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OCR for page 16
The Nature of
Alcohol Problems
For most people most of the time, even the immediate effects of drink-
ing, to say nothing of the long-term effects, are hardly noticeable. When
effects are noted, they vary across a broad range of kinds, degrees, and
levels of desirability. As the rich vocabulary of descriptive terms, some
of them centuries old, suggests, one can be mellow, tipsy, or pleasantly
plastered; stoned, skunked, or sloshed; or dead drunk, wrecked, or
under the table. Whatever the degree, however, intoxication alters the
mental, behavioral, and physiological capacities of drinkers. An intox-
icated person is generally less mentally alert in scanning the environment
for hazards, less reliable in interpreting what is observed, and inclined
to relax or forget about some things that might be the focus of intense
concern in a sober state (Cappell and Herman 1972~. On the behavioral
dimension, the drinker is likely to become distractible and clumsy.
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. Given
enough alcohol, one can reliably produce a stupor even death—no
matter what other factors are operating on the drinker (Poikolainen
1977~. In the more usual case, however, the effects depend on such
factors as the spacing of drinks, the drinker's size and weight, how
recently he or she has eaten, his or her own hopes and expectations
about the effects of drinking, and even the expectations and demands
of the people present in addition to the amount consumed. An excited,
skinny teenager anticipating a big night with pals can become quite
16
OCR for page 17
The Nature of Alcohol Problems
17
exhilaratingly "drunk" on a quantity of alcohol that would produce no
effect or perhaps a mild relaxation in a heavy, middle-aged man who
had just finished a large dinner and had no greater aspiration than to
pass the evening quietly.
Of course, some people regard even the most temporary departure
from sobriety as a significant moral and social problem a willful denial
of individual responsibility in a society that both values and depends
fundamentally on a sturdy, universal commitment to this standard. But
for most people, short-lived infrequent periods of intoxication, to say
nothing of drinking events that stop short of noticeable intoxication, do
not create or indicate substantial harms (Cahalan et al. 1969~. Many
people regard drinking and intoxication as beneficial a harmless, pleas-
ant indulgence when they feel beset or entitled or a way of turning an
ordinary event into a festive occasion. To create problems for drinkers
and others, some special characteristics beyond drinking and drunken-
ness 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 drunken-
ness and hangovers; the aging heavy drinker whose damaged liver be-
comes a chronic health problem and ultimately a cause of death; and
perhaps even the rowdy teenagers or the skid row resident whose be-
havior offends others' sense of propriety and order.
These paradigmatic situations may capture only a portion of an ac-
curate accounting of alcohol problems. But, if we can take these as
typical, we can make an important observation: few of the bad conse-
quences result from drinking only. Instead, they emerge from relatively
complex causal systems in which drinking is a major but only a single-
contributing factor. Some of the consequences depend on unfortunate
combinations of episodic drunkenness with dangerous or demanding
environments. Others depend on being drunk frequently enough in sit-
uations in which sobriety is expected and demanded that the drinker
comes to be regarded as irresponsible and unreliable. In many cases,
however, the environments in which the drinking is done as well as the
frequency and degree of intoxication play major roles in determining
whether bad effects occur. Figure 1 presents a schematic view of the
hypothesized relationships.
This observation should not be used to minimize the role that drinking
OCR for page 18
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OCR for page 19
The Nature of Alcohol Problems
19
itself can play in creating problems for drinkers and others. Sustained
frequent drinking can be directly responsible for some of the more
important physiological consequences of drinking (e.g., fatty liver, phys-
ical dependence) without regard to circumstance and even without no-
table drunkenness. Moreover, for many important consequences (such
as drunken driving and drunken falls), some contributing features of the
environment (nighttime roads, steep stairways) may be so common and
resistant to change that they might just as well be treated as inalterable
features of nature, with all the variation in accident experience attributed
to drinking.
What the observation does suggest is that a simple equivalence of
drinking with problems, and more drinking with more serious problems,
while often true, can be somewhat misleading. Much seems to depend
on how and where alcohol is absorbed in a drinker's life: how much
drunkenness is generated and how that drunkenness is fitted into more
or less demanding physical and social environments. To be sure, one
would expect heavy drinkers to cause and suffer many of the bad con-
sequences 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. Moreover, some kinds and degrees of
risk confronting drinkers of all kinds depend on certain characteristics
of the social and physical environment.
These considerations have two crucial implications for policy. One is
that alcohol problems may be distributed over a large segment of the
drinking population. They may not be only, or even mainly, problems
of alcoholics. To the extent that this is true, focusing exclusively or even
primarily on the treatment of alcoholics is not sufficient. A second
implication is that there may be other avenues open to controlling al-
cohol problems besides reducing alcohol consumption. For example,
one can think of influencing the drinking practices of individuals so that
a given quantity of alcohol could be distributed more safely and appro-
priately within a given individual's activities, or one can think of altering
the structural characteristics of the environment to make it safer for
drunken people.
We have now sketched the main outline of a complex conception of
alcohol problems. In this view alcohol produces a variety of significant
consequences some good and some bad. Moreover, the quantity of
alcohol consumed is not the only cause producing the bad consequences;
also significant are: (1) "drinking practices" that generate different de-
grees and frequencies of drunkenness from given quantities of alcohol
and place these episodes of drunkenness in different environments and
(2) characteristics of social and physical environments that can make
OCR for page 20
20
REPORT OF THE PANEL
drunkenness more or less risky. Since drunkenness, drinking practices,
and environments all play a role in creating and shaping alcohol prob-
lems, some of the problems may occur among drinkers who drink, not
heavily and continuously, but simply unwisely or unluckily.
The remainder of this chapter develops this conception with greater
rigor and more detail, then tests the conception against observed facts.
We first build an account of the important consequences commonly
associated with alcohol and present some information about their mag-
nitudes. 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. Finally, we analyze
the relationship between the observed effects and the underlying pattern
of drinking practices: specifically, the role that things other than alcohol
itself play in producing the varied effects and how alcohol problems are
distributed across the population of drinkers. We conclude with the
major policy implications of this conception.
EFFECTS OF ~ PINKING
A complete, evenhanded accounting of the important consequences of
current alcohol use is beyond current intellectual resources. We cannot
report the simple frequencies of all the important events and conditions
in which alcohol is implicated, to say nothing of gauging the infinitely
more subtle issue of how much alcohol alone contributes to the character
of the events and conditions we observe. But to facilitate the design of
an effective policy, it is important that we develop an accounting scheme
that strains to be comprehensive and orderly in arraying relevant effects,
even if we know at the outset that the data will be incomplete. In
particular, the scheme should be constructed in accordance with two
. .
prlnclp es.
The first principle is that in identifying relevant effects of drinking,
it is better to err on the side of inclusiveness rather than exclusiveness.
Otherwise the scheme loses its value as a device for alerting us to (po-
tentially) important aspects of the problem. The accounting scheme
should include social as well as economic effects, collective as well as
individual ones. It should include effects that are easily quantified as
well as those that are not. It should include effects that have already
been well measured, those that could in principle be studied but still
await careful investigation, and those that cannot in principle be pre-
cisely or reliably measured.
This principle suggests that we include not only the effects of drinking
in the accounting scheme, but also the effects created by the current
OCR for page 21
The Nature of Alcohol Problems
21
policies and programs designed to manage drinking. Drinking never
occurs in a vacuum; it occurs in a social setting in which it is influenced
by private attitudes and practices and by governmental policies and
programs. Thus, when we observe the effects of current alcohol con-
sumption, 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 drink-
ing as well as bad. That benefit results from drinking is usually conceded
even by those who are most appalled by the damages. Over $35 billion
was spent in 1980 on alcohol by people who could have chosen to spend
the money on better housing, new clothes, roast beef, or vacations. (For
that matter, they could have chosen to spend the money on cocaine,
marijuana, casino bets, or sexual services.) In describing the nature of
alcohol problems the beneficial effects usually get short shrift: analysts
are far more industrious in seeking out, enumerating, and marshalling
impressive statistical evidence revealing the damages (e.g., Berry and
Boland 1977; National Institute on Alcohol Abuse and Alcoholism 1978;
Institute of Medicine 1980~. We are not major exceptions to this rule,
first, because our concern is primarily with damage reduction and, sec-
ond, because our discussion of beneficial effects is constrained by the
dearth of available evidence. Still, we insist on the principle that pro-
tection of benefits must be weighed if we are to know whether a policy's
net effect is favorable (see Walsh and Walsh 1970, Makela and Osterberg
1979~.
The second principle is that the accounting scheme should keep track
of who is experiencing the varied effects as well as what the various
effects are. For our purposes, it is useful to distinguish among the effects
on (1) drinkers themselves, (2) people who are intimately connected to
(or dependent on) the drinker, and (3) people who are relatively remote
from the drinker (i.e., the general population). Such distinctions are
important because they provide clues about who might be interested in
controlling the drinking. For example, people who take losses from
drinking problems might well be motivated to help solve at least the
aspect of the problems that affects them.
The distinctions are also important, however, because this society
attaches different significance to effects that seem consciously chosen
by individuals and those that individuals receive involuntarily from
others. To be sure, the boundaries between state intervention and in-
dividual choices are far from clearly established, and we do not propose
to adjudicate them here. Our purpose is to array information so that
one can see how such concerns are reflected in alcohol problems.
Figure 2 presents the important effects of alcohol use and of relevant
OCR for page 22
22
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OCR for page 23
The Nature of Alcohol Problems
23
policies for dealing with drinking. In principle, one can track any sig-
nificant changes in the size and character of the alcohol problem by
measuring these effects over time. Thus, if drinkers started to do ap-
preciably less driving while drunk, one would see decreases in the num-
ber of fatalities, injuries and, economic losses associated with traffic
accidents: these categories (and possibly others) would all move in fa-
vorable directions. However, if this change in drivers' habits had resulted
from more aggressive enforcement of traffic laws and a major effort to
mobilize public opinion, increases in public spending and losses in the
social independence of certain drinkers would also be recorded. In prac-
tice, it is difficult to find or develop reliable empirical estimates of all
the phenomena of interest; the figure provides a basic orientation. (More
detailed discussion and review of many of these effects are included in
the paper by Gerstein in this volume.)
It is important to understand that the detailed entries in each of the
categories may respond negatively or positively—or both with respect
to drinking. For example, some evidence now suggests that low or mod-
erate levels of alcohol intake may be associated with reduced levels of
ischemic heart disease and fatal coronary events; other evidence suggests
that heavy drinking may be associated with elevated incidence of other
cardiovascular diseases such as cardiomyopathy and hypertension
(deLint and Schmidt 1976, Hennekins et al. 1978, Klatsky et al. 1978,
Regan and Ettinger 1979~. Similarly, the effects of drinking on the ability
to develop, sustain, and enjoy personal relationships include some pos-
itive contributions of drinking, even though for many people drinking
interferes with developing and enjoying relationships, inducing losses
in this category. The positive gains may be judged to be small or large
relative to the risks, yet the effects listed in Figure 2 do seem to include
beneficial effects as well as harms and costs associated with drinking.
Which effects of drinking should be the primary focus of our concern
is an important but ultimately ambiguous issue. To a degree, this judg-
ment can be usefully informed by empirical evidence on the frequencies
and magnitudes of the various effects (e.g., the number of people who
die of alcohol-induced cirrhosis, the frequency of alcohol-induced crim-
inal assaults among strangers in public locations, the number of people
who drink so much that their spouses seek divorces, etc.~. Ultimately,
however, reliable information of this sort exists for only a few of the
effects. In his paper in this volume, Gerstein finds a high degree of
confidence in a figure between 20,000 and 25,000 for annual deaths from
alcohol-induced cirrhosis of the liver. Reed (in this volume) provides
a stable Bayesian estimate of about 12,000 annual traffic fatalities
causally attributable to (not just "associated with") drunken driving and
OCR for page 24
24
REPORT OF THE PANEL
somewhat less than $.5 billion in property damage from the same cause.
Estimated medical expenditures for sequelae of alcohol abuse and al-
coholism have been consistently placed in the neighborhood of $10
billion annually (Berry and Boland 1977), a figure that very roughly
equals the annual receipts from state and federal excise taxes on alco-
holic beverages (Hymen et al. 1980~. For other categories, the intervals
of estimation are too open for numerical summary or do not now exist
as operationally defined concepts. Even if this kind of information were
available for all the effects of drinking, however, the question of which
effects are most important would remain ambiguous. The reason is
simply that "social importance" is ultimately a value question about
which reasonable people can disagree.
Thus, while Figure 2 does not pretend to give a precise, quantitative
account of alcohol problems, it prevents one from thinking too narrowly
about it. Drinking is not just a health problem or a social problem or
an economic problem; it is not even just a problem. Moreover, it involves
more than just drinkers and their intimates. Figure 2 alerts the reader
to the variety of effects of choosing or having a given policy toward
alcohol use.
UNDERLYING PATTERNS OF DRINKING PRACTICES
Beneath the effects outlined in Figure 2 lie drinking practices. Drinking
practices produce these effects, not necessarily directly, but probabil-
istically in combination with some important characteristics of the phys-
ical and social environments. In order to see how the effects of drinking
are associated with (or are the result of) drinking, one must begin with
the drinking practices of the general population. To the extent that we
expect to affect the current shape of the problem by altering drinking
practices, it is important to understand what aspects of drinking behavior
should be included in useful descriptions of drinking practices, what the
current practices are, and what kinds of factors seem to be shaping
them.
DEFINITION OF DRINKING PRACTICES
At the outset, it is important to be clear about what we mean by drinking
practices. This may appear to be largely a semantic issue, but the def-
inition is of crucial importance in structuring our conception of the
problem and how it might be controlled. Specifically, it emphasizes the
complexity of the link between the concepts of "drinking" and "alcohol
problems." Moreover, the problem is not simply that characteristics of
OCR for page 25
The Nature of Alcohol Problems
25
the physical and social environment must operate to shape and create
the consequences; choices about how much drinking is done, how much
intoxication is generated, and how the periods of intoxication are woven
into settings and activities that bring drinkers into contact with dangerous
parts of the environment seem to be at least as important in creating
risks for drinkers as the general level of hazards in their environment.
We include these additional aspects of drinking behavior in the idea of
drinking practices.
If one could describe how the effects in the various dimensions of
Figure 2 were linked to specific characteristics of drinking practices, our
ability to design effective alcohol prevention policies would be signifi-
cantly enhanced. For one thing, we would then be able to recommend
or prescribe certain drinking practices and discourage others. In addi-
tion, we would be able to see more precisely how risks and benefits of
drinking are distributed across the population of drinkers. Unfortu-
nately, at this stage the analytic or empirical work is still insufficient to
fully define drinking practices as we want to use the concept. What can
be done is to outline the dimensions that are likely to be linked impor-
tantly 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 con-
cerns settings and activities (contexts) commonly associated with drink-
ing. With respect to consumption, as we have said, it is useful to dis-
tinguish three characteristics. First, many effects depend on the degree
of intoxication. At very high levels of blood alcohol content (BAC:
above 0.30, absent any other drug effects), a drinker can die of acute
alcohol poisoning. At somewhat lower levels of BAC, in the 0.15 to
0.30 range, the drinker does not risk death by poisoning but is likely to
be so clumsy and inattentive that even benign physical environments
become hazardous. At even lower levels, the drinker may still be suf-
ficiently clumsy and inattentive to be unable to cope with moderately
taxing physical or social demands; these lower levels generally are those
at which psychological mood is most favorably affected (Mello 1972~.
Thus, other things being equal, the degree of intoxication itself will
probably increase the risks and decrease the benefits a drinker creates
for others and himself or herself, beyond the threshold at which effects
are noted.
Second, certain effects of drinking depend on how often one is drunk
(or how much time one spends above a given level of BAC). The chance
of being drunk at the wrong place at the wrong time increases as a
person is drunk more often. But it also seems plausible that some im-
OCR for page 26
26
REPORT OF THE PANEL
portent consequences of drinking (specifically, bad social consequences
in the areas defined in Figure 2) begin to occur only when a person is
drunk sufficiently often (or at sufficiently awkward moments) to become
"undependable." After all, in social terms, a person can be drunk in-
frequently (or even fairly frequently if drunkenness is confined to "ap-
propriate" times and places) without being seen as irresponsible and
undependable. But if a person is drunk often and allows drunkenness
to intrude on times when and in situations in which others need and
expect him or her to be sober, he or she will become "undependable"
and cause harm to those who count on him or her. The eventual result
will be a loss of self-esteem for the drinker as well.
Third, it seems fairly certain that the total quantity of alcohol con-
sumed has important independent effects on certain attributes. It is fairly
well established that the best-known medical risks of alcohol use (e.g.,
liver damage) are primarily linked to total quantity consumed and not
the particular way in which it is consumed. The extent to which alcohol
becomes a financial drain on the drinker or his or her dependents also
depends in large part on the total quantity consumed.
The specification of contexts involves greater complexity. The times
and places one chooses for drinking are important in determining the
effects of the practice. Drinking while at work is generally much riskier
(in its health, social, and economic dimensions) than drinking at home
during leisure time (Aarens et al. 1977~. Being drunk in a neighborhood
bar where one is known well is probably safer and more satisfying than
being drunk in a bar in which strangers fight (Bruun 1969~. Similarly,
the activities one combines with drinking can be more or less risky or
rewarding. Even a safe home can be a dangerous place if one combines
late-night smoking or cleaning rain gutters with drinking. And it is
especially dangerous to operate moving equipment when one is drunk.
In general, to describe drinking contexts in ways that reveal riskiness,
it is necessary to talk about how well a given degree of intoxication is
welcomed or accommodated in a given context.
It is important for our scheme to distinguish drinking episodes from
drinking practices. A drinking episode describes a discrete period of
time in which a given degree of intoxication is combined with a given
context and associated activities. A drinking practice refers to a char-
acteristic 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. Therefore, a drinking practice not only
generates the sum of effects associated with each episode, but also has
effects that depend on the cumulative result of repeated episodes.
To summarize, then, our definition of drinking practices is built on
OCR for page 37
The Nature of Alcohol Problems
37
of intoxication with given features of the environment, the context in
which drinkers do their drinking can shape the risks confronting drinkers
by affecting amounts of consumption as well as by differentially exposing
them to environmental hazards. We are interested in drinking contexts
because they shape some of the effects associated with drinking.
Despite the potential interest of the subject and despite frequent
surveys and observational studies that capture some qualitative notions
about U.S. drinking practices, we have surprisingly little quantitative
information about how periods of drinking are distributed among given
contexts and virtually nothing systematic on how the contexts are com-
bined within a given individual's drinking history. Investigations of
drinking contexts have been of two types. One type has focused on the
micro question of whether the local contingencies of drinking contexts
can shape short-term quantities and rates of alcohol consumption; the
answer to this question has been a definite yes. Rates of drinking can
be influenced in given contexts by such factors as price, the example of
other drinkers in the same context, the relationship of the drinker to
others in the same context, and the setting of the drinking (Babor et al.
1978, Harford 1979, Mass Observation 1970~. The other type has sought
to establish differences in the contexts of drinkers who drank different
amounts and suffered different kinds and degrees of problems (Cahalan
and Room 1974~. Again, a fairly clear answer has emerged: heavier
drinkers (and those drinkers with problems) use a much broader array
of drinking contexts than light drinkers and are, in particular, more
frequent users of bars and restaurants as drinking places (Clark 1977~.
Such studies have their uses, but they fail to provide any clear answer
to the questions of how different kinds of risks and benefits attach to
different kinds of contexts and how the contexts of drinking episodes
have been changing in quantitive density over time. All we have is a
tantalizing suggestion that the context seems to shape alcohol con-
sumption and that heavy drinkers seem to frequent on-premise estab-
lishments.
From our perspective, two important facts about drinking contexts
are now available. The first is that sales for off-premise consumption
now account for approximately three-quarters of total consumption-
up from less than half at the end of World War II. This predominance
of off-premise consumption shows up in survey results indicating that
home is the most preferred drinking site and that drinking episodes at
home or at friends' homes are much more common than drinking in
bars and restaurants (Harford 1979~. It is hard to know whether this is
good or bad news, however, from the point of view of reducing the bad
consequences of drinking. To the extent that this trend takes drinking
contexts out of the direct control of state-regulated enterprises, we may
OCR for page 38
38
REPORT OF THE PANEL
TABLE 5 Where, When, and With Whom People Drink (Drinking
Contexts), by Age of Drinker
Weekdays
Private Public ~
Relatives Friends Relatives Friends
Weekends
Private Public
Relatives Friends Relatives Friends
(Total
Total* Events)
1~25 11% 14% 2% 16°/c ll~ic 20°/c 4°/c 23~c 100 °%c 2 107
2~35 17~o 12% 4% 13°fc 18°Xc 16°%c 7% 13°/c 100% 2. 172
3~48 28% 6% 3% 10°%c 25°/c 10°/c 5% 13% 100 °%c 2,513
49 62 33% 5% who 5°/c 29°/c 9% 6°Xc 6°Xc 100°%c 1,414
>63 43~o to 2% 3% 33°Xc 8% 2°/c 4% 100 °Xc 1.013
*Addition to less or more than lOO percent is due to rounding error. Solitary drinking episodes were quite
rare and were coded under "friends'' (none present).
Source: Adapted from Harford (1979, p. 171).
judge that public capacity to shape drinking contexts is being reduced.
On the other hand, privately created drinking contexts may tend to
moderate drinking and insulate the drinker from certain dangerous con-
sequences of drunkenness more effectively than publicly sanctioned
drinking opportunities. To the extent that this is true, the shift toward
off-premise sales and consumption is a good sign, but not enough is now
known about this change (Partanen 1975~.
The second fact is that preferred drinking contexts change dramati-
cally 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 dimin-
ish with age. In addition, young people tend to prefer public locations
with friends, while older people do more of their drinking in private
with relatives. Again, because we do not know exactly how these dif-
ferent contexts are linked to different risks, these findings are difficult
to interpret. One might hypothesize that this aggregate pattern makes
young people more vulnerable to risks of auto accidents, fights, and
other disturbances linked to public intoxication. This is speculation,
however; the data presented in Table 5 are useful primarily to indicate
the kind of information and data that must be developed to discover
current aggregate patterns of drinking contexts and to explore the re-
lationship among them and the risks and benefits of drinking.
We think a major opportunity exists to do additional research on
drinking contexts. In fact, we think much data could be reanalyzed to
discover important facts about aggregate patterns of drinking contexts.
The crucial questions involve how the contexts are linked to certain
kinds of risks and whether the contexts are changing in more dangerous
or safer directions.
OCR for page 39
The Nature of Alcohol Problems
Drinking Status
in College
Abstinent M
in College F
Non-Problem M
in College F
Problem M
in College F
39
Drinking Status
25 Years Later
~\\\\\\\\\\\~38~\\\\\\~ ~.i.~ 5 1
~3
16~ ~~ :~: 73 ~ ~~ 11
<^,5~_~ 7
>8~ ~~ ~ ~ 22
2~ ... :.
17 ~
thy % Abstinent
A\\\ 25 Years Later
I..:. ~ % Non-Problem
I. . ~ 25 Years Later
~ I % Problem
25 Years Later
FIGURE 5 Reported drinking status of men and women in college and 25 years later.
Source: Adapted from Fillmore et al. (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 prac-
tices are. It is common to think of drinking practices, particularly those
that cause problems, as relatively deeply rooted and difficult to alter.
There is evidence, however, that drinking practices and associated prob-
lems are not so constant. A major source of evidence on changing
drinking practices comes from a study in which individuals surveyed
about their drinking practices in college during 1949-1952 were resurv-
eyed 20 and 25 years later (Fillmore 1974, 1975; Fillmore et al. 1977~.
Figure 5 presents one set of the results of the follow-up. The figure
indicates a clear but modest relationship between drinking problems in
college and drinking practices 25 years later. Certainly, the probability
of later problems is considerably higher, in terms of relative risk? for
problem drinkers in college than for others. But the vast majority of
problem drinkers in college were not problem drinkers 25 years later,
just as the majority of those who were abstinent in college were not
problem drinkers 25 years later. Thus, while the drinking patterns of
early adults do influence subsequent patterns, the influence is far from
decisive. Such differences across time are apparent during shorter pe-
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40
REPORT OF THE PANEL
riods of a few years as well (Clark and Cahalan 1976~. Cahalan et al.
(1969) found that retrospective reports of changes in consumption were
common in an adult national sample, especially among men. Two-thirds
of all male drinkers recalled broad variations in their quantity of con-
sumption at different periods. The least lifetime variation was reported
by abstinent women, 80 percent of whom were consistently so.
Evidence about the volatility of drinking practices of clinical problem
drinkers comes from follow-up studies of drinkers who have been in
treatment. In a 4-year follow-up study, Polich et al. (1980, p.168) found
that "although there is frequent improvement tin terms of drinking
practices), there is also frequent relapse and much instability." Appar-
ently, the drinking practices of even alcoholic drinkers are not etched
permanently into their lives: there are good periods and bad periods
lasting for several months or years. Moreover, the changes do not bear
a necessary relationship to treatment.
The fact of impermanence in drinking practices has several important
policy implications. It suggests that effective influence might be brought
to bear on current drinking practices: they are not so deeply embedded
in personal characteristics that it is fruitless to think of trying to change
them. On the other hand, it suggests that there are few permanent
victories in the efforts to shape drinking practices. Nor can people with
serious problems be treated then discharged with the expectation that
the drinking (or nondrinking) practices of more than a few will retain
for long or without further ado the pristine quality they may have had
at the end of treatment. Apparently, the factors that shape drinking
practices are varied, transient to some degree, and under the control
of many different parts of society. 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? The only
certain answer to these latter questions is that no single explanation is
adequate. The complexity of causes of drinking is indicated by Sulku-
nen's (1976, 1978) discussions of the three "use values" of alcohol: as
a food and beverage, an intoxicant, and a symbol of sociality.
As a food, alcohol is itself a carbohydrate; most alcoholic beverages
contain additional nutrients; these beverages are generally quite resist-
ant to spoilage or infestation; and they are free of most water-borne
diseases. Thus, fermented products have a long history as useful, durable
basic commodities. People make and use them for reasons as diverse
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The Nature of Alcohol Problems
41
as biological thirst and hunger, personal taste, and cuisinary custom
(Gastineau et al. 1979~.
In addition, however, alcohol is an intoxicant, and its multiple effects
on psychological mood and alertness are well known. Alcohol is var-
iously a stimulant and depressant, euphorigen and soporific, irritant and
anxiety reducer~epending on a myriad of factors such as dose and
schedule of use, individual metabolism, personality factors, and situa-
tion. Alcohol, like other intoxicants, can produce such dependency phe-
nomena as persistent search behavior, withdrawal, relapse, and loss of
control, although these terms are controversial (see the forthcoming
report on Commonalities in Substance Abuse and Habitual Behavior
from the Committee on Substance Abuse and Habitual Behavior, Na-
tional Research Council, National Academy of Sciences).
Finally, alcohol carries symbolic values that are independent of its
nutritional value or its intoxicating effects" for example, the religious
symbolism of communion and sabbath wines; the celebration that calls
for champagne; the slave-trade heritage of "demon rum"; and the laugh-
ter in numberless jokes about drunkenness.
The drinking practices we observe in society are shaped by a variety
of factors- those noted above and others acting simultaneously. Some
factors are individually based (e.g., genetic proclivities, psychological
and developmental needs); some are rooted in intimate, informal social
processes (e.g., family, ethnic, or religious traditions; the practices of
one's spouse; the rituals of one's working companions); some are based
on the marketing efforts of alcohol producers; and some are managed
explicitly by government (e.g., taxes on alcohol, restrictions on avail-
ability, laws regulating drinking conduct, and a variety of educational
messages about drinking). We assume that these factors operate with
varying degrees of force and varying degrees of persistence. Some factors
(such as general personality traits and restrictions on availability) may
operate continuously, with diffuse rather than precise impact on drinking
practices. Other factors (events such as an illness, a divorce, or a firing)
may operate with great force in the short run, with relatively transient
effect. Still others (such as strong biological aversions or family drinking
traditions) may be both powerful and persistent. 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, ex-
pert views on the most important factors seem to depend more on
disciplinary training than on persuasive facts currently in hand. Alcohol
policy would benefit from the identification of those factors that are
powerful but can be efficiently influenced by government a difficult
combination to locate.
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42
REPORT OF THE PANEL
Although we have stressed observations of the impermanence of
drinking practices over individual drinkers' lifetimes, it is clear that in
the short run, at least, drinking practices do have some inertia. Past
practices exercise important influence over future practices, particularly
in the short run. This is true in part because some of the factors shaping
practices are powerful, persistent, and not easy to manipulate or escape,
and in part because people generally tend to maintain in their lives
habits and routines that work. In general, then, we hypothesize that the
longer a given practice has continued, the more meaning the individual
attaches to that practice; and the more stable the social environment
surrounding the individual is, the more stable the drinking practice will
be. On the other hand, we assume that drinking practices are to some
degree modifiable by changes in the experiences of the drinker. Often
the experiences that lead to modification of drinking practices are the
result of small-scale, private initiatives: e.g., a husband begins encour-
aging his wife to drink more often with him in the evening; an employer
complains about tardiness and threatens firing; a favorite neighborhood
tavern closes. At other times, the experiences that cause individuals to
change can be the result of broader efforts of social management (e.g.,
a persistent and persuasive mass media campaign designed to make
people more self-conscious about drunken driving, a tax increase on
alcohol, or a reduction in availability). In any event, we assume that
drinking practices can change first as immediate circumstances change,
then as persisting new conditions force continued adjustments and the
development of new practices supported in part by the surrounding
circumstances and in part by recent experience.
THE PROBLEM OF ATTRIBUTING EFFECTS
It is one thing to determine how much, how often, and how people
drink. It is quite another to pinpoint how much the different dimensions
of drinking practices and different characteristics of the environment
contribute to the important social effects of drinking. For the purpose
of informing policy judgments, the question of attribution seems fun-
damental: 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. Drink-
ing is a major factor, but the degrees and frequency of intoxication as
well as cumulative consumption must be considered to develop any clear
sense of the kinds of risks and benefits that a drinker may encounter.
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The Nature of Alcohol Problems
43
In addition, the contexts in which drinkers do their drinking play an
important role In creating effects, in part by differentially exposing drink-
ers to the hazards of the environment and in part by exerting an inde-
pendent influence on quantities and rates of alcohol consumption. Fi-
nally, general features of the envirnments into which drinking may be
fitted by the choice of context also play a role in producing different
kinds of effects. 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) in terms of the dimensions of
Figure 2. This suggests that policies toward alcohol use require complex
choices about the relative importance of different consequences as well
as choices about which instruments to select from a large and diverse
array some targeted at cumulative consumption, some at drunkenness,
some at contexts, and some at characteristics of the social and physical
environment.
A separate question about the attribution of risks and consequences
of drinking can be usefully addressed: how the risks and consequences
of Figure 2 are distributed across the population of drinkers. The adverse
consequences are doubtlessly at highest concentration in the small frac-
tion of the drinking population who drink a lot, get drunk frequently,
and do so with little respect for time and place. This expectation has
justified the current focus of policy on alcoholics and chronic, intensive
users of alcohol. What is less obvious, however, is how much of the
total social problem described in Figure 2 lies beyond this small fraction
of the heaviest drinkers.
Current answers to this question are preliminary but revealing. Table
6 presents data from the Air Force survey showing the fraction of people
in given drinking patterns who experienced two or more serious incidents
associated with alcohol in the past year. As we would expect, the fraction
of people having these problems increases noticeably with given levels
of consumption. But if we calculate the fraction of all the people ex-
periencing two or more serious incidents related to alcohol who were
in the highest consumption groups, we find that the heaviest drinkers
account for only 24 percent of the population having problems. The
reason is that there are so many more people in the lower-consuming
groups that even small proportions in trouble can swamp the larger
fraction of people who are in trouble from the higher-consuming groups.
These qualitative results also stand up when we look at data from
national surveys conducted in 1967 and 1977. Table 7 shows the fraction
of people at different levels of consumption who experienced certain
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44 REPORT OF THE PANEL
TABLE 6 Alcohol Incidents by Total Alcohol Consumption Level
in a Sample of Air Force Men
Average Daily Number of People with Percentage of All
Consumption Level in Total Two or More Serious People with Two or
Ounces of Alcohol Number Incidents More Serious Incidents
0.1-1.0 1,761 37 26.8
1.1-2.0 418 33 23.9
2.1-3.0 181 13 9.4
3.1~.0 79 14 10.1
4.1-5.0 49 8 5.8
5.0+ 111 33 23.9
TOTAL 2,599 138 99.9
Source: Adapted from Polich and Orvis (1979~.
kinds of problems. Again, it is clear that the chance of experiencing
difficulties associated with drinking increases as one drinks more. But
Table 8 shows how much each portion of the drinking population con-
tributed to people who have problems associated with drinking. Again,
it turns out that the heavy drinkers typically account for less than half
of the people with problems.
Thus, in attributing the consequences of alcohol consumption to var-
ious causal factors and types of drinkers, we can make two important
observations. 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 con-
texts, or changing the external environment as well as by reducing cu-
mulative individual consumption. Second, while chronic drinkers with
high consumption both cause and suffer far more than their numerical
share of the adverse consequences of drinking, their share of alcohol
problems is still only a fraction- typically less than half the total.
Alcohol problems occur throughout the drinking population. They occur
at lower rates but among much greater numbers as one moves from the
heaviest drinkers to more moderate drinkers.
CONCLUSION: AVENUES FOR AFFECTING
ALCOHOL PROBLEMS
The main conclusions of this chapter are that controlling alcohol and
treating relatively small numbers (even as many as 1 or 2 million) of the
most troubled drinkers are not the only, and may not be very effective,
ways of coping with alcohol problems.
We have developed these conclusions largely by analyzing the complex
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The Nature of Alcohol Problems
TABLE 7 Percentage of U.S. Population Experiencing Different
Problems Associated with Drinking, by Level of Consumption
45
Prob- Prob-
lems lems
with with
Friends Spouse
Total
Number
Job Accidents/ of
Prob- Legal Respon-
lems Problems dents
1967 National
Survey
Light drinkers 6 1
Moderate
drinkers 8 5
Heavy
drinkers 14 20
1979 National
Survey
Light drinkers
Moderate
* * * * 394
2 . . ~
a ~ 499
8 5 11 0 1o2
1 1 * 1 * 444
drinkers 5 10 4 2 6 2 ss7
Heavy
drinkers 10 31 6
6 24 7 124
* Less than 0.5 percent.
Source: Clark and Midanik (1980).
TABLE 8 Contribution of Different Consuming Groups to
Reported Experience of Problems
Problems Problems Job Accidents/
Health Bellig- with with Prob- Legal
Problems erence Friends Spouse lems Problems
1967 National Survey
Light drinkers 26~o Ho * * * *
Moderate drinkers 51 45 42~c 30% 54% 100%
Heavy drinkers 23 46 58 70 45 0
Total percentage 100 100 100 100 99 100
(Total number) (83) (56) (19) (10) (33) (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** 100
(Total number) (46) (103) (32, (21) (70) (20)
* Less than 0 5 percent.
** Totals do not add to 100 percent due to rounding error.
Source: Clark and Midanik (1980~.
OCR for page 46
46
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OCR for page 47
The Nature of Alcohol Problems
47
causal machinery that linked drinking with the important consequences
of drinking. Figure 6 presents a schematic view of our conception of the
broad causal system. In this scheme, drinking is incorporated into the
concept of a drinking practice, which specifies drinking in several di-
mensions (degree of intoxication, frequency of intoxication, and cu-
mulative consumption) and includes commonly chosen contexts for
drinking as well. Drinking practices mediate the effects of drinking but,
for many effects, do so only in combination with some features of the
physical and social environment. Note that the environment appears in
this scheme twice: as something that combines with a given drinking
practice to produce consequences (see Figure 2) and as something that
shapes drinking practices by making alcohol available, by defining at-
titudes toward drinking practices, and so on. Often, the same features
of the environment play a role in both shaping practices and producing
consequences; still, one can analytically distinguish among the different
causal roles. Contexts appear in this scheme as a description of how
drinkers incorporate pieces of the environment into their drinking ac-
tivities. We assume that the contexts exert an independent influence on
consumption and that the environment influences the frequency with
which certain contexts appear in drinking practices.
The sheer complexity of this system argues for the existence of al-
ternative 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. Although
the theoretical existence of these alternative approaches can hardly be
taken alone as a strong argument supporting their use, their existence
does stir our curiosity about whether they might be exploited.
The conclusion that treating alcoholics is not sufficient response to
the problem is based on an empirical result: namely, that the problems
associated with drinking are distributed rather broadly through the pop-
ulation of drinkers. It is true that the small proportion of the most
troubled drinkers cause and suffer far more than their numerical share
of alcohol problems; it is also true that if all the clinically diagnosable
alcoholics were to stop drinking tomorrow, a substantial fraction of what
we understand as alcohol problems would still remain. The general
alcohol problem, then, is more than what the standard view of "alco-
holism" suggests, because it affects many more of us than we are ac-
customed to believing. The problem may have less to do with alcohol
than the alcoholism concept suggests and have much more to do with
how alcohol is fitted into daily life and the external environment.
Representative terms from entire chapter:
drinking contexts
