Alcohol and Public Policy Beyond the Shadow of Prohibition (1981) / Chapter Skim
Currently Skimming:
Alcohol Use and Consequences
Alcohol Use and Consequences
Pages 182-224
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From page 182... ...
Alcohol Use and Consequences DEAN R GERSTEIN INTRODUCTION In a perceptive and scholarly analysis, Harry G
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From page 183... ...
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.
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From page 184... ...
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.
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From page 185... ...
3. The last measure, total consumption' involves the accumulation ' BAC level (expressed as a decimal percentage of a gram per liter.
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From page 186... ...
. 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.
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From page 187... ...
The numerator is usually compiled from figures supplied by producers or wholesalers of alcoholic beverages; specifically, the "tax paid withdrawal" 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.
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From page 188... ...
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.
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From page 189... ...
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.
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From page 190... ...
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 alcoholism has a known likelihood: a "hazardous level of consumption" (Schmidt and Popham 1975-1976; Popham and Schmidt 1978~.
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From page 191... ...
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.
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From page 192... ...
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]
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From page 193... ...
This price-conscious high consumption base provides a foundation for economies of scale in manufacture, 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.
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First, the United States is unremarkable in its total consumption during this period relative to other similar national societies. It is neither especially dry nor especially wet.
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From page 195... ...
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)
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From page 196... ...
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 relaxation. These usages are only rough guides, of course, and are historically associated with particular ethnic-national practices.
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From page 197... ...
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*
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From page 198... ...
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 generalization, 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.
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From page 199... ...
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.
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From page 200... ...
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.
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From page 201... ...
Since large-scale survey research is basically a post-World War II phenomenon, detailed quantitative 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.
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It is important to note that even where drinking patterns for a population appear to be stable across a number of years, there is continual flux in the drinking patterns of many individuals within the population.
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From page 203... ...
The presence of specifiable other factors, some permanent but others subject to manipulation, 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.
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From page 204... ...
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.
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From page 205... ...
For 12,000 former alcoholism patients 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)
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(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.
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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
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"sometimes but not often" or "frequently") are indistinguishable from criteria for moderate drinking patterns.
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From page 209... ...
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.
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From page 210... ...
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 depending on whether the depth of intoxication, drinking patterns, or total consumption is considered.
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From page 211... ...
, 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.
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From page 212... ...
Studies in Ontario, Canada, 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.
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From page 213... ...
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.
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From page 214... ...
But if there are proportionately as many unhappy abstainers as unhappy drinkers, 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.
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From page 215... ...
Studies of accident rate linkage and total consumption have not? as a rule, yielded significant relations (but see Cook, in this volume)
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From page 216... ...
In the case of accidents induced by drunk driving, 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.
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From page 217... ...
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.
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From page 218... ...
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~.
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Beyond direct sales, alcoholic beverages have become an integral part of several institutions that serve U.S. consumers.
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Berkeley, Calif.: Social Research Group. Aarens, M., and Roizen, R
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(1977) The Economic Costs of Alcohol Abuse and Alcoholism 1975.
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From page 222... ...
Quarterly Journal of Alcohol Studies 25 :634-650. National Center for Health Statistics (1963)
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From page 223... ...
National Institute on Alcohol Abuse and Alcoholism (1978) Third Special Report to the U.S.
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From page 224... ...
(1976) Drinking patterns and the level of alcohol consumption: An international overview.
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