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Alcohol and Public Policy: Beyond the Shadow of Prohibition (1981)

Chapter:Alcohol Use and Consequences

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Alcohol Use and Consequences DEAN R. GERSTEIN INTRODUCTION In a perceptive and scholarly analysis, Harry G. Levine (1978) has identified four distinct parts to the American perspective on alcohol use, each of which was initiated in, and was characteristic of, a distinct historical period, although none has disappeared from American con- sciousness, politics, or scientific discourse. The first component, largely dominating the 150-year colonial era of American history, focused on sentimental or customary attachment to drinking and the moral qualities of drunkenness. For most Americans in this period, drinking and drun- kenness aroused as much interest as eating and obesit~which is to say, while there was plenty of both, they were widely accepted as normal. Those few who did choose to stand against drink did so on religious grounds: habitual drunkenness was sinful, a dissipation of the moral energies that colonial society expected to be devoted to God's work on earth. Yet the fault was not laid to alcohol itself, but to the defective moral character of those few who besotted themselves entirely too often. The problem was not addiction, but an overweening love of intoxication. During the expansionary period of American history, approximately the century and a half from the Revolutionary War to the first decades of the current century, the notion took hold that alcohol was addicting Dean R. Gerstein study director of the panel. is senior research associate of the Committee on Substance Abuse and Habitual Behavior locational Research C ouncil. 182

Alcohol Use and Consequences 183 and that this addiction was capable of corrupting the mind and body. With this concept, alcohol itself became the focus of concern. By 1850 the temperance movement had set out to remove the destructive sub- stance, and the vertically monopolized industries that promoted its use, from the country. The movement held that while some drinkers might escape unharmed, even the most moderate of them flirted with danger at the rim of every cup. This view of alcohol and its purveyors as a public menace was carried into force by the 18th Amendment and the Volstead Act. But despite the broad public majorities voting in favor of prohibition, the older customary attachments to drinking proved to be deeply rooted. The consequent unwillingness of most jurisdictions to adopt Draconian en- forcement measures, or (in the days of Harding, Coolidge, and Hoover) to commit more than a bare minimum of public funds to such activities, ensured that illegal marketeers, buoyed by the willingness of drinkers to pay three to four times the prewar going rates, developed a strong black market in booze. Prohibition was swept off the books in the first months of the new Roosevelt Administration. In the ensuing period, two rather different perspectives have grown up and coexisted. The disease view of alco- holism has shifted from the earlier focus on alcohol as an invasive agent to an approach based on a scientific model of chronic disease. Alcoholics have come to be viewed as a population with a special vulnerability to alcohol, while all other people can be exposed to it at virtually no risk to themselves. In contrast to the colonial view that alcohol is physically and morally innocuous but that some morally defective individuals take to perpetual drunkenness as a sign of their dissipation, this view holds that while alcohol is innocuous for most, a minority—fine people in all other respects~annot touch it without succumbing to the addictive disease process, for which there is no cure except total abstinence. This is the professional viewpoint of the "alcoholism movement" and its organizational focus, Alcoholics Anonymous. As an ideological foun- dation for widespread public support of alcoholism treatment, this def- inition of the situation has proven to be quite effective. The fourth perspective, which has roots in the repeal movement, places less emphasis on the qualities of alcohol or individuals who drink it than on the social arrangements and social consequences that surround the practice of drinking. This perspective is most closely identified with social and behavioral scientists, originally at Columbia University around 1930 and more recently at the Addiction Research Foundation in Toronto, the Finnish Foundation for Alcohol Studies in Helsinki, and the Social Research Group- at the University of California at Berkeley.

84 GERSTEIN The principal ideas in this public health perspective are that: · the rates of alcohol-related problems in society are the focus of concern; · these rates are contingent on the social arrangements involving both drinking and the activities that drinkers may engage in; and · it is eminently rational to try to minimize the incidence of alcohol- related problems by managing these arrangements properly rather than only treating their results. The following discussions both criticize and draw on certain tenets of this public health view. I first discuss the measurement of drinking per se and its distribution through societies, which has been of particular importance for the public health perspective. Then I discuss evidence on the relation of drinking to a series of biosocial functions and dys- functions that are thought to be related to alcohol use. The concern throughout is with issues of measurement and attribution in the empirical analysis of alcohol consumption and associated behavior. ALCOHOL USE: INTOXICATION, DRINKING PATTERNS, AND TOTAL CONSUMPTION The relation between alcohol use and consequences is seldom simple, direct, or universal, despite many of our common sense conceptions about the matter. The central scientific issue for policy research on alcohol is how different patterns, levels, or circumstances of alcohol use are translated into different types, ranges, and degrees of consequences. First, imagine alcohol use alone, stripped of any considerations of place, person, companions, or consequences. How can an individual's alcohol use be measured or described in an efficient, useful way? Use of alcoholic beverages is generally conceived to occur on "drinking occasions" or "drinking events," much the way we conceive of eating as occurring at meals or occasional snacks. There are three distinct ways to think about such occasions. First, we might inquire into the amount consumed on an occasion, to try to determine just how drunk, how intoxicated, the drinker became. Second, we can ask about the frequency and distribution, the pattern, of such occasions especially, how a sus- tained pattern of intoxication impinges on everyday life. Third, we can ask about the total amount drunk across a number of such occasions. Each of these three ways of thinking about drinking emphasizes a dif- ferent aspect of alcohol use and ultimately, a different order of as- sociated consequences.

Alcohol Use and Consequences 185 1. Interest in the amount drunk on a given occasion focuses concern on the degree of intoxication or "drunkenness" achieved. Intoxication is not a simple consequence of the amount of alcohol consumed, since body weight, spacing of drinks, and metabolic rate (which may reflect previous experience with alcohol) intervene between the amount drunk and the biobehavioral states involved in being drunk. The most common technical measure of intoxication, blood alcohol content (BAC),~ rep- resents the volume of alcohol circulating in the body at a given time, once these intervening variables have had their effect. Since the human liver detoxifies alcohol at a substantial rate, a very important feature of intoxication is its temporary, transient nature. BAC tends to rise during a drinking occasion and then decline toward zero not long after drinking ceases. The decisions that individuals make about where to drink and how to behave while intoxicated have great bearing on the effects that accrue while being drunk. Most of the behavioral and subjective states that we find easy to ascribe to drunkenness - sociability or sadness, daring or tranquillity, aggression or passivity not spring directly from the bottle but find expression due to the social circumstances and person- alities in which drunkenness is brought into play. Even the effects most consistently tied to intoxication~lumsiness and befuddlement are only consequential if the drunk tries to engage in complex performances or enters a dangerous environment. 2. The second way of characterizing drinking involves its frequency and distribution in time most importantly, the frequency and distri- bution of intoxication. The question is how this pattern of intoxication fits misfits~ther patterns of responsibility and role performance; to what degree it is inappropriate, unwanted, or disruptive. All of these features impropriety, undesirability, or disruption have to do with the social and physical setting of intoxication. What the question of pattern emphasizes is not how drunk someone might become on occa- sion, but how repeated occasions of drunkenness impinge on everyday life. 3. The last measure, total consumption' involves the accumulation ' BAC level (expressed as a decimal percentage of a gram per liter. e.g., 0.03) correlates reliably, in dose-dependent fashion, with degradations in psychomotor coordination, es- pecially of such complex performances as precise reasoning, eye-hand coordination, and balance while in motion. At a BAC of 0.05, which for most people requires more than two drinks within an hour, performance begins to consistently degrade. At 0.0~0.10, most jurisdictions consider a motor vehicle operator "legally intoxicated" and unable to drive safely. At 0.15-0.30, consciousness may be lost, while a BAC above 0.30 is consid- ered potentially lethal (Haberman and Baden 1978).

186 GERSTEIN of all the alcohol that an individual has drunk over a specified period of time. Total consumption usually means during a year or a number of years, although shorter periods are often used to estimate (extrap- olate) these accumulations and to make the figures more easily under- stood. Thus, total consumption is often reported as an average amount of pure alcohol (e.g., 80 grams, 100 milliliters, or 3 ounces) per day. This is known as a volume index: it implies that this average is sustained over long periods and might be reported as 10 gallons (38 liters) per year. This way of looking at alcohol use tends to emphasize the way in which sustained exposure to volumes of alcohol may be related to various risks of morbidity and mortality. A great deal of the evidence used in the recent scientific analysis of drinking by partisans of the public health perspective hinges on the appropriate use and interpretation of total alcohol consumption statistics in local, regional and national populations (and samples). The major argument made in the manifesto of this perspective (Bruun et al. 1975) is that: ". . . changes in the overall consumption of alcoholic beverages have a bearing on the health of the people in any society. Alcohol control measures can be used to limit consumption: thus, control of alcohol availability becomes a public health issue" (p. 90~. The "overall consumption of alcoholic beverages . . . in any society" is a key term in this argument, for overall or total consumption figures have been regarded as good measures of the central tendency of alcohol use by whole populations. This particular line has been linked to a larger argument that the general consumption level of any alcohol-using pop- ulation, which reflects the societal "climate of acceptance" of drinking, determines the prevalence of heavy alcohol users and the rate of alcohol- related morbidity, mortality, and related costs such as lost production values and extra medical care. It therefore is important to closely examine the measurement of ag- gregate or overall consumption, to see how sound a basis such statistics can be for scientific or policy judgments. METHODS OF MEASUREMENT The most common form of alcohol statistic used is unquestionably the annual per-capita consumption attributed to the drinking age population (typically interpreted as older than 14) of a nation or state. Derivation of the annual per-capita figure (technically a "period ratio") requires enumerations or estimates of two quantities. First, the numerator: the total quantity of pure or "absolute" ethyl alcohol contained in beverages

Alcohol Use and Consequences drunk by the population during the year; Second, the denominator: the average number of individuals meeting the specified age criteria living in the area during the year. Estimates of the denominator are usually derived from census enu- merations and extrapolations. These data generally exclude institution- alized populations and are known to disproportionately underestimate various segments of the population by unknown amounts. Inner-city residents, migrant laborers, and illegal aliens are most often cited as undercounted groups in the United States. The numerator is usually compiled from figures supplied by producers or wholesalers of alcoholic beverages; specifically, the "tax paid with- drawal" of beverages from wholesale stocks available at the beginning or produced during the course of the year, along with their reported alcohol content. In the United States and most industrialized countries, the regulation of manufacturers by government agencies ensures a fairly uniform content of alcohol in respective classes of such beverages; but lapses have occurred, for example, in notorious French and Italian wine frauds. In the liberal and fairly inexpensive mass markets of recent years, it seems safe to assume that the quantity of consumed alcohol that has not been produced and counted under taxation and licensing control is probably small (Makela 1978, Gavin-Jobsen Associates 1978~. This in- cludes illicit beverage production for sale or home consumption, labo- ratory and commercial ethanol diverted to beverage use, trace alcohol in soft drinks and other consumables, and drink produced legally but diverted from taxed inventories. The comparability of U.S. data in this regard with data from other countries is probably satisfactory for recent years in industrialized states. Taxed withdrawal from local wholesalers' stocks, however, is not a direct measure of consumption by local residents. Consider the rank- ordering of states by per-capita sales in Table 1. The three locations with the greatest apparent consumption Nevada, New Hampshire, and the District of Columbia—all have small local populations relative to large tourist trades. While all three would be very likely to rank in the upper end of the list without the tourism factor, it is probable that about half of their apparent per-capita consumption can be attributed to vis- itors not counted in the census of local residents. (This may also account to some degree for the high rate in Vermont due to its ski resorts.) In addition, alcoholic beverages are cheaper in New Hampshire and the District of Columbia than in surrounding areas and the border-crossing "liquor run" is a well-known local custom (Rooney and Butt 1978~. As these considerations suggest, gross estimated per-capita consump- tion figures are subject to error, the more so as migration, transiency' 187

188 G E RSTE IN TABLE 1 Apparent Consumption of Absolute Alcohol, Population Aged 14 Years and Older u.s. u.s. u.s. Gallons Gallons Gallons Per Per Per State Capita State Capita State Capita Nevada 7.05 Delaware 3.04 South Dakota 2.49 District of 5.72 New Mexico 3.03 Virginia 2.41 Columbia New Hampshire 5.66 Illinois 2.96 Pennsylvania 2.38 Alaska 3.73 Oregon 2.90 Missouri 2.37 Vermont 3.70 New York 2.86 Iowa 2.30 California 3.57 Michigan 2.84 Ohio 2.28 Colorado 3.54 Texas 2.82 Mississippi 2.24 Wyoming 3.51 North Dakota 2.79 North Carolina 2.22 Wisconsin 3.42 New Jersey 2.79 Indiana 2.18 Arizona 3.41 Minnesota 2.78 Oklahoma 2.10 Florida 3.40 Connecticut 2.76 Alabama 2.03 Hawaii 3.28 Louisiana 2.75 Tennessee 2.02 Montana 3.20 Maine 2.74 Kansas 1.96 Rhode Island 3.17 Idaho 2.69 Kentucky 1.92 Maryland 3.15 South Carolina 2.68 West Virginia 1.89 Massachusetts 3.15 Nebraska 2.64 Arkansas 1.85 Washington 3.12 Georgia 2.55 Utah 1.77 Source: Adapted from Hyman et al. (1980, p. 4.) or census errors affect the accuracy of the denominators (people count) and as untaxed production/distribution affects the numerators (gallon count). As a result, both random errors and systematic biases may enter the calculations. As a rule of thumb, in comparisons of a single juris- diction across time where the systematic bias is not likely to change rapidly, year-to-year estimates using invariant procedures are likely to have confidence margins of 1-5 percent. In comparisons of different areas, error margins on the order of 5-50 percent may be assumed, depending on knowledge of such factors as recordkeeping efficiency, extent of migration and tourism, tax evasion, beverage quality control, and the like. USES OF PER-CAPITA CONSUMPTION At this point we an put aside the matter of accuracy of estimates and inquire what it is that per-capita period consumption averages should tell us about alcohol use in populations. First, we should observe that per-capita consumption is an arithmetic mean. Usually a mean is com-

Alcohol Use and Consequences puted from data directly about individuals. For example, we measure the height of everyone in a group, sum the measurements, then divide by the number of individuals. Mean alcohol consumption using tax-paid withdrawals is arrived at quite differently. Instead of observing and measuring the consumption of individuals, we measure produced alcohol at one step in its distribution for sale, assume that all alcohol destined for drinking passes through this step, assume that little is thrown away, assume that retail and private stocks beyond this step do not increase or decrease much relative to the total production and flow of alcohol in a year, and, finally, assume that we have aimed our population count at all and only the people who might possibly drink the alcohol being measured. While none of these assumptions seems to unduly threaten the validity of derived means, except as noted above, all serve to indicate that per-capita consumption is an index that has been constructed to represent an implied set of behaviors. What, then, do we know about the relation between this index and the set of consumption behaviors? Most of our knowledge about this derives from two sources: surveys of individual drinking practices and comparison of per-capita consumption with public health statistics about diseases strongly related to very heavy drinking. Before discussing this, however, a brief statistical note is in order. 189 We are accustomed to thinking about the mean, and assigning statistical meaning to it, in terms of the familiar bell-shaped normal distribution. If we think con- sumption is normally distributed, then the mean lies at the peak of the sym- metrical bell-shaped curve that graphs the frequency distribution of individuals across alcohol consumption rates. In a normal distribution, more people con- sume the mean amount than any other amount (the mean is therefore also the mode); half drink more than the mean and half less (it is therefore equal to the median); and, depending on the degree of dispersion (indexed by the variance or standard deviation) of the curve, the majority of people consume an amount that is fairly close to the mean figure, with fewer people drinking at a given rate the farther it is from the mean. The mathematics that underlie the bell-shaped curve lead us to expect that an approximate normal distribution will generally occur when there is a large number of independent causes, each of which contributes a small fraction of the total variance in a dependent variable. Thus, if individual rates of annual alcohol use were normally distributed, one would reason that the sufficient causes for single drinking events (person-drink occasions) were many in number and that variations in the occurrence of these causes were largely independent or uncorrelated with each other. Investigation of the actual distribution of consumption rates has oc- curred largely in Europe and Canada, spurred by the work of Ledermann

190 G E RSTE IN (19564. Ledermann wanted to develop a new basis for estimating the prevalence of harmful effects of alcohol use. He developed a rather bold, theoretically based hypothesis: that frequency distributions of con- sumption in a population are always logarithmic normal distributions (the normal frequency function, not of the consumption rate, but of its logarithm). The resulting curves are skewed to the right so that the median and mode lie below the mean (see Figure 14. Ledermann fit these data to various small samples of drinkers. Subsequent studies (deLint and Schmidt 1968, Makela 1971, Skog 1971) have confirmed that lognormal curves may be roughly fit to a variety of survey data on consumption involving other, larger populations. Bruun et al. (1975) went a step further, arguing that "differences as to dispersion between populations with similar levels of consumption are quite small" (p. 32, authors' emphasis). These authors go on to treat the dispersion across levels as practically invariant. There are two important aspects to this argument. First, the lognormal function involves only two variables,2 the mean and the standard de- viation. If dispersion, and thus standard deviation, can be treated as invariant, then we have a "one-parameter" distribution: knowledge of the mean figure alone enables us to know the exact proportions below, within, or above any given consumption level or range. In order to calculate the rate of alcoholism, then, given the mean consumption, one need only define a consumption rate beyond which a diagnosis of al- coholism has a known likelihood: a "hazardous level of consumption" (Schmidt and Popham 1975-1976; Popham and Schmidt 1978~. The term "hazardous consumption" can then stand as a quantitative proxy for the prevalence of clinical "alcoholism." Under the lognormal/one-parameter (also called the single-distribu- tion) model, the relationship between mean consumption and the prev- alence of hazardous consumption is well defined, and the mean, appro- priately transformed, becomes an index for the rate of alcoholism. Since the transformation is exponential (parabolic), an increase (or decline) in mean consumption translates into a more pronounced increase (or decline) in alcoholism. Hence, changes in mean consumption may pro- vide quite dramatic evidence in building a public health perspective. I have stated that there are two important aspects to the argument. The second aspect has to do with interpretation of the mean not only as an index useful for estimating the size of a high-risk subgroup, but as an indicator of the alcohol-using behavior of the population as a 2 More exactly. two degrees of freedom. which are captured by two independent parametric variables or parameters (metric attributes of a whole series or population or measure- ments) .

Alcohol Use and Consequences 20 c', 1 0 He UJ C) 15 5 o 110 100 90 80 70 60 In Z 50 40 30 20 10 o ,~ \ 1 6 12 18 24 30 36 ALCOHOL CONSUMPTION 0 2 4 6 8 10 ALCOHOL CONSUMPTION FIGURE 1 Exemplary logarithmic normal curves. 191 whole. If dispersion is truly invariant, then any change in the value of the mean implies change in the number at all consumption levels not only at the highest ones. The impression is given that a whole population changes its alcohol use together. This impression is reinforced by one of the mathematical assumptions that underlie the lognormal function; namely, that the many causal impulses involved in generating empirical lognormal distributions are not additive but multiplicative. In addition to these considerations is the latent habit of thinking that the mean, as central tendency, directly describes the approximate behavior of a large proportion of the population.

192 GERSTEIN Actually this modal property accrues only if the mean value is close to the mode and if the dispersion of the curve is relatively small. In virtually every empirical consumption survey analyzed in the available [iterative (Skog 1971, 1979; Guttorp and Song 1977, 1979), one or the other of these conditions does not appear to be met. But this habit is strong, especially in the presence of limited data. Thus, Bruun et al. (1975) are led to say: The reasons for this invariance are unknown; little research has been done on this subject [The apparent stability in dispersion'] and given our present state of knowledge no plausible explanation can yet be offered, other than that the level of consumption of each individual may be presumed to reflect his social milieu. One might well say, to paraphrase Euripides, "Tell me the company you keep, and I'll tell you how much you drink" (p. 34~. There are three difficulties with this way of thinking about consump- tion data. First, the invariance of the lognormal curve is not so apparent. Skog (1979), on whose analyses Bruun et al. relied for this finding (Skog being one of the alit), has subsequently argued that the gamma distri- bution is a better fit to most available survey data than the lognormal and that "there seems to exist an inverse relationship between per capita consumption and the dispersion of the distribution" (p. 3; but see Gut- torp and Song 1977, 19794. Second, adding to the uncertainty regarding the universal adequacy of the single-distribution model, if the consumption surveys that underlie the one-parameter model are used to estimate the mean statistics, their results diverge sharply from the figures derived by the production or sales/census method. Survey-based estimates of mean consumption have been found to be only one-third to one-half as large as those computed for the same populations by the production method (Houthakker and Taylor 1970, Makela 1971, National Institute on Alcohol Abuse and Alcoholism tNIAAA] 1978~. Room (1971) reported that "our best survey questions uncover about two-thirds of the total expected consumption." By way of comparison, Warner (1978) estimated that in tobacco-use surveys, people report smoking about 75 percent of the cigarettes that manufacturers report selling a figure that was 90 percent a decade ago. Third, the theoretical interpretation is not compelling. Let us suppose that the statistical evidence favoring the single-distribution model was strong and exact, rather than tentative and approximate. Still, this evi- dence is all correlational. Rather than arguing that the overall company of users spreads its influence widely among members, pushing them into (or pulling them back across the edge of) hazardous consumption, one

Alcohol Use and Consequences 193 could just as plausibly argue that the small fraction of relatively dedi- cated drinkers "sets the pace" for the rest. It does this not only by boisterous example, but also by supplying the bulk of the economic ballast for the alcoholic beverage industry. This price-conscious high consumption base provides a foundation for economies of scale in man- ufacture, for aggressive marketing, and for antitax lobbying all of which keep prices down for high-end and low-end consumers alike. Thus, it is just as plausible to think that more heavy drinking leads to overall consumption increases, as the other way around. Without further investigation, which has not yet occurred, the mean index, even under strong statistical interpretation, does not yield definite causal accounts of the sort that- have been attributed. Fortunately, the mean statistic, even as derived from production/cen- sus reports, need not be supported by invariant distributional properties or strong theoretical interpretations in order to be of ~ alue. Even if the observed distributions can be fitted with a wide range of curves, the evidence is persuasive that these curves are all similar in shape: unimodal and skewed strongly to the right. If we were to reduce the overall U.S. consumption curve to a representative sample of 10 drinking-age adults, their annual consumption of absolute ethanol would not be very different from the following rough approximation: 3 nondrinkers, 3 drinking a gallon among them, and the others drinking 1.5, 3, 6, and 15 gallons, respectively (extrapolated from Cahalan et al. 1969~. The total is 26.5 gallons or 2.65 gallons per capita, roughly the national figure for the past decade. The point to be noticed is that one drinker (10 percent of the population) consumes 57 percent of the total; two drinkers (20 percent) consume 78 percent of the total. If we examine changes in the mean statistic across time, we will largely be tracking the drinking be- havior of this fraction of the population, the 20 percent, 10 percent, or less of heaviest drinkers whatever changes may be occurring (or not occurring) among the remainder (see also Room 1978~. As a statistical observation, we can simply note that given a skewed distribution, the mean is fairly responsive to the behavior of the long tail of the curved This was the original point of Lederman's (1956) investigations, and without further regard to specific aspects of the distribution function, it justifies the conclusion of Bruun et al. (1975, p. 45~: "A substantial 3 For lognormal and gamma curves that have been fit to available consumption data, the median or the mode (rather than the mean) would give much better estimates of how the bulk of the population is behaving, since neither responds so much to the tail on the right of the curve. The proportion abstaining is a good longitudinal proxy for the mode in most populations. Of course, it tells us very little about heavy consumption, as Bales (1944, 1946) observed.

94 GERSTEIN increase in mean consumption is very likely to be accompanied by an increased prevalence of heavy users." On the other hand, this by no means justifies such unqualified attri- butions as "a fall in the average level of consumption . . . will lead to a fall in the number of heavy drinkers" (Hetzel 1978, p. 84~. It is at least as plausible to say that the reverse is true, as is implied by Skog's theoretical demonstration of the long-term effect of a large shift in consumption preference by a small fraction of the members of a hy- pothetical social drinking network (1980~. To sum up the methodological implications thus far: the mean alcohol consumption statistic is a reasonable gross index of the amount of po- tentially hazardous consumption in a society. It is most valuable for this purpose when used as a time series or longitudinal index. To see this in operation, see Figure 2, which gives a 150-year record of this index in the United States. The long trend of per-capita consumption in the United States can be divided into four distinct periods: pre-1850, 1850-1914, 1915-1945, and 1946 to the present. Prior to 1850 the trend was downward from the high level (6-7 gallons annually per adult) that characterized colonial and revolutionary America. From 1850 to 1914, the level hovered in the area of 2 gallons, but began to rise appreciably at the turn of the century, reaching its highest level just prior to U.S. entry into World War I. During the third period (the time of the world wars), state and federal prohibition laws reduced per-capita consumption to about half or slightly more of the pre-World War I level, from which it recovered to about two-thirds that level by the end of World War II. After 1945 the rate hovered about the 2-gallon level for some 15 years, then rose during the 1960s back to the pre-World War I level of roughly 2.7 gallons per capita. For comparative purposes, Table 2 supplies a two-point time series for the postwar era for a number of industrial (mostly European) coun- tries. As indicated above, caution is necessary regarding the accuracy of comparison of these consumption statistics between different coun- tries, but there are two indisputable general observations to be made. First, the United States is unremarkable in its total consumption during this period relative to other similar national societies. It is neither es- pecially dry nor especially wet. Moreover, the postwar increase in U.S. consumption is also unremarkable. With little exception, increases on this order or greater have been common throughout the industrialized world and, for that matter, virtually everywhere else for which statistics have been compiled (Sulkunen 1976, Moser 1979~. In both the static and comparative perspectives, the United States is in the middle of the pack formed by the array of mean consumption figures.

Alcohol Use and Consequences 4.0 3.6 3.2 In of o J 2.0 2.8 _ 2.4 1.6 0.8 0.4 195 \ - \/ - - Consumption Trend - Cirrhosis Death Trend (1910-1945) Alcoholism Death Trend (1910-1945) O ~1 Y" 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1840 1860 1880 1900 1920 1940 1960 1 980 YEAR FIGURE 2 Time trend of U.S. consumption of absolute alcohol, per-capita drinking age population, 1830-1977. Note: Data points are less dense and less reliable prior to 1900. All estimates adjusted to reflect population 15 years and older. Sources: Consumption statistics from Keller and Gurioli (1976~; alcoholism death trend from Jellinek (1947-1948, p. 40~; cirrhosis death trend from Bureau of the Census (1975, p. 58~. In estimating Prohibition-era consumption, Jellinek favored use of cirrhosis-based estimators; Warburton (1932) principally used alcoholism death rates and production estimates. DISAGGREGATED CONSUMPTION STATISTICS I have devoted considerable attention to the average absolute alcohol use measure, first because it has proven to be of strategic importance for one major set of alcohol-related problems (liver disease), and second because its use in Alcohol Control Policies in Public Health Perspective (Brunn et al. 1975) and related literature has generated so much interest and controversy, both scientific and political. There are, however, compelling arguments for dividing total con- sumption statistics into finer grain. Currently, four such disaggregating strategies have been employed, singly and/or in combination, in the literature. The most easily accessible of these is the division of aggregate statistics by type of beverage. Pekke Sulkunen (1976) has forcefully argued for the consideration of the "use values" involved in alcohol

196 GERSTEIN TABLE 2 Changes in Apparent Consumption of Absolute Alcohol in 20 Countries in Gallons Per Capita of the Population Aged 15 Years and Over Total Total Absolute Absolute Percentage Country Year Alcohol Year Alcohol of Change France 1955 6.8 1972 5.9 - 13 West Germany 1959 2.2 1974 3.9 + 80 Belgium 1958 2.2 1973 3.8 + 72 Switzerland 195~1960 3.0 1971-1973 3.7 + 23 Italy 1958 2.8 1973 3.6 + 28 Australia 1957-1958 2.4 1972-1973 3.5 + 44 New Zealand 1957 2.5 1972 3.3 + 31 Denmark 1958 1.4 1973 2.9 + 112 Canada 1958 1.9 1974 2.8 + 51 Netherlands 1958 1.8 1974 2.8 + 53 USA 1960 2.1 1975 2.8 + 34 United Kingdom 1959 1.6 1974 2.7 + 71 USSR 1957 1.3 1972 2.3 + 83 Ireland 1959 1.1 1973 2.2 + 100 Poland 1959 1.7 1974 2.1 + 22 Finland 1957 0.8 1973 2.0 + 157 Sweden 1958 1.3 1973 1.8 + 43 Norway 1959 0.9 1974 1.5 + 68 Iceland 1956 0.7 1973 1.3 + 84 Israel 1959 0.10 1974 0.9 - 12 Note: Arranged in order of consumption in most recent year available as of 1976. Comparisons are for the available data approximating 15 years prior for each country. See text on problems of comparisons between countries. Even a 1-year difference in dates could substantially alter percentage changes. Certain European countries, not listed due to missing early data points, appear in Table 3. Source: Adapted from Keller and Gunoli (1976~. consumption. At the most basic level, he identifies three sets of values: intoxication, nutrition, and conviviality. Very roughly, these tend to be differentiated in parallel with the three main types of Western alcoholic beverages: distilled spirits are used as an intoxicating drug, wine as the liquid part of a meal, and beer as an accompaniment to sociable relax- ation. These usages are only rough guides, of course, and are historically associated with particular ethnic-national practices. Sulkunen points out that in the postwar period, there has been a mild trend toward "ho- mogenization" of drinking cultures worldwide, with one region's drink- ing preferences and practices being imported and superimposed on the practices native to other regions. However, traditional wine drinkers,

Alcohol Use and Consequences for example, in adopting the use of distilled spirits, tend to use them in ways more consonant with their traditional use of wine; e.g., to use distilled spirits in the form of liqueurs and brandies not far removed from mealtimes. If we follow Sulkunen's arguments and, as in Table 3, identify coun- tries by their predominant (according to absolute alcohol volume) bev- erage, we see that the highest-ranked countries (by mean per-capita total alcohol) are wine-drinking, the lowest-ranked consume mainly spir- its, and the heavy beer-drinking countries are mainly found in between. There is also, among the European countries, a regional concentration 197 TABLE 3 Apparent Consumption of Absolute Alcohol in Gallons Per Capita of the Population Aged 15 Years and Older, in 25 Countries, by Beverage Type Year of Latest Distilled Country Data Spirits Wine Beer Total Portugal 1974 0.46 5.27* 0.54 6.37 France 1972 0.80 4.07* 0.99 5.87 Italy 1973 0.66 3.79* 0.24 4.69 Switzerland 1971-1973 0.75 1.70* 1.39 3.85 Spain 1971 1.07 2.18* 0.53 3.78 West Germany 1974 0.91 0.82 2.02* 3.75 Austria 1972 0.84 1.25 1.63* 3.72 Belguim 1973 0.61 0.63 2.15* 3.39 Australia 1972-1973 0.47 0.45 2.40* 3.32 Hungary 1972 1.00 1.54* 0.69 3.23 New Zealand 1972 0.49 0.35 2.34* 3.18 Czechoslovakia 1973 0.92 0.57 1.49* 2.98 Canada 1974 1.01 0.32 1.51* 2.84 Denmark 1973 0.53 0.35 1.71 * 2.79 USA 1976 1.14 0.34 1.31 * 2.78 United Kingdom 1974 0.53 0.28 1.94* 2.76 Netherlands 1974 0.97 0.44 1.34* 2.75 Ireland 1975 0.78 0.14 1.56* 2.47 USSR 1972 1.22* 0.91 0.21 2.34 Poland 1974 1.43* 0.29 0.49 2.21 Finland 1976 1.07* 0.24 0.82 2.14 Sweden 1973 0.87* 0.30 0.67 1.84 Norway 1974 0.63 0.15 0.69* 1.47 Iceland 1973 0.94* 0.10 0.12 1.16 Israel 1974 0.48* 0.18 0.20 0.86 *Indicates predominant beverage type. Source: Adapted from NIAAA (1978~.

198 GERSTEIN TABLE 4 Apparent Consumption of Absolute Alcohol, in U.S. Gallons Per Capita of the Population Aged 14 and Older and the Percentage Contribution of Each Class of Beverage to the Total, in U.S. Geographical Regionsa Spirits Wine Beer Total Abso- To Abso- To Abso- To lute Contri- lute Contri- lute Contri- Absolute Alcohol button Alcohol button Alcohol button Alcohol New England 1.41 44 0.45 14 1.35 42 3.21 (minus New (1.28) (42) (0.44) (15) (1.30) (43) (3.02) Hampshire) Middle Atlantic 1.06 40 0.33 12 1.24 47 2.63 East North Central 1.03 40 0.13 5 1.39 54 2.55 West North Central 0.93 38 0.19 ~ 1.32 54 2.44 South Atlantic 1.25 44 0.29 10 1.28 45 2.82 (minus District of (1.21) (44) (0.27) (10) (1 27) (46) (2.75) Columbia) East South Central 0.85 42 0.10 5 1.07 53 2.02 West South Central 0.91 35 0.22 8 1.49 57 2.62 Mountain 1.35 40 0.42 12 1.61 48 3.38 (minus Nevada) (1.17) (38) (0.38) (12) (1.56) (50) (3.11) Pacific 1.33 38 0.71 20 1.41 41 3.45 TOTAL 1.12 40 0.36 12 1.34 48 2.82 [One U.S. gallon = 3.785 liters = 0.833 imperial gallon.] a The standard regions of the U.S. Census Bureau. Source: Hyman et al. (1980, p. 7~. Reprinted by permission of Journal of Studies on Alcohol, Inc. of wine countries in the southwest, where the grape vine grows plen- tifully. The dispersion and range down the table are greatest for wine: a number of countries are separated by geometric ratios in excess of 25 and as high as 50, much more than the differences for beer (fox) and spirits (3x). We do know that ratios of consumption between beer and spirits have been known to shift abruptly in European countries, such as in Denmark, when in 1917 the beverage taxation rates were quite drastically modified (Wilkinson 1970~. Regional distributions are also evident in the United States (Table 4~? although they are much milder. Wine varies by about Sx, spirits by 2x, and beer by no more than 1.5x. Although the limited comparability of regional indices is, as indicated above, an inherent caution against gen- eralization, it seems very safe to say that the states are, as a whole, quite uniform in their prevalence of heavy beer drinking and less so in regard to spirits. (Note the high rate in New England versus the low rate in South-Central.) The greatest regional difference lies between the wine preferences of the Pacific states in contrast to the Midwest although

Alcohol Use and Consequences 199 these wine-growing coastal states unquestionably lie well below the prev- alence of heavy consumption found in the European wine countries. We may also examine changes in the consumption of different bev- erages across time. A [SO-year trend for the three main classes of bev- erage types in the United States is displayed in Figure 3. The overall configurations are quite different. (Note that these graphs are scaled in gallons of beverage rather than gallons of absolute alcohol.) Wine remained at fairly low stable levels throughout the 19th century and into the 20th century. The World War I mobilization, along with state (then national) prohibitions, succeeded in suppressing the apparent mini-boom about 1910, but home winemaking became popular during the 1920s. Heavy wine drinking recovered rapidly from the Great Depression, and average wine consumption was the most vigorous bev- erage index during the consumption boom of the late 1960s. Beer, by contrast, only began to be drunk in the United States about 1850, but its heavy use grew remarkably (the index increasing by 10- fold) in the next 65 years. The drastic effects of Prohibition were not shaken off for a full generation, and the mean consumption of beer today is less than it was in 1915. Most notably, the mode of drinking beer in the prewar period in draught from tavern barrels has been very largely replaced by canned and bottled beer (Rooney and Butt 1978~. Finally, consumption of heavy spirits dropped steadily during the 19th century, finally leveling off about 1880. The wartime state prohibitions and the Volstead Act depressed this index for a few years, but it re- bounded during the mid-1920s to about 30 percent higher than its Vic- torian level. The Great Depression appears to have strongly affected the index, although the switch in data base from indirect measures of illicit production (1930) to tax records of legal distillation (1934) exag- gerate this. The index was somewhat below the 1880-1915 level after World War II, then rose by 1970 to its recent plateau still below the levels of heavy spirits drinking estimated during Prohibition. In brief we find that consumption trends for the three alcoholic bev- erage types diverged widely during the 19th century and through about 1935. Wine use (nutritional) was stable (until a growing popularity after 1900), intoxication (spirits) fell to 25 percent or less of Jacksonian levels, and heavy beer drinking in the convivial atmosphere of the tavern grew steadily until Prohibition effectively ended it. Since 1935, which is to say since the reinstatement of federal control over production and state control over distribution, the consumption trends of all three types have been quite similar. The largest difference is in the more rapid growth of wine drinking, which now contributes about 13 percent of all absolute alcohol consumed in the United States.

200 3.2 2.8 2.4 z 2.0 3 .6 0.8 GERSTEIN Beer 28 ~4 4 _ O _ (before 185~mostly cider) ,~ 1 1 1 1 1 1 1 1 840 1860 ,,, 1~ 1 1 1 1 1 ~ 1980 1880 1900 1920 1 940 1 960 (1830 9.5 gallo;) Spirits 0.4 oL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1840 1860 1880 1900 1920 1940 1960 1980 YEAR FIGURE 3 Time trend of U.S. consumption of types of alcoholic beverages, 1830-1977. Note: The solid lines for the years 1920-1935 are consistent with Warburton's (1932) estimates, while the dotted lines represent Jellinek's (1947-1948) views. Other data are derived from Keller and Gurioli (1976) and Gavin-Jobsen Associates (1978~. See also notes to Figure 2.

Alcohol Use and Consequences 2.e He o ~ 1.2 2.4 _ 2.0 _ 1.6 0.8 0.4 201 wine _~4' 1 1 1 1 1840 1860 1880 1900 1920 1940 1960 1980 FIGURE 3 (continued) DRINKING PATTERNS IN SURVEY DATA The total consumption approach draws on sales data for its mean statistic and on sample surveys of drinking for its single-distribution argument. A rather different use of sample survey data is made by those who are interested in the frequency and distribution of intoxication, what has come to be called "drinking practices" or "patterns." Although the study of drinking patterns has been carried on largely by questionnaire survey research, a few smaller studies have used "daily drinking diaries," which have recently been compared with survey meth- odology and have demonstrated relatively minor deviations in summary results (Gerstel et al. 1975, Harford 1979~. Since large-scale survey research is basically a post-World War II phenomenon, detailed quan- titative data about drinking patterns are virtually confined to this period. One approach that has been widely assimilated is to divide drinkers into categories such as abstainer, infrequent, light, moderate, and heavy drinkers, taking into account the frequency of drinking occasions, the usual quantity consumed, and the frequency and quantity consumed during maximum drinking episodes. This is the quantity-frequency-var- iability or Q-F-V approach (Mulford 1964, Knupfer 1966, Cahalan et al. 1969, Cahalan and Room 1974~. Mapped against the skewed distri- bution of annual per-capita alcohol consumption, each of these discrete subtypes of drinker would generate its own characteristic curve, "un- derneath" the aggregate total consumption curve, which the summation

202 GERSTEIN of the five would yield. Many of the surveyed individuals whose drinking pattern might qualify them as light or moderate drinkers (small amounts every day; seldom noticeably intoxicated) have a total annual con- sumption greater than individuals whose pattern classifies them as heavy drinkers (twice a month "blind drunker. The topological approach iden- tified here is especially sensitive to such occasions of extreme drunken- ness and thus to "binge drinking," a type that has haunted the alcohol literature, both empirically and conceptually, since Jellinek (1960) orig- inally formulated this as a distinct type. The topological method clearly assumes that particular consumption characteristics, beyond period con- sumption per se, dramatically escalate any risks associated with alcohol. According to successive surveys, the proportion of reported abstainers (no alcohol drunk in the past-year) among U.S. adults was about 45 percent in the middle and late l950s, but declined to about one-third by 1970; the figure has been unchanged since that time. However, there is considerable difference between adult men and women. About 27 percent of men, but 42 percent of women, are now abstainers. It is conventional to distinguish heavy from moderate drinkers. The criteria for drawing this line vary from study to study. In the major national survey carried out in the 1960s, the designation "heavy" was used for a conglomerate of patterns; it included those who had five to six drinks twice a month, a drink or two nearly every day, five to six drinks "once in a while," and a drink three times a day; and it encom- passed patterns combining or exceeding these frequencies. By these lights, 1 in 5 men, and 1 in 10 women were heavy drinkers in 1965. Annual surveys initiated in the 1970s (see Johnson et al. 1977) using a simpler definition of "heavier drinking" (an average of 2 or more drinks per day) yielded virtually identical proportions. These figures too have shown no significant change since 1970. In a comparative perspective, the United States is remarkable among Western industrial nations for its proportion of adult abstainers, which is higher in the United States than in Canada or in any nation in western Europe (these countries range from 3 percent to 30 percent abstainers; [NIAAA 1978~. There is considerable regional variation in the United States, however. The proportion is lowest in the Mid-Atlantic states (17 percent) and highest in the Bible Belt states of the South (65 per- cent). It is not possible to make broad international comparisons for proportions of "heavy drinkers" using such survey data due to incom- patible or nonexistent data for the different countries. It is important to note that even where drinking patterns for a pop- ulation appear to be stable across a number of years, there is continual flux in the drinking patterns of many individuals within the population.

Alcohol Use and Consequences 203 At the extreme, many clinically diagnosed alcoholics alternate between periods of heavy consumption and periods of abstention. There is also a tendency for drinking to decline markedly beyond the age of 50, and there are often significant differences in drinking rates between age and sex cohorts as well as within the same cohort at different points in time. Skog (1979) has argued that these different drinking subpopulat~ons are the primary explanation for the departure of consumption curves from Ledermann's predictions. USE AND CONSEQUENCES: THE PROBLEM OF ATTRIBUTION It is one thing to know how much or how often people drink; it is another to pinpoint the effects of that drinking. For virtually every possible consequence of alcohol use that we may be interested in, alcohol is neither- a necessary nor a sufficient cause, but rather one in a series of factors that may combine in various ways to yield effects. The presence of specifiable other factors, some permanent but others subject to ma- nipulation, is just as important as drinking per se to the production of alcohol-related effects. For example, sustained heavy alcohol use is demonstrably associated with the pathological and potentially fatal liver condition called cirrhosis. The data on this connection are as strong as those linking heavy smoking with lung cancer. But the mechanism by which alcohol use causes this gradual-accumulation of scar tissue in the liver is still speculative. It is known that cirrhosis can occur in people who have never drunk alcohol. It is known that various nutritional deficiencies or imbalances can not only cause cirrhosis directly, but also can markedly change the vulner- ability of liver tissue to alcohol-related cirrhosis. Good nutrition prob- ably cannot prevent alcoholic cirrhosis; but bad nutrition can certainly hasten it along. Another example is automobile accidents. Drunken driving is noto- riously a precursor of traffic fatalities. But at least half of all traffic fatalities in the United States evidence no alcohol "involvement" at all. Perhaps 1 in 500 to 2,000 of legally drunk-driving episodes result in arrest—and there are far more arrests than fatalities. Moreover, an individual can hardly cause a traffic fatality, no matter how drunk, in the absence of a lethal vehicle. This may seem trivial in a nation of 100 million automobiles, but it is not trivial if changes in gasoline costs drastically depress people's use of cars or change the way autos are built and driven. In short, certain of the socially most important consequences of alcohol use are rare, may occur with no alcohol present and/or require the presence of additional factors in order to happen at all.

204 GE RSTEIN These two examples involved the negative effects of alcohol on phys- ical well-being. In looking at psychological and social well-being, the difficulties do not decrease. A number of studies have found some common properties among the personalities of diagnosed alcoholics: depression, anxiety, low frustration tolerance, feelings of powerlessness, etc. But virtually the same properties have been deemed to cause al- coholism. If depression is both a.cause and an effect of heavy drinking, how can one decide what part of the alcoholic's depression, or of suicides that follow from depressive episodes, is due to drinking? Similarly, attempting to pinpoint the exact part played by drinking in problematic social behavior is exceedingly difficult, compounded as it is by interaction with others during numerous situations over time. Statistical methods to separate alcohol consumption from other causes do offer some help in disentangling multiple causes, but since the prob- lems are generally long-term ones, in which both the drinker and "sig- nificant others" build up a history of cumulative perceptions and judg- ments, such attempts to isolate and assign weight to one factor may have little relationship to reality. All of these problems in attribution apply to the positive effects of alcohol use as well. They are somewhat aggravated by the disinclination of researchers to investigate positive effects, which means that less data are available for analysis. For example, the best-known study of eco- nomic effects of alcohol is on the costs of alcohol abuse and alcoholism and does not attempt to estimate effects that may yield economic pos- itives. Mortality studies ask how many deaths alcohol may have been at least partly responsible for and do not concern themselves with the lives alcohol may preserve, even though studies on heart disease have indicated certain advantages possibly associated with moderate drinking. There is no avoiding the difficulties in attributing the effects of alcohol use; however, it is necessary to have some scheme of accounts for these effects if we are to consider alcohol-related policy. If a central principle of any policy is to preserve and promote good effects while minimizing bad ones, then it is difficult to evaluate any policy without identifying the effects of relevance and observing how they change over time. Since the consequences of alcohol use are manifold, it is important in the first place to identify the ones of greatest social importance, to assess the relative importance of alcohol in generating them as best we can, and then to be systematic and comprehensive in thinking about how these effects can be modified. A more exact feel for the difficulties of attribution may be achieved by examining recent responsible attempts to estimate the effects of drink- ing in the United States. Three of these were prepared in the 1970s

Alcohol Use and Consequences 205 under the auspices of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and were prominently featured in the Third Spe- cial Report to the U.S. Congress on Alcohol and Health. Each examines a different dimension or measure of effects: mortality (deaths), eco- nomic costs (dollars), and psychobehavioral problems (symptoms). Mortality Table 5, reproduced in Alcohol and Health 3 (NIAAA 1978), estimates that the number of deaths related to alcohol use in the United States in 1975 was between 61,000 and 95,000. The associated text notes that other mortality studies have respectively estimated 140,000; 185,690; and "as high as 205,000 deaths per year, which was 11 percent of the total 1.9 million deaths in 1975." The largest figure has received the widest publicity. A comprehensive study of deaths among clinical alcoholics (Schmidt and Popham 1980, also see Polich et al. 1980) suggests how the totals in Table 5 could have been inflated. For 12,000 former alcoholism pa- tients in Ontario, Canada, who were followed up at an average of 8.5 TABLE 5 Estimated Deaths Related to Alcohol in the United States, 1975 Estimated Number Percent Number of Deaths, Related to Related to Cause of Death 1975 Aleohol Alcohol Aleohol as a direct cause Alcoholism 4,897 100 4,897 Alcoholic psychosis 356 100 356 Cirrhosis 31,623 41-95 12,965-30,042 TOTAL 36,876 18,218-35,295 Aleohol as an indirect cause Accidents Motor vehicle 45,853 30-50 13,75~22,926 Falls 14,896 44.4 6,614 Fires 6,071 25.9 1,572 Othera 33,026 11.1 3,666 Homicides 21,310 49-70 10,442-14,917 Suicides 27,063 25-37 6,76~10,013 TOTAL 148,219 29-40 42,81~59,708 OVERALL TOTAL 185,095 61,03~95,003 a Includes all accidents not listed above, but excludes accidents incurred in medical and surgical procedures. Sources: Day (1977) and National Center for Health Statistics (NCHS) (1975b).

206 GERSTEIN TABLE 6 Percentage of Excess Deaths in a Clinical Alcoholic Population in Canada Heart disease Accidents Cirrhosis Suicide Alcoholism Cancers of the mouth, throat, esophagus, windpipe Pne~monia/bronchitis Alimentary ailments Other causes (includes homicides) TOTAL (20)* (20) (16) (12) (9) (9)* (6)* (5)* (3) 100 * Not counted in Table 5. Source: Adapted from Schmidt and Popham (1980). years, 1,062 excess deaths (compared with age-standardized population norms) were attributed to the causes listed in Table 6. The authors of this study caution that alcoholics smoke cigarettes at considerably higher rates than the comparison population and, hence, that excess heart disease and cancer deaths are associated to an unclear degree with tobacco rather than alcohol exposure. They also warn that nutritional and other life-style differences intervene in the relation be- tween drinking alcohol and dying. Still, 40 percent of the deaths in Table 5 were from causes not directly considered in Table 6; hence, an absolute maximum figure in the range of 150,000 for deaths "related to alcohol" might be acceptable, presum- ing that all untreated alcoholics have the same death risks as clinical patients. But what does this mean? If we wish to determine how alcohol affects the overall death rate in the United States, i.e., to discover its net causal impact, we would have to estimate both deaths resulting from and deaths prevented by alcohol use. (There is some evidence, for example, that moderate drinking is correlated with decreased risk of death, particularly death involving ischemic heart disease.) However, being related to or correlated with does not amount to causal proof. In this sense, the 150,000 figure is simply a pool within which whatever deaths might be caused by alcohol and thus prevented by minimizing its use or misuse are to be found. The number will be no more--it will be much less. How much less is not certain, but a figure in the area of 50,000 theoretically preventable deaths seems reasonable. This is not 200,000—but neither is it negligible.

Alcohol Use and Consequences 207 TABLE 7 Economic Costs of Alcohol Misuse and Alcoholism in the United States, 1975 Item Cost (billion $) Lost production Health and medical Motor vehicle accidents Violent crime Social responses Fire losses TOTAL 19.64 12.74 5.14 2.86 1.94 0.43 $42.75 Source: NIAAA (1978, p. 31; prepared by Berry et al. 1977). Economic Costs Table ? is a tabulation of how much alcohol abuse and alcoholism cost the United States in 1975. This $42.75 billion figure is not a "net cost" estimate; that is, it is not intended to represent the net reduction in gross national product resulting from alcohol use. It is a conglomeration of dollar values: discounted lifetime earnings attributable to about 69,000 people whose deaths in 1975 were estimated to be alcohol-related (25 percent of the $42.75 billion); lessened production as estimated by certain household wage differentials (35 percent); assignment of health care resources to alcohol-related problems (21 percent); and assorted other estimates. This collection of dollar values is held by its authors (Berry et al. 1977, Berry and Boland 1977) to be the "external cost" of alcohol abuse paid not by the alcohol abuser but by the rest of society. It is difficult to assign precise significance to this result. For one thing, a large fraction of the costs tabulated here do appear to be borne by the alcohol abuser: from 25 percent to 50 percent of the total amount cited. There are implicit assumptions about the labor supply in 1975 namely, that it was short—that are not consistent with the then-prevailing eco- nomic indicators (unemployment was at 8.5 percent). The transposition of "associated with alcohol" into "due to alcohol abuse," which is to say transformation of an estimated correlation into a direct cause, occurs in the discussion despite explicit cautions by the authors to the contrary. There are some problems raised by this approach of estimating costs in absolute, autonomous terms. Economic cost estimates are usually related either to a specific program of action or to a specific annual budget. In the first instance, one might estimate the costs and benefits of a specific program to modify alcohol abuse. In the second instance, one would try to estimate the proportion of, for example, the federal

208 GERSTEIN budget or aggregate personal income, or capital stock, expended on, diverted by, or destroyed as a result of alcohol-related problems (Walsh 1979, Makela and Osterberg 1979~. Absent from such contexts, a mul- tibillion dollar cost figure is simply a large price tag on an empty box. It draws attention, but gives little guidance. Behavior In Table 8, approximately 1 in 10 drinking American adults (about 10 million people) are classified as "problem drinkers"; an additional 1 in 4 (25 million) as "potential problem drinkers"; the other 65 million or so drinkers reportedly had "no problems." What precisely do these rather ominous figures mean? In the original table Johnson et al. 1977), the authors listed these categories as "frequent problem drinking symp- toms," "potential symptoms," and "no symptoms." The most common of these symptoms ("taking 2 or 3 drinks at one sitting"—"sometimes but not often" or "frequently"; "going several days or weeks without taking a drink and then having several drinks at one time". "sometimes but not often" or "frequently") are indistinguishable from criteria for moderate drinking patterns. The next most common symptoms ("talking TABLE 8 Rates of Problem Drinking Among U.S. Drinkers, by Drinking Population, 197~1975 Percentages for Each Survey Drinking March January January June Population 1973 1974 1975 1975 All Drinkers No problems 64 70 65 63 Potential problemsa 26 24 24 26 Problem drinkersb 11 6 10 10 Males No problems 57 66 62 57 Potential problemsa 29 27 23 31 Problem drinkersb 14 . 8 15 13 Females No problems 74 77 70 73 Potential problemsa 21 19 27 21 Problem drinkersb 5 4 3 6 a A potential problem drinker experienced two or three of sixteen problem drinking symptoms frequently or four to seven symptoms sometimes. b A problem drinker experienced four or more of sixteen problem drinking symptoms frequently or eight or more symptoms sometimes. Source: NIAAA (1978, p. 26; adapted from Johnson et al. 1977~.

Alcohol Use and Consequences 209 a lot about drinking" "sometimes but not often" or "frequently"; "showing the effects of liquor more quickly than most people" "some- times but not often" or "frequently"; "taking a drink to feel better"- "sometimes but not often" or "frequently") are not, on their face, "problems." Sixty percent of the reported symptoms fall into one of the categories above. The authors warn that "this problem index is presented for comparison purposes over time and should not be used as an absolute definition of problem drinkers." As an index it simply demonstrates that there has been relative stability between 1973 and 1975 in reports of these drinking patterns. These data really shed little light on the relationship between alcohol use and consequences. A few categories of symptoms (not the most common ones) are markedly more prevalent among heavier drinkers than other drinkers. But this report's conglomeration and renaming of categories obscures more than it enlightens. It is impossible to attach meaning to Table 8 beyond the indication of stability across time. SOCIALLY IMPORTANT EFFECTS OF ALCOHOL USE It is clear that there are problems with efforts to assay the effects of alcohol by toting up detached dollar values, "associated" deaths, and "symptoms." There are a number of alternative ways to present and organize information about these effects. No single way is right for all purposes, but my concern here is to highlight the socially important effects, to examine the degree to which alcohol is a principal cause, to roughly estimate the population affected, and to note what other gen- erative factors besides alcohol use might be important and subject to modification. Taking this view, I can identify five principal environments that, when combined with alcohol, produce effects. Each is best visualized as a system. First is the internal organic environment of the body, in W. B. Cannon's (1932) sense: its basic, enduring physiological forms and proc- esses. Our principal interests here are the organs most sensitive in the long term to alcohol exposure: the heart and the liver. The second environment is the-personality. It is also internal to the person and one can even speak of it as based in an organ: the brain. But the physiological base does not suffice to complete our thinking about effects on the personality system. We need to use psychological concepts that we would not think of applying to hearts or livers. The third system is external and the one that we so often think of as "the" environment: i.e., the physical one. It is of great importance that the physical environment we touch most directly is heavily transformed

210 GERSTEIN by human activity. The world of moving vehicles, building elevations, and concrete and floating surfaces is no less physical for being fabricated. The fourth system, external like the last, is the system of intimate social relations, most particularly those we traditionally regard as pri- mary and important to us: kin and coworkers or, to stress the long view, family and occupational careers. Finally, there is the institutional environment, the relatively imper- sonal social matrix of secondary relations that we can ordinarily relate to only in abstract or remote terms, although it diffusely and sometimes very directly transfigures our lives. Most particularly, we are interested here in the broad public systems of responsibility for health care, civil safety, and economic well-being. Physiological Effects When the possibilities of sustained changes in physiological systems due to alcohol use are examined, very different effects come into view de- pending on whether the depth of intoxication, drinking patterns, or total consumption is considered. Due to the surprising capacity of the liver to rapidly convert alcohol to usable carbohydrate, the physiological effects of intoxication tend to be short-lived. The principal exception is intoxication that leads quite immediately to death. In examining drink- ing patterns, on the other hand, the primary effect involves physical dependence on alcohol, which induces vulnerability to the pathological syndrome of withdrawal or abstinence. The medical recognition and management of this syndrome, however, has relegated it to a fairly insignificant role in terms of physiological health in contrast to the effects (which physiological alcohol addiction may accentuate or sup- port) of drinking patterns on psychological and interpersonal matters. Finally, clear links between drinking patterns and physiological changes have been investigated most thoroughly in relation to total consumption. In this connection, rates of coronary heart disease and cirrhosis of the liver are by far the most prominent physiological aspects known at this time. Deaths from alcohol overdoses, alone and in combination with other drugs, account for close to 10,000 deaths and perhaps 100,000 episodes of medical intervention each year. The finding of BAC in excess of 0.3 in autopsy toxicological findings is generally considered to strongly sug- gest the possibility that the death was the consequence of an acute alcohol reaction. Approximately 5?0OO such deaths occur each year (Day 19774. In addition, approximately 5~000 fatal overdoses involving alcohol in combination with other drugs occur in the country each year, based

Alcohol Use and Consequences 211 - on extrapolation from Drug Abuse Warning Network (DAWN) data (IMS America 1976~. Since these reports indicate only measurable pres- ence of blood alcohol and not specific BAC and do not speculate about relative mechanisms, it is difficult to know in how many of these deaths alcohol was a sufficient or necessary cause. The incidence of suicide within this group is not known, although in the alcohol-in-combination cases the death certificates estimate suicidal intent in about 40 percent of the cases. Cirrhosis of the liver is a disease process known to have multiple causes, that are not all well understood (French 1971~. Certain protein deficiencies are invariably followed by appearance of cirrhosis- the dis- solution of liver cells and their replacement by scar tissue. Cytological studies on the effects of alcohol use have shown that there is a buildup of fatty yellow liver cells as a consequence of metabolizing alcohol. In laboratory studies of short-term high-level exposure to alcohol, mito- chondria (essential organelles within liver cells) disintegrate. Both of these processes may contribute to liver cell death and fibrosis (cirrhosis). The supply of certain amino acids in the diet also appears to have a strong influence on how well liver cells resist deterioration; but this protective effect is by no means absolute (Lieber et al. 1971~. These microbiological findings are strongly supported by macroepi- demiological studies (Schmidt 1977), which show that gross rates of cirrhosis deaths track shifting rates of total consumption in a population. Among clinical alcoholic populations in which consumption of 5 ounces of alcohol daily for long stretches of time is an approximate lower limit of alcohol use, a prevalence of cirrhosis damage of 8 percent has been reported, far in excess of the general population; another 25 percent suffer acute liver inflammation, generally regarded as a precursor to cirrhosis. In postmortem studies of individuals identified as alcoholics in New York City (Haberman and Baden 1978), the incidence of mod- erate-to-severe fatty changes in the liver exceeded the rate of cirrhosis by approximately the same proportions. In general, it is expected that a long period of exposure to high levels of consumption' on the order of 15 years or more, is necessary to bring the disease process to a life- threatening state; however, cessation of alcohol use can freeze the proc- ess. The rate of liver cirrhosis death in the United States at several points, beginning in 1961, is reported in Table 9. It has been estimated that if no alcohol were consumed, the death rate from cirrhosis would ap- proximate 3-4 per 100,000 (see Schmidt 1976' 1977; Skog 1979~. The rise from 11.3 to 15.4 between 1961 and 1971 coincides with the 26- percent increase in per-capita U.S. alcohol consumption in this period.

212 GERSTEIN TABLE 9 Statistics Relevant to Alcohol-Related Mortality in the United States, Death Rates per 100,000 by Year and Cause of Death Cause of Death 1961 1971 1975 1979 Malignant neoplasms of buccal cavity and pharynx 3.5 3.7 3.8 3.6 Malignant neoplasms of respiratory system 23.1 35.3 40.7 46.6 Ischemic heart disease 274.6 326.1 301.7 283.6 Cerebrovascular disease 105.5 101.1 91.1 76.5 Atherosclerosis 19.3 15.2 13.6 13.0 Peptic ulcer 6.3 3.9 3.2 2.2 Cirrhosis 11.3 15.4 14.8 13.4 Motor vehicle accidents 20.8 26.3 21.5 23.3 Other accidents 29.6 28.6 26.8 23.7 Suicide 10.4 11.7 12.7 11.7 Homicide 4.7 9.1 10.0 10.0 Pneumonia 29.0 26.9 24.1 21.4 Sources: National Center for Health Statistics (1963, 1975a. 1978. 1980~. Since 1971, however, alcohol use has held steady while the cirrhosis death rate has declined to 13.6. The reason for this decline is simply not known. It is expected that cirrhosis death rate changes lag somewhat behind changes in total consumption, so we would have actually ex- pected the increase to continue somewhat into the 1970s. However, general death rates in the United States have been declining steadily during the 1970s, and the decrease in cirrhosis death is in approximate line with this general decrease. In the 35-54 age band, cirrhosis accounted for 6.5 percent of all deaths in 1979. Of the 1.93 million deaths in the United States in 1979, 30,000 were due to cirrhosis. At best guess, between 20,000 and 25,000 of these were a primary result of alcohol consumption. Studies in Ontario, Can- ada, which has a total consumption similar to the United States as a whole, lead to the estimate that roughly one-half of this last figure involved individuals whose total consumption is above the lower limit observed in clinical alcoholic populations (Schmidt 1977~. We would therefore estimate that about 10,000-12,000 deaths from cirrhosis occur among clinical alcoholics in the United States, and another 10,000-12,000 among people who would most likely not meet clinical criteria for chronic alcoholism. Alcohol use has also been investigated in relation to heart disease. The findings here are not clear-cut (see Klatsky et al. 1978, Hennekens et al. 1978~. Very high consumption of alcohol has been linked to car-

Alcohol Use and Consequences 213 diomyopathy and hypertension; however, moderate consumption has been linked in a number of prospective and case control studies to reductions in ischemic heart disease, the major cause of death in the United States, claiming about 525,000 lives in 1979. Relative to non- drinkers, these studies indicate risk reduction of 20 percent to as much as 70 percent. However, the samples are specialized and the studies are inconsistent in regard to whether or when increases in consumption beyond two drinks per day cease being "protective." From 1961 to 1971, while alcohol use on the whole increased 26 percent, the rate of death from ischemia increased 18 percent; but this change was confined to cohorts born before 191() there was virtually no change in rates of coronary death for age brackets below 65. Since 1971, ischemic heart death has been declining dramatically in all age categories. This could be a lagged effect of earlier consumption changes, a result of improved cardiological care or general health, or the result of other causes entirely. In summary, the major significant physiological effects of alcohol in the United States today are overdose, liver disease, and heart disease. Alcohol is involved in roughly 10,000 overdose deaths annually, half in combination with other drugs. It is difficult to place any boundaries around the precise population at risk for all of these overdoses, although it has been shown that in the combination deaths the sexes are evenly split and most were people under 30, whereas alcohol overdose deaths follow the general demographic profile of clinical alcoholic populations: mostly 30- to 55-year-old men. Alcohol is also involved in 20,000-25,000 cirrhosis deaths annually, of which about half occur in populations that probably meet appropriate criteria for clinical alcoholism. There is rea- son to believe that alcohol use may have a significant effect on coronary disease. If alcohol use were responsible for a 5-percent net decrease in coronary mortality, this would be 33,000 lives saved, and concomitant decreases in nonfatal heart attacks and other disabilities. The population of reduced risk in this instance would extend to 55 or 60 percent of the adult population of the United States. Personality It is likely that alcohol cannot create effects in the system of personality that cannot be created in other ways or that have not been observed in people who have never consumed alcohol. The primary clinical criterion by which alcoholism is recognized is "loss of control" over intake of alcohol (Jellinek 1960, DSM-III 1980~. The concept of loss of control

214 GERSTEIN has considerable kinship with other important notions in abnormal psy- chology, particularly the notions of locus of control and of powerlessness or anomie. Both have been deemed pervasive aspects of modern life. In terms of clinical presentation, the psychiatric syndrome most often and most worrisomely associated with alcoholism is depression (Schuckit 1978) and particularly depressive states serious enough to entail risk of . · . sulclae. The relation of alcohol use to suicide has been studied enough to develop some rough notions about its quantitative contributions (Aarens and Roizen 1977~. It can be estimated that alcohol was present in about one-third of the annual 25,000 U.S. suicides, and about half of these drinking suicides could have been diagnostically ascertained as alco- holics. The prevalence among attempted suicides (estimated to number 200,000-400,000 per year) of such drinking problems as alcohol-related job loss, spouse loss or threat thereof, and self-identification as a prob- lem drinker or alcoholic, all run approximately five times the rates to be expected in a demographically comparable group. There is consid- erable overlap between these alcohol-involved suicide figures and the alcohol-in-combination overdose deaths reported through the DAWN system. If we attempt to examine the structure of personality by such simple measures as are available in wide-scale population surveys, we can make some estimate of the nonclinical impact of alcohol on personality in the United States. Insofar as evidence bears on this (Cahalan et al. 1969), it indicates that across the general span of drinkers, there is little dif- ference (as there is little difference from abstainers) in either the struc- ture of personal goals or degrees of satisfaction with the attainment of such. This is not to say that there are not unhappy or dissatisfied in- dividuals among drinkers, as the numbers appealing to Alcoholics Anonymous and other treatment modalities clearly assure us. But if there are proportionately as many unhappy abstainers as unhappy drink- ers, we should be especially hesitant to expect that alcohol itself has a significant independent impact on the "general happiness" or any index of it such as the rate of suicide. When we examine changes in this suicide rate in Table 9, we note that the rate increased between 1961 and 1971, the period during which alcohol use increased; increased at an even more rapid rate between 1971 and 1975, the period during which total consumption was stable; and then decreased again in the latter years of the 1970s. These figures suggest that while alcohol may be involved in patterns of depression and suicide, the involvement does not have very much independent causal force.

Alcohol Use and Consequences Physical Environment 215 Because intoxication's most reliable correlate in behavior is a certain clumsiness in handling things and in moving about, accidental displace- ment of mass and energy is among the most serious aspects of drun- kenness. Correlation of accident involvement with intoxication depth and, to some degree, patterns of intoxication, is best established. Studies of accident rate linkage and total consumption have not? as a rule, yielded significant relations (but see Cook, in this volume). There are four principal types of accidents that concern us: motor vehicles, fires, falls, and drownings. The association between auto ve- hicle accidents and drinking is both the most notorious and largest but it is also subject to a lot of misconception. The most common observation is that "50 percent of all driver fatalities are drunk drivers." Driver fatalities are not the only the fatalities associated with motor vehicles; about half of these fatalities are pedestrians and passengers. Moreover, fatalities are not the only consequence of motoring accidents. There are roughly 45,000 deaths, but there are also 1-2 million injuries, in 15-30 million crashes. Not all the "drunk" drivers in any of the well-known statistics are legally drunk many were not perceptibly intoxicated ex- cept by sensitive measurement (BAC less than 0.05~. At any time, about 10-20 percent of all drivers on the road have measurable BAC levels, so one would expect this fraction of accidents to involve alcohol, even though no causal significance might be attached to the fact. Once all these factors are taken into account' if we ask how many bad effects of motor vehicle operations might theoretically be prevented if no one ever entered a driver's seat under any alcohol influence, we would estimate about 12,000 lives, 200,000 injuries, and about 1 million crashes respectively 24 percent, 12 percent, and 6 percent of each of these effects (Reed, in this volume; see also Ouellet et al. 1977, 1978~. Additional savings could be achieved if no pedestrian ever crossed a street while intoxicated but this is a different matter from drunk driving and has more in common with the other types of fatalities. Deaths in fires, falls, and drownings constitute a somewhat different type of problem. Accident deaths of these sorts approximately equal fatal motor crashes in number. In comparing changes in these across recent years, it is clear that the motor vehicle death rates have changed much more dramatically than other accident rates (most of which are for fires, falls, and drownings)' particularly in the 15-44 age band. While there is evidence of alcohol involvement for each of these accident categories, centering in the 30- to 40-percent range for fatalities in the most careful studies, it is again true that a relatively smaller proportion

216 GERSTEIN can be attributed to alcohol, since measurable BAC is quite prevalent in the situations in which these accidents occur. The attributable frac- tions are probably below the range of those for auto crash effects (Aarens et al. 1977, Ouellet et al. 1977~. It is difficult to say how the risk of alcohol-caused accidents is spread through the population. In the case of accidents induced by drunk driv- ing, there is a considerable mismatch between the older character of clinical alcoholic populations and the young male emphasis in the death statistics. In the other accident cases, there is significant difference in the distribution of rates across ages; the cirrhosis death rate climbs rapidly after 25, peaks in the 45-54 age band, and then declines, whereas other accidents occur at a steady rate between lS and 44 and then rise progressively with each older age. The clinical alcoholic populations display higher accident mortality and morbidity, but are clearly not responsible for the bulk of alcohol-caused accidents. Interpersonal Effects The effects of alcohol on one's private relations with others, especially in the family, comprise a most important part of the effects of alcohol in society. We know from clinical histories the ways in which alcohol use can seriously aggravate problems that disturb families and mar work relations and career opportunities. But the very complexity of these long-term bonds makes it exceedingly difficult to know how and whether alcohol acts as an autonomous causal agent in such troubles. At the same time, we know that alcoholic beverages are an integral part of special family occasions ranging from shared evening cocktails to the wedding toast. How do we quantify the effects of alcohol as parts of such occasions? On the basis of current data, we simply cannot do so. This does not make them less real. The interpersonal effects of alcohol that have drawn the most attention and provide the best opportunities for study are its putative links to belligerence and impoverishment. These, after all, are dramatic events and conditions; they are more likely to come to light beyond the family circle than the milder, but perhaps ultimately as tragic, breakdowns in trust, cooperation, and morale to which chronic alcohol dependence may contribute. Belligerent behavior in the family has become a prom- inent topic in the 1970s (Yahraes 1979) on which there are limited data available, and they are mainly on injurious assaultive behavior. At the current time, the most common view of researchers is that when alcohol is involved in familial assault, its role is to provide a rationale for jus- tifying or excusing assaultive behavior (Straus et al. 1977~. In studies

Alcohol Use and Consequences of marital disputes, it appears that a past episode of drinking is as often a subject in a dispute as a current drinking episode is a precipitant (Epstein et al. 1977~. In disputes serious enough to lead to calling of the police, drinking has been found to be about half as prevalent in cases of actual assault as in cases of no assault (Bard and Zacker 1974~. This does not suggest that drinkers do not engage in belligerent family behavior, but it does argue that drinking may defuse as well as precipitate assaults. Data on causes of child abuse are sparse, but those available do not indicate elevated rates of "problem drinking" among families of physically abused children (Scientific Analysis Corporation 1976~. 217 In none of these areas are longitudinal records yet available. It is doubtful that total consumption of alcohol, with which such records might be compared, would be of great significance in this connection. We know, for example, that the overall homicide rate, which largely reflects intimate violence, increased 94 percent, *om 4.7 to 9.1 per 100,000 between 1961 and 1971, while total alcohol consumption increased 26 percent. Both rates have remained approximately level through 1980. But among black men between 15 and 54, whose total consumption of alcohol is less than that of white men, the homicide rate is 10 times as high, accounting for nearly half of all homicide victims. This suggests the need for great caution in ascribing a significant causal role to alcohol consumption in this connection. Expenditure on alcoholic beverages has been a theme of long standing in the literature on temperance. Family complaints about money spent on alcohol do show up in surveys of drinking problems. It is nonetheless unlikely that the cost of alcohol as such can be as broad an issue as the possible effects of drinking on employability. The mean proportion of U.S. personal income spent on alcoholic beverages has declined steadily during the past 25 years, despite stable or increasing per-capita con- sumption, and now is lower than in any country in the industrial world. The relations between drinking and occupational careers are doubtless complex. On one hand, consumption of alcohol is positively correlated to income; on the other hand, the heaviest drinking patterns are in households whose income distribution lies below the national average. There are occupations in which drinking is forbidden for long periods and others in which a pattern of frequent intoxication is virtually an occupational hazard (Trice and Roman 19794. At the aggregate level, the period of increasing total consumption, 1961 to 1970, corresponds to the largest sustained boost in per-capita income in U.S. history. We do not know whether serious shifts in drink- ing patterns occurred during this expansion, and we do not know to what degree the economic gains were differentiated by drinking patterns.

218 GERSTEIN In summary, while we have a long history of imagery that pits drinking against the family (Levine 1978), suggesting that it leads to abuse, ne- glect, and poverty, there is little evidence from the recent past of the United States to support this conception. Drinking may indeed be an important screen on which the inner drama and tension of family re- lations or career difficulties can be projected, but when we look beyond the clinical data there is little evidence to indict it for anything further. Institutional Effects In looking at the institutional effects of alcohol use, three distinct types of effects have attracted the greatest interest: public safety, health care delivery, and the economy. Each involves a formidable coalition of interests affected by alcohol around which a history of policy measures has risen. The main concern in public safety has been public intoxication, most particularly intoxication of sufficient depth to create serious incapacity for walking or driving safely. The extent of the driving problem was discussed above; here we focus on the ambulatory problem. Public in- toxication as an institutional issue has two components: one is the public nuisance aspect, that many citizens find the sight and sound of public drunkenness to be obnoxious; in the second place, drunks in public are vulnerable to crime and exposure. For both of these reasons, public drunkenness becomes a matter of public interest, and an institutional response is called for, mainly police and judicial involvement. It has been noted across different countries that arrest rates for public drunkenness vary slightly inversely with total consumption of alcohol (NIAAA 1978~. The "wetter" the country, the less concerned its citizens are to see their drunken fellows whisked into police vans (Makela 1978; Room 19784. Since 1970 the trend in U.S. jurisdictions has been to decriminalize public intoxication, i.e.' to delete criminal statutes gov- erning inebriation and instead provide protective custody for drunks (Giffen and Lambert 19784. The net result has been to steadily decrease police contact with drunks and to shift responsibility for securing their safety from the jails and courts to special alcohol detoxification units. (It is still largely police who convey drunks to these units.) Regarding the effect of alcohol use on health care delivery it has been reported that, special treatment programs aside, patients in hospitals tend either to be alcoholics or report alcohol-related problems more frequently than one would expect from prevalence in the population. Estimates of the prevalence of problem drinkers in general hospital populations run to 30 percent or more; however' it is difficult to attach

Alcohol Use and Consequences 219 credence to these estimates since the inclusion criteria are ill defined. As we have seen, sufficiently lax definitions of "problem drinking symp- toms" can qualify 35 percent of drinkers (25 percent of adults) in "prob- lem" categories. The types of specific problems that might lead heavier drinkers to excessive hospitalization include liver ailments, traumatic injuries, depression, and heart problems. But there are no studies that document excesses of heavy drinkers in any of these areas in hospital populations (Berry and Boland 1977~. In general, trends of hospitalization in recent years have been steadily downward. Rates of admission and average length of stay declined dur- ing the 1970s across virtually all categories of diagnosis. The impressive inflation of daily hospital costs has been used largely to capitalize high- technology medical equipment and to maintain overhead in the face of declining bed counts. There is little ground for thinking that any of these factors are especially influenced by alcohol use. The final area of institutional effects is the economy. There are two respects in which drinking has economic impact. First, there is economic activity in the alcoholic beverage industry itself: manufacturing, distri- bution, and retail sales. Second, there is the leisure and recreational complex in which drinking has come to play a strong supportive role. The alcoholic beverage industry is substantial and includes three tiers: distillers, brewers, and vintners; importation and distribution compa- nies; and bars, taverns, liquor stores, groceries, restaurants, and other licensees selling drinks and packaged beverages directly to the public. Sales of alcoholic beverages at final retail outlets now amount to roughly $35 billion annually in retail trade. About one-third of this income is retained as government revenue. Beyond direct sales, alcoholic bever- ages have become an integral part of several institutions that serve U.S. consumers. Drink sales are a profit leader that provides important mar- gins for an indeterminate number of general goods stores, groceries, and restaurants. Spectator and participation sports have become closely allied, via advertising and concession sales, to alcoholic beverages. Over the past decades, drinking has largely shifted from public places to private homes, and drinking of wine and white spirits (vodka, gin, etc.) has become much more prominent (Gavin-Jobsen Associates 1978~. While per-capita alcohol consumption has remained stable, sta- tionary excise taxes on alcohol have retarded price growth' and therefore alcohol has become less expensive relative to other commodities (Cook, in this volume). The shrinkage in overall revenue share has not signif- icantly affected the industry, since it has largely accrued as tax reduction' and government revenues have been compensated by income tax bracket inflation. Changes in the composition of demand for types of beverages

220 GERSTEIN have been accompanied by horizontal monopolization and acquisition among large manufacturing firms. In summary, while the industry today does not by any means have the degree of economic importance that the vertical beer monopolies of the late 1800s had, its contribution to economic activity is considerable. CONCLUSION Scientific knowledge about alcohol use and its consequences, like our knowledge about nearly all human activity, has been strongly molded by our collective needs. Of course, this molding is only a first step in the process, for practical questions can only shape not supply their own answers. We have fair-to-good information about alcohol in its social context in relation to those effects about which modern societies have chosen to be intensely concerned. Where that concern is very recent, where it has simply not arisen, or where strong, high-quality research traditions that could be adapted for use have not beer right at hand, our knowledge is poor or virtually nil. Historically, interest in alcohol in the United States after repeal moved away from the terrain of family structures, market forces, and non- pathological personality, and instead came to focus on internal medicine, on abnormal psychology, and later on automobile casualties. The state of the art reflects this. The reemergence since 1960 of an increasingly sophisticated public health and social science research community com- mitted to the study of alcohol problems should, by the end of the century, have brought things back into balance. REFERENCES Aarens, M., Cameron, T., Roizen' J., Roizen, R., Room, R., Schneberk, I)., and Win- gard, D. (1977) Alcohol, Casualties, and Crime. Final Report of Alcohol, Casualties, and Crime Project, NIAAA Contract No. ADM-281-76-0027 (reprinted August 1978~. Berkeley, Calif.: Social Research Group. Aarens, M., and Roizen, R. (1977) Alcohol and suicide. Pp. 466-524 in Alcohol, Cas- ualties, and Crime. Final Report of Alcohol, Casualties, and Crime Project, NIAAA Contract No. ADM-281-76-0027 (reprinted August 1978~. Berkeley, Calif.: Social Re- search Group. Bales, R. F. (1944) The 'Fixation Factor' in Alcohol Addiction: An Hypothesis Derived from a Comparative Study of Irish and Jewish Social Norms. Unpublished Ph.D. dis- sertation, Harvard University. Bales, R. F. (1946) Cultural differences in rates of alcoholism. Quarterly Journal of Studies on Alcohol 6:480-499. Bard, M., and Zacker, J. (1974) Assaultiveness and alcohol use in family disputes: Police perceptions. Criminology 12~3~:281-292.

Alcohol Use and Consequences Berry, R. E. Jr., Boland, J. P., Smart, S. and Kanak, J. (1977) The Economic Costs of Alcohol Abuse and Alcoholism 1975. Unpublished report prepared for National In- stitute on Alcohol Abuse and Alcoholism under Contract No. ADM-281-76-0016. Berry, R. E. Jr., and Boland, J. P. (1977) The Economic Cost of Alcohol Abuse. New York: The Free Press. Bruun, K., Edwards, G., Lumio, M., Makela, K., Pan, L., Popham, R. E., Room, R., Schmidt, W., Skog, O.-J., Sulkunen, P., and Osterberg, E. (1975) Alcohol Control Policies in Public Health Perspective. New Brunswick, N.J.: Rutgers Center of Alcohol Studies. Bureau of the Census (1975) Historical Statistics of the United States. Colonial Times to 1970. Bicentennial Edition. Part 1. Washington, D.C.: U.S. Department of Commerce. Cahalan, D., Cisin, I. H., and Crossley, H. M. (1969) American Drinking Practices. New Haven, Conn.: College and University Press. Cahalan, D., and Room, R. (1974) Problem Drinking AmongAmerican Men. New Bruns- wick, N.J.: Rutgers Center of Alcohol Studies. Cannon, W. B. (1932) The Wisdom of the Body. New York: Norton. Day, N. (1977) Alcoholand Mortality. Paper prepared for NationalInstituteon Alcohol Abuse and Alcoholism under Contract No. NIA-76-10(P). Berkeley, Calif.: Social Research Group. deLint, J., and Schmidt, W. (1968) The distribution of alcohol consumption in Ontario. Quarterly Journal of Alcohol Studies 29:968-973. DSM III; Diagnostic and Statistical Manual of Mental Disorders, 3rd Ed. (1980) Wash- ington, D.C.: American Psychiatric Association. Epstein, T., Cameron, T., and Room, R. (1977) Alcohol and family abuse. Pp. 526-573 in M. Aarens et al., Alcohol, Casualties, and Crime. Final Report of Alcohol, Casualties, and Crime Project, NIAAA Contract No. ADM-281-76-0027 (reprinted August 1978~. Berkeley, Calif.: Social Research Group. French, S. W. (1971) Acute and chronic toxicology of alcohol. Pp. 437-511 in B. Kissin and H. Begleiter, eds., The Biology of Alcoholism, Volume 1: Biochemistry. New York: Plenum Press. Gavin-Jobsen Associates (1978) The Liquor Handbook. New York: Gavin-Jobsen As- sociates. Gerstel, E. K., Harford, T. C., and Pautler, C. (1975) Final Report: A Pilot Study of the Social Contexts of Drinking. RTI Project No. 234-892, for Contract No. HSM-42-73- 110 (NIA). Research Triangle Park, N.C.: Research Triangle Institute. Giffen, P. J., and Lambert, S. (1978) Decriminalization of public drunkenness. Pp. 395- 440 in Y. Israel, F. B. Glaser, H. Kalant, R. Popham, W. Schmidt, and R. G. Smart, eds., Research Advances in Alcohol and Drug Problems, Vol. 4. New York: Plenum Press. Guttorp, P., and Song, H. H. (1977) A note on the distribution of alcohol consumption. Drinking and Drug Practices Surveyor 13:7-8. Guttorp, P., and Song, H. H. (1979) A rejoinder to Skog. Drinking and Drug Practices Surveyor 14~6~:29-30. Haberman, P. W., and Baden, M. M. (1978) Alcohol, Other Drugs and Violent Death. New York: Oxford University Press. Harford, T. C. (1979) Ecological factors in drinking. Pp. 147-182 in H. T. Blane and M. E. Chafetz, eds., Youth, Alcohol, and Social Policy. New York: Plenum Press. Hennekens, C., Rosner, B., and Cole, D. S. (1978) Daily alcohol consumption and fatal coronary heart disease. American Journal of Epidemiology 107~3~:196-200. Hetzel, B. S. (1978) The implications of increasing alcohol consumption in Australia A new definition of the alcohol problem. Community Health Studies 2(2~:81-87. 221

222 GERSTEIN Houthakker, H. S., and Taylor, L. D. (1970) Consumer Demand in the United States: Analyses and Projections. Cambridge, Mass.: Harvard University Press. Hyman, M. H., Zimmerman. M. A., Gurioli, C., and Helrich, A. (1980) Drinkers, Drinking, and Alcohol-Related Mortality and Hospitalizations: A Statistical Compen- dium. New Brunswick, N.J.: Center on Alcohol Studies, Rutgers University. IMS America (1976) Project DAWN III: Drug Abuse Warning Network, Phase III Report. Ambler, Pa.: IMS America, Ltd. Jellinek, E. M. (1947-1948) Recent trends in alcoholism and alcohol consumption. Quart- erly Journal of Studies on Alcohol 8:1-42. Jellinek, E. M. (1960) The Disease Concept of Alcoholism. New Haven, Conn.: College and University Press. Johnson, P., Armor, D. J., Polich, J. M., and Stambul, H. (1977) U.S. Adult Drinking Practices: Time Trends, Social Correlates and Sex Roles. A working note prepared for the NIAAA under Contract No. ADM-281-76-0020. Santa Monica, Calif.: The Rand Corporation. Keller, M., and Gurioli, C. (1976) Statistics on Consumption of Alcohol and on Alcoholism. New Brunswick, N.J.: Journal of Studies on Alcohol, Inc. Klatsky, A. J., Friedman, G. D., and Siegelaub, A. B. (1978) Alcohol use, myocardial infarction, sudden cardiac death, and hypertension. Alcoholism: Clinical and Experi- mental Research 3~1~:33-39. Knupfer, G. (1966) Some methodological problems in the epidemiology of alcoholic beverage usage: Definition of amount of intake. American Journal of Physical Health 56~2~:237-242. Ledermann, S. (1956) Alcool—Alcoolisme—Alcoolisation. Donnees scientifiques de car- actre physiologique, economique et social, Institut National d'Etudes Oemographiques, Travaux et Documents, Cahier No 29. Paris: Presses Universitaires de Prance. Levine, H. G. (1978) The discovery of addiction: Changing conceptions of habitual drun- kenness in America. Journal of Studies on Alcohol 39(1~:143-177. Lieber, C. S., Rubin, E., and DeCarli, L. M. (1971) Effects of ethanol on lipid, uric acid, intermediary, and drug metabolism, including the pathogenesis of the alcoholic fatty liver. Pp. 275-305 in B. Kissin and H. Begleiter, eds., The Biology of Alcoholism, Volume 1: Biochemistry. New York: Plenum Press. Makela, K. (1971) Measuring the Consumption of Alcohol in the 1968-1969 Alcohol Con- sumption Study. Helsinki, Finland: Social Research Institute on Alcohol Studies. Makela, K. (1978) Level of consumption and social consequences of drinking. Pp. 303- 348 in Y. Israel. F. B. Glaser, H. Kalant, R. E. Popham, W. Schmidt, and R. G. Smart, eds., Research Advances in Alcohol and Drug Problems, Vol. 4. New York: Plenum Press. .. Makela, K., and Osterberg. E. (1979) Notes on analyzing economic costs of alcohol use. The Drinking and Drug Practices Surveyor 15:7-10. Mosher, J. (1979) Dram shop liability and the prevention of alcohol-related problems. Journal of Studies on Alcohol 40~9~:773-798. Mulford, H. A. (1964) Drinking and deviant drinking, U.S.A., 1963. Quarterly Journal of Alcohol Studies 25 :634-650. National Center for Health Statistics (1963) Vital Statistics of the United States, 1961. Washington, D.C.: U.S. Government Printing Office. National Center for Health Statistics (1975a) Vital Statistics of the United States, 1971. Washington, D.C.: U. S. Government Printing Office. National Center for Health Statistics (1975b) Vital Statistics of the United States, 1972, Vol. II. Washington, D.C.: U.S. Government Printing Office.

Alcohol Use and Consequences 223 National Center for Health Statistics (1978) Vital Statistics of the United States, 1975. Washington, D.C.: U.S. Government Printing Office. National Center for Health Statistics (1980) Monthly Vital Statistics Report, Provisional Statistics, Annual Summary for the United States, 1979. Births, Deaths, Marriages, and Divorces. DHHS Publication No. (PHS) 81-1120, Vol. 28, No. 13. Hyattsville, Md.: National Center for Health Statistics. National Institute on Alcohol Abuse and Alcoholism (1978) Third Special Report to the U.S. Congress on Alcohol and Health (Technical Support Document). Washington, D.C: U.S. Department of Health, Education and Welfare. Ouellet, B. L., Romeder, J.-M., and Lance, J.-M. (1977) Premature Mortality Attributable to Smoking and Hazardous Drinking in Canada. Volume I: Summary. Ottawa, Canada: Long Range Health Planning Branch of the Department of National Health and Wel- fare. Ouellet, B. L., Romeder, J.-M., and Lance, J.-M. (1978) Premature Mortality Attributable to Smoking and Hazardous Drinking in Canada. Volume II: Detailed Calculations. Ottawa, Canada: Long Range Health Planning Branch of the Department of National Health and Welfare. Polich, J. M., Armor, D. J., and Braiker' H. B. (1980) The Course of Alcoholism: Four Years After Treatment. Santa Monica, Calif.: The Rand Corporation. Popham, R. E., and Schmidt, W. (1978) The biomedical definition of safe alcohol con- sumption: A crucial issue for the researcher and the drinker. British Journal of Add- ictions 73:233-235. Room, R. (1971) Survey vs. sales data for the U.S. Drinking and Drug Practices Surveyor 3: 15-16. Room, R. (1978) Evaluating the effect of drinking laws on drinking. Pp. 267-289 in J. A. Ewing and B. A. Rouse, eds., Drinking. Chicago: Nelson-Hall. Rooney, J. F., Jr., and Butt, P. L. (1978) Beer, bourbon and Boone's Farm: A geo- graphical examination of alcohol drink in the United States. Journal of Popular Culture 11(4):832-856. Schmidt, W. (1976) Effects of Alcohol Consumption on Health. Toronto, Canada: Add- iction Research Foundation. Schmidt, W. (1977) The epidemiology of cirrhosis of the liver: A statistical analysis of mortality data with special reference to Canada. In M. M. Fisher and J. G. Rankin, eds., Alcohol and the Liver. New York: Plenum Press. Schmidt, W., and Popham, R. E. (1975-1976) Heavy alcohol consumption and physical health problems: A review of the epidemiological evidence. Drug and Alcohol De- pendence 1:27-50. Schmidt, W., and Popham, R. E. (1980) Sex differences in mortality: A comparison of male and female alcoholics. Pp. 365-384 in O. J. Kalant. ea., Research Advances in Alcohol and Drug Problems. Vol. 5. New York: Plenum Press. Schuckit. M. A. (1978) The identification and management of alcoholic and depressive problems. Drug Abuse and Alcoholism Review 1~4~: 1-8. Scientific Analysis Corporation (1976) Family Problems, Social Adaptation, and Sources of Help for Children of Alcoholic and Non-Alcoholic Parents. San Francisco Calif.: Scientific Analysis Corporation. Skog, O.-J. (1971) Alkoholkonsumetsfordeling i befolkningen (The Distribution of Al- cohol Consumption in the Population). Oslo, Norway: National Institute for Alcohol Research. Skog, O.-J. (1979) Is Alcohol Consumption Lognormally Distributed? SIFA Mimeograph No. 21. Oslo, Norway: National Institute for Alcohol Research.

224 GERSTEIN Skog, O.-J. (1980) Social interaction and the Distribution of Alcohol Consumption. SIFA Mimeograph No. 30. Oslo, Norway: National Institute for Alcohol Research. Straus, M. A., Gelles, R. J., and Steinmetz, S. K. (1977) Violence in the family: An assessment of knowledge and research needs. In M. Van Stolk, ea., Child Abuse, Its Treatment and Prevention: interdisciplinary Approach. Toronto: McClelland and Stew- art. Sulkunen, P. (1976) Drinking patterns and the level of alcohol consumption: An inter- national overview. Pp. 223-281 in R. J. Gibbins et al., eds., Research Advances in Alcohol and Drug Problems' Vol. 3. New York: John Wiley. Trice, H. M., and Roman, P. M. (1979) Spirits and Demons at Work: Alcohol and Other Drugs on the Job, 2nd ed. Ithaca, N.Y.: Cornell University. Walsh, B. M. (1979) The economic cost of alcohol abuse in Ireland: Approaches and problems. The Drinking and Drug Practices Surveyor 15:3-6, S7-59. Warburton, C. (1932) The Economic Results of Prohibition. New York: Columbia Uni- versity Press. Warner, K. E. (1978) Possible increases in the underreporting of cigarette consumption. Journal of American Statistical Association 73~362~:314-318. Wilkinson, R. (1970) The Prevention of Drinking Problems: Alcohol Control & Cultural Influences. New York: Oxford University Press. Yahraes, H. (1979) Physical violence in families. Pp. 553-576 in Families Today, A Re- search Sampler on Families and Children, Vol. II. Rockville. Md.: National Institute of Mental Health.

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