Sampling

In accordance with best practice for qualitative research we sought to implement a maximum variation sampling strategy which would achieve diversity in key variables for which views and experience around alcohol would likely differ.⁴³ Research elsewhere has suggested that the profile of drinking behaviours varies by age; consequently, within our age group (25–44 years) we sought to ensure individuals were represented in both the 25–35 years and 36–44 years age bands. In addition, we sought to include a number of individuals who may be aged between 44 and 60 years in order to obtain their views on past behaviour (with the experience of hindsight).

Recruitment

We purposively sampled from a variety of social venues likely to represent the target group of interest to the study. Venues included Saturday amateur football league clubs, public houses, an employment training centre and a further education college (Table 1). Systematic reviews have shown that the provision of monetary incentives can significantly increase recruitment to research studies.^44,45 Consequently, men agreeing to take part were given a £10 gift voucher and travel expenses. They found the experience rewarding because a prestigious organisation (the university) was interested in their lives and believed what they had to say was valuable. Many said it was therefore something they could share with pride in their social network.

TABLE 1

Summary of focus group membership

Thus, 28 men aged 21–57 years living in areas of high deprivation were recruited to the study. Deprivation was measured using the Scottish Index of Multiple Deprivation (SIMD),⁴⁶ which is similar to the English Index of Multiple Deprivation. Individual-level socioeconomic position was also assessed from brief questionnaires on current socioeconomic and demographic characteristics. Summary characteristics of participants are shown in Table 2.

TABLE 2

Summary of sociodemographics of focus group participants

Data collection and analysis

Data were collected using a focus group approach. It was clear that much drinking reflected a social practice influenced in part through group norms and sets of social expectancies. Consequently, enabling men to talk as a group would enable identification of these expectancies, attitudes and values.⁴⁷ A topic guide was constructed based on a background search of relevant literature in the area. However, conversations were not limited to these areas. All participants were informed of the confidential nature of the research. All groups were audio-recorded and transcribed. Analysis was conducted by three members of the research team (JC, DWF and BW) using the framework approach.⁴⁸ Pseudonyms have been used in direct quotations to protect participant identity.

Private purpose and social roles

Our findings suggest that alcohol consumption behaviours vary in accordance with two parallel drivers: private purpose and public role. Private purpose refers to an individual's personal reasons for and against particular forms of alcohol consumption. While these purposes may sometimes be made public, they are generally tacit. Public role highlights the social role of alcohol in many individuals' lives. As with any role it brings a set of social expectations and duties which must be followed if sanctions are to be avoided. Private purpose may be seen to be a driver of private drinking, while social drinking may be influenced by both private purpose and social role.

Social roles

While some older men used alcohol as a form of release and thus a way of achieving ‘freedom from’ (the stresses and problems of everyday life), for many more it was seen also as a means of achieving ‘freedom to’ – it facilitated the achievement of personal attributes and fulfilling public social roles that they otherwise would not have had the self-confidence to attempt: ‘it can help people, shy people actually come out of their shell, ken.’

However, all quotes relating to this were notable in that they referred to their view of other people's reliance on alcohol to achieve this, or to their own but in earlier years. Using alcohol to improve social confidence and fulfil other social roles and identities was therefore either less important for older men, or was something they were reluctant to admit to personally.

In addition to enhancing one's ability to achieve a valued social identify and fulfil a public role, it became apparent that the social nature of drinking in the pub environment was in fact a social role characterised by a set of expectations, duties and potential sanctions (Box 1). These included expectations to drink alcohol (rather than soft drinks) and to pay one's fair share of rounds. There was evidence of significant disapproval of individuals not conforming, giving rise to a felt pressure to conform and drink.

BOX 1

Alcohol and ‘roles’ I know a lot of people that go out, just to have a drink, to look for women, ken what I mean. A lot of the guys that are sober couldn’t chat a woman up unless they’ve had something inside them

Shifting purpose and role – the importance of age

Participants frequently generated a narrative looking back to earlier times in their lives; in addition, they sometimes compared their own motives, experiences and behaviours to other contemporary younger drinkers. Through these comparisons it became clear that they perceived a very significant shift in both the social role expectations and duties, and the private purpose motives for drinking. Consequently, there was a move towards what might be termed the ‘mature drinker’. Indeed, these were sufficiently consistent as to suggest that there may broader agreement on the existence of younger and mature drinker roles. This shift is shown in Table 3.

TABLE 3

Shifts in motives and expectations from the younger to the ‘mature’ drinker

There was a general view that older drinkers were less likely to be drinking in order to get drunk and more likely to drink for general relaxation, social company, reward and as a means of escaping from daily pressures. In addition, older drinkers saw themselves as more able to know their limits and more likely to be able to ‘hold’ their drink. Some felt that they had more money to drink now that they were older while others found that finance was a major obstacle. Consequently, these drivers meant that more mature drinkers might well consume greater volumes of alcohol but be drunk less frequently.

Although these issues suggested that greater quantities of alcohol might frequently be consumed, there were multiple examples of explanations of changes in drinking behaviour rooted in the adoption of multiple new social roles which competed and were sometimes incompatible with their past drinking behaviours. These provided a new and perhaps wider ‘perspective’ on the role and impact of alcohol in their lives:

Yeah because maybe if you're seeing a lassie, you’ll maybe get a bottle of wine and a DVD or have a glass of wine with my tea most nights or a couple of beers maybe watching the Champions League. You've got a different perspective on drink because you’re older.

Simon, aged 27 years

A commonly reported shift was with regard to their obligations within family roles and relationships. This included both partners and children:

But you do, even like when kids come on the scene, if you’ve got your partner, you split up, you get your bairn one week, you get the bairn weekends. That changes yourself as well. That’s like me, I get [inaudible] every weekend, so I don’t go out. I go out every Wednesday, that’s when I got out.

Fred, aged 34 years

More frequently expressed were their current identities and obligations as employees. When they were younger such responsibilities were not of concern, but now they constrained what the men could do:

With my job and responsibilities, I can’t just go out, I’m not working in a warehouse like I was when I was 18 where you can just do what you want the next day, it doesn’t matter. But now, during the week, it just can’t happen, with my job the next day, I just couldn’t function properly.

Jim, aged 31 years

There was recognition that the adoption of these wider life roles and responsibilities were appropriate and to be expected as part of the process of becoming more mature. They were not expressed in pejorative forms and there was little sense of nostalgia about what they were losing in terms of past drinking behaviour. Consequently, even among those older men who were still drinking significantly there was a willingness to publicly express their intention to change as these new roles emerged for them:

Well I don’t want to be, my ideal at some point would be to settle down and have some sort of family unit that my focus was on them, and go for the occasional night out with the boys and the odd couple of pints. But certainly not drink socially the way we drink now and I wouldn’t want to be drinking to that extent when I get older. I’m not saying I might, what I want and what will happen might be two different things but certainly, for the picture of where I want my life to go I don’t want to be still having the nights out the way I have them just now in say 5–10 years’ time. I would rather want my focus to be somewhere more important.

Simon, aged 27 years

Awareness of consequences and the importance of concrete personal experience over abstract risk

High levels of alcohol consumption among the older men do not appear to be rooted in a lack of awareness of the consequences of drink. There was ample evidence, and graphic examples, of the consequences including hangovers, significant financial cost, changed character, poor health and violence with its associated implications.

Underpinning many of the consequences was recognition that during the drinking process their usual selves, with their typical motives, intentions, values and self-discipline diminish, culminating with a complete disappearance and a lack of awareness or memory of anything that occurred:

Your judgement could be all wrong.

Martyn, aged 38 years

You forget a lot, you don’t ken what you’ve done. You lose your identity as well because you don’t know what you’ve done.

Derek, aged 28 years

Yeah me, I have. Quite a few years ago. I was out with a mate, a friend of mine and ended up having quite a few drinks and the next thing I knew I woke up in hospital.

Jeff, aged 40 years

I woke up in Orkney Street in Govan and I thought ‘How did I get here?’

Brian, aged 31 years

Consequently, while alcohol had been described as facilitating the achievement of social roles and valued personal identity in their earlier years through improved social confidence (‘freedom to’), alcohol now frequently proved to be an obstacle to achieving such an identity (partly because that valued identity had changed as new domestic, work and even the mature drinker role had been adopted). Ultimately, it was seen to change one's character and desired behaviours:

I think it hampers your personality on all points, and that’s not always a good thing. I mean, you can say things you regret or those feelings that have been sitting on your mind or your boss, maybe you shouldn’t say something if you’re at a work night out, or a girl, that you’d maybe regret the next day, when you've left a text or a comment on a social network site or anything. And you’re like, this seemed like a good idea at the time. . . [laughter]

Tony, aged 28 years

My dad said to me at one point, he says, I always know when you’re back on the drink or drugs, you’re an obnoxious little shit.

Ross, aged 37 years

. . . she just says ‘I don’t like you when you drink, I don’t like your attitude and the way you are.’ She says I get quite aggressive.

Jim, aged 31 years

The most common seemingly powerful consequences of alcohol consumption for participants were in relation to aggression and physical violence. Many participants knew of others who had been in trouble with the police (including assault and murder), while others had personal experience:

Yeah. I’ve been arrested and put in the cells overnight and stuff like that. I’ve been in quite a few fights because of it, so.

Ben, aged 38 years

When I used to drink, if I drank whisky, it just made me drowsy. I’d get a heavy hangover and I’d probably start fighting with somebody.

Graeme, aged 43 years

Although there was widespread awareness of a range of negative consequences from alcohol consumption, it was interesting to note that explanations for changes in participants' drinking were rooted in past personal experience of these issues rather than knowledge of their more abstract existence and risk. The most important of these appeared to be the impact on the person's children, although multiple causes were often seen to combine.

The main reason for me is one, no more criminal record. Two, I’ve got two children that I haven’t seen for two years now. And obviously the money as well. And health. My brother’s only 40 and he drinks and he had a stroke last year, so that’s a bit worrying when you’ve got heart problems in the family as well, so I thought, I’ll stop as well, so.

Ben, aged 38 years

Other reported triggers to changing included the financial impact, e.g. falling behind in paying bills, and personal health events. Although most examples related to the individual's own personal experience of a substantive problem, a few individuals did indicate that it was the observed experience of a close friend or relative which had prompted their change in drinking. In earlier discussions regarding consequences of excessive drinking, participants frequently reported the consequences that they had observed in other people; however, observations only appeared to motivate actual reported change in the participant when it was someone close to them. This suggested that in some instances vicarious experience may prompt change, or at least intentions to change consumption patterns.

The importance of the ‘mature drinker’ role

Our data suggest that contemporary society may have a particular set of expectations and beliefs about the more ‘mature drinker’: someone who can tolerate greater amounts of alcohol without becoming drunk, has greater self-discipline, is more likely to be able to resist social pressures to drink, and drinks as a means of reward, relaxation and release. The existence of such a set of social expectancies is perhaps evident in the way society may interpret public drunkenness by a teenager or person in their early 20s differently compared with a man in his 40s. The existence of the ‘mature drinker’ role and the individual's desire to conform/live up to the identity it affords may prove useful in both behavioural interventions and those employing more social marketing approaches.^49,50

The development of competing social roles and identities as an explanation for changes in drinking behaviour with age

Our findings also show that reasons for alcohol consumption among older disadvantaged men differ from their younger counterparts. Therefore, brief interventions to tackle the problem must incorporate different approaches. The literature suggests the perceived benefits of alcohol (alcohol expectancies) for young people include mood enhancement and enjoyment, stress relief and escapism, easier socialising and social success, and conformity with peers.^51,52 Thus, three different types of drinkers have been identified: enhancement drinkers, social drinkers and coping drinkers.⁵³ Although similar benefits were stressed by the older men in this study, there was a clear shift in emphasis away from the use of alcohol as a means of achieving valued social identities, social confidence and group membership (‘freedom to’), towards a greater value attached to the use of alcohol as reward, relaxation and release (‘freedom from’). Such changes were clearly rooted in changes in social identities and roles acquired as men grew older. They became employees, partners and fathers – roles and responsibilities which had the potential to constrain alcohol consumption, or at least excessive drinking. The existence of these competing roles as a constraint may provide a means through which potential behavioural interventions may operate. The power of social roles to influence behaviour comes from the potential social sanctions applied when expectations and duties associated with those roles are not fulfilled (e.g. failing to be a good employee, partner or parent).⁵⁴ Consequently, the psychological concept of ‘subjective norm’ (an individual's perception of social normative pressures, or relevant others' beliefs that he or she should or should not perform such behaviour⁵⁵) may be helpful in future behavioural interventions for this population.

Studies have shown that peer pressure is a significant factor in the level of alcohol consumption among young people.⁵⁶ Low levels of drinking refusal self-efficacy have been found to increase the acquisition and maintenance of binge drinking.⁵⁷ However, the adult version of the Drinking Motives Questionnaire (DMQ) has no scale to measure peer (conformity) motives, because it assumes the influence of peer pressure declines with age.⁵³ Although this, to a large extent, is true, our findings suggest the influence of peers and social networks on the older cohort may be more complex and subtle than first assumed. Although some men felt that their friends were more accepting of their decisions to slow their drinking down, other men still felt pressure from their peers to consume large amounts of alcohol. In the second context it was the behaviour – the consumption of alcohol – that signified membership of the group and gave the men a sense of belonging. The men's refusal self-efficacy therefore largely depended on whether the group was predominantly defined by its drinking behaviour or another organising factor. A brief intervention might therefore highlight that the men have a choice about the different social networks they are accessing, and that this choice will affect the amount of alcohol they consume and ultimately their health and well-being.

Alcohol and role incompatibilities: the potential of ‘developing discrepancy’

Drinking was a component of many rituals that were deeply satisfying to the older men in the study, and which reinforced the pleasure because of this association. Yet many of the benefits the men identified were not compatible with being very drunk. This presents an opportunity to highlight the inconsistency between an individual's drinking habits and the intended aims of drinking. Thus, brief interventions could highlight the mismatch between being drunk, and success in socialising, working, ‘doing good turns’ and feeling good about oneself. The utilisation of such discrepancies is at the centre of MI, suggesting that this approach may be effective, or at least a contributory approach, to behavioural strategies in this area. Indeed, the efficacy of MI in addressing drinking behaviours has demonstrated success in meta-analyses,⁵⁸ and the feasibility of implementing it through brief intervention formats has been shown.⁵⁹

Concrete personal or vicarious experience as a trigger for behaviour change

Young people tend to believe that they will not come to harm, and that drinking will have few negative consequences.⁵¹ Thus, they are unlikely to modify dangerous drinking habits because they do not perceive themselves as being susceptible to harm. On the contrary, such beliefs are associated with increased levels of consumption.⁶⁰ However, in marked contrast, the older men in our study believed they were susceptible to (or had actually experienced) the health and social consequences of excessive alcohol consumption. The most frequently cited negative consequences were the risk of injury or criminal record (through aggression and violence); serious illness (such as liver disease or stroke); family disruption and separation; and financial drain. Critically, a minority believed that any health damage was irreversible and therefore saw little point in reducing alcohol consumption.

However, although acknowledgement of the existence of these dangers was widespread, it appeared only to be those who had experienced them personally (or vicariously through a very close family member or friend) who reported them as a driver to behaviour change. This finding is unsurprising given both behavioural theory and empirical research elsewhere that suggests that beliefs that are less abstract and experientially more concrete are more likely to result in behaviour change.^61,62 Consequently, any intervention needs not only to present the true risks of alcohol, but wherever possible to ensure that this is expressed in non-abstract and more direct or even concrete/experiential terms. This may include anything from the use of graphics over abstract text, through to reminding people of key past negative personal experiences of alcohol and its impact on others. Although some participants were sceptical regarding the use of images in interventions, this centred primarily on the potential ambiguity of meanings within images compared with clear text. This is clearly important. Indeed, issues of what is now termed ‘visual literacy’ are well acknowledged and must be taken into consideration when designing any images.⁶³ Where such personal experiences do not exist then utilising those of close family, friends or even well-known and liked public figures may prompt similar results through vicarious experience. The potential of vicarious experience has been little studied but empirical evidence in other behavioural contexts suggests there may be potential for its use.⁶⁴ The potential of concrete personal experience as a motivator also raises questions regarding whether or not coinciding the timing of the delivery of the intervention to a point soon after any such experience may significantly improve its effectiveness. Certainly, concepts such as ‘triggers to action’⁶⁵ and, more recently, the idea of the ‘teachable moment’^66,67 would support this.