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1 Drinking in America A PARENT RAISES A GLASS of champagne to toast a newly wedcled couple. Friends gather after work or on week- ends to talk, drink, and relax. A host produces a prized liqueur to top off a special meal. These are some of the images that come to mind when one thinks about drinking in America. There are other, darker images of drinking: an intoxicated driver losing control of a car; a family argument, fueled by alcohol, escalating into a bloody assault; an employee missing work due to increasingly frequent hangovers; a homeless man clutching a bottle on a downtown street. These images capture only part of what alcohol means in America. But they are enough to demonstrate an important point: drinking is a pervasive and creep-rooted feature of Amer- ican life. Alcoholic beverages have been widely consumed throughout American history, despite attempts by the govern- ment ant! other institutions to shape or even eliminate drinking (see Figure 1-1~. The most radical attempt by the government to influence drinking in the United States came in the years 1920 to 1933, when the lSth Amendment to the U.S. Constitution brought about Prohibition by banning the manufacture and sale of al- coholic beverages. Although majorities voted for Prohibition, many people were opposed or indifferent to its enforcement, 1

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2 / ALCOHOL IN ~ERICA GALLS - ., to 1 900 1 ~ I IB6\O064 PER CAPITA CONSUMPTION OF ALCOHOL 80 FIGURE 1.1 The per capita consumption of alcoholic beverages in the United States has varied widely over the last 140 years. Before 1850, per capita consumption was falling from the high levels (6 to 7 gallons annually of pure alcohol per adult) characteristic of early America. Between 1850 and the be- ginning of World War I, it varied between 1.75 and 2.75 gallons, reaching its high point just before the war. Prohibition reduced per capita consumption to its lowest level in U.S. history, probably less than 1.5 gallons. Since about 1960, per capita consumption has again been rising, with a particularly marked acceleration in the 1960s. Today it is about what it was at the beginning of World War I. Source: Rutgers University Center of Alcohol Studies. and the years of the "noble experiment" were a time of wide- spread and flagrant abuses of the law. But after its repeal by the 2Ist Amendment, Prohibition came to have a much broader meaning in the public consciousness. For many people it be- came an example of the futility of governmental attempts to legislate morality. The corollary of this view is that any attempt by the government to change drinking practices is doomed to fail.

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DRINKING IN AMERICA / 3 The evidence does not support such a far-reaching conclu- sion. Prohibition demonstrated beyond doubt that drinking and the problems caused by drinking cannot simply be eliminated from the United States. But though such problems may always exist, their extent can grow smaller or larger depending on the steps taken or not taken- to control them. Drinking practices can change for an endless variety of rea- sons. Sometimes these changes are the result of small-scare, personal initiatives, such as an employer's threats or com- plaints, a spouse's encouragement, or the closing of a neigh- borhood bar. At other times these changes may come about through broader, public actions, such as mass media campaigns about drunk driving, changes in the laws governing when tav- erns may stay open, or shifts in the price of alcohol. This book explores some of the private and public initiatives that can help reduce the substantial number of problems caused by drinking in the United States. Specifically, it focuses on those initiatives that can help prevent these problems before they occur or appear to be inevitable. Many of these prevention alterna- tives have been overlooked or slighted in the past. But they have the potential to make a major contribution. They can help produce, in the words of Mark Moore of Harvard University, a society "with fewer drinking problems not zero drinking, not unlimited drinking, but some level of drinking with a much lower profile of harmful consequences than we now experi- ence." To lay the foundation for an examination of prevention pol- icies, this chapter presents a brief history of drinking in America and explores the dimensions of drinking today. It asks the questions, how much do people drink and what are the con- sequences of that drinking? The second chapter introduces the general concept of prevention, distinguishing it from other ap- preaches to alcohol problems, and examines some of the ar- guments for and against a prevention approach. The third chapter discusses perhaps the most visible challenge facing prevention today: drunk driving. Expanding on this focus, each succeeding chapter considers a different aspect of prevention, from the taxation of alcohol to educational campaigns to changes in the physical environment. The first part of the final chapter reviews

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4 / ALCOHOL IN AMERICA the major conclusions of the book ant! can be read as a sum- mary of its findingswhile the last part of the chapter looks toward the future of drinking and drinking problems in Amer- ica. Drinking has been an integral part of American society throughout the country's history. The Colonial and Temperance Views of Drinking During the 150 years before the American Revolution the colonists of North America tended to regard heavy drinking as normal. According to Paul Aaron of Brancleis University and David Musto of Yale University, who review the historical re- search on drinking in America in Alcohol and Public Policy: Beyond the Shadow of Prohibition, "The colonists brought with them from Europe a high regard for alcoholic beverages. Distillecl and fer- mented liquors were considered important and invigorating foods, whose restorative powers were a natural blessing. Peo-

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DRINKING IN AMERICA / 5 ple in all regions and of all classes drank heavily. Wine and sugar were consumed at breakfast; at 11:00 and 4:00 workers broke for their 'bitters'; cider and beer were drunk at lunch and toddies for supper and during the evening." Alcohol was also a prominent feature of the colonists' social life. Such gatherings as barn railings, fairs, and the mustering of militia were all accompanied by alcohol. In addition, taxes on alcohol were an important source of revenue for the fledgling colonial govern- ments. In this society drunkenness was seen as a personal failing, as a sin against a natural order. "Drunkenness was condemned and punished, but only as an abuse of a God-given gift," write Aaron and Musto. "Drink itself was not looked upon as cuip- able, any more than food deserved the blame for the sin of gluttony. Excess was personal indiscretion." The blame for drunkenness fell squarely on the shoulders of the drinker, not on rum or cider. Thus the solution to drunkenness was to chastise the moral character of the drunkard, whether in the stocks or from the pulpit. During the 150 years after the revolution, a quite different view of drinking took hold. Many people came to see alcohol as an addicting and even poisonous drug. In this view, the drunkard was not a moral weakling but the victim of an alien substance. Alcohol could make normal people violent, disso- lute, or degenerate. In this, it led to the breakdown of the family, which in turn weakened the social order. Moreover, because of alcohol's addictive qualities, even occasional drink- ers flirted with danger at the rim of every cup. This view found its institutional voice in the temperance so- cieties of the 1SOOs and early 19OOs. The mainly middle-cIass members of these societies renounced indulgence in liquor and other vices, often with evangelical fervor. In the IS30s these societies grew so rapidly that they prompted Alexis de Toc- queville's observation that America was a nation of joiners. By 1835, note Aaron and Musto, 1.5 million of America's 13 million citizens "had vowed never to consume ardent spirits again." Though originally focused on self-improvement and exhor- tation, some of these groups developed political aims and fought for legislation at federal, state, and local levels to stem the

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6 / ALCOHOL IN ~ERICA ravages of alcohol. Several waves of prohibitionist sentiment swept the country in the nineteenth and early twentieth cen- turies, culminating in a surge of political action in the first two decades of this century. By 1916, 23 states had passed (mainly by referendum) prohibitionist laws of various kinds. Finally in 1920, after years of skilled single-issue politicking led by the Anti-Saloon League, the 1Sth Amendment extended prohibi- tion to the nation as a whole. Prohibition anct the Alcoholism Movement The ISth Amendment, drafted by the Anti-Saloon League in 1917 and ratified by the states in 1919, reads: "After one year from the ratification of this article the manufacture, sale, or transportation of intoxicating liquors within, the importation thereof into, or the exportation thereof from the United States and all territory subject to the jurisdiction thereof for beverage purposes is hereby prohibited." Close inspection of this word- ing reveals an interesting point. The amendment prohibits only the manufacture, sale, and transportation of intoxicating bev- erages, not their possession, consumption, or home produc- tion. This division was a foreshadowing of the difficulties to come. According to Aaron and Musto, "The ISth Amendment . . . was so full of compromise and disparity as to be 'amphib- ious' rather than 'dry.' " The Anti-Saloon League and other temperance societies had a specific reason for trying to ban only the commerce of alcoholic beverages. They felt that once saloons and other cirin~ng haunts were swept away, the taste for liquor would gradually die out. "According to Prohibitionist doctrine," write Aaron and Musto, "Americans had once been pure. A nefarious trade had robbed people of their reason and corrupted domestic and social in- tegrity. The I8th Amendment represented a millennial triumph inaugurating personal self-restraint and national solidarity." Nevertheless, even the temperance societies realized that this transformation would not occur overnight. The amendment gave people a year to dispose of their existing stocks, and the

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DRINKING IN AMERICA / 7 Anti-Saloon League helped Congress write legislation to en- force the amendment. Thus was born the Volstead Act, a com- plicated ant! often ambiguous legal code. With 72 separate sections, the Volstead Act was an attempt to synthesize the best features of various state prohibitionist laws, but its con- tradictions and modifications of normal criminal procedures created enormous administrative and legal problems. Furthermore, governments did not give a high priority to enforcing Prohibition. The Harding, Coolidge, and Hoover ad- ministrations committed a bare minimum of funds to enforce- ment; partly as a result, the Volstead Act was widely violated. Some of America's most notorious criminals date from this pe- riod. Bootlegging, moonshining, and speakeasies all thrived during Prohibition. TIlegal marketeers developed a strong black market in booze, especially with drinkers willing to pay three to four times the prewar prices for it. TIlegal alcohol came from many sources. Among the largest, note Aaron and Musto, was alcohol used legally in industry. The 1920S were boom years for the young automotive industry, and because many of the new cars were enclosed they could be used in the winter. Their radiators therefore needed alcohol to use as antifreeze, and a portion of this increased alcohol production could be skimmed off and diverted to bootleggers. People also made much more beer and wine at home. "Dur- ing the first five years of Prohibition, the acreage of vineyards increased 700 percent," write Aaron and Musto. "The grapes were marketed as concentrate in 'blocks of port,' 'blocks of Rhine Wine,' and so forth and came with a warning: 'After dissolving the brick in a gallon of water, do not place the liquid in the jug away in the cupboard for 20 days, because then it would turn to wine.' " Despite the flagrant abuses of Prohibition, much of the public remained strongly in favor of it. The elections of 1928 returned heavy majorities supporting the ISth Amendment to Congress. But the economic collapse that began the following year changed the situation drastically. The bulwarks of Prohibition crumbled in the face of a disaster that so clearly overshadowed alcohol as a source of social disorder and personal misery. The people

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~ / ALCOHOL IN ~ERICA who were fighting to repeal Prohibition gained a new argu- ment. Relegalizing alcoholic beverages would both generate tax revenues and put Americans back to work. Roosevelt cam- paigned hard on these issues in his bid for the presiclency. After his election in 1932, he promoted repeal as a key part of a recovery program, and in December 1933 the 2ist Amend- ment ended what Roosevelt called the "damnable affliction of Prohibition." Since the repeal of Prohibition, a view of drinking different from either the colonial or temperance views has steadily gained adherents. This view holds that excessive drinking is a chronic disease, a disease known as alcoholism. Neither the ctrinker nor the drink is morally evil. Rather the problem stems from a particular kind of chemistry between alcohol and certain drink- ers. According to the alcoholism perspective, most people can drink with virtually no risk. But a minorityfine people in all other respectscannot drink without succumbing to the ctis- ease. The only known cure for the disease is total abstinence. Thus it is the responsibility of the alcoholic or those who care about him or her to see that the disease is treated and abstinence is maintained. No single view of alcohol completely shapes personal atti- tudes and public policies in the United States. Earlier views remain strong in certain ways, and alcohol policy in the years after Repeal was heavily shaped by the alcoholic beverage con- tro! movement, which held that the government should shape the context in which drinking took place to minimize its harmful consequences. But the alcoholism perspective lies at the heart of such organizations as Alcoholics Anonymous, and it pro- vides the basis for many of the treatment programs that have arisen under medical auspices. In recent years, the alcoholism concept has also found expres- sion at the governmental level. The main federal agency con- cerned with alcohol problems is the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which was formed in 1971 as part of the Alcohol, Drug Abuse, and Mental Health Admin- istration. The NIAAA sponsors research on alcohol abuse and alcoholism (including the reports on which this book is based).

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DRONING IN AMERICA / 9 Also, many state and local treatment programs are basect on the idea of alcoholism as a disease. Compared with the temperance view, the alcoholism per- spective is relatively new. But in the last 15 years it has shown itself capable of building a powerful institutional base. Like the temperance societies, the alcoholism movement has struck a chord among people who fee} that their drinking or the drinking of people close to them threatens to overwhelm the rest of their lives. Also, the alcoholism movement, unlike the temperance movement, has been able to garner support from the alcoholic beverage industry. In terms of public attitudes and institutional backing, this conception promises to remain strong. The Dimensions of Drinking Alcoholic beverages are complex substances. Part drink, part food, and part drug, alcoholic beverages are consumed for rea- sons as diverse as thirst, culinary custom, and addiction. Al- cohol is itself a source of calories, and most alcoholic beverages contain traces of other nutrients. Alcoholic beverages also rarely spoil and are free of most waterborne diseases. This was one reason why colonial Americans preferred alcohol to water, which was often considered impure and dangerous to drink. Alcohol is also an intoxicating drug that can induce physical addiction. Depending on many different factors, it can stimu- late or depress, make a person euphoric or sleepy, and heighten or reduce anxiety. The immediate effects of drinl~g vary widely in their degree and desirability, as evidenced by a rich vocab- ulary of descriptive terms. A person can be mellow, tipsy, or tight; plastered, soused, or loaded; dead drunk, under the table, or out cold. The term alcoholism implies, at minimum, a loss of control over the intake of alcohol or an inability to stop drinking. Def- initions and diagnostic criteria vary beyond this core element, but they generally refer to the quantities of alcohol consumed, the recurrence of physical signs such as blackouts, habits such as morning drinking or binge drinking, disruption of life such as job absenteeism or arrest, and tolerance or withdrawal symp-

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10 / ALCOHOL IN~ERICA toms.i Alcoholism is a subset of the broader category of excessive drinking, aZcoho! abuse, or problem drinking, terms which are used in this book to characterize all problems caused by or associated with drinking. In this broader category, the amount consumed may be considered excessive, even though it is not repeated on a regular basis. The measurement of consumption generally begins with the amount of alcohol in a drink. The common denominator joining the three types of alcoholic beverages beer, wine, and distilled spirits is ethyl alcohol, which is present in quite different concentrations in each type of beverage. Beer is generally 3 to 6 percent alcohol by volume, with "light" beer at the low end and "malt liquor" at the high end; wine is generally 10 to 20 percent alcohol, with table wine low and fortified "dessert" wine high; and spirits are today generally bottled at 40 percent alcohol (80 proof), with higher proofs for special labels. The way that beverages are ordinarily served in individual drinks greatly reduces these disparities in alcohol concentra- tion. A 12-ounce can of 4 percent beer, a 4-ounce serving of 12 percent wine, and a cocktail with 1.2 ounces of 80-proof spirits contain iclentical amounts of alcohol. Obviously, commercial vendors and private hosts can freely vary the size ant! dilution of their drinks. But as an overall rule of thumb, a single drink typically contains in the neighborhood of one-half fluid ounce of pure alcohol, about 12 grams by weight. Once consumed and passed from the stomach to the small intestine, alcohol is rapidly absorbed and ctiffusec! throughout Nor more detailed definitions, see Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Washington, D.C.: American Psychiatric Association, 1980; Lester Grinspoon, ea., "Part IV: Alcohol Abuse and Dependence," pp. 299-389 in Psychiatry Update, The American Psychiatric Association Annual Review, Volume III, Washington, D.C.: American Psychiatric Press, 1984; Jeffrey H. Boyd, Myrna M. Weissman, W. Douglas Thompson, and Jerome K. Myers, Different definitions of alcoholism, I: Impact of seven definitions on preva- lence rates in a community survey, American Journal of Psychiatry 140~1983~:1309- 1313; and Division of Health Promotion and Disease Prevention, Institute of Medicine, Alcoholism, Alcohol Abuse and Related Problems: Opportunities for Re- search, Washington, D.C.: National Academy of Sciences, 1980.

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DRONING IN AMERICA / ~ ~ the bocly. The most common laboratory measure of intoxication is blood alcohol concentration, or BAC. This measurement is typically expressed in terms of the weight of alcohol that is found in a standard volume of blood, also known as the "grams percent" figure. Thus a reading of .10 percent BAC means that there are .10 grams of pure alcohol per 100 milliliters of blood. The liver metabolizes alcohol at an average rate of about one drink per hour, so that any drinking in excess of this rate will elevate the BAC. However, this clearance rate and other phys- iological characteristics vary greatly, making some people more sensitive to alcohol than others. Also, an individual's responses can differ as a result of aging, illness, fatigue, or tolerance. Body weight, gender, the spacing of drinks, metabolic rates, how much food has been eaten, the drinker's expectations, and even the expectations of others influence the degree of intox- ication. A skinny teenager anticipating a big night with friends can become exhilarated on a quantity of alcohol that would produce virtually no effect in a heavy middle-aged man who had just finished a large dinner. The BAC correlates reliably with loss of coordination, espe- cially for such tasks as precise reasoning, eye-hand coordina- tion, and balance while moving. Intoxication also makes people generally less alert in scanning the environment for hazards, less reliable in interpreting what is observed, and inclined to relax or be easily distracted. At a BAC of 0.05 percent, which for most people requires three or more drinks within an hour, physical skills begin to deteriorate. At BACs of 0.08 to 0.10 percent, most jurisdictions consider a person legally intoxi- cated. At BACs of 0.15 to 0.30 percent a person can grow stu- porous or lose consciousness. Above 0.30 percent a person can die due to respiratory depression or inhaling vomit while un- conscious. Another important measure of drinking, besides the amount consumed in a single drinking episode, is the average amount of alcohol drunk over many drinking episodes. There are sev- eral ways to obtain such statistics, but the most valuable source of information is household surveys of the general population. These surveys do have limitations, however. Most important, people report drinking only about two-thirds of the total amount

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12 / ALCOHOL IN~ERICA of alcohol purchased. Nevertheless, because relatively small changes in the overall figures can account for the alcohol that goes unreported, such surveys provide a fairly good idea of how drinking habits are distributed across the population. The most remarkable result of these surveys is how much of the adult population does not drink or drinks very little (see Figure 1-2~. Approximately one third of all adults report not having drunk any alcohol over the previous year. This figure is down from the late 1950s, when 45 percent of all aclults reported abstaining. But it remains higher than in Canada or any of the countries of western Europe. For the nation as a DEAlLY COWSLIP on 50 pe8CEuT or D8l~6 _10 8 1 ~ _4 2 -2 10 FIGURE 1.2 Surveys of the general population indicate that roughly a third of the adult population in the United Stated does not drink, while another third has an average of less than three drinks per week. Such surveys account for only about two thirds of the total amount of alcohol purchased, but they give a fairly good idea of how consumption is distributed across the popu- lation. Source: Rand Corporation (Santa Monica, California).

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DRONING IN AMERICA / 13 whole, about 27 percent of men don't drink, compared with 42 percent of women. This widespread abstinence testifies to the continued strength of the temperance outlook in America. Another third of the adult population reports drinking very little fewer than three drinks per week. Thus two thirds of the adult population is very temperate. The next fifth or so of the population averages about two drinks per day. About the next tenth of all adults average three or more drinks per day. Twice as many men as women report this level of consumption. Finally, the last ~ to 4 percent of the population averages 10 or more drinks per day. Almost all people being treated for al- coholism report drinking this much, although this level of con- sumption is not a hard and fast definition of the disorder. Another standard way to assess the average consumption of alcohol in a given area is to divide the total amount of alcohol sold in that area by the area's adult population. The resulting per capita consumption rate can be skewed by large numbers of tourists, by the importation or exportation of alcohol (border- crossing "liquor runs," for example), and by unreported pro- duction (including production at home). But over a large area, such as an entire country, per capita consumption can be es- timated fairly well. The per capita consumption of pure alcohol in the United States is about two and three-quarter gallons per year, which corresponds to just under an ounce a day, or close to two drinks. Of course, this overall figure disguises a wicle variation in the drinking habits of individuals. The per capita consump- tion rate actually depends strongly on the drinking patterns of a minority of the population. A third of the adult population drinks 95 percent of all the alcohol consumed, with 5 percent of the population accounting for half of the overall total. Thus, changes in consumption among a small fraction of the popu- lation have a large impact on per capita consumption. The Consequences of Drinking Given the prevalence and variety of drinking in America, it is not surprising that the link between drinking and the con- sequences of drinking is very complex. Drinking never occurs in a social or psychological vacuum. It is done at a certain time,

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14 / ALCOHOL IN AMERICA in a certain place, often in the company of others, and in the context of profoundly intricate personal and social histories. All of these factors can influence what the consequences of drink- ing, whether positive or negative, will be. One way to begin untangling the links between the use of alcohol and its consequences is through an analysis of drinking practices. These practices have two components: the amount and distribution of alcohol consumed, and the settings and activities associated with drinking. Either of these aspects can play a critical role in determining the consequences of drinking. For instance, the more often a person is drunk, the greater the chance of being drunk in the wrong place at the wrong time. The frequency of drunkenness may also signal the onset of unreliability in a spouse or employee. The setting in which a person drinks can also be a pivotal factor. For instance, drinking at work or in public is generally more risky than drinking at home, where family members and familiar surroundings can keep a drinker out of trouble. Even drinking at home can be dangerous if combined with late-night smoking or hazardous household chores. It is especially dan- gerous to mix drinking and driving. There are certain negative consequences of drinking that do depend almost exclusively on the amount of alcohol consumed. An example is the disabling and potentially fatal liver disease known as cirrhosis. In this disease the cells of the liver are poisoned by excessive exposure to alcohol. Increasing numbers of these cells become inflamed and die, leaving useless scar tissue. Approximately 30,000 Americans die each year from ad- vanced cirrhosis, and it is one of the leading causes of death among micIdIe-aged men in much of the industrialized world. A large fraction of the victims of cirrhosis would not have con- tracted the disease if they did not drink. Among alcoholics who drink the equivalent of 10 drinks daily, 3 percent have cirrhosis and 25 percent have acutely inflamed livers, a precursor to cirrhosis. Furthermore, only half the people who die from cir- rhosis would meet the main diagnostic criteria for alcoholism, although most of them are heavy drinkers. In actuarial terms, a person who has three to four drinks daily incurs some ad- ditional risk of liver injury. But generally a person has to drink

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DRINKING IN ~ERICA / 15 very heavily for a number of years probably 15 or more- before cirrhosis becomes not only a disability but a threat to life. Another important type of alcohol-related death occurs in traffic accidents. Each year some 15 million people are involved in reported motor vehicle crashes in the United States, accord- ing to figures from the National Highway Traffic Safety Ad- ministration. In 1984 these crashes caused about 44,000 fatalities and over 3 million injuries. David Reect of Harvard University has calculated that approximately one quarter of these deaths and one tenth of these injuries are the direct result of intoxi- cation, meaning that they would not have occurred if the drivers involved in the accidents had not been drinking (Chapter 3 discusses these findings in more detail). Perhaps another quarter of all traffic deaths involve alcohol in a more tangential way. Traffic accidents receive the most attention, but as many peo- ple die each year from other kinds of accidents- especially falls, fires, and drownings as on the nation's highways. People who ctie in these accidents do not routinely have their blood tested for the presence of alcohol, as is the case with traffic fatalities, so it is more difficult to accurately attribute a per- centage of these accidents to drinking. But researchers have estimated that alcohol may be involved in as many as 40 percent of these accidents the equivalent of over 20,000 deaths. Alcohol-related overdoses are another major source of mor- tality. About 10,000 people die each year from this cause, half from alcohol alone, half from the combination of alcohol and other drugs. In the latter cases, death certificates list suicide as the cause of death about 40 percent of the time. Alcohol has an appallingly strong connection with suicide. One third of the nearly 30,000 suicides in the United States each year have al- coho! in their blood at death. Among the 200,000 to 400,000 attempted suicides each year, alcohol problems are five times more common than in a comparable nonsuicidal group. Homicides are another form of violent cleath that may be related to drunkenness. Each year about 10,000 murders occur in situations involving alcohol. However, as with suicides in- volving alcohol, it is impossible to unambiguously attribute these deaths to drinking, since so many other factors are in- variably involved.

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16 / ALCOHOL IN AMERICA Fetal alcohol syndrome is a substantial medical problem caused by excessive maternal drinking during pregnancy. An esti- mated 500 to 1,000 of the infants born each year to alcoholic mothers are mentally handicapped due to fetal alcohol syn- drome. Finally, there is a statistically uncertain contribution of alcohol abuse to deaths and disabilities due to heart and neck cancers; cardiovascular diseases, especially stroke; diabetes; and ALCoHoLlS] clPRHOSI' TRAFFIC ACCIDEN oTHER ACCIDENT HoMlClDE' S0lClDE'- _ . 30,000 CZECHS 60,0oo A CoHo,-RELATED, T SELECTED CAUSES OF DEATH U.S., 1975 FIGURE 1.3 The number of fatalities in the United States related to alcohol cannot be precisely determined, because of complicating factors and inade- quate reporting networks. But various ranges for alcohol-related deaths can be estimated using data for a given year in this case 1975. Sources: Uni- versity of California, Social Research Group (Berkeley, California), National Center for Health Statistics.

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DRINKING IN AMERICA / 17 organic brain syndromes. The presence of heavy smoking and other risk factors for these diseases among heavy cirinkers com- plicates statistical analyses. Adding up all of the fatalities related to excessive drinking, Dean Gerstein of the National Research Council concludes that alcohol may be involved in a maximum of 150,000 deaths per year (see Figure Id. Approximately 2 million people died in 1983 in the United States. Alcohol could therefore have been involved in about ~ out of every 13 cleaths. This does not mean that 150,000 people would not die each year if they did not drink. But curtailing the abuse of alcohol would certainly pre- vent some of these deaths. "How much less is not certain," writes Gerstein, "but a figure in the area of 50,000 theoretically preventable deaths seems reasonable." These are tragic statistics, and few people in the United States do not know someone who has been touched by them. But they are far from the whole picture. Fatalities are the most drastic consequences of alcohol abuse, but they also point to a much larger body of injuries, illnesses, psychological difficul- ties, and interpersonal problems related to alcohol. Health care expenses are a partial indicator of these more widespread negative consequences of drinking. Estimates of problem drinkers in hospital populations run to 30 percent or more, and many diagnoses in hospitals could include secondary diagnoses of alcoholism or alcohol abuse. Medical expenditures required by alcohol abuse anc! alcoholism have been calculated at $10 to $20 billion per year, and estimates of lost productivity in the workplace tend to be much higher. These numbers are hard to pin down, since alcohol abuse is so often just one of several factors contributing to an illness. But there is wide- spread agreement that excessive drinking exacts a heavy toll on overall levels of health. Another category of consequences known to be widespread but hard to quantify consists of the negative emotional effects of alcohol abuse. Many alcoholics report feeling depressed, anx- ious, powerless, or troubled. But all of these feelings also occur in people who don't drink. According to Gerstein, "Most of the behavioral and subjective states that we find easy to ascribe to drunkenness sociability or sadness, daring or tranquillity,

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IS / ALCOHOL IN~ERICA aggression or passivity do not spring directly from the bottle but find expression due to the social circumstances and per- sonalities in which drunkenness is brought into play." The same complexities mark the link between alcohol and social relationships. Personal accounts make it clear that alcohol abuse can exacerbate family problems, mar work relationships, and limit or abort career opportunities. But social relationships are so complex that it is difficult to analyze the specific role of alcohol in shaping them. In many cases, drinking can act more as a justification or excuse for destructive behavior than as a root cause of that behavior. The Positive Side of Drinking No accounting of the consequences of alcohol consumption would be complete without mention of the positive aspects of drinking. As the National Research Council pane} on alcohol abuse noted in its 1981 report, "That benefit results from drink- ing is usually conceded even by those who are most appalled by the damages. Over [$60 billion was spent in 1983] on alcohol by people who could have chosen to spend the money on better housing, new clothes, roast beef, or vacations." These expen- ditures on alcoholic beverages make a substantial contribution to the nation's economy. The alcoholic beverage industry consists of three tiers: the distillers, vintners, and brewers; the distribution and impor- tation companies; and the bars, taverns, liquor stores, groceries, restaurants, and other outlets that sell alcohol to the public. Many of these outlets depend on the sale of alcohol for their profit margins. Also, many spectator and participant sports have become closely linker! with alcohol sales. Another important consideration is the amount of drinking that does not lead to any serious trouble. Although some people regard any departure from sobriety as a deplorable social and moral problem, for most people short-lived periods of mild intoxication do not cause any substantial harm. Many people regard drinking and intoxication as relaxing and enjoyable, as a harmless indulgence, or as a way of turning an ordinary event

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DRONING IN AMERICA / 19 into a festive occasion. Alcohol can also contribute to such pos- itive family events as shared evening cocktails or celebratory toasts. "How do we quantify the effects of alcohol as parts of such occasions?" asks Gerstein. "On the basis of current data, we simply cannot do so. This cloes not make them any less real." Moderate drinking may even have a positive effect on health in certain circumstances. A number of studies have suggested a statistical association between moderate consumption of al- coho! and a reduced risk of ischemic heart diseases, the leading cause of death in the United States. If the use of alcohol were responsible for even a ~ percent reduction in the net risk of coronary death, about 5,000 fewer people would die from this cause each year. However, these studies have only examined special groups of people and have disagreed on what level of consumption is protective. Efforts to find a biochemical mech- anism responsible for this protection have so far been unsuc- cessful, anc! the possibility of significant unidentified variables exists. It may be that the benefits of moderate drinking are simply a reflection of the benefits of moderation as a personal style. Relatively few researchers have concentrated on the benefi- cial effects of drinking, whether economic, social, or personal. They have been much more industrious in uncovering and quantifying its negative consequences. There can be no ques- tion that these consequences are severe. But as we begin in the next chapter to investigate policies that can reduce the number of problems associated with drinking, the positive conse- quences must be kept in mind. If the cost of curtailing alcohol problems is a marked reduction in the possible benefits of drink- ing, an initiative in that direction is unlikely to gain wide sup- port. 2Ischemic heart disease refers to tissue damage caused by obstruction of the flow of arterial blood to the heart.