Alcohol and Public Policy Beyond the Shadow of Prohibition (1981) / Chapter Skim
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2. The Nature of Alcohol Problems
2. The Nature of Alcohol Problems
Pages 16-47
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From page 16... ...
Of course, these effects of alcohol intoxication are all matters of degree, and the degree depends on various factors. Among these, the amount of alcohol consumption itself can be very important.
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From page 17... ...
To create problems for drinkers and others, some special characteristics beyond drinking and drunkenness must come into play. The idea of an alcohol problem brings some paradigmatic situations to mind: the drunk driver who causes a serious accident by ignoring a road sign or losing control of the car; the domestic fight that, fueled by alcohol and the ready availability of a weapon, flares into a bloody assault; the previously responsible husband, father, and employee whose ability to meet the needs and expectations of his family and employer deteriorates as a result of increasingly frequent and ill-timed drunkenness and hangovers; the aging heavy drinker whose damaged liver becomes a chronic health problem and ultimately a cause of death; and perhaps even the rowdy teenagers or the skid row resident whose behavior offends others' sense of propriety and order.
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From page 19... ...
To be sure, one would expect heavy drinkers to cause and suffer many of the bad consequences of drinking. But moderate and light drinkers could also cause and suffer problems if they consumed their smaller quantities of alcohol in unusually dangerous patterns.
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From page 20... ...
We then analyze drinking practices: how much Americans drink; how drinking is distributed across the population; where current patterns stand in historical and cross-cultural perspective; and in what contexts drinking (and intoxication) typically occur.
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From page 21... ...
Thus, when we observe the effects of current alcohol consumption, we are inevitably looking simultaneously at the effects of drinking and of the policies and programs we maintain to shape drinking practices and to cope with whatever problems emerge. This first principle also requires us to recognize good effects of drinking as well as bad.
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From page 22... ...
22 in — ,_ — it, _ O .C ' ~ ~ ~ ~ ' ° ' ~ u, ~ O ~ ', " ~ ~ ° '' Z E Z = · 0 · ~ ~ ~ ' ~ , e ~ ~ E O C' ~ ~ O ~ c: ~ ~ m an A t11 uJ ~ O u.
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From page 23... ...
provides a stable Bayesian estimate of about 12,000 annual traffic fatalities causally attributable to (not just "associated with") drunken driving and
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From page 24... ...
UNDERLYING PATTERNS OF DRINKING PRACTICES Beneath the effects outlined in Figure 2 lie drinking practices. Drinking practices produce these effects, not necessarily directly, but probabilistically in combination with some important characteristics of the physical and social environments.
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From page 25... ...
What can be done is to outline the dimensions that are likely to be linked importantly to risks and benefits and report what is known about how the population is distributed across these dimensions. Drinking practices as we define them involve two distinct dimensions: one concerns the description of alcohol consumption and the other concerns settings and activities (contexts)
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From page 26... ...
A drinking practice refers to a characteristic clustering of drinking episodes. The distinction is important for the simple reason that many of the effects defined in Figure 2 depend on accumulated experience.
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From page 27... ...
In addition, the precision of the surveys depends fundamentally on how accurate respondents are about their drinking, how willing and able they are to report what they know about their own drinking to an interviewer, how skillfully the survey instrument is designed, and how adequately the sample represents all drinkers (see Midanik 1980~. Since drinking rates reported in such surveys do not account for all of the alcohol sold, it is likely that heavy drinkers are underrepresented and that some respondents tend to underestimate their consumption.
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From page 28... ...
. of the average daily consumption of pure alcohol.
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From page 29... ...
The heaviest-drinking 5 percent of the population accounts for roughly 50 percent of total consumption, and the heaviest third accounts for over 95 percent of the total alcohol consumed. It is worth noting that among clinical alcoholic populations, daily consumption of 5 ounces or more is reported by virtually all patients (Schmidt and Popham 1975~.
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From page 30... ...
light, moderate, and heavy drinkers distribute their consumption over time. Since many important consequences of drinking are related to frequency of drunkenness rather than cumulative quantity consumed, it is useful to know how the population is distributed with respect to drunkenness as well as total consumption.
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From page 31... ...
It appears that those who drink an average of 1.0-3.0 ounces per day have proportionately more "drunk days" than do very light drinkers or very heavy drinkers. Figure 3 illustrates this phenomenon by plotting the average number of drunk days per year against average daily consumption.
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From page 32... ...
Second, as we discussed above, the moderate to heavy drinkers are more "efficient" producers of drunk days than the very heavy drinkers. Both the number of these drinkers and their relative tendency to binge result in their contributing an unexpectedly large share of the total drunkenness experienced by this population.
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From page 33... ...
If the bad consequences of alcohol consumption began when one reached a yearly average of more than 8 drinks per day, we could calculate that virtually all of these bad effects would be concentrated in the worst 5 percent (or less) of the drinkers.
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From page 34... ...
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. Aggregate Patterns of Drinking Contexts In addition to facts about quantities and rates of alcohol consumption, we would like to know something about the contexts in which Americans
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From page 35... ...
consumption of absolute alcohol, cirrhosis death rate, and alcoholism death rate in the drinking age population, 1830-1977. Note: Data points are less dense and less reliable prior to 1900.
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From page 36... ...
Substantial empirical evidence exists showing that the context exerts a separate, independent effect on the quantity and rate of alcohol consumption. Drinkers take cues from the people around them about how much and how fast they should drink.
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From page 37... ...
All we have is a tantalizing suggestion that the context seems to shape alcohol consumption and that heavy drinkers seem to frequent on-premise establishments. From our perspective, two important facts about drinking contexts are now available.
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From page 38... ...
The second fact is that preferred drinking contexts change dramatically with age (Table 5~. Drinking for all ages is heavily concentrated on weekends~about half of all drinking episodes are crammed into the relatively short weekend period—but this concentration tends to diminish with age.
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From page 39... ...
(1977~. STABILITY OF INDIVIDUAL DRINKING PRACTICES A crucial question affecting the feasibility of controlling the alcohol problem by shaping drinking practices is simply how stable these practices are.
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From page 40... ...
They are neither permanent features of individual character nor monopolized by government agencies. CAUSES OF DRINKING PRACTICES To this point we have treated drinking practices descriptively, asking what they are rather than posing the issue in explanatory terms: i.e., why do people drink and why do they drink in these ways?
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From page 41... ...
Unfortunately, little is known about the relative power of the different kinds of factors shaping drinking practices, and discussion of such factors draws heavily on speculative assumptions (Institute of Medicine 1980~. Moreover, expert views on the most important factors seem to depend more on disciplinary training than on persuasive facts currently in hand.
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From page 42... ...
For the purpose of informing policy judgments, the question of attribution seems fundamental: we need to know what interventions targeted at different aspects of drinking practices or different features of the physical and social environment can be expected to yield in terms of positive and negative effects. Unfortunately for this purpose, a main conclusion of this chapter is that a variety of factors shape the effects associated with drinking.
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From page 43... ...
The sheer complexity of this conception defeats any simple effort to attribute quantitative risks or benefits to specific factors. What our analysis suggests that is useful in guiding policy choices is a more general idea: namely, that various avenues for reducing the bad consequences of drinking exist, and that pursuit of each avenue results in slightly different gains (and losses)
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From page 44... ...
First, alcohol consumption itself is important as a sufficient cause for some effects. Other consequences of drinking can be attacked by reducing drunkenness, motivating people to change drinking contexts, or changing the external environment as well as by reducing cumulative individual consumption.
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From page 45... ...
(6) 1977 National Survey Light drinkers 13~o Ho 12~o 5~c 9% 0% Moderate drinkers 59 59 66 62 49 55 Heavy drinkers 28 37 22 33 43 45 Total percentage 100 100 100 lOO 101*
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From page 46... ...
46 ·~ =1 ~ o ol I ul cn ~ ~, E `,, ° w ~ ~ | ~__ ° ~o .
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From page 47... ...
The sheer complexity of this system argues for the existence of alternative routes for controlling the dimensions and shape of the alcohol problem, apart frown reducing total consumption. At a minimum, one can conceive of reducing consumption levels, shaping drinking practices, and changing features of the physical and social environment.
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