Alcohol Proseminar Fall, 2002
Address to the legislature by a Mississippi state senator in 1958. You have asked me how I feel about whisky. All right, here is just how I stand on this question: If, when you say whisky, you mean the devil's brew, the poison scourge, the bloody monster that defiles innocence, yea, literally takes the bread from the mouths of little children; if you mean the evil drink that topples the Christian man and woman from the pinnacles of righteous, gracious living into the bottomless pit of degradation and despair, shame and helplessness, then certainly I am against it with all my power.
But, if you when you say whisky, you mean the oil of conversation, the philosophic wine, the stuff that is consumed when good fellows get together, that puts a song in their hearts and laughter on their lips and the warm glow of contentment in their eyes; if you mean Christmas cheer, if you mean the stimulating drink that puts the spring in the old gentleman's step on a frosty morning, if you mean the drink that enables a man to magnify his joy, and his happiness, and to forget, if only for a little while, life's great tragedies and heartbreaks and sorrows,
if you mean that drink, the sale of which pours into our treasuries untold millions of dollars, which are used to provide tender care for our little crippled children, our blind, our deaf, our dumb, our pitiful aged and infirm, to build highways, hospitals, and schools, then certainly I am in favor of it. This is my stand, I will not retreat from it; I will not compromise.
Period Up to 1906 1907–1913 1914–1918 1917 January 1918 January 1919 Status 3 Prohibition States 23 Prohibition States (17 by referenda) 48 Prohibition States (25 new referenda; 16 < war) 18th Amendment introduced Ratified by Congress U.S. Prohibition Effective Prohibition: Legislative Summary Source: Moore & Gerstein, 1981
Repeal: Alcohol Control • 1932: Roosevelt campaigns for repeal of 18th Amendment • December 1933: 21st Amendment (Repeal) ratified by 35 states • Alcohol Control becomes “a pivotal idea” in post-Repeal era Federal • regulate production of spirits, wine & beer (curb illegal production) • manage product purity and labeling; impose excise taxes • Authority with Department of Justice (ATF since 1972) State • Devolved Powers including dry option, retail monopolies, taxation • Alcoholic Beverage Control (ABC Laws) Sources: Levine 1980; Moore & Gerstein, 1981
Alcohol Warning Label(PL100-690, 1988) Federal law required health warning on container labels • Government warning from credible source: Surgeon General • Pregnant women should not drink : risk of birth defects • Impairs ability to drive a car or operate machinery and may cause health problems Major Results • By 1994, 60% drinkers reported exposure to label–curve flattening • Messages reach many but not all target groups, heavier drinkers; e.g., > 50% males 18-20 (drunk driving); > 65% drinkers 18-29 (pregnancy); may miss less educated and ethnic groups • Modest associations with precautionary behavior, conversations Sources: Greenfield & Kaskutas, 1998; Greenfield et al, 1999; Hankin et al, 1993
U.S. Support for Stronger Alcohol Policies % Room et al, 1995; Giesbrecht & Greenfield, 1999
Domains of Alcohol Involvement • Abstention vs. Drinking • Frequency of Consumption • Quantity of Consumption • Quantity-Frequency (Volume) • Volume Variability • Frequency of heavy consumption or drunkenness • “Risky” drinking
Domains of Alcohol Involvement(continued) • Alcohol-related problems (consequences, disabilities) • Alcohol dependence syndrome • Alcohol use disorders • Alcohol abuse • Alcohol dependence
Total Beer Spirits Wine
Relative Price of Alcoholic Beverages, 1970-1997 Relative Price, 1970 $ Sources: Mosher, 1997; Mosher & Cowan, 1985; Bureau of Labor Statistics, 1996
Abstention by Age, Sex and Race From NLAES, 1992
Concentration of U.S. Alcohol Consumption Greenfield TK & Rogers JD. J Stud Alcohol 60:78 (1999)
Hazardous U.S. Alcohol Consumption Rogers & Greenfield, 1999
Total Per Capita Consumption of Ethanol among Current Drinkers by State, United States, 1997
Quantity-Frequency • Frequency: Drinking days/year. • How often did you have a drink containing alcohol, that is beer, wine or liquor? • Quantity: Drinks per Drinking Day • About how many drinks would you have on average on a typical day when you drank? • Volume: (Drinking days/year X Drinks per drinking day)/days in a year = Drinks per day
Graduated QF Think of all kinds of alcoholic beverages combined, that is, any combination of cans of beer, glasses of wine, or drinks containing liquor of any kind. During the past 12 months, Start with largest amount drunk;what is the largest number ask frequency of consumingof drinks on a single day? successively lower amounts per day. •Was it 24 or more drinks on • Daily or nearly every day a single day? • 3 or 4 times a week • 12 to 23 drinks on a single day? • Once or twice a week • 8-11? • 2 or 3 times a month • 5-7? • Once a month • 3-4? • 11-3 times in the past year • 1-2? • Twice in the past year • No drinks • Once in the past year • Never
Drinking Pattern Questionnaire--DPQ 1. On Fridays during a typical month, how often did you drink - every Friday, three Fridays, two Fridays, one Friday, or hardly ever on Fridays? 2. How many drinks would you usually have on a Friday? 3. Repeat for Saturday, Sunday, and weekdays. 4. Were there days when you had more than your usual in the past 12 months? 5. If yes, what did you typically drink and how often.? 6. Proportion of time you drank with a meal, while snacking, or without eating anything. 7. Did you ever drink enough to get drunk or very high, that is, your speech was slurred or you were unsteady on your feet? 8. If yes, how often did you drink enough to get drunk or very high?
Heavy Drinking* by Age, Sex, and Race From NLAES, 1992, *> 1 oz. ethanol per day
Drinking Volume Partitioned by 6 Contexts TOTAL HAZARDOUS 37% 1984 & 1995 National Alcohol Surveys; Clark, 1988; Greenfield et al, 2000
Hispanics, Abstention and Heavy Drinking by Gender and Country of Origin, United States, 1984. Abstention Heavy Drinking* *Drinks at least once a week and has five or more at a sitting at least once a year.
Asian-Americans: Abstention and Heavy Drinking by Gender and Country of Origin, Los Angeles, 1980s. Abstention Heavy Drinking* *Drinks at least once a week and has five or more at a sitting at least once a year.
Drinking Patterns of Japanese in Japan, Japanese-Americans in Hawaii, and Japanese-Americans in Santa Clara, California, 1988. Abstention Heavy Drinking
DSM-IV Alcohol Abuse A person's maladaptive alcohol use causes clinically important distress or impairment, as shown in a single 12-month period by one or more of the following: • failure to carry out major obligations at work, home, or school because of repeated alcohol use, • repeated use of alcohol even when it is physically dangerous to do so, • repeated experience of legal problems, or • continued use of alcohol despite knowing that it has caused or worsened social or interpersonal problems.
DSM-IV Alcohol Dependence A person's maladaptive pattern of alcohol use leads to clinically important distress or impairment, as shown in a single 12-month period by three or more of the following: • tolerance; • withdrawal; • amount or duration of use often greater than intended; • repeatedly trying without success to control or reduce alcohol use; • spending much time using alcohol, recovering from its effects, or trying to obtain it; • reducing or abandoning important work, social, or leisure activities because of alcohol use; or • continuing to use alcohol, despite knowing that it has probably caused ongoing physical or psychological problems.
1992 National Longitudinal Alcohol Epidemiology Survey (NLAES) • Only 10% of the U.S. adult population currently abusing or dependent on alcohol had received any treatment in the 12 months prior to interview. • Only 28% of individuals with a past diagnosis of alcohol dependence reported ever having any kind of alcohol treatment. • 75% of the people who recovered from a previous alcohol disorder did so without having received any treatment, often termed “natural recovery.”
Core Medical Expenditures:$10.5 Billion Specialty organizations (33%) Short-stay hospitals (44%) Nursing homes (10%) Support & Other (13%) Indirect:$70.3 Billion Morbidity (52%) Mortality (48%) Other Alcohol-related Costs:$15.8 Billion Crime (36%) Victims of crime (3%) Incarceration (30%) Motor vehicle crashes (24%) Fire destruction (4%) Social welfare administration (1%) Fetal Alcohol Syndrome:$2.1 Billion Total: $98.6 Billion Costs of Alcohol Abuse to the Nation - 1990 Rice, 1993; NIAAA, Alcohol & Health, 1997
Percent distribution of principal (first-listed) diagnoses among discharges with any (all-listed) mention of an alcohol-related diagnosis, 1997
Trends in percent of discharges with principal (first-listed) or any (all-listed) mention of an alcohol-related diagnosis among all discharges, 1979-97
The influence of alcohol on morbidity and mortality: Alcohol-Attributable Fractions (AAF) AAF Age Causes of death directly attributable to alcohol 1.0 >15 Diseases indirectly attributable to alcoholCancer of the esophagus 0.75 > 35Acute pancreatitis 0.42 > 35 Injuries and adverse effects indirectly attributable to alcoholMotor vehicle traffic and non-traffic deaths 0.42 > 0Suicide and self-inflicted injury 0.28 > 15Homicide and injury purposefully inflicted by others 0.46 > 15 Source: Stinson, F.S., and DeBakey, S.F., Alcohol-related mortality in the United States, 1979-1988, Brit. J. Addict. 87:777-783, 1992.
Death Rates and Premature Mortality by Years of Potential Life Lost (YPLL), 1980. Percent ofPercent of YPLL Deaths Accidents, adverse effects 26.8 5.2 Suicides, homicides 14.0 2.5 Chronic liver disease, cirrhosis 3.0 1.7 Malignant neoplasms (CA) 18.0 21.9 Diseases of heart (CHD) 16.4 37.5 Cerebrovascular disease (CVD) 2.8 8.3
Age-adjusted death rates of liver cirrhosis by sex (death registration States, 1910-32, and United States, 1933-96)
Reductions in Problems During Prohibition Source: Moore & Gerstein, 1981
Total and alcohol-related traffic fatality rates per 100 million vehicle miles traveled (VMT), United States, 1977-97
What We’ll Be Doing This Semester • Learning about various aspects of alcohol use, consequences, and dependence • Epidemiology • Assessment • Neurobiology • Genetics • Comorbidity • Personality and Motivation • Treatment • Prevention
What We’ll Be Doing This Semester (cont’d) • Getting training in various aspects of alcohol research • Learning about other forms of substance use, abuse, and dependence • Have a chance to hear from a variety of scientists and clinicians with various perspectives on alcohol research
Alcohol Policies: Levels, Types, Issues Jurisdictional Level • Federal, state, county, municipal (or local community) Type • Taxation/pricing, access, advertising, transportation, etc. • Legally based policies, enforcement, and justice system • Institutional policies (e.g., schools, workplace, military) • Health services and public health measures • Science priorities and research policies Issues • Studies of policy making, policy analysis • Evidentiary basis of policies and the role of science
Prevention Policies “They are all policies that operate in a non- personalized way to alter the set of contingencies affecting individuals as they drink or engage in activities that (when combined with intoxication) are considered risky.” Moore & Gerstein (1981), p 53 Beyond the Shadow of Prohibition
Controversy in Optimal Policy Approaches • Single Distribution Theory (Ledermann Theory) Posits that a substantial decrease in a population’s mean (or per capita) consumption will be accompanied by a decrease in the prevalence of heavy drinkers • Harm Reduction: Abates hazardous drinking patterns Attention is less on trying to modify everyone’s drinking, be it light or heavy, and more on policy measures targeting heavy quantity per occasion drinking patterns Sources: Skog, 1985; Edwards et al, 1994; Rehm et al, 1996; Stockwell et al, 1997
Concentration of U.S. Alcohol Consumption Greenfield & Rogers, 1999
Economic costs of alcohol abuse by type, 1990 U.S. Data (e.g., medical) (e.g., crime, crashes) Rice, 1993; NIAAA, Alcohol & Health, 1997
Jurisdictional Levels: Example Policies Federal • Excise taxes • Transportation (e.g., Minimum Drinking Age, aviation) • Commercial regulation, labeling, advertising • Federal agencies: NIAAA, SAMHSA, CDC, USDA, FTC, ATF, etc. State • State alcohol taxes • Access: alcohol distribution systems, State ABCs, retail monopolies, local options, regulating outlets, labeling, etc. • Server licensing, training, dram shop or server liability • Drinking driver laws: mandatory license actions, treatment,etc.
Price and Taxation Policies Studies at both federal and state levels show: • generally significant price effect on consumption • heavier drinkers are as or more affected than light ones • some studies have found affects on population-level problem indicators: cirrhosis mortality, vehicular crashes • not particularly regressive tax measure compared to other commodity taxes—there is a lower burden on the poor • supported by public health experts, anathema to industry Sources: Coate & Grossman, 1988; Babor et al, 1978; Cook & Tauchen, 1982; Edwards et al, 1994
Drinking Driving Legislative Policies Minimum Drinking Age (MDA) • Federal law required 21 year old MDA for states to receive national highway funds; created incentive • By mid 1980’s all states adopted uniform MDA of 21 • Changes before and after federal law provide natural experiments: most studies found reductions in indicators 1987 GAO Review • Reviewed 32 studies; 14 deemed methodologically sound • Found reductions of from 5 to 28% in drivers under 21 • Conclusion: Sound scientific evidence for effectiveness of MDA policy Sources: Moore & Gerstein, 1981; Edwards et al, 1994
U.S. Adults Seeing Warning Label, 1993 Weighted percentages of subgroup. Source: Greenfield, 1994; Greenfield, 1997
Alcohol Access Regulation Access primarily regulated at state and local levels • Responsibility of State Alcoholic Beverage Control agency Monopoly States • By 2 years after Repeal, 15 states enacted retail monopolies • 1980’s saw increasing deregulatory pressure with privatization of wine sales in Idaho, Maine, Virginia, and Washington (3 of 4 showed increased wine consumption); also Iowa, W. Virginia • Iowa and West Virginia case studied separately: significant increase in wine consumption and net increase in ETOH Sources: Wagenaar & Holder, 1991; Edwards et al, 1994; Holder & Wagenaar, 1990.