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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

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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 minorityfine 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.

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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.

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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).

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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

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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 Columbiaall 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

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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-

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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

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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) .

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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.

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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

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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.

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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

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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

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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.

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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

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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

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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.

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