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Simplifying Conceptions of Alcohol Problems and Policies In a democracy, government policy is inevitably guided by commonly shared simplifications. This is true because the political dialogue that authorizes and animates government policy can rarely support ideas that are very complex or entirely novel. There are too many people with diverse perceptions and interests and too little time and inclination to create a shared perception of a complex structure. Consequently, influ- ential policy ideas are typically formulated at a quite general level and borrow heavily from commonly shared understandings and conventional opinions. Alcohol policy is no exception to this rule. Current policy is pro- foundly shaped by a body of conventional wisdom, including the belief that alcohol problems are created largely by a small group of alcoholics who require intensive, prolonged treatment and that any effort to restrict drinking practices in the general population is doomed to failure. The power of these ideas is apparent in that they are widely treated as the most obvious and incontrovertible facts the foundation of an informed and intelligent discussion of alcohol policy. Much can be said for the wisdom of governing through commonly shared perceptions. If many people understand and agree with an idea, apr~mufacie legitimacy much valued in democratic society is established. Moreover, widespread understanding and acceptance establishes a nec- essary condition for effective implementation in a society in which gov- ernmental power is broadly dispersed. Finally, it is often the case that although the shared simplifications fail to reflect or capture all the im- 6

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Simplifying Conceptions of Alcohol Problems and Policies 7 portent aspects of a problem, they often do focus attention on some of the most important. Thus, the simplifications help to concert social attention and action something that a more complicated idea could not achieve. There is also a price to be paid for simple ideas. Simplification inev- itably distorts our perception of a problem. While some important fea- tures of the problem are elevated, others that could plausibly claim equal importance are subordinated. While some avenues for social in- tervention are brightly illuminated, others plausibly as effective are ob- scured or condemned to darkness. Moreover, precisely because the simplifications are so powerful and seem so much a part of our current society, it is hard to be skeptical about them and to ask effective and probing questions about their limitations. Such limitations can be of two sorts. One simplifying strategy is to focus on a limited set of effects. Thus, one can focus on adverse health effects and promote policies to reduce cirrhosis and accidental injuries associated with alcohol, taking everything else as secondary in impor- tance. Alternatively, one might be primarily concerned with the social degradation accompanying chronic alcohol dependency and concentrate on policies to locate and rehabilitate (or at least provide humane care to) alcoholics. Or one might consider the appearance of public sobriety to be of overriding importance and choose policy instruments that will simply but effectively keep drunkenness out of public view. In short, by choosing a limited range of effects to be the dominant objective of alcohol policy effects that are the largest, or most important, or the only ones that are conceived to be an appropriate concern of govern- ment the problem can be simplified sufficiently to gain confidence in designing and recommending alcohol policy. A different simplifying approach is to decide which causal variables are most important in generating the effects of drinking, then to choose policy instruments that operate most directly on these causes. Thus, one might judge (on the basis of available evidence) that the quantity of alcohol drunk is itself the major causal variable determining the observed pattern of effects and try to develop policies that will ration the amount of individual access to it. Alternatively, one might conclude that the aggressiveness with which alcohol is marketed and the kinds of settings in which drinking occurs are capable of making otherwise moderate and sensible people into dangerous, risky drinkers. This judgment might lead to efforts to "take the profit out of selling alcohol" or to carefully shape the times, places, and settings in which drinking takes place. Then again, one might determine that whenever there are alcohol problems, they are due to a relatively small number of unusually reckless or vul-

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8 REPORT OF THE PANEL nerable drinkers and consequently tailor alcohol policy to prevent such people from drinking or to "treat" them so that they are more resistant to it. In short, by limiting one's attention to a small set of causal vari- ables, one can find a comfortable basis for supporting a given policy. The most successful simplifications of the alcohol problem have in- volved both kinds of limitations simultaneously: the major objective of the policy and the judgment about what causes this particular effect are sewn together into a neat conceptual bundle. A few such bundles have had widespread and durable appeal in U.S. society, because they have proven compatible with common social views, individual experiences, and the interests and purposes of organized groups concerned with al- cohol. We refer to these cognitive bundles as governing ideas. A few other such bundles have considerable intellectual appeal and have at times claimed the interest and loyalty of "experts" who influence alcohol policy, but they have not succeeded in capturing the imagination of the broad population or in shaping their actions. We will refer to these as minority conceptions. Before looking at the kinds of policy choices that our analysis suggests are available, it is well worth understanding the basic structure of the three ideas that have succeeded in profoundly shaping alcohol policy as well as two others that are interesting and have appeared historically but have made lesser claims on credibility. GOVERNING IDEAS A review of the history of alcohol in the United States reveals three dominant conceptions associated with its use (see Aaron and Musto in this volume; Beauchamp 1973;N. Clark 1976; Levine 1978, 1980; Room 1974; Rorabaugh 1979; Wiener 1980~. Each of these governing ideas was initiated and became most prominent in a distinct historical period, but none has disappeared from American consciousness, politics, or scientific discourse. The first governing idea, dominating the 150-year colonial era of American history, focused on customary attachment to drinking and the moral qualities of drunkenness. During this period, drinking and drun- kenness aroused as much interest as eating and obesity which is to say, there was plenty of both and they were widely accepted as normal. Drinking was done largely at the local inn, and the local innkeeper was a community notable. Drinking was a social affair largely public and under responsible community control. In these times, those few who raised alarms about drinking did so on religious grounds: that habitual drunkenness was sinful, a dissipation of the moral energies that the colonial ministry expected to be devoted to

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Simplifying Conceptions of Alcohol Problems and Policies 9 God's work on earth. The fault was not in the rum or cider, however, but in the defective moral character of those who besotted themselves when they should have been soberly at work or prayer. The solution was not in controlling alcohol, but in disciplinin~visibly in the stocks, audibly from the pulpit the moral character of such drinkers. During the central expansionary period of American history (ap- proximately the century-and-a-half from the Revolutionary War to the first decades of the 20th century), a quite different notion took hold: that alcoholic beverages, formerly held to be benign and healthful, were in fact toxic and addicting. In this concept, alcohol itself (rather than the character of the drinker) became the focus of concern. As befits this concentration on the substance, extensive discussion occurred about which forms of alcohol were dangerous. Liquor (distilled spirits) was held to be the central evil, but there was considerable dispute whether the milder drinkscider, beer, and winecould be considered tem- perate and acceptable. The preoccupation with alcohol itself altered the views of the consequences of drinking. Instead of viewing drunkenness as an annoying personal habit, the excessive drinker came to be seen as someone who was ravaged and transformed by an alien substance. Otherwise decent people could be transformed by drink to become dissolute, violent, or degenerate. Moreover, since alcohol was an ad- dicting substance, even the most moderate drinker flirted with danger at the rim of every cup. The institutional carriers of this conception were the temperance pledge societies voluntary associations whose core tenet was the mu- tual renunciation of liquor by their memberships. Most of these societies were evangelical in tone and middle class in origin. Membership was open to all, and these clubs appealed to many with their optimistic and communal creed. The growth of pledge societies in the 1820s and 1830s constituted a remarkable social movement, the archetype for de Toc- queville's observation of America as a nation of joiners. Eventually these groups developed political aims and sought to em- body their views in legislation at federal, state, and local levels. The purveyor of drink was viewed with increasing suspicion, rather than as a respected (indeed a leading) citizen. The grogshop or tavern, con- tractually tied to a manufacturer, pushing drink to its profit-making limit, and attracting to itself prostitution, vote-buying, thievery, and murder, became a stock image. In the early 1850s, 13 states passed prohibitions on the sale of hard liquor. Although these bans were in most cases soon rescinded, they were an early efflorescence of the main aim of temperance activity between 1875 and 1920: the reform of the corrupt political and moral culture associated with the urban saloon.

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10 REPORT OF THE PANEL The political aims of the second governing image, which viewed al- cohol and its sale as a public menace, were carried into fullest bloom by the skilled single-issue politicking of the Anti-Saloon League. By 1916, prohibitionist laws of various sorts had been established (mainly by referendum) in 23 states and were finally extended to the nation as a whole by the lath Amendment and the Volstead Act. The consequent unwillingness of most jurisdictions to adopt Draconian enforcement 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 affluent drinkers to pay three to four times the prewar going rates, developed a strong black market in booze. Federal prohibition was swept off the books in the first months of the Roosevelt Administration's New Deal. With it went the future of radical legal controls over the supply of alcohol as devices to control alcohol problems. In the half-century since repeal, a third governing idea has steadily gained adherents: the modern "disease" view of alcoholism. In this conception, both the drinker and the supplier of alcohol were stripped of their moral imputations. The problems associated with al- cohol that attracted attention were those involving the social collapse of the chronic, heavy drinker. These problems were seen to result neither from moral weakness in the drinker nor from the universally addicting power of alcohol itself, but from a little-understood chemistry that oc- curred between the substance and certain drinkers. In contrast to the colonial view that although alcohol is physically and morally innocuous, some morally defective individuals take to perpetual drunkenness as a sign of their dissipation, this modern view holds that although alcohol is innocuous for most people, a minority fine people in all other re- spectscannot use it without succumbing to alcoholism, a disease proc- ess for which there is no known cure except total abstinence. This view makes it the responsibility of the alcoholic, and those who care person- ally or professionally about him or her, to see that a treatment or re- covery process is initiated and that abstinence is maintained. These three governing ideas can be summarized as follows: The Colonial View: drinking is a valued social custom; overindulg- ence is a weakness in moral character; public discipline is the appropriate response. The Temperance View: alcohol (at least, strong liquor) is an ad- dicting poison; its sale is a public hazard; use of the law to restrict its sale is the appropriate response. o The Alcoholism View: alcoholism is a disease; its causes are as yet

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Simplifying Conceptions of Alcohol Problems and Policies 11 unknown; treatment of those who are vulnerable to it is the appropriate response. Each of these ideas, aged by historical experience and colored by current affairs, has its residue in contemporary public policy. The first, the colonial view, survives most visibly in laws regarding public drunkenness. Many jurisdictions have recently reduced the sanc- tions for drunken demeanor from criminal penalties (fines, jail terms) to civil ones (compulsory education or treatment). These results of the societal drift toward greater tolerance of unconventional life-styles on one hand, and therapeutic justice on the other, serve only to soften, not to efface, the lines of moral judgment on the sidewalk drunk. The second notion, the temperance view, has been shaped by two key forces: the widespread post-repeal conviction that Volsteadism was a failure and the growth of government regulation of commerce as a central feature of national life (itself the legacy of Progressivism, the New Deal, and war mobilization). The alcoholic beverage industry, from manufacture through retail sale, is thoroughly regulated, principally by the U.S. Bureau of Alcohol, Tobacco, and Firearms (BATF), the Food and Drug Adminstration (FDA), and the many state and county Al- coholic Beverage Control (ABC) boards. Part food, part drug, part hazardous substance, alcohol is subject to a system of regulatory control that includes strict purity, packaging, and labeling rules; special (and unusual) principles of taxation; and a differentiated system of licensing restrictions, including (in 18 states) government liquor monopolies. The third idea, the alcoholism view, has only recently moved from the realm of voluntary organization and private clinical practice to es- tablishment in public policy. Its main institutional basis has been the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the current system of formula grants to state agencies that supports and encourages local treatment efforts. The disease view has successfully allied modern medical science with the organizational form of the mutual pledge societies, as in Alcoholics Anonymous (AA). The emphasis of NIAAA, AA, and a host of related institutions has been on the refine- ment, financing, and legitimation of the treatment of alcoholism. At the same time, there have been efforts to institutionalize alcoholism treat- ment in occupational programs and in health care financing by favorable federal regulation as well as private-sector action. It is also notable that this governing idea, projecting the conception of vulnerability onto a small part of the population, has been able to establish and maintain support from the alcohol industry itself. The alcoholism treatment idea is still relatively new in the context of

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2 REPORT OF THE PANEL our historical perspective. It has become clear in the last decade, how- ever, that this governing idea and its constituency are capable of building a powerful institutional base. Whether the current base can be defended or enlarged in the face of current government fiscal retrenchment cannot be vouchsafed. Nevertheless, there is little question about the hardiness and sustained growth of the concept of alcoholism in public attitudes, interested organizations, and formal government policy. MINORITY CONCEPTIONS In addition to these three dominant conceptions of alcohol and alcohol policy, two other conceptions are worth noting. Although they have not achieved the prominence and influence of the governing ideas, they have the same synthetic qualities. Moreover, they have exerted consid- erable force in the communities of "experts" who are influential with respect to conceptions of the problem and implied solutions. One idea the concept of alcohol control was strong at the time of repeal of Prohibition, played an important role in establishing the system of reg- ulation of drinking at the state level, then quietly disappeared. The other idea- the public health perspective has made its appearance more re- cently. Following the repeal of Prohibition, the direction of alcohol policy was strongly influenced by an organization called the Association Against the Prohibition Amendment, a business-based alliance that drew heavily on the intellectual resources of Columbia University. In the eyes of this group, the principal problem was neither the alcohol itself (as most of the temperance movement believed) nor certain drink- ers (which the colonists and later the alcoholism movement believed), but the aggressive, ruthless, and at times criminal way in which com- merce in alcohol had been developed. As a result, the contexts in which drinking occurred became the natural targets of policy. Since many of these contexts are created by small, informal, private arrangements, there were limitations to what could be accomplished. But the public contexts of drinking (bars, taverns, saloons, restaurants, etc.) could be brought under governmental scrutiny. And it was possible that private informal settings could be influenced by regulating the hours, accessi- bility, and prices charged by stores selling alcohol. Thus, in this con- ception, the alcohol problem could be controlled by governing the terms and conditions on which alcohol was available for both on-site and off- site consumption and, using this control, temperate drinking practices could be promoted.

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Simplifying Conceptions of Alcohol Problems and Policies 13 This idea never achieved the sustained prominence that the idea of alcoholism has gained. But the concepts (and the group that pressed them) were powerful enough to provide a rationale for replacing the Volstead Act with the institutional apparatus of state ABC systems and to give early shape to these institutions. Originally, the state boards were authorized to regulate the marketing of alcohol to inhibit vicious or excessive drinking as well as to rid the business of criminal influence. The first part of this idea was vague and lacked a potent constituency, and the state ABC systems have become concerned mainly with the protection, promotion, and orderly development of the legitimate in- dustry per se. The institutional legacy of this perspective thus remains hardy but is generally unconcerned with a major component of its orig- inal justification. The concern that proponents of repeal expressed in seeking to inhibit abusive drinking through the management of social contingencies around drinking has been revived- with a different institutional base - in the public health perspective. As with the other ideas, the public health perspective focuses attention on selected aspects of alcohol prob- lems and carries with it a variety of normative and empirical assertions. Two basic principles seem fundamental to this idea, which is still de- veloping. First, the public health perspective focuses on the health consequences of alcohol use (particularly cirrhosis and traumatic deaths) as the most visible aspect of alcohol problems. In doing so, it shifts away slightly from the historical preoccupation with the social collapse of individual heavy drinkers. In this view the health consequences of drinking seem compelling because: (1) the objective conditions (mortality and mor- bidity rates associated with alcohol-induced disease and trauma) are large enough and serious enough to warrant attention; (2) the evidence on alcohol's contribution to such problems is fairly convincing; (3) it is generally preferred that people die later rather than earlier; and (4) social intervention in health problems draws on a strong (although not uncontested) tradition of public concern. Second, in this view alcohol problems arise, not from a small group of chronic dependents, but from the drinking habits of the general pop- ulation. This is true in part because certain health consequences of concern can occur in a large segment of the drinking population (not just those who are chronically dependent) and in part because some empirical evidence suggests that the absolute number of chronically dependent drinkers is not fixed simply by an underlying distribution of "vulnerability to alcoholism," but can be importantly affected by factors

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14 REPORT OF THE PANEL that govern the consumption patterns of the general population. This evidence argues that the more drinking there is in the general popula- tion, the greater the number of people chronically dependent on alcohol and the greater the extent, therefore, of serious alcohol-related health effects. In important respects this public health conception of alcohol prob- lems fits well into some current American ideologies and moods. To a great degree, the approach escapes those moralistic qualities of other approaches that have made them currently suspect in the public mind. It does not focus attention on the work ethic, the importance of the family, or individual life-styles. Of course, there is no small amount of moralism involved in asserting the importance of remaining healthy. But it appears to be characteristic of our epoch that health is a cause that government has been allowed and even encouraged to pursue to considerable lengths. By focusing on alcohol-induced mortality and morbidity, this perspective points to a problem that clearly costs society a great deal of personal pain and loss, to say nothing of economic resources. Given the current mood, the public health conception of the problem is a tempting one. On the other hand, this conception has some significant liabilities as a governing idea of the problem. Perhaps its greatest liability is the fact that it includes in the problem many people who do not see themselves as being at risk and do not desire protective measures. It is possible that some of those who had regarded themselves as not at risk are surprised by the outcome; they may end up regretting the absence of barriers between them and their unhappy fate. Before the fact, however, they may feel that their prerogatives are being infringed without any benefit to them, since they are the kinds of individuals who can live healthily, eveIl in a world that is not designed to protect them from risk; or that the political or economic costs of protection are not justified by the benefits. In addition, the public health perspective faces the problem of competing with other governing ideas. In going beyond the alcoholism view and its preoccupation with chronically dependent drinkers, it de- parts from another conceptually satisfying and institutionally entrenched idea. In addition, since it focuses on drinking in the general population and tinkers with the idea of restricting alcohol availability, it cannot quite shed the taint of "the great experiment." Since Prohibition has been so widely repudiated as a clumsy, ineffective, if not malicious social intervention, anything that looks like a move toward Prohibition will now be stubbornly resisted.

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Simplifying Conceptions of Alcohol Problems and Policies 15 CONCLUSION these five different simplifying conceptions of the nature, source, and solution of alcohol problems have been presented as distinct, explicit ideas embraced by particular groups at particular times and exercising measurable degrees of influence over governmental (and, more broadly, public) responses. 'lo this extent the recounting of these ideas may be viewed as an intellectual history of alcohol policies, recognizing that ideas are a limited part of the full history of alcohol in U.S. society. Our purpose here is to use these ideas to orient our investigation of the problem. At a minimum, the ideas reveal the diverse perspectives one can adopt as one circumnavigates alcohol problems. The diversity, in turn, suggests the fundamental complexity of the underlying problem. More particularly, however, these simplifying conceptions point to the crucial dimensions in which simplifying choices must be made. The most vivid choice concerns the question of what exactly is causing the concrete problems created by drinkers: is it the alcohol, the drinker, or the environment around the drinker? Much seems to depend on which of these things one chooses to emphasize. Only slightly less vivid is the choice about which effects of alcohol are the most important: is it the capacity of the drinker to meet economic and social responsibilities, the health of the drinker, or the risks that the drinker creates for others? Again, both the image of the problems and the implied response change as one becomes more or less preoccupied with a given idea. Finally, the question of what forms of government intervention are tolerable and efficient is always in the background. The roles of individual freedom, collective responsibility, and the social contract are subtly changed as one shifts the emphasis from economic problems to breaches of public order to acts (or accidents) of nature. Thus, the underlying complexity of the problem gives relatively free rein to simplifications; many different ones can be supported. Which onets) should be encouraged is the issue. Presumably, this depends on a set of empirical and normative judgments about which causal mech- anisms are powerful and which effects of drinking are both large and socially significant. Only against the backdrop of a fairly detailed in- vestigation of the complex structure of the underlying problem can a judgment be made about the virtues and liabilities of any given simpli- fication. Consequently, it is to the complex structure of the problem, as best we can describe it, that we next turn.