What are the risk factor for early initiation to alcohol use and progression to alcohol use disorder in Uganda? And what do people who are seeking treatment say about why they developed alcohol use disorder?
David and Sylvia provide a great overview of individual, family, community, and society level rivers of alcohol use disorder.
And they discuss how risk factors can be turned into protective factors.

Is Addiction Brewed By Parents and Served by Peers?

Perspectives on Causes of Alcohol Use Problems By Patients Attending to Treatment of Alcohol Use Disorder

This article has been co-authored by Dr David Kalema and Sylvia Teopista Nabirye

In Uganda, one in every four persons is assumed to consume alcohol yet every tenth alcohol use is said to have an Alcohol Use Disorder (AUD). AUD is often used interchangeably with the term alcohol abuse to mean a cluster of cognitive, behavioral, and physiological symptoms, for individuals who continue using alcohol despite significant alcohol-related problems. Addiction, an obsessive-compulsive brain disorder to use alcohol despite the harmful consequences is considered the severest form of AUD where an individual becomes completely dependent on alcohol for normal functioning. The line between facilitating factors for alcohol use and addiction is thin and ambiguous and understanding the former is crucial to dealing with the latter. Alcohol is the most prevalent harmful substance and often a gateway to other drugs among substance users.

In this article, we supplement existing evidence on causes of alcohol use disorder with the information collected from 72 inpatients that were attending treatment for AUD at Hope and Beyond. Protective factors against addiction are also explored towards the end of the article. 

Parents’ role in the Initiation and sustenance of alcohol Use

According to our research, familial factors play a key role in the initiation and sustenance of alcohol use. In our case, 13% of the clients categorically blamed their initiation into alcohol use on the family.

A male respondent aged 45 years mentioned that he was introduced to alcohol by his mother at 3 years and recalls consuming the alcohol leftovers in glasses and bottles whenever family members were inebriated away from home.

Relatedly, another participant testified the modeling role of his mother in the initiation of alcohol use:

My mother used to like drinking a lot. She used to stock different types of alcohol and would share with me one sweet brand ‘Amarula’. I was told that after drinking, I would dance for the guests and they gave me lots of money”, the 30-year-old male respondent narrated. 

Patient attending AUD treatment at Hope and Beyond

Family is normally the first point of exposure to alcohol and the family environment is largely responsible for future problems with alcohol use. Studies in Australia estimate that 13% of children aged twelve years or less are exposed to an adult who is a regular binge alcohol user (Askforce, P. H. (2009). Parents directly or indirectly influence the initiation of alcohol use among teenagers and subsequently lead to heavy episodic alcohol intake for young people (Kaynak., et al 2014).  Parents’ own alcohol use displays to kids pro-alcohol attitudes yet some parents just don’t stop with consuming alcohol in front of their children but for various reasons provide alcohol to their children. Some parents mistakenly think that giving their children alcohol helps them to get used to it early enough and subsequently acquire the necessary discipline to control alcohol use. This is not substantiated in research. Studies show the probability of the teen’s risky alcohol use when provided with alcohol from parents (Mattick, R. P., et al. (2017). Provision of alcohol to adolescents by parents reinforces positive associations with alcohol (e.g. it feels good) and avoidance of negative consequences (e.g. I won’t get in trouble) and makes them perceive the benefits of alcohol to be more likely and the risks to be less likely.

Finally, parents influence the initiation of alcohol use through permisssiveness. According to Hayes, et al. (2004), adolescents who are poorly monitored begin alcohol consumption at an earlier age; they tend to consume more alcohol and are more likely to develop heavier alcohol use patterns.

Role of peers in sustenance of alcohol Use 

Peer pressure appears the most important factor combining the initiation and continuation of alcohol use among AUD treatment recipients in Kampala, Uganda. In our research, 76% of the patients blamed peer pressure for both their initiation and continuation of alcohol use.

A respondent aged 32 years indicated that he used alcohol to show his friends that he is a ‘bad man’ while another one aged 44 years narrated how he used to consume alcohol to impress others who always praised his binges.

We used to sit with all sorts of people ‘idle worshippers’…. they would tell me that professors are meant to drink a lot of alcohol and as a teacher, I derived a lot of pleasure in their praises.” 

Patient attending AUD treatment at Hope and Beyond

He further noted that he could use alcohol as a result of facilitation from others. He had friends who were always willing to buy alcohol for him.

Another female participant (29 years) said that she was made a leader and the group would exert pressure on her to use alcohol. In the morning the group members would come for her to officially open the alcohol consumption spree and as a leader, she obliged even when she was still nursing a hangover.

School laxity seems to be an enabling environment for promoting initiation of alcohol use in educational institutions. One mentioned that as a school prefect, he oversaw the alcohol inflows and related programs and ensured that others who would curtail alcohol supplies are not on duty.

Teen alcohol use predominately occurs in a social context and thus it is important to understand how alcohol consumption with peers affects later alcohol use. For instance, high school students most often report consuming alcohol with friends, either at a friend’s home or at a party (Beck et al. 1991;). Using alcohol with peers is not only associated with experimentation but also models alcohol use behaviors. Yet numerous studies have demonstrated that the peer modeling of alcohol use behavior increases personal alcohol consumption. Additionally, alcohol use with peers likely increases the positive expectancies associated with alcohol use (beliefs about the positive consequences of using alcohol). 

Other factors responsible for alcohol addiction

Leisure: Enjoyment for leisure is the other factor that was mentioned by several participants for both initiation and continuation of alcohol use. Addictive behavior is motivated by anticipation of pleasure (Surujlal and Keyser (2014). According to Finely (2012) serious leisure activities (aside from athletics) are associated with lower alcohol use, whereas casual activities such as spending the night out for fun or membership in a social fraternity, are linked to heavy alcohol use.

Drinking to feel better leading to loss of control was reported by half of our respondents for continued use of alcohol.

One patient said:

I realized that I couldn’t stop.” 

Male respondent, 25 years, patient attending AUD treatment at Hope and Beyond

A participant indicated that he reached a time when he needed alcohol to study but ended up losing his studies. Understandably, when some users reach a severe dependency stage, their perception of the risks associated with their alcohol use diminishes. One patient testified to continue alcohol use because he felt that he was able to control it. Alcohol dependency, tolerance and craving are also well-documented scientific concepts connected to continued alcohol use and their feature among patients’ response for continued use does not surprise. In many instances, continued alcohol use is attributable to addiction. Surujlal and Keyser (2014) explained that behaviour is motivated by the anticipation of relief from craving.

While alcohol use for pain relief has been documented to cause alcohol use disorder, our research also attributed AUD to misinterpretation of medical recommendations. An example is a participant in his early 50s who attributed his continued use to medical advice.

I had a kidney problem and was told never to consume alcohol, but the doctor told me that at least if you drink, do beer.”

Male respondent, ca. 50 years, Patient attending AUD treatment at Hope and Beyond

In our earlier research on AUD treatment, service users have also testified to consume alcohol as a kind of self-medication to cope with psychological pain.

Other internal factors include inheritance of the addiction gene and alcohol use to boost personal confidence and relational skills (Chen & Nath, 2016). Such are the factors behind progression into alcohol dependence when people with insufficient coping mechanisms and/or support systems are faced with stressful events and situations such as disasters, domestic challenges and poverty. 

The catalyzing influence of culture, media and the alcohol industry

Our findings underpin families and peers as major reasons for alcohol addiction yet these two factors are highly influenced by cultural expectations. According to Rantala and Sulkunen (2012), addictive behaviors develop from culturally defined and regulated pleasures. Cultural norms and functions determine acceptability of alcohol and range from total abstinence over ritual consumption to use for personal pleasure and conviviality.

As reported earlier, alcohol is considered as a usual drink in some societies and is embedded in social and cultural traditions. Alcohol plays a hospitality function and is served to visitors ‘like a cup of tea’. Regular ‘boozing episodes’ are a common occurrence and the abstinent are laughed at as social misfits. The general pro-alcohol consumption culture ignites automatic motivational cues (conditioned by drives, emotions and habits) and biases reflective processes [e.g. conscious cost-benefit analysis (Heyman, 2009) thereby escalating use. 

A key facilitator of cultural norms is the alcohol industry. According to Rukundo, Kibanja, and Steffens (2017), the alcohol industry creates a ‘non-addictive and relatively harmless alcohol impression’. Since addiction is related to repeated association, reinforcement and modelling (Giovazolias & Themeli, 2014), media images glamorizing alcohol and associating it with modernity and fun seem to fuel AUDs. 

Remedies to alcohol use disorder: Turning causes into protective factors to delay/prevent alcohol debut of youngsters

Delaying alcohol debut for youngsters: what parents need to know

Initiation of alcohol use at a young age increases the likelihood of negative physical and mental health conditions, social problems and alcohol dependence. Once teens begin using alcohol, many become regular consumers of alcohol. Frequent alcohol inebriation in adolescence is said to be a major predictor of alcohol-related harm and alcohol use disorder later in life. Public health experts suggest that delaying the onset of alcohol use reduces long-term consumption levels into adulthood (Hayes et. al, 2004). 

Turning causes into protective factors

Family and peers can also be used as protective factors to protect the individual from addiction.  The importance of identification of these factors, and their impact upon the progression or not of substance use in particular individuals underscores the importance of prevention and early intervention programs for young people.  

Family reforms are needed

A supportive family environment or caring relationship with at least one adult has been documented as a major protection against alcohol addiction. Even without actually providing alcohol to their child, parents can play a role by setting the environmental context in which alcohol use might occur. Parents imposing strict rules related to teenage alcohol use is overwhelmingly associated with less alcohol use and fewer alcohol-related behaviours (Kaynak, et. al. (2014).

Studies have found more teenagers’ chose not to consume alcohol if parents did not permit them to use alcohol at home or did not provide them with alcohol to take at parties or social events. Delaying the age that children start to drink alcohol (initiation) is a protective factor against harm.

Other parental roles for delayed initiation of alcohol use include alcohol-specific communication; disapproval of teenage alcohol use; rules about alcohol; parental monitoring; parent-child relationship quality; family conflict, parental support; parental involvement; and general communication (Mattick, R. P., et al. (2017).  

Peer modeling and influence in preventing alcohol abuse: Lessons for youth workers and policy makers

Peer related activities are crucial for prevention and treatment components for AUDs. Enhancement of young people’s capabilities for peer resistance and increasing their stress management skills are global concerns (Rukundo et al., 2017).

It is important to encourage alcohol free activities among young people.

Other necessary skills such as assertiveness, friendship formation and peer resistance are also necessary in the prevention of alcohol use initiation and alcohol use disorder.

Regarding opportunities, the strong peer influence as evident from the study findings along with the rampant availability of alcohol, including occasions in and around educational institutions, calls for school/college-based interventions in both societies (Suneel, 2015;). Botvin and others studied the effectiveness of a drug use prevention program and enhanced life skills (psychosocial competence) training. At 6-year follow-up, this study showed that self-reported substance use was 44% less in the intervention group and poly-drug use was 66% less.

Self- esteem is about how we rate or appraise ourselves and this attribute is closely related to self-confidence, a measure of one’s beliefs about one’s own judgment, skills and abilities. Young people with high levels of self-esteem were more likely to be non-users of alcohol. And among the users, those with high levels of self-esteem were less likely to have discontinued use.  

Finally, factors to address alcohol free leisure activities can help in prevention of alcohol use disorder and addiction. For example, volunteering is associated with less alcohol inebriation and heavy alcohol use among college students. Similarly, among adolescent girls, church attendance was linked with lower frequency of alcohol use.


Our research confirms the complex interaction of factors leading to the initiation and sustenance of alcohol use. Familial factors and peer pressure were most pronounced factors in the initiation and continuation of alcohol use, respectively. School laxity, misinterpretation of medical advice, alcohol dependency and alcohol use for enjoyment, accounted for continued use despite the risks involved. Prevention and treatment interventions should explore promotion of life and social skills (good friendship formation and peer resistance) while familial interventions can help to prevent early exposure and support those in recovery. Clients in recovery should be helped to identify alternative means of leisure and enjoyment to replace the pivotal role of alcohol. 


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