Contrary to popular belief, ethanol (the alcohol in alcoholic beverages) is not a stimulant, but a depressant. Although many of those who drink alcoholic beverages feel relaxation, pleasure, and stimulation, these feelings are in fact caused by the depressant effects of alcohol on the brain.
WHAT CONSTITUTES A DRINK?
In the United States a standard drink contains about twelve grams (about 0.5 fluid ounces) of pure alcohol. The following beverages contain nearly equal amounts of alcohol and are approximately standard drink equivalents:
- One shot (1.5 ounces) of spirits (eighty-proof whiskey, vodka, gin, etc.)
- One 2.5-ounce glass of a cordial, liqueur, or aperitif
- One five-ounce glass of table wine
- One three- to four-ounce glass of fortified wine, such as sherry or port
- One twelve-ounce bottle or can of beer
- One eight- to nine-ounce bottle or can of malt liquor
ALCOHOL CONSUMPTION IN THE UNITED STATES
After caffeine, alcohol is the most commonly used drug in the United States. Although researchers frequently count how many people are drinking and how often, the statistics do not necessarily reflect the true picture of alcohol consumption in the United States. People tend to underreport their drinking. Furthermore, survey interviewees are typically people living in households; therefore, the results of survey research may not include the homeless, a portion of the U.S. population traditionally at risk for alcoholism (alcohol dependence).
Per Capita Consumption of Alcohol
According to Table 2.1, the yearly per capita consumption of alcoholic beverages peaked at 28.8 gallons in 1981. (The per capita consumption includes the total resident population and all age groups.) Per capita consumption declined to 24.7 gallons in 1995 and has climbed only slightly since then. In 2004 the per capita consumption of alcoholic beverages was 25.2 gallons.
Beer remained the most popular alcoholic beverage in 2004, being consumed at a rate of 21.6 gallons per person. Nonetheless, this level of consumption (also seen in 2003 and 1997) is the lowest level since 1976, when 21.5 gallons were consumed. Beer consumption peaked in 1981 at 24.6 gallons per person, but its consumption declined steadily to its present relatively stable level by 1995. The per capita consumption of wine and spirits in the United States is much lower than that of beer; the 2004 per capita consumption of wine was 2.3 gallons, while per capita consumption of distilled spirits (liquor) was 1.4 gallons.
A complex set of factors contributes to variations in alcohol use over people's life spans. Part of the decline in alcohol consumption is a result of population trends. In the 1980s and 1990s the number of people in their early twenties—the leading consumers of alcohol—declined fairly steadily. The United States is also seeing a growing number of residents in their fifties and sixties. This is a group that is, in general, unlikely to consume as much alcohol as younger people.
Individual Consumption of Alcohol
The data for alcohol consumption noted in the previous section are per capita figures, which are determined by taking the total consumption of alcohol per year and dividing by the total resident population, including children. This figure is useful to see how consumption changes from year to year because it takes into account changes in the size of the resident population. Nonetheless, babies and small children generally do not consume alcohol, so it is also useful to look at consumption figures based on U.S. residents aged twelve and over.
|Per capita consumption of beer, wine, and distilled spirits, 1966–2004|
|Year||Total resident population|
|Notes: Alcoholic beverage per capita figures are calculated by Economic Research Service using industry data. Uses U.S. resident population, July.|
|aBeginning in 1983, includes winecoolers.|
|bComputed from unrounded data.|
|Source: "Alcoholic Beverages: Per Capita Consumption," U.S. Department of Agriculture, Economic Research Service, December 21, 2005, http://www.ers.usda.gov/data/foodconsumption/spreadsheets/beverage.xls#PccLiq!a1 (accessed October 2, 2006)|
Table 2.2 shows the percentage of respondents aged twelve and over who reported consuming alcohol in the past month in 2004 and 2005 when questioned for the annual National Survey on Drug Use and Health, which is conducted by the Substance Abuse and Mental Health Services Administration. In 2005, 51.8% of this total population had consumed alcohol in the month prior to the survey, as opposed to 50.3% of the total population in 2004. A higher percentage of males consumed alcoholic beverages in the past month than did females in both years. Table 2.2 also shows that alcohol consumption varies by race. A higher percentage of whites had used alcohol within the month prior to the survey than had African-Americans or Hispanics.
Prevalence of Problem Drinking
Table 2.2 also shows the percentages of Americans aged twelve and older who engaged in binge drinking or heavy alcohol use in the month prior to the survey. Binge drinking means that a person had five or more drinks on the same occasion, that is, within a few hours of each other. Heavy alcohol use means that a person had five or more drinks on the same occasion on each of five or more days in the past thirty days. All heavy alcohol users are binge drinkers, but not all binge drinkers are heavy alcohol users.
People aged eighteen to twenty-five were more likely than people in other age groups to have binged on alcohol and been heavy alcohol users in both 2004 and 2005. Much higher percentages of males binge drank and used alcohol heavily than females in the month prior to each of these surveys. In addition, American Indians and Alaskan Natives were the most likely to have engaged in binge and heavy alcohol use.
Most people consider an alcoholic to be someone who drinks too much and cannot control his or her drinking. Alcoholism, however, does not merely refer to heavy drinking or getting drunk a certain number of times. The diagnosis of alcoholism applies only to those who show specific symptoms of addiction, which the Institute of Medicine (1996, http://www.iom.edu/) defines as a brain disease "manifested by a complex set of behaviors that are the result of genetic, biological, psychological, and environmental interactions."
Robert M. Morse and Daniel K. Flavin, in "The Definition of Alcoholism" (Journal of the American Medical Association, August 1992), define alcoholism as:
A primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic.
"Primary" refers to alcoholism as a disease independent from any other psychological disease (for example, schizophrenia), rather than as a symptom of some other underlying disease. "Adverse consequences" for an alcoholic can include physical illness (liver disease, withdrawal symptoms, etc.), psychological problems, interpersonal difficulties (such as marital problems or domestic violence), and problems at work. "Denial" includes a number of psychological maneuvers by the drinker to avoid the fact that alcohol is the cause of his or her problems. Family and friends may reinforce an alcoholic's denial by covering up his or her drinking (for example, calling an employer to say the alcoholic has the flu rather than a hangover). Such behavior is also known as enabling. In other words, the friends and family make excuses for the drinker and enable him or her to continue drinking as opposed to having to face the repercussions of his or her alcohol abuse. Denial is a major obstacle in recovery from alcoholism.
|Percentage of past-month alcohol use, binge alcohol use, and heavy alcohol use among drinkers aged 12 and older, by demographic characteristics, 2004 and 2005|
|Demographic characteristic||Type of alcohol use|
|Alcohol use||Binge alcohol use||Heavy alcohol use|
|*Low precision; no estimate reported.|
|Note: Binge alcohol use is defined as drinking five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days. Heavy alcohol use is defined as drinking five or more drinks on the same occasion on each of 5 or more days in the past 30 days; all heavy alcohol users are also binge alcohol users.|
|Source: "Table 2.52B. Alcohol Use, Binge Alcohol Use, and Heavy Alcohol Use in the Past Month among Persons Aged 12 or Older, by Demographic Characteristics: Percentages, 2004 and 2005," in Results from the 2005 National Survey on Drug Use and Health: Detailed Tables, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2006, http://www.oas.samhsa.gov/nsduh/2k5nsduh/tabs/Sect2peTabs47to56.pdf (accessed October 3, 2006)|
|26 or older||53.0||55.1||21.1||21.0||6.1||5.6|
|Hispanic origin and race|
|Not Hispanic or Latino||51.8||53.2||22.6||22.5||7.2||6.7|
|Black or African American||37.1||40.8||18.3||20.3||4.4||4.2|
|American Indian or Alaska Native||36.2||42.4||25.8||32.8||7.7||11.5|
|Native Hawaiian or other Pacific Islander||*||37.3||*||25.7||4.9||5.3|
|Two or more races||52.4||47.3||23.5||20.8||6.9||5.6|
|Hispanic or Latino||40.2||42.6||24.0||23.7||5.3||5.6|
ALCOHOLISM AND ALCOHOL ABUSE
The American Psychiatric Association (APA), which publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM), first defined alcoholism in 1952. DSM-III, the third edition of the APA's publication, renamed alcoholism as alcohol dependence and introduced the phrase alcohol abuse. According to DSM-III 's definitions of alcohol abuse, the condition involves a compulsive use of alcohol and impaired social or occupational functioning, whereas alcohol dependence includes physical tolerance and withdrawal symptoms when the drug is stopped. DSM-IV-TR, the most recent edition, refines these definitions further, but the basic definitions remain the same.
Four symptoms of alcoholism
Alcoholism, also known as "alcohol dependence," is a disease that includes four symptoms:
- Craving: A strong need, or compulsion, to drink.
- Loss of control: The inability to limit one's drinking on any given occasion.
- Physical dependence: Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, occur when alcohol use is stopped after a period of heavy drinking.
- Tolerance: The need to drink greater amounts of alcohol in order to "get high."
source: Adapted from Alcoholism: Getting the Facts, U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, revised 2004, http://pubs.niaaa.nih.gov/publications/GettheFacts_HTML/Facts.pdf (accessed October 6, 2006)
The World Health Organization publishes the International Classification of Diseases (ICD), which is designed to standardize health data collection throughout the world. The tenth edition (ICD-10 ) generally defines abuse and tolerance similarly to the DSM-IV-TR.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA), in its September 2004 update of Alcoholism: Getting the Facts, states that alcoholism (alcohol dependence) is a disease that includes the four symptoms listed and described in Table 2.3.
Four symptoms of alcohol abuse
Alcohol abuse is defined as a pattern of drinking that results in one or more of the following situations within a 12-month period:
- Failure to fulfill major work, school, or home responsibilities;
- Drinking in situations that are physically dangerous, such as while driving a car or operating machinery;
- Having recurring alcohol-related legal problems, such as being arrested for driving under the influence of alcohol or for physically hurting someone while drunk; and
- Continued drinking despite having ongoing relationship problems that are caused or worsened by the drinking.
source: Adapted from Alcoholism: Getting the Facts, U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, revised 2004 http://pubs.niaaa.nih.gov/publications/GettheFacts_HTML/Facts.pdf (accessed October 6, 2006)
According to the NIAAA, "alcohol abuse differs from alcoholism in that it does not include an extremely strong craving for alcohol, loss of control over drinking, or physical dependence." The symptoms of alcohol abuse are listed in Table 2.4. The NIAAA notes that "although alcohol abuse is basically different from alcoholism, many effects of alcohol abuse are also experienced by alcoholics."
Other characteristics of alcohol abuse include the need to drink before facing certain situations, frequent drinking sprees, a steady increase in intake, solitary drinking, early morning drinking, and the occurrence of blackouts. Blackouts for heavy drinkers are not episodes of passing out, but are periods drinkers cannot remember later, even though they appeared to be functioning at the time.
Prevalence of Alcohol Dependence, Alcohol Abuse, Binge Drinking, and Heavy Drinking
The Strategic Plan 2001–2005 of the NIAAA notes that nearly fourteen million Americans—one in every thirteen adults—have alcohol-abuse or alcohol-dependence problems.
Figure 2.1 shows the percentages of people who engaged in alcohol use, binge drinking, and heavy alcohol use in 2005 by age group. The graph shows that people aged eighteen to twenty-nine are more likely to engage in binge drinking and heavy alcohol use than those aged twelve to seventeen or those aged thirty and older. The graph also shows that as people grow older, alcohol use (not binge or heavy) becomes prevalent, and binge and heavy alcohol use decline.
Table 2.2 compares the rates of binge drinking for males and females across all age groups. In 2004 and 2005 the rate of binge drinking in males was substantially higher than that of females. The percentage of males who binge drank in 2004 and 2005 was 31.1% and 30.5%, respectively, whereas the percentage of females who binge drank was about half that, at approximately 15%. In addition, heavy alcohol use was much more prevalent in males than in females. Approximately 10% of males were heavy alcohol users in 2004 and 2005, whereas only about 3% of females were in this group.
ALCOHOL ABUSE AND ALCOHOLISM IN VARIOUS RACIAL AND ETHNIC GROUPS
As shown in Table 2.2, patterns of alcohol consumption vary across racial and ethnic groups. The NIAAA suggests that low alcoholism rates occur in certain groups because the drinking customs and sanctions (permissions) are well established and consistent with the rest of the culture. Conversely, multicultural populations have mixed feelings about alcohol and no common rules; they tend to have higher alcoholism rates. Frank H. Galvan and Raul Caetano note in "Alcohol Use and Related Problems among Ethnic Minorities in the United States" (Alcohol Research and Health, Winter 2003) that a population's alcohol norms (how one should behave in relation to alcohol) and attitudes (general beliefs about drinking) have been found to be strong predictors of drinking.
In addition, certain populations may be at a higher or lower risk because of the way their bodies metabolize (chemically process) alcohol. For example, many Asians have an inherited deficiency of aldehyde dehydrogenase, a chemical that breaks down ethyl alcohol in the body. Without it, toxic substances build up after drinking alcohol and rapidly lead to flushing, dizziness, and nausea. Therefore, many Asians experience warning signals very early on and are less likely to continue drinking. Conversely, research results suggest that Native Americans may lack these warning signals. They are less sensitive to the intoxicating effects of alcohol and are more likely to develop alcoholism. Table 2.2 shows that the prevalence of binge alcohol use and heavy alcohol use is the lowest for Asians and the highest in for Native Americans.
RISK FACTORS OF ALCOHOL ABUSE AND ALCOHOLISM
The development of alcoholism is the result of a complex mix of biological, psychological, and social factors. Table 2.5 summarizes risk factors for alcohol use, abuse, and dependence. Genetics and alcohol reactivity (sensitivity) are biological factors. The rest are psychosocial factors.
A variety of studies investigating family history, adopted versus biological children living in the same families, and twins separated and living in different families all indicate that genetics plays a substantial role in some forms of alcohol dependence and heavy drinking. For example, in "Genetics of Alcohol and Tobacco Use in Humans" (Annals of Medicine, 2003), Rachel F. Tyndale
indicates that many genes are likely to be involved, each contributing a small part of the overall risk.
ALCOHOL REACTIVITY (SENSITIVITY)
Alcohol reactivity or sensitivity refers to the sense of intoxication one has when drinking alcohol. The research on this topic has been conducted primarily on sons of alcoholics and reveals that, in general, they have a lower reactivity to alcohol. That is, when given moderate amounts of alcohol, sons of alcoholics report a lower subjective sense of intoxication compared with sons of nonalcoholics. Sons of alcoholics also show fewer signs of intoxication on certain physiological indicators than do sons of nonalcoholics. Without early signals of intoxication, men with a low reactivity to alcohol may tend to drink more before they begin to feel drunk and thus may develop a high physiological tolerance for alcohol, which magnifies the problem. Susan Nolen-Hoeksema notes in "Gender Differences in Risk Factors and Consequences for Alcohol Use and Problems" (Clinical Psychology Review, December 2004) that "long-term studies of men with low reactivity to moderate doses of alcohol suggest they are significantly more likely to become alcoholics over time than are men with greater reactivity to moderate doses of alcohol." (See Table 2.5.)
SOCIAL SANCTIONS, GENDER ROLES, AND COPING STYLES
Social sanctions are a mechanism of social control for enforcing a society's standards. Social sanctions may be one factor explaining why men drink more alcohol than women. A "double standard" appears to exist for men and women in American society with regard to consuming alcohol. Research findings support this idea. For example, Nancy D. Vogeltanz and Sharon C. Wilsnack find in "Alcohol Problems in Women: Risk Factors, Consequences, and Treatment Strategies" (Sheryle J. Gallant, Gwendolyn Puryear Keita, Reneé Royak-Schaler, eds., Health Care for Women: Psychological, Social, and Behavioral Influences, 1997) that in 1996 women thought that 50% of people at a party would disapprove of a woman getting drunk but that only 30% would disapprove of a man doing the same.
Besides social sanctions against women drinking as heavily as men, American culture appears to identify alcohol consumption as more of a part of the male gender role than of the female gender role. While discussing and reviewing the results of several studies, Nolen-Hoeksema "find[s] that people, particularly women, who endorse
|Risk factors for alcohol use, abuse, and dependence|
|Source: Reprinted from Susan Nolen-Hoeksema, "Gender Differences in Risk Factors and Consequences for Alcohol Use and Problems," in Clinical Psychology Review, vol. 24, no. 8, 2004, 981 = 1010, http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VB8-4DG3DCH-1&_user=10&_handle=V-WA-A-W-E-MsSAYVW-UUA-U-AAZZEZBYWZ-AAZVCVVZWZ-EYBCEWVZ-E-U&_fmt=summary&_coverDate=12%2F01%2F2004&_rdoc =4&_orig=browse&_srch=%23toc%235920%232004%23999759991%23527116!&_cdi=5920&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=40d785e3d01008ef15122c95de7802f7 (accessed October 6, 2006). Copyright © 2004 with permission from Elsevier.|
|Genetics||Most studies find genetics contribute to alcoholism and alcohol use in both women and men; some studies suggest genetics play a stronger role in alcoholism for men than for women.|
|Alcohol reactivity||Studies of men find low alcohol reactivity is associated with a history of familial risk for alcohol use disorders and the development of alcohol use disorders in men. There are only a few small studies of women, but these studies also tend to find an association between familial risk for alcoholism and low alcohol reactivity. It is unknown whether there are gender differences in alcohol reactivity, but other studies find women may be more cognitively and motorically impaired at lower doses of alcohol, suggesting they have greater alcohol reactivity.|
|Social sanctions||Social sanctions are perceived to be greater for women drinking than for men drinking. It is unclear whether or not women actually suffer more negative social consequences as a result of heavy drinking than men.|
|Gender roles||Feminine traits (e.g., nurturance and warmth) are associated with less use and fewer alcohol problems. Undesirable masculine traits (aggressiveness and overcontrol) are associated with heavy and problematic alcohol use. Socially desirable masculine traits (instrumentality) are associated with fewer drinking problems. Patterns are generally the same for males and females. One study found that gender differences in gender role traits mediated gender differences in alcohol use and problems.|
|Coping styles||Avoidant coping is more consistently associated with alcohol consumption and drinking problems in men than in women. It is not clear whether there are gender differences in avoidant coping.|
|Motives and expectancies||Drinking to cope with distress and positive expectancies for the outcomes of alcohol consumption (e.g., that it will reduce distress) are associated with alcohol consumption and problem drinking; this relationship tends to be stronger for men than for women. Men tend to be more likely than women to report drinking to cope and positive expectancies for alcohol use.|
|Depression/distress||Among social drinkers, some studies show a stronger relationship between distress and drinking for men than women, whereas others show the opposite gender pattern; among alcoholics, the relationship between distress and alcohol use or problems is stronger for women than men.|
|Self-esteem||Some evidence suggests that low self-esteem is associated with alcohol-related problems in women more than men, but this result is inconsistent.|
|Behavioral undercontrol/sensation-seeking/impulsivity||Men score higher than women on measures of behavioral undercontrol, sensation-seeking, and impulsivity. These variables are consistently associated with alcohol use and problems in men, less consistently so in women.|
|Antisociality||Males are more likely to show symptoms of antisociality and delinquency than females. Antisociality is associated with alcohol use and disorders in both males and females.|
|Interpersonal relationships||There are strong similarities between partners in heterosexual couples in drinking patterns. It is not clear whether the effects of a partner on the individual's drinking are stronger for women or men.|
|Sexual assault||A history of sexual assault is associated with problem drinking and alcohol use disorders in both women and men. Women are more likely to have a history of sexual assault.|
traditionally feminine traits (nurturance, emotional expressivity) report less quantity and frequency of alcohol use." (See Table 2.5.) In contrast, traits often associated with the male gender role, such as aggressiveness and overcontrol of emotions, have been associated with heavy and problem alcohol use in both men and women. In fact, heavy drinking may be a way that some people cope with stress and avoid emotions, a behavior referred to as "avoidant coping."
DRINKING MOTIVES, EXPECTATIONS, AND DEPRESSION/DISTRESS
People consume alcohol for various reasons: as part of a meal, to celebrate certain occasions, and to reduce anxiety in social situations. Nolen-Hoeksema comments that people also consume alcohol to cope with distress or depression or to escape from negative feelings. Consequently, people expect that drinking alcohol will reduce tension, increase social or physical pleasure, and facilitate social interaction. Those who have positive expectations for their drinking, such as the belief that alcohol will reduce distress, tend to drink more than those who have negative expectancies, such as the belief that alcohol will interfere with the ability to cope with distress. In general, men have more positive expectations concerning alcohol consumption than women. These stronger motives to drink are more strongly associated with alcohol-related problems in men than in women, although Nolen-Hoeksema reports that the relationships among depression, general distress, alcohol consumption, and problems are quite complex. (See Table 2.5.)
SELF-ESTEEM, IMPULSIVITY, SENSATION-SEEKING, BEHAVIORAL UNDERCONTROL, AND ANTISOCIALITY
As Table 2.5 shows, research results are inconclusive regarding the relationship between self-esteem and alcohol use. However, impulsivity, sensation-seeking, and behavioral undercontrol (not controlling one's behavior well) are consistently associated with alcohol use and problems in men. This association is less clear in women and may be another factor determining why a higher percentage of men than women are alcohol dependent.
Antisociality is a personality disorder that includes a chronic disregard for the rights of others and an absence of remorse for the harmful effects of these behaviors on others. People with this disorder are usually involved in aggressive and illegal activities. They are often impulsive and reckless and are more likely to become alcohol dependent. Males are more likely than females to demonstrate antisociality. (See Table 2.5.)
INTERPERSONAL RELATIONSHIPS AND SEXUAL ASSAULT
Married couples often have strongly similar levels of drinking. It is unclear whether men and women with problem drinking patterns seek out partners with similar drinking patterns or whether either is influenced by the other to drink during the marriage. However, marital discord is often present when spouses' drinking patterns differ significantly.
Being a victim of sexual assault is a risk factor for problem drinking. The results of many studies show that women who have experienced a history of sexual assault, whether during childhood or as an adult, are at increased risk for problem drinking and alcohol abuse. According to Nolen-Hoeksema, the correlation is not as clear in men.
Effects of Alcoholism on Family Members
Living with someone who has an alcohol problem affects every member of the family. Children seem to suffer the most. The National Association for Children of Alcoholics, in the fact sheet "Children of Addicted Parents: Important Facts" (2000, http://www.nacoa.net/pdfs/addicted.pdf), estimates that there are more than twenty-eight million children of alcoholics in the United States, including more than eleven million under the age of eighteen. Researchers suspect that children of alcoholics have a risk for alcoholism and other drug abuse two to nine times greater than that of children of non-alcoholics. They are also thought to be more likely to suffer from attention-deficit hyperactivity disorder, behavioral problems, and anxiety disorders. They tend to score lower on tests that measure cognitive and verbal skills. Children of alcoholics are also more likely to be truant, repeat grades, drop out of school, or be referred to a school counselor or psychologist.
SHORT-TERM EFFECTS OF ALCOHOL ON THE BODY
When most people think about how alcohol affects them, they think of a temporary light-headedness or a hangover the next morning. Many are also aware of the serious damage that continuous, excessive alcohol use can do to the liver. Alcohol, however, affects many organs of the body and has been linked to cancer, mental and/or physical retardation in newborns, heart disease, and other health problems.
Low to moderate doses of alcohol produce a slight, brief increase in heartbeat and blood pressure. Large doses can reduce the pumping power of the heart and produce irregular heartbeats. In addition, blood vessels within muscles constrict, but those at the surface expand, causing rapid heat loss from the skin and a flushing or reddening. Thus, large doses of alcohol decrease body temperature and, additionally, may cause numbness of the skin, legs, and arms, creating a false feeling of warmth. Figure 2.2 illustrates and describes in more detail the path alcohol takes through the body after it is consumed.
Alcohol affects the endocrine system (a group of glands that produce hormones) in several ways. One effect is increased urination. Urination increases not only because of fluid intake but also because alcohol stops the release of an antidiuretic hormone—ADH, or vasopressin—from the pituitary gland. This hormone controls how much water the kidneys reabsorb from the urine as it is being produced and how much water the kidneys excrete. Therefore, heavy alcohol intake can result in both dehydration and an imbalance in electrolytes, which are chemicals dissolved in body fluids that conduct electrical currents. Both of these conditions are serious health hazards.
Alcohol is sometimes believed to be an aphrodisiac (sexual stimulant). Whereas low to moderate amounts of alcohol can reduce fear and decrease sexual inhibitions, larger doses tend to impair sexual performance. Alcoholics sometimes report difficulties in their sex lives.
The speed of alcohol absorption affects the rate at which one becomes intoxicated. Intoxication occurs when alcohol is absorbed into the blood faster than the liver can oxidize it (or break it down into water, carbon dioxide, and energy). In a 160-pound man, alcohol is metabolized (absorbed and processed by the body) at a rate of about one drink every two hours. The absorption of alcohol is influenced by several factors:
- Body weight—Heavier people are less affected than lighter people by the same amount of alcohol because there is more blood and water in their system to dilute the alcohol intake. In addition, the greater the body muscle weight, the lower the blood alcohol concentration (BAC) for a given amount of alcohol.
- Speed of drinking—The faster alcohol is drunk, the faster the BAC level rises.
- Presence of food in the stomach—Eating while drinking slows down the absorption of alcohol by increasing the amount of time it takes the alcohol to get from the stomach to the small intestine.
- Drinking history and body chemistry—The longer a person has been drinking, the greater his or her tolerance (in other words, the more alcohol it takes him or her to get drunk). An individual's physiological functioning or "body chemistry" may also affect his or her reactions to alcohol. Women are more easily affected by alcohol regardless of weight because women metabolize alcohol differently than men. Women are known to have less body water than men of the same body weight, so equivalent amounts of alcohol result in higher concentrations of alcohol in the blood of women than men.
As a person's BAC rises, there are somewhat predictable responses in behavior.
- At a BAC of about 0.05 g/dL (0.05 grams of alcohol per 1 deciliter of blood), thought processes, judgment, and restraint are more lax. The person may feel more at ease socially. Also, reaction time to visual or auditory stimuli slows down as the BAC rises. (Note: A measurement of g/dL—a mass/volume measure—is approximately equal to a volume/volume—or a percentage—measurment when calculating BAC, and the two are often used interchangeably; so, a BAC of 0.05 g/dL can also mean a BAC of 0.05%.)
- At 0.10 g/dL, voluntary motor actions become noticeably clumsy. (It is illegal to drive with a BAC of 0.08 g/dL or higher.)
- At 0.20 g/dL, the entire motor area of the brain becomes significantly depressed. The person staggers, may want to lie down, may be easily angered, or may shout or weep.
- At 0.30 g/dL, the person generally acts confused or may be in a stupor.
- At 0.40 g/dL, the person usually falls into a coma.
- At 0.50 g/dL or more, the medulla is severely depressed, and death generally occurs within several hours, usually from respiratory failure. The medulla is the portion of the brainstem that regulates many involuntary processes, such as breathing.
There have been some cases of delayed death from circulatory failure as long as sixteen hours after the last known ingestion of alcohol. Without immediate medical attention, a person whose BAC reaches 0.50 g/dL will almost certainly die. Death may even occur at a BAC of 0.40 g/dL if the alcohol is "chugged," or consumed quickly and in a large amount, causing the BAC to rise rapidly.
Time is the only way to rid the body of alcohol. The more slowly a person drinks, the more time the body has to process the alcohol, so less alcohol accumulates in the bloodstream. According to the National Clearinghouse for Alcohol and Drug Information, five drinks consumed in quick succession by a 180-pound man will produce a BAC of 0.11 g/dL. In a 140-pound man this intake will produce a BAC of 0.13 g/dL. In a 120-pound woman it will produce a BAC of 0.19 g/dL. The body takes nearly seven hours to metabolize this blood concentration of alcohol. Under normal conditions five drinks consumed with an hour or so between each drink will produce a BAC of only 0.02 g/dL, depending on the gender and weight of the person. It will likely produce a BAC higher than 0.02 g/dL in women and people weighing less than 180 pounds.
|Symptoms of a hangover|
|Source: Max H. Pittler, Adrian R. White, Clare Stevinson, and Edzard Ernst, "Box 1. Symptoms Assessed in Hangover Questionnaire," in "Effectiveness of Artichoke Extract in Preventing Alcohol-Induced Hangovers: A Randomized Controlled Trial," in Canadian Medical Association Journal, vol. 169, no. 12, December 9, 2003, http://www.cmaj.ca/cgi/reprint/169/12/1269?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=hangover&searchid=1&FIRSTINDEX=0&volume=169&issue=12&resourcetype=HWCIT (accessed November 24, 2006). Copyright © 2003 Canadian Medical Association or its licensors. Reprinted by permission of the publisher.|
|Alertness (lack of)||Laziness, fatigue|
|Clumsiness, uncoordination||Lightheadedness, dizziness|
|Dazed state||Loose bowels|
|Difficulty concentrating||Muscle aches|
|Drowsiness, mental slowness||Nausea|
Hangovers cause a great deal of misery as well as absenteeism and loss of productivity at work or school. A person with a hangover experiences two or more physical symptoms after drinking and fully metabolizing alcohol. The major symptoms of a hangover are listed in Table 2.6, but the causes of these symptoms are not well known. Results from Jeff Wiese et al.'s study "Effect of Opuntia ficus indica on Symptoms of the Alcohol Hangover" (Archives of Internal Medicine, June 28, 2004) support the idea that the symptoms of a hangover are largely because of an inflammatory response of the body to impurities in alcohol and by-products of alcohol metabolism. Fluctuations in body hormones and dehydration intensify hangover symptoms.
There is no scientific evidence to support popular hangover cures, such as black coffee, raw egg, chili pepper, steak sauce, "alkalizers," and vitamins. To treat a hangover, health care practitioners usually prescribe bed rest as well as eating food and drinking nonalcoholic fluids.
LONG-TERM EFFECTS OF ALCOHOL ON THE BODY
The results of scientific research help health care practitioners and the general public understand both the positive and negative health consequences of drinking alcohol. Table 2.7 summarizes major diseases and injury conditions related to alcohol use and the proportions attributable to alcohol worldwide. As Table 2.7 notes, about one-fifth of mouth and throat cancers are related to drinking alcohol. Nearly one-third of cancers of the esophagus (food tube) and one-fourth of cancers of the liver are linked to alcohol consumption as well. Alcohol consumption is also related to heart disease and stroke and is associated with cirrhosis of the liver, a condition in which the liver becomes scarred and dysfunctional. In addition, one-fifth of motor vehicle accidents are related to alcohol consumption.
Scientists have developed research-based hypotheses (explanations) about the interaction between alcoholism and various characteristics, such as aging, gender, family history, and vitamin deficiency. They have also developed explanations about how alcohol affects the brain. These explanations are based on evidence from scientific studies, brain scans, and analyses of brain tissue after death. For example, results from Marlene Oscar-Berman and Ksenija Marinkovic's study "Hypotheses Proposed to Explain the Consequences of Alcoholism for the Brain" (Alcohol Research and Health, Spring 2003) support the idea that alcoholism accelerates aging, affects women more than men, and runs in families.
Not all the effects of alcohol consumption are harmful to health. Table 2.8 presents five tables (A to E) that list levels of alcohol consumption and the relative risk for total mortality and a variety of other diseases and conditions. Table A in Table 2.8 shows alcohol consumption versus relative risk of total mortality in men aged forty to eighty-five. To obtain these data, researchers compared total mortality (death rate; similar to life expectancy) among those who rarely or never drank alcohol with those who did drink alcohol. Those who rarely or never drank were assigned a value of 1.00 for their risk of total mortality. Numbers above 1.00 mean a higher risk of total mortality (lower life expectancy). Numbers below 1.00 mean a lower risk of total mortality (higher life expectancy). Table A shows that men aged forty to eighty-five who drank up to (and possibly slightly over) two drinks per day had a lower total mortality risk than those who did not drink. That is, this level of drinking was good for the men's overall health and life expectancy.
Table B in Table 2.8 shows alcohol consumption versus relative risk of hypertension (chronic high blood pressure) in women aged twenty-five to forty-two. This table shows that women in this age group who had up to one drink per day had a lower risk of hypertension than women in the same age group who did not drink alcohol. Drinking slightly more than one drink per day to 1.5 drinks per day put these drinkers at equal relative risk for hypertension as those who did not drink alcohol. Drinking more than 1.5 drinks per day was detrimental and put these heavier drinkers at a higher relative risk for hypertension than their nondrinking counterparts.
|Major diseases and injuries linked to alcohol and the extent of effects worldwide, 2005|
|Source: Reprinted from Robin Room, Thomas Babor, and Jürgen Rehm, "Table 1. Major Diseases and Injury Conditions Related to Alcohol and Proportions Attributable to Alcohol Worldwide," in "Alcohol and Public Health," in The Lancet, vol. 365, February 5, 2005, 519=530, http://www.thelancet.com (accessed October 3, 2006). Copyright © 2005, with permission from Elsevier.|
|Mouth and oropharynx cancers||22%||9%||19%|
|Unipolar depressive disorders||3%||1%||2%|
|Alcohol use disorders: alcohol dependence and harmful use||100%||100%||100%|
|Ischaemic heart disease||4%||−1%||2%|
|Cirrhosis of the liver||39%||18%||32%|
|Motor vehicle accidents||25%||8%||20%|
Table C in Table 2.8 shows a similar pattern of alcohol consumption versus relative risk. Drinking small amounts of alcohol had positive health effects, whereas drinking above a certain threshold limit had negative health effects. With respect to dementia in adults aged sixty-five and over, those consuming one to six drinks weekly had a lower risk of dementia than those who abstained from drinking. Those consuming fourteen or more drinks per week had a higher risk of dementia than those who abstained.
Tables D and E in Table 2.8 show somewhat different patterns than tables A to C. Although drinking two to four drinks per week reduced the risk of age-related macular degeneration (a disease of the retina of the eye), one drink per week had no protective effect and five to six drinks per week appeared to raise the relative risk of this disease in men aged forty to eighty-five. Table E shows that women who drank even small amounts of alcohol raised their relative risk of breast cancer. Although Table E shows that drinking 31 to 40 grams per day of alcohol (about 2.5 to 3.5 drinks per day) may have a protective effect, the results of most studies on this topic do not show this effect. They conversely show that a moderately high consumption of alcohol is linked to a greater risk of breast cancer.
|Alcohol consumption and risk of death or serious health problems, by age and gender|
|Note: One drink is approximately 14g of alcohol|
|aAdjusted for age and other cardiovascular risk factors.|
|bLess than 1 drink/week was the referent group.|
|Source: Adapted from Ronald C. Hamdy and Melissa McManama Aukerman, "Alcohol on Trial: The Evidence," in Southern Medical Journal, vol. 98, no. 1, 2005, 35-56, http://www.sma.org/smj/ (accessed October 9, 2006)|
|(A) Alcohol consumption and total mortality in men aged 40-85|
|Alcohol consumption||Relative riska|
|(B) Alcohol consumption and risk of hypertension in women aged 25-42|
|Alcohol consumption||Relative risk|
|(C) Alcohol consumption and risk of dementia in adults aged 65 and older|
|Alcohol consumption||Relative risk|
|(D) Alcohol consumption and risk of macular degeneration in men aged 40-84|
|Alcohol consumption||Relative risk|
|1 or more drinks/day||1.27|
|(E) Alcohol consumption and risk of breast cancer in women aged 40-59|
|Alcohol consumption||Relative risk|
With so many studies and so many health-related factors to take into account, how does a person know how much alcohol is beneficial and how much is too much? The American Cancer Society (2006, http://www.cancer.org/) recommends that people should "drink alcohol only occasionally, and sparingly." The National Cancer Institute (2005, http://progressreport.cancer.gov/) states that "in general, these [cancer] risks increase after about one daily drink for women and two daily drinks for men…. Also, using alcohol with tobacco is riskier than using either one alone, because it further increases the chances of getting cancers of the mouth, throat, and esophagus." The American Heart Association (December 7, 2006, http://www.americanheart.org/presenter.jhtml?identifier=4422) weighs in with the following: "If you drink alcohol, do so in moderation. This means an average of one to two drinks per day for men and one drink per day for women…. Drinking more alcohol increases such dangers as alcoholism, high blood pressure, obesity, stroke, breast cancer, suicide and accidents. Also, it's not possible to predict in which people alcoholism will become a problem. Given these and other risks, the American Heart Association cautions people NOT to start drinking … if they do not already drink alcohol. Consult your doctor on the benefits and risks of consuming alcohol in moderation."
EFFECTS OF ALCOHOL ON SEX AND REPRODUCTION
Alcohol consumption can affect sexual response and reproduction in profound ways. Many alcoholics suffer from impotence and/or reduced sexual drive. Some studies, such as Jane Y. Polsky et al.'s "Smoking and Other Lifestyle Factors in Relation to Erectile Dysfunction" (BJU International, 2005), suggest that alcohol consumption, even at low levels, is associated with a greater risk of erectile dysfunction (impotence). Many alcoholics suffer from depression, which may further impair their sexual function. In addition, Jerrold S. Greenberg, Clint E. Bruess, and Debra Haffner report in Exploring the Dimensions of Human Sexuality (2004) that alcohol use is associated with poor sperm quality in men.
In premenopausal women chronic heavy drinking can contribute to a variety of reproductive disorders. According to Greenberg, Bruess, and Haffner, these disorders include the cessation of menstruation, irregular menstrual cycles, failure to ovulate, early menopause, increased risk of spontaneous miscarriages, and lower rates of conception. Some of these disorders can be caused directly by the interference of alcohol with the hormonal regulation of the reproductive system. They may also be caused indirectly through other disorders associated with alcohol abuse, such as liver disease, pancreatic disease, malnutrition, or fetal abnormalities.
Fetal Alcohol Spectrum Disorders
Research shows that alcohol consumption during pregnancy can result in severe harm to the fetus (unborn child). The development of such defects can begin early in pregnancy when the mother-to-be may not even know she is pregnant.
Drinking during pregnancy can cause fetal alcohol spectrum disorders (FASD). As Edward P. Riley and Christie L. McGee note in "Fetal Alcohol Spectrum Disorders: An Overview with Emphasis on Changes in Brain and Behavior" (Experimental Biology and Medicine, 2005), "The term FASD … is an umbrella term that describes the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects can be physical, mental, or behavioral, with possible lifelong implications."
The key facial characteristics of a child born with FASD are shown in Figure 2.3. These characteristics are the most pronounced in fetal alcohol syndrome (FAS), the most recognizable form of FASD. Children with FASD also exhibit a complex pattern of behavioral and cognitive dysfunctions, which are listed in Table 2.9. Besides these characteristics and dysfunctions, results of studies, such as Maria de Los Angeles Avaria et al.'s "Peripheral Nerve Conduction Abnormalities in Children Exposed to Alcohol in Utero" (Journal of Pediatrics, March 2004), show that prenatal alcohol exposure is associated with abnormalities in the electrical properties of nerves.
Cognitive and behavioral characteristics typical of Fetal Alcohol Spectrum Disorders (FASD)
Slow reaction time
Delayed motor development
Disruptive and impulsive behavior
Difficulties in learning and in abstract thinking
source: Created by Sandra Alters for Thomson Gale, 2006
Results of studies conducted by the National Center on Birth Defects and Developmental Disabilities of the Centers for Disease Control and Prevention (CDC) show FAS rates range from 0.2 to 1.5 per one thousand live births. In addition, researchers believe that other prenatal alcohol-related conditions less severe than FAS, such as alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD), occur approximately three times as often as FAS. ARND and ARBD were formerly and collectively known as fetal alcohol effects. Now all prenatal alcohol-related conditions are collectively known as FASD.
In February 2005 U.S. Surgeon General Richard H. Carmona issued an advisory on alcohol use in pregnancy. Key points of the advisory are listed in Table 2.10. As noted in the advisory, there is no known safe level of alcohol consumption during pregnancy. The CDC emphasizes, along with the surgeon general, that FAS and other prenatal alcohol-related disorders are 100% preventable if a woman does not drink alcohol while she is pregnant or if she is of reproductive age and is not using birth control. Yet, data show that some women who might become pregnant, or who are pregnant, consume alcohol and put themselves at risk for having a child with FASD.
Table 2.11 shows that 12.1% of pregnant women consumed alcohol in the past month in 2004–05 when questioned for the annual National Survey on Drug Use and Health. This figure was up from 9.8% in the 2002–03 period. In 2002–03 and 2004–05 approximately one-fifth (19.6% and 20.6%, respectively) drank during their first trimester of pregnancy, a time when all the organ systems of the fetus are developing. Fewer women drank in their second and third trimesters. More than half of women who might become pregnant (51.3% and 51.4%, respectively) used alcohol.
In the report "Alcohol Consumption among Women Who Are Pregnant or Who Might Become Pregnant—United States, 2002" (December 24, 2004, http://www.cdc.gov/MMWR/preview/mmwrhtml/mm5350a4.htm), the CDC reports that in 2002, 2% of pregnant women engaged in binge drinking and 2% in frequent use of alcohol when they were pregnant. In addition, greater binge drinking prevalence was reported among younger women, non-Hispanic whites, current smokers, unmarried women, and impaired drivers.
Key points in the U.S. Surgeon General's advisory on alcohol use during pregnancy, 2005
Based on the current, best science available we now know the following:
- Alcohol consumed during pregnancy increases the risk of alcohol related birth defects, including growth deficiencies, facial abnormalities, central nervous system impairment, behavioral disorders, and impaired intellectual development.
- No amount of alcohol consumption can be considered safe during pregnancy.
- Alcohol can damage a fetus at any stage of pregnancy. Damage can occur in the earliest weeks of pregnancy, even before a woman knows that she is pregnant.
- The cognitive deficits and behavioral problems resulting from prenatal alcohol exposure are lifelong.
- Alcohol-related birth defects are completely preventable.
For these reasons:
- A pregnant woman should not drink alcohol during pregnancy.
- A pregnant woman who has already consumed alcohol during her pregnancy should stop in order to minimize further risk.
- A woman who is considering becoming pregnant abstain from alcohol.
- Recognizing that nearly half of all births in the United States are unplanned, women of childbearing age should consult their physician and take steps to reduce the possibility of prenatal alcohol exposure.
- Health professionals should inquire routinely about alcohol consumption by women of childbearing age, inform them of the risks of alcohol consumption during pregnancy, and advise them not to drink alcoholic beverages during pregnancy.
source: Adapted from "Surgeon General's Advisory on Alcohol Use in Pregnancy," in News Release: U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy, U.S. Department of Health and Human Services Press Office, February 21, 2005, http://www.hhs.gov/surgeongeneral/pressreleases/sg02222005.html (accessed October 30, 2006)
ALCOHOL'S INTERACTION WITH OTHER DRUGS
Because alcohol is easily available and such an accepted part of American social life, people often forget that it is a drug. When someone takes a medication while drinking alcohol, he or she is taking two drugs. Alcohol consumed with other drugs—for example, an illegal drug such as cocaine, an over-the-counter (without a prescription) drug such as cough medicine, or a prescription drug such as an antibiotic—may make the combination harmful or even deadly or may counteract the effectiveness of a prescribed medication.
To promote the desired chemical or physical effects, a medication must be absorbed into the body and must reach its site of action. Alcohol may prevent an appropriate amount of the medication from reaching its site of action. In other cases alcohol can alter the drug's effects once it reaches the site. Alcohol interacts negatively with more than 150 medications. Table 2.12 shows some possible effects of combining alcohol and other types of drugs.
|Percentage of past-month alcohol use among females aged 15-44, by pregnancy status, 2002–03 and 2004–05|
|Demographic characteristic||Totala||Pregnancy status|
|*Low precision; no estimate reported.|
|N/A: Not applicable.|
|aEstimates in the total column are for all females aged 15 to 44, including those with unknown pregnancy status.|
|bPregnant females aged 15 to 44 not reporting trimester were excluded.|
|Source: "Table 7.73B. Alcohol Use in the Past Month among Females Aged 15 to 44, by Pregnancy Status and Demographic Characteristics: Percentages, Annual Averages Based on 2002–2003 and 2004–2005," in Results from the 2005 National Survey on Drug Use and Health: Detailed Tables, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2006, http://www.oas.samhsa.gov/nsduh/2k5nsduh/tabs/Sect7peTabs68to75.pdf (accessed October 17, 2006)|
|Hispanic origin and race|
|Not Hispanic or Latino||53.7||54.1||10.1||13.4||55.3||55.7|
|Black or African American||41.0||40.5||6.4||13.4||42.2||41.6|
|American Indian or Alaska Native||49.8||44.3||*||*||51.7||45.0|
|Native Hawaiian or other Pacific Islander||40.9||*||*||*||42.1||*|
|Two or more races||53.3||60.5||*||*||55.6||61.8|
|Hispanic or Latino||37.9||37.4||8.6||6.8||39.6||39.1|
|Interactions between alcohol and medications|
|Source: Created by Staff of Information Plus for Thomson Gale|
|Antidepressants||Alcohol slows the breakdown of these drugs and increases their toxicity.|
|Acetaminophen (aspirin substitute)||Alcohol can increase this pain killer's toxic effects on the liver.|
|Aspirin||Aspirin may increase stomach irritation caused by alcohol.|
|Antihistamines||Alcohol increases the sedative effects of these drugs.|
|Sedatives||Alcohol increases the effects of many of these drugs and can be dangerously toxic.|
|Antacid histamine blockers||These drugs can interfere with the metabolism of alcohol, making it more intoxicating.|
The U.S. Food and Drug Administration recommends that anyone who regularly has three alcoholic drinks per day should check with a physician before taking aspirin, acetaminophen (such as Tylenol or Excedrin), or any other over-the-counter painkiller. Combining alcohol with aspirin, ibuprofen (such as Advil or Motrin), or related pain relievers may promote stomach bleeding. Combining alcohol with acetaminophen may promote liver damage.
In Deaths: Final Data for 2003 (April 19, 2006, http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_13.pdf), Donna L. Hoyert et al. report that 20,687 people in the United States died of alcohol-induced causes in 2003. This category included deaths from dependent use of alcohol, nondependent use of alcohol, and accidental alcohol poisoning. It excluded accidents, homicides, and other causes indirectly related to alcohol use, as well as deaths because of fetal alcohol syndrome. The age-adjusted death rate for males was 3.3 times the rate for females. In 2003, 12,360 people died from alcoholic liver disease.
MOTOR VEHICLE AND PEDESTRIAN ACCIDENTS
The National Highway Traffic Safety Administration (NHTSA) of the U.S. Department of Transportation defines a traffic crash as alcohol-related if either the driver or an involved pedestrian had a BAC of 0.01 g/dL or greater. People with a BAC of 0.08 g/dL or higher are considered intoxicated.
The NHTSA reports that 42,636 people were killed in traffic accidents in 2004, with 16,694 of them caused by alcohol-related crashes. (See Table 2.13.) These alcohol-related traffic deaths represented 39% of all car crash fatalities in 2004. The percentage of alcohol-related traffic fatalities has declined somewhat steadily from a high of 60% in 1982. The peak number of fatalities occurred in 1988, when 47,087 traffic accident deaths (including both alcohol related and nonalcohol related) were recorded.
|Fatalities in motor vehicle accidents, by blood alcohol concentration (BAC) at time of crash, 1982–2004|
|Year||BAC=.00 (no impairment)||BAC=.01−.07 (slight to significant impairment)||BAC=.08 + (impaired)||Total number||Total fatalities in alcohol-related crashes|
|Note: The National Highway Traffic Safety Administration estimates alcohol involvement when alcohol test results are unknown.|
|Source: "Table 13. Persons Killed, by Highest Blood Alcohol Concentration (BAC) in the Crash, 1982–2004," in Traffic Safety Facts 2004, U.S. Department of Transportation, National Center for Statistics and Analysis, National Highway Traffic Safety Administration, January 2006, http://www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSFAnn/TSF2004.pdf (accessed October 6, 2006)|
A number of important factors contribute to the decline of drunk driving fatalities. Mothers against Drunk Driving was founded in 1980. This organization's most significant achievement was lobbying to get the legal drinking age raised to twenty-one in all states, which occurred in 1988. There were also successful campaigns such as "Friends Don't Let Friends Drive Drunk." The use of seat belts has also helped reduce deaths in motor vehicle accidents.
As of July 2004 all states, the District of Columbia, and Puerto Rico had lowered the BAC limit for drunk driving from 0.1 g/dL to 0.08 g/dL, with all states implementing this limit by August 2005. According to the Insurance Institute for Highway Safety (http://www.iihs.org/laws/state_laws/dui.html), by June 2006 forty-one states and the District of Columbia also had administrative license revocation laws, which require prompt, mandatory suspension of drivers' licenses for failing or refusing to take the BAC test. This immediate suspension, before conviction and independent of criminal procedures, is invoked right after arrest.
As Table 2.14 shows, in both 1995 and 2005 drivers aged twenty-one to forty-four were the ones most likely to be involved in fatal crashes in which the driver had a BAC of 0.08 g/dL or higher. Whereas the percentage of drivers within the twenty-one- to twenty-four-year-old age group stayed steady over the decade shown, the percentages in the twenty-five to forty-four group declined.
In 2005 the percentage of male drivers involved in fatal crashes who had a BAC of 0.08 g/dL or greater was nearly twice that of female drivers involved in fatal crashes (23% versus 13%, respectively). When compared with 1995, the percentage of drunk male drivers in fatal accidents in 2005 dropped. (See Table 2.14.)
Alcohol was related to a higher percentage of fatal crashes by motorcycles (27%) in 2005 than for crashes involving automobiles (22%) and light trucks (21%). Fatal crashes involving large trucks were very unlikely to be alcohol related (1%). (See Table 2.14.)
As Table 2.15 shows, in both 1995 and 2005 about half of all pedestrians aged twenty-one to forty-four who were killed in a traffic accident had a BAC of 0.08 g/dL or higher. This percentage was considerably higher than that for other age groups.
|Drivers with a blood alcohol count (BAC) of 0.08 or higher killed in motor vehicle crashes, by age, gender, and vehicle type, 1995 and 2005|
|Total number of drivers||BAC .08 g/dL or higher||Total number of drivers||BAC .08 g/dL or higher|
|Number||Percent of total||Number||Percent of total|
|Note: Numbers shown for groups of drivers do not add to the total number of drivers due to unknown or other data not included.|
|Source: Adapted from "Table 6. Drivers in Fatal Crashes with BAC 0.08 gm/dl or Higher by Age, Gender, and Vehicle Type, 1995 and 2005," in Traffic Safety Facts 2005 Data Alcohol, National Highway Traffic Safety Administration, National Center for Statistics and Analysis, October 2006, http://www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSF2005/AlcoholTSF05.pdf (accessed October 29, 2006)|
|Drivers by age group (years)|
|Drivers by sex|
|Drivers by vehicle type|
|Pedestrians and pedalcyclists with a blood alcohol count (BAC) of 0.08 or higher killed in motor vehicle crashes, by age group, 1995 and 2005|
|Total number of fatalities||BAC .08 g/dL or higher||Total number of fatalities||BAC .08 g/dL or higher|
|Number||Percent of total||Number||Percent of total|
|Note: Includes pedestrians age 15 and younger and pedestrians of unknown age.|
|Source: "Table 4. Nonoccupants with BAC 0.08 gm/dl or Higher Killed in Motor Vehicle Crashes by Age Group, 1995 and 2005," in Traffic Safety Facts: 2005 Data—Alcohol, U.S. Department of Transportation, National Center for Statistics and Analysis, National Highway Traffic Safety Administration, October 2006, http://www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSF2005/AlcoholTSF05.pdf (accessed October 29, 2006)|
|Pedestrian fatalities by age group (years)|
Table 2.16 shows arrest trends for alcohol-related offenses and driving under the influence from 1970 to 2004. Arrests were the highest for alcohol-related offenses from 1975 to 1992, with 1981 being the peak year. Arrests for driving under the influence were highest from 1977 to 1996, with 1983 being the peak year.
In 2004 there were nearly 2.4 million alcohol-related arrests; slightly more than one million of those arrests were for driving under the influence. (See Table 2.16.) According to the Federal Bureau of Investigation report Crime in the United States, 2004 (February 17, 2006, http://www.fbi.gov/ucr/cius_04/documents/CIUS2004.pdf), there were nearly fourteen million arrests in 2004. Of those, more than 2.6 million were alcohol-related arrests.
Doris J. James mentions in Profile of Jail Inmates (July 2004, http://www.ojp.usdoj.gov/bjs/pub/pdf/pji02.pdf) that in 2002, 33.4% of convicted jail inmates reported that they had been under the influence of alcohol alone (not in combination with any other drug) when they committed their offenses. This figure decreased since 1996. A higher percentage of jail inmates used alcohol when committing a violent offense than did those committing other types of crimes, such as property or drug offenses.
In the report ADAM Preliminary Finds on Drug Use and Drug Markets (December 2001, http://www.ncjrs.gov/pdffiles1/nij/189101.pdf), a 2001 study of adult male arrestees in thirty-two U.S. cities, the U.S. Department of Justice finds that many had used alcohol before committing their crimes. More than 50% of the adult arrestees reported binge drinking in the thirty days before they were interviewed. Rates ran as low as 39.3% of arrestees in New York City to 70.1% in Albuquerque, New Mexico. In Phoenix, Arizona, 54.1% of arrestees reported binge drinking; 57.6% reported it in Spokane, Washington, 62.1% in Oklahoma City, and 64.8% in Denver, Colorado. A significant percentage of male arrestees also reported heavy drinking in the thirty days before their interview as well.
|Arrests for alcohol-related offenses and driving under the influence, 1970–2004|
|Alcohol-related offenses||Driving under the influence|
|Note: This table presents data from all law enforcement agencies submitting complete reports for 12 months. Alcohol-related offenses include driving under the influence, liquor law violations, drunkenness, disorderly conduct, and vagrancy.|
|Source: Ann L. Pastore and Kathleen Maguire, eds. "Table 4.27.2004. Arrests for Alcohol-Related Offenses and Driving under the Influence, United States, 1970–2004," in Sourcebook of Criminal Justice Statistics Online, 31st Edition, U.S. Department of Justice, Bureau of Justice Statistics, University at Albany School of Criminal Justice, Hindelang Criminal Justice Research Center, http://www.albany.edu/sourcebook/pdf/t4272004.pdf (accessed October 29, 2006)|
This section contains articles on some aspects of alcohol, and the following topics are covered: Chemistry and Pharmacology; Complications; History of Drinking ; and Psychological Consequences of Chronic Abuse. For discussions of alcoholism, its treatment, and withdrawal symptoms, see the section entitled Alcoholism; Treatment ; and Withdrawal. See also the articles Alcoholics Anonymous (AA) and Treatment Types: Twelve Steps. Other articles on related topics are listed throughout the Encyclopedia.
Chemistry and Pharmacology
Chemical determination has discovered five separate forms of alcohol that have little molecular variation, but enough variation to produce substantial differences in their characteristics. Occurring naturally through the fermentation of fruits, vegetables and grains exposed to the bacteria in the air, alcohol production can be expedited by producing conditions conducive to the environmental needs of the alcohol producing organisms. The form of alcohol produced intentionally for use is ethyl alcohol, also called ethanol.
People do not drink pure ethanol. Most drinks with alcoholic content do not exceed an 8 percent concentration, such as beer. Most wines do not exceed 15 percent, and most liquors are still below 50 percent, or, in the terms of the United States, 100 proof by weight or volume. Furthermore, alcoholic beverages are often diluted by water before they are consumed.
Ethanol has a very simple molecular structure, C2H6O. It is composed of only two carbon atoms, six hydrogen atoms, and one oxygen atom, yet its precise mechanism of action is not fully understood. Although it is commonly believed that ethanol is useful in a number of physical ailments (as medicinal alcohol, the medieval elixir of life), in reality its uses are not therapeutic—and its chronic use is toxic.
EFFECTS ON THE BODY AND THERAPEUTIC USES
Ethanol is a general central nervous system depressant, producing sedation and even sleep at higher doses. The degree of this depression is proportional to its concentration in the blood; however, this relationship is more predictable when ethanol levels are rising than three or four hours later, when blood levels are the same but ethanol levels are falling. This variance occurs because during the first fifteen or twenty minutes after an ethanol dose, the peripheral venous blood is losing ethanol to the tissues while the brain has equilibrated with arterial blood supply. Thus, brain levels are initially higher than the venous blood levels, and since all blood samples for ethanol determinations are taken from a peripheral vein, the ethanol concentrations are appreciably lower than a few hours later, when the entire system has achieved equilibrium.
The reticular activating system of the brain stem is the most sensitive area to ethanol's effects; this accounts for the loss of integrative control of the brain's higher functions. Anecdotal reports of a stimulating effect, especially at low doses, are likely due to the depression of the mechanisms that normally control speech and other behaviors that evolved from training or prior experiences. However, there may be a genetic basis for this initial stimulating effect, since rodents differing genetically show differences in the degree of initial stimulation or excitement. Upon drinking a moderate amount of ethanol, humans may quickly pass through the "stimulating" phase. Memory, the ability to concentrate, and insight are affected next whereas confidence often increases as moods swing from one extreme to another. If the dose is increased, then neuromuscular coordination becomes impaired. It is at this point that drinkers may be most dangerous, since they are still able to move about but reaction times and judgment are impaired—and sleepiness must be fought. The ability to drive an automobile or operate machinery is compromised. With higher doses, general (sleep) or surgical (unconsciousness) anesthesia may develop, but respiration is dangerously depressed.
Ethanol is believed by many to have a number of medicinal (therapeutic) uses; these are mostly based on anecdotal reports and have few substantiated claims. One example of a well-known but misguided use is to treat hypothermia—exposure to freezing conditions. Although the initial effects of an alcoholic beverage appear to "warm" the patient, ethanol actually dilates blood vessels, causing further loss of body heat. Another example is its effects on sleep—it is believed that a nightcap relaxes one and puts one to sleep. Acute administration of ethanol may decrease sleep latency, but this effect dissipates after a few nights. In addition, waking time during the latter part of the night is increased, and there is a pronounced rebound insomnia that occurs once the ethanol use is discontinued. Except as an emergency treatment to reduce uterine contractions and delay birth, the therapeutic use of oral ethanol is confined to treating poisoning from methanol and ethylene glycol. Most of ethanol's therapeutic benefits are derived from applying it to the skin, since it is an excellent skin disinfectant. Ethanol can lessen the severity of dermatitis, reduces sweating, cools the skin during a fever and, when added to ointments, helps other drugs penetrate the skin. These therapeutic uses for ethanol are for acute problems only.
Until recently, it had been felt that the chronic drinking of ethanol led only to organ damage. Recent evidence suggests that low or moderate intake of ethanol (1-2 drinks per day) can indirectly reduce the risk of heart attacks. The doses must be low enough to avoid liver damage. This beneficial effect is thought to be due to the elevation of high-density lipoprotein cholesterol (HDL-C) in the blood which, in turn, slows the development of arteriosclerosis and, presumably, heart attacks. This relationship has not been proven, but has been culled from the results of several epidemiological studies.
Several mechanisms have been proposed to explain how oral ethanol exerts its effects. One is thought to be its ability to alter the fluidity of cell membranes—particularly neurons. This disturbance alters ion channels in the membrane resulting in a reduction in the propagation of neuronal transmission. The anesthetic gases share this property with ethanol. Furthermore, it has been shown that the degree of membrane disordering is directly proportional to the drug's lipid solubility. It has also been argued that such membrane effects occur only at very high doses. More recently, scientists have reported that ethanol may augment the activity of the neurotransmitter GABA by its actions on a receptor site close to the GABA receptor. The effect of this action is to increase the movement of chloride across biological membranes. Again, this effect would alter the degree to which neuronal transmission is maintained.
PHARMACOKINETICS AND DISTRIBUTION
Ethanol is quickly and rapidly absorbed from the stomach (about 20%) and from the first section of the small intestines (called the duodenum). Thus the onset of action is related in part to how fast it passes through the stomach. Having food in the stomach can slow absorption because the stomach does not empty its contents into the small intestines when it is full. However, drinking on an empty stomach leads to almost instant intoxication because the ethanol not absorbed in the stomach passes directly to the small intestines. Maximal blood levels are achieved about thirty to ninety minutes after ingestion. Ethanol mixes with water quite well, and so once it enters the body it travels to all fluids and tissues, including the placenta in a pregnant woman. After about twenty to thirty minutes for equilibration, blood levels are a good estimate of brain levels. Ethanol freely enters all blood vessels, including those in the small air sacs of the lungs. Once in the lungs, ethanol exchanges freely with the air one breathes, making a breath sample a good estimate of the amount of ethanol in one's body. A breathalyzer device is often used by police officers to detect the presence of ethanol in an individual.
Between 90 and 98 percent of the ethanol dose is metabolized. The amount of ethanol that can be metabolized per unit of time is roughly proportional to the individual's body weight (and probably the weight of the liver). Adults can metabolize about 120 mg/kg/hr which translates to about thirty ml (one ounce) of pure ethanol in about three hours. Women generally achieve higher alcohol blood concentrations than do men, even after the same unit dose of ethanol, because women have a lower percentage of total body water but also because they may have less activity of alcohol-metabolizing enzymes in the wall of the stomach. The enzymes responsible for ethanol and acetaldehyde metabolism—alcohol dehydrogenase and aldehyde dehydrogenase, respectively—are under genetic control. Genetic differences in the activity of these enzymes account for the fact that different racial groups metabolize ethanol and acetaldehyde at different rates. The best-known example is that of certain Asian groups who have a less active variant of the aldehyde dehydrogenase enzyme. When they consume alcohol, they accumulate higher levels of acetaldehyde than do Caucasian males, for example; this causes a characteristic response called "flushing," actually a type of hot flash with reddening of the face and neck. Some experts believe that the relatively low levels of alcoholism in such Asian groups may be linked to this genetically based aversive effect.
Chronic consumption of excessive amounts of ethanol can lead to a number of neurological disorders, including altered brain size, permanent memory loss, sleep disturbances, seizures, and psychoses. Some of these neuropsychiatric syndromes, such as Wernicke's encephalopathy, Korsakoff's psychosis, and polyneuritis can be debilitating. Other, less obvious problems also occur during chronic ethanol consumption. The chronic drinker usually fails to meet basic nutritional needs and is often deficient in a number of essential vitamins, which can also lead to brain and nerve damage.
Chronic drinking also causes damage to a number of major organs. Permanent alterations in brain function have already been discussed. By far, one of the most important causes of death in alcoholics (other than by accidents) is liver damage. The liver is the organ that metabolizes ingested and body toxins; it is essential for natural detoxification. Alcohol damage to the liver ranges from acute fatty liver to hepatitis, necrosis, and cirrhosis. Single doses of ethanol can deposit droplets of lipids, or fat, in the liver cells (called hepatocytes). With an accumulation of such lipid, the liver's ability to metabolize other body toxins is reduced. Even a weekend drinking binge can produce measurable increases in liver fat. It was found that liver fats doubled after only two days of drinking; blood ethanol levels ranged between twenty and eighty mg/dl, suggesting that one need not be drunk in order to experience liver damage.
Alcohol-induced hepatitis is an inflammatory condition of the liver. The symptoms are anorexia, fever, and jaundice. The size of the liver increases, and its ability to cleanse the blood of other toxins is reduced. Cirrhosis is the terminal and most dangerous type of liver damage. Cirrhosis results after many years of intermittent bouts with hepatitis or other liver damage, resulting in the death of liver cells and the formation of scar tissue in their place. Fibrosis of the blood vessels leading to the liver can result in elevated blood pressure in the veins around the esophagus, which may rupture and cause massive bleeding. Ultimately, the cirrhotic liver fails to function and is a major cause of death among alcoholics. Although only a small percentage of drinkers develop cirrhosis, it appears that a continuous drinking pattern results in greater risk than does intermittent drinking, and an immunological factor may be involved.
The role of poor nutrition in the development of some of these disorders is well recognized but not very well understood. Ethanol provides 7.1 kilocalories of energy per gram. Thus, a pint of whiskey provides around 1,300 kilocalories, which is a substantial amount of raw energy, although devoid of any essential nutrients. These nutritional disturbances can exist even when food intake is high, because ethanol can impair the absorption of vitamins B1 and B 12 and folic acid. Ethanol-related nutritional problems are also associated with magnesium, zinc, and copper deficiencies. A chronic state of malnutrition can produce symptoms that are indistinguishable from chronic ethanol abuse.
Fetal alcohol syndrome (FAS) was recognized and described in the 1980s. Children of chronic drinkers are born deformed; the abnormality is characterized by reduced brain function as evidenced by a low IQ and smaller than usual brain size, slower than normal growth rates, characteristic facial abnormalities (widely spaced eyes and flattened nasal area), other minor malformations, and developmental and behavioral problems. Fetal malnutrition caused by ethanol-induced damage to the placenta can also occur, and fetal immune function appears to be weakened, resulting in the child's greater susceptibility to infectious disease. Depending on the population studied, the rate of FAS ranges from 1 in 300 to 1 in 2,000 live births; however, the incidence is 1 in 3 infants of alcoholic mothers. Even today, it is not known if there is a safe lower limit of ethanol that can be consumed by pregnant women without risk of having a child with FAS. The lowest reported level of ethanol that resulted in FAS was about 75 ml (2.5 oz.) per day during pregnancy. Among alcoholic mothers, if drinking during pregnancy is reduced, then the severity of the resulting syndrome is reduced.
TOLERANCE, DEPENDENCE, AND ABUSE
Tolerance, a feature of many different drugs, develops rather quickly to many of ethanol's effects after frequent exposure. When tolerance develops, the dose must be increased to achieve the original effect. Ethanol is subject to two types of tolerance: tissue (or functional) tolerance and metabolic (or dispositional) tolerance. Metabolic tolerance is due to alterations in the body's capacity to metabolize ethanol, which is achieved primarily by a greater activity of enzymes in the liver. Metabolic tolerance only accounts for 30 to 50 percent of the total response to alcohol in experimental conditions. Tissue tolerance, however, decreases the brain's sensitivity to ethanol and may be quite extensive. The development of tolerance can take just a few weeks or may take years to develop, depending on the amount and pattern of ethanol intake. As with other central nervous system depressants, when the dose of ethanol is increased to achieve the desired effects (e.g., sleep), the margin of safety actually decreases, as the dose comes closer to producing toxicity and the brain's control of breathing becomes depressed.
Like tolerance, dependence on ethanol can develop after only a few weeks of consistent intake. The degree of dependence can be assessed only by measuring the severity of the withdrawal signs and symptoms observed when ethanol intake is terminated. Victor and Adams (1953) provided perhaps one of the best descriptions of the clinical aspects of ethanol dependence. Patients typically arrive at the hospital with the "shakes," sometimes so severe that they cannot perform simple tasks by themselves. During the next twenty-four hours of their stay in the hospital, an alcoholic might experience hallucinations, which typically are not too distressing. Convulsions, however, which resemble those in people with epilepsy, may occur in susceptible individuals about a day after the last drink. Convulsions usually occur only in those who have been drinking extremely large amounts of ethanol. If the convulsions are severe, the individual may die. Many somatic effects, such as nausea, vomiting, diarrhea, fever, and profuse sweating are also part of alcohol withdrawal. Some sixty to eighty-four hours after the last dose, there may be confusion and disorientation; more vivid hallucinations may begin to appear. This phase of withdrawal is often called the delirium tremens, or DTs. Before the days of effective treatment, a mortality rate of 5 to 15 percent was common among alcoholics whose withdrawal was severe enough to cause DTs.
TREATMENT FOR ALCOHOL DEPENDENCE
The first step in treating alcoholics is to remove the ethanol from the system, a process called detoxification. Since rapid termination of ethanol (or any other central nervous system depressant) can be life threatening, people who have been using high doses should be slowly weaned from the ethanol by giving a less toxic substitute depressant. Ethanol itself cannot be used because it is eliminated from the body too rapidly, making it difficult to control the treatment. Although barbiturates were once employed in this capacity, the safer benzodiazepines have become the drugs of choice. Not only do they prevent the development of the potentially fatal convulsions, but they reduce anxiety and help promote sleep during the withdrawal phase. New medications are constantly being tested for their abilities to aid in the treatment of alcohol withdrawal.
Once a person has become abstinent, various methods can be used to maintain abstinence and encourage sobriety—some are pharmacologic and others are through social-support networks or formal psychological therapies. One type of treatment involves making drinking an adverse toxic event for the individual, by giving a drug such as Disulfiram (Antabuse) or citrated Calcium Carbimide, which inhibits the metabolism of acetaldehyde and causes facial flushing, nausea, and rapid heartbeat. When ethanol is ingested by someone on disulfiram, the acetaldehyde levels rise very high, very quickly. Disulfiram has not been successful in maintaining abstinence in all patients, however.
Many support groups are available to help people remain abstinent. Alcoholics Anonymous (AA) is one of the most widely known and available; it is structured around a self-help philosophy. The AA program emphasizes total avoidance of alcohol and any medication. Instead it relies on a "buddy" or "sponsor" system, providing support partners who are personally experienced with alcoholism and alcoholism recovery. A number of other types of psychological and behavioral approaches to treatment also exist.
(See also: Accidents and Injuries from Alcohol ; Alcoholism ; Fetus, Effects of Drugs on ; Complications ; Social Costs of Alcohol and Drug Abuse )
Gilman, A. G., et al. (Eds.). (1990). Goodman and Gilman's the pharmacological basis of therapeutics, 8th ed. New York: Pergamon.
Goldstein, A., Aronow, L., & Kalman, S. M. (1974). Principles of drug action: The basis of pharmacology. New York: Wiley.
Hoffman, F. G. (1975). A handbook on drugs and alcohol abuse: The biomedical aspects. New York: Oxford University Press.
West, L.J. (Ed.). (1984). Alcoholism and related problems: Issues for the American public. Englewood Cliffs, NJ: Prentice-Hall.
Scott E. Lukas
Revised by Andrew J. Homburg
Through their ethanol (alcohol) content, alcoholic beverages significantly affect the body's cellular function as well as its cognitive actions. Many of these effects are the consequence of a complex set of biochemical reactions, long-term exposure to ethanol with an accumulation of damage that is manifested in diverse ways, or the result of increased incidence or severity of major disease states, including AIDS, Cancer, or heart disease. However, some effects of ethanol are immediate and do not require prolonged exposure, nor are they induced as the end product of many physiological changes. For example, ethanol induces changes in cell membranes' fluidity by mixing with the lipids there. The membrane changes inhibit neurological functions and thus can cause car Accidents. All of these can occur with a single exposure and thus could be considered a direct effect of the ethanol in alcoholic beverages.
Ethanol Absorption and Metabolism.
Because the ethanol molecule has a hydroxyl group, its metabolism involves dehydrogenase enzymes. After some metabolism in the stomach and intestine, it is transported to the liver for further metabolism. Alcohol dehydrogenase produces acetaldehyde, which causes many of the indirect effects attributed to ethanol. Because females metabolize alcohol less efficiently in the stomach wall than males, their exposure can be higher, with more direct consequences, from the same amount of alcohol consumption. Ethanol is also metabolized by the liver cells' MEOS system. Ethanol also affects the transportation of proteins across membranes in the cell. Thus aldehyde dehydrogenase's transportation into the mitochondria from the cell's cytoplasm is retarded. This reduces the oxidation of acetaldehyde to acetic acid, and increases ethanol's indirect effects by altering its metabolism and that of its metabolites. Acetaldehyde is very reactive with proteins. Thus increased levels result in damage to proteins with which it reacts. As many are vital for cell function, cell death or dysfunction occurs. This damage persists for the life of the protein or cell.
Alcohol and Nutrition.
Alcohol has major effects when consumed frequently or in high amounts by affecting the frequency and quality of foods consumed. This directly affects the amounts of vitamins and minerals that are consumed and available for absorption. The long-term consequences involve undernutrition, nutritional deficiencies, and ultimately malnutrition. Ethanol also directly affects the absorption of vitamin A, betacarotene (a vitamin A precursor), vitamin B1 (thiamine), folate, vitamin E, vitamin D, and folate. Vitamins are critical for many enzymatic reactions, so ethanol causes indirect effects by altering vitamin levels. Acute alcohol ingestion changes many vitamin metabolic pathways. Folate and vitamin A metabolism can cause increased urinary excretion. Thiamine deficiency is responsible for a severe neurological consequence of excessive alcohol use—Wernicke ' Syndrome.
ACTIONS OF ALCOHOL ON THE BRAIN
The molecular site of alcohol's action on neurons is unknown. Alcohol may work by perturbing lipids in the cell membrane of the Neuron, interacting directly with the hydrophobic region of neuronal membrane proteins, or interacting directly with a lipid-free enzyme protein in the membrane. Ethanol alters the function of neuron-specific proteins. For example, evidence suggests that the activity of the chloride ion channel linked to the A-type receptor of the GABA Neurotransmitter increases during exposure to intoxicating amounts of alcohol. Acute exposure to alcohol effects the actions of Glutamate, the major excitatory transmitter in the mammalian central nervous system. Chronic exposure to alcohol can result in Tolerance for and Physical Dependence on the drug. Tolerance is recognized as a chronic drinker's ability to consume increasing amounts of alcohol without displaying gross signs of intoxication. Alcohol's effects on stress may be regulated by the combination of its effect on information processing. Thus it can decrease internal conflicts and block inhibitions, thereby making social behaviors more extreme.
Free Radical Generation by Alcohol.
Free radicals are a highly reactive oxygen species. They are important components of the body's host defense, yet in high levels can cause tissue damage. Cytochrome P-450 is an oxidizing system that generates free radicals from ethanol. The reactive oxygen species include superoxide and hydrogen peroxide. They react with DNA, protein, and lipids. Products of the free radical reactions include lipid peroxides; thus alcohol's production of free radicals indirectly initiates cancer, heart disease, and other major health problems. Free radicals are produced in higher levels when ethanol and acetaldehyde begin to accumulate in cells and saturate dehydrogenases. Then other products, such as free radicals and cocaethylene (when cocaine is present), are produced.
Cholesterol and Fatty-Acid Production from Alcoholic Beverages.
Excessive ethanol intake leads to formation of ethanol- and fatty-acid-containing ethyl esters, produced by synthases. Thus tissues containing large amounts of synthases, such as the heart, would be more likely to be damaged. These products can adversely affect protein synthesis, alter cell membranes that contain large amounts of normal lipids, and suppress energy production by the cells' mitochondria. Cholesterol esterase connects cholesterol to fatty acids, thus producing fatty-acid cholesterol esters. When ethanol is present, the esterase produces fatty-acid ethyl esters with a reduction of cholesterol. Ethanol consumption modifies components of cell membranes, phospholipids, through the phospholipase D. The importance of these changes is poorly defined and understood.
Cocaethylene and Drug Metabolism.
When alcohol and cocaine are ingested together, the "high" is accentuated. Ethanol can react with Co-Caine via the enzyme cocaine esterase, producing a potentially toxic product, Cocaethylene. This enzyme inactivates cocaine in the absence of ethanol. Metabolism of cocaine and other drugs occurs in large part via cytochrome P-450 IIEI. It is increased by chronic alcohol consumption. This cytochrome oxidizes ethanol in the liver as well as many other compounds, including cocaine and the pain killer acetaminophen. Oxidative products of cytochrome P-450 are more toxic than the parent compounds, and thus can accentuate liver damage.
Metabolism of Protein.
Consumption of alcoholic beverages affects the metabolism of ethanol and other alcohols, and alters the NADH/NAD ratio—the ratio of reduced nicotinamide adenine dinucleotide to oxidized nicotinamide adenine dinucleotide—which influences lipid, vitamin, and protein metabolism, membrane composition and function, and energy production. Such changes lead to indirect effects including cell damage, undernutrition, and weight loss. Chronic alcohol beverage use reduces type II muscle fibers, reducing the capacity for prolonged muscle activity and thus the ability to exercise, run, or do physical work. Loss of this fiber produces muscle pain, weakness, and damage. Reduced type II fibers may be due to lower RNA, which would indicate less protein synthesis.
Metabolism of Lipids and Fats.
Fat and lipid functions and metabolism are altered by alcohol consumption. High alcohol intakes result in changes in the ratio of NADH/NAD +, which rduces breakdown of fats and lipids. The accumulated lipids are stored in the liver, producing a fatty liver. The NADH/NAD + ratio also inhibits synthesis of cholesterol and related steroid hormones. Thus production of progesterone and and rostenedione are reduced by alcohol use. Such changes may be the cause of hypogonadism in males who consume alcohol chronically. Lipoprotein lipase is inhibited by ethanol, thus reducing removal of long acyl chains from lipids. In heart muscle this reduces available energy and could be a component of heart disease. Lipoproteins are transport molecules for fats, including cholesterol, in plasma fluids. Alcohol increases both low- and high-density lipoproteins, which could be beneficial and damaging, respectively, to the heart.
Lipids in the Function and Composition of Cell Membranes.
Membranes have lipids and proteins as major components. Ethanol clearly affects lipids and membranes directly and indirectly. Alcohol affects cell membranes directly by its entry into them. Its physical characteristics modify arrangement of lipids in the cell membrane, and hence should affect cell function directly. For example, electrolyte balance within all cells is produced by sodium and potassium ion transportation. High alcohol intake reduces the ion transporters, which causes cells to take up water and thus to swell, affecting function. In addition, cells respond to hormones and other chemicals in the plasma outside the cell membrane by signal transduction. These signals regulate the functions of the various cell types, affecting overall physiology of the body. Important enzymes in this process include phospholipases. Ethanol acts like hormones and signal molecules, changing membrane phospholipases, which should modify cell function.
ALCOHOL TRAUMA, ACCIDENTS, AND BEHAVIORAL EFFECTS
Alcohol is directly involved in injuries by altering neurological function in ways that lead to motor vehicle Accidents, plane crashes, drownings, Suicide, and homicide. It appears to play a role in both unintentional and intentional injuries. Nearly one-fourth of suicide victims, one-third of homicide victims, and one-third of unintentional injury victims have high Blood Alcohol Concentrations. Alcohol was a factor in half of fatal traffic crashes and 5 percent of all deaths. It causes premature mortality (not including deaths from indirect, biochemical changes induced by long-term exposure).
Alcohol and Auto Accidents.
Alcohol consumption directly and promptly impairs many perceptual, cognitive, and motor skills needed to operate motor vehicles safely. Although in 1989 traffic fatalities involving at least one intoxicated driver or nonoccupant (pedestrian or other) decreased by half, 22,413 people were killed in alcohol-related motor vehicle crashes, representing approximately half of all traffic fatalities. The decrease in alcohol's involvement may be partially attributed to changes in Minimum Drinking Age Laws. Women drivers are involved in half as many alcohol-related car accidents as men. Impaired drivers arrested are significantly more hostile; they have greater psychopathic deviance, nontraffic arrests, and frequency of impaired driving, and they drink more than drunk drivers caught in roadblocks. Thus, impaired driving and alcohol-related accidents are part of problematic behaviors that can be directly modified by ethanol.
Alcohol and Airplane Accidents.
Alcohol has not been shown to have caused a U.S. commercial airline accident. However, it plays a direct and prominent role in general aviation accidents. Pilot function is impaired by cognitive, perceptual, and psychomotor changes due to ethanol use. Positional alcohol nystagmus may contribute to many aviation crashes involving spatial disorientation.
Alcohol and Water Accidents.
Alcohol is associated with between half and two-thirds of adult drownings. Alcohol is also important in water-related spinal cord injuries.
Alcohol and Sexual Behavior.
Via neurological changes, alcohol impairs rational thought, thus decreasing behavioral inhibitions. Alcohol is an excuse for behavior that violates social norms. Problem drinking behavior is associated with sexually transmitted disease.
Alcohol and Violence.
High alcohol consumption reduces inhibition, impairs moral judgment, and increases aggression; thus there is greater likelihood of homicide or assault resulting from fights. Frequently, alcohol use has occurred in situations that emerge spontaneously from personal disputes. Alcohol is linked to a high proportion of violence, with perpetrators more often under the influence of alcohol than victims. Very high rates of problem drinking are reported among both property and violent offenders.
(See also: Accidents and Injuries from Alcohol ; Complications )
Secretary of Health and Human Services. (1993). Eighth special report to the U.S. Congress on alcohol and health. Washington, DC: U.S. Government Printing Office.
Watson, R. R. (1995). Alcohol and accidents. Totowa, N.J.: Humana Press.
Watson, R. R. (1995). Alcohol and hormones. Totowa, N.J.: Humana Press.
Watson, R. R. (1992). Alcohol and neurobiology. I. Receptors, membranes and channels. Boca Raton, FL: CRC.
Ronald R. Watson
History of Drinking
The key to the importance of alcohol in history is that this simple substance, presumably present since bacteria first consumed some plant cells nearly 1.5 billion years ago, has become so deeply embedded in human societies that it affects their religion, economics, age, sex, politics, and many other aspects of human life. Furthermore, the roles that alcohol plays differ, not only from one culture to the next but even within a culture over time. A single chemical compound, used (or sometimes emphatically avoided) by a single species, has resulted in a complex array of customs, attitudes, beliefs, values, and effects. A brief review of the history of this relationship illustrates both unity and diversity in the ways people have thought about and treated alcohol. Special attention is paid to the United States as a case study of particular interest to many readers.
THE QUESTION OF ORIGINS
Ethanol, the form of alcohol desired for use to produce favorable effects, is both created naturally, in the fermentation of exposed fruits, vegetables, and grains that have become overripe, and through the intervention of people who accelerate the process by controlling the conditions of fermentation. If we assume that it is ethanol that produces a host of presumed favorable effects, as well as alcohol-related problems, then the logic of labeling some drinks "alcoholic" can be justified. It is important to remember, however, that labels are merely a social convention. No matter how great its alcohol content may be, wine is thought of as "food" in much of France and Italy—as is beer in Scandinavia and Germany. Similarly, in the United States, many people who regularly drink beer in considerable quantities do not think of themselves as using alcohol. Some fruit juices, candies, and desserts come close to having enough alcohol to be so labeled, but they are not. Thus many of the concerns that people have about alcohol relate more to their expectations than to the actual pharmacological or biochemical impact that the substance would have on the human body.
According to the Bible, one of the first things Noah did after the great Flood was to plant a vineyard (Genesis 9:21). According to the predynastic Egyptians, the great god Osiris taught people to make beer, a substance that had great religious as well as nutritional value for them. Similarly, early Greeks credited the god Dionysus with bringing them wine, which they drank largely as a form of worship. In Roman times, the god Bacchus was thought to be both the originator of wine and always present within it. It was a goddess, Mayahuel, with 400 breasts, who supposedly taught the Aztecs how to make pulque from the sap of the century plant; that mild beer is still important in the diet of many Indians in Mexico, where it is often referred to as "the milk of our Mother." In each of these instances, whether the giver was male or female, alcohol was viewed as supernatural, reflecting deep appreciation of its important roles in nourishing and comforting people.
Anthropologists often treat myths as if they were each people's own view of history, but clearly it would be difficult to take all myths at face value. We cannot know when or where someone first sampled alcohol, but we can imagine that it might well have been just an attempt to make the most of an overripe fruit or a soured bowl of gruel. The taste, or the feeling that resulted, or both, may have been pleasant enough to prompt repetition and then experimentation. Probably it happened not just once but various times, independently, at a number of different places, just as did the beginnings of agriculture.
PREHISTORY AND ARCHEOLOGY
Although it is impossible to say where or when Homo sapiens first sampled alcohol, there is firm evidence, from chemical analysis of the residues found in pots dating from 3500 b.c., that wine was already being made from grapes in Mesopotamia (now Iran). This discovery makes alcohol almost as old as farming, and, in fact, beer and bread were first produced at the same place at about the same time from the same ingredients. We know little about the gradual process by which people learned to control fermentation, to blend drinks, or to store and ship them in ways that kept them from souring, but the distribution of local styles of wine vessels serves as a guide to the flow of commerce in antiquity.
It would be misleading to think of early wines and beers as similar to the drinks we know today. In a rough sense, the distinction between them is that a wine is generally derived from fruits or berries, whereas a beer or ale comes from grain or a grain-based bread. Until as recently as a.d. 1700, both were often relatively dark, dense with sediments, and extremely uneven in quality. Usually handcrafted in small batches, home-brewed beers tend to be highly nutritious but to last only a few days before going sour (i.e., before all the fermenting sugars and alcohol are depleted and become vinegar). By contrast, homemade wines have relatively little in the way of vitamins or minerals but can last a long time if adequately sealed.
In Egypt between 2700 and 1200 b.c., beer was not only an important part of the daily diet; it was also buried in royal tombs and offered to the deities. Many of the paintings and carvings in Egyptian tombs depict brewing and drinking; early papyri include commercial accounts of beer, a father's warning to his student son about the danger of drinking too much, praises to the god who brought beer to earth, and other indications of its importance and effects.
The earliest written code of laws we know, from Hammurabi's reign in Babylon around 2000 b.c., devoted considerable attention to the production and sale of beer and wine, including regulations about standard measures, consumer protection, and the responsibilities of servers.
In ancient Greece and Rome (roughly 800 b.c.-a.d. 400), there was wider diffusion of grape-growing north and westward in Europe, and wine was important for medicinal and religious purposes, although it was not yet a commonplace item in the diet of poor people. The much-touted sobriety of the Greeks is presumably based on their custom of diluting wine with water and drinking only after meals, in contrast to neighboring populations who often sought drunkenness through beer as a transcendental state of altered consciousness. Certainly heavy drinking was an integral part of the religious orgies that, commemorating their deities, we now call "Dionysiac" (or, in the case of Rome, "Bacchic"). The temperate stereotype also overlooks the infamous chronic drunkenness of Alexander the Great. Born in Macedon, in 356 b.c., he managed to conquer most of the known world in his time, by 325 b.c., bringing what are now Egypt and most of the Middle East under the rule of Greece before he died in 323 b.c.
Romans were quick to point out how their relative temperance contrasted with the boisterous heavy drinking of their tribal neighbors in all directions, whom they devalued as the bearded ones, "barbarians." To a remarkable degree, the geographic spread of Latin-based languages and grape cultivation coincided with the spread of the Roman Empire through Europe and the accompanying diffusion of the Mediterranean diet—rich in carbohydrates and low in fats and protein—with wine as the usual beverage. In striking contrast were non-Latin speakers, who were less reliant on bread and pasta and without olive oil; they drank beers and meads, with drunkenness more common. Plato considered wine an important adjunct to philosophical discussion, and St. Paul recommended it as an aid to digestion.
The Hebrews established a new pattern around the time of their return from the Babylonian exile, and the construction of the Second Temple (c. 500 b.c.). Related to a new systematizing of religious practices was a strong shift toward family rituals, in which the periodic sacred drinking of wine was accompanied by a pervasive ethic of temperance, a pattern that persists today and often marks drinking by religious Jews as different from that of their neighbors. Early Christians (many of whom had been Jews), praised the healthful and social benefits of wine while condemning drunkenness. A majority of the many biblical references to drinking are clearly favorable, and Jesus' choice of wine to symbolize his blood is perpetuated in the solemn rite of the Eucharist, which has become central to practice in many Christian churches as Holy Communion.
In the Iron Age in France (c. 600 b.c.), distinctive drinking vessels found in tombs strongly suggest that political leadership involved the redistribution of goods to one's followers, with wine an important symbol of wealth. Archeologists have learned so much about the style and composition of pots made in any given area that they can often trace routes and times of trade, military expansion, or migrations by noting where fragments of drink containers are found. Although we know little about Africa at that time, we assume that mild fermented home brews (such as banana beer) were commonplace, as they were in Latin America. In Asia, we know most about China, where as early as 2000 b.c. grain-basedbeer and wine were used in ceremony, offered to the gods, and included in royal burials. Most of North America and Oceania, curiously, appear not to have had any alcoholic beverages until contact with Europeans.
Alcohol in classical times served as a disinfectant and was thought to strengthen the blood, stimulate nursing mothers, and relieve various ills, as well as to be an ideal offering to both gods and ancestral spirits. Obviously, drink and drinking had highly positive meanings for early peoples, as they do now for many non-Western societies.
FROM 1000 TO 1500
The Middle Ages was marked by a rapid spread of both Christianity and Islam. Large-scale political and economic integration spread with them to many areas that had previously seen only local warring factions, and sharp social stratification between nobles and commoners was in evidence at courts and manors, where food and drink were becoming more elaborate. National groups began to appear, with cultural differences (including preferred drinks and ways of drinking) increasingly noted by travelers, of whom there were growing numbers. Excessive drinking by poor people was often criticized but may well have been limited to festive occasions. With population increases, towns and villages proliferated, and taverns became important social centers, often condemned by the wealthy as subverting religion, political stability, and family organization. But for peasants and craftspeople, the household was still often the primary economic unit, with home-brewed beer being a major part of the diet.
During this period, hops, which enhanced both the flavor and durability of beer, were introduced. In Italy and France, wine became even more popular, both in the diet and for expanding commerce. Distillation had been known to the Arabs since about 800, but among Europeans, a small group of clergy, physicians, and alchemists monopolized that technology until about 1200, producing spirits as beverages for a limited luxury market and for broader use as a medicine. Gradual overpopulation was halted by the Black Death (a pandemic of bubonic plague), and schisms in the Catholic church resulted in unrest and political struggles later in this period.
Across northern Africa and much of Asia, populations, among whom drinking and drunkenness had been lavishly and poetically praised as valuable ways of altering consciousness, became temperate and sometimes abstinent, in keeping with the tenets of Islam and the teachings of Buddha and of Confucius. China and India both had episodes of prohibition, but neither country was consistent. In the Hindu religion, some castes drank liquor as a sacrament, whereas others scorned it—vivid proof that a culture, in the anthropological sense (as a set of beliefs and practices that guide one through living), is often much smaller than a religion or a nation, although we sometimes tend to think of those larger entities as more homogenous than they really are.
As the Middle Ages gave way to the Renaissance, both the population and the economy expanded throughout most of Europe. Because the Arabs (who had ruled from 711 to 1492) had been expelled from Spain and Portugal, they cut off overland trade routes to Asia; European maritime exploration therefore resulted in increasing commerce all around the coasts of Africa. The so-called Age of Exploration led to the startling encounter with high civilizations and other tribal peoples who had long occupied North America, Central America, and South America. Ironically, alcoholic beverages appear to have been totally unknown north of Mexico, although a vast variety of beers, chichas, pulques, and other fermented brews were important in Mexico as foods, as offerings to the gods and to ancestral spirits, and as shortcuts to religious ecstasy—if we assume that Native Americans then lived much as those who were soon to be described by the European conquerors and missionaries.
Throughout sub-Saharan Africa, we assume, home-brewed beers were plentiful nutritious, and symbolically important, as they came to be described in later years.
During the Middle Ages, drinking was treated as a commonplace experience, little different from eating, and drunkenness appears to have been infrequent, tolerated in association with occasional religious festivals and of little concern in terms of health or social welfare. Alcoholic beverages themselves were becoming more diverse but still were thought to be invigorating to humans, appreciated by spirits, and important to sociability.
FROM 1500 TO 1800
Wealth and extravagance were manifest in the rapidly growing cities of Europe, but so were poverty and misery, as class differences became even more exaggerated. The Protestant Reformation, which set out to separate sacred from secular realms of life, seemed to justify an austere morality that included injunctions against celebratory drunkenness. If the body was the vessel of the spirit, which itself was divine, one should not desecrate it with long-term heavy drinking. Puritans viewed intoxication as a moral offense—although they drank beer as a regular beverage and appreciated liquor for its supposed warming, social, and curative properties. Public drinking establishments evolved, sometimes as important town meeting places and sometimes as the workers' equivalent of social clubs, with better heat and lighting than at home, with news and gossip, games and companionship. Coffee, Tea, and Chocolate were also introduced to Europe at this time, and each became popular enough to be the focus of specialized shops. But each was also suspect for a time, while physicians debated whether they were dangerous to the health; clergy debated their effects on morality; and political and business leaders feared that retail outlets would become breeding places of crime, labor unrest, and civil disobedience. Brandies (brantwijns, liquor distilled from wines to be shipped as concentrates) spread among the aristocracy, and champagne was introduced as a luxury beverage (wine), as were various cordials and liqueurs. Brewing and wine-making grew from cottage industries to major commercial ventures, incorporating many technical innovations, quality controls, and other changes.
The "gin epidemic" in mid-eighteenth-century London is sometimes cited as showing how urban crowding, cheap liquor, severe unemployment, and dismal working conditions combined to produce widespread drinking and dissolution, but the vivid engravings by William Hogarth may exaggerate the problem. At the same time, the artist extolled beer as healthful, soothing, and economically sound. In France, even peasants began to drink wine regularly. In 1760, Catherine the Great set up a state monopoly to profit from Russia's prodigious thirst, and Sweden followed soon after.
Throughout Latin America and parts of North America, the Spanish and Portuguese conquistadors found that indigenous peoples already had home brews that were important to them for sacred, medicinal, and dietary purposes. The Aztecs of Mexico derived a significant portion of their nutritional intake from pulque but reserved drunkenness as the prerogative of priests and old men. Cultures throughout the rest of the area similarly used chicha or beer made from maize, manioc, or other materials. The Yaqui (in what is now Arizona) made a wine from cactus as part of their rain ceremony, and specially made chicha was used as a royal gift by the Inca of Peru. Religious and political leaders from the colonial powers were ambivalent about what they perceived as the risks of public drunkenness and the profits to be gained from producing and taxing alcoholic beverages. A series of inconsistent laws and regulations, including sometime prohibition for Indians, were probably short-lived experiments, affected by such factors as local revolts and different opinions among religious orders.
As merchants from various countries competed to gain commercial advantage in trading with the various Native American groups of North America, liquor quickly became an important item. It has become popular to assume that Native Americans are genetically vulnerable to alcohol, but some tribes (such as Hopi and Zuni) never accepted it, and others drank with moderation. The Seneca, in New York state, are an interesting case study, because they went from having no contact with alcohol through a series of stages culminating in a religious ban. When brandy first arrived, friends would save it for an unmarried young man, who would drink it ceremoniously to help in his required ritual quest for a vision of the animal that would become his guardian spirit. In later years, drinking became secular, with anyone drinking and boisterous brawling a frequent outcome. In 1799, when a tribal leader, who was already alcoholic, had a very different kind of vision, he promptly preached abstention from alcohol, an end to warfare, and devotion to farming—all of which remain important today in the religion that is named after him, Handsome Lake.
Throughout the islands of the Pacific, local populations reacted differently to the introduction of alcohol, sometimes embracing it enthusiastically and sometimes rejecting it. Eskimos were generally quick to adopt it, as were Australian Aborigines, to the extent that some interpret their heavy drinking as an attempt to escape the stresses of losing valued parts of their traditional ways of life. Detailed information about the patterns of belief and behavior associated with drinking among the diverse populations of Asia and Africa vividly illustrates that alcohol results in many kinds of comportment—depending more on sociocultural expectations than any qualities inherent in the substance.
In what is now the United States, colonial drinking patterns reflected those of the countries from which immigrants had come. Rum (distilled from West Indies sugar production) became an important item in international trade, following routes dictated by the economic rules of the British Empire. In the infamous Triangle Trade, captive black Africans were shipped to the West Indies for sale as slaves. Many worked on plantations there, producing not only refined sugar, a sweet and valuable new faddish food, but also molasses, much of which was shipped to New England. Distillers there turned it into rum, which was in turn shipped to West Africa, where it could be traded for more slaves. During the American Revolution (1775/6-1783), however, that trade was interrupted and North Americans shifted to whiskey. Farmers along what was then the frontier, still east of the Mississippi, were glad to have a profitable way of using surplus corn that was too bulky to bring to distant markets. After the war, when the first federal excise tax was imposed (on whiskey) in 1790, to help cut the debt of the new United States, producers' anger about a tax increase was expressed in the Whiskey Rebellion of 1794. To quell the uprising, federal troops (militia) were used for the first time. At about the same time, Benjamin Rush, a noted physician and signer of the Declaration of Independence, started a campaign against long-term heavy drinking as injurious to health.
Evidently, alcohol plays many roles in the history of any people, and changes in attitudes can be abrupt, illustrating again the importance that social constructions of reality have in relation to drinking.
The large-scale commercialization of beer, wine, and distilled liquor spread rapidly in Europe as many businesses and industries became international in scope. Large portions of the European proletariat were no longer tied to the land for subsistence, and new means of transportation facilitated vast migrations. The industrial revolution was not an event but a long process, in which, for many people, work became separated from home. The arbitrary pace imposed by wage work contrasted markedly with the seasonal pace of traditional agrarianism.
In some contexts neighbors still drank while helping each other—as, for example, in barn-raising or reciprocal labor exchange during the harvest. But for the urban masses, leisure and a middle class emerged as new phenomena. Drinking, which became increasingly forbidden in the workplace as dangerous or inefficient, gradually became a leisure activity, often timed to mark the transition between the workday and home life. As markets grew, foods became diverse, so that beers and ciders (usually hard) lost their special value as nourishing and energizing.
In Europe, political boundaries were approximately those of the twentieth century; trains and steamships changed the face of trade; and old ideas about social inequality were increasingly challenged. Alcohol lost much of its religious importance as ascetic Protestant groups, and even fervent Catholic priests in Ireland, associated crime, family disruption, unemployment, and a host of other social ills with it, and taxation and other restrictions were broadly imposed. In Russia, the czar ordered prohibition, but only briefly as popular opposition mounted and government revenues plummeted. Those who paid special attention to physical and mental illnesses were quick to link disease with long-term heavy drinking, although liquor remained an important part of medicine for various curative purposes. A few institutions sprang up late in the nineteenth century to accommodate so-called inebriates, although there was little consensus about how or why drinking created problems for some people but not for others, nor was there any systematic research.
A wave of mounting religious concern that has been called the "great awakening" swept over the United States early in the 1800s, and, by 1850, a dozen states had enacted prohibition. Antialcohol sentiment was often associated with opposition to slavery. The local prohibition laws were repealed as the Civil War and religious fervor abated, and hard drinking became emblematic of cowboys, miners, lumberjacks, and other colorful characters associated with the expanding frontier. Distinctions of wealth became more important than those of hereditary social status, and a wide variety of beverages, of apparatus associated with drinking, and even of public drinking establishments accentuated such class differences.
Near the end of the century, another wave of sentiment against alcohol grew, as large numbers of immigrants (many of them Catholic and anything but ascetic) were seen by Protestant Yankees as trouble—competing for jobs, changing the political climate, and challenging old values. Coupled with this attitude was enthusiasm for "clean living," with an emphasis on natural foods, exercise, fresh air and water, loose-fitting clothing, and a number of other fads that have recently reappeared on the scene.
Native American populations, in the meantime, suffered various degrees of displacement, exploitation, and annihilation, sometimes as a result of deliberate national policy and sometimes as a result of local tensions. The stereotype of the drunken Indian became embedded in novels, news accounts, and the public mind, although the image applied to only a small segment of life among the several hundred native populations. Some Indians remained abstinent and some returned to abstinence as part of a deliberate espousal of indigenous values—for example, in the Native American Church, using Peyote as a sacrament, or in the sun dance or the sweat lodge, using asceticism as a combined religious and intellectually cleansing precept.
From Asia, Africa, and Oceania, explorers, traders, missionaries, and others brought back increasingly detailed descriptions of non-Western drinking practices and their outcomes. It is from such ethnographic reports—often sensationalized—that we can guess about the earlier distribution of native drinks and can recognize new alcoholic beverages as major commodities in the commercial exploitation of populations. Although some of the sacramental associations of traditional beverages were transferred to new ones, the increasing separation of brewing from the home, the expansion of a money-based economy, and the apparent prestige value of Western drinks all tended to diminish the significance of home brews. In African mines, Latin American plantations, and even some U.S. factories, liquor became an integral part of the wage system, with workers required to accept alcohol in lieu of some of their cash earnings. In some societies where drinking had been unknown before Western colonization, the rapid spread of alcohol appears to have been an integral part of a complex process that eroded traditional values and authority.
THE TWENTIETH CENTURY
It has been said that the average person's life in 1900 was more like that of ancestors thousands of years earlier than like that of most people today. The assertion certainly applies to the consumption of liquor. Pasteurization, mass production, commercial canning and bottling, and rapid transport all transformed the public's view of beer and wine in the twentieth century. The spread of ideas about individualism and secular humanism loosened the hold of traditional religions on the moral precepts of large segments of the population. New assumptions about the role of the state in support of public health and social welfare now color our expectations about drinking and its outcomes. Mass media and international conglomerates are actively engaged in the expansion of markets, especially into developing countries.
World War I prompted national austerity programs in many countries that curtailed the diversion of foodstuffs to alcoholic beverages but didn't quite reach the full prohibition for which the United States became famous. Absinthe was thought to be medically so dangerous that it was banned in several European countries, and Iceland banned beer but not wine or liquor. Sweden experimented with rationing, and the czar again tried prohibition in Russia. The worldwide economic depression of the 1930s appears to have slowed the growth of alcohol consumption, which grew rapidly during the economic boom that followed World War II. The Scandinavian countries, beset by a pattern of binge drinking, often accompanied by violence, tried a variety of systems of regulation, including state monopolies, high taxation, and severely restricted places and times of sale, before turning to large-scale social research.
While several Western countries were expanding their spheres of influence in sub-Saharan Africa, they agreed briefly on a multinational treaty that outlawed the sale of alcoholic beverages there, although they did nothing to curtail production of domestic drinks by various tribal populations. A flurry of scientific analyses of indigenous drinks surprised many by demonstrating their significant nutritional value, and more detailed ethnographic studies showed how important they were in terms of ideology, for vows, communicating with supernatural beings, honoring ancestors, and otherwise building social and symbolic credit—among native societies not only in Africa but also in Latin America and Asia. Closer attention to the social dynamics of drinking and other aspects of culture showed that the impact of contact with Western cultures is not always negative and that for many peoples the role of alcohol remained diverse and vital.
In the United States, a combination of religious, jingoistic, and unsubstantiated medical claims resulted in the enactment of nationwide prohibition in 1919. Often called "the noble experiment," the Eighteenth Amendment to the Constitution was the first amendment to deal with workaday behavior of people who have no important public roles. It forbade commercial transaction but said nothing about drinking or possession. Most authorities agree that, during the early years, there was relatively little production of alcoholic beverages and not much smuggling or home production. It was not long, however, before illegal sources sprang up. Moonshiners distilled liquor illegally, and bootleggers smuggled it within the U.S. or from abroad. Speakeasies sprang up as clandestine bars or cocktail lounges, and a popular counterculture developed in which drinking was even more fashionable than before prohibition. Some entrepreneurs became immensely wealthy and brashly confident and seemed beyond the reach of the law, whether because of superior firepower or corruption or both. The government had been suffering from the loss of excise taxes on alcohol, which accounted for a large part of the annual budget. The stock-market crash, massive unemployment, the crisis in agriculture, and worldwide economic depression aggravated an already difficult situation, and civil disturbances spread throughout the country. Some of the same influential people who had pressed strongest for prohibition reversed their stands, and the Twenty-first Amendment, the first and only repeal to affect the U.S. Constitution, did away with federal prohibition in 1933. Although the national government retained close control over manufacturing and distribution to maximize tax collection, specific regulations about retail sales were left up to the states. An odd patchwork of laws emerged, with many states remaining officially dry, others allowing local option by counties or towns, some imposing a state monopoly, some requiring that drinks be served with food and others expressly prohibiting it, some insisting that bars be visible from the street and others the opposite, and so forth. The last state to vote itself wet was Mississippi, in 1966, and many communities remain officially dry today. The older federal law prohibiting sales to Indians was not repealed until 1953, and many Indian reservations and Alaska native communities remain dry under local option.
The experience of failed prohibition in the U.S. is famous, but a similar combination of problems with lawlessness, corruption, and related issues led to repeal, after shorter experiments, in Iceland, Finland, India, Russia, and parts of Canada, demonstrating again that such drastic measures seem not to work except where supported by consensus and religious conviction (e.g., Saudi Arabia, Iran, and Ethiopia). It is ironic that some Indian reservations with prohibition have more alcohol-related deaths than those without. A more salutary recent factor is the growth of culturally sensitive programs of prevention and treatment that are being developed, often by the communities themselves, for Indian and other minority populations.
In the middle decades of the twentieth century, a number of alcoholics formed a mutual-help group, modeled on the earlier Washingtonians, and Alcoholics Anonymous has grown to be an international fellowship of individuals whose primary purpose is to keep from drinking. At about the same time, scientists from a variety of disciplines started studying various aspects of alcohol, and our knowledge has grown rapidly. Because of the large constituency of recovering alcoholics, the subject has become politically acceptable, and the disease concept has overcome much of the moral stigma that used to attach to alcoholism. Establishment of a National Institute on Alcohol Abuse and Alcoholism in 1971 signaled a major government commitment to the field, and its incorporation among the National Institutes of Health in 1992 indicates that concerns about wellness have largely displaced theological preoccupations.
Consumption of all alcoholic beverages increased gradually in the U.S. from repeal until the early 1980s, with marked increase following World War II, although it never reached more than one-third of what is estimated for the corresponding period a century earlier. Around 1980, sales of spirits started dropping and have continued to do so. A few years later, wine sales leveled off and have gradually fallen since; beer sales also appear to have passed their peak even more recently. These reductions occurred, despite increasing advertising, along with a return of the "clean living" movement and another shift toward physical exercise, less-processed foods, and concern for health. Linked with the reduction in drinking, what some observers call a "new temperance movement" has emerged, in which individuals not only drink less but call for others to do the same; the decline would be enforced by laws and regulations that would increase taxes, index liquor prices to inflation, diminish numbers and hours of sales outlets, require warning labels, ban or restrict advertising, and otherwise reduce the availability of alcohol. Such a "public health approach" is by no means limited to the U.S.; its popularity is growing throughout Europe and among some groups elsewhere, even as alcohol consumption continues to rise in Asia and many developing countries.
A quick review of the history of alcohol lends a fresh perspective to the subject. The vast literature on ethnographic variation among populations demonstrates the different ways in which peoples, widely separated geographically and historically, have used and thought about alcohol. The idea of alcohol as being implicated in a set of problems is peculiar to the recent past and is not yet generally accepted in many areas.
What some observers call the "new temperance movement" and others call "neoprohibitionism" is a recent phenomenon that grew out of Scandinavian social research. The conclusion, on the basis of transnational comparisons, was that there appeared to be some relationship between the amount of alcohol people drink and a broad range of what the researchers called "alcohol-related problems" (including spouse abuse, child neglect, social violence, psychiatric illness, a variety of organic damages, and traffic fatalities). The vague and general findings gradually came, through a process of misquotation and paraphrasing, to be treated as a pseudoscientific iron-clad law, to the effect that problems are invariably proportionate to consumption, so that the most effective way to diminish problems would be to cut drinking. This approach is sometimes called the "control of consumption model," or the "single distribution model" (referring to the fact that heavy drinkers are on the same distribution-of-consumption curve as low and moderate drinkers, with no clear points that would objectively divide the groups).
This movement is not restricted to the U.S. and Scandinavia, however. The World Health Organization of the United Nations called for a worldwide reduction, by 25 percent, of alcohol consumption during the last decade and a half of the twentieth century, recommending that member countries adopt similar policies. Throughout most of central and western Europe and North America, sales have fallen markedly, although the opposite trend can be seen in much of the third world. An ironic development has been recent loosening of controls in Scandinavian countries, traditionally the exemplars of that approach, while controls are being introduced and progressively tightened in southern Europe, where drinking has traditionally been an integral part of the culture.
The European Community standardization of tariffs may result in further changes soon. A more realistic way of lessening whatever problems may be related to alcohol consumption would appear to be the "sociocultural model" of prevention, emphasizing, on the basis of cross-cultural experience, that people can learn to drink differently, to expect different outcomes from drinking, and actually to find their expectancies fulfilled. This program would not be quick or easy, requiring intensive public education, but it seems more feasible than simply curtailing availability—in which case those who enjoy moderate drinking would be inconvenienced but those who insist on drinking heavily would continue to do so. Concern over policy is not only directed at helping individuals who may have become dependent; it also has the aim of making life safer and more pleasant for all. The history of alcohol indicates that problems are by no means inherent in the substance but, rather, are mediated by the individual user and by social norms.
(See also: Beers and Brews ; Temperance Movement ; Treatment, History of )
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Dwight B. Heath
Revised by Andrew J. Homburg
Psychological Consequences of Chronic Abuse
Chronic alcohol abuse (heavy drinking over a long period) can lead to numerous adverse effects—to direct effects such as impaired attention, increased Anxiety, depression, and increased risk-taking behaviors—and to indirect affects such as impaired cognitive abilities, which may be linked to nutritional deficiencies from long-term heavy drinking.
A major difficulty in describing the effects of chronic alcohol abuse is that many factors interact with such consumption, resulting in marked individual variability in the psychological consequences. In addition, defining both what constitutes chronicity and abusive drinking in relation to resulting behavioral problems is not simply a function of frequency and quantity of alcohol consumption. For some individuals, drinking three to four drinks per day for a few months can result in severe consequences, while for others, six drinks per day for years may not have any observable effects. One reason for this variability is related to genetic differences in the effects of alcohol upon an individual. While not all of the variability can be linked to genetic predispositions, it has been demonstrated that the interactions between individual genetic characteristics and environmental factors are important in determining the effects of chronic alcohol consumption.
Other factors to consider when assessing the effects of chronic drinking relate to the age and sex of the drinker. In the United States, heavy chronic drinking occurs with the greatest frequency in white men, ages nineteen to twenty-five. For the majority of individuals in this group, heavy drinking declines after age twenty-five to more moderate levels and then decreases to even lower levels after age fifty. As might be expected, the type and extent of psychological consequences depend on the age of the chronic drinker. Research has indicated that younger problem drinkers are more likely to perform poorly in school, have more arrests, and be more emotionally disturbed than older alcoholics. Also, younger drinkers have more traffic accidents, which may result from a combination of their heavy drinking and increased risk-taking behavior. Many of the more serious consequences of chronic alcohol use occur more frequently in older drinkers—individuals in their thirties and forties; these include increased cognitive and mental impairments, divorce, absenteeism from work, and suicide. Chronic drinking in women tends to occur more frequently during their late twenties and continuing into their forties—but the onset of alcohol-related problems appears to develop more rapidly in women than in men. In a study of Alcoholics Anonymous members, women experienced serious problems only seven years after beginning heavy drinking, as compared to an average of more than eleven years for men.
Black and Hispanic men in the United States tend to show prolonged chronic drinking beyond the white male's reduction period during his late twenties. Thus, for many of the effects of chronic drinking discussed below, age, sex, and duration of drinking are important factors that mediate psychological consequences.
In the early 1990s, it was estimated that between 7 and 10 percent of all individuals drinking alcoholic beverages will experience some degree of negative consequences as a result of their drinking pattern. Most people believe that chronic excessive drinking results in a variety of behavioral consequences, including poor work/school performance and inappropriate social behavior. These two behavioral criteria are used in most diagnostic protocols when determining if a drinking problem exists. Several surveys have found that heavy chronic drinking does produce a variety of school- and job related problems. A survey of personnel in the U.S. armed services found that for individuals considered heavy drinkers, 22 percent showed job-performance problems. Health professionals also show high rates of alcohol problems, with a late 1980s British survey indicating that physicians experience such problems at a rate of 3.8 times that of the general population. A variety of surveys have consistently shown that chronic excessive drinking leads to loss of support by moderate-drinking family and friends. The dissolution of marriage in couples in which only one member drinks is estimated to be over 50 percent. Often the interpersonal problems that surround a problem drinker can lead to family violence; a 1980s study found that more than 44 percent of men with alcohol problems admitted to physically abusing their wives, children, or significant-other living partners. Survey data also indicate that people who use alcohol frequently are more likely to become involved with others who share their drinking patterns—particularly those who do not express concern about the individual's excessive and altered behavior that results from drinking. This increased association with fellow heavy drinkers as one's main social-support network can itself result in increased alcohol use.
The interaction between the social setting and the individual, the current level of alcohol intoxication, and past drinking history all play a role in the psychological consequences of chronic heavy drinking. It is impossible to determine which changes in behavior result only from the use of alcohol.
One major psychological consequence resulting from heavy chronic drinking for a subpopulation of alcohol abusers (predominantly women) is the feeling of loss of control over one's life, commonly manifested as depression. (While not conclusive, some studies suggest that the menstrual cycle may be an additional factor for this population.) In many cases, increased drinking occurs as the depression becomes more intense. It has been postulated that the increased drinking is an attempt to alleviate the depression. Unfortunately, since this "cure" usually has little success, a vicious drinking cycle ensues. While no specific causality can be assumed, research on suicide has indicated that chronic alcohol abuse is involved in 20 to 36 percent of reported cases. The level of suicide in depressed individuals with no alcohol abuse is somewhat lower—about 10 percent. At this time, it is not clear if the chronic drinking results in depression or if the depression is a pre-existing psychopathology, which becomes exacerbated by the drinking behavior. The rapid improvement of depressive symptoms seen in the majority of alcoholics within a few weeks of detoxification (withdrawal) suggests that, for many, depressive symptoms are reflective of toxic effects of alcohol. Regardless of the mechanism, it appears that the combination of depression and drinking can be a potent determinant for increasing the potential to commit suicide.
For another subpopulation of chronic alcohol abusers (mainly young men), an increase in overall aggressive behaviors has been reported. Again, there is an indication that these individuals represent a group that has an underlying antisocial personality disorder, which is exacerbated by chronic alcoholic drinking.
Although it is often assumed that alcohol increases sexual behavior, chronic excessive use has been found to decrease the level of sexual motivation in men. In some gay male populations, where high alcohol consumption is also associated with increased high-risk sexual activity, this decrease in sex drive does not appear to result; however, for many chronic male drinkers, a long-term consequence of heavy drinking is reduced sexual arousal and drive. This may be the combined result of the decreased hormonal levels produced by the heavy drinking and the decline of social situations where sexual opportunities exist.
Perhaps the best-documented changes in psychological function resulting from chronic excessive alcohol use are those related to cognitive functioning. While no evidence exists for any overall changes in basic intelligence, specific cognitive abilities become impaired by chronic alcohol consumption. These most often include visuo-spatial deficits, language (verbal) impairments, and in more severe cases, memory impairments (alcoholic amnestic syndrome). A specific form of dementia, alcoholic dementia, has been described as occurring in a small fraction of chronic alcohol abusers. The pattern and nature of the cognitive effects, as measured on neuropsychiatric-assessment batteries in chronic alcohol abusers, exhibit a wide variety of individual patterns. Also, up to 25 percent of chronic alcoholics tested show no detectable cognitive deficits. Although excessive alcohol use has been clearly implicated in such deficits, a variety of coexisting lifestyle behaviors might be responsible for the cognitive impairments observed. For example, poor eating habits leading to vitamin deficiencies result in cognitive deficits similar to those observed in some alcohol abusers. Head trauma from accidents, falls, and fights (behaviors frequent in heavy drinkers) may also produce similar cognitive deficits. Therefore, it is extremely difficult to determine the extent to which alcohol abuse is directly responsible for the impairments—or if they are a result of the many alterations in behaviors that become part of the heavy-drinker lifestyle.
The specific psychological consequences of chronic drinking are complex and variable, but there is clear evidence that chronic abuse of alcohol results in frequent and often disastrous problems for the drinker and for those close to him or her.
(See also: Aggression and Drugs: Research Issues ; Complications )
Akers, R. (1985). Deviant behavior: A social learning approach. Belmont, CA: Wadsworth.
Cahalan, D. (1970). Problem drinkers: A national survey. San Francisco: Jossey-Bass.
Fishburne, P., Abelson, H. I., & Cisin, I. (1980). National survey on drug abuse: Main findings. Washington, DC: U.S. Government Printing Office.
Royce, J. E. (1989). Alcohol problems and alcoholism, rev. ed. New York: Free Press.
Vaillant, G. (1983). The natural history of alcoholism. Cambridge: Harvard University Press.
Herman H. Sampson
Nancy L. Sutherland
Revised by Andrew J. Homburg
What Kind of Drug Is It?
Alcohol is an ancient drug. Beer and wine jugs well over 5,000 years old have been excavated from archaeological sites in southwest Asia and northern Africa. Prehistoric peoples are thought to have produced the first alcoholic beverages by accident. This occurred when mixtures of water, a bit of fungus, and wild berries left alone in the sun turned into alcohol through a process known as fermentation.
Alcohol acts as a depressant. A depressant is a substance that slows down the activity of an organism or one of its parts. At the same time, drinking alcohol also lowers one's inhibitions. When this happens, someone might act more recklessly than he or she would normally.
Through the ages, alcohol has been used as an all-purpose drug: a painkiller, an antiseptic, a disinfectant, a teething aid for babies, a sedative, a battlefield medicine, and a drowner of sorrows. It is also associated with celebrations: offering a toast to a newly married couple is a common tradition.
During the Middle Ages (c. 500–c. 1500), alcohol became something of a status symbol among Europe's upper classes. Wine production became very important to the economies of Italy and France throughout the Renaissance period, which spanned the fourteenth through the early seventeenth centuries. Meanwhile, in the New World, the first distillery opened in 1640 in what would later become the state of New York. In the 1700s, home brewing processes were replaced largely by the commercial manufacture of beer and wine in Europe.
Official Drug Name: Ethyl alcohol, ethanol, grain alcohol
Also Known As: Booze, hooch, moonshine, sauce, spirits (for alcohol in general); brew, suds (for beer); vino (for wine)
Drug Classifications: Not classified, depressant
Laws banning the sale of alcoholic beverages date back to the fourteenth century, when Germany banned the sale of alcohol on Sundays and other religious holidays. Even earlier, Switzerland instituted laws requiring drinking establishments to close at certain times to combat public drunkenness. The United States has seen historical increases and decreases in alcohol use as well. High periods of alcohol consumption coincided with periods of war: during the American Civil War (1861–1865), World War I (1914–1918), and
World War II (1939–1945), drinking increased among Americans. These peaks in alcohol usage were interrupted by so-called "dry" periods in U.S. history—times when the consumption of alcohol dropped to very low levels throughout the nation.
The Era of Prohibition in the United States
The longest span of dry years in the United States occurred during prohibition, which lasted from 1920 to 1933. At that time,
many Americans viewed alcohol as a destructive force in society. Crime, poverty, gambling, prostitution, and declining family values were blamed on alcohol consumption. A ban on the manufacture and sale of all alcoholic beverages in the United States began on January 16, 1920, with the passage of the Eighteenth Amendment to the Constitution. However, Prohibition did not stop all drinking in the United States. Some people produced alcohol in illegal stills, especial in rural areas. The brew created in these stills was often referred to as Moonshine. The liquor was then sold on the black market. Otherpeople brewed alcoholic beverages at home, hoping to not get caught.
During Prohibition, some people even went to other countries, such as Canada, to buy alcohol and smuggle it back into the United States. Smugglers used all sorts of methods to hide the illegal drink. They hid it under false floors in trucks, under their clothing, and even in vials placed within walking sticks or canes. Prohibition proved to be highly unpopular. Thirteen years after it had begun, Prohibition ended and alcohol was once again deemed a legal substance in the United States.
Alcohol consumption rose considerably in the early and middle 1980s, when many states lowered the drinking age to eighteen. Because of the increase in the number of teen deaths tied to drinking and driving, the legal drinking age was raised to twenty-one throughout the nation in 1987. The rate of alcohol consumption dipped in the 1990s, but alcohol remains the most commonly used legal drug. Consumption of alcohol by young people is very high.
Much could be written on the topic of alcohol as an addictive substance. The following entry attempts to provide as much relevant information as possible for the scope and intended audience of this encyclopedia.
What Is It Made Of?
The chemical composition for ethanol or ethyl alcohol, otherwise known as alcohol, is C2H5OH. That means it is composed of two atoms of carbon, one atom of oxygen, and six atoms of hydrogen. Ethanol is a colorless liquid that is highly flammable. Aside from being an ingredient in alcoholic beverages, it is used in fuels, solvents, disinfectants, and preservatives.
Pure alcohol is too strong to drink by itself. It must be diluted with water and other substances to create alcoholic beverages. Ethyl alcohol is the only alcohol considered safe to drink. Other alcohols such as methanol (also called wood alcohol) and isopropyl alcohol (pronounced EYE-so-PROPE-uhl; also called rubbing alcohol) are not used in beverages. They are highly toxic (poisonous) to the body. Methanol, in particular, can cause blindness and even death if swallowed.
No Nutritional Value
Alcohol contains what are called "empty calories." Beer, wine, wine coolers, and liquor have no nutritional value, but they still cause weight gain. Drinking alcohol is bad for the skin as well as the waistline. It increases the number and severity of acne breakouts. It is also known for causing bad breath among users.
Types of Alcoholic Beverages
Wines and beers are produced by fermenting fruits, vegetables, and grains. Fermentation occurs when sugar in berries or grains is combined with yeast, which is a fungus. A fungus is a sort of recycler that dissolves nutrients and changes them. A chemical reaction takes place as yeast cells eat up the sugars in food. Those sugars are changed into carbon dioxide and alcohol. Wine is formed when the combination of sugar, yeast, and berries reaches an alcohol concentration point between 9 and 15 percent. Similarly, when sugar, yeast, and grains such as barley are combined and reach an alcohol concentration of 3 to 6 percent, beer is made and fermentation stops.
Hard liquor is produced by a process called distillation, which adds an extra step to the fermentation process. In distillation, liquids that have already been fermented are boiled to remove the alcohol. At the boiling point, the alcohol separates from the fermented liquid to create a vapor. The vapor is captured and then held separately in a cooling tube until it turns back into a liquid. The resulting alcohol, now removed from the original fermented liquid, becomes hard liquor when mixed with water.
Alcohol makes up 50 percent of distilled liquors such as whiskey, rum, vodka, scotch, and gin. The percentage of alcohol in hard liquor is used to determine the "proof" number printed on every bottle. Proof is determined by doubling the percentage of pure alcohol in a liquor and then dropping the percentage sign. For instance, whiskey that is 50 percent alcohol is said to be 100 proof.
Liqueurs (pronounced lick-OARZ) are distilled from grain and mixed with fruit, herbs, spices, and sugary syrups. They are extremely sweet and very high in alcohol content. They are intended to be drunk in very small quantities, usually as an "after dinner" drink. Popular liqueurs include Cointreau (pronounced KWANNtroh), Tia Maria, and Drambuie (pronounced dram-BOO-ee).
The difference between hard liquors lies in the grains or vegetables that are used to make them. Rye, corn, and barley are used to make whiskey. Vodka is distilled from potatoes, rye, or wheat. Scotch is derived from malted barley. Gin is a combination of distilled spirits (alcohol) flavored with juniper berries. Rum is made from molasses.
Adding carbonated drinks to hard liquor—mixing rum with cola or whiskey with ginger ale, for instance—produces a drink that seems stronger than liquor mixed with plain water. Carbonation speeds up the absorption of alcohol into the bloodstream.
Sweet and powerful drinks like brandy and port are made from distilled wine, which increases the alcohol content of 12 percent to two to three times that amount. "The original idea of distillers," wrote Andrew Weil and Winifred Rosen in From Chocolate to Morphine, "was to concentrate wine to a smaller volume to make it easier to ship it in barrels overseas. At the end of the voyage the brandy was to be diluted with water back to an alcohol content of 12 percent. What happened… was that when people got their hands on what was in the barrels, no one waited to add water. Suddenly a new and powerful form of alcohol flooded the world."
How Is It Taken?
Alcohol is swallowed, usually in a liquid form. It is also swallowed in gel form in semisolid "Jell-O shots." These Jell-O shots are medicine-cup-sized mixtures of gelatin and hard liquor, such as vodka, which are chilled before serving. The high sugar content in the gelatin hides the taste of the alcohol, making Jell-O shots particularly dangerous. Fruit punch spiked with hard liquor can have the same powerful effect. Users could accidentally consume far more alcohol than they intended in a short period of time.
According to Ron Weathermon and David W. Crabb in Alcohol Research & Health, a standard drink is defined as one 12-ounce can of beer or bottle of wine cooler, one 5-ounce glass of wine, or 1.5 ounces of distilled liquor. Each of these drinks contains the equivalent of 1 ounce of pure alcohol.
Are There Any Medical Reasons for Taking This Substance?
"Alcohol actually blocks some of the messages trying to get to the brain," according to the TeensHealth Web site. That is the primary reason it has been used for thousands of years to suppress pain, treat injuries and infections, and prepare people for surgery. In the past, alcohol has been used as an anesthetic, a sedative, and even a treatment for a lung disease called typhus.
The facts about youth & alcohol
Alcohol use is widespread among today's teenagers
- Nearly 70% of 8th graders perceive alcoholic beverages as "fairly easy" or "very easy" to get.
- By the time they complete high school nearly 80% of teenagers have consumed alcohol, 30% report having been drunk in the past month, and 29% report having 5 or more drinks in a row in the past two weeks.
Alcohol use increases substantially from middle to high school
- Approximately 20% of 8th graders report having recently (within the past 30 days) consumed alcohol compared to 35% of 10th graders and almost 50% of 12th graders.
- A little over 20% of 8th graders report having been drunk at least once in their life compared to almost 45% of 10th graders and 60% of 12th graders.
The consequences of underage drinking
- A person who begins drinking as a young teen is four times more likely to develop alcohol dependence than someone who waits until adulthood to use alcohol.
- During adolescence significant changes occur in the body, including the formation of new networks in the brain. Alcohol use during this time may affect brain development.
- Motor vehicle crashes are the leading cause of death among youth ages 15 to 20, and the rate of fatal crashes among alcohol-involved drivers between 16 and 20 years old is more than twice the rate for alcohol-involved drivers 21 and older. Alcohol use also is linked with youthful deaths by drowning, suicide, and homicide.
- Alcohol use is associated with many adolescent risk behaviors, including other drug use and delinquency, weapon carrying and fighting, and perpetrating or being the victim of date rape.
source: "The Facts About Youth & Alcohol," National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD [Online] http://www.niaaa.nih.gov/publications/PSA/factsheet. pdf#search='the%20facts%20about%20youth%20&%20alcohol' [accessed May 24, 2005]
Research in the 1990s showed that moderate amounts of alcohol could help reduce the risk of heart attacks. Abuse of alcohol, however, has been connected to heart disease. "Between the extremes of heavy and light drinking lies a 'gray area' that is not completely understood," explained Cynthia Kuhn and her coauthors in their book Buzzed: The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy. "Moreover, this gray area appears to be rather small. That is, while an average of one-half to one drink per day may be healthy for your heart, it is perfectly clear that an average of two drinks per day significantly increases your risk of dying from heart disease or cancer." As of 2005, there were no known therapeutic uses for alcohol.
"Next to tobacco and caffeine, alcohol is the world's most popular drug," wrote Paul M. Gahlinger in Illegal Drugs: A Complete Guide to Their History, Chemistry, Use, and Abuse. Peer pressure, depression, and a need to fit in are all factors leading to alcohol use by teens.
There is a difference between alcohol abuse and alcoholism. In 1956, the American Medical Association defined alcoholism as a disease. Alcoholism is described as a loss of control over drinking—a preoccupation with drinking despite negative consequences to one's physical, mental, and emotional makeup as well as one's work and family life. Problem drinkers might start out by abusing alcohol occasionally without being addicted to it. However, Kuhn pointed out that "continued exposure to alcohol changes the brain in ways that produce dependence." Therefore, anyone who drinks heavily over a long period of time "will become physically dependent on the drug."
According to the National Council on Alcoholism and Drug Dependence (NCADD), about 18 million Americans have alcohol problems. Excessive drinkers are generally defined as: 1) men who consume more than two drinks per day, every day, or more than three drinks at a time; and 2) women who consume more than one drink per day, every day, or more than three drinks at a time. Women used to make up one-third of the problem drinking population, but they are quickly catching up to men in terms of abuse. In general, if a woman and a man consume the same amount of alcohol, the woman will become more intoxicated in a shorter period of time. And because of their physical makeup, women are more likely than men to damage their hearts, livers, and brains due to drinking. An increased risk of breast cancer has also been linked to drinking.
Problem drinkers can be rich or poor, young or old, male or female. They come from all racial and ethnic backgrounds. Although anyone can become an alcoholic, a child with an alcoholic parent runs a greater risk of developing the disease of alcoholism than a child of non-alcoholic parents.
Young People and Alcohol
New York Times contributor Howard Markel wrote, "Because the brains of teenagers are still developing, many experts believe they are at greater risk for becoming addicted." According to the National Institutes of Health (NIH), young people who begin drinking before the age of thirteen are four times more likely to develop an addiction to alcohol than people who begin drinking at age twenty-one.
The results of the 2004 Monitoring the Future (MTF) study were released to the public on December 21, 2004. Conducted by the University of Michigan (U of M), the MTF was sponsored by research grants from the National Institute on Drug Abuse (NIDA). Since 1991, U of M has tracked patterns of alcohol and drug use, as well as attitudes toward alcohol and drugs, among students in the eighth, tenth, and twelfth grades. (Prior to that, from 1975 to 1990, the MTF survey was limited to twelfth graders.)
The 2004 MTF survey results indicate that alcohol use among students in the eighth and tenth grades has fallen each year since 2001. Researchers noted, however, that "drinking and drunkenness did not continue to decline" among twelfth graders in 2004. According to MTF charts for 2003 to 2004, about three in every ten high school seniors reported "being drunk in the past 30 days." The ease with which seniors said they would be able to get the drug held steady, with more than 94 percent of the twelfth graders surveyed saying it would be "fairly easy" or "very easy" to obtain alcohol. Only 26 percent of twelfth graders disapproved of kids their age "trying one or two drinks of an alcoholic beverage." Beer and fruit-flavored alcoholic beverages, such as wine coolers, seemed to be a favorite among middle school and high school drinkers.
The 2004 Monitoring the Future survey also showed that:
- 44 percent of eighth-grade students, 64 percent of tenth-grade students, and 77 percent of twelfth-grade students admit to having tried alcohol.
- 20 percent of eighth-grade students, 42 percent of tenth-grade students, and 60 percent of twelfth-grade students report having been drunk from alcohol use at least once.
In the late 1990s, "binge drinking" became an accepted term for a night of heavy drinking or simply for heavy alcohol consumption at one sitting. The NCADD claimed that in 1999 "44 percent of college students reported binge drinking (five or more drinks in a row for males or four or more drinks in a row for females)" at some point in their college years. This does not make them frequent binge drinkers; it means that they have engaged in binge drinking at least once. As of 2002, about one in four students could be classified as a frequent binge drinker. To make matters worse, "59 percent of frequent binge drinkers report driving after drinking," noted Dr. Henry Wechsler, director of the Harvard School of Public Health's College Alcohol Study, in his book Dying to Drink: Confronting Binge Drinking on College Campuses, written with Bernice Wuethrich.
Alcohol and the Entertainment Industry
Nels Ericson, a writer for the U.S. Office of Juvenile Justice and Delinquency Prevention, pointed out that alcohol is a standard prop in more than 90 percent of America's most popular movie rentals. Television is another media source that bombards youth with pro-drinking messages. The National Council on Alcoholism and Drug Dependence (NCADD) reported that "the typical American young person will see 100,000 beer commercials before he or she turns 18."
The New York Times reported in 2002 that a link may exist between movie-viewing habits and alcohol usage among teens. A Dartmouth College survey based on information from more than 4,500 fifth through eighth graders in the eastern United States revealed that "teenagers whose parents place no restrictions on their viewing R-rated movies appear much more likely to use tobacco or alcohol." Most of the students interviewed were fourteen years old or younger. By law, moviegoers are supposed to be seventeen or older to view an R-rated film at a theater. Nearly half of the students who saw R-rated films on a regular basis admitted they had tried alcohol, versus only 4 percent of the students who were not allowed to view R-rated films.
Research conducted by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) indicates that some 1,400 college students die each school year in alcohol-related incidents. Another 100,000 became victims of sexual assault after drinking too much.
Effects on the Body
Even though alcohol is considered "one of the most widely accepted recreational drugs," noted Gahlinger, its overall impact on public health "is far worse than all illegal drugs combined." Prolonged use of alcohol can have serious negative effects on the body. Long-term alcohol use can result in memory loss. Alcohol can suppress the immune system, making people more susceptible to infections. Heavy drinking can increase the user's risk of nutritional deficiencies, ulcers, high blood pressure, heart disease, stroke, certain cancers, and liver disease.
Paying the Price
In addition to the high one gets when drinking alcohol, the substance produces a variety of other potentially embarrassing, not to mention uncomfortable, effects. Read on to learn more.
- The human body has all sorts of natural protective mechanisms. Vomiting is one of them. Nausea and stomach cramps are two ways that the brain alerts the body to the presence of poisons—like alcohol—in the system. The stomach rids itself of the poison by vomiting. People who have too much alcohol in their systems often end up clutching a toilet bowl and heaving up every bit of food and drink in their stomachs. And those are the lucky ones. Vomiting in a toilet is preferable to vomiting somewhere else, and sometimes people under the influence of alcohol just cannot reach a toilet in time. Accidental urination can occur under the influence of alcohol as well, compounding the embarrassment.
- Alcohol makes the blood vessels inside the brain expand. Drinking to the point of intoxication (drunkenness) often results in an uncomfortable set of physical effects known as a "hangover." Contrary to popular belief, drinking coffee, eating high-sugar foods, or taking a cold shower will not relieve hangover symptoms. The pounding headache, upset stomach, and trembling feelings that often follow a night of heavy drinking will not subside until the brain's blood vessels return to their normal size. In short, nothing but time will get rid of a hangover.
The NIAAA reported that "alcohol-induced liver disease is a major cause of illness and death in the United States." The liver is the organ that breaks down alcohol in the body. It removes alcohol from the blood, leaving water, carbon dioxide gas, and energy as by-products. The carbon dioxide gas leaves the body through the lungs, and the water is eliminated in urine. Depending on the size, gender, and general health of the drinker, it can take the liver between one and two hours to process a glass of wine, a single beer, a shot of hard liquor, or one mixed drink.
If large quantities of alcohol are present in the body, the liver has to work overtime to break it down and eliminate it from the body. Until the liver has a chance to filter all of the toxins, or highly poisonous substances, out of a drinker's blood, the remaining alcohol will simply stay in the bloodstream and recirculate. "There are limits on the number and amounts of toxic substances a liver can handle without harm to it," explained Laurence Pringle in Drinking: A Risky Business. Heavy drinking can lead to cirrhosis of the liver, a deadly disease common among alcoholics. "In cirrhosis," continued Pringle, "cells of the liver are actually being killed by alcohol.… Continued heavy drinking may cause the liver to fail entirely."
Down the Hatch, and Then What?
After alcohol is swallowed, it passes first into the stomach and then into the small intestine. Most of the alcohol is absorbed into the
bloodstream through the small intestine and carried to the brain through the blood. Alcohol has profound effects on the brain's ability to function effectively. Even though alcohol is a depressant, low doses of it can cause the release of certain brain chemicals that produce a sense of euphoria. This "high" is misleading because it makes alcohol seem like a stimulant.
First and foremost, alcohol causes a loss of inhibition in those who drink it. "Judgment is the first function of the brain to be affected," wrote Gail Gleason Milgram of the Rutgers University Center of Alcohol Studies in an online article. "The ability to think and make decisions becomes impaired." People with lowered inhibitions tend to take more chances and engage in riskier behavior than they would if they had not been drinking. A self-conscious individual who has had a drink or two may become more confident. A shy person may become more talkative. People who have had too much to drink often engage in unsafe sex and are at a much greater risk for contracting sexually transmitted diseases, including HIV (the human immunodeficiency virus), which can lead to AIDS (acquired immunodeficiency syndrome).
The most obvious physical effects of alcohol consumption are slowed reflexes, a lack of coordination, difficulty walking "a straight line," and slurred speech. As more alcohol is consumed, drinkers experience dizziness, nausea, dehydration, and an inability to reason. Having a large number of drinks in rapid succession puts many drinkers to sleep. Those who remain awake and continue drinking increase their likelihood of passing out, which can be very dangerous. Intoxicated people who throw up while unconscious risk choking on their vomit. This can be—and often is—fatal, because vomit easily blocks the drinker's airway, making breathing impossible.
"Chronic, repeated drinking damages and sometimes kills the cells in specific brain areas," noted Kuhn. "And it turns out that it might not take a very long history of heavy drinking to kill cells in certain areas of the brain" involved in memory formation and problem solving.
|Blood alcohol concentration (BAC) levels and effects|
|Blood alcohol concentration||Changes in feelings and personality||Impaired activities (continuum)|
|source: Adapted from "Table 4," in Understanding Alcohol, Biological Sciences Curriculum Study, for the National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD [Online] http://science.education.nih.gov/supplements/nih3/alcohol/guide/info-alcohol.htm [accessed May 24, 2005].|
Sense of well being
Loss of inhibition
Numbness of feelings
|Coordination (especially fine motor skills)|
|Reasoning and depth perception|
Inappropriate social behavior (e.g., obnoxiousness)
Lack of balance
Loss of temperature regulation
|Loss of bladder control|
|0.41 and greater||Death||Slowed heart rate|
Effects May Vary
The physical effects of alcohol on the body depend on several different factors. Both the amount of food present in the stomach when drinking and the amount of time that elapses between drinks influence a person's physical response to alcohol. "Peak blood alcohol concentration [BAC] could be as much as three times greater in someone with an empty stomach than in someone who has just eaten," wrote Kuhn. Five drinks consumed in one hour will have drastically different effects on the drinker than five drinks consumed with food over five hours.
The gender, size, and mental outlook of the drinker also affect the body's response to alcohol. "Alcohol does not dissolve in fat tissues," explained Weathermon and Crabb. Because women have a larger proportion of body fat than men, they tend to feel the effects of alcohol after drinking smaller doses than men do. A smaller person will become intoxicated sooner than a larger person because the larger person has more blood and body fluids mixing with the alcohol he or she consumes. A person's reaction to alcohol also varies according to the circumstances under which it is consumed. "The same amount of wine that makes someone pleasantly high at a party may make a depressed person in a lonely room even more depressed," commented Weil.
Drinking and Driving
"Alcohol abuse kills some 75,000 Americans each year and shortens the lives of these people by an average of thirty years," noted MSNBC.com in the fall of 2004. The statistics, which were provided by the Centers for Disease Control and Prevention (CDC), indicate that about 35,000 of these people died from diseases connected with heavy drinking. The other 40,000 were killed in alcohol-related car crashes and other accidents, including falls, fires, and drownings. Young people under twenty-one years of age accounted for about 4,500 of alcohol-related deaths.
The rate of fatal motor-vehicle crashes in alcohol-involved drivers age sixteen to twenty is more than twice the rate for alcohol-involved drivers over the age of twenty-one. The probable reason for this statistic, according to an NIAAA "Alcohol Alert" from 2003, is that younger drivers have less experience behind the wheel. Adding alcohol to the mix is a recipe for disaster. In addition, Newsweek reported in 2005 that, according to the NIH, "the area of the brain that inhibits risky behavior isn't fully developed" in humans until they reach the age of twenty-five.
Alcohol and Pregnancy
Alcohol and pregnancy do not mix. Alcohol use can interfere with a woman's ability to become pregnant. It can also lower a man's sperm count and reduce his sexual drive.
There is no safe level of alcohol consumption for a woman at any time during a pregnancy. Every bottle of alcohol bears a warning label that reads: "According to the Surgeon General, women should
not drink alcoholic beverages during pregnancy because of the risk of birth defects." If a pregnant woman drinks alcohol, so does her baby. If she becomes drunk, so does her baby.
Drinking alcohol during pregnancy can cause miscarriages, stillbirths, and serious birth defects. Alcohol "disrupts [the] formation of nerve cells in a baby's brain," wrote Margaret O. Hyde and John F. Setaro in Drugs 101: An Overview for Teens.fetal alcohol syndrome (as) can occur when a woman drinks while she is pregnant. It is one of the leading causes of birth defects in children and the most preventable cause of mental retardation. FAS babies have low birth weights, small heads, slowed mental and physical growth rates, and certain facial and skeletal abnormalities. It is a hard condition to diagnose because its symptoms can mimic those of other disorders. Babies born with FETAL ALCOHOL EFFECTS (ae) are less severely impaired than FAS babies. FAE babies do not have distinctive facial and skeletal abnormalities, nor do they suffer the same level of brain damage as FAS babies, but they can have physical and behavioral problems such as poor coordination, learning disabilities, and attention deficit disorders.
Reactions with Other Drugs or Substances
Alcohol should not be consumed with any over-the-counter or prescription medications because harmful interactions can occur. Sometimes, the effect of a medicine is increased by alcohol. In other cases, a medication may not be able to break down properly in the presence of alcohol. Drinking alcohol with antihistamines, for instance, will increase the drowsiness that can occur with cold-type medicines. Alcohol can cause liver damage when taken in combination with acetaminophen (best known by the brand name Tylenol).
Alcohol has additional negative effects when taken with other drugs. For example, when taken with aspirin, alcohol can irritate the stomach lining and cause gastrointestinal bleeding. Alcohol combined with antidepressants affects the user's coordination and reaction time, making the operation of motor vehicles and other machinery extremely risky. Alcohol taken with barbiturates ("downers" such as Nembutal, Seconal, Amytal, and Tuinal) can increase depression.
Mixing alcohol with tranquilizers, muscle relaxants, sleeping aids, and other medicines can cause serious side effects, especially in elderly people. Alcohol consumed with illegal drugs such as marijuana, cocaine, heroin, or amphetamines can be deadly.
Alcohol-Related Vehicle Crashes
According to the U.S. Department of Transportation's National Highway Traffic Safety Administration (www.nhtsa.dot.gov):
- 17,013 people in the United States died in alcohol-related motor-vehicle crashes in 2003
- Alcohol-related crashes on America's roads injure someone every two minutes
- Alcohol-related crashes in the United States cost roughly 51 billion dollars each year.
Treatment for Habitual Users
There is no cure for alcoholism, but the advancement of the disease can be stopped if the user quits drinking. The Hazelden Foundation's "Alcohol Screening" Web page states that "for one in thirteen American adults, alcohol abuse or alcohol dependence (alcoholism) causes substantial harm to their health and disruption in their lives." In "Substance Abuse: The Nation's Number One Health Problem," Nels Ericson noted that "only a quarter of individuals who abuse alcohol and illicit drugs get treatment.… Treatment for alco holism is successful for 40 to 70 percent of patients."
There are several types of treatment options available for alcoholics. Most incorporate at least some of the principles that make up the twelve-step program used by Alcoholics Anonymous (AA). AA offers a popular and effective approach to rehabilitation. It helps the user gain an understanding of alcoholism as a disease. The first AA group was formed in Akron, Ohio, in 1935, by Bill Wilson and Dr. Bob Smith. According to the AA Web site, there were more than 100,000 groups and over 2 million members in 150 countries as of 2005.
Inpatient programs, which are often found in hospital settings, usually begin with a period of detoxification, followed by extensive counseling and, if necessary, a drug program to discourage the drinker from relapsing. (Certain medications are designed to make an alcoholic feel very sick when combined with alcohol.) Detoxification, or detox, addresses the physical aspect of "drying out" the drinker. Withdrawal symptoms can be intense and frightening to the recovering alcoholic. At their worst, symptoms can include hallucinations, tremors (uncontrollable shaking), and seizures.
Detox is usually followed up with individual and/or family counseling and involvement in a twelve-step program such as the one offered by AA. Psychiatric hospitals address both the problem of alcohol abuse and the emotional issues that accompany it. Treatment includes individual, group, and/or family counseling, drugs to treat psychiatric illnesses, and the additional support of a twelve-step program.
Another type of inpatient program is the 28-day rehabilitation facility. This type of treatment program offers detoxification from alcohol as well as: 1) support from substance abuse counselors; 2) education on the disease concept of alcoholism; and 3) individual, group, and family therapy. In addition, it uses support group meetings both on and offsite. Residential programs are yet another alternative. In residential programs, patients stay at a home for recovering alcoholics. At these "sober houses," as they are called, several alcoholics work together to stay alcohol-free. They receive counseling, job assistance, and group support.
People have been known to do things under the influence of alcohol that they would never consider doing when sober. Drinking too much can leave users with little or no recollection of what they did or said while drunk. NCADD statistics show that alcohol is
involved in one out of every four emergency room admissions, one out of every three suicides, and one out of every two homicides and incidents of domestic violence. "A report from the British Medical Association," stated Emma Haughton in Drug Abuse? (1997), estimated that up to 70 percent of all murders in the United Kingdom were somehow "associated with alcohol abuse."
People who drink heavily develop a tolerance to alcohol. As the disease of alcoholism progresses, an alcoholic will need to drink more and more to get the desired result that lower doses of alcohol had once produced. Tolerance actually changes the alcoholic's brain impulses and the chemical makeup of cell membranes.
Alcoholics typically go through several stages, changing their patterns of use to patterns of abuse. They may begin using alcohol as an occasional stress reliever. They promise themselves and others that their drinking is just a "temporary thing." But over several years it becomes a habit. Their families struggle to hide the drinkers' growing problems with alcohol. As the disease progresses, drinkers usually experience mood changes, problems with friends and family, and trouble on the job. In the final stage, alcoholics begin to suffer physical decline as a result of drinking and may develop illnesses like liver disease or heart failure.
The personal consequences of alcoholism reach far beyond the alcoholic. An alcoholic's drinking affects many people, especially the members of his or her family. Children of alcoholics sometimes continue the cycle of alcoholic behavior when they reach adulthood. Alateen is an international organization for teens who are relatives or friends of a problem drinker. Support groups like Alateen help young people break the cycle of addiction and lead healthy lives.
It is against the law to consume alcohol in the United States until the age of twenty-one, but, according to the TeensHealth Web site, nearly 80 percent of teens have done it. Underage drinking can lead to arrest. In the United Kingdom, it is illegal for anyone under the age of eighteen to buy alcohol, whether in a supermarket or a pub. It is also illegal to supply someone under the age of eighteen with alcohol.
For years, the legal blood alcohol concentration for adult drivers ranged from 0.08 percent to 0.1 percent throughout the United States. A stricter national standard of 0.08 was adopted by most states in the first few years of the twenty-first century. The BAC limit for drivers under twenty-one was set at 0.02 in every state. Penalties for driving while intoxicated vary from state to state and can include fines, jail sentences, probation, driver's license suspension, mandatory community service, or participation in an alcohol education program.
The National Center for Injury Prevention and Control (NCIPC), a division of the Centers for Disease Control and Prevention, released a summary of impaired-driving statistics in December of 2004. The latest information available for that report came from the records of the National Highway Traffic Safety Administration (NHTSA) for 2002 and 2003. According to the data, about 1.5 million people were arrested for driving under the influence (DUI) in 2002. More than 100 million other drunk drivers were on the roads but were not caught. Alcohol consumption was a factor in two out of every five traffic-related deaths in 2003. In addition, about 25 percent of all drivers under the age of twenty who were killed in motor vehicle crashes that year had a bloodalcohol level of 0.08 or higher.
Drunk on Mouthwash
Listerine mouthwash is 26.9 percent alcohol. In January of 2005, a Michigan woman was arrested for drunk driving after drinking three glasses of Listerine. Her blood alcohol concentration (BAC) was more than three times Michigan's legal limit of 0.08 percent.
Alcoholic beverage control laws (ABC laws) were developed in the United States to prevent the illegal sale of alcohol. ABC laws are enforced by federal, state, and local law enforcement agencies. Each state regulates where alcohol can be sold and where it can be consumed. Restaurants, convenience stores, grocery stores, and bars selling alcohol must have special licensing. A person must be twenty-one years old to purchase and consume alcohol. Buying alcohol for an underage drinker is illegal, even if the buyer is over twenty-one. Warning labels are required on all alcoholic beverages sold in the United States. These labels alert consumers to the possible dangers of alcohol use when pregnant, driving an automobile, or operating machinery.
For More Information
Gahlinger, Paul M. Illegal Drugs: A Complete Guide to Their History, Chemistry, Use, and Abuse. Las Vegas, NV: Sagebrush Press, 2001.
Haughton, Emma. Drug Abuse? London: Franklin Watts, 1997.
Hyde, Margaret O., and John F. Setaro. Drugs 101: An Overview for Teens. Brookfield, CT: Twenty-first Century Books, 2003.
Kuhn, Cynthia, Scott Swartzwelder, Wilkie Wilson, and others. Buzzed: The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy, 2nd ed. New York: W.W. Norton, 2003.
Milam, James R., and Katherine Ketcham. Under the Influence. New York: Bantam Books, 1984.
Nagle, Jeanne. Polysubstance Abuse. New York: Rosen Publishing Group, Inc., 2000.
Pringle, Laurence. Drinking: A Risky Business. New York: Morrow Junior Books, 1997.
Schull, Patricia Dwyer. Nursing Spectrum Drug Handbook. King of Prussia, PA: Nursing Spectrum, 2005.
Wechsler, Henry, and Bernice Wuethrich. Dying to Drink: Confronting Binge Drinking on College Campuses. New York: Rodale, 2002.
Weil, Andrew, and Winifred Rosen. From Chocolate to Morphine. New York: Houghton Mifflin, 1993, rev. 2004.
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The active principle of intoxicating drinks, produced by the fermentation of sugars.
A Congressman was once asked by a constituent to explain his attitude toward whiskey. "If you mean the demon drink that poisons the mind, pollutes the body, desecrates family life, and inflames sinners, then I'm against it," the Congressman said. "But if you mean the elixir of Christmas cheer, the shield against winter chill, the taxable potion that puts needed funds into public coffers to comfort little crippled children, then I'm for it. This is my position, and I will not compromise."
The legal history of alcohol in the United States closely parallels the economic and social trends that shaped the country. The libertarian philosophy that ignited the whiskey rebellion was born in the American Revolution. Shifting concerns about morality and family harmony that were characteristic of the Industrial Revolution inspired the temperance movement and brought about prohibition, which began with the passage of the eighteenth amendment to the Constitution in 1919 and ended with its repeal in 1933. The return of legalized drinking in the United States led to renewed discussion of the many health and safety issues associated with alcohol consumption. Over the years, the states have addressed these issues through a variety of laws, such as those dealing with a minimum age for the purchase or consumption of alcohol, the labeling of alcoholic beverages, and drunk driving. Private litigants have expanded protections against harm from alcohol through tort actions, and various groups, both national and local, continue to lobby for increased legislation and higher penalties for alcohol-related acts that lead to injury.
Historical Background of Alcohol in the United States
Drink is in itself a good creature of God,
and to be received with thankfulness,
but the abuse of drink is from Satan,
the wine is from God, but the Drunkard is from
(Increase Mather, Puritan clergyman, Wo to Drunkards )
Alcoholic beverages have been consumed in the United States since the days of Plymouth Rock. In fact, beer and wine were staples on the ships carrying settlers to the New World. In colonial times, water and milk were scarce and susceptible to contamination or spoilage, and tea and coffee were expensive. The Pilgrims turned to such alternatives as cider and beer, and, less frequently, whiskey, rum, and gin. In 1790, per capita consumption of pure alcohol, or absolute alcohol, was just under six gallons a year. (Pure alcohol constitutes only a small percentage of an alcoholic drink. For example, if a beverage contains 10 percent alcohol by volume, one would have to drink ten gallons of it to consume one gallon of pure alcohol.)
Although the majority of the colonists drank alcohol regularly, strong community social strictures curbed any tendency toward immoderation. Drunken behavior was dealt with by emphasizing the need to restore community harmony and stability, rather than by imposing punishment.
Alcohol consumption continued without much controversy until after the Revolutionary War when whiskey and other distilled spirits became valuable commercial commodities. When Congress imposed an excise tax on the farmers who produced liquor in the 1790s, they resisted paying the tax. Their resistance became known as the Whiskey Rebellion, a protest movement of farmers who felt the tax placed an undue burden on their commercial activities.
The courts have long struggled with the problem of what sanctions to impose on people who violate the law while under the influence of liquor. Punishing these offenders fails to address the root cause of the behaviors, the uncontrolled consumption of alcohol. Many judges order offenders to undergo alcohol-dependency treatment or counseling as part of a sentence or as a condition of probation.
One of the most popular programs for treating alcoholism is Alcoholics Anonymous (AA). AA was founded in 1935 by New York stockbroker Bill Wilson and Ohio surgeon Robert Smith. Wilson and Smith recognized their inability to control their drinking and were determined to overcome their problem. They developed the Twelve Steps, on which AA is based and which have become the foundation for similar self-help and recovery programs. AA comprises ninety thousand local groups in 141 countries. Participation is voluntary, and there are no dues or other requirements. Members attend meetings run by nonprofessionals, many of whom are recovering alcoholics. The meetings offer fellowship, support, and education to those with a desire to stop drinking.
Participants in AA declare that they cannot control their drinking alone, and invoke a higher power to help them overcome their dependence on alcohol. AA's Twelve Steps require a fundamental change in personality and outlook. Members admit their power-lessness over alcohol to themselves, to God, and to their friends and families. They attempt to make amends for any wrongs they have committed because of alcohol abuse. Finally, through prayer, meditation, and daily self-evaluation, AA members strive for a radical transformation or spiritual awakening, which results in changed perceptions, thought processes, and actions. Finally, participants share their experiences with others.
Although AA's Twelve Steps speak of God, a higher power, and spiritual awakening, AA maintains that it is not a religious organization. However, the group's religious underpinnings and the tone of its meetings, which may begin with the Serenity Prayer and generally end with group recitation of the Lord's Prayer, are objectionable to some. Courts have split over the issue of whether forced participation in AA violates the first amendment religion clauses.
Before the nineteenth century, farming was the predominant occupation, and, although it involved grueling work, it did not demand precision or speed. The Industrial Revolution brought millions of workers into factories where efficiency, dexterity, and rigid scheduling were necessary. With these economic changes came a shift in societal attitudes toward alcohol. Gone was the time when people considered the midday liquor break a benign diversion.
Drinking on Campus: a Rite of Passage Out of Control?
Alcohol has had its advocates and its critics, particularly on college campuses, where the desires of students to enjoy the rights and freedoms of adults collide with the concerns of parents, university officials, and the police. Although some widely publicized studies from the late 1980s and early 1990s indicated that student drinking was at an all-time high, threatening students' health and academic careers, others indicated that the problem of student drinking was overblown and on the decline. Those concerned about the problem have proposed a variety of solutions, with some suggesting that lowering the drinking age might diminish the lure of alcohol as a forbidden fruit.
During the 1980s and 1990s, attention focused increasingly on alcohol use by college students. An article published in the December 7, 1994, issue of the Journal of the American Medical Association reported the findings of a study conducted by Dr. Henry Wechsler, director of the Alcohol Studies Program at the Harvard School of Public Health. Wechsler and his team surveyed more than 17,000 students, first-year students to seniors, at 140 colleges in 40 states. They concluded that college students were drinking more than ever before.
In Wechsler's study, 44 percent of the students surveyed reported binge drinking, defined as having five consecutive drinks in a row for men or four in a row for women, on at least one occasion in the two weeks before the survey. (Wechsler defined binge drinking at a lower level of consumption for women because women's bodies take longer to metabolize alcohol, causing them to be affected by lesser amounts in a given time period.) Nineteen percent of all the surveyed students were found to be frequent binge drinkers, meaning they had at least three recent binges.
Similar findings were reported in 1994 by the Commission on Substance Abuse at Colleges and Universities, a group established by the Center on Addiction and Substance Abuse at Columbia University. Its report, titled Rethinking Rites of Passage: Alcohol Abuse on America's Campuses, stated that white males were the biggest drinkers on campus. However, the commission noted a sharp rise in the percentage of college women who drank to get drunk, from 10 percent in 1977 to 35 percent in 1994. Unlike women students in earlier studies, those in 1994 reported that they felt little or no social stigma attached to their drinking. At the same time, they felt pressure to succeed, and consuming alcohol was one way they chose to relieve some of that pressure.
College administrators were not surprised by the findings of the two studies. The Harvard study reported that an over-whelming majority of the supervisors of security, deans of students, and directors of health services at the colleges surveyed considered heavy alcohol use a problem on their campuses. And a survey by the Carnegie Foundation revealed that college presidents considered alcohol abuse their most pressing challenge.
College presidents and administrators have had practical reasons to be concerned about student drinking. Reports of drunken brawls, sexual assaults, even deaths attributable to alcohol create public relations nightmares for schools competing for students. There has also been the issue of liability: is a college responsible for injuries inflicted by a drunk student? In addition, much of the drinking on campus has been done illegally by students who are under age.
Academic administrators have found particularly disturbing the increases in drinking among women. According to women students, the desire to compete with men in all arenas, including social, is one reason they feel the need to demonstrate their equality by drinking as much as or more than their male peers. A study conducted by Virginia's College of William and Mary indicated that the number of women at the college who had five or more drinks at one sitting increased from 27 percent to 36 percent during the early 1990s.
Both men and women students have cited intense peer pressure to join the partying that takes place on college campuses, which may begin as early as Wednesday or Thursday night and last through the weekend. At some schools, alcohol-centered gatherings can readily be found any night of the week. Administrators acknowledge that partying may have been just as hearty in the past but note that before the late 1980s, it was generally confined to the weekend.
The fallout from uncontrolled drinking has been felt throughout campus life. According to the report issued by the Commission on Substance Abuse at Colleges and Universities, 95 percent of violent crimes and 53 percent of injuries on campus are alcohol related. In 90 percent of all campus rapes, the assailant, the victim, or both had been drinking. Sixty percent of college women who acquire sexually transmitted diseases, including herpes and AIDS, report that they were drunk at the time they were infected. The financial costs are high as well. Students spend $5.5 billion on alcohol each year, more than they spend on books, coffee, tea, sodas, and other drinks combined. Although athletes might be expected to take fewer risks with their health than other students, the commission concluded that they were equally affected by alcohol abuse.
The commission also found that students who belong to fraternities and sororities drink three times more than their non-Greek counterparts, averaging fifteen drinks a week. Indeed, fraternity drinking has been blamed in several disciplinary actions and at least one death. In July 1994, the national office of Alpha Tau Omega (ATO) announced it was closing 11 of its chapters for violating rules against hazing and alcohol abuse. ATO had already closed its chapter at Wittenberg University, in Springfield, Ohio, after a newly recruited pledge was hospitalized in January 1994 for alcohol poisoning. Similarly, the national office of Beta Theta Pi (BTP) announced in 1994 that it would intensify enforcement of rules against hazing and alcohol use in its chapters. According to Erv Johnson, director of communications for the national office, BTP was concerned not only about the legal issues involved but also about the image of the fraternity and the national office's desire to emphasize that the primary purpose of going to college is to learn.
Excessive drinking has a direct effect on academic performance. Students with an A average generally have 3.6 drinks a week, C students average 9.5 drinks a week, and D and F students consume almost 18 drinks a week. According to college officials, alcohol is implicated in almost half of all academic problems and is an issue for more than one-fourth of dropouts.
Excessive drinking has obvious negative consequences for the students who engage in it, but it also affects those who do not partake. During the early 1990s, some students and school officials began to speak out against the damage and disorder that binge drinkers cause. Just as nonsmokers brought awareness of the effects of secondhand smoke, moderate and nondrinking students called attention to the results of "secondhand bingeing." Likewise, administrators, who had traditionally tried to downplay the severity of the problem, began to acknowledge it and tried several approaches to controlling it. One method involved having peer counselors educate students about the dangers of excessive drinking and about the effects of their actions on others. Another program provided students with recreational options that did not include alcohol. Some schools offered houses or sections of dorms where residents pledged not to drink or smoke. In 1994, the University of Pittsburgh considered requiring first-year students to take a one-credit course on responsible drinking. The action came after a premed student died after drinking 16 shots of liquor and some beer in less than an hour. However, most administrators stopped short of preaching abstinence, acknowledging that most students have begun to drink before they enter college.
Some college officials advocate lowering the legal drinking age, on the theory that if alcohol is readily available to students it may lose some of its appeal. Susan Vaughn, coordinator of judicial affairs at Miami University, of Ohio, stated that laws setting the minimum drinking age at 21 are unenforceable. She argued that the higher drinking age entices students to drink to excess in order to prove their maturity and that lowering the legal age would bring drinking "out of the closet," where it can be properly supervised.
Others who have studied college drinking vehemently dispute the wisdom of lowering the minimum age. Joseph A. Califano Jr., former health secretary and president of the Center on Addiction and Substance Abuse, asserted that lowering the minimum drinking age would encourage more drinking and that drinking by college students should no longer be thought of as a rite of passage but rather should be considered a stumbling block to success. His sentiments were echoed by the Reverend Edward A. Malloy, president of the University of Notre Dame, who stated that heavy alcohol use is an unhealthy trend that runs counter to the goals of an educational institution. Still, some people believe that learning how to drink is part of the college experience, essential to growing up and breaking away from home and parental control.
Some 1990s evidence suggested that drinking on college campuses was declining. A 1994 survey of 300,000 students nationwide found that nearly half abstained from virtually all alcohol; in 1971, only one in four abstained. Another 1994 study indicated that, although binge drinking remained a problem, light to moderate drinkers were consuming fewer drinks a week than their counterparts in a 1982 survey. Some experts speculated that these students were following the lead of their parents, who drank less in the 1990s than they had in the 1970s and 1980s. Others felt that the trend reflected an increased awareness of health and safety issues.
Additional evidence that student drinking may not be as big a problem as some surveys have suggested appeared in a 1994 study conducted by Dr. David Hanson and Dr. Ruth Engs, of the State University of New York College at Potsdam. The Hanson and Engs study contradicted the findings of the Center on Addiction and Substance Abuse and indicated that student drinking had declined from that in previous years. Furthermore, Hanson questioned the center's statistics on an increase in binge drinking among college women, stating that if such behavior had actually increased 250 percent between 1977 and 1994, other studies conducted during that time would have shown the same rise.
Some who noted a decrease in college drinking speculated that it may have been because college students of the 1990s grew up with a higher minimum drinking age and stricter drunk driving laws. They asserted that it takes a number of years for changes in the law to affect the targeted population. With those changes finally having the desired effect, they maintained, it would be counterproductive to return to a lower minimum age.
Concern over binge drinking on college campuses continued to rise at the beginning of the twenty-first century. In 2002, the Task Force on College Drinking of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) released a study indicating that 1,400 college students died and another 500,000 were injured per year as a result of alcohol abuse. The study also found that more than 600,000 college students were assaulted annually by another student who had been drinking, and more than 70,000 were victims of alcohol-associated sexual assaults or date rapes.
Also in 2002, the Harvard School for Public Health College Alcohol Study issued a report putting the number of binge drinkers on colleges campuses in 2001 at 44 percent—the same amount as in the school's 1994 report. This second report indicated that almost a decade of trying to combat binge drinking by colleges and universities had not succeeded in driving down the number of binge drinkers. Indeed, the 2002 survey found an increase in binge drinking among several groups, including binge drinkers at women's colleges, which rose from 24 percent to 32 percent of the population.
As of 2003, the most recent College Alcohol Study found the number of frequent binge drinkers, defined as students who binged three or more times over a two week period, had also remained steady at 20 percent. These frequent binge drinkers accounted for 70 percent of all alcohol consumption on campus. Drinking rates were highest among incoming freshmen, males, members of fraternities or sororities, and athletes. Students who attended two-year institutions, religious schools, commuter schools, or predominantly or historically black colleges and universities drank the least.
There were some positive aspects of the 2002 College Alcohol Study report, including the fact the number of high school binge drinkers had dropped and a larger number of students reported living in substance-free housing. But the fact that the number of binge drinkers failed to drop despite these positive trends showed colleges and universities what a struggle they had on their hands. Senator Joseph Lieberman (D-CT) held hearings in 2002 shortly after both the College Alcohol Study and the NIAAA study were released in which he said "alcohol abuse on college campuses has reached a point where it is far more destructive than most people realize and today threatens too many of our youth."
In response to the failure to bring down binge drinking rates, colleges and universities tried innovative approaches to tackle the problem. One was the use of "social norms" advertising, telling students that drinking on colleges was less prevalent than they thought, to convince students that most students do not binge drink, and that it is socially acceptable to abstain. Critics pointed out, however, that social norms advertising might simply send the wrong message to administrators and other policy makers—that drinking on campus was no big deal.
Other universities tried harsher enforcement policies, banning alcohol from college-run housing, even eliminating sororities and fraternities. Some colleges also tried to curb alcohol related advertising on campus, refusing to allow sponsorship of university activities by beer producers and asking bars and taverns near campus to limit promotions to college students. Several reinstated Friday and Saturday morning classes as a way to encourage students not to drink on weekends.
Okie, Susan. 2002. "Study Cites Alcohol Link in Campus Deaths; 1,400 Die Yearly in Accidents." Washington Post (April 10).
Russell, Jenna. 2002. "Little Improvement Seen in College Binge Drinking." Houston Law School: Boston Globe (March 25).
Sullivan, Michelle. 2002. "Students at Risk Due to 'Culture of Drinking.'" Clinical Psychiatry News (June 1).
The Temperance Movement
'Mid pleasures and palaces, though we may roam,
Be it ever so humble, there's no place like home.
But there is the father lies drunk on the floor,
The table is empty, the wolf's at the door,
And mother sobs loud in her broken-back'd chair,
Her garments in tatters, her soul in despair.
(Nobil Adkisson, Ruined by Drink [c. 1860])
As the United States entered the Industrial Age, attitudes about alcohol consumption gradually changed. A moralistic and punitive view of alcohol replaced the laissez-faire attitudes of earlier times. What had been the "good creature of God" in the eighteenth century became the "demon rum" of the nineteenth.
The U.S. temperance movement emerged around 1826 with the formation of the American Society for the Promotion of Temperance, later called the American Temperance Society. In the 1840s, the society began crusading for com plete abstinence from alcohol. Dissemination of the temperance message caused a fall in per capita consumption of pure alcohol from a high of over seven gallons a year in 1830 to just over three in 1840, the largest ten-year drop in U.S. history. By the outbreak of the Civil War, 13 states, beginning with Maine in 1851, had adopted some form of prohibition as law.
Other temperance organizations became prominent during the middle to late 1800s. In 1874, the Woman's Christian Temperance Union (WCTU) was founded. The only temperance organization still in operation, the WCTU has worked continuously since its inception to educate the public and to influence policies that discourage the use of alcohol and other drugs. In 1990, the group was nominated for a Nobel Peace Prize.
In 1869, the anti-alcohol movement created its own political party—the National Prohibition party—devoted to a single goal: to inspire legislation prohibiting the manufacture, transportation, and sale of alcoholic beverages. The party made modest showings in state elections through the 1860s and 1870s, and reached its peak of popular support in 1892 when John Bidwell won almost 265,000 votes in his bid for the presidency. The Prohibition party's main effect was its influence on public policy. It succeeded in placing Prohibition planks into many state party platforms and was a potent impetus behind passage of the Eighteenth Amendment.
One of the most powerful forces in the Prohibition movement was the Anti-Saloon League, a nonpartisan group founded in 1893 by representatives of temperance societies and evangelical Protestant churches. The Anti-Saloon League, unlike the prohibition party, worked within established political parties to support candidates who were sympathetic to the league's goals. By 1916, the league, with the help of the Prohibition party and the WCTU, had sent enough sympathetic candidates to Congress to ensure action on a Prohibition amendment to the Constitution.
Prohibition is an awful flop.
We like it.
It can't stop what it's meant to stop.
We like it.
It's left a trail of graft and slime
It don't prohibit worth a dime
It's filled our land with vice and crime,
Nevertheless, we're for it.
(Franklin P. Adams, quoted in Era of Excess)
In December 1917, the temperance movement achieved its goal when Congress approved the Eighteenth Amendment, which prohibited the manufacture, sale, transportation, importation, or exportation of intoxicating liquors from or to the United States or its territories. The amendment was sent to the states, and, by January 1919, it was ratified. In January 1920, the United States officially became dry.
The demand for liquor did not end with Prohibition, however. Those willing to violate the law saw an opportunity to fill that demand and become wealthy in the process. Illegal stills produced the alcohol needed to make "bathtub gin." Rum and other spirits from abroad were commonly smuggled into the country from the east and northwest coasts, and illegal drinking establishments, known as speakeasies or blind pigs, proliferated. The illicit production and distribution of alcohol, called bootlegging, spawned a multibillion-dollar underworld business run by a syndicate of criminals.
Perhaps the most famous of the bootleggers was al capone, who ran liquor, prostitution, and racketeering operations in Chicago—one of the wettest of the wet towns. At the height of his power in the mid-1920s, Capone made hundreds of millions of dollars a year. He employed nearly a thousand people and enjoyed the cooperation of numerous police officers and other corrupt public officials who were willing to turn a blind eye in return for a share of his profits. For years, Capone and others like him evaded attempts to shut down their operations. Capone's reign finally ended in 1931 when he was convicted of income tax evasion.
Historians differ about the success of Prohibition. Some feel that the effort was a ludicrous failure that resulted in more severe social problems
than had ever been associated with alcohol consumption. Others point to ample evidence that Prohibition, although never succeeding in making the country completely dry, dramatically changed U.S. drinking habits. Per capita consumption at the end of Prohibition had fallen to just under a gallon of pure alcohol a year, and accidents and deaths attributable to alcohol had declined steeply.
Although Prohibition enjoyed widespread popular support, a substantial minority of U.S. citizens simply ignored the law. Also, although Prohibition unquestionably fostered unprecedented criminal activity, many people were concerned that the government's enforcement efforts unduly intruded into personal privacy. In cases such as Carroll v. United States, 267 U.S. 132, 45 S. Ct. 280, 69 L. Ed. 543 (1925), the Supreme Court indicated its willingness to stretch the limits of police power in order to enforce Prohibition. In Carroll, the Court held that federal agents were justified in conducting a warrantless search of an automobile, because they had probable cause to believe it contained illegal liquor.
Concerns over diminished liberties led to feelings that Prohibition was too oppressive a measure to impose upon an entire nation. This sentiment was bolstered by arguments that the production and sale of alcohol were profitable enterprises that could help boost the nation's depressed economy. By the beginning of the 1930s, after little more than a decade as law, Prohibition lost its hold on the U.S. conscience. The promise of jobs and increased tax revenues helped the anti-Prohibition message recapture political favor. The twenty-first amendment, repealing Prohibition, swept through the necessary 36-state ratification process, and the "noble experiment" ended on December 5, 1933.
Post-Prohibition Regulation and Control
The repeal of Prohibition forced states to address once more the dangers posed by excessive alcohol consumption. The risks are well documented. The National Highway Traffic Safety Administration (NHTSA) estimated that, in 2001, alcohol was involved in 41 percent of all fatal crashes (over 17,000 fatalities). NHTSA also estimates that three out of ten Americans will be involved in an alcohol-related crash sometime during their lives. Alcohol is the most widely used drug among teenagers and is linked to juvenile crime, health problems, suicide, date rape, and unwanted pregnancy. Alcohol-related traffic accidents are the leading cause of death among 15- to 24-year-olds.
In the face of rising concerns about liquor consumption and personal injury, many states chose to regulate alcohol through dramshop laws. A dramshop is any type of drinking establishment where liquor is sold for consumption on the premises. Dramshop statutes impose liability on sellers of alcoholic beverages for injuries caused by an intoxicated patron. Under such statutes, a person injured by a drunk patron sues the establishment where the patron was served. The purpose of dramshop laws is to hold responsible those who enjoy economic benefit from the sale of liquor, thereby ensuring that a loss is not borne solely by an innocent victim (as when the intoxicated person who caused the injuries has no assets and no insurance).
The first dramshop law, enacted in Wisconsin in 1849, required saloons or taverns to post a bond for expenses that might result from civil lawsuits against their patrons. Many states followed Wisconsin's lead, and dramshop laws were prominent until the 1940s, 1950s, and 1960s, when most were repealed. However, the 1980s brought renewed concern over the consequences of overindulgence in alcohol, and public pressure led to the passage of new dramshop statutes. By 1993, 36 states had imposed some form of liability on purveyors of alcoholic beverages for injuries caused by their customers.
All states and the District of Columbia also regulate the sale of liquor to minors or to individuals who are intoxicated. Challenges to the age restriction on equal protection grounds have been unsuccessful.
Along with statutory measures, most courts have also recognized a common-law cause of action against alcohol vendors for the negligent sale of alcohol. In Rappaport v. Nichols, 31 N.J. 188, 156 A.2d 1 (1959), the court held that a tavern could be held liable for the plaintiff's husband's death after the tavern served an intoxicated minor who caused the accident that killed the man. The court relied on the public policy concerns underlying liquor control laws. Such laws are intended to protect the general public as well as minors or intoxicated persons, the court reasoned, and therefore the tavern should be held liable if its negligence was a substantial factor in creating the circumstances that led to the husband's death. Under Rappaport, serving as well as consuming alcohol can be construed to be the proximate cause of an injury. A majority of jurisdictions now follow the Rappaport court's reasoning.
In determining the extent of an alcohol vendor's liability, a growing number of courts apply comparative negligence principles. Comparative negligence assesses partial liability to a plaintiff whose failure to exercise reasonable care contributes to his or her own injury. In Lee v. Kiku Restaurant, 127 N.J. 170, 603 A.2d 503 (1992), and Baxter v. Noce, 107 N.M. 48, 752 P.2d 240 (1988), the plaintiffs sued under dramshop statutes for injuries suffered when they rode with drunk drivers. The courts in both cases recognized the importance of dramshop statutes in protecting innocent victims of drunk behavior. However, they also recognized the need to hold individuals responsible to some degree for their own safety. Under comparative negligence, which divides liability among the parties in accordance with each party's degree of fault, both goals are achieved.
A few courts have extended liability for injuries to social hosts who serve a minor or an intoxicated guest. In Kelly v. Gwinnell, 96 N.J. 538, 476 A.2d 1219 (1984), the New Jersey Supreme Court found both the host and the guest jointly liable when the guest had an accident after drinking at the host's house. The court based the host's liability on his continuing to serve alcoholic beverages to the guest when he knew the guest was intoxicated and likely to drive a car. Similarly, in Koback v. Crook, 123 Wis.2d 259, 366 N.W.2d 857 (1985), the Wisconsin Supreme Court held that a social host was negligent for serving liquor to a minor guest at a graduation party. The guest was later involved in a motorcycle accident in which the plaintiff was injured. However, the Ohio Supreme Court refused to extend liability to the social host in Settlemyer v. Wilmington Veterans Post No. 49, 11 Ohio St. 3d 123, 464 N.E.2d 521 (1984). The court in Settlemyer held that assigning liability to a social host is a matter better left to the legislature.
All states and many local governments regulate the sale of alcohol through the issuance of licenses. These licenses limit the times and locations where liquor sales can take place. The government also regulates alcohol through taxation. Current taxes on liquor serve the same dual purpose as did the first excise tax on liquor when it was proposed by alexander hamilton in 1791: they provide a source of revenue for the government and, theoretically, discourage overindulgence. Enforcement of the laws regulating alcohol and taxing it is carried out by the Bureau of alcohol, tobacco, firearms, and explosives (ATF), an agency of the U.S. justice department, and the Tax and Trade Bureau (TTB), an agency of the treasury department, respectively. The collection of alcohol revenues is important to the federal government: in 2001, liquor taxes exceeded $7.6 billion.
During the 1980s and 1990s, public awareness of the dangers of alcohol led to a number of changes in the law. Specifically, special interest groups such as mothers against drunk driving (MADD) and Students Against Drunk Driving (SADD) pressured state legislatures to greatly increase enforcement and penalties for driving while intoxicated (dwi). Criminal statutes make DWI a misdemeanor offense. Historically, few persons served jail time unless they were repeat offenders. Moreover, prosecutors often reduced DWI charges to lesser charges, such as reckless driving, so defendants could avoid the stain of a DWI conviction on their driving records.
MADD was formed by mothers of children who had been killed by drunk drivers. They were outraged at the way the criminal justice system treated DWI crimes. A major focus in the 1990s for MADD was convincing state legislatures to reduce the blood alcohol count needed to constitute a DWI offense. Specific blood-alcohol concentration (BAC) limits varied from state to state, but .10 percent BAC usually qualified as driving while intoxicated. MADD sought to reduce the BAC to .08 percent and successfully lobbied many state legislatures. However, alcohol wholesalers, retailers, and the hospitality industry fought a lowered BAC, arguing that it would hurt business and unfairly penalize drivers.
The debate moved to the national level in 1998 when Congress first rejected and then enacted legislation that requires all states to lower the drunken driving arrest threshold to .08 percent. States that failed to change their laws would forfeit millions of dollars in federal highway construction funds. By the end of 2002, one-third of the states had not complied with the law, arguing that studies did not show that a reduction from .10 to .08 BAC saved many lives. Opponents of the law contended that a .08 BOC merely led to thousands of additional arrests of casual drinkers who did not pose a serious safety risk. The additional arrests absorbed more police and prosecutorial resources, which would not be offset by the federal highway funds.
An increased knowledge about the consequences of alcohol consumption also had an effect on the makers of alcohol. Concerned individuals felt that liquor manufacturers had the duty to warn consumers that their product may be hazardous. Before 1987, manufacturers of alcoholic beverages were immune from civil liability for injuries resulting from the use of liquor. Garrison v. Heublein, Inc., 673 F.2d 189 (7th Cir. 1982), held that the defendant did not have a duty to warn the plaintiff of the dangers of its product. The court stated that the dangers inherent in the use of alcohol are "common knowledge to such an extent that the product cannot objectively be considered to be unreasonably dangerous."
Garrison was followed by other jurisdictions until 1987 when Hon v. Stroh Brewery, 835 F.2d 510 (3d Cir. 1987), signaled a shift in judicial sentiment. In Hon, the plaintiff's 26-year-old husband died of pancreatitis attributable to his moderate consumption of alcohol over a six-year period. The plaintiff alleged that the defendant's products were "unreasonably dangerous" because consumers were not warned of the lesser-known dangers of consumption. The court, relying on the Restatement (Second) of Torts § 402A, held that a product is defective if it lacks a warning sufficient to make it safe for its intended purpose. Since the general public is unaware of all the health risks associated with liquor consumption, the court found the defendant liable for failing to warn the plaintiff.
The reasoning in Hon has been followed in other cases, including Brune v. Brown-Forman Corp., 758 S.W.2d 827 (Tex. Ct. App. 1988), where the court found that the defendant's product was unreasonably dangerous because it bore no warning about the dangers of excessive consumption. The plaintiff's daughter, a college student, died after consuming 15 shots of tequila over a short period of time.
The duty of liquor manufacturers to warn consumers of the hazards of drinking was codified when Congress passed the Alcoholic Beverage Labeling Act of 1988 (27 U.S.C.A. § 215). The act requires all alcoholic beverage containers to bear a clear and conspicuous label warning of the dangers of alcohol consumption.
The United States's long history of ambivalence toward the consumption of alcoholic beverages shows no sign of abating. At the same time that manufacturers are required to warn consumers about the health risks inherent in liquor, some medical studies indicate that certain health benefits may be associated with moderate imbibing.
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Boyd, Steven R., ed. 1985. The Whiskey Rebellion. Westport, Conn.: Greenwood Press.
Cochran, Robert F., Jr. 1994. "'Good Whiskey,' Drunk Driving, and Innocent Bystanders: The Responsibility of Manufacturers of Alcohol and Other Dangerous Hedonic Products for Bystander Injury." South Carolina Law Review 45 (winter).
Cordes, Renee. 1992. "Alcohol Manufacturer Held Partially Liable for Student's Death." Trial 28 (December).
Goldberg, James M. 1992. "Social Host Liability for Serving Alcohol." Trial 28 (March).
Gorski, Terence T. 1989. Understanding the Twelve Steps. New York: Prentice-Hall/Parkside.
Jacobs, James B. 1989. Drunk Driving: An American Dilemma. Chicago: Univ. of Chicago Press.
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OFFICIAL NAMES: Ethyl alcohol, ethanol, grain alcohol
STREET NAMES: Booze, hooch, juice, sauce, spirits
DRUG CLASSIFICATIONS: Not classified, depressant
Jugs that held beer and wine have been found dating back to 3500 b.c. It was easy enough for prehistoric peoples to make alcohol. Mixtures of water and berries left alone in the sun turned into alcohol. Alcohol had its medicinal qualities as well. It was used as a disinfectant, to stimulate the flow of milk in nursing mothers, and to remedy a variety of illnesses.
By the Middle Ages, the upper classes consumed alcohol in abundance, while the peasant population made beer at home. In Italy and France, wine became an important product in commercial markets and continued to be an integral part of the European economy throughout the Renaissance period. Home brewing was largely replaced by the commercial manufacture of beer and wine in Europe by the early eighteenth century.
The first distillery in the United States opened in New York in 1640. Mass production, international trade, and expanding commercialism facilitated an increase in alcohol use into the twentieth century and brought with it concern over alcohol abuse.
In the United States there have been historical increases and decreases in alcohol use. There were high periods of alcohol consumption during the Civil War, World War I, and World War II. Low periods occurred during Prohibition and the Depression. Alcohol consumption rose in the 1980s, when many states in the United States lowered the drinking age to 18. Because of the number of teen deaths due to drinking and driving, the legal age of drinking was raised to 21 in 1987. Coincidentally, the rate of alcohol consumption decreased in the 1990s, but alcohol remains the most commonly used legal drug, and consumption of alcohol by young people is very high.
The chemical composition for ethanol or ethyl alcohol, otherwise known as alcohol, is C2H5OH. This means it is composed of two atoms of carbon, six atoms of hydrogen, and one oxygen atom. Ethanol is colorless and highly flammable. Alcohol is too strong to drink by itself, so it is mixed with water and other substances to create alcoholic beverages. Ethyl alcohol is the only safe alcohol to drink. Other alcohols like methanol (wood alcohol; CH3OH) and isopropyl alcohol [rubbing alcohol; (CH3)2CHOH] are highly toxic and poisonous to the body.
Alcohol is produced by fermenting fruits, vegetables, and grains. Fermentation occurs when sugar in berries or grains is combined with yeast. An enzyme is released that changes the sugar into carbon dioxide and alcohol. When the combination of sugar, yeast, and berries reaches an alcohol concentration point of 14%, fermentation is complete and wine is formed. Similarly, when sugar, yeast, and grains such as barley, corn, or rice are combined and reach an alcohol concentration of about 6%, beer is made and fermentation stops.
Hard liquor is produced by a process called distillation. In distillation, liquids that have been fermented are boiled and the alcohol is extracted. At the boiling point, the alcohol separates from the fermented liquid to create a vapor. The vapor is held in a cooling tube until it turns into a liquid once again. The alcohol is then mixed with water. Hard liquor is about 60% water. Whiskey, rum, vodka, scotch, and gin are distilled liquors. These alcoholic beverages contain about 50% alcohol. The percentage of alcohol in hard liquor is called "proof." Proof is double the amount of pure alcohol, which means that a 100 proof whiskey contains 50% alcohol. A 4-ounce glass of wine, a 12-ounce beer, and a 1-ounce shot glass of hard liquor all have the same amount of alcohol or alcohol content. Cordials like brandy, port, and liqueurs are made from wine and have pure alcohol added to them. Sugar is added to make them sweet, thus hiding the taste of alcohol and making these drinks seem less potent than they really are.
When a person drinks alcohol, it immediately travels from the stomach to the small intestine and then into the bloodstream. When alcohol enters the bloodstream, a person begins to feel its effects. Because alcohol is absorbed faster than it is metabolized, the alcohol level in a person's blood rises quickly. Drinking alcohol on an empty stomach also causes blood alcohol levels (BAL) to rise quickly. High-protein foods in the body can slow down the absorption of alcohol, whereas carbonated alcoholic beverages such as champagne, rum and coke, and whiskey and ginger ale speed up the absorption of alcohol into the bloodstream. A smaller person will begin to feel the effects of alcohol sooner than a larger person because the larger person has more blood and body fluids.
Alcohol leaves the body through a process of elimination and oxidation. The liver removes alcohol from the blood and causes the alcohol to break down into water and carbon dioxide gas. The carbon dioxide gas leaves the body through the lungs, and the water is eliminated in urine. It takes the liver about one hour to process a glass of wine, one to two hours to process hard liquor, and about two hours to process a glass of beer. If large quantities of alcohol are present in the body, the liver has to work overtime to break it down and eliminate it from the body.
Alcohol is carried to the brain through the bloodstream. Because alcohol is a depressant, it has immediate effects on the brain's ability to function effectively. Alcohol can impair judgement, affect behavior and coordination, and cause nausea, slurred speech, and dehydration. Gail Gleason Milgram, Professor and Director of Education and Training at the Center of Alcohol Studies, offers a profile of behavior that can follow a rise in blood alcohol levels (BAL) due to drinking. She explains that when a person has a BAL of0.03%, which is approximately one drink, "the drinker will feel relaxed and experience a slight feeling of exhilaration." After two drinks and a BAL of 0.06%, "the drinker will experience a feeling of warmth and relaxation" as well as a decline in coordination. After three drinks, speech can be slurred and muscle control can be affected. When a drinker has had five or six drinks, he or she can have difficulty walking and staying awake. At this point a person's BAL could reach0.30%. Milgram further explains that when the BAL reaches 0.50%, "the drinker is in a deep coma or in danger of death." Many states use a BAL of 0.1% as a measure for drunk driving.
In the past, alcohol has been used as a treatment for infection, as an anesthetic, and as a sedative. Alcohol is known as a pain suppressant and was used for hundreds of years for treating people with injuries and for those needing surgery. Alcohol was used to treat typhus as recently as the 1920s. Research in the 1990s showed that moderate amounts of alcohol could help reduce the risk of heart attacks but, conversely, alcohol abuse has been connected to heart disease. Today, there are no known therapeutic uses for alcohol.
According to the National Council on Alcoholism and Drug Dependence (NCADD), close to 14 million Americans use and abuse alcohol. One third are women and the rest are men. Fifty percent of adults in the United States admit to having alcoholism in their family. One out of every four children come from families where alcohol abuse is a problem.
Adult women drink less than men overall, but are more likely to damage their hearts, livers, and brains due to drinking. The death rate for women who drink large amounts of alcohol frequently is 50% to 100% higher than it is for male alcoholics. Young people who begin drinking before their teenage years are four times more likely to develop an addiction to alcohol than people who begin drinking at age 21. Data taken from The 2000 Monitoring the Future Survey indicate that:
- 22% of middle school students and close to 50% of high school students admit to having tried alcohol.
- 8% of middle school students and close to 30% of high school students report having been drunk from alcohol use.
- 14% of teens from ages 13 to 14 admitted to binge drinking as compared to 30% of high school teens.
The National Council on Alcoholism and Drug Dependence (NCADD) claims that in 1999 "44% of college students reported binge drinking (five or more drinks in a row for males or four or more drinks in a row for females)." The NCADD also reported that binge drinking among college fraternity and sorority students can be higher.
|Alcohol and Calorie Content of Common Beverages|
|source: Adapted from Gordon Wardlaw and Paul Insel. Perspectives in Nutrition. 3rd ed.|
|Gin, rum, vodka, whiskey, tequila||1.5||15||105|
|Bourbon and soda||4||15||102|
Scope and severity
Over 50% of Americans who currently drink report having a close relative who abuses alcohol; 25% are children of an alcoholic parent. Alcohol abuse can devastate families by causing separation, divorce, and domestic violence, as well child abuse and neglect. Six million children live with an alcohol-abusing parent, and this can result in problems at school such as low attendance, academic difficulties, attention deficit disorders, and behavioral problems. Each year in America, more than 100,000 people die from alcohol-related accidents (cars, falls, fires, drownings, burns), cancer, liver disease, and stroke.
Age, ethnic, and gender trends
According to the National Household Survey on Drug Abuse (NHSDA), "male and female rates of alcohol use among 12–17 year olds were similar in the 1990s for the first time." Peer pressure, incidence of teenage depression, and a need to fit in are all factors leading to alcohol use by teens. According to the U.S. Department of Health and Human Services, women drink most heavily when they are between the ages of 26 and 34. As women and men get older, there is evidence that drinking among men is greater than that of women. College-bound students are reported to drink less than those students not headed for college.
The biochemical reaction of alcohol in the body explains the differences in ethnic susceptibility to alcohol. Dr. Bert Vallee from Harvard Medical School has
|Alcohol Concentration and Effect Relationship|
|source: Vijay A. Ramchandani. Pharmacology and Neurobiology slide presentation. Alcohol Medical Scholars Program.|
|0.02-0.03||Mood elevation; slight muscle relaxation|
|0.05-0.06||Relaxation and warmth; increased reaction time; decreased fine muscle coordination|
|0.08-0.09||Impaired balance, speech, vision, hearing, and muscle coordination; euphoria|
|0.14-0.15||Gross impairment of physical and mental control|
|0.20-0.30||Severely intoxicated; very little control of mind or body|
|0.40-0.50||Unconscious; deep coma; death from respiratory depression|
determined that the enzymes involved in the metabolism of alcohol can vary from ethnic group to ethnic group, and this variation influences the way in which individual members of these groups are affected by alcohol. These enzymes appear to be genetically inherited. For example, alcoholism among Jews and Italians is low compared to the levels seen among Scandinavians, Irish, and French. The ethnic groups with the highest susceptibility to alcohol are the Native Americans and Eskimos. These two groups have difficulty oxidizing and eliminating alcohol from the body. Asian populations show a physical reaction to alcohol sooner than Americans and Europeans because of the genetic makeup in their enzyme groupings that react with alcohol.
Alcohol acts as a depressant on the brain. Blood carries alcohol to the brain, where it acts on the body's central nervous system to slow a person's mental responses. There are a variety of mental effects associated with alcohol consumption. The more immediate are: a lessening of inhibitions, mental relaxation, exaggerated emotional response to people and situations, extreme changes in behavior, and impaired judgment. Low doses of alcohol can cause the release of certain chemicals in the brain that can cause a sense of euphoria—a "high" that makes alcohol seem like a stimulant. Memory is sharpened and the ability to think creatively is strengthened, but when alcohol consumption increases, its sedative effects cause a loss of self-control and inhibition. A self-conscious individual becomes more confident; a shy person becomes more talkative. Alcohol also can cause people to become argumentative or emotionally withdrawn. Relationship problems can develop. Judgment is affected and risk-taking behaviors can result. People are known to do things under the influence of alcohol that they would never consider doing when sober. As alcohol consumption increases and levels of alcohol in the blood rise, the reflexes are slowed; memory loss and a sense of confusion can occur. Committing crimes or being the victim of a crime, domestic violence, child abuse, automobile accidents, homicide, and suicide are among the events related to the consumption of alcohol.
The effects of alcohol are related to the size of the person and the amount of alcohol in the blood, as well as to the rate of consumption. After one drink a person weighing about 150 lb (68 kg) will feel relaxed and happy. After two drinks in an hour a person will fell less inhibited. Three drinks will affect a person's muscle control. Speech can become slurred and walking may be difficult. After four drinks judgment is affected and the ability to reason becomes impaired. Five drinks will make speech patterns difficult to understand and impair vision. After six drinks a person may begin to lose consciousness and fall asleep. Ten or more drinks can cause a person to fall into a deep sleep also known as "passing out." Long-term alcohol use can result in serious neurological disorders in the brain such as confusion, coordination problems, short-term memory loss, and emotional as well as psychological problems.
The physical effects of alcohol on the body depend on the person's size, weight, sex, and age. Additionally, the amount of food present in the body and the amount of alcohol consumed determine one's physical response to alcohol. The immediate physical effects of alcohol consumption are slurred speech, nausea, lack of coordination, dizziness, and dehydration. Alcohol has no nutritional value, but it can have an effect on a person's weight. It decreases one's appetite by filling the body with empty calories and convinces the body it has had enough to eat. People who abuse alcohol run the risk of becoming malnourished.
Harmful side effects
Alcohol can suppress the immune system, making people more susceptible to infections. Because alcohol reduces inhibitions and impairs judgment, those under its influence may be prone to engage in unsafe sexual activity, raising the risks of HIV infection and sexually transmitted diseases. Alcohol use can interfere with a woman's ability to become pregnant. It can lower a man's sperm count and reduce his sexual drive.
|Deaths Caused by Injuries Related to Alcohol, 1992|
|sources: Analysis by the Lewin Group based on data from the National Institute of Alcohol Abuse and Alcoholism (1993), Stinson, et al. (1993), National Center for Health Statistics (1996), and Rice, et al. (1990).|
|Motor vehicle accidents||17,196|
|Pedal cycle, other road accidents||45|
|Water transport accidents||167|
|Air and space transport accidents||175|
|Accidents caused by fire/flames||1,831|
|Accidental drowning, submersion||1,339|
|Suicide and self-inflicted injury||8,476|
|Homicide and injury purposely inflicted by other persons||11,609|
There is no safe level of alcohol consumption for a woman at any time during a pregnancy. Every bottle of alcohol bears a warning label that reads: "According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects." If a pregnant woman drinks alcohol, her baby is drinking alcohol. If she becomes drunk, her baby is drunk.
Drinking alcohol during pregnancy can cause miscarriages, stillbirths, and serious birth defects such as fetal alcohol syndrome (FAS) and fetal alcohol effect (FAE). FAS is one of the leading causes of birth defects in children and the most preventable cause of mental retardation in the United States. Over 8,000 babies are born each year with fetal alcohol syndrome. It wasn't until 1973 that FAS was defined. FAS babies have lower birthweight, slower mental and physical growth rates, and abnormal facial features such as droopy eyelids, broad noses, large nostrils, and possible cleft palates. Additionally they can have deformed sex organs, internal problems, skeletal abnormalities, brain damage, and mental retardation. FAS is hard to diagnose because the symptoms can mimic those of other birth defects. Thirty thousand babies are born each year with fetal alcohol effect. FAE babies do not have the obvious facial and/or skeletal abnormalities, nor do they have the same level of brain damage as FAS babies, but FAE babies can have physical and behavioral problems such as learning disabilities, attention deficit disorders, and hyperactivity.
Both the mother and father can be responsible for birth defects by drinking alcohol. Miscarriages can be a result of sperm damaged by alcohol. A man's sperm count can be lowered by alcohol consumption. A breast-feeding mother needs to know that any alcohol she consumes passes from her breast milk into her baby. The simplest way to prevent alcohol problems during pregnancy is not to drink while pregnant and to avoid any alcohol consumption when planning a pregnancy.
Long-term health effects
Prolonged use of alcohol can have serious negative effects on the body. It causes vitamin deficiencies. Alcohol can reduce iron levels, causing anemia, and deplete the body of niacin, causing skin damage. Internally, alcohol can cause inflammation of the stomach, liver, pancreas, and esophagus, causing ulcers, hepatitis, cirrhosis, pancreatitis, and several forms of cancer. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) reports that "alcohol-induced liver disease is a major cause of illness and death in the United States." Long-term alcohol use is associated with high blood pressure, heart disease, stroke, and death.
REACTIONS WITH OTHER DRUGS OR SUBSTANCES
Alcohol should not be consumed while taking medications. Drinking alcohol along with antihistamines will increase the drowsiness that can occur with cold medicines. Alcohol can cause liver damage when taken in combination with acetaminophen. It has additional adverse effects when taken with other drugs. For example, when taken with aspirin alcohol can cause inflammation of the stomach and increase gastrointestinal bleeding. Alcohol combined with antidepressants slows down psychomotor performance. Alcohol taken with barbiturates (Nembutal, Seconal, Amytal, Tuinal, etc.) can increase depression. Tranquilizers that depress the central nervous system like Valium and Librium taken along with alcohol can cause high blood pressure, drowsiness, depression, and confusion in elderly people. Elderly people should avoid alcohol when taking antidepressants, muscle relaxants, sleeping aids, or cold medicines. Those people taking prescription or over-thecounter medicines should check with a physician about alcohol use.
Polysubstance use refers to combining one drug with another drug or drugs. It often involves the use of a legal drug like alcohol with an illegal drug such as marijuana, cocaine, heroin, and/or pills. Polysubstance use is common among young people. The user may get high on a stimulant like speed or cocaine and then use a depressant like alcohol to come down from the high. Alcohol is considered by many to be a gateway drug, as are nicotine and marijuana. Individuals who use one or more of these gateway drugs are believed to go on to deeper and more severe drug involvement. Jeanne Nagel in her book Polysubstance Abuse says "statistics reveal that alcoholics are 35 times more likely than nonalcoholics to use cocaine." She goes on to say that alcoholics are "17 times more likely to abuse sedatives, 13 times more likely to take opiates, 12 times more likely to ingest hallucinogens, and 11 times more likely to abuse stimulants." Furthermore, Nagel reports 90% of alcoholics smoke cigarettes, and alcohol abusers are six times more likely to abuse marijuana. When someone develops an addiction to more than one drug, the person is said to be cross-addicted.
TREATMENT AND REHABILITATION
There is no cure for alcoholism, but the progression of the disease can be arrested by total abstinence from alcohol. According to the 1998 National Household Survey on Drug Abuse, an estimated 9.7 million Americans are dependent on alcohol. This figure includes the 915,000 young people ages 12 to 17 who have a drinking problem. Public and private treatment facilities in the United States are capable of treating about 1.7 million people each year, a far cry from the number needing help.
There are several types of inpatient and outpatient treatment options available in this country. Inpatient programs are often found in hospital settings such as a hospital detox unit or a psychiatric unit. Detox is a short-term solution because it only addresses the physical aspect of drying out the drinker. It should be followed up with individual and/or family counseling and an understanding of the disease concept of alcoholism through a program like Alcoholics Anonymous. Psychiatric hospitals address both the problem of alcohol abuse and the emotional problems that accompany it. Treatment includes individual, group, and/or family counseling, drugs to treat psychiatric illnesses, and the additional support of a twelve-step program. Another type of inpatient program can be found at a 28-day rehabilitation facility. This type of treatment program offers detox from alcohol as well as support from substance abuse counselors; education on the disease concept of alcoholism; and individual, group, and family therapy. In addition, it utilizes support group meetings both on and offsite.
Outpatient programs can be connected to a hospital or a public or private treatment facility. These programs are often short term and require the patient to complete a series of daily or weekly visits for a period of several months. Like inpatient treatment, outpatient programs include individual and/or group therapy, trained substance abuse counselors, education on the disease of alcoholism, and a recommendation to attend a support group.
Another type of treatment program is a residential program in which the patient stays at a home for recovering alcoholics—a sober house where several alcoholics are working to stay sober with the help of counseling, job assistance, and regular attendance at support group meetings. There are residential programs specific to men, women, and young people trying to recover from alcohol addiction. The criminal justice system currently helps offenders get alcohol abuse treatment, and many prisons offer weekly Alcoholics Anonymous meetings for prison inmates trying to stay sober. There is no definitive evidence as to what treatment works best for which patient. Due to the lack of data on the effectiveness of individual programs, it is important for treatment facilities to offer a variety of options to meet the needs of their patients.
Treatment programs based on the twelve steps of Alcoholics Anonymous and that encourage attendance at Alcoholics Anonymous meetings have been the most common approach used in the United States. The first Alcoholics Anonymous group was formed in Akron, Ohio in 1935 by Bill Wilson and Dr. Bob Smith. Today there are approximately 99,000 groups in existence across America.
PERSONAL AND SOCIAL CONSEQUENCES
Alcoholism is a chronic, progressive disease that can be fatal. An Edinburgh physician described the disease concept of alcoholism as far back as 1804, but it wasn't until 1956 that the American Medical Association defined alcoholism as a disease. In 1990, the National Council on Alcoholism and Drug Dependence along with the American Society of Addictive Medicine defined alcoholism as a chronic disease that has genetic, psychological, and environmental factors that influence it. Alcoholism is described as a loss of control over drinking—a preoccupation with drinking despite negative consequences to one's physical, mental, and emotional makeup as well as one's work and family life. Alcoholics can be rich or poor, young or old, male or female, white or black. Anyone can become an alcoholic, but children of an alcoholic parent are four times more likely to develop the disease of alcoholism than children of non-alcoholic parents.
People who drink develop a tolerance to alcohol. Tolerance is the result of the way in which the body handles alcohol as well as alcohol's effect on the central nervous system. A non-alcoholic will have a consistent level of tolerance for alcohol, but an alcoholic's tolerance for alcohol will constantly change, requiring him or her to drink more to get the desired result that lower doses of alcohol had once produced. Tolerance changes the alcoholic's brain impulses, hormone levels, and the chemical make-up of cell membranes.
The alcoholic goes through several stages as the disease progresses. The stages of alcoholism were documented by E.M. Jellinek in 1952. The four stages are: the prealcoholic stage, the prodromal stage, the crucial stage, and the chronic or final stage.
The prealcoholic stage refers to that period of time when the individual has every intention of drinking socially but begins to use alcohol as a relief from stress and tension. This stage can last for several months to two years. During the prodromal stage the alcoholic continues to drink when others have stopped. He or she experiences blackouts—periods during which the individual continues to function (walking and talking) but has no memory of things that have been said or done. This stage can go on for four or five years.
The crucial stage is when the individual has lost control over the drinking—perhaps promising to stop, but unable to do so. The alcoholic may become defensive when confronted, looks for excuses to drink, blames others for his or her problems, and looks for relief in what is called "the geographic cure"—a new job, moving to a new location, or a change in marital status. At this stage the alcoholic's moods change from being pleasant and understanding to becoming irritable and unreasonable without warning. The alcoholic may experience job loss or the loss of family and friends. Legal problems may arise.
The final stage of alcoholism is the chronic stage. The alcoholic begins to suffer physical decline as a result of drinking, and may develop illnesses like liver disease or heart failure. There is the risk of overdose or possible suicide as the individual sees no way out of this malady.
The personal consequences of alcoholism reach far beyond the alcoholic. An alcoholic's drinking affects many people, especially the members of his or her family. Alcoholism is a family disease, and the members of an alcoholic family system develop roles that are unconsciously played out to draw attention away from the alcoholic. The spouse or partner of the alcoholic is called the enabler. The enabler's role is to protect the alcoholic from the negative consequences of drinking. The enabler works hard to control life in an alcoholic family.
Children tend to take on one of the following roles:
- The oldest child in an alcoholic family most commonly assumes the hero role. The hero brings honor and respect to the family by being a good student, an accomplished athlete, being involved in school activities, and caretaking younger children at home as a substitute parent. The hero is a perfectionist who hopes that by doing everything well the family's problem with alcohol will go away.
- The scapegoat tries to win the alcoholic's attention by engaging in negative behavior. This child often does poorly in school, can have behavioral problems or attention deficit disorders that affect learning, and emotional problems that may lead to alcohol and drug use.
- The lost child in an alcoholic family system withdraws into the isolation of his or her own world. This child has difficulty making friends, lacks the ability to develop intimate relationships, and often turns to food for comfort from the loneliness.
- The mascot is the family member who uses humor to mask pain. This child feels a responsibility to lighten the family tension by being funny and quick-witted. This behavior becomes a handicap in the development of the child's emotional maturity.
Without an understanding of the alcoholic family system, these children will often grow up and continue the cycle of alcoholic behavior. Through counseling and the help of support networks, these children can learn to break the cycle of family addiction and go on to lead healthy lives in adulthood.
Alcohol abuse in the United States costs an estimated $170 billion each year. Close to half of this figure is due to a loss in workplace productivity resulting from illness and work-related injury. Other contributing factors are alcohol-related health care expenses costing society over $26 million and automobile accidents estimated at $15 million. Fifty percent of the adults in prison are incarcerated for crimes that are alcohol related. Alcohol is involved in one-third of all suicides, one-half of all homicides, and one-third of all reported child abuse cases. Drinking can lead to physical injury. People who drink are four times more likely to be hospitalized than nondrinkers. Alcoholism can lead to family violence and physical abuse of children.
In October 2000, the U.S. Congress passed a transportation spending bill that included the establishment of a national standard for drunk driving for adults at a0.08% blood alcohol level (BAL). States are required to adopt this stricter standard by 2004 or face penalties. As of 2001, more than half the states had adopted this stricter standard, while most other states have a BAL limit of 0.1% in place. Penalties for DUI (driving under the influence of alcohol) offenses vary from state to state and can include fines, jail sentences, driver license supension or revokation, driving record points, community service, mandatory participation in a drug/alcohol program, and/or probation.
In 1999, according to the FBI's Uniform Crime Reports, the number of people arrested for DUI was 1,511,300. Alcohol is a factor in close to two-thirds of the homicides and assaults committed in this country. It is known to be connected to rape in both the offender and the victim. Sixty percent of sexual offenders have committed the offense under the influence of alcohol. Studies of prison inmates show that men are more likely to be drinking at the time of the offense than female offenders.
Dram Shop laws hold bar and restaurant owners responsible for the harm that intoxicated customers cause to other people or, in some cases, to themselves. As a result, college campuses and business organizations are placing greater emphasis on providing alcohol-free organizations and activities. Some colleges have established alcohol-free fraternities, sports events have instituted seating sections where no alcohol is allowed, and many bar owners provide taxi service for patrons who are too intoxicated to drive safely.
Laws banning the sale of alcoholic beverages date back to the fourteenth century, when Germany banned the sale of alcohol on Sundays and other religious holidays. Even earlier Switzerland instituted laws requiring drinking establishments to close at certain times to combat public drunkenness. The first formal temperance movement began in Germany but movements promoting drinking in moderation became popular in other countries. In the middle of the seventeenth century, England imposed high taxes on alcoholic beverages. In America, taxes on whiskey brought about resistance by the distillers resulting in the Whiskey Rebellion of 1794.
Temperance movements began to spring up in America largely supported by religious groups. By the eighteenth century the American Temperance Society promoted the concept of total abstinence from alcohol. In 1919 laws prohibiting the sale and consumption of alcohol nationwide were enacted, but these laws were repealed in 1933 by the Twenty-first Amendment to the Constitution.
Federal guidelines, regulations, and penalties
Alcoholic beverage control laws (ABC laws) were developed to prevent the illegal sale of alcohol, to control the sale of alcohol, and to collect revenue for each state selling alcoholic beverages. The laws vary from state to state and are enforced by federal, state, and local law enforcement agencies. Restaurants, convenience stores, grocery stores, and bars selling alcohol must have special licensing. The licensing differs for the type of establishment selling alcohol or alcoholic beverages. Each state regulates where alcohol can be sold and where it can be consumed. A person must be 21 years old to purchase alcohol. Warning labels are required on all alcoholic beverages sold in the United States. These labels alert consumers to the possible dangers of alcohol use when pregnant, driving an automobile, or operating machinery.
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Wegscheider, Sharon. Another Chance, Hope & Health for the Alcoholic Family. Palo Alto, CA: Science and Behavior Books, Inc., 1981.
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CNN.Com-Health. "Alcohol Named Europe's Youth Killer." February 20,2001. <http://www.cnn.com/2001/health/02/19/deaths.alcohol/index.html>.
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National Institute on Alcohol Abuse and Alcoholism (NIAAA). <http://www.niaaa.nih.gov>.
The Cool Spot. National Institute on Alcohol Abuse and Alcoholism (NIAAA) Web Site for Kids. <http://www.thecoolspot.org>.
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Barbara Sullivan Smith
The sociological study of alcohol in society is concerned with two broad areas. (1) The first area is the study of alcohol behavior, which includes: (a) social and other factors in alcohol behavior, (b) the prevalence of drinking in society, and (c) the group and individual variations in drinking and alcoholism. (2) The second major area of study has to do with social control of alcohol, which includes: (a) the social and legal acceptance or disapproval of alcohol (social norms), (b) the social and legal regulations and control of alcohol in society, and (c) efforts to change or limit deviant drinking behavior (informal sanctions, law enforcement, treatment, and prevention). Only issues related to the first area of study, sociology of alcohol behavior, will be reviewed here.
PHYSICAL EFFECTS OF ALCOHOL
There are three major forms of beverages containing alcohol (ethanol) that are regularly consumed. Wine is made from fermentation of fruits and usually contains up to 14 percent of ethanol by volume. Beer is brewed from grains and hops and contains 3 to 6 percent ethanol. Liquor (whisky, gin, vodka, and other distilled spirits) is usually 40 percent (80 proof) to 50 percent (100 proof) ethanol. A bottle of beer (12 ounces), a glass of wine (4 ounces), and a cocktail or mixed drink with a shot of whiskey in it, therefore, each have about the same absolute alcohol content, one-half to three-fourths of an ounce of ethanol.
Alcohol is a central nervous system depressant, and its physiological effects are a direct function of the percentage of alcohol concentrated in the body's total blood volume (which is determined mainly by the person's body weight). This concentration is usually referred to as the BAC (blood alcohol content) or BAL (blood alcohol level). A 150-pound man can consume one alcoholic drink (about three-fourths of an ounce) every hour essentially without physiological effect. The BAC increases with each additional drink during that same time, and the intoxicating effects of alcohol will become noticeable. If he has four drinks in an hour, he will have an alcohol blood content of .10 percent, enough for recognizable motor-skills impairment. In almost all states, operating a motor vehicle with a BAC between .08 percent and .10 percent (determined by breathalyzer or blood test) is a crime and is subject to arrest on a charge of DWI (driving while intoxicated). At .25 percent BAC (about ten drinks in an hour) the person is extremely drunk, and at .40 percent BAC the person loses consciousness. Excessive drinking of alcohol over time is associated with numerous health problems. Cirrhosis of the liver, hepatitis, heart disease, high blood pressure, brain dysfunction, neurological disorders, sexual and reproductive dysfunction, low blood sugar, and cancer, are among the illnesses attributed to alcohol abuse (National Institute on Alcohol Abuse and Alcoholism 1981, 1987; Royce 1990; Ray and Ksir 1999).
SOCIAL FACTORS IN ALCOHOL BEHAVIOR
Alcohol has direct effects on the brain, affecting motor skills, perception, and eventually consciousness. The way people actually behave while drinking, however, is only partly a function of the direct physical effects of ethanol. Overt behavior while under the influence of alcohol depends also on how they have learned to behave while drinking in the setting and with whom they are drinking with at the time. Variations in individual experience, group drinking customs, and the social setting produce variations in observable behavior while drinking. Actions reflecting impairment of coordination and perception are direct physical effects of alcohol on the body. These physical factors, however, do not account for "drunken comportment"—the behavior of those who are "drunk" with alcohol before reaching the stage of impaired muscular coordination (MacAndrew and Edgerton 1969). Social, cultural, and psychological factors are more important in overt drinking behavior. Cross-cultural studies (MacAndrew and Edgerton 1969), surveys in the United States (Kantor and Straus 1987), and social psychological experiments (Marlatt and Rohsenow 1981), have shown that both conforming and deviant behavior while "under the influence" are more a function of sociocultural and individual expectations and attitudes than the physiological and behavioral effects of alcohol. (For an overview of sociocultural perspectives on alcohol use, see Pittman and White 1991)
Sociological explanations of alcohol behavior emphasize these social, cultural, and social psychological variables not only in understanding the way people act when they are under, or think they are under, the influence of alcohol but also in understanding differences in drinking patterns at both the group and individual level. Sociologists see all drinking behavior as socially patterned, from abstinence, to moderate drinking, to alcoholism. Within a society persons are subject to different group and cultural influences, depending on the communities in which they reside, their group memberships, and their location in the social structure as defined by their age, sex, class, religion, ethnic, and other statuses in society. Whatever other biological or personality factors and mechanisms may be involved, both conforming and deviant alcohol behavior are explained sociologically as products of the general culture and the more immediate groups and social situations with which individuals are confronted. Differences in rates of drinking and alcoholism across groups in the same society and cross-nationally reflect the varied cultural traditions regarding the functions alcohol serves and the extent to which it is integrated into eating, ceremonial, leisure, and other social contexts. The more immediate groups within this sociocultural milieu provide social learning environments and social control systems in which the positive and negative sanctions applied to behavior sustain or discourage certain drinking according to group norms. The most significant groups through which the general cultural, religious, and community orientations toward drinking have an impact on the individual are family, peer, and friendship groups, but secondary groups and the media also have an impact. (For a social learning theory of drinking and alcoholism that specifically incorporates these factors in the social and cultural context see Akers 1985, 1998; Akers and La Greca 1991. For a review of sociological, psychological, and biological theories of alcohol and drug behavior see Goode 1993.)
SOCIAL CHARACTERISTICS AND TRENDS IN DRINKING BEHAVIOR
Age. Table 1 shows that by time of high school graduation, the percentages of current teenage drinkers (still under the legal age) is quite high, rivaling that of adults. The peak years for drinking are the young adult years (eighteen to thirty-four), but these are nearly equaled by students who are in the last year of high school (seventeen to eighteen years of age). For both men and women, the probability that one will drink at all stays relatively high from that time up to age thirty-five; about eight out of ten are drinkers, two-thirds are current drinkers, and one in twenty are daily drinkers. The many young men and women who are in college are even more likely to drink (Berkowitz and Perkins 1986; Wechsler et al. 1994). Heavy and frequent drinking peaks out in later years, somewhat sooner for men than women. After that the probability for both drinking and heavy drinking declines noticeably, particularly among the elderly. After the age of sixty, both the proportion of drinkers and of frequent or heavy drinkers decrease. Studies in the general population have consistently found that the elderly are less likely than younger persons to be drinkers, heavy drinkers, and problem drinkers (Cahalan and Cisin 1968; Fitzgerald and Mulford 1981; Meyers et al. 1981-1982; Borgatta et al. 1982; Holzer et al. 1984; Akers 1992).
Sex. The difference is not as great as it once was, but more men than women drink and have higher rates of problem drinking in all age, religious, racial, social class, and ethnic groups and in all regions and communities. Teenage boys are more likely to drink and to drink more frequently than girls, but the difference between male and female percentages of current drinkers at this age is less than it is in any older age group. Among adults, men are three to four times more likely than women (among the elderly as much as ten times more likely) to be heavy drinkers and two to three times more likely to report negative personal and social consequences of drinking (National Institute on Alcohol Abuse and Alcoholism 1987).
|Percentages Reporting Drinking by Age Group (1997)|
|age group||lifetime||past year||past month|
|source: Substance Abuse and Mental Health Services Administration 1998; University of Michigan (for high school seniors) 1998.|
|high school seniors||81.7||74.8||52.7|
Social Class. The proportion of men and women who drink is higher in the middle class and upper class than in the lower class. The more highly educated and the fully employed are more likely to be current drinkers than the less educated and unemployed. Drinking by elderly adults increases as education increases, but there are either mixed or inconsistent findings regarding the variations in drinking by occupational status, employment status, and income (Holzer 1984; Borgatta 1982; Akers and La Greca 1991).
Community and Location. Rates of drinking are higher in urban and suburban areas than in small towns and rural areas. As the whole country has become more urbanized the regional differences have leveled out so that, while the South continues to have the lowest proportion of drinkers, there is no difference among the other regions for both teenagers and adults. Although there are fewer of them in the South, those who do drink tend to drink more per person than drinkers in other regions (National Institute on Alcohol Abuse and Alcoholism 1998a).
Race, Ethnicity, and Religion. The percent of drinking is higher among both white males and females than among African-American men and women. Drinking among non-Hispanic whites is also higher than among Hispanic whites. The proportion of problem or heavy drinkers is about the same for African Americans and white Americans (Fishburne et al. 1980; National Institute on Drug Abuse, 1988; National Institute on Alcohol Abuse and Alcoholism 1998a). There may be a tendency for blacks to fall into the two extreme categories, heavy drinkers or abstainers (Brown and Tooley 1989), and black males suffer the highest rate of mortality from cirrhosis of the liver (National Institute on Alcohol Abuse and Alcoholism 1998b). American Indians and Alaskan Natives have rates of alcohol abuse and problems several times the rates in the general population (National Institute on Alcohol Abuse and Alcoholism 1987).
Catholics, Lutherans, and Episcopalians have relatively high rates of drinking. Relatively few fundamentalist Protestants, Baptists, and Mormons drink. Jews have low rates of problem drinking, and Catholics have relatively high rates of alcoholism. Irish Americans have high rates of both drinking and alcoholism. Italian Americans drink frequently and heavily but apparently do not have high rates of alcoholism (see Cahalan et al. 1967; Mulford 1964). Strong religious beliefs and commitment, regardless of denominational affiliation, inhibit both drinking and heavy drinking among teenagers and college students (Cochran and Akers 1989; Berkowitz and Perkins 1986).
Trends in Prevalence of Drinking. There has been a century-long decline in the amount of absolute alcohol consumed by the average drinker in the United States. There was a period in the 1970s when the per capita consumption increased, and the proportion of drinkers in the population was generally higher by the end of the 1970s than at the beginning of the decade, although there were yearly fluctuations up and down. The level of drinking among men was already high, and the increases came mainly among youth and women. But in the 1980s the general downward trend resumed (Keller 1958; National Institute on Alcohol Abuse and Alcoholism 1981, 1987, 1998). Until the 1980s, this per capita trend was caused mainly by the increased use of lower-content beer and wine and the declining popularity of distilled spirits rather than a decreasing proportion of the population who are drinkers.
Alcohol-use rates were quite high in the United States throughout the 1970s and into the 1980s (see table 2). Since then, there have been substantial declines in use rates in all demographic categories and age groups. In 1979 more than two-thirds of American adolescents (twelve to seventeen years of age) had some experience with alcohol and nearly four out of ten were current drinkers (drank within the past month). In 1988, these proportions had dropped to one-half and one-fourth respectively. In 1997, adolescent rates had dropped even lower to four out of ten having ever used alcohol and only two out of ten reporting use in the past month. Current use in the general U.S. population (aged twelve and older) declined from 60 percent in 1985 to 51 percent in 1997. Among the adult population eighteen years of age and older, current use declined from 71 percent in 1985 to 55 percent in 1997. Lifetime use rates have also declined from 88.5 percent in 1979 to 81.9 percent in 1997 (aged twelve and older). Generally, there have been declines in both annual (past year) prevalence of drinking (decreases of 3 to 5 percent) and current (past month) prevalence of drinking (decreases of 7 to 10 percent) among high school seniors, young adults, and older adults. Although lifetime prevalence is not a sensitive measure of short-term change in the adult population (since the lifetime prevalence is already fixed for the cohort of adults already sampled in previous surveys), it does reflect an overall decline in alcohol use. It should be remembered, however, that most of this is light to moderate consumption; the modal pattern of drinking for all age groups in the United States has long been and continues to be nondeviant, light to moderate social drinking.
The relative size of the reductions in drinking prevalence over the last two decades have been rather substantial; however, the proportions of drinkers remains high. By the time of high school graduation, one-half of adolescents are current drinkers and the proportion of drinkers in the population remains at this level throughout the young adult years. Three-fourths of high school seniors and young adults and two-thirds of adults over the age of thirty-five have consumed alcohol in the past year (see table 1).
Although lifetime use and current use rates appear to be continuing a slight decline in all categories, there have been some slight increases in rates of frequent (daily) drinking among high school seniors and young adults. While these increases do not approach the rates observed in the 1980s they may indicate that the overall rates are stabilizing and hint of possible increases in alcohol use rates in the future.
Estimates of Prevalence of Alcoholism. In spite of these trends in lower levels of drinking,
|Percentages Reporting Lifetime, Past Year, and Past Month Use of Alcohol in the U.S. Population Aged 12 and Older (1979–1997)|
|source: Substance Abuse and Mental Health Services Administration 1998.|
alcoholism remains one of the most serious problems in American society. Alcohol abuse and all of the problems related to it cause enormous personal, social, health, and financial costs in American society. Cahalan et al. (1969) in a 1965 national survey characterized 6 percent of the general adult population and 9 percent of the drinkers as "heavy-escape" drinkers, the same figures reported for a 1967 survey (Cahalan 1970). These do not seem to have changed very much in the years since. They are similar to findings in national surveys from 1979 to 1988 (National Institute on Alcohol Abuse and Alcoholism 1981, 1987, 1988, 1989; Clark and Midanik 1982), which support an estimate that 6 percent of the general population are problem drinkers and that about 9 percent of those who are drinkers will abuse or fail to control their intake of alcohol. Royce (1989) and Vaillant (1983) both estimate that 4 percent of the general population in the United States are "true" alcoholics. This estimate would mean that there are perhaps 10.5 million alcoholics in American society (see also Liska 1997). How many alcoholics or how much alcohol abuse there is in our society is not easily determined because the very concept of alcoholism (and therefore what gets counted in the surveys and estimates) has long been and remains controversial.
THE CONCEPT OF ALCOHOLISM
The idea of alcoholism as a sickness traces back at least 200 years (Conrad and Schneider 1980). There is no single, unified, disease concept, but the prevailing concepts of alcoholism today revolve around the one developed by E. M. Jellinek (1960) from 1940 to 1960. Jellinek defined alcoholism as a disease entity that is diagnosed by the "loss of control" over one's drinking and that progresses through a series of clear-cut "phases." The final phase of alcoholism means that the person is rendered powerless by the disease to drink in a controlled, moderate, nonproblematic way.
The disease of alcoholism is viewed as a disorder or illness for which the individual is not personally responsible for having contracted. It is viewed as incurable in the sense that alcoholics can never truly control their drinking. That is, sobriety can be achieved by total abstention, but if even one drink is taken, the alcoholic cannot control how much more he or she will consume. It is a "primary" self-contained disease that produces the problems, abuse, and "loss of control" over drinking by those suffering from this disease. It can be controlled through proper treatment to the point where the alcoholic can be helped to stop drinking so that he or she is in "remission" or "recovering." "Once an alcoholic, always an alcoholic" is a central tenet of the disease concept. Thus, one can be a sober alcoholic, still suffering from the disease even though one is consuming no alcohol at all. Although the person is not responsible for becoming sick, he or she is viewed as responsible for aiding in the cure by cooperating with the treatment regimen or participation in groups such as Alcoholics Anonymous.
The disease concept is the predominant one in public opinion and discourse on alcohol (according to a 1987 Gallup Poll, 87 percent of the public believe that alcoholism is a disease). It is the principal concept used by the vast majority of the treatment professionals and personnel offering programs for alcohol problems. It receives widespread support among alcohol experts and continues to be vigorously defended by many alcohol researchers (Keller 1976; Vaillant 1983; Royce 1989). Alcoholics Anonymous, the largest single program for alcoholics in the world, defines alcoholism as a disease (Rudy 1986). The concept of alcoholism as a disease is the officially stated position of the federal agency most responsible for alcohol research and treatment, the National Institute of Alcoholism and Alcohol Abuse (National Institute on Alcohol Abuse and Alcoholism 1987).
Nonetheless, many sociologists and behavioral scientists remain highly skeptical and critical of the disease concept of alcoholism (Trice 1966; Cahalan and Room 1974; Conrad and Schneider 1980; Rudy 1986; Fingarette 1988, 1991; Peele 1989). The concept may do more harm than good by discouraging many heavy drinkers who are having problems with alcohol, but who do not identify themselves as alcoholics or do not want others to view them as sick alcoholics, from seeking help. The disease concept is a tautological (and therefore untestable) explanation for the behavior of people diagnosed as alcoholic. That is, the diagnosis of the disease is made on the basis of excessive, problematic alcohol behavior that seems to be out of control, and then this diagnosed disease entity is, in turn, used to explain the excessive, problematic, out-of-control behavior.
In so far as claims about alcoholism as a disease can be tested, "Almost everything that the American public believes to be the scientific truth about alcoholism is false" (Fingarette 1988, p.1; see also Peele 1989; Conrad and Schneider 1980; Fingarette 1991; Akers 1992). The concept preferred by these authors and by other sociologists is one that refers only to observable behavior and drinking problems. The term alcoholism then is nothing more than a label attached to a pattern of drinking that is characterized by personal and social dsyfunctions (Mulford and Miller 1960; Conrad and Schneider 1980; Rudy 1986: Goode 1993). That is, the drinking is so frequent, heavy, and abusive that it produces or exacerbates problems for the drinker and those around him or her including financial, family, occupational, physical, and interpersonal problems. The heavy drinking behavior and its attendant problems are themselves the focus of explanation and treatment. They are not seen as merely symptoms of some underlying disease pathology. When drinking stops or moderate drinking is resumed and drinking does not cause social and personal problems, one is no longer alcoholic. Behavior we label as alcoholic is problem drinking that lies at one extreme end of a continuum of drinking behavior with abstinence at the other end and various other drinking patterns in between (Cahalan et al. 1969). From this point of view, alcoholism is a disease only because it has been socially defined as a disease (Conrad and Schneider 1980; Goode 1993).
Genetic Factors in Alcoholism. Contrary to what is regularly asserted, evidence that there may be genetic, biological factors in alcohol abuse is evidence neither in favor of nor against the disease concept, any more than evidence that there may be genetic variables in criminal behavior demonstrates that crime is a disease. Few serious researchers claim to have found evidence that a specific disease entity is inherited or that there is a genetically programmed and unalterable craving or desire for alcohol. It is genetic susceptibility to alcoholism that interacts with the social environment and the person's drinking experiences, rather than genetic determinism, that is the predominant perspective.
The major evidence for the existence of hereditary factors in alcoholism comes from studies that have found greater "concordance" between the alcoholism of identical twins than between siblings and from studies of adoptees in which offspring of alcoholic fathers were found to have an increased risk of alcoholism even though raised by nonalcoholic adoptive parents (Goodwin 1976; National Institute on Alcohol Abuse and Alcoholism 1982; U.S. Department of Health and Human Services 1987; for a review and critique of physiological and genetic theories of alcoholism see Rivers 1994). Some have pointed to serious methodological problems in these studies that limit their support for inherited alcoholism (Lester 1987). Even the studies finding evidence for an inherited alcoholism report that only a small minority of those judged to have the inherited traits become alcoholic and an even smaller portion of all alcoholics have indications of hereditary tendencies. Whatever genetic variables there are in alcoholism apparently come into play in a small portion of cases. Depending upon the definition of alcoholism used, the research shows that biological inheritance either makes no difference at all or makes a difference for only about one out of ten alcoholics. Social and social psychological factors are the principal variables in alcohol behavior, including that which is socially labeled and diagnosed as alcoholism (Fingarette 1988; Peele 1989).
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RONALD L. AKERS THOMAS R. HEFFINGTON
ALCOHOL.CULTURAL AND HISTORICAL FOUNDATIONS
HISTORIOGRAPHY AND INTERPRETATIVE PARADIGMS
TRENDS AND NATIONAL VARIATIONS IN ALCOHOL REGULATION
TRENDS AND NATIONAL VARIATIONS IN ALCOHOL CONSUMPTION
The production and consumption of alcoholic beverages have been characteristic features of European societies for centuries. Europe is the origin of beverage forms known the world over: distilled beverages such as gin, vodka, scotch, and cognac; wines that include champagne, Bordeaux, Burgundy, and Chianti; and beer styles such as lager, stout, and ale. Indeed, Europe has been the fount of the global flow of alcohol over the last several centuries, having exported both the taste for alcohol through worldwide emigration and colonization and the means of production through advanced knowledge of commercial viti-culture, brewing, and distilling. Indigenous forms of alcohol have survived throughout the world together with these imported—and sometimes imposed—traditions, but nearly everywhere these European beverages and their many cousins, with their familiar brand names, have been associated with affluence, upward mobility, and a Western cultural outlook. The global market for alcoholic beverages totals about 780 billion dollars, and western European consumption accounts for 280 billion dollars, more than a third of the total. If alcohol is a factor in the global economy, it is also a factor in global health. The World Health Organization estimated for the year 2000 that alcohol consumption was a major factor in the global burden of disease, a measure of premature deaths and disability. Alcohol-related death and disability accounted for about 10 percent of the global burden of disease in developed countries, making it the third most important risk.
Alcohol, of course, is no ordinary commodity. Its special character is recognized in myth and layers of symbolic association and cultural meaning that are not far below the surface even in the early twenty-first century. For the ancient Greeks, alcohol was an extraordinary gift of the gods, bestowed on humanity by Dionysus. Wine has played an important symbolic role in both Christian and Jewish rituals and traditions, and alcohol is closely linked to secular rituals of reciprocity and trust. Glimpses of this archaeology of meaning may still be seen—in toasts at dinner parties among family and friends; in the rituals of drinking together to conclude important business dealings; in elaborate wedding ceremonies, which combine the convivial blessing of the couple and the sealing of the marriage contract; in the practice of alternate treating that confirms equality of status and solidifies social ties; and in the drinking bouts of young men—comrades in arms, teammates, fraternity brothers, or workmates—who test their ability to stand up to alcohol's powers, and thereby draw a circle of shared experience and trust around themselves.
Alcohol's duality as a food-drug is the foundation of its special cultural significance. Alcoholic beverages provide calories and refreshment; they nourish but also produce bodily harm. Alcohol is also an intoxicant—a source of pleasure and release but also of danger and disorder. Every society that has known the benefits of alcohol has also known its costs. For that reason, alcohol consumption is always closely regulated, both by formal institutional sanctions and, perhaps more importantly, by informal social controls that enforce standards of decorum through peer pressure, gossip, and ostracism. Together, they define who can drink, when they can drink, with whom they can drink, and how they should behave.
Over time, alcohol has become available in increasing quantities to more and more people in European societies and around the world. The democratization of access to alcohol accelerated rapidly in European societies beginning in the late eighteenth and early nineteenth centuries. The intersection of the spread of rising wages and growing concentrations of people in towns and cities with the commercialization and industrialization of alcohol production and distribution made alcohol consumption more affordable, more frequent, and more visible. As a result, the discussion of the causes, consequences, and control of popular drinking behavior became a major public issue in the industrializing societies of Europe and North America. Led by middle-class Protestant reformers, temperance advocates in all these societies eschewed alcohol themselves and advocated greater controls on the drinking of others, particularly of the working men whose drinking, often boisterous and public, seemed a threat to the middle-class values of self-discipline, thrift, and domesticity upon which economic prosperity and social order were thought to depend. For the people doing the drinking, on the other hand, the consumption of alcohol was a first form of modern consumer satisfaction and a focal point for their leisure-time activities and limited opportunities for relaxation and socializing outside of work.
American prohibition in the 1920s was undoubtedly the global culmination and most extreme manifestation of the antialcohol sentiment that characterized leading sectors of Western societies in the nineteenth century. Its failure, and the collapse of the utopian expectations that had accompanied the "noble experiment," also put a definitive end to any remaining grand designs for comprehensive alcohol reform in Europe. In the early 2000s alcohol consumption is a fully integrated part of the modern consumer economy in ways that would have been unimaginable at the beginning of the twentieth century, when the battle against alcohol was about to be won. The notion that alcohol consumption is a fundamental obstacle to social integration and progress has almost universally been replaced by an acceptance of alcoholic beverages as part of the good life that Western economic development promised in the first place. Shaped by modern advertising, marketing, and packaging techniques, alcohol consumption is thoroughly normalized and domesticated, a part of home life as well as public social life. From an economic standpoint, the production and distribution of alcohol and associated hospitality businesses make significant contributions to local and national economies. Despite long-term trends toward consolidation of ownership and production, the alcoholic beverages business remains relatively disaggregated and local compared to other global commodities. Producers and distributors are part of the social fabric of any local, regional, or national community and constitute one set of interests the state must balance in formulating alcohol policy.
The social context—and meaning—of drinking substantially changed over the course of the twentieth century. By the time of World War I, a transition was under way from the nineteenth-century era in which alcohol was widely considered an inferior consumer good associated with poverty and deprivation (even if a means of relief from them) to a world in which alcohol consumption was more universally recognized as a mark of affluence and drinking a means of partaking in a consumer society and demonstrating one's standing within it. The relative prosperity of the 1920s, and alcohol's association with the avant-garde, the Jazz Age, and the cosmopolitan life of the great European cities, helped change the tide. After World War II, alcohol consumption increased rapidly into the 1970s as European economies rebuilt and prospered.
While social observers have commented on European drinking habits for centuries, only since the 1970s have historians made alcohol a subject of sustained study. Beginning with Brian Harrison's Drink and the Victorians in 1971, historians have covered the major European countries, both explicating the history of alcohol production, consumption, and control as a subject in its own right and illuminating larger social, cultural, and political themes through the particularly revealing lens that alcohol provides. Their monographs have examined the role of alcohol in popular culture; the growth of the alcohol industry; the motives, methods, and accomplishments of temperance reformers; and the roles political parties and government agencies played in shaping alcohol policy. A substantial number of article-length studies extend and complement this work, and brief treatments of alcohol-related topics are more and more often included in wider studies as a means of illustrating particular issues in social and cultural history. The two-volume international encyclopedia Alcohol and Temperance in Modern History (2003) cites much of this literature. The Alcohol and Drugs History Society, founded in 1979 as the Alcohol and Temperance History Group, publishes the Social History of Alcohol and Drugs: An Interdisciplinary Journal (formerly The Social History of Alcohol Review) and maintains a useful Web site: http://historyofalcoholanddrugs.typepad.com.
Virtually all of this work by professional historians focuses on the nineteenth century (or earlier eras), with coverage typically ending with World War I. However, alcohol-related themes in twentieth-century Europe have received attention from other disciplines—sociology, public health, and medicine, for example—and much of this work does provide historical coverage, if not historical interpretation. Economic and business aspects of alcohol production, marketing, distribution, and consumption are also well documented.
Historians and policy analysts have distinguished three eras in modern efforts to conceptualize and manage the individual and social costs associated with alcohol consumption. The nineteenth century was the era of voluntary associations, the creation of temperance organizations, and the mobilization of middle-class sentiment in campaigns of public education about the dangers of alcohol and efforts to persuade legislatures and state agencies to tighten alcohol controls. Temperance reformers, of course, saw much more harm than good in alcohol, linking it to poverty, urban squalor, and a host of contemporary social problems. They operated with two complementary theories about the ultimate source of problems with alcohol. Many proponents of alcohol control believed that alcohol was inherently debilitating, a threat to all who consumed it; others emphasized the moral failings and weak character of those who drank to excess, flaws they saw in some social groups more than others. (Some socialists and trade-unionists offered an alternative view: that problem drinking was the result of capitalist labor conditions.) The substantial mobilization of social energies around the "drink question" largely ended with World War I. Europe had other preoccupations after the war, and the closely watched failure of American prohibition seemed to confirm that a political solution to the drink question could not be achieved.
After the end of this period of public mobilization, alcohol concerns were left primarily to experts in the health professions. As in the United States, the "disease concept of alcoholism" gained ascendancy. The predominant theory about the source of problems with alcohol no longer blamed alcohol itself or the moral failings of drinkers; experts pointed instead to a predisposition in some individuals—a disease—whose manifestation was an inability to control alcohol consumption. The focus shifted from public policy measures that might influence the drinking behavior of the whole population, or substantial segments of it, to individuals susceptible to drinking problems and their appropriate treatment. In extreme cases, as in Nazi eugenics policy, treatment could mean sterilization rather than individual rehabilitation. This basic paradigm for explaining and managing problems with alcohol carried into the post–World War II welfare state, which generously supported therapeutic interventions to manage individual problems with alcohol. Meanwhile, under prevailing liberal economic policies and with the lowering of trade barriers within Europe, the business of producing, marketing, and distributing alcoholic beverages expanded largely unchecked by government intervention, and European alcohol consumption increased rapidly.
Beginning in the mid-1970s, a new public health focus emerged in European (and North American) discussions about alcohol. Epidemiological analyses underscored the collective social harm that was the correlate of the individual freedom to drink, and these discussions pointed again to general public policy solutions rather than just individual therapeutic ones. This movement has been called neoprohibitionist because of its renewed focus on alcohol itself, rather than on the individual drinker, and on measures to limit aggregate supply and demand. The World Health Organization and the European Union have supported cooperative studies and strategies across the European states. Even within this public health paradigm there have been substantial debates about how to balance the interests of consumers and producers with the overall interests of the state and society. Alongside originally proposed prevention strategies aimed at reducing aggregate consumption on the theory that alcohol-related harm is directly correlated to the total volume of consumption in any given society (the so-called Lederman total consumption model), a variant perspective has emerged more recently that focuses on harm reduction and aims not primarily at reducing overall consumption but at mitigating risk.
Even though debates about alcohol have not had the place on the social and political agenda they occupied before World War I, European societies have continued to adjust social policies regarding alcohol to balance the often conflicting interests between individual rights and social consequences, between economic benefits and social costs. In a survey of the evolution of alcohol control policies in fifteen western European countries since 1950, Esa Österberg and Thomas Karlson found a pattern of increasing government engagement. They developed a twenty-point rating scale to evaluate the strictness of formal alcohol controls in each society, considering such matters as drinking age, hours of distribution, marketing restrictions, excise taxes, drunk-driving laws, and educational initiatives.
Figure 1 compares the 2000 rating score to the 1950 rating score for each country in the study. The chart is ordered from left to right from the currently least restrictive (Austria) to the currently most restrictive (Norway). The three Scandinavian countries have had the most restrictive policies over the entire period, though they have become marginally less restrictive. Every other country has become more restrictive over the last half century, with the biggest changes among the wine-producing countries (France, Greece, Italy, Portugal, and Spain)—these are also the areas where per capita consumption has declined the most. Figure 2 shows the total change in the rating scale for each country over the fifty-year study period.
Although increased social attention to alcohol issues is evident in these trends, the forms of state involvement in the alcohol realm have been changing, with fewer direct controls on production and retail—and hence consumer freedom—and more efforts to control outcomes through education programs and the regulation of drinking and driving. The effect has been less to limit supply and consumer choice than to educate consumers about responsible drinking and to set clearer limits on socially accepted behavior.
In the fifteen European societies covered in the European Comparative Alcohol Study (2002), aggregate per capita consumption rose rapidly and steadily from 1950 to the late 1970s, with a total increase of more than 50 percent, from the equivalent of approximately eight liters of 100 percent alcohol per capita to slightly more than twelve. Since the late 1970s, per capita consumption has been in a gradual and unabated decline, falling from more than twelve to approximately eleven liters per capita by 1995. The overall growth is clearly associated with Europe's economic recovery, the spread of consumer values, and growing purchasing power. The gradual decline is associated with moderating influences associated with increasing awareness of alcohol's risks, the growing popularity of health and fitness as part of consumer culture, the marketing of newer, nonalcoholic beverages, and the breakdown—particularly in the wine-drinking cultures—of the close-knit traditional family, whose mealtimes together almost invariably involved alcohol consumption. Figure 3 provides a comparative profile of per capita consumption in the ECAS study countries.
Europe is often divided according to predominant beverage preference into wine-drinking, beer-drinking, and spirits-drinking regions. These preferences are rooted in national production patterns, relative taxation and price, and longstanding consumer preferences, especially among the older generations. Among younger consumers, especially young professionals, these traditional patterns hold less sway. While these regional differences have receded in importance, they continue to be evident. In the 1950s consumption in seven of the fifteen study countries was dominated by a single beverage type that accounted for 75 percent or more of total consumption; by the 1990s, only one country (Italy) fit that description. Still, if the differences are less pronounced, they remain important. In the 1990s, a single beverage type accounted for 50 percent or more of total consumption in twelve of the fifteen study countries. Figure 4 depicts aggregate consumption trends in each of the three consumption groups.
The wine-producing and -consuming countries share a Mediterranean climate, a Catholic heritage, and drinking traditions that are deeply entwined in everyday life, especially at mealtimes. In general, per capita consumption is highest in these countries, and drinking is an everyday occurrence. Women are more likely to consume alcohol regularly than in other regions, but even in the wine-drinking countries they drink much less often and consume smaller quantities than men. Young people are acculturated to drinking practices and behavioral expectations gradually and from an early age within extended family circles. Only recently have minimum drinking ages been established, generally sixteen. (In Italy and Spain, there is no age limit if a young person is accompanied by an adult.) Virtually all adults consume alcohol on occasion, if not daily, and very few people abstain from alcohol completely. It is in these countries, however, that per capita consumption has been declining, particularly in France, as awareness of the health risks of alcohol consumption has begun to balance appreciation for its benefits, especially among younger consumers. Overall, per capita consumption in the wine-drinking countries was fairly stable from 1950 through the late 1970s at an average of about sixteen liters of 100 percent alcohol per capita aged fifteen and over; consumption has fallen steadily since then, bottoming at twelve liters per capita in 1995, a 25 percent reduction. France dominates, with a long-term, steady decline from the mid-1960s level of twenty-five liters per capita to about fifteen liters per capita in 1995, a 40 percent reduction. Consumption has also fallen sharply in Italy, but only from the mid-1970s, when it stood at about nineteen liters per capita, decreasing to nine liters per capita in 1995, a 40 percent reduction. Figure 5 depicts the per capita consumption trend for each of the predominantly wine-drinking countries.
The predominantly beer-producing and -consuming countries include Austria, Belgium, Denmark, Germany, Ireland, the Netherlands, and the United Kingdom. Wine has become more popular over time in these countries, but beer is still the predominant beverage, accounting for 50 percent or more of all beverage consumption in each nation. The post–World War II consumption curves of all these countries look very similar, with steadily rising consumption from 1950 to the early 1970s and essentially stable consumption thereafter. Average per capita consumption in the beer-drinking countries more than doubled from 1950 to the early 1970s, increasing from five to twelve liters per capita, where it essentially remained through the mid-1990s. Per capita consumption is highest in the Austria, followed closely by Germany. Figure 6 shows per capita consumption trends in each of the predominantly beer-consuming countries.
The classic spirits-consuming countries in the ECAS study are Finland, Norway, and Sweden. In all three countries, at least 50 percent of total consumption was in the form of spirits in the early 1950s, but by the mid-1990s the role of spirits had been reduced by half. Beer, and to a lesser extent wine, have played increasing roles in these societies. The general trend since World War II shows stable consumption in the 1950s and early 1960s at about four liters per capita, then a rapid rise from the mid-1960s to the mid-1970s, with consumption reaching more than seven liters per capita, a 75 percent increase, and remaining generally stable at that level through the mid-1990s. Norway and Sweden conform to this general pattern, while Finland appears to be a special case, with a doubling of consumption in the early 1970s, from four to eight liters per capita, and an increase to nearly ten liters per capita in the early 1990s before a period of declining consumption began. Figure 7 charts per capita consumption trends for the traditional spirits-consuming countries.
The production and consumption of alcoholic beverages have deep roots in European culture. Like all other societies that use alcohol, European societies have developed both formal institutional means and informal cultural norms to regulate the production and consumption of alcohol and to balance its benefits and risks. The nations of western Europe and North America experienced rapid changes in the availability of alcohol and the social context of drinking during the late eighteenth and early nineteenth centuries, and alcohol consumption was a focal point in discussions about how to create an orderly society that would mitigate the social problems and social conflicts connected with rapid industrialization and urbanization. During the interwar years, discussions about alcohol were less prominently a part of debates about the major issues of the day, though of course every society had to continue its own form of regulatory watch over production and consumption. In general, however, alcohol issues moved from the public realm of policy debate to the private realm of therapeutic intervention in the lives of the most conspicuous problem drinkers. This shift of focus allowed the production and consumption of alcohol to gain an accepted role in the modern consumer economy, and especially after World War II the combination of rising prosperity, new marketing techniques, and older drinking traditions led to rapidly rising consumption—no longer associated with the grinding conditions of industrialization and urbanization but with the spread of middle-class lifestyles and consumer values and the integration of alcohol into the home. Of course all of these trends can be decomposed into many layers of continuities and innovations, regional variations, and differences according to gender, age, ethnicity, religion, and social class. More recently, a new consciousness of the global social consequences of relatively unconstrained alcohol has prompted increased government attention, within and across the countries of Europe, and the advance of public health perspectives to the forefront. Europe is no longer a growth market for alcoholic beverages, but neither is it a region where dramatic state interventions are likely. A modus vivendi has been struck among producers, consumers, and the state to createarealm for informed consumer choice within a framework that combines individual therapeutic interventions with public health perspectives to mitigate alcohol's associated risks. This is a Sisyphean labor, as the dialectic among production, consumption, and control is constantly evolving in every society that enjoys Dionysus'swonderful, terriblegift.
Alcohol, Society, and the State. Toronto, 1981.
Barrows, Susanna, and Robin Room, eds. Drinking: Behavior and Belief in Modern History. Berkeley, Calif., 1991.
Blocker, Jack S. J., David M. Fahey, and Ian R. Tyrell. Alcohol and Temperance in Modern History: An International Encyclopedia. Santa Barbara, Calif., 2003.
Heath, Dwight B., ed. International Handbook on Alcohol and Culture. Westport, Conn., 1995.
Jellinek, E. M. "The Symbolism of Drinking; a Culture-Historical Approach." Journal of Studies on Alcohol 38 (1977): 852–866.
Müller, Richard, and Harald Klingemann, eds. From Science to Action?: One Hundred Years Later—Alcohol Policies Revisited. Dordrecht, Netherlands, 2004. See especially essays by Thomas Babor, Irmgard Eisenbach-Stangl, and Barbara Lucas.
Norström, Thor, ed. Alcohol in Postwar Europe: Consumption, Drinking Patterns, Consequences, and Policy Responses in Fifteen European Countries. Stockholm, Sweden, 2002. See especially essays by Håkan Leifman and Esa Österberg and Thomas Karlsson.
Roberts, James S. "Long-Term Trends in the Consumption of Alcoholic Beverages." In The State of Humanity, edited by Julian L. Simon, 114–120. Oxford, U.K., 1995.
James S. Roberts
Alcohol has a long history predating European colonialism in sub-Saharan Africa. African traditional drinks include first and foremost the thick, cloudy grain beers of the savannah areas of East Africa and southern Africa and the Sahelian zone, and the palm and banana wines of the higher rainfall areas, especially in Central and West Africa.
TRADITIONAL PATTERNS OF PRODUCTION AND CONSUMPTION IN AFRICA
The indigenous alcoholic drinks of Africa were fermented and usually of low ethanol content—between 2 and 4 percent. The grain-based beer production and consumption in rural areas was highly seasonal, whereas the supply of palm wine would have been continuous throughout the year. Traditionally, the pattern of ceremonial festivities and drinking occasions rotated around the agricultural cycle. Many family and community celebrations, such as weddings and puberty rites, would have been deliberately scheduled to take place in the post-harvest period when the availability of ingredients for alcohol production was assured. A successful grain harvest was a cause for celebration and the giving of thanks to the ancestors. Alcohol could appear out of season at other occasions, such as funerals. Given alcohol's close association with ancestors, it was not surprisingly a feature of wakes.
Traditionally, alcohol drinking to the point of intoxication was considered primarily the privilege of male elders, who held the highest status in Africa's rural communities. The drinking of low-ethanol alcohol, which was woven into special community-wide ceremonies and occasions marking life-cycle passages, constituted an intensely social event.
Fermented alcoholic beverages also provided basic food and drink. Men were more likely to consume their grain intake in the form of beer than women and children. However, traditional forms of thick, cloudy sorghum and millet beers veer toward the boundary between alcohol and nutritional gruel. Women and children drank the nutritious gruel. Furthermore, these beverages provided liquid refreshment in places where the water supply was unsafe.
ALCOHOL USE IN AFRICA DURING THE COLONIAL ERA
Onto this localized pattern of community-based alcohol production and consumption, Portuguese, Dutch, British, French, and German, as well as Danish and Swedish, slave-trade activities in Africa expanded the world trade in distilled liquor. Distilled liquor was an ideal long-distance trading good, capable of being stored for exceptionally long periods, little damaged by climatic fluctuation, and eagerly demanded in a wide range of foreign lands. In effect, alcohol served as a currency in early European trading, conquest, and labor recruitment.
The slave trade and European alcohol importation were intricately entwined. European mercantile interests introduced parts of the African continent to strong distilled alcohol and recreational drinking habits that were divorced from community ritual contexts. Alcohol was traded primarily with chiefs and merchant elites, and the drinking of imported spirits was generally restricted to coastal areas or navigable river routes. Thus, at a very early stage, these parts of Africa became part of the global market for alcohol under an economic regime of unfettered free trade.
Along the Gold Coast, imported spirits became prevalent during the seventeenth century and, according to foreign travelers, were incorporated into rituals by the eighteenth century. Hair, Jones, and Law's 1992 study of the letters of a French slave trader, Jean Barbot, reveal the multiple utilities of spirits. Besides trading French brandy for slaves, the brandy served as a tribute payment and a lubricant for trade negotiations, helping European traders gain bargaining advantage. The ship's crew drank it liberally as well, so its inclusion in the hold was never in vain, even when, as on one unexpected occasion, Barbot found that the English traders who preceded him had swayed local demand in favor of Barbados rum.
Beyond West Africa, seventeenth-century records of the Dutch East Indies Company at the Cape of Good Hope reveal that their African slaves were issued a daily glass of brandy in the belief that it would increase their alertness. After the abolition of slavery, tots of spirits and, later, wine were used as a method of payment for manual labor. Attitudes of the day embraced the notion that alcohol had medicinal benefits. European traders and employers complained about the market sale of alcohol, fearing that public drunkenness and disorder could threaten social stability, but the desire for public regulation of alcohol did not coalesce into any systematic legal control.
The end of the nineteenth century saw a glut of so-called trade spirits on the world market. These consisted primarily of cheaply produced potato schnapps that had been the staple drink of peasants throughout much of continental Europe. As the Industrial Revolution absorbed Europe's rural populations, their drinking tastes gravitated toward smoother grain schnapps and beer. New markets were sought just as Africa was being colonized. Traders based in Hamburg and Rotterdam acted with alacrity, finding a receptive market in West Africa. They even managed to circumvent import duties to penetrate the booming South African market by shipping their schnapps via Portugal.
Alcohol played a significant role in mobilizing wage labor on a continent with no legacy of wage labor and where acute labor scarcity prevailed. In effect, alcohol provided the lever for labor recruiters to pry self-sufficient agrarian societies open, and it served as an expedient means for employers to attract and hold their workforce, given their limited need for cash. By the 1880s Portuguese wine and spirit imports in Mozambique had helped mold a proletarianized workforce whose dependence on alcohol was readily recognized as an asset across the border in South Africa. The Transvaal gold mines, rapidly expanding their labor force, eagerly recruited such workers.
TEMPERANCE AND PROHIBITION
Khama III (d. 1923) of Bechuanaland (later Botswana) was notable as a traditional leader who took a firm stand against the trade in bottled spirits. The mining concession he granted in 1887 stipulated the ban of such imports. Temperance concerns began to be expressed, bolstered by local merchants interested in diverting some of the cash spent on drinks at mining canteens to the purchase of their commodities.
However, it was mine owners themselves who decisively threw their weight behind tighter controls. The poor productivity and high absentee rates of a drunken labor force were expensive, as well as posing a threat to civil order in frontier mining settlements where effective police control was lacking. At the turn of the twentieth century, heavy investment in deep-level mining necessitated a more disciplined and productive labor force. Mine owners radically altered their position, forsaking their financial interests in canteen alcohol sales. Bigger financial stakes beckoned, and they began pressing for total alcohol prohibition.
They did so in an atmosphere of increasing British imperial sympathy for the temperance cause. British empire builders Cecil Rhodes (1853–1902) and Frederick Lugard (1858–1945) joined ranks with Christian missionaries to advocate tighter alcohol controls, despite the inevitable loss of alcohol import duties that such a position would entail. Colonial economies had the onus of being financially self-sustaining, and many West African colonies relied heavily on the fiscal flow of alcohol import duties.
At the Berlin Conference of 1884, the dominant European powers of the day had mutually agreed to partition sub-Saharan Africa amongst themselves, but the issue of the lucrative alcohol trade that had been fostered during the preceding three centuries was left as unfinished business. As palm oil and other agricultural commodities replaced slaves as the region's major exports, more Africans gained access to cash, facilitating the expansion of alcohol imports into West Africa.
Prohibition groups felt that the "white man's burden" was to prevent Africans' alcoholic overindulgence and moral degeneration. They successfully pressured the European powers attending the Brussels Conference of 1890 into establishing an alcohol prohibition zone between the latitudes 20° north and 22° south across the continent. In this zone, the signatory governments agreed to ban the importation and distillation of liquors where their use did not already exist.
The significance of an international treaty was more symbolic than real in curbing African access to alcohol. South Africans and most West Africans accustomed to imported alcohol were not included in the ban. Prohibition did not extend to the non-African population anywhere on the continent, so imports per se did not cease, making leakages of supply common, especially in northern Nigeria, where the ban was implemented to accommodate the predominately Muslim population.
Minimum duty rates were set, and a secretariat in Brussels was established to monitor the controls without powers of enforcement. Following World War I, the international moral crusade of alcohol prohibition gave way to political pragmatism. Alcohol control represented an overconcentration of too many conflicting emotions and economic interests to be tackled by the League of Nations' prudent international civil service cadre.
International intervention had given colonial governments scope to institute policies that rewarded or punished segments of the population with differential alcohol access according to their attainment of "civilized" behavior in the eyes of colonial officialdom. Alcohol control served as a signposting on the rungs of the colonial social hierarchy based on race and class; it amounted to a "division of leisure," the reverse side of the colonial division of labor.
Broadly, the policies of the higher-latitude beer-drinking and spirit-drinking European colonial nations like Britain and Germany differed from those of the more southern wine-drinking French and Portuguese, who were far less influenced by the temperance movement. France and Portugal accommodated the possibility of cultural assimilation and class advancement by making wine and beer available to Africans who could afford to purchase it. Alcohol access in British and German colonies was more punitive in nature, pivoting on a stark racial distinction between Europeans and Africans. Africans in the British colonies of East Africa and southern Africa were not allowed European drinks, defined as wine, clear beer, and bottled spirits. In southern and South Africa, the racial content of alcohol policy was reinforced by the presence of a large white settler population. The rural/urban divide among Africans was ignored: urban Africans were assumed to have "unrefined" rural tastes.
NEW PATTERNS OF PRODUCTION AND CONSUMPTION IN AFRICA
Generally, most rural agricultural production consisted of low-alcohol beers and wines. Limitations on brewing to conserve staple food crops and prevent famine were commonly incorporated into native authority bylaws. Home brewing was left to the jurisdiction of local native authorities.
Local brewing recipes were changing as new crops and foods were adopted. Throughout much of East and southern Africa, higher-yielding maize edged out lower-yielding indigenous sorghums and millets, nudging the importance of maize forward in alcohol production and encouraging the discovery of faster brewing techniques. Brewing became more commercialized with women producers at the center of the growth of alcohol as a cottage industry, first in urban areas and later throughout rural Africa. Women's illegal brewing was often highly beneficial to family provisioning at the microlevel.
Evidence suggests that alcohol consumption increased during colonial rule with a proliferating array of alcoholic drinks, widening availability, and increasing alcoholic strength, while the proportion of the population drinking and the amount they drank on an annual per capita basis rose. In the process, the purpose of drinking gradually transformed from public ceremonial celebration at which relatively few imbibed, to a communally-shared leisure pastime in which broader sections of the community participated. Drinking took on new temporal dimensions. Previously alcohol had been limited by seasonal supply. Now the market offered year-round availability.
At the turn of the twentieth century, sugar became readily available in towns, and its ethanol-enhancing properties were quickly exploited, spreading to rural areas as well. Fermented sugar drinks boosted alcohol contents to between 6 and 8 percent, offering value for the money for those desiring intoxication. It was these new experimental drinks, concentrated in the urban areas, rather than the traditional rural brews, that colonial officialdom endeavored to curb.
At the same time, distillation techniques were expanding, fanned in West Africa by the attempts of colonial governments to curtail or ban importation of European distilled drinks like gin and whiskey that had been a feature of the area since the transatlantic slave trade. In East and southern Africa, distillation techniques were often introduced by worldly-wise returning soldiers or contract laborers who appreciated the get-drunk-quickly quality of the beverages produced. This occurred despite the dangers of producing alcohol with sometimes suspect ingredients and relatively primitive equipment that, under the pressurized conditions of the distilling process, was liable to explode. The production of distilled drinks was generally banned in rural and urban areas on health and safety grounds.
The colonial state had a strong fiscal interest in alcohol, dating back to early colonial penetration. In Nigeria, import duties on alcohol provided about half of the state's fiscal revenue. Gradually, domestic alcohol production displaced imports, and other forms of liquor taxation had to be devised. The difficulty of licensing and collecting taxes from alcohol producers in the ubiquitous informal sector led some governments to embark on state production. Interventionist states, notably those of southern Africa, favored the erection of production and distribution monopolies. The South African beer hall became a model for urban beer distribution in the region during the first half of the twentieth century. Revenues were used by the state to finance the building of the apartheid urban infrastructure in the name of African welfare.
In connection with this move, governments embarked on production of officially authorized brews. To ensure the market for their product, the state outlawed local cottage alcohol production, subjecting women brewers and distillers to campaigns of harassment. The aim was to produce a beer that African drinkers, particularly male laborers in urban areas and mining compounds, would be willing to drink, but that had a relatively low alcohol content and was nutritious like home brews. South Africa pioneered this effort, and other southern African colonies followed. By contrast, in Francophone Africa the manufacture of beer by private enterprises was more pronounced.
Over time, the heavy drinking patterns of southern African waged laborers, first cultivated then repressed by state and market forces, coalesced into a drinking subculture with its own momentum. In South Africa, a strong temperance movement supported by an emerging class of Christianized, educated Africans emerged in the early twentieth century in reaction to it. Middle-class black township women in Johannesburg voiced concern about the association between male drinking and the role of "lower-class" women brewers and prostitutes.
In the twilight years of colonial rule, the racist basis of the colonial divisions of labor and leisure were increasingly challenged. Resistance to state regulatory control of alcohol surfaced. In northern Rhodesia, the beer hall boycotts of the 1950s made alcohol an overt political issue. As nationalist pressures mounted, bans on Africans drinking "European liquor" were lifted in one colony after another.
A political victory for African nationalism, the consumption of nontraditional manufactured drinks was also an economic victory for the embryonic African elite, catalyzing conspicuous consumption, which marked the line between the rapidly rising affluence of the civil service cadre and the rest of the population. National independence had arrived with alcohol production and consumption patterns taking on new contours of African self-determination.
Akyeampong, Emmanuel K. Drink, Power, and Cultural Change: A Social History of Alcohol in Ghana, c. 1800 to Recent Times. Oxford: James Currey, 1996.
Ambler, Charles. "Alcohol, Racial Segregation, and Popular Politics in Northern Rhodesia." Journal of African History 31 (1990): 295-313.
Ambler, Charles, and Jonathan Crush, eds. "Alcohol in Southern African Labor History." In Liquor and Labor in Southern Africa, 1-55. Athens: Ohio University Press, 1992.
Bryceson, Deborah F. Food Insecurity and the Social Division of Labour. London: Macmillan, 1990.
Bryceson, Deborah F. "Changing Modalities of Alcohol Usage." In Alcohol in Africa: Mixing Business, Pleasure, and Politics, edited by Deborah F. Bryceson, 23-52. Portsmouth, NH: Heinemann, 2002.
Dumett, R. E. "The Social Impact of the European Liquor Trade on the Akan of Ghana (Gold Coast and Asante), 1875–1910." Journal of Interdisciplinary History 5 (1) (1974): 69-101.
Gewald, Jan-Bart. "Diluting Drinks and Deepening Discontent: Colonial Liquor Controls and Public Resistance in Windhoek, Namibia." In Alcohol in Africa: Mixing Business, Pleasure, and Politics, edited by Deborah F. Bryceson, 117-138. Portsmouth, NH: Heinemann, 2002.
Hair, P. E. H., Adam Jones, Robin Law, eds. Barbot on Guinea: The Writings of Jean Barbot on West Africa, 1678–1712. London: Hakluyt Society, 1992.
Heap, Simon. "'We Think Prohibition is a Farce': Drinking in the Alcohol-Prohibited Zone of Colonial Northern Nigeria." International Journal of African Historical Studies 31 (1) (1998): 23-51.
Heap, Simon. "Living on the Proceeds of a Grog Shop: Liquor Revenue in Nigeria." In Alcohol in Africa: Mixing Business, Pleasure, and Politics, edited by Deborah F. Bryceson, 139-159. Portsmouth, NH: Heinemann, 2002.
Karp, Ivan. "Beer Drinking and Social Experience in an African Society: An Essay in Formal Sociology." In Explorations in African Systems of Thought, edited by Ivan Karp and Charles S. Bird, 83-119. Bloomington: Indiana University Press, 1980.
La Hausse, Paul. Brewers, Beerhalls, and Boycotts: A History of Liquor in South Africa. Johannesburg, South Africa: Ravan Press, 1988.
Molamu, Louis, and Winnie G. Manyeneng. Alcohol Use and Abuse in Botswana: Report of a Study. Gaborone, Botswana: Health Education Unit, 1988.
Pan, Lynn. Alcohol in Colonial Africa. Helsinki, Finland: Finnish Foundation for Alcohol Studies, 1975.
van Onselen, Charles. "Randlords and Rotgut, 1886–1905: An Essay on the Role of Alcohol in the Development of European Imperialism and South African Capitalism." History Workshop Journal 2 (1976): 32-89.
Willis, Justin. Potent Brews: A Social History of Alcohol in East Africa, 1850–1999. Oxford: James Currey, 2002.
ALCOHOL. The word "alcohol" is derived from the Arabic word al kuhul, meaning 'essence'. The favorite mood-altering drug in the United States, as in almost every human society, continues to be alcohol. One of the reasons for the significant use of alcohol and its health impact is its feature of being (along with nicotine) a legally available drug of abuse and dependence.
Our knowledge of alcohol rests on a heritage of myth and speculation. Many health benefits have been attributed to alcohol by ancient healers who saw ethanol as the elixir of life, but almost none of its positive benefits have stood the test of time. Alcoholic beverages have been revered, more than any other substance, as mystical and medicinal agents. In recent years, however, we have stripped away much of the mystery surrounding alcohol and now recognize it as a drug with distinct pharmacological effects. However, one of the reasons that beverages containing alcohol continue to be consumed is related to the folklore and history that surround its many combinations with other flavors and its many sources of fermentation and distillation.
Today one thinks of alcohol and alcoholic spirits as being synonymous, yet to a chemist an alcohol is any of an entire class of organic compounds containing a hydroxyl (OH) group or groups. The first member of its class, methyl alcohol or methanol, is used commercially as a solvent. Isopropyl alcohol, also known as rubbing alcohol, serves as a drying agent and disinfectant. Ethyl alcohol or ethanol shares these functions but differs from other alcohols in also being suitable as a beverage ingredient and intoxicant. Ethanol also differs from other alcohols in being a palatable source of energy and euphoria. It is a small, un-ionized molecule that is completely miscible with water and also somewhat fat-soluble. The remainder of this article pertains to ethanol, but refers to it simply as alcohol.
Biology of Production
Making alcoholic beverages dates back at least eight thousand years; for example, beer was made from cereal mashes in Mesopotamia in 6000 b.c.e. and wine in Egypt in 3700 b.c.e.
Ethyl alcohol is actually a by-product of yeast metabolism. Yeast is a fungus that feeds on carbohydrates. Yeasts are present ubiquitously. For example, the white waxy surface of a grape is almost entirely composed of yeast. When, for example, the skin of a berry is broken, the yeast acts quickly and releases an enzyme that, under anaerobic conditions, converts the sugar (sucrose, C12H22O11) in the berry into carbon dioxide (CO2) and alcohol (C2H5OH). This process is known as fermentation (if the mixture is not protected from air, alcohol turns into acetic acid, producing vinegar). When cereal grains and potatoes are used, each requires a sprouting pretreatment (malting) to hydrolyze starch, during which diastase enzymes are produced that break down starches to simple sugars that the yeast, which lacks these enzymes, can anaerobically convert to alcohol. This process makes the sugar available for the fermentation process. The yeast then continues to feed on the sugar until it literally dies of acute alcohol intoxication.
Because yeast expires when the alcohol concentration reaches 12 to 15 percent, natural fermentation stops at this point. In beer, which is made of barley, rice, corn, and other cereals, the fermentation process is artificially halted somewhere between 3 and 6 percent alcohol. Table wine contains between 10 and 14 percent alcohol, the limit of yeast's alcohol tolerance. This amount is insufficient for complete preservation, and thus a mild pasteurization is applied.
Distillation, which was discovered about 800 C.E.in Arabia, is the man-made process designed to take over where the vulnerable yeast fungus leaves off. The distilled, or hard, liquors, including brandy, gin, whiskey, scotch, bourbon, rum, and vodka, contain between 40 and 75 percent pure alcohol. Dry wines result when nearly all the available sugar is fermented. Sweet wines still have unfermented sugar. Pure alcohol also is added to fortify wines such as port and sherry. This addition boosts their percentage of alcohol to 18 or 20 percent (such wines do not require further pasteurization). "Still wines" are bottled after complete fermentation takes place. Sparkling wines are bottled before fermentation is complete so that the formed CO2 is retained. "White" wines are made only from the juice of the grapes; "reds" contain both the juice and pigments from skins.
The percentage of alcohol in distilled liquors commonly is expressed in degrees of "proof" rather than as a percentage of pure alcohol. This measure developed from the seventeenth-century English custom of "proving" an alcoholic drink was of sufficient strength. This was accomplished by mixing it with gunpowder and attempting to ignite it. If the drink contained 49 percent alcohol by weight (or 57 percent by volume), it could be ignited. Thus, proof is approximately double the percentage of pure alcohol (an 86 proof whiskey is 43 percent pure alcohol).
Pure alcohol is a colorless, somewhat volatile liquid with a harsh, burning taste, which is used widely as a fuel or as a solvent for various fats, oils, and resins. This simple and unpalatable chemical is made to look, taste, and smell appetizing by combining it with water and various substances called congeners (pharmacologically active molecules other than ethanol, including higher alcohols and benzene). Congeners make bourbon whiskey taste different from Scotch whiskey, distinguish one brand of beer from another, give wine its "nose" and sherry its golden glow. In trace amounts, most congeners are harmless, but their consumption has been linked to the severity of hangovers and other central nervous system symptoms that include sleepiness.
Use in Food Products
Wines, liqueurs, and distilled spirits are used to prepare main dishes, sauces, and desserts, creating new and interesting flavors. The presence of alcohol in significant amounts affects the energy value of a food. Alcohol is rich in energy (29 kJ/g, or 7.1 kcal/g). It is assumed that, because of its low boiling point, alcohol is evaporated from foods during cooking. However, almost 4 to 85 percent of alcohol can be retained in foods. Foods that require heating for prolonged periods (over two hours—for example, pot roast), retain about 4–6 percent; foods like sauces (where alcohol is typically added after the sauce has been brought to a boil) may retain as much as 85 percent.
Alcohol and Malnutrition
Alcoholism is a major cause of malnutrition. The reasons are threefold. First, alcohol interferes with central mechanisms that regulate food intake and causes food intake decreases. Second, alcohol is rich in energy (7.1 kcal/g), and like pure sugar most alcoholic beverages are relatively empty of nutrients. Increasing amounts of alcohol ingested lead to the consumption of decreasing amounts of other foods, making the nutrient content of the diet inadequate, even if total energy intake is sufficient. Thus chronic alcohol abuse causes primary malnutrition by displacing other dietary nutrients. Third, gastrointestinal and liver complications associated with alcoholism also interfere with digestion, absorption, metabolism, and activation of nutrients, and thereby cause secondary malnutrition.
It is important to note that although ethanol is rich in energy, its chronic consumption does not produce the expected gain in body weight. This may be attributed, in part, to damaged mitochondria and the resulting poor coupling of oxidation of fat metabolically utilizable with energy production. The microsomal pathways that oxidize ethanol may be partially responsible. These pathways produce heat rather than adenosine triphosphate (ATP) and thereby fail to couple ethanol oxidation to useful energy-rich intermediates such as ATP. Thus, perhaps because of these energy considerations, alcoholics with higher total caloric intake do not experience expected weight gain despite physical activity levels similar to those of the non-alcohol-consuming overweight population.
Absorption and Metabolism
Unlike foods, which require time for digestion, alcohol needs no digestion and is absorbed quickly. The presence of food in the stomach delays emptying, slowing absorption that occurs mainly in the upper small intestine.
Only 2 to 10 percent of absorbed ethanol is eliminated through the kidneys and lungs; the rest is metabolized, principally in the liver. A small amount of ethanol also is metabolized by gastric alcohol dehydrogenase (ADH) [first-pass metabolism (FPM)]. This FPM explains why, for any given dose of ethanol, blood levels are usually higher after an intravenous dose than following a similar amount taken orally. FPM is partly lost in the alcoholic.This lost function is due to decreased gastric ADH activity. Premenopausal women also have less of this gastric enzyme than do men. This difference partially explains why women become more intoxicated than men when each consume similar amounts of alcohol.
Hepatocytes are the primary cells that oxidize alcohol at significant rates. This hepatic specificity for ethanol oxidation, coupled with ethanol's high energy content and the lack of effective feedback control of alcohol hepatic metabolism, results in the displacement of up to 90 percent of the liver's normal metabolic substrates.
Oxidation. Hepatocytes contain three main pathways for ethanol metabolism. Each pathway is localized to a different subcellular compartment: (1) the alcohol dehydrogenase (ADH) pathway (soluble fraction of the cell); (2) the microsomal ethanol oxidizing system (MEOS) located in the endoplasmic reticulum; and (3) catalase located in the peroxisomes. Each of these pathways produces specific toxic and nontoxic metabolites. All three result in the production of acetaldehyde (CH3CHO), a highly toxic metabolite. The MEOS may account for up to 40 percent of ethanol oxidation. Normally, the role of catalase is small. It is not discussed further here.
- The ADH pathway. The oxidation of ethanol by the ADH results in the production of acetaldehyde (CH3CHO) and the transformation of nicotinamide adenine dinucleotide (NAD) to nicotinamide adenine dinucleotide-reduced form (NADH). Substantial levels of acetaldehyde can result in skin flushing. Regeneration of NAD from NADH is the rate-limiting step in this ADH pathway of alcohol metabolism. It can metabolize approximately 13 to 14 grams of ethanol per hour (the amount in a typical drink). This rate is observed when blood alcohol concentrations reach 10 mg/dL. The large amounts of reducing equivalents that are generated by the alcohol oxidation overwhelm the hepatocyte's ability to maintain homeostasis and as a consequence a number of metabolic abnormalities ensue. Increased NADH, the primary form of reducing equivalents, promotes fatty acid synthesis, opposes lipid oxidation, and results in fat accumulation.
- MEOS. This pathway also converts a portion of ethanol to acetaldehyde. Cytochrome P4502E1 (CYP2E1) is the responsible enzyme. As other microsomal oxidizing systems, this system also is inducible, that is, it increases in activity in the presence of large amounts of the target substrate. This induction contributes to the metabolic tolerance to ethanol that develops in alcoholics. This tolerance, however, should not be confused with protection against alcohol's toxic effects. It is important to note that, even though larger amounts of alcohol may be metabolized by individuals when this capability has been induced fully, most of alcohol's harmful effects remain unabated.
Physiological Effects at Different Levels
Beneficial effects. A large variety of alcoholic beverages are available, and most people can find at least one that provides gustatory and other pleasures. Alcohol is said to reduce tension, fatigue, anxiety, and pressure and to increase feelings associated with relaxation. It also has been claimed that drinking in moderation may lower the risk of coronary heart disease (mainly among men over 45 and women over age 55), but whether that putative protection is due primarily to the alcohol or some other associated factors, such as lifestyle, remains controversial. Moderate alcohol consumption provides no health benefit for younger people, and in fact may increase risks to alcohol's ill effects because the potential for alcohol abuse increases when drinking starts at an early age.
Harmful effects. The problems of individuals who occasionally become drunk differ from those who experience drinking binges at regular intervals.
"Acute" harmful effects of alcohol intoxication: Occasional excess drinking can cause nausea, vomiting, and hangovers (especially in inexperienced drinkers). The acute neurological effects of alcohol intoxication are dose-related. These progress from euphoria, relief from anxiety, and removal of inhibitions to ataxia, impaired vision, judgment, reasoning, and muscle control. When alcohol intakes continue after the appearance of these signs and symptoms, progress to lethal levels occurs very quickly, resulting in the anesthetization of the brain's circulatory and respiratory centers.
"Chronic" harmful effects of alcohol excess: Chronic excessive alcohol consumption can affect adversely virtually all tissues. Alcoholics have a mortality and suicide rate 2½ times greater, and an accident rate 7 times greater than average. Some of the dire consequences that are associated with alcohol abuse are:
- Cardiovascular problems. Alcohol causes vasodilation of peripheral vessels (causing flushing), vasoconstriction (producing resistance to the flow of blood and increasing work load on the heart) and alcoholic cardiomyopathy (characterized by myocardial fiber hypertrophy, fibrosis, and congestive heart failure).
- Cancer. Alcohol increases the risk of alimentary, respiratory tract, and breast cancers.
- Liver disease. Alcohol can result in fatty liver, hepatitis, and cirrhosis.
- Central nervous system disorders. Alcohol causes premature aging of the brain. Blackouts may occur (for example, those affected walk, talk, and act normally and appear to be aware of what is happening, yet later have no recollection of events experienced during the blackout).
- Gastrointestinal disorders. Alcohol increases risk of esophageal varices, gastritis, and pancreatitis.
- Metabolic alterations. Alcohol increases nutritional deficiencies (primary and secondary), and adversely affects absorption and utilization of vitamins. It impairs the intestinal absorption of B vitamins, notably thiamin, folate, and vitamin B12. Wernicke's encephalopathy also may occur. This condition is the result of severe thiamine deficiency. It is characterized by visual disorders, ataxia, confusion, and coma.
- Immunological disorders. Alcohol decreases immunity to infections and impairs healing of injuries.
- Others. Alcohol causes personality changes, sexual frigidity or impotency, sleep disturbances, and depression.
There are two major approaches that are used in the treatment of alcohol abuse: (1) correction of the medical, nutritional, and psychological problems; and (2) the alleviation of dependency on alcohol. Many sedatives or tranquilizers (for example, chlordiazepoxide) are effective in controlling minor withdrawal symptoms such as tremors. More serious symptoms include delirium tremens and seizures. For treatment of alcohol dependence, the anticraving agent naltrexone has shown promising results. Nutritional deficiency, such as lack of thiamine or magnesium, when present, must be corrected. Psychological approaches such as the twelve steps of Alcoholics Anonymous are also effective in achieving more sustained abstinence. These approaches, although helpful, too often come too late to revert the liver to its normal state. Other approaches, such as those focusing on prevention (utilizing biochemical markers), screening (through use of improved blood tests), and early detection are needed to impact on the prevalence of liver disease. The correction of nutritional deficiencies and supplementation with other substrates that may be produced in abnormally low quantities by affected patients, for example, S -adenosylmethionine (SAMe) and polyunsaturated lecithin have been shown to offset some of the adverse manifestations of alcohol's toxic effects. These and others are now being tested in humans.
Alcoholism, an addiction to heavy and frequent alcohol consumption, is a major public health issue. However, many believe that this condition does not attract attention that it merits from either the public or the health professions. Alcoholism is a multifaceted problem that cannot be solved by any single approach. The "consumption control approach" is a worthwhile endeavor with proven efficacy, but consumption control efforts by themselves are not sufficient. Prevention of alcohol misuse before it occurs also can be beneficial. Another prevention strategy includes establishing standards and guidelines for advertising and emphasizing responsibility and moderation in the serving and consumption of alcohol. "Behavioral" approaches focus on recognition of social and psychological factors and their correction. Finally, the "disease-control" approach provides new insights. Continued research into the pathophysiology of alcohol-induced disorders increases understanding of the condition and provides prospects of earlier recognition, and improved efforts for its early prevention and treatment, prior to the medical and social disintegration of its victims. By combining all of these approaches, chances to alleviate the suffering of the alcoholic are multiplied in a positively synergistic manner and the public health impact of alcoholism on our society can be minimized.
See also Beer; Fermentation; Fermented Beverages Other than Wine or Beer; Nutrients; Nutrition; Wine.
Lieber, Charles S. Medical and Nutritional Complications of Alcoholism: Mechanisms and Management. New York: Plenum, 1992.
Lieber, Charles S. "Medical Disorders of Alcoholism." New England Journal of Medicine 333 (1995): 1058–1065.
Lieber, Charles S. "Alcohol: Its Metabolism and Interaction with Nutrients." Annual Reviews in Nutrition 20 (2000): 395–430.
Khursheed P. Navder Charles S. Lieber
Alcohol is any carbon-hydrogen compound with at least one hydroxyl group (symbolized as–OH) in its molecular structure. Categorized by the number and placement of the–OH groups, and the size and shape of the attached carbon molecule, alcohols are fundamental to organic chemical synthesis. The chemical industry produces and uses many different kinds of alcohols.
Techniques for producing beer and wine, the first alcoholic beverages, were developed millennia ago by various Middle Eastern and Far Eastern cultures. Even the word alcohol is of Arabic derivation. Ancient Egyptian papyrus scrolls gave directions for making beer from dates and other plant foods. These beverages contained ethyl alcohol, since pure alcohol could not be made at that time; it was always mixed with the water, flavorings, and plant residue from the original fermentation. Almost all ethanol produced was used for drinking.
Fermentation, the oldest kind of alcohol production and possibly the oldest chemical technology in the world, is the action of yeast on sugars in solution. When fruits, vegetables, honey, molasses, or grains such as barley are mashed up in water, the yeast’s metabolism of the sugars produces ethanol as a byproduct. Wood and starches can also be fermented, although their complex molecules must be broken down somewhat first. They always give small amounts of other larger alcohols (collectively called fusel oil) in addition to ethanol.
The process of distillation was discovered sometime after the first century AD. Purer ethanol distilled from crude fermentation mixtures was then available for consumption, medicinal, and chemical uses. In 1923 the first industrial process for generating methanol was developed; since then many different alcohols have been made by direct chemical synthesis (the production of complex chemical compounds from simpler ones).
The formal name of an alcohol tells the number of hydroxyl (–OH) groups and the number of carbon atoms in the molecule, the names of any other atoms, and the attachment of the atoms in the molecule. Most simple alcohols end with the —ol suffix, added to the name of the molecule that had the same number of
carbon atoms, but with a hydrogen atom in place of the hydroxyl group. Methanol, for example, has one carbon atom (like methane) and one hydroxyl group. Ethanol has two carbon atoms (like ethane) and one hydroxyl group. Two isomers of propanol exist (1-propanol and 2-propanol) because the hydroxyl group can be attached either at the end or in the middle of the three-carbon atom chain. Rubbing alcohol (also called isopropanol or isopropyl alcohol) contains mostly 2-propanol.
As the number of carbon atoms increases, the alcohol’s solubility in water decreases. But as the number of hydroxyl groups grows, the solubility increases, as does its boiling point. Alcohols with two hydroxyl groups on adjacent carbon atoms are called glycols or diols. Ethylene glycol’s properties of high water solubility, high boiling point, and low freezing point make it a good antifreeze for cars. These characteristics are due to the hydrogen bonding making the glycol associate firmly with water. Alcohols with more than three hydroxyl groups are called polyols. The sweetener sorbitol, often found in packaged baked goods and sugar-free gum, is a polyol with six carbon atoms and six hydroxyl groups in its molecules.
Most alcohols burn in air, a quality that makes ethanol a fuel additive. Methanol can sometimes be used as a fuel, though it evaporates too quickly for regular use in cars. Isopropyl alcohol is widely used in industry as a paint solvent and in chemical processes. In addition to its presence in alcoholic beverages, ethanol also is used as a solvent for food extracts such as vanilla, perfumes, and some types of paints and lacquers. Some alcohols can be ingested, although methanol is extremely toxic, and even ethanol is poisonous in large quantities. Glycerol, an alcohol with three carbon atoms and three hydroxyl groups in its molecules, has very low toxicity. It also possesses good moisturizing properties; about 50% of the amount produced goes into foods and cosmetics.
Almost any organic chemical can form with the smaller alcohols, so both methanol and ethanol are in the top 50 industrial chemicals in the United States. Methanol is particularly important in the synthesis of organic chemicals such as formaldehyde (used to make various polymers), methyl-tert-butyl ether (the octane enhancer that replaced lead in gasoline), acetic acid, and synthetic gasoline, though this use has not yet become common.
Alcohols are produced industrially from petroleum, coal, or other natural products. The “cracking” of crude petroleum yields many lower-molecule-weight chemical compounds, including some starting materials for alcohols such as ethylene and propylene. Ethylene reacts with hot steam over a catalyst to yield ethanol directly. A process known as hydration produces isopropyl alcohol when water is chemically added to propylene.
When “gasified,” (heated to a high temperature with very little oxygen) coal and other carbon-based compounds yield a mixture of hydrogen gas and carbon monoxide called synthesis gas, an important starting material for a variety of low- or high-molecular-weight alcohols. Methanol is now made almost entirely from synthesis gas. Before direct chemical synthesis was available, methanol was produced by the destructive distillation of wood (hence its older name, wood alcohol). Wood heated to a high temperature without air does not burn in the regular sense but decomposes into a large number of different
Alcohol— Any of the large number of molecules containing a hydroxyl (–OH) group bonded to a carbon atom to which only other carbon atoms or hydrogen atoms are bonded.
Azeotrope— A liquid mixture of substances that distill together at the same boiling temperature, instead of separately.
Destructive distillation— An antiquated process for obtaining small amounts of alcohols, particularly methanol, from wood. The wood, heated to a high temperature in the absence of air, gradually decomposes into a large number of chemicals.
Distillation— Collecting and condensing the vapor from a boiling solution. Each distinct volatile chemical compound boils off individually at a specific temperature, so distillation is a way of purifying the volatile compounds in a mixture.
Ester— A molecule with a carbon both bonded to an ether linkage (carbon-oxygen-carbon), and double bonded to an oxygen.
Fermentation— The action of yeast metabolism on sugar solutions, which produces ethanol and carbon dioxide.
Glycol— An alcohol with two hydroxyl groups bonded to adjacent carbons in the molecule. Also called a diol.
Hydroxyl group— The–OH group attached to a carbon atom in a molecule. If the carbon atom itself is attached to only other carbon atoms or hydrogen atoms, the molecule is an alcohol.
Polyol— An alcohol with many hydroxyl groups bonded to the carbon atom backbone of the molecule.
Synthesis gas— A mixture of carbon monoxide and hydrogen gases, obtainable both from coal and natural gas, and used widely for the synthesis of alcohols and other organic compounds in the chemical industry.
chemicals, of which methanol and some other alcohols are a small fraction.
Distilling the ethanol from fermentation products gives a mixture of 95% ethanol and 5% water, resulting in an azeotrope: a liquid composed of two chemicals that distill together instead of separating at their different boiling temperatures. Most industrial ethanol is 95% alcohol unless there is specific need for very dry ethanol.
The plastics industry is a major consumer of all types of alcohols, because they are intermediates in a large variety of polymer syntheses. The hydroxyl group makes the alcohol molecule relatively reactive and thus useful in synthesis. Important esters made from ethanol include the insecticide malathion, the fragrance compound ethyl cinnamate, and the polymer building blocks ethyl acrylate and ethyl methacry-late. Esters made from methanol include methyl salicylate (oil of wintergreen), the perfume ingredients methyl paraben and methyl benzoate, and the polymer starting material methyl acrylate. High-molecule-weight alcohols converted into esters are widely used in the polymer industry as plasticizers, and very high-molecule-weight alcohols with 12-18 carbon atoms are used to make biodegradable surfactants (detergents).
Alcohols can also be oxidized. If the hydroxyl group is at the end of a carbon atom chain, an oxidation reaction produces either a carboxylic acid or an aldehyde. If the hydroxyl group is in the middle of a straight carbon atom chain, it produces a ketone. An alcohol whose hydroxyl group is attached to a carbon atom that also has three other carbon branches attached to it cannot be oxidized.
Alcohols can also be dehydrated to form double bonds in hydrocarbons. Adding acid to the alcohol removes not only the hydroxyl group, but a hydrogen atom from an adjacent carbon atom as well. The reaction is called a dehydration, because H–O–H (water) is removed from the molecule and a double bond forms between the two carbon atoms.
Bailey, James E. Ullmann’s Encyclopedia of Industrial Chemistry. New York: VCH, 2003.
Bruice, Paula. Organic Chemistry. 3rd ed. Englewood Cliffs, NJ: Prentice-Hall, 2001.
Meyers, Robert A. Encyclopedia of Analytical Chemistry: Applications, Theory and Instrumentation. New York: John Wiley & Sons, 2000.
Gail B. C. Marsella