Alcohol

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.

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.

DEFINING ALCOHOLISM

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.

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.

TABLE 2.3

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.

TABLE 2.4

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.

Biological Factors

GENETICS

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.)

Psychosocial Factors

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

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.

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 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.

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 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.

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 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.

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.

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.

TABLE 2.9

Cognitive and behavioral characteristics typical of Fetal Alcohol Spectrum Disorders (FASD)

Low IQ

Attention deficit

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.

TABLE 2.10

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:

1. A pregnant woman should not drink alcohol during pregnancy.
2. A pregnant woman who has already consumed alcohol during her pregnancy should stop in order to minimize further risk.
3. A woman who is considering becoming pregnant abstain from alcohol.
4. 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.
5. 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.

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.

ALCOHOL-RELATED DEATHS

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.

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.

ALCOHOL-RELATED OFFENSES

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.

ALCOHOL

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.

CHEMISTRY

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.

TOXIC EFFECTS

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 )

BIBLIOGRAPHY

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.

Goldstein, D. B. (1983). Pharmacology of alcohol. New York: Oxford University Press.

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

Complications

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.

ALCOHOL METABOLISM

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 )

BIBLIOGRAPHY

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 1800s

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.

CURRENT IMPLICATIONS

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 )

BIBLIOGRAPHY

Austin, G. A. (1985). Alcohol in Western society from Antiquity to 1800: A chronological history. Santa Barbara, CA: ABC-Clio Information Services.

Badri, M. B. (1976). Islam and alcoholism. Indianapolis: American Trust Publications.

Barrows, S., & Room R. (Eds.). (1991). Drinking: Behavior and belief in modern history. Berkeley: University of California Press.

Barrows, S., et al. (Eds.). (1987). The social history of alcohol: drinking and culture in modern society. Berkeley, CA: Alcohol Research Group, Medical Research Institute of San Francisco.

Blocker, J. S. (1980). American temperance movements: Cycles of reform, 2nd ed. Boston: Twayne.

Blum, R. H. (1974). Society and drugs I. Social and cultural observations. San Francisco: Jossey-Bass.

Chang, K.C. (Ed.). (1977). Food in Chinese cultures: Anthropological and historical perspectives. New Haven: Yale University Press.

Eames, A. (1993). Blood, sweat, and beer. Berkeley, CA: Milk and Honey Press.

Gomberg, E. L., et al. (Eds.). (1982). Alcohol, science, and society revisited. Ann Arbor: University of Michigan Press.

Gusfield, J. (1986). Symbolic crusade: Status politics and the American temperance movement, 2nd ed. Urbana: University of Illinois Press.

Hamer, J., & Steinbring, J. (Eds.). (1980). Alcohol and native peoples of the north. Lanham, MD: University Press of America.

Hattox, R. S. (1985). Coffee and coffeehouses: The origins of a social beverage in the medieval Near East. University of Washington Near Eastern Studies 3, Seattle.

Heath, D. B. (1994). International handbook on alcohol and culture. Westport, CT: Greenwood.

Heath, D. B., & Cooper, A. M. (1981). Alcohol use in world cultures: A comprehensive bibliography of anthropological sources. Toronto: Addiction Research Foundation.

Lender, M., & Martin, J. (1987). Drinking in America: A social-historical explanation, rev. ed. New York: Free Press.

Mac Andrew, C., & Edgerton, R. B. (1969). Drunken comportment: A social explanation. Chicago: Aldine.

Mail, P.D., & Mc Donald, D. R. (1980). Tulapai to Tokay: A bibliography of alcohol use and abuse among Native Americans of North America. New Haven: Human Relations Area Files Press.

Marshall, M. (1979). Beliefs, behaviors, and alcoholic beverages: A cross-cultural survey. Ann Arbor: University of Michigan Press.

Mc Govern, P., et al. (Eds.). (1993). The origins and ancient history of wine. New York: Gordon & Breach.

Musto, D. (1989). The American disease: Origins of narcotic control, rev. ed. New York: Oxford University Press.

O' Brien, J. M., & Alexander, T. W. (1992). Alexander the Great: The invisible enemy. New York: Routledge.

Pan, L. (1975). Alcohol in colonial Africa. Helsinki: Finnish Foundation for Alcohol Studies.

Partanen, J. (1991). Sociability and intoxication: Alcohol and drinking in Kenya, Africa, and the modern world. Helsinki: Finnish Foundation for Alcohol Studies.

Rorabaugh, W. (1987). The alcoholic republic: An American tradition. New York: Oxford University Press.

RouchÉ, B. (1960). Alcohol: The neutral spirit. Boston: Little, Brown.

Royce, J. E. (1989). Alcohol problems and alcoholism: A comprehensive survey, 2nd ed. New York: Free Press.

Segal, B. M. (1990). The Drunken society: Alcohol abuse and alcoholism in the Soviet Union. New York: Hippocrene.

Segal, B. M. (1987). Russian drinking: Use and abuse of alcohol in pre-revolutionary Russia. New Brunswick, NJ: Rutgers Center of Alcohol Studies.

Siegel, R. K. (1989). Intoxication: Life in pursuit of artificial paradise. New York: Dutton.

Snyder, C. R. (1958). Alcohol and the Jews: A cultural study of drinking and sobriety. Glencoe, IL: Free Press.

Waddell, J.O., & Everett, M.W. (Eds.). (1980). Drinking behavior among southwestern Indians: An anthropological perspective. Tucson: University of Arizona Press.

Wallace, F. C. (1970). The death and rebirth of the Seneca. New York: Knopf.

Weil, A. (1986). The natural mind: A new way of looking at drugs and the higher consciousness, rev. ed. Boston: Houghton Mifflin.

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.

NEGATIVE 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.

Depression.

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.

Aggression.

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.

Sex Drive.

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.

Cognitive Changes.

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 )

BIBLIOGRAPHY

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

Alcohol

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.

Overview

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).

Hard Liquors

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.

Usage Trends

"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.

Alcoholism Defined

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.

Binge Drinking

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.

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.

Consequences

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.

The Law

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

Books

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.

Periodicals

Black, Susan. "Dying for a Drink." American School Board Journal (August, 2003).

Brink, Susan. "Your Brain on Alcohol." U.S. News & World Report (May 7, 2001): pp. 50-57.

Croal, N'Gai. "Kids, Don't Talk and Drive." Newsweek (February 14, 2005): p. 12.

Ehrenfeld, Temma. "New Hope for Addicts? An Epilepsy Drug May Help Alcoholics Stop Drinking." Newsweek (June 13, 2005): p. 68.

Gegax, T. Trent. "An End to 'Power Hour': A Tragic Alcohol Fatality Spurs a Crackdown on the Time-Honored Custom of Bingeing Up North." Newsweek (June 6, 2005): p. 28.

Hingson, R., and others. "Magnitude of Alcohol-Related Mortality and Morbidity among U.S. College Students Ages 18-24." Journal of Studies on Alcohol (April 12, 2002): pp. 136-144.

Markel, Howard. "Tailoring Treatments for Teenage Drug Users." New York Times (January 7, 2003).

Nagourney, Eric. "Behavior: When 'R' Stands for Risky." New York Times (February 26, 2002).

Nagourney, Eric. "A Sobering Effect on Teenage Drivers." New York Times (May 8, 2001).

"Sex, Drugs, and Rock 'n' Roll." Independent (January 28, 1996): p. 8.

Weathermon, Ron, and David W. Crabb. "Alcohol and Medication Interactions." Alcohol Research & Health, vol. 23, no. 1 (1999): pp. 40-54.

Windell, James. "Teen Binge Drinking Is a Serious Health Problem." Oakland Press (December 16, 2004).

Web Sites

"A to Z of Drugs: Alcohol." The BBC's Crime Web Site.http://www.bbc.co.uk/crime/drugs/alcohol.shtml (accessed June 16, 2005).

Alateen.http://www.al-anon.alateen.org/alateen.html (accessed June 16, 2005).

"Alcohol." TeensHealth.http://kidshealth.org/ (accessed June 16, 2005).

"Alcohol Linked to 75,000 U.S. Deaths a Year." MSNBC.com, June 25, 2005. http://www.msnbc.msn.com/id/6089353/ (accessed June 30, 2005).

"Alcohol Screening." Hazelden Foundation.www.hazelden.org/ (accessed June 16, 2005).

"Alcoholism and Drug Dependence Are America's Number One Health Problem." National Council on Alcoholism and Drug Dependence.http://ncadd.org/ (accessed June 16, 2005).

"The Big Book Online Fourth Edition." Alcoholics Anonymous.http://www.aa.org/ (accessed June 16, 2005).

"The Cool Spot: The Young Teen's Place for Info on Alcohol and Resisting Peer Pressure." National Institute on Alcohol Abuse and Alcoholism.http://www.thecoolspot.gov/ (accessed June 16, 2005).

"Drinking: It Can Spin Your World Around: Facts for Teens." American Academy of Family Physicians Family Doctor.org.http://familydoctor.org/ (accessed June 16, 2005).

Ericson, Nels. "Substance Abuse: The Nation's Number One Health Problem: An Office of Juvenile Justice and Delinquency Prevention Fact Sheet." National Criminal Justice Reference Service.http://fulltextpubs.ncjrs.org/content/FullTextPubs.html (accessed June 16, 2005).

"Impaired Driving Facts." Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.http://www.cdc.gov/ncipc/factsheets/drving.htm (accessed June 16, 2005).

Milgram, Gail Gleason. "Online Facts: The Effects of Alcohol." Rutgers University Center of Alcohol Studies.http://alcoholstudies.rutgers.edu/onlinefacts/effects.html (accessed June 16, 2005).

Monitoring the Future.http://www.monitoringthefuture.org/ and http://www.nida.nih.gov/Newsroom/04/2004MTFDrug.pdf (both accessed June 16, 2005).

National Institute on Drug Abuse.http://www.nida.nih.gov/ and http://www.drugabuse.gov (both accessed June 30, 2005).

The Robert Wood Johnson Foundation.http://www.rwjf.org (accessed June 16, 2005).

"Teens Targeted in Drugged Driving Campaign." MSNBC.com, December 3, 2004. http://www.msnbc.msn.com/id/6639590/ (accessed June 16, 2005).

"Traffic Safety Facts: 2003." U.S. Department of Transportation, National Highway Traffic Safety Administration.http://www-nrd.nhtsa.dot.gov/ (accessed June 16, 2005).

"Underage Drinking: A Major Public Health Challenge: Alcohol Alert No. 59." National Institute on Alcohol Abuse and Alcoholism. http://www.niaaa.nih.gov/publications/aa59.htm (accessed June 16, 2005).

ALCOHOL

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
the Devil.
(Increase Mather, Puritan clergyman, Wo to Drunkards [1673])

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.

Alcoholics Anonymous

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.

cross-references

First Amendment; Religion.

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.

further readings

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

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.

further readings

Alcoholics Anonymous World Services (AAWS). Twelve Steps and Twelve Traditions. New York: AAWS.

Blocker, Jack S., ed. 1979. Alcohol, Reform and Society. Westport, Conn.: Greenwood Press.

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.

Khoury, Clarke E. 1989."Warning Labels May Be Hazardous to Your Health: Common-Law and Statutory Responses to Alcoholic Beverage Manufacturers' Duty to Warn." Cornell Law Review 75.

Kyvig, David E., ed. 1985. Law, Alcohol, and Order. Westport, Conn.: Greenwood Press.

Lender, Mark. 1987. Drinking In America: A History. New York: Free Press.

Moore, Pamela A. 1993. "Lee v. Kiku Restaurant: Allocation of Fault between an Alcohol Vendor and a Patron—What Could Happen after Providing 'One More for the Road'?" American Journal of Trial Advocacy 17: 1.

Smith, Christopher K. 1992. "State Compelled Spiritual Revelation: The First Amendment and Alcoholics Anonymous as a Condition of Drunk Driving Probation." William and Mary Bill of Rights Journal 1 (fall).

Vartabedian, Ralph. 2002. "Some States Resist Lower Alcohol Limits." Los Angeles Times (December 30).

Wagenaar, Alexander C., and Traci L. Toomey. 2000. "Alcohol Policy: Gaps Between Legislative Action and Current Research." Contemporary Drug Problems 27 (winter).

cross-references

Alcohol, Tobacco, Firearms, and Explosives, Bureau of; Automobile Searches; Blue Laws; Organized Crime; Product Liability.

ALCOHOL

OFFICIAL NAMES: Ethyl alcohol, ethanol, grain alcohol

STREET NAMES: Booze, hooch, juice, sauce, spirits

DRUG CLASSIFICATIONS: Not classified, depressant

OVERVIEW

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.

CHEMICAL/ORGANIC COMPOSITION

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.

INGESTION METHODS

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.

THERAPEUTIC USE

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.

USAGE TRENDS

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.

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

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.

MENTAL EFFECTS

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.

PHYSIOLOGICAL EFFECTS

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.

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.

LEGAL CONSEQUENCES

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.

Legal history

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.

RESOURCES

Books

Alcoholics Anonymous. The Big Book. 3rd ed. New York: Alco holics Anonymous World Service, 1976.

Berkow, Robert, ed. The Merck Manual of Medical Information. Home ed. Whitehouse Station, NJ: Merck Research Laboratories, 1997.

Carson-Dewitt, Rosalyn, ed. Encyclopedia of Drugs, Alcohol & Addictive Behavior. 2nd ed. Vol.1-4. New York: Macmillan Ref erence USA, 2001.

Kinney, Jean, and Gwen Leaton. Loosening the Grip. 4th ed. Boston: Mosby-Year Book, Inc., 1991.

Milam, James R., and Katherine Ketcham. Under The Influence. New York: Bantam Books, 1981.

Nagle, Jeanne. Polysubstance Abuse. New York: Rosen Publish ing Group, Inc., 2000.

National Institute on Alcohol Abuse and Alcoholism. Tenth Spe cial Report to the U.S. Congress on Alcohol and Health. Bethes da, MD: NIAAA, 2000.

Schneider Institute for Health Policy at Brandeis University. Substance Abuse, The Nation's Number One Health Problem. Prince-ton, NJ: The Robert Wood Johnson Foundation, 2001.

Wegscheider, Sharon. Another Chance, Hope & Health for the Alcoholic Family. Palo Alto, CA: Science and Behavior Books, Inc., 1981.

Periodicals

Brink, Susan. "Your Brain On Alcohol." U.S. News & World Report (May 7, 2001): 50–57.

Johnston, L. D., P. M. O'Malley, and J.G. Bachman. National Survey Results on Drug Use from The Monitoring the Future Study. Rockville, Maryland: National Institute on Drug Abuse, 1975–1998.

U.S. Department of Health and Human Services (DHHS). Office of Applied Studies. National Household Survey on Drug Abuse: Main Findings (1997): 106–111.

Other

CNN.Com-Health. "Alcohol Named Europe's Youth Killer." February 20,2001. <http://www.cnn.com/2001/health/02/19/deaths.alcohol/index.html>.

National Council on Alcoholism and Drug Dependence, Inc. (NCADD). <http://www.ncadd.org>.

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>.

ONDCP Teens Page. Office of Drug Control Policy. <http://www.mediacampaign.org/kidsteens/teens.html>.

Prevline (Prevention Online). National Clearinghouse for Alcohol and Drug Information(NCADI). <http://www.health.org/>.

Organizations

Al-Anon Family Group Headquarters, 1600 Corporate Landing Parkway, Virginia Beach, VA, USA, 23454-5617, <http://www.al-anon.alateen.org>.

Alcoholics Anonymous (AA) World Services, 475 Riverside Drive, 11th Floor, New York, NY, USA, 10115, (212) 870-3400, <http://www.alcoholics-anonymous.org>.

Barbara Sullivan Smith