CONTEXTS: Alcohol-branded merchandise (ABM) has a longer shelf-life than other forms of alcohol marketing and the potential to become integrated into children’s self-identities.
OBJECTIVE: This review sought to explore the current literature on children’s exposure to, and the impact of, ABM.
DATA SOURCES: PsycInfo, Proquest, Science Direct, and ABI-Inform databases were searched from the earliest available date to May 2015. Additional studies were identified by a manual review of the reference lists of retrieved articles and contacting the corresponding author of each included study.
STUDY SELECTION: Articles that reported on child or adolescent ownership of ABM and/or the relationship between ABM ownership and drinking were included.
DATA EXTRACTION: Data on key measures were tabulated; where data of interest were not reported, requests for further information were sent to the articles’ authors.
RESULTS: Nine cross-sectional and 4 longitudinal studies were identified. ABM ownership ranged from 11% to 59% and was higher among older children and males. Seven cross-sectional studies reported associations between ABM ownership and drinking-related behaviors. All 4 longitudinal studies reported a significant relationship between ownership at baseline and drinking initiation at follow-up.
LIMITATIONS: The small number of available studies, with different measures of ABM ownership and of associations/effects.
CONCLUSIONS: The few studies exploring ABM ownership are consistent in showing high rates of ownership and associations between ownership and current and future drinking. There is a need for further research into specific aspects of ABM ownership. However, there is also a need for policy interventions to reduce children’s access to and ownership of ABM.
- ABM —
- alcohol-branded merchandise
- aOR —
- adjusted odds ratio
- OR —
- odds ratio
Adolescent alcohol use is associated with a range of physical, psychological, and social harms; and there is increasing evidence that earlier alcohol initiation is associated with greater drinking problems in adult years.1,2 Although there are numerous influences on adolescent drinking, including individual, family, peer/social group, and community influences, there is substantial evidence that alcohol advertising affects alcohol initiation as well as frequency and quantity of consumption.3–5
Much of the research into the effects of alcohol marketing on young people has focused on print and broadcast media, where advertisements appear in locations and at times determined by the marketer. In the current environment, the Internet and social media provide a platform for alcohol marketing that blurs the lines between “advertising” and social discourse6–8; and alcohol brand sponsorship of sporting and cultural events enables messages developed by the marketer but communicated by (or on) the performers, such as on players’ jerseys.9–11 The majority of these forms of advertising are “perishable,” in that they appear at a place in time and are then replaced by other stimuli (eg, the reader turning the page in a magazine or newer Facebook posts pushing previous ones down the feed).
Alcohol-branded merchandise (ABM), also referred to as alcohol promotional items, has a longer shelf-life than other forms of advertising. For example, a branded keyring may be used, and seen, on a daily basis or a branded clothing item may be worn many times and in many locations. Because ABM is generally something that a person wears or carries on their person, it has the potential to become part of, or be used to convey, their self-image. Marketers seek not only immediate sales of their products but also to form “relationships” between their brands and current and future consumers.12,13 Young people, who are developing their self-concepts, use brand ownership as a way of constructing and communicating their self-image and group membership.13–15 There is evidence that adolescents actively engage with alcohol marketing and incorporate alcohol brands into their self-identity.16,17 Even among children, preference for alcohol-branded promotional items over nonalcohol-branded items appears to prime future drinking.18,19
There have been several systematic reviews of the impact of alcohol advertising and/or promotions on adolescent alcohol use, but these have incorporated a wide range of exposures. A review of alcohol advertising effects identified 7 studies, none of which included ABM.4 A subsequent review of 13 longitudinal studies5 included 2 that focused specifically on ABM20,21 and 2 that included ABM ownership among a wider range of alcohol marketing exposures.22,23 The authors concluded that 12 of the 13 studies showed that exposure to alcohol marketing predicts drinking initiation and increased levels of consumption. However, they did not draw specific conclusions about the effects of ABM, an important distinction given that several studies have identified that the association between drinking and ABM ownership is stronger than that for other marketing variables.22–25 Thus, this review sought to explore the current literature on child and adolescent ownership of ABM and the effects of ABM ownership.
A 3-stage approach was taken to identifying relevant articles for inclusion in the review. The first was a systematic search of electronic databases (PsycInfo, Proquest, Science Direct, and ABI-Inform). The keywords used were “alcohol brand* merchandise OR alcohol brand ownership OR alcohol promotional items.” A separate search was conducted by using “ABM” as the keyword, but this identified >2000 articles (due to the multiple terms that use that abbreviation), only 8 of which were potentially relevant and all of which were also identified in the initial search.
The inclusion criteria were as follows: reported on child or adolescent ownership of ABM (whether as the sole alcohol marketing exposure variable or one of several variables) and/or the relationship between children’s or adolescents’ ABM ownership and drinking (initiation, frequency, or degree), cross-sectional and longitudinal study designs, and written in English. Articles excluded were those in which information on ABM ownership was not provided, such as studies that reported generically on exposure, opinion pieces, or policy/position statements.
The searches identified a total of 435 unique articles, the abstracts of which were reviewed by 2 researchers to identify those that referred to or mentioned ABM. Forty-two articles were identified as potentially relevant and uploaded into Covidence software (www.covidence.org) for full-text review. On full-text review, 31 articles were excluded (see Table 1); the remaining 11 articles consisted of 7 cross-sectional and 4 longitudinal studies.
The second stage was a manual review of the reference lists of retrieved articles, which resulted in the inclusion of 1 additional article.57 Because this article was not identified in the database searches and used the term “alcohol promotional clothing items,” a search was re-run in all 4 databases using this term, which resulted in the identification of 1 additional article (by the same author) for inclusion in review.58
The third stage was to contact the corresponding author of each included article and ask whether they were aware of any further studies that addressed this topic. The contacted authors provided details of 2 further studies they had authored and 7 authored by others; however, all of these had already been included in the review (3 articles) or excluded because they did not meet the inclusion criteria (6 articles). Thus, a total of 13 articles were included in the review: 9 reported on cross-sectional studies and 4 on longitudinal studies (see Fig 1 for the PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] flow diagram).
In cases in which information important for the review was not reported in the original articles, the corresponding author was asked (in the same e-mail as the request for further relevant studies) to provide this information; for example, 8 articles did not report ownership by gender and 6 did not provide the wording of the question(s) asked. In 5 cases, no response was obtained from the corresponding author or he or she was unable to provide these data.
Of the 9 cross-sectional studies, 6 were conducted in the United States and 1 each in the Philippines, Uganda, and Australia. The articles were published between 2003 and 2015, with data collected between 2000 and 2012 (see Table 2 for ownership and Table 3 for associations). There was considerable variation between the articles in the nature of the analyses conducted and statistics reported; where odds ratios (ORs) and/or adjusted ORs (aORs) for drinking initiation were provided these are reported below.
A survey of 7th- to 12th-grade students (N = 260) in a Midwestern US state found that >36% owned ≥1 items of ABM (mean: 4.5 items).57 ABM ownership was twice as likely among susceptible adolescents as nonsusceptible adolescents* and 4 times as likely among established drinkers, suggesting a relationship with both susceptibility and drinking initiation. A subsequent study in university students aged 18 to 25 years (N = 320) found a higher rate of ownership of (clothing) ABM: 44.7% owned ≥1 items.58 Ownership was significantly higher among established drinkers than susceptible experimental drinkers, and ABM owners were significantly more likely to report having drunk alcohol in the last 7 days, more than twice as likely to be weekly drinkers, and 3 times as likely to report having been drunk in the last 7 days.
A survey of fifth- to eighth-grade students (N = 2406) in New England found 14.2% (n = 341) reported owning ≥1 ABM items.21 ABM owners were significantly more likely to have initiated alcohol use (OR = 2.3), adjusting for covariates (including demographic characteristics, personality characteristics, parenting style, and peer drinking) and accounting for clustering by school (aOR = 1.5).
Of 2125 California middle school students in sixth to eighth grade, one-fifth (20.0%) reported owning ≥1 items of ABM.24 ABM ownership was associated with an increased likelihood of ever drinking (OR = 6.7) and having drunk alcohol in the last 30 days (OR = 1.8). After controlling for demographic characteristics, peer and parent drinking, risk taking, and parental supervision, both associations remained significant (aORs = 3.3 and 1.5, respectively).
In a cross-sectional survey25 of 1734 ever-drinkers aged 15 to 20 years (remaining participants from an earlier longitudinal study63 supplemented by a sample of African-American youth), one-third (33%) reported owning ABM and ownership had both a direct association with binge drinking and indirect associations (mediated by drinker identity and having a favorite alcohol brand). The article did not report on drinking initiation or recent drinking.
A survey of 920 adolescents in the second year of high school (aged 12–14 years) in Scotland found 45% owned ≥1 items of alcohol-branded clothing, far exceeding any other form of involvement with alcohol marketing.59 ABM ownership was significantly higher among drinkers than nondrinkers (51% compared with 43%; P < .05).64
The Philippines’ arm of the Global School–based Student Health Survey asked 5290 students aged 11 to 16 years about their alcohol use and exposure to alcohol marketing.60 One in eight (14.7%) reported owning an item of ABM; in bivariate analysis this was associated with an increased likelihood of current alcohol use (OR = 1.86) and experience of drunkenness (OR = 1.43). A survey of urban youth aged 14 to 24 years living in the slums of Kampala, Uganda (n = 457), found 25.9% of these vulnerable young people owned ≥1 items of ABM61; in bivariate analyses, ABM ownership was associated with increased likelihood of current alcohol use (OR = 6.34), problem drinking (OR = 6.36), and reported drunkenness (OR = 5.91). However, in both of these studies, the relationship between ABM ownership and drinking behavior was not significant in the multivariate analyses.
Of 210 secondary students aged 12 to 17 years surveyed in New South Wales, Australia, 59.0% reported owning at least 1 item of ABM.62 ABM ownership was significantly associated with alcohol initiation (but not drinking recency among initiators), perceived peer drinking, and perceptions that friends would think it was a good idea for them to drink alcohol.
Six of the cross-sectional studies did not report controlling for covariates, controlled for only a few limited variables, and/or did not separately report the associations for ABM when controlling for other variables.57–62 Three controlled for demographic characteristics (age/year level, gender, race/ethnicity), individual characteristics (eg, school grades, personality factors), and social influences (eg, peer drinking, parental drinking, parenting style).21,24,25
All 4 of the longitudinal studies were conducted in the United States. ABM was the sole exposure focus in 1 article,63 1 of 2 components of alcohol marketing awareness or receptivity in 2 articles,20,23 and 1 of several alcohol marketing exposures in 1 article.22 The articles were published between 2007 and 2009, with data collected between 1998 and 2005 (see Table 2 for ownership and Table 4 for effects). All 4 studies controlled for a range of known covariates, as well as baseline drinking.
A study in South Dakota elementary school students explored associations between exposure to alcohol marketing in sixth grade (mean age of 11.8 years) and drinking intentions and behaviors in seventh grade.22 A total of 1786 students completed the survey at both time points; 19% owned an item of ABM at baseline. Controlling for sixth-grade drinking, baseline ownership of ABM was associated with an increased likelihood of drinking in the seventh grade (OR = 1.76) and intending to drink in the next 6 months (OR = 1.65).
A national survey of 5511 adolescents aged 11 to 18 years at baseline found 26% owned or were willing to use an item of ABM.23 At 12-month follow-up 19% of girls and 17% of boys who were never-drinkers at baseline had initiated alcohol use; those who owned or were willing to use ABM were more likely to have done so (OR = 1.74 for girls, OR = 1.78 for boys).
A study of alcohol marketing receptivity in 1080 California middle and high school students (never-drinkers at baseline) found 21% owned at least 1 item, and 19% wanted to own an item, of ABM.20 Those who owned or wanted to own ABM at baseline were more likely to have initiated alcohol use at the 12-month follow-up (OR = 1.77) and to be current drinkers (OR = 1.75).
A 4-wave national survey of 6522 US adolescents (4309 of whom were never-drinkers) collected data on ABM ownership at wave 2 (8 months), wave 3 (16 months), and wave 4 (24 months).63 The prevalence of ABM ownership increased from 11% at wave 2 to 20% at wave 4. Using a cross-lagged panel model, the authors identified a reciprocal relationship between ABM ownership and susceptibility to drinking (3 items that assessed response to peer offers, intentions, and positive expectancies) and both direct and indirect effects of ABM ownership on drinking initiation. Adolescents who owned ABM at 8 months were more likely to have initiated drinking at 16 months (hazard ratio† =1.41) and nonsusceptible adolescents who owned ABM at 8 months were more likely to become susceptible to drinking by 16 months (hazard ratio = 1.66). They found a similar reciprocal relationship between ABM ownership and susceptibility, and direct and indirect effects of ABM, for binge drinking.
The longitudinal studies20,22,23,63 all reported data from analyses that controlled for a wide range of known covariates, demographic characteristics, individual characteristics, and social influences. One study also controlled for exposure to a range of other forms of alcohol marketing,22 1 study controlled for television viewing and exposure to alcohol portrayals in movies,63 1 controlled for alcohol brand recall and recognition,20 and 1 controlled for talking to friends about alcohol advertisements.23
Demographic Correlates of ABM Ownership
Studies that focused on younger adolescents, and reported data by age, generally found that ABM ownership increases with age21,63 and/or with increasing grade level.57 The majority of cross-sectional studies found that ABM ownership is higher among males in both school20,21,24,59,63 and university58 samples. Two studies, 1 in the United States57 and 1 in Australia,62 found that boys and girls were equally likely to report owning ABM, although in the US study boys owned more items on average.57 Ownership by gender was not available for 4 articles.22,25,60,61 Although most of the studies did not separately report and/or did not find differences in effects by gender, 1 study found that after adjusting for covariates the relationship between ABM ownership and early alcohol initiation was only significant for girls (aOR = 3.3)21 and another found that ABM ownership was a significant predictor of initiation for both genders but of binge drinking only for girls (OR = 1.79).23
ABM ownership has also been found to be higher among those who report that their peers drink21,23 and those scoring high on rebelliousness, sensation seeking, and engagement in risk behaviors,21 with inconsistent findings regarding association between ABM ownership and parental drinking.24,63
Type of ABM Owned
The majority of the studies included in this review, including all of the longitudinal studies, included a single measure of ABM ownership (dichotomous yes/no for all forms of ABM). In 2007, Hurtz et al24 noted the need for research that provides more detailed evidence about the number and nature of ABM items that young people own and whether there is a dose-response relationship.
Of the 5 studies that collected data on types of ABM owned, there were some consistencies and some differences between findings. All 4 US studies that included this measure reported that ABM owned by adolescents was predominantly clothing and headwear.21,57,58,63 The 1 Australian study identified different forms of ABM ownership,62 with cups or bottle holders more prevalent (34.8%) than hats (25.7%) or T-shirts (19.0%); ownership of bags and coolers (18.6%) was not identified in the US studies. This finding may indicate differences in the ABM products that are distributed, or made available, to adolescents in the 2 countries and/or that ABM has become more diverse over time, given that the Australian study was conducted more recently than the US studies.
Source of ABM
McClure et al21 noted that it is important to consider the source of ownership of ABM because of likely differences in the influences on youth drinking. They posited that an adolescent who purchases their own ABM may have a preexisting positive attitude toward drinking, whereas an adolescent who receives an item of ABM from a parent may interpret this to mean that his/her parent condones their alcohol use. In a subsequent study,63 these authors asked adolescents where they obtained their ABM: 71.0% reported that it was a gift from a friend or family member, 24.1% that they purchased it, and 4.1% that they won, found, or got it for free. In an earlier study, Workman57 found that parents were the primary source of adolescents’ ABM and, consistent with this premise, that those who had been given ABM by their parents were more likely to perceive that their parents approved of them drinking. A study in an older cohort (18–25 years) found the most common sources of ABM were alcohol vendors and stores, with parents the source of only 10.2% of recalled items.58
The Australian study62 also included qualitative research in parents of adolescents, which found they were aware of ABM and could recall items that they and their children owned and used but appeared not to have previously critically engaged with the concept of ABM as alcohol marketing. Once engaged in the discussion, many began to express concerns about its potential impact on young people’s alcohol-related attitudes and behaviors.
It is evident that ownership of ABM among adolescents is prevalent in all of the countries in which this issue has been studied. Studies from outside the United States suggest lower rates of ABM ownership in lower-income countries than in higher-income countries; however, differences in the nature of the question(s) asked make comparisons across countries and time points difficult.
Of the 8 cross-sectional studies that focused on children/younger adolescents (ie, sample solely or predominantly aged <18 years), 4 reported ORs for ABM ownership and drinking behavior. It is noteworthy that the 2 that were of higher quality (large sample sizes, analyses controlled for a wide range of covariates) reported significant aORs for drinking initiation, ranging from 1.521 to 3.3.24 Cross-sectional studies, however, can only report associations between factors measured at the same point in time; that is, it could be argued that ABM ownership influences young people to initiate drinking or that initiating drinking influences young people to obtain ABM.
Longitudinal studies enable the inference of causation by controlling for the baseline level of the posted dependent variable (in this case, drinking initiation). All 4 longitudinal studies reported a significant relationship between ABM ownership at baseline and drinking initiation at follow-up with remarkable consistency (aORs between 1.4 and 1.8).20,22,23,63 The 2 studies that included a measure of binge drinking reported similar aORs.23,63
The longitudinal studies reported much greater associations with drinking initiation for ABM than for other measured marketing variables: for example, an OR of 1.2 for exposure to sports beer ads and radio listening and no significant effect of magazine reading,22 no significant effect for exposure to beer concessions,22 an OR for exposure to in-store displays of 1.5 for ever-drinking and nonsignificant for current drinking (compared with 3.3 and 1.5 for ABM ownership),22 and no significant association for other measures of receptivity such as being able to name a favorite alcohol brand.20
An Internet survey of reasons for selection of specific alcohol brands among 13- to 20-year-olds in the United States identified that 10.2% stated that their choice of brand was influenced by their ownership of products with the brand’s logo.49 It is noteworthy that 30.8% of these 1031 young people also reported that their choice was influenced by the fact that they “identify with this brand,” given that having a favorite alcohol brand or advertisement has been shown to be an indicator of susceptibility to future drinking.20,65
There is preliminary evidence that even very young children may have an interest in ABM, with parents in a qualitative study describing ABM items that appealed to their primary school–aged children.62 A study of preferences for ABM compared with similar nonalcohol-branded items among third- to fifth-graders (not included in the review because did not assess ownership of ABM) identified an association between preferences for ABM and perceived desirability and identification with alcohol ads.47 This was a cross-sectional survey that did not assess causation, and further research could explore whether allowing young children to own ABM may enhance their positive views of alcohol advertising and alcohol per se.
Implications for Research
The small number of studies identified suggests a need for more research into the nature, extent, and effects of ABM. The questions used to measure ABM ownership varied between studies, in terms of both their breadth (eg, some focused only on clothing and others on all forms of ABM) and depth (ranging from a single yes/no question to detailed exploration of the number and type of items owned). Future research in this area would benefit from the use of consistent questions across time points and jurisdictions.
Given the wide variations in reported prevalence of ABM ownership between studies conducted in different countries, future research could explore the nature and extent of ABM available in the different jurisdictions as well as whether this availability has changed over time. Cross-jurisdictional studies could explore the differential extent and effects of ABM ownership in countries with differing social norms and legal drinking ages. Including a broad age range of participants in such studies would enable exploration of reasons for age-related differences in ABM ownership, including differences in accessibility as well as appeal of different ABM product types.
Studies not included in this review that focused on alcohol media literacy often included a measure of preference for ABM over other branded or nonbranded merchandise.18,66 These studies generally positioned preference for ABM as a measure of receptivity to alcohol marketing. Future research could explore the extent to which allowing young children to own ABM may enhance their attention to and engagement with alcohol brands and alcohol advertising more generally, the extent to which preference for ABM drives and/or reflects interest in alcohol, and children’s motivations for wanting to purchase or own ABM.
This research gap is particularly important given that ABM is a largely unregulated form of alcohol marketing; exposure to ABM occurs in home, social, and educational environments; and this exposure is mediated by friends and family and thus contributes to social norms. Few studies have assessed exposure to ABM owned/worn by peers,‡ and none have asked about exposure in the home beyond personal ownership; future research could explore the effects of ABM exposure via important others as well as cumulative exposure (dose-response effects). Future research could explore parents’ awareness of the effects of ABM and the messages parents believe they are communicating (and adolescents believe they are receiving) by parental provision, or condoning of ownership, of ABM.
Implications for Policy
Although this review identified a surprisingly small number of studies on adolescents’ ownership of ABM and the effects of this ownership on drinking behaviors, these studies showed strong and consistent effects of ABM ownership on young people’s drinking-related attitudes and behaviors. Given that these associations were stronger than for other marketing variables, which are subject to legislative controls in many jurisdictions to reduce youth exposure, there is a clear need for strategies to reduce youth ownership of ABM.
There are a number of gaps in the evidence base to be addressed before we can fully understand the extent of, and reasons for, this apparently strong association between ABM and current and future drinking. However, as set out in the first part of this review, there are aspects of ABM that differentiate it from other forms of alcohol marketing. Unlike alcohol advertising in traditional or even new (electronic) media, ABM has the potential to become a part of, and to communicate, a young person’s self-identity. Qualitative research from both New Zealand and the United Kingdom has found that teenagers associate desirable characteristics with specific alcohol brands, identify brands that fit their self-image, and believe that this association endows them with positive attributes that are associated with that brand in the eyes of their peers.16,17 ABM is accessible to children and teenagers and enables them to identify with a brand even before they begin drinking; this relationship with an alcohol brand as part of “who I am” may thus have the potential to facilitate drinking initiation.
In 2008, reporting the strong association between ABM ownership and drinking status 12 months later, Henriksen et al20 called on government to take action to document the nature and extent of ABM: “more detailed information is needed about the production and distribution of alcohol promotional items” (p 34). They also noted that the findings on alcohol marketing receptivity (measured by ownership/desire to own ABM) are “consistent with the research on tobacco marketing receptivity, which formed the evidence base for banning cigarette promotional items in the United States” (p 34) and called for a similar policy for ABM. However, 7 years later, there is still no systematic collection of data on its production, availability, or restrictions (in the United States or elsewhere; the World Health Organization asks about sponsorship and product placement in their periodic questionnaire regarding alcohol policies but not ABM).
Restrictions on the placement of alcohol advertisements, such as on television or in magazines, are put in place by governments due to the recognition that these exposures have the potential to increase young people’s susceptibility to drinking. Due to its nature, it would not be feasible to impose placement restrictions on ABM (governments would be unlikely to legislate where people could wear their branded hat or use their branded keyring), although it would be possible to impose restrictions on where ABM can be sold or distributed. Perhaps more feasible, given governments’ general unwillingness to legislate alcohol marketing, would be to exert pressure on the alcohol industry to self-regulate to restrict the distribution of ABM in forms that would be appealing, and locations that would be accessible, to young people.
This review identified a surprisingly small number of studies on the prevalence and effects of ABM ownership by young people. A total of 14 articles were identified, with the earliest in 2003 and the most recent in 2015. The most powerful evidence comes from longitudinal studies; however, there is an absence of such data reported in the past decade (the included studies collected data between 1998 and 2005).
The small body of evidence that does exist shows a high prevalence of ABM ownership among adolescents and associations between ownership and current and future drinking. There is a need for further research into specific aspects of ABM ownership, including types and sources of ABM, and more current longitudinal studies that reflect changes in the alcohol marketing landscape. However, there is also a clear need for policy interventions to reduce young people’s access to and ownership of ABM and to increase parents’ and other stakeholders’ awareness of the insidious nature of this form of alcohol marketing.
I thank Ms Georgia Draper for assistance with the identification and screening of articles for inclusion in the review, Ms Kelly Andrews for her advice and review of the manuscript, and Ms Kate Francis and Dr Mairtin McDermott for assistance with interpreting varying study findings. I also thank the several authors of included studies who took the time to provide additional unpublished details of their methodology and findings.
- Accepted February 10, 2016.
- Address correspondence to Sandra C. Jones, Director, Centre for Health and Social Research (CHaSR), Australian Catholic University, Level 5, 215 Spring St, Melbourne, Victoria 3000, Australia. E-mail:
FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.
FUNDING: Dr Jones is supported by an Australian Research Council Future Fellowship (FT120100932).
POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.
↵* Respondents were considered “susceptible” if their answer to the question “Do you think you will use alcohol in the next 2 months?” was “yes,” “probably,” “I don’t know,” or “I don’t think so” and “nonsusceptible” if their answer was “no, definitely not.”
↵‡ More commonly used in medical sciences to describe survival rates or treatment effects, in this context a hazard ratio is the percentage change in the hazard (eg, drinking initiation) for a 1-unit increase in the predictor (e.g., ownership of ABM).
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