0.323 0.408

Exposure to war-related traumatic eventsYes 10.79 0.98 5.26 0.71 5.53 0.72No 12.50 1.05 4.17 0.63 8.33 0.87P-value of the trend test 0.464 0.497 0.245

Geographical locationBeirut 8.00 0.86 2.00 0.44 6.00 0.75Mount Lebanon 9.63 0.93 3.12 0.55 6.52 0.78North 21.18 1.29 10.84 0.98 10.34 0.96South 3.85 0.61 1.92 0.43 1.92 0.43Bekaa 13.97 1.10 8.09 0.86 5.88 0.74

Usual place of drinkingAt home and alone 18.68 1.23 6.59 0.78 12.09 1.03At home with other drinkers 11.81 1.02 4.22 0.64 7.59 0.84At other people’s home 18.18 1.22 6.06 0.75 12.12 1.03In restaurants 17.88 1.21 8.39 0.88 9.49 0.93In other public places such as pubs, bars, or discotheques 33.33 1.49 25.00 1.37 8.33 0.87

Seeking help to stop drinkingYes 16.67 1.18 16.67 1.18 0.00 0.00No 16.69 1.18 7.37 0.83 9.32 0.92

aIndicates that characteristic is associated with alcohol dependence, alcohol abuse, or both disorders.SE D Standard Error.* P < 0.05.*** P < 0.001.Note: no analysis for trend for the last 3 characteristics was performed.

LEBANESE EPIDEMIOLOGIC SURVEY ON ALCOHOL 227

to the greater social control in adolescence thanin young adulthood.53

Adults with a family income of $500 to$1000 compared to those whose family income

was greater than $3000 per month showed agreater risk only for dependence. This patternwas consistent with what has been described inthe NESARC: poor people were more at risk of

TABLE 4. Unadjusted Odds Ratios of 12-Month DSM-IV Alcohol Use Disorders by Different Characteristics of the Respondentsa

Characteristic Alcohol use disorder Alcohol dependence Alcohol abuse

GenderMale 11.82 (10.92¡12.73)** Too large to calculate # 5.79 (4.87¡6.72)**Female 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]

Age, years18–34 1.94 (1.38¡2.49)** 2.38 (1.54¡3.22)** 1.54 (0.84¡2.25)35–49 1.53 (0.93¡2.13) 1.52 (0.58¡2.45) 1.50 (0.74¡2.25)50–64 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]

Marital statusSingle 1.31 (0.92¡1.71) 1.74 (1.16¡2.32)** 1.01 (0.49¡1.54)Married 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]Widowed # #Divorced 0.73 (¡1.33¡2.79) 0.85 (¡1.22¡2.93) # #

OccupationStudent without any job 10.00 (8.66¡11.34)** 6.70 (5.03¡8.38)** 13.52 (11.35¡15.70)**Student with a job 6.24 (4.68¡7.80)** 2.11 (¡0.33¡4.54) 13.73 (11.43¡16.03)**Unemployed or house wife 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]Employee 3.28 (2.07¡4.5)** 2.00 (0.48¡3.52) 5.58 (3.54¡7.61)**Liberal 6.76 (5.59¡7.94)** 4.19 (2.75¡5.64)** 10.54 (8.54¡12.54)**

Academic levelNone 0.29 (¡1.75¡2.34) 0.63 (¡1.45¡2.71) ##Primary schooling 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]Complementary schooling 1.05 (0.53¡1.56) 1.19 (0.5¡1.87) 0.91 (0.19¡1.62)Secondary schooling 0.77 (0.18¡1.36) 0.13 (¡1.38¡1.63) 1.35 (0.62¡2.08)Technical formation 0.47 (¡0.53¡1.47) 0.81 (¡0.35¡1.96) 0.19 (¡1.86¡2.24)University 0.81 (¡0.09¡1.72) 0.10 (¡1.95¡2.14) 0.71 (¡0.24¡1.65)

ReligionChristian 1.43 (1.02¡1.85)** 0.88 (0.29¡1.47) 2.17 (1.60¡2.74)**Muslim 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]Druze 1.83 (1.13¡2.54)** 0.25 (¡1.76¡2.26) 4.22 (3.42¡5.02)**

Family monthly income<$500 0.77 (¡0.59¡2.13) 1.32 (¡1.11¡3.76) 0.63 (¡0.97¡2.24)$500–$1000 0.86 (0.12¡1.60) 2.67 (1.21¡4.14)** 0.42 (¡0.46¡1.31)$1000–$3000 0.99 (0.28¡1.7) 2.03 (0.57¡3.49) 0.72 (¡0.08¡1.53)>$3000 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]

Having a family member thoughtto suffer from alcohol problemYes 2.27 (1.69¡2.84)** 3.97 (3.28¡4.66)** 0.98 (0.04¡1.92)No 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]

SmokingYes 2.49 (2.02¡2.95)** 5.08 (4.22¡5.95)** 1.51 (0.96¡2.07)No 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]

Physical exerciseNot at all 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]Occasionally 0.75 (0.29¡1.21) 0.72 (0.01¡1.43) 0.80 (0.21¡1.38)Often 0.55 (¡0.24¡1.33) 0.69 (¡0.41¡1.79) 0.47 (¡0.60¡1.55)Daily 0.97 (0.42¡1.51) 1.42 (0.69¡2.15) 0.66 (¡0.12¡1.44)

Exposure to war-related traumatic eventsYes 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]No 1.18 (0.74¡1.63) 0.78 (0.07¡1.49) 1.55 (1.00¡2.11)

aUnadjusted odds ratios (95% confidence intervals).**Odds ratio was significant.#Odds ratio could not be computed because the prevalence of disease (dependence) in the reference-subgroup (female) was zero.##Odds ratio was not presented because the prevalence of the corresponding disease in the subgroup was zero.

228 J.-C. YAZBEK ET AL.

dependence and they were less at risk ofabuse.6 Nonetheless, family monthly income isnot a very good predictor of wealth statusbecause it does not consider the income percapita.

Adults having a family member thought toexperience alcohol problems were at a higherrisk of dependence and of alcohol use disor-ders. These findings could be considered con-sistent with the literature, which has repeatedlyemphasized the increased prevalence of posi-tive family history of alcohol use disordersamong individuals who suffer from alcoholdependence.54–63 Numerous rigorous—family,twin, and adoption—studies have alreadypointed out the importance of genetic and envi-ronmental factors in the etiology of alcoholism(mainly alcohol dependence) and have esti-mated that the heritability for this disease ishigh (50%–60%).55–59,62,63 A study by Prescottet al.57 in 2005 has confirmed prior studies’conclusions of strong genetic influences onalcoholism in men but has suspected lowergenetic influence in women.

Smoking was strongly associated with alco-hol dependence (OR D 5.08) and with alcoholuse disorders. This finding was consistent withprevious studies, such as the NESARC survey6

and the Collaborative Study on the Genetics ofAlcoholism (COGA).64 Smoking and alcoholdependence frequently co-occur, and thegenetic factors that influence both conditionsappear to overlap. The COGA has investigatedgenetic factors that contribute to both alcoholdependence and habitual smoking.64 It has sug-gested that both common and drug-specificgenetic influences play a role in the develop-ment of alcohol and nicotine dependence.64

Finally, no association was found betweenalcohol use disorders and exposure to at leastone war-related traumatic event.

Several limitations were inherent to theLESA. The prevalence estimates were relativelyhigh when compared to previous epidemiologi-cal works.7–8,25,27,32 The first set of limitationswas due to the properties of the target popula-tion. The Lebanese population is not used forpublic opinion research endeavors.32 Despitedeclarations of anonymity and confidentiality,

the will to participate in the survey and themotivation to be completely sincere andactively search for precise answers were notalways present. For example, the nonresponserate was 20.95%, with women being mostreluctant to participate. For cultural, social, andsometimes religious reasons, the reporting ofbehaviors pertaining to alcohol use was fre-quently seen as embarrassing and unwel-comed.51 A second set of limitations was due tothe cross-sectional structure.6 This kind ofapproach cannot detect any change of diagno-ses over time, and it cannot guarantee enoughrepresentation of diseased people, especiallyfor uncommon disorders. A direct consequencewas the absence of detection of any alcohol-dependent woman in the entire sample. Thesampling process itself brought about manybiases because of the way respondents wereselected. Individuals with a history of mental ill-ness are less inclinded to participate in surveysbecause of an even greater reluctance to coop-erate,31,65-67 sample frame exclusion (eg,excluding people with no homes, those withmajor handicaps),27,31 differential mortality(especially in the Lebanese society, where thosewith both major illnesses and a lack of familialsupport have little access to proper health care),and a high level of associated stigma to displaytheir characteristics (mental illnesses and espe-cially substance misuse disorders are still verystigmatized in Lebanon).27,31,32,68,69 Finally,another important limitation was that the Arabictranslations of the AUDIT and MINI have notbeen officially validated yet.

CONCLUSION

The LESA study has demonstrated that alcoholuse disorders were highly prevalent among theLebanese general population. It has identifiedpopulation subgroups at particular risk andunveiled many findings that deserve to be fur-ther investigated. By treating the substance mis-use symptoms before a full-blown alcohol usedisorder sets in and by reducing the alreadyidentified risk factors, the percentage of individ-uals who will ever develop serious disorders

LEBANESE EPIDEMIOLOGIC SURVEY ON ALCOHOL 229

can be favorably altered.7 Accordingly, a sys-temic preventive action that targets the Leba-nese population is needed. This action shallencompass educating the public and the gov-ernmental organizations about the AUDconsequences.

ACKNOWLEDGEMENTS

The authors thank Elsa Yazbek Charabati andher team for the translation of all the parts ofthe questionnaire used in the LESA, includingthe AUDIT and MINI, and Dr. Andr�e Yazbek(Professor in Gastroenterology) and Dr. Elvireel-Hage-Chahine Yazbek for their suggestionsconcerning the writing of the questionnairesand of the study.

FUNDING

The Research Department of the Saint JosephUniversity of Beirut (USJ) provided funds for thecollection, management, and analysis of thedata. The design and the conduct of the study,as well as the preparation, writing, reviewing,and approval of the manuscript, were not sup-ported by any fund or grant; they were thework and the responsibility of the authors (andmostly of the first author).

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