CHAPTER 3
ALCOHOL—WHAT IT IS AND WHAT IT DOES

Contrary to popular belief, ethanol (the alcohol in alcoholic beverages) is not a stimulant; it is 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 fourteen grams (about 0.6 fluid ounces) of pure alcohol. The following beverages contain approximately 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 5-ounce glass of table wine
• One 3- to 4-oz. glass of fortified wine, such as sherry or port
• One 12-ounce bottle or can of beer
• One 8- to 9-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. It is legal, generally acceptable (in moderate amounts), readily available, and relatively inexpensive. 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.

Per Capita Consumption of Alcoholic Beverages

According to the Economic Research Service of the U.S. Department of Agriculture, the 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 remained somewhat stable since then. In 2003, the per capita consumption of alcoholic beverages was 25.1 gallons. Table 3.1 shows per capita consumption of alcoholic beverages since 1966 and also shows the per capita consumption of beer, wine, and distilled spirits.

Beer remained the most popular alcoholic beverage in 2003, being consumed at a rate of 21.6 gallons per person. Nonetheless, this level of consumption (also seen in 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 2003 per capita consumption of wine was 2.2 gallons and of distilled spirits (liquor) 1.3 gallons.

It is interesting to see how the level of consumption of alcoholic beverages compares with other beverages. As Table 3.2 shows, per capita consumption in 2003 of milk (21.6 gallons) was exactly the same as beer. That same year, the per capita consumption of coffee was 24.3 gallons—higher than either beer or milk. Bottled water has become a popular beverage in recent years. Per capita consumption increased from 17.4 gallons in 2000 to 22 gallons in 2003. Per capita consumption of carbonated soft drinks in 2003 topped consumption of all other drinks at 46.4 gallons.

A complex set of factors contributes to variations in alcohol use over individuals' 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 in the population over twelve years of age.

The Substance Abuse and Mental Health Services Administration (SAMHSA), in its 2003 National Survey on Drug Use and Health (released September 9, 2004), reported that 83.1% of the U.S. population twelve years of age and over had tried an alcoholic beverage at least once in their lives. (See Table 3.3.) Among them, 42.9% of those twelve to seventeen years old had tried alcohol at some time in their lives, as had 87.1% of those between the ages of eighteen and twenty-five. Sixty-five percent of Americans twelve years of age and over had consumed at least one drink during the year prior to the survey, while 50.1% had used alcohol in the month prior to the survey. As Table 3.3 shows, consumption of alcohol in all age groups and in all categories increased from 2000 to 2003.

Table 3.4 shows the percentage of survey respondents who reported consuming alcohol in the past month in 2000-2003. The percentage use of alcohol by the total population age twelve years and over increased from 46.6% in 2000 to 50.1% in 2003. Men aged eighteen and older were more likely to have consumed alcoholic beverages in the past month than were women aged eighteen and older. Girls aged twelve to seventeen were more likely to have consumed alcoholic beverages in the past month than were boys in the same age group.

Table 3.4 also shows that alcohol consumption varies significantly by race and level of education. Across all age groups, a higher percentage of whites had used alcohol within the month prior to the survey than had African-Americans or Hispanics. Among twelve- to seventeen-years-olds in 2000-2003, those reporting past-month use of alcohol was highest among Native American or Alaska Natives. Among respondents aged eighteen years and over, past-month alcohol use increased with level of education.

The Prevalence of Problem Drinking

The National Health Interview Survey (NHIS) is one of the major data collection programs of the National Center for Health Statistics (NCHS). The NCHS is one of twelve centers, institutes, and offices of the Centers for Disease Control and Prevention (CDC) located in Atlanta, Georgia. The CDC, an agency of the U.S. Department of Health and Human Services (HHS), is the lead federal agency charged with protecting the health and safety of the people of the United States.

The National Health Interview Survey has been conducted annually since 1957. Figure 3.1 shows 1997 to 2002 NHIS data on excessive alcohol consumption. The 2002 NHIS estimate of the percentage of adults who

consumed alcohol excessively was 9.3%. This estimate is not statistically different from the estimates for 1997-99, which are shown on the graph. This means that approximately the same percentage of people consumed alcohol excessively each year from 1997 to 2002. The variation shown from year to year can be due simply to chance variations within the samples of the population from which the data were taken. The brackets at the top of the bars show the amount of variation likely for each year.

Data from the 1991-1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES) and the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) show that the twelve-month prevalence of alcohol abuse within the total U.S. population over the age of eighteen years was higher in 2001-2002 than in 1991-1992. (See Table 3.5.) In 2001-2002, 4.65% of the population over eighteen years of age abused alcohol. In 1991-1992, 3.03% of the population over eighteen abused alcohol. The percentages of males and females who abused alcohol were also higher in 2001-2002 than in 1991-1992.

In contrast, the twelve-month prevalence of alcohol dependence within the total U.S. population over the age of eighteen years was lower in 2001-2002 compared with 1991-1992. (See Table 3.6.) In 2001-2002, 3.81% of the population over eighteen years of age was dependent on alcohol. In 1991-1992, 4.38% of those over eighteen were alcohol dependent. The percentages of males and females who were dependent on alcohol were also lower in 2001-2002 than in 1991-1992.

The estimated national costs related to alcohol abuse and dependence (everything from crime, treatment services, health care costs, and lost wages) were projected to be approximately $185 billion in 1998, up from slightly more than $148 billion in 1992. (See Table 3.7; these are the latest figures available.)

PROBLEM DRINKING AND THE ELDERLY.

Elderly people may turn to alcohol periodically to cope with depression, the loss of a spouse, or an injury, but data suggest an overall rise in problem drinking among senior citizens. According to "Inebriated Elders," by Susan Abrams (Elder Law Journal, May 2002), as many as one in six Americans over sixty years of age are dependent on alcohol. Twenty percent of the elderly admitted to psychiatric wards exhibit symptoms of alcoholism or some other form of substance abuse. As many as 10 to 15% of health problems among the elderly may be linked to excessive alcohol use ("When Seniors Drink," MissouriBar, http://www.mobar.org/law/seniors.htm, accessed March 11, 2005). The prevalence of problem drinking in nursing homes may be as high as 30 to 49%. A 2000 report by Alcohol Concern (a national agency on alcohol misuse in the United Kingdom) cited a 75% increase in drinking among women over age sixty-five during a recent ten-year period.

THE 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, producing irregular electrocardiograms (EKGs), which are recordings of the electrical activity of the heart. Blood vessels within muscles constrict, but those at the surface expand, causing rapid heat loss from the skin. This causes the flushing or reddening of the skin that often accompanies alcohol intake. Large doses of alcohol decrease body temperature and may cause numbness of the skin, legs, and arms, creating a false feeling of warmth. Figure 3.2 illustrates 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 also inhibits the release of the hormone oxytocin from the pituitary gland. Oxytocin normally stimulates contractions of the uterus during childbirth. Because alcohol inhibits uterine contractions, it was used in the past to control premature labor.

Alcohol is sometimes believed to be an aphrodisiac (sexual stimulant). While 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.

Intoxication

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 systems 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

  	Male		Female		Total
  Sociodemographic characteristic	NLAES*(1991-1992)	NESARC*(2001-2002)	NLAES(1991-1992)	NESARC(2001-2002)	NLAES(1991-1992)	NESARC(2001-2002)
  Total
  Total	4.67	6.93	1.51	2.55	3.03	4.65
  18-29	9.26	9.35	3.83	4.57	6.54	6.95
  30-44	4.58	8.69	1.50	3.31	3.02	5.95
  45-64	2.38	5.50	0.38	1.70	1.35	3.54
  65+	0.55	2.36	0.04	0.38	0.25	1.21
  White
  Total	5.09	7.45	1.71	2.92	3.33	5.10
  18-29	10.75	10.19	4.83	5.56	7.83	7.86
  30-44	5.16	10.10	1.68	4.13	3.41	7.09
  45-64	2.55	5.97	0.44	2.02	1.47	3.96
  65+	0.52	2.38	0.04	0.36	0.24	1.21
  Black
  Total	2.38	5.71	0.73	1.41	1.46	3.29
  18-29	3.83	6.92	1.27	2.10	2.44	4.28
  30-44	2.54	7.04	1.00	1.51	1.70	3.95
  45-64	1.19	4.48	0.02	1.25	0.54	2.66
  65+	0.00	1.79	0.00	0.12	0.00	0.78
  Native American
  Total	12.80	7.47	4.31	4.18	8.14	5.75
  18-29	27.88	15.25	8.19	6.68	17.59	10.35
  30-44	2.64	7.67	3.73	6.52	3.22	7.07
  45-64	0.00	4.85	0.00	0.00	0.00	2.57
  65+	0.00	3.59	0.00	4.12	0.00	3.91
  Asian
  Total	1.65	3.20	0.47	1.13	1.08	2.13
  18-29	3.30	4.77	0.74	3.89	2.02	4.35
  30-44	1.67	4.22	0.21	0.23	0.93	2.18
  45-64	0.00	1.13	0.66	0.20	0.30	0.61
  65+	0.00	0.00	0.00	0.00	0.00	0.00
  Hispanic/Latino
  Total	4.15	6.21	0.87	1.65	2.52	3.97
  18-29	5.85	9.08	1.56	3.04	3.71	6.28
  30-44	3.30	4.88	0.86	1.46	2.15	3.23
  45-64	3.08	4.35	0.13	0.63	1.60	2.43
  65+	2.90	3.69	0.00	0.00	1.16	1.56
  *Data are from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) 1991-1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES) and 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

  get from the stomach to the small intestine. Only a small amount of alcohol is absorbed through the stomach wall.
• Drinking history and body chemistry—The longer a person has been drinking, the greater his or her tolerance (i.e., 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. In general, women have less body water than men of similar body weight, so that equivalent amounts of alcohol result in higher concentrations of alcohol in the blood of women than men. However, women appear to eliminate alcohol from the blood faster than men.

As a person's BAC rises, there are somewhat predictable responses in behavior.

• At a BAC of about 0.05% (0.05 grams of alcohol per 100 milliliters 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.
• At 0.10%, voluntary motor actions become noticeably clumsy. (Note: it is illegal to drive with a BAC of 0.08% or higher.)

• At 0.20%, 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%, the person generally acts confused or may be in a stupor.
• At 0.40%, the person usually falls into a coma.
• At 0.50% or more, the medulla is severely depressed, and death generally occurs within a couple of 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% will almost certainly die. Death may even occur at a BAC of 0.40% if the alcohol is "chugged," or consumed quickly and in a large amount, causing the BAC to rise rapidly.

Sobering Up

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 that less alcohol accumulates in

the bloodstream. According to the National Clearing-house for Alcohol and Drug Information, five drinks consumed in quick succession by a 180-pound man will produce a BAC of 0.11. In a 140-pound man, this intake will produce a BAC of 0.13. And in a 120-pound woman, it will produce a BAC of 0.19. 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, depending on the gender and weight of the person. It will likely produce a BAC higher than 0.02 in women and persons weighing less than 180 pounds.

Hangovers

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 3.8, but the causes of these symptoms are not well known. Results from one study (Jeff Wiese et al., "Effect of Opunitia ficus indica on Symptoms of the Alcohol Hangover," Archives of Internal Medicine, vol. 164, June 28, 2004) support the idea that the symptoms of a hangover are largely due to 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 HEALTH CONSEQUENCES

The results of scientific research have helped health care practitioners and the general public understand more specifically both the positive and the negative health consequences of drinking alcoholic beverages. Table 3.9 summarizes the major disease and injury conditions related to alcohol and the proportions attributable to alcohol worldwide. As Table 3.10 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 (see Table 3.10). 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 of these studies and analyses support the ideas that alcoholism accelerates aging, that alcoholism affects women more than men, that alcoholism runs in families, and that thiamine deficiency can contribute to damage within the brain.

An example of the type of data that supports hypotheses about the interaction between alcoholism and various characteristics is shown in Figure 3.3. This figure shows that the brain of the alcoholic (left) has less tissue than the brain of the nonalcoholic (right). Both subjects are fifty-seven-year-old men, but the difference in their lifetime consumption of alcohol and their amount of brain tissue is striking. The graph on the bottom shows that older alcoholics have less cortical tissue (the "thinking" part of the brain) in almost all parts of the brain than do younger alcoholics. Only the posterior temporal lobe of the brain shows equivalent tissue. However, both the younger and the older alcoholics have less cortical tissue than nonalcoholics (control subjects).

Scientists have also studied the vulnerability (susceptibility) of the various parts of the brain to alcohol. These hypotheses on brain vulnerability to alcohol are shown on the lower portion of Table 3.10. In addition, Figure 3.4 shows the regions of the brain vulnerable to alcoholism-related abnormalities.

Not all of the effects of alcohol consumption are harmful to health. Table 2.1 in Chapter 2 shows levels of alcohol consumption that can provide beneficial health effects, but notes the levels that can provide harmful health effects. The number of scientific studies that support the data listed in each row of the table are noted in the "comment" column.

Compare the data listed in Table 2.1 and Table 3.9 Table 3.9 shows that the consumption of alcohol is linked to heart disease in men and stroke in both men and women. Nevertheless, moderate consumption of alcohol can benefit the heart and blood vessels. As Table 2.1 shows, a fourteen to twenty-nine gram per day intake of alcohol (about two standard drinks) provided maximum risk reduction for coronary heart disease to the individuals in the studies that were analyzed. Nevertheless, a consumption of greater than one alcoholic drink per day for women and two for men can detrimentally affect the liver and is linked to

various cancers in both men and women. Clearly, the amount of alcohol consumed is important to health and must be watched carefully to reap possible beneficial health effects without risking detrimental health effects.

Alcohol-Related Hospitalization

According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Surveillance Report #68, Trends in Alcohol-Related Morbidity among Short-Stay Community Hospital Discharges, United States, 1979-2002 (August 2004), about 437,000 hospital visits in 2002 resulted in first-listed (primary) alcohol-related diagnoses. Alcohol was also listed as a contributing factor in another 1.5 million hospital visits. Table 3.11 lists the alcohol-related diagnostic categories.

Alcohol dependence syndrome accounted for 35% of first-listed diagnoses related to alcohol in 2002. Cirrhosis made up 30%; alcoholic psychoses, 24%; and nondependent abuse of alcohol, 11% (see Figure 3.5). Figure 3.6 shows trends in these first-listed diagnoses related to alcohol from 1979 to 2002. The percentage of alcohol dependence syndrome as a first-listed diagnosis dropped dramatically from 1979 to 2002. Conversely, alcoholic psychoses have risen

as a first-listed diagnosis about 20% during that time. Cirrhosis and nondependent use of alcohol have risen as well, but not as dramatically.

The length of hospital stays varies by diagnosis, as reported in the NIAAA's Surveillance Report #68. In 2002 the hospital stay of persons diagnosed as alcohol dependent averaged 5.5 days, down from 10.7 days in 1988. The stay of those with cirrhosis averaged 6.4 days. Those diagnosed with alcoholic psychoses stayed an average of 5 days, while those with nondependent abuse of alcohol were in the hospital for 2.2 days.

Liver Diseases

Because the liver plays a central role in removing substances from the body, it is the major organ damaged by chronic drinking. This damage is called alcoholic liver disease (ALD). The most prevalent types of alcoholic liver disease are fatty liver, alcoholic hepatitis, and cirrhosis (Mann et al., "The Epidemiology of Alcoholic Liver Disease," Alcohol Research and Health, vol. 27, no. 3, 2003).

Alcohol consumption produces changes in the meta-bolism of lipids (fats) that can cause these compounds to accumulate in liver cells, producing "fatty liver." Often there are no external signs of this ailment except in severe cases. This condition is usually reversible and improves with abstinence from alcohol but can be fatal if alcohol consumption is not reduced or stopped. About 20% of alcoholics and heavy drinkers develop fatty liver.

Alcoholic hepatitis is an inflammation of the liver accompanied by other changes to the liver cells. The liver becomes enlarged and tender, and jaundice (yellowing of the skin and other tissues) is usually present. The condition can be, but is not always, fatal. Some complications, however, may cause hepatitis to persist for long periods after the person stops drinking. Alcoholic hepatitis is often a precursor to cirrhosis. Women have a higher incidence of alcoholic hepatitis than do men.

Cirrhosis of the liver is the most serious form of alcoholic liver disease. It is an inflammatory condition in which functioning liver cells are replaced by scar tissue. Steady, heavy drinking (five or more drinks a day for several years) is necessary to produce enough liver damage to cause cirrhosis. An estimated 10 to 15% of people with alcoholism develop cirrhosis. Ninety percent of alcoholics with cirrhosis who stop drinking survive five years or more, while only 70% of those who do not stop drinking survive (Mann et al., "The Epidemiology of Alcoholic Liver Disease," Alcohol Research and Health).

Figure 3.7 shows that at any given level of alcohol consumption, women are more likely to develop cirrhosis than men. One explanation for this phenomenon is that the levels of an enzyme that breaks down alcohol in the stomach may be lower in women than in men, permitting more alcohol to get into the bloodstream and from there to the liver.

Abstinence from alcohol is the treatment for fatty liver, alcoholic hepatitis, and alcoholic cirrhosis. For those whose medical condition has greatly deteriorated, liver transplants are the only alternative.

Digestion and Nutrition

The gastrointestinal (GI, or digestive) tract is also affected by chronic heavy drinking. Alcohol interferes with the functions of all parts of the GI tract, from the mouth to the large intestine. Alcohol abuse may damage the lining of the stomach and intestines, causing the formation of bleeding ulcers and producing abdominal pain and discomfort.

Alcohol is very high in empty calories; it contains no vitamins or minerals (except for a very few in beer). A drinker who gets many calories from alcohol often has little appetite for other food. In addition, alcohol reduces the absorption of food through the lining of the small intestine and interferes with the absorption of amino acids, glucose, zinc, and vitamins. As a result, excessive alcohol consumption may result in malnutrition. A lack of vitamin B₁ (thiamine) can cause Wernicke's disease, damaging the brain.

Heavy alcohol consumption is a primary cause of chronic pancreatitis. More than 75% of patients with this disease have a history of heavy drinking, most often for five to ten years before the symptoms appear. Pancreatitis causes severe abdominal pain, often accompanied by nausea, vomiting, and fever. Medical researchers do not yet fully understand how alcohol damages the pancreas.

Cancer

Drinking alcoholic beverages has been linked to cancer, particularly cancers of the upper airway and the gastrointestinal tract. In addition, alcohol consumption has been linked to cancers of the colon and rectum, and to breast cancer in women. The association between alcohol consumption and stomach, pancreatic, prostate, and endometrial cancer is still controversial. Alcohol has not been shown (as has cigarette smoking) to cause cancer, but the consumption of alcoholic beverages increases the risk of developing some cancers.

Figure 3.8 shows the relationship between consuming increasing amounts of alcohol and the relative risk (RR) of developing various cancers. The RR for any of these cancers in nondrinkers is considered to be a baseline of 1.0. The values on the graphs show the relative risk for that cancer at various levels of alcohol consumption. For example, a person consuming 28 grams of alcohol per day (about two standard drinks) is about 1.8—a higher risk than that of a person who consumes no alcohol. People who consume moderate amounts of alcohol within the range most beneficial to lower the risk of coronary heart disease (see Table 2.1 in Chapter 2) raise their risk of cancer very little or not at all for most cancers.

Results of a study by Morten Gronbaek and his colleagues, "Population-Based Cohort Study of the Association between Alcohol Intake and Cancer of the Upper Digestive Tract" (British Medical Journal, September 1998), show that intake of wine tends to decrease the risk of upper digestive tract cancer, while intake of beer and spirits significantly increases the risk. The researchers suggest that their findings are strongly supported by studies showing that resveratrol, a substance in grapes and wine, may be protective against cancer, while nitrosamines in beer and spirits may promote cancer.

The Brain

Alcohol injures the brain as it does other organs. About half of the twenty million alcoholics in the United States, however, appear to be free of cognitive impairments, note Marlene Oscar-Berman and Kasenija Marinkovic in "Alcoholism and the Brain: An Overview" (Alcohol Research and Health, vol. 27, no. 2, 2003). Nonetheless, up to two million people develop such serious debilitating brain conditions that they require life-long care. Such conditions include alcoholic dementia and Wernicke-Korsakoff syndrome.

Alcoholic dementia is characterized by physical changes in the brain along with an intellectual decline, including a loss of abstract thinking and problem-solving abilities, difficulty in swallowing, and difficulty in manipulating objects. If a person stops drinking, the deterioration may stop and, in some instances, reverse itself.

Korsakoff's psychosis, a brain syndrome caused by chronic alcohol dependency, is a permanent state of cognitive dysfunction—the inability to remember recent events or to learn new information. Previously learned information may interfere with new learning, and it may also be difficult to recall events that occurred before the onset of the psychosis. A related syndrome called Wernicke's disease manifests itself with vision problems, ataxia (loss of the ability to control muscle movement), and confusion. Unlike Korsakoff's psychosis, Wernicke's disease can be reversed with an adequate intake of thiamine (vitamin B₁). Both conditions in the same patient at the same time are called Wernicke-Korsakoff syndrome.

The Heart

Chronic alcohol consumption may contribute to congestive heart failure through toxic effects on the heart muscle, producing cardiomyopathy (degeneration of the heart muscle). This damage often follows a long period (about a decade) of heavy drinking. Symptoms of damage include shortness of breath, ankle swelling, unusual fatigue, and eventual heart failure.

Heavy alcohol intake also interferes with the ability of the heart to contract, and heartbeat irregularities (cardiac arrhythmias) are common in alcoholics. Chronic alcohol consumption is also associated with a significant increase in hypertension (high blood pressure) and may be an important factor in ischemic heart disease (deficient blood circulation to the heart) and cerebrovascular disorders, including stroke.

Other Muscles

Alcohol abuse can also weaken skeletal muscles. Alcoholic myopathy (muscle disease) may be either acute (having rapid onset, severe symptoms, and short duration) or chronic (long-lasting and recurrent). Symptoms of acute myopathy include muscular pain, tenderness, and weakness, usually confined to one limb or a group of muscles. The chronic form of the disease causes a slow progression of muscular weakness and atrophy (wasting). Mild symptoms occur in about one-third of alcoholics. Alcohol also affects involuntary smooth-muscle contractions, a primary reason why it was once used as a treatment for controlling the contractions of the uterus in premature labor.

The Blood and Immune Systems

Alcohol can cause blood abnormalities. Common problems are anemia, a decrease in hemoglobin in the blood, and abnormally enlarged red blood cells. When an alcohol-dependent person stops drinking, his or her red blood cells do not return to their normal size for at least four months.

Another common blood abnormality in alcoholics is a lowered white blood cell count. White blood cells are an integral part of the body's defense against disease, and a low white cell count leaves many alcoholics more susceptible to infectious diseases than nonalcoholics. Additionally, chronic alcohol use reduces the T-cell population in lymphoid tissue and the spleen. T-cells are white blood cells that are key to the immune response.

There is no evidence of a direct association between alcohol use and AIDS (acquired immunodeficiency syndrome); however, alcohol use may increase risk-taking behavior such as sharing drug needles or having sex without taking proper precautions to reduce the risk of contracting sexually transmitted infections.

Some evidence also shows that long-term drinking can produce irregularities in blood sugar levels, although alcoholism has not been tied conclusively to diabetes.

Sexuality and Reproduction

Many alcoholics suffer from impotence and/or reduced sexual drive. Some studies suggest that about 25% of alcoholics become impotent, even after they stop drinking. This figure may actually be much higher. Male alcoholics tend to have much lower levels of testosterone, the principal male hormone, than do nonalcoholics, while their levels of estrogen, a female hormone, are increased. Many alcoholics suffer from depression, which may further impair their sexual performance.

In premenopausal women, chronic heavy drinking can contribute to a variety of reproductive disorders. These include the cessation of menstruation, irregular menstrual cycles, failure to ovulate, early menopause, and increased risk of spontaneous miscarriages. 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 Syndrome

Research has shown that alcohol consumption during pregnancy can result in severe harm to the baby. Alcohol can cause birth defects, which can begin to develop within the first three to eight weeks of pregnancy. Since the development of such defects begins so early in pregnancy, the mother-to-be may not even know she is pregnant.

Drinking during pregnancy can cause fetal alcohol syndrome (FAS), which was first described in studies in France in 1968 and in the United States in 1973. The key features of FAS are listed in Table 3.12. In addition to these features, results of recent studies show that prenatal alcohol exposure is associated with abnormalities in nerve electrical properties (De Los Angeles Avaria et al., "Peripheral Nerve Conduction Abnormalities in Children Exposed to Alcohol in Utero," Journal of Pediatrics, vol. 144, no. 3, 2004). Children with FAS also exhibit a complex pattern of behavioral and cognitive dysfunctions, which are listed in Table 3.13.

Research results of Philip A. May and Phillip Gossage ("Estimating the Prevalence of Fetal Alcohol Syndrome: A Summary," Alcohol Research and Health, vol. 25, no. 3, 2001) show the prevalence rate of FAS in the United States during the 1980s and 1990s to have been 0.5 to two cases per one thousand live births. Results of studies conducted by the National Center on Birth Defects and Developmental Disabilities (NCBDDD) of the CDC show FAS rates to range from 0.2 to 1.5 per one thousand live births. In addition, the NCBDDD notes that 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 or FAE.)

There is no known safe level of alcohol consumption during pregnancy. The Centers for Disease Control and

Prevention (CDC) notes 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 have a child with FAS, ARND, or ARBD.

Table 3.14 shows that in 2002 slightly more than 10% of pregnant women consumed alcohol and approximately 2% engaged in binge drinking or frequent use of alcohol. More than half the women who might become pregnant used alcohol, approximately 13% consumed alcohol frequently, and more than 12% engaged in binge drinking.

The prevalence of binge drinking among women of childbearing age varies from state to state. (See Figure 3.9.) In addition, greater binge drinking prevalence was reported among younger women, non-Hispanic whites, current smokers, unmarried women, and impaired drivers. (See Table 3.15.)

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 taken in combination with other drugs, such as an illegal drug like cocaine, an over-the-counter drug like cough medicine, or a prescription drug like an antibiotic, may find the combination to be 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 3.16 shows some possible effects of combining alcohol and other types of drugs.

The Food and Drug Administration (FDA) recommends that anyone who regularly has three alcoholic drinks a day should check with a physician before taking aspirin, Tylenol, or any other over-the-counter painkiller. Combining alcohol with aspirin, ibuprofen (such as Advil or Motrin brands), or related pain relievers may promote stomach bleeding. Combining alcohol with acetaminophen (such as Tylenol) may promote liver damage.

ALCOHOL-RELATED DEATHS

In the United States 19,928 people died of alcohol-induced causes in 2002 (Kochanek et al., "Deaths: Final Data for 2002," National Vital Statistics Reports, vol. 53, no. 5, October 12, 2004). 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 due to fetal alcohol syndrome. The age-adjusted death rate for males was 3.4 times the rate for females. Slightly more than twelve thousand people died from alcoholic liver disease in 2002.

ALCOHOL AND TRAUMA

The association between alcohol and unintentional injury has long been recognized. A passage in an Egyptian papyrus from 1500 B.C., for example, warned that drinking could lead to falls and broken bones. Short-term effects of alcohol include diminished motor coordination and balance, and impaired attention and judgment. Alcohol contributes to many types of unintentional injuries: motor vehicle and pedestrian accidents, as well as falls, drownings, and burns.

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 blood alcohol concentration (BAC) of 0.01% (grams per deciliter) or greater. People with a BAC of 0.08% or higher are considered intoxicated.

The NHTSA reported that 42,643 people were killed in traffic accidents in 2003, with 17,013 of them caused by alcohol-related crashes. These alcohol-related traffic deaths represented 40% of all car crash fatalities in 2003. The percentage of alcohol-related traffic fatalities has declined somewhat steadily from a high of 60% in 1982. (See Figure 3.10.) The peak number of fatalities occurred in 1988, when 47,087 traffic accident deaths (including both alcohol-related and nonalcohol-related) were recorded.

A number of important factors have contributed to the decline of drunk driving fatalities. Mothers against Drunk Driving (MADD) was founded in 1980. This organization's greatest 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 limit for drunk driving from 0.1 to 0.08, with all states implementing this limit by August 2005. At the beginning of 2005, forty-two states and the District of Columbia also had administrative license revocation (ALR) laws, which require prompt, mandatory suspension of drivers' licenses for failing or refusing to take the BAC test. This immediate suspension, prior to conviction and independent of criminal procedures, is invoked right after arrest.

As Table 3.17 shows, in both 1993 and 2003, drivers aged twenty-one to forty-four were the ones most likely to be in fatal crashes in which the driver had a BAC of 0.08 or higher. While the percentage of drivers within this group dropped between 1993 and 2003, the sharpest decline (16%) occurred among drivers aged twenty-five to thirty-four. The rate of fatal crashes for drivers between the ages of fifty-five and sixty-four and having a BAC of 0.08 or greater decreased by 14% as well.

In 2003 the percentage of male drivers involved in fatal crashes who had a BAC of 0.08 or greater was twice that of female drivers involved in fatal crashes (24% versus 12% respectively). When compared with 1993,

the ratio remains somewhat consistent, but the percentages of drunk male and female drivers in fatal accidents dropped by 11% in males and 14% in women. (See Table 3.17.)

Alcohol was related to a higher percentage (29%) of fatal crashes by motorcycles than for crashes involving automobiles and light trucks (22% for each vehicle type). Fatal crashes involving large trucks were very unlikely to be alcohol related (1%). (See Table 3.17.)

As Table 3.18 shows, in both 1993 and 2003, roughly half of all pedestrians aged twenty-one to forty-four who were killed in a traffic accident had a BAC of 0.08 or higher. This percentage was considerably higher than that for other age groups. Alcohol consumption is less of a factor in fatal pedestrian/motor vehicle accidents than it once was. The percentage of pedestrians killed in traffic accidents who were legally alcohol impaired dropped between 1993 and 2003 for all age groups except forty-five- to sixty-four-year-olds, who stayed at 38%.

Falls, Drowning, and Burns

Data from the National Center for Injury Prevention and Control (NCIPC), an office of the Centers for Disease Control and Prevention, show that excessive alcohol consumption is a significant factor in accidental deaths. In 2003, 16,926 fatalities resulted from falls, up from 16,257 in 2002 (National Vital Statistics Reports, February 28, 2005). It was the third-leading cause of unintentional injury death, closely following accidental poisoning. (Motor vehicle accidents were first.) According to the NCIPC's Fact Book for the Year 2000, alcohol consumption is involved in 18 to 53% of nonfatal falls each year. Alcohol (and its misuse) can be linked to as much as 40% of industrial fatalities and 47% of industrial injuries, according to the U.S. Department of Labor.

The NCIPC reports that alcohol is involved in 40 to 50% of drowning deaths among teenage boys. In addition, alcohol use is involved in about 50% of all deaths associated with water recreation, such as boating. An NCIPC analysis of survey data on alcohol use during recreational boating revealed that 31% of respondents who operated motorboats reported doing so at least once while alcohol-impaired. Most of these respondents were male and between the ages of twenty-five and thirty-four.

All fifty states, the District of Columbia, and Puerto Rico impose a BAC limit of below 0.08 for driving. In addition, states impose a BAC limit of either 0.08 or 0.10 or lower for boating. All states have boating-under-the-influence laws (National Association of State Boating Law Administrators, Reference Guide to State Boating Laws, 5th ed., 1999 [most recent edition available at this writing]). Penalties for boating while intoxicated include fines, imprisonment, substance abuse or boating safety classes, and suspension of boat operating privileges.

Fires were the fourth-leading cause of unintentional injury death in the United States in 2003, killing 3,363 people (National Vital Statistics Reports, February 28, 2005). According to a study cited by the NCIPC in its Fact Book for the Year 2000, alcohol contributes to 40% of deaths in residential fires.

ALCOHOL, VIOLENCE, AND CRIME

Alcohol and Crime

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 has 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. (See Table 3.19.)

Two-thirds of jail inmates reported regular use of alcohol in 2002, unchanged since 1996 (see Table 3.19). Whites are more likely to be regular alcohol users than are African-Americans or Hispanics, and males are more likely than females to drink alcohol regularly.

A 2001 study of adult male arrestees in thirty-two U.S. cities found many had used alcohol before committing their crimes (U.S. Department of Justice, ADAM Preliminary Finds on Drug Use and Drug Markets, January–September 2001). In more than half the thirty-two sites, more than 50% of the adult

arrestees reported binge drinking in the thirty days before they were interviewed. (Binge drinking is defined as consuming five or more drinks on at least one occasion.) Rates ran as low as 30.9% of arrestees in New York City to 70% in Albuquerque, New Mexico. Other examples include: in Phoenix, Arizona, 56% of arrestees reported binge drinking; 58.4% in Spokane, Washington; 56.6% in Oklahoma City; and 57.2% in Denver, Colorado. A significant percentage of male arrestees also reported heavy drinking in the thirty days before their interview as well. (Heavy drinking is defined as five or more drinks on five or more occasions.)

More than two million alcohol-related arrests are made each year, representing nearly a quarter of total arrests. In Sourcebook of Criminal Justice Statistics 2002, the Federal Bureau of Investigation (FBI) reported that there were

• 1,067,185 arrests for driving under the influence of alcohol.
• 487,123 arrests for liquor law violations (open container laws, selling to minors, etc.).
• 515,007 arrests for alcohol-related disorderly conduct.
• 431,939 arrests for drunkenness.
• 21,102 arrests for alcohol-related vagrancy.

Alcohol and Violence among College Students

During the college years, alcohol abuse becomes a serious problem for some students. A study by the Harvard School of Public Health released in June 2002 found that 6% of college students met criteria for alcohol dependence (or alcoholism) and 31% met the definition for alcohol abuse. More than two of every five students reported at least one symptom of these conditions. Some young people experiment with alcohol, experience negative effects, and discontinue use, of course. But such figures cause concern, in part, because alcohol abuse often begins or accelerates during the college years.

According to the NIAAA, an estimated fourteen hundred college students between the ages of eighteen and twenty-four die annually from alcohol-related unintentional injuries. Another five hundred thousand in this same age group are thought to be unintentionally injured under the influence of alcohol each year. Some six hundred thousand students are assaulted by another student who has been drinking. More than seventy thousand report alcohol-related sexual assaults or date rapes.

According to the most recent College Alcohol Survey, 1979-2000 (Fairfax, VA, and West Chester, PA: George Mason University and West Chester University, 2001), in 2000 students believed that about 60% of all violent-behavior incidents on campus involved alcohol and that about 55 to 60% of campus property damage was the result of alcohol use.

Alcohol and Domestic Violence

Researchers have also reported a high level of alcohol use in cases of domestic violence, both child abuse and partner abuse. In addition, heavy drinking, both before and after marriage, is considered a risk factor for potential domestic violence. In some cases of spousal abuse, both husband and wife have been drinking before the violence occurs; in other cases, only one spouse has been drinking.

According to the Bureau of Justice Statistics, approximately 66% of victims who suffered violence by a current or former spouse, boyfriend, or girlfriend reported that alcohol had been a factor. Among spouse victims, about 75% were perceived to be alcohol-related. In contrast, only about 31% of stranger victimizations were perceived to be alcohol-related.

Studies of domestic violence have found that alcohol does not cause abuse but that it is used by abusers as an excuse for the behavior. Alcohol abusers often claim that they are out of character when they are drunk and, consequently, not accountable for their behavior. Dr. Richard Gelles, the Joanne T. and Raymond B. Welsh Chair of Child Welfare and Family Violence at the University of Pennsylvania, observes in Intimate Violence in Families, 3rd edition (Thousand Oaks, CA: Sage Publications, 1997):

[In many cases,] individuals who wish to carry out a violent act become intoxicated in order to carry out the act. Alcohol leads to violence because it sets off a primary conflict over drinking that can extend to arguments over spending money, working, and sex. In these cases, drinking may serve as a trigger for long-standing marital disputes and disagreements; the existence of suitable and acceptable justifications for violence serves to normalize and neutralize the violence. These justifications also may play a causal role in family violence by providing, in advance, an excuse for behavior that is normally prohibited by societal and familial norms and standards.