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OCR for page 104
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
OCR for page 105
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-
OCR for page 106
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
OCR for page 107
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
OCR for page 108
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
OCR for page 109
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 problems—and 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
OCR for page 110
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
idea—not 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
OCR for page 111
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-
OCR for page 112
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."
Representative terms from entire chapter:
drunk driving
