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Summary Alcohol problems have been a part of this society since colonial times, and they have left profound marks in the nation's consciousness, in- cluding two amendments to the Constitution. There is every reason to think that drinking and its effects for good and ill are here to stay for the foreseeable future. The permanence of drinking and its effects as a feature of society is a necessary premise for any realistic analysis but permanence does not necessarily mean unresponsiveness. Problems may always remain, yet they may grow larger or smaller, change shape or focus, depending on the measures taken or not taken to affect them. These measures, in turn, reflect values that people place on alcohol use, values that are diverse and, at various points, conflicting. Public efforts to control the making, selling, use, and effects of bev- erage alcohol have waxed and waned over the 200 years of U.S. history. On balance, it is clear that a laissez faire approach has not prevailed, and there are sound reasons why it has not. The Prohibition era, how- ever, left a sour taste on the national palate, inducing not only a decisive rejection of radical measures of control, but also inclining people toward the belief that no measure of prevention can have a beneficial result. That belief is not sustained by the evidence. In the first part of this report, we provide a picture of alcohol use and its effects drawn in a broad perspective, with dimensions extending historically, conceptually, and demographically. The historical review points out how a few simple governing ideas have dominated and defined 112

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Summary 113 the problem: the idea of normal drinking customs, of alcohol as an addicting poison, and of alcoholism as a disease. The hoary parable of the elephant and the blind men seems to apply, except that in this case the men are not simply groping for descriptions, they are outfitting the beast. The conceptual model of alcohol problems provided in chapter 2 is meant to escape this tendency of each model to provide too few moving parts, to simplify too greatly. The basic concepts ought to have enough degrees of freedom to see why and where any single plan might go awry and to permit one to consider the use of a number of different levers. In defining alcohol problems, we began with the set of effects that assume social significance. These include health, economic and social effects. These effects are differentiated among drinkers, their intimates, and others in society. Moreover, in looking at how these effects emerge from drinking practices, we found it useful to distinguish among degrees of intoxication (how drunk), frequency of intoxication (how often), and cumulative consumption (how much altogether); the contexts and ac- tivities that were commonly paired with intoxication (where, when, while doing what); and the general level of risks built into the existing social and physical environment of drinkers. These distinctions are important partly because they contribute differentially to the significant social ef- fects, but even more importantly because each of these features could become a separate avenue for seeking to alter the size and shape of alcohol problems. When the magnitude and distribution of this complex of effects are examined in the light of our understanding of how they are produced, we discover something unexpected about the location of alcohol prob- lems in the drinking population. As one might expect, a small fraction of drinkers the heaviest onescarry a disproportionate amount of the consequences of drinking. But this proportion does not actually account for most of the problems. Even though the rate of drinking problems per person among non-heavy drinkers may be much lower than for heavy drinkers, the sheer number of such people is very large. There- fore, substantial fractions of alcohol problems the major parts of many particulars are not isolated in a small fraction of the population. These problems are broadly based and cannot be effectively approached except through broad, general measures of the sort that we have called pre- vention policies. If these measures are to be general, they must of ne- cessity be relatively nonpersonal, because of the enormous costs eco- nomic and political that would arise from trying to tailor such a mass activity to the variable personal characteristics of tens of millions of

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4 REPORT OF THE PANEL people. Wide individual variation is a bedrock reality of drinking be- havior, but public prevention policies based on individual-attention are well beyond the practical limits of current resources. Beyond the characteristics of being general and nonpersonal, pre- vention policies do not conform to a single model. For our purposes, we divided prevention policies into three broad classes according to their proximate targets: first, those instruments directed at the supply of alcohol and places to drink it; second, those aimed at the drinking practices of consumers once they have alcohol; and finally those that seek to alter characteristics of the social and physical environment in- volved in producing certain consequences of drinking (e.g., automobiles in drunken driving, employers' attitudes toward recovered alcoholics). In the second part of this report we reviewed the evidence regarding these instruments and came to the following conclusions: 1. Regulating the supply of alcohol, through such mechanisms as licensing, limited prohibitions (age, location), and relatively high tax- ation have a long history in the United States and elsewhere. The ma- chinery of implementation for these measures is available in local; state, and federal Alcoholic Beverage Control (ABC) authorities. The trend in the last 25 years has been a general relaxation of restrictions on the alcohol market, including lower legal purchasing age-minima; gradual expansion of outlet numbers, types, and hours; and substantial reduc- tions in real tax rates. This trend has been commensurate with increases in alcohol consumption. The evidence about regulation of supply induces caution in regard to continued relaxation of controls. Most studies have been of single ef- fects, and it is probable that these effects are cumulative. The evidence is most extensive and uniform in regard to the effects of taxation. It shows that taxes affect prices, prices affect the quantity of consumption, and the quantity of consumption affects the health and safety of drinkers. An increased tax on alcoholic beverages has the particular effect of improving the chronic health picture (as indexed by liver failure) of the heavier drinkerswho are, it can be added, paying most of the tax increase. Therefore we see good grounds for incorporating an interest in the prevention of alcohol problems into the setting of tax rates on alcohol. 2. Drinking practices can be affected principally by law and by ed- ucation. The use of law to reduce drunken driving has received the most careful study. But legal action does not just mean passing stiffer pen- alties. The crucial elements appear to be letting the public know police are bent on enforcing the law and increasing police surveillance of night-

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Summary 115 time traffic patterns, in which most alcohol-induced highway deaths occur. Such programs appear to have had measurable short-run effects in reducing the number of fatal alcohol-related crashes. Paying for levels of enforcement sufficient to sustain these effects, including the effort to keep these programs salient in the public eye. is apt to be costly. Education, information, and training to reduce alcohol problems have had a checkered history. In recent years, curricular materials about alcohol use and consequences have improved considerably in their bal- ance and accuracy. But good tools alone do not build bridges skilled labor and clear plans are necessary as well. As yet, alcohol education has been short on both, and there is little encouragement to be gotten from previous efforts. Nevertheless, a series of new developments in the field of health education combine mass communication principles to increase the salience of a given issue with relatively nonpersonal training techniques designed to help people change their behavior in ways they think are desirable. There is sufficient promise in these new efforts to warrant investment in experimental alcohol training on this model, understanding that, at this stage, collection of knowledge is the primary goal to be sought in such efforts. The feasibility and costs of managing these programs on a large scale remain uncertain. 3. The strategy of environmental intervention in the consequences of drinking follows from the observation that certain ill effects of drink- ing occur only when particular physical or sociocultural contexts are combined with drunkenness. In many of these cases, altering certain features of the context will reduce the ill effect. This is so especially when drunkenness, like fatigue, reduces alertness in situations in which human factors engineering would help protect against human error. Automobiles are the best-studied example and passive restraint tech- nology the most promising innovation. But auto crashes cause less than half of the fatal accidental injuries sustained in the United States an- nually. The systematic extension of blood alcohol content testing to reporting systems in other areas of accident and safety research would help considerably in reducing the range of uncertainty about the size of alcohol problems in different areas and would permit concentration on preventive measures that are most likely to have significant effect. In developing and applying the prevention perspective, we have been struck by, and had to resist most forcibly, the tendency to think about policy in terms of opposed pairs: dry versus wet, prohibition versus unlimited access, treatment versus prevention, good drinking versus bad drinking. A clear-eyed examination of current policies shows them to be juxtapositions of different governing ideas. In such an architecture

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116 REPORT OF THE PANEL of compromise, it is often the case, as Mies van der Robe has said, that "God is in the details." We are convinced that the regulation of supply, legal and pedagogical approaches to drinking practices, and interven- tions in the environment mediating between drinking and certain of its consequences, represent valid approaches with promise for sustained improvement. Each detailed element will fail or succeed only as it is implemented properly and thoroughly; tactics that are undertaken as part of a broad and coordinated approach are more likely to be effective than ones undertaken in isolation. The building of effective policy thus needs a general vision as well as a fine hand. The vision that we propose is threefold: Alcohol problems are permanent, because drinking is an important and ineradicable part of this society and culture. Alcohol problems tend to be so broadly felt and distributed as to be a general social problem, even though they are excessively prevalent in a relatively small fraction of the population. The possibilities for reducing the problem by preventive measures are modest but real and should increase with experience; they should not be ignored because of ghosts from the past.