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9 Summary and Outlook The easy problems in public health have mainly been solved. Alcohol-related problems are far more complicated and their solutions more fraught with trouble than when our predecessors tried to clean up the water supply, wipe out cholera and dysentery, and immunize people against smallpox. I do not mean to suggest that conquering smallpox and purifying the water supply were really easy.... But we see in alcohol-related problems a spectrum of considerations broader than any involved in the great achievements of public health in the past. William Mayer, former head of the Alcohol, Drug Abuse, and Mental Health Administration A s WILLIAM MAYER OBSERVES, reducing the number of alcohol-relatect problems in America is a substantial ~ ~ challenge. in part, this is because of the prominent and deep-rooted role of drinking in American society (Chapter I). Prohibition demonstrated that it is impossible to eliminate drinking in the United States. So, too, is it impossible to elim- inate all of the problems caused by drinking the accidents, the illnesses, the social and psychological impairments. But one of the major themes running through this book has been that these problems are not unassailable. Their extent can be made smaller or larger by taking or failing to take appropriate actions. 104

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SUMMARY AND OUTLOOK / 105 The links between drinking and the various consequences of drinking both beneficial and detrimental are exceedingly complex. Some of them depend on how much people drink, how their bodies react to alcohol, how often they drink, how much they drink altogether, where they drink, when they drink, what they do while and after they drink, anc! how risky the environment is in which they drink. This tangled web of cause and effect makes it difficult to design policies that reduce alcohol problems while not overly curtailing the positive consequences of drinking. But it can also be seen as an opportunity: Each separate link between drinking and its adverse consequences offers a different approach to dealing with alcohol-related problems. An examination of which kinds of drinkers are susceptible to problems associated with alcohol reveals an unexpected find- ing (Chapter 2~. Very heavy drinkers, including people gen- eraBy considered alcoholics, do not suffer all of the problems caused by drinking. In fact, they do not even suffer most of them. Certainly, an alcoholic or heavy drinker has a greater chance of getting into trouble from drinking than does a more moderate drinker. But even a moderate drinker can be in an accident, become ill, or have difficulties with family or job that relate to drinking. Furthermore, there are many more moderate drinkers than heavy drinkers and many more heavy drinkers than alcoholics. As a result, at least half of the alcohol-related problems that occur in the United States cannot be reached by treatment pro- grams for alcoholics and other very heavy drinkers. It would be impossible to extend such programs to all drinkers. It would be too expensive, for one thing, and most light and moderate drinkers would justifiably fee! that they don't need individ- ualized treatment. There is a different way to influence this sizable fraction of America's alcohol-related problems. It is through initiatives that seek to prevent such problems before they occur or become inevitable. Such initiatives differ in several fundamental ways from treatment programs for alcoholics. They are impersonal actions that apply uniformly to large groups of people, thus reaching many people for whom treatment would be inappro-

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106 / ALCOHOL IN~ERICA priate. To be effective, they should be light and unburdensome rather than powerful and controlling. The most serious problem that preventive policies must face is drunk driving (Chapter 3~. About half of the 44,000 people killed in 1984 in traffic accidents had alcohol in their blood. Not all of these traffic fatalities were caused solely by the intoxication of a driver. But researchers estimate that somewhere around a quarter of these lives could have been saved if no one ever drove after Tracing. Similar estimates are that 150,000 to 300,000 disabling injuries and over $l billion in property damage could be prevented annually by keeping people who have been drink- ing off the road. Many of the preventive measures discussed in this book can help reduce drunk driving. But drunk drivers kill and injure enough innocent third parties to also require the intervention of the law. Research shows that raising the risk of arrest is a much more effective threat to potential ctrunk drivers than is imposing harsher penalties. An increased risk of arrest is es- pecially important at night, when most of the traffic accidents caused by alcohol occur. The other preventive measures considered in this book can be divided into three broad categories. In the first are those that affect the supply of alcohol and the places in which it is drunk. For the past 30 years, the price of alcohol and the re- str~ctions on its availability have gradually been declining (Chapter 4). Because taxes on alcohol have not kept up with inflation, alcohol has become cheaper in real terms. Simultaneously, more outlets selling alcohol have opened, these outlets have kept longer hours, and reduced drinking ages have made alcohol available to more people. During this same period, per capita alcohol consumption has gone up in the United States, increas- ing by over 30 percent since 1950. Research findings generally link increased consumption with lower real prices or increased availability. The evidence is now strong enough to urge caution upon legislators and Alcohol Beverage Control boards. For instance, studies have indicated that when taxes on alcohol go up, per capita consumption, cirrhosis death rates, and traffic fatalities all tend to go down. In making moves that will affect the price or availability of

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SUMMARY AND OUTLOOK / 107 alcohol, decision makers should realize that their actions also influence the health and welfare of people who drink alcohol. Another way to alter the supply of alcohol is by having com- mercial servers or social hosts see to it that their customers or guests do not drink too much or do not get in trouble if they do (Chapter 5~. Server intervention is encouraged by dramshop laws in over half of the states. These laws make servers liable for damages if they serve an underage or "obviously intox~- cated" person who later causes an accident. However, current ciramshop laws have proven relatively ineffective. The term "obviously intoxicated" offers little guidance to servers or to members of a jury, and many servers have chosen simply to insure against dramshop liability rather than to take active mea- sures to avoid it. Concerned groups and individuals have sug- gestecl that one way to make these laws more effective would be to rewrite them to recognize servers' overall degree of effort, including their willingness to intervene in the drinking of pa- trons and their efforts to see that patrons have a way to get home safely. The second category of preventive measures focuses on the drinking practices of people once they have access to alcohol. Education, especially of school-age children, has long been seen as one way for society to shape these drinking practices in beneficial ways (Chapter 6~. However, alcohol education in the schools has never been shown to have much effect. One prob- lem may be that this education sets its sights too high. Young people have plenty of problems with alcohol while in school, including violence, peer pressure, accidents, and reduced cIass- room performance. Lessons that focused on these problems, perhaps by teaching ways to avoid them, could be more useful than lessons that seek to make people responsible drinkers for the rest of their lives. There are many other forces in society that tend to moderate or increase drinking problems, including friends, family, and the mass media. Among the messages that may influence drinldng are alcohol advertising and the frequent depiction of drinking on television (Chapter 7~. However, as with violence on television, * is exceedingly difficult to conduct definitive research on the relationship between media depictions and real-life behavior. v v

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108 / ALCOHOL IN AMERICA The mass media can also be used to try to teach people that it is acceptable not to drink or that there are ways to drink more safely. Research shows, however, that isolated mass media campaigns have had little or no success in the past. A new approach that combines mass communication principles with individualized training for people who want to change has shown promise. But it is still uncertain if such efforts could be adapted to address alcohol-relatect problems on a large scale. The third category of preventive measures considers ways to make drinking safer even if people don't change their drinking practices. This entails making changes in the physical or social environment to reduce the risk for people who drink and for those around them (Chapter S). Because traffic fatalities account for about half of all the people killed in accidents, passive re- straints in automobiles, including air bags and automatic seat belts, are the technological devices with the greatest potential to reduce alcohol-related accidental deaths. But as many people are killed in other kinds of accidents falls, drownings, fires, etc. as in traffic accidents, and alcohol may be involved in as many or more of these deaths. A more thorough accounting of alcohol's role in all accidental deaths and injuries would make it easier to design products, surroundings, tools, and vehicles that are safer for everyone, not just for people who have been drinking. The quality of the evidence demonstrating the effectiveness of these various preventive measures differs. For changes in the price of alcohol and certain alterations in the physical en- vironment, the evidence is fairly persuasive. For educational campaigns and changes in availability, the evidence is frag- mentary or nonexistent. It should be remembered, however, that each preventive ini- tiative builds on the strength of all others. Another major theme of this book has been that prevention is a comprehensive con- cept, linking dozens of creative, well-balanced measures by the simple idea that they be broacily applied, impersonal, and prop- erly directed. As Lawrence Wallack of the University of Cali- fornia at Berkeley says, "Too much comes out in the form, 'it is this or that' and not enough in the form, 'l:t is all of these things, and each has to be developed and constructed in relation

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SUMMARY AND OUTLOOK / ^109 to the development and construction of the others.' A single program in and of itself may not make a detectable difference, but in relation to other strategies, both individual and aggre- gate, every individual effort may in fact serve a very important function." The Need for Community Support The past few years have seen a tremendous outpouring of enthusiasm and support for prevention as a way to deal with alcohol-related problems. Many of the most innovative, vital, and effective measures that have been taken have at least one thing in common: they have been created and sustained at the community level: In San Francisco, where a petition from an of} company to permit alcoholic beverage sales at drive-through gas station minimarts became a raDying point around which individuals and groups gathered to confront alcohol problemsand even- tually forced the withdrawal of the petition. In the south Bronx, where a community planning board has been working with state agencies to prevent the reestab- lishment of a high density of liquor stores in rebuilt areas. In Illinois, where community groups can draw upon two prevention resource centers for information, materials, and per- sonne! to set up their own prevention programs. O In the many corporations and other private companies that have found Dreventive Programs to be cheaper than their share of the health care costs generated by alcohol abuse. O In the over 100 chapters nationwide of Mothers Against Drunk Driving (MADD), in which people write letters, meet with local politicians, speak before community organizations, and otherwise work to achieve MADD's goals. ~ A - ~ ~ ~ --- - -- r ~ r - - o- Movements like this, which largely concentrate on state and local initiatives, are well suited to today's political climate. Since the 1980 elections, many federal programs have been placed in block grants to the states. This has moved a great deal of the detailed decision making out of federal agencies and into the

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110 / ALCOHOL IN AMERICA states. Interest has therefore intensified in prevention policies that can be implemented at the state and local levels. The community is a particularly important focus of preven- tive efforts. By nature, prevention programs are either based in a community or must have support there to survive. This requires that the people of a community acknowledge that al- coho! problems belong to everyone in the community, not just to the people clirectly afflicted. As Margaret Hastings of the TIlinois Commission~on Mental Health and Developmental Dis- abilities says, "Budgets for prevention programs are protected most effectively when there is community ownership of the ideanot just the schools or a parent group, but a consortium of community institutions. Then the chances that the preven- tion program will last are great." Similarly, preventive initiatives that arise spontaneously within a community are the ones with the greatest chance of success. "Ultimately, action initiated within the community is the action most likely to seize the community agenda and provide the opportunity for successful community cooperation to reduce alcohol problems," says Robert Reynolds of San Diego County's Department of Health Services. "All too seldom are those in- terested in prevention policies able to capture the public's at- tention; we in the alcohol field must learn to respond with sensitivity, support, and creativity to the opportunities pro- videct by others." An important component of preventive measures instituted at the community level should be the sharing of information among groups and indivicluals pursuing similar aims. A wide variety of experiments are going on throughout the country in all three categories of prevention. As much as possible should be learned from these experiments. The National Institute on Alcohol Abuse and Alcoholism could take the lead in dissem- inating the results of these experiments and other information about prevention. Such a service could let people know what is possible and how to achieve it. According to Michael Fox of the Ohio General Assembly, "A resource that pulls together the social costs in the criminal justice system, the health care system, the drunk driving fatalities, the teenage population problems that catalogs these costs and offers a menu from

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SUMMARY AND OUTLOOK / 111 A candlelight vigil organized by Mothers Against Drunk Driving (MADD). MADD and other groups like it are working to channel today's widespread concern about alcohol problems into specific legal and social actions. which we can choose programs that have proven to be suc- cessful in a cost-effective way would be extremely useful to policymakers, in the legislatures and state bureaucracies, and in county governments." As more and more people learn about what prevention can do, its successes are likely to multiply. As Reynolds says, "Suc- cess tends to have a catalytic effect." When communities learn that they can deal with alcohol problems at a public beach or park, at a sports stadium, or at a neighborhood corner, they are more willing to take on additional or larger problems. People in the field of prevention have seen this happening, and they are working to encourage it. it is an exciting time for the idea of prevention. Great energy and enthusiasm exist among many different groups and at many different levels. By putting these energies to use, a long-stand-

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Il2 / ALCOHOL IN AMERICA ing and serious problem in the United States could be signifi- cantly reduced. "Alcohol problems are now a topic of community discussion at the local, state, and national level," says Rey- nolds. ". . . This new social movement may well lead to major redefinitions of the role of alcohol in our society in the years ahead."