World Health Organization , Regional Office for Europe /
Copenhagen
Management of drinking problems
WHO Regional Publications, European Series, No. 32
The World Health Organization is a specialized agency of the United Nations with primary responsibility for international health matters and public health. Through this Organization, which was created in 1948, the health professions of some 165 countries exchange their knowledge and experience with the aim of making possible the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life.
The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health problems of the countries it serves. The European Region has 31 active Member States,° and is unique in that a large proportion of them are industri- alized countries with highly advanced medical services. The European pro- gramme therefore differs from those of other regions in concentrating on the problems associated with industrial society. In its strategy for attaining the goal of "health for all by the year 2000" the Regional Office is arranging its activities in three main areas: promotion of lifestyles conducive to health; reduction of preventable conditions; and provision of care that is adequate, accessible and acceptable to all.
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a Albania, Austria, Belgium, Bulgaria, Czechoslovakia, Denmark, Finland, France, Federal Republic of Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, Netherlands, Norway, Poland, Portugal, Romania, San Marino, Spain, Sweden, Switzerland, Turkey, USSR, United Kingdom and Yugoslavia.
CORRIGENDUM
Management of drinking problems
WHO Regional Publications, European Series, No. 32
It is regretted that, owing to an oversight, the author's name has been omitted from this book. Kindly ensure that it appears in all references to this publication.
The author's name and affiliation are:
Peter Anderson Director, National Unit for Health Promotion
in Primary Health Care Churchill Hospital Oxford, United Kingdom
Management of drinking problems
WHO Library Cataloguing in Publication Data
Management of drinking problems
(WHO regional publications. European series ; no. 32)
1.Alcohol drinking 2.Alcoholism - prevention & control 3.Community health services 5.Europe I.Series
ISBN 92 890 1123 8 (LC Classification: HV 5275) ISSN 0378 -2255
World Health Organization , Regional Office for Europe l
Copenhagen %
WHO Regional Publications, European Series, No. 32
Management of drinking problems
ICP /ADA 031 Text editing by Diana Gibson
ISBN 92 890 1123 8 ISSN 0378 -2255
©World Health Organization 1990
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CONTENTS
Page
Introduction 1
1. What we drink 5
Recorded consumption 5
Unrecorded consumption 11
Routinely collected national data 12
Ad hoc surveys 14
2. Why we drink 23
Incentives 24
Disincentives 29
Reinforcing influences 29
Moderating influences 31
3. Damage 35
National data 35
Individual data 46
Individual risk and level of consumption 59
Population -attributable risk 61
4. Resources 63
Community involvement and health promotion 66
Self -help and self -care 67
Informal care 69
Primary health care 70
General hospitals 73
Community-based programmes 74
Specialist treatment services 75
Detoxification services 75
5. Promoting health and preventing damage 77
National influences on consumption 77
Local action 86
6. Screening, case identification and assessment 91
Population screening 91
Screening for alcohol consumption 92
Measurement of psychosocial consequences 94
Self- assessment questionnaires and biological markers 100
Case identification 103
Assessment 108
7. Management 115
Prognosis and treatment of advanced alcohol problems 115
The therapeutic response 119
Working with particular population groups 128
Other potential resources 131
Organic and other problems 132
Referral 134
8. Education, training and research 137
Education and training 137
Research issues 143
References 147
Introduction
In many parts of Europe alcohol consumption has increased considerably during the last 25 -30 years. Simultaneously there has been a huge increase in alcohol- related problems, which are now regarded by a number of European countries as a major public health problem, second only to cigarette smoking (1,2).
Alcohol services have tended in the past to provide sophisticated specialist treatment for the few patients who either could afford to pay or lived near cities - but clearly the response to drinking and its conse- quences cannot come just from health workers. It is also quite unrealistic to expect any country to produce a group of specialists concerned solely with recognizing and treating these problems. WHO emphasizes the importance of a response embedded in the community (3) and the need for early recognition, and has also suggested ways of using reporting systems or other strategies for small -scale monitoring and evaluation (4,5). These strategies imply that early recognition is possible, and that nipping the problem in the bud will prevent further damage.
There is now increasing evidence that such strategies are justified. Nevertheless, careful evaluation of health promotion and simple inter- vention studies must continue, and more evidence of their efficacy is required. The logic and economic practicality of primary-level interven- tion is undisputed. However, more work is urgently needed to translate the rhetoric into workable, everyday activities. WHO has recently published a manual for community health workers on dealing with drug dependence and alcohol - related problems, which includes a set of guide- lines for trainers (6).
This book aims to take these issues further and examine them in more detail. It is based on the reports of three working groups convened by WHO. The first group considered treatment and rehabilitation pro- grammes for alcohol abuse (7). It concluded that in most European countries alcohol- dependent people place a heavy burden on society in terms of individual suffering, harm to others and high expenditure for
1
health and social services. But it also recognized that far more wide- spread damage may be done by the much larger percentage of people with high or even moderate levels of alcohol consumption, who may never reach the stage of alcohol dependence and whose physical, mental and social problems and their repercussions on the community go unrecog- nized and untreated.
In its report, this working group emphasized that the situation cannot be alleviated merely through recourse to long -term institutional care for people labelled as "alcoholics ". In addition to major efforts aimed at the prevention of alcohol -related problems, there is an outstanding need for the recognition of incipient alcohol problems and for intervention start- ing at an early stage. This work can only be undertaken with the collaboration of personnel in the primary health care services. Their willingness and ability to do it, however, is generally impeded by their lack of training and by the inadequacy of assessment and intervention techniques for use in primary health care.
The second working group examined the respective roles of primary health care and specialized services in the development and implemen- tation of programmes for problem drinkers (8). It concluded that there should be a redistribution of resources, emphasizing the role of primary care in the identification and management of individuals with drinking problems. This redistribution would depend on a community and political will that could be expected only from a population enlightened as to the nature of alcohol -related problems. This in turn implied an investment in health education in order to create a background of information from which responsible attitudes towards health and health promotion could develop. In the longer term, the group thought it likely that specialist services will take on a different role. If this happens then specialist personnel will help in making the transition to a more consulta- tive and educational role, less identified with the institutional setting.
The third group reported on the implementation and evaluation of programmes for problem drinkers (9). It concluded that the risk factor approach - in which alcohol is viewed as a risk factor for social, psychological and physical ill health - should be adopted in the training and work of primary health care personnel. The services provided in a community should reflect that community's needs. In particular, ser- vices should be provided for moderate and heavy drinkers as well as for people with really severe drinking problems. This would require better coordination and joint planning by primary health care and specialist services.
The main body of this book follows the logical sequence of a strategy for the prevention and management of alcohol problems in primary care. Chapter 1 examines the part played by alcohol and drinking in com- munities and in individual lives. The risk to health from alcohol varies according to the level of consumption, the pattern of consumption and the time it has taken to reach that level. Each individual's consumption is the
2
result of a balance between factors that encourage drinking and those that discourage it; Chapter 2 discusses this balance and how it varies over a lifetime. In so far as they are rational and have access to good infor- mation, people are autonomous and can choose their own lifestyles and habits.
Chapter 3 catalogues the harm that can result from the use of alcohol in terms of social, psychological and physical functions; the extent of the damage done varies according to levels of consumption. This chapter also emphasizes that efforts to reduce the "moderate" drinking of the majority of patients will have a greater effect on the total health of society than similar efforts to reduce the consumption of those already damaged by alcohol.
Chapter 4 discusses the resources available for preventing and man- aging alcohol problems. There are four levels of care: self -care, informal care, primary health care, and care by specialist services. Only a minority of individuals with alcohol -related problems reach the secondary care level. Chapter 5 lists ways of promoting health and preventing alcohol problems. An ecological approach is recommended and ways are proposed of influencing both national and local decisions.
Chapter 6 suggests a structure for ascertaining and categorizing the alcohol -related risks for individuals seen in primary health care. After assessment, they can be placed in one of three categories, which will help determine the action needed. Chapter 7 discusses this action and suggests ways of informing, advising and helping both the large majority of patients in primary health care who will make minimal demands on staff time - those with low or intermediate level of consumption - and also the remainder, whose management will require the combined resources of primary health care staff, the patient's family, and outside bodies. It is emphasized that these demands are no different in scale or scope from those in other areas of clinical management such as raised blood pressure, sexual problems or the early detection of cancer.
The staff of primary health care services will need training to carry out the tasks outlined in the proposed strategy: they must be flexible in their methods, alert to the needs of the community, and ready to work with and learn from other professional and lay people. Chapter 8, therefore, discusses the entire sequence of education and training, ranging from undergraduate education through general and higher pro- fessional training to continuing medical education in practices and local communities. This education and training needs to be firmly grounded in facts determined by audit and research. Learning, audit and research should merge imperceptibly into each other and in turn form the basis of policies for prevention, screening, assessment and management.
3
1
What we drink
Alcohol consumption has roughly doubled in a number of European countries in the last 25 years. From 1960 to 1972 world production of beer increased by 68 %, spirits production by 61% and wine production by 19% (10). Since that time, consumption has continued to increase in most European countries with the exception of France and, more re- cently, Sweden.
Recorded Consumption
Because of tax and excise, many countries have good records of national alcohol consumption (11 -15). Routine national data are available for trade, production and consumption.
Table 1 presents the figures for European Community trade in alcoholic drinks between 1965 and 1985. Community trade in alcohol has expanded with increased membership, but it has also grown steadily between periods of accession. Intra- Community trade imports of wine increased despite low consumption levels in new member states, more than replacing imports from the rest of the world. The growth in intra- Community beer imports between 1970 and 1975 was stimulated by the accession of Denmark, Ireland and the United Kingdom, all countries with a high per capita beer consumption. However, extra -Community beer imports more than doubled after 1975. The most dramatic trade effect was the increase in intra- Community imports of spirits after United Kingdom accession and the parallel decline in the imports of foreign spirits.
The export figures in Table 1 also reflect the rapid expansion of Community trade in alcoholic beverages. The European Community is now the world's largest wine producer with growing exports to non- member countries.
5
0\ Table 1. European Community trade in alcoholic beverages, 1965 -1985
(in thousands of kilograms)
Wines Beer Spirits Year
European Community
Intra Extra Intra Extra Intra Extra
Imports
1965 6 343 788 1 133 671 146 275 72 891 17155 59 950 1970 6 759 782 1 108171 222 493 88 297 50 745 127 961 1975 9 1 735 628 501 141 812 949 37 565 203 849 113 842 1980 9 1 836 820 532 583 871 067 49 507 296 357 105 658 1985 10 2 287 385 471 428 1 039 997 79 615 349 982 77 813
Exports
1965 6 283 980 306 960 154 870 165 156 26 671 84 043 1969 6 416 560 348 539 198 051 196 640 49 548 108 687 1975 9 1 658 352 494 551 800 698 441 273 239 922 544 473 1980 9 1 911 341 928 845 827 930 555 896 341 456 629 595 1985 10 2 588 723 1 095 248 980 664 835 760 385 324 616 989
a Total number of European Community member states at the time.
Source: Houveel aikohoihoudende dranken vorden er in wereld gedronken? (14).
Data on beer, spirits and wine production are given in Tables 2 -4. The Federal Republic of Germany and the United Kingdom are the main brewers, producing nearly 60% of total beer output in 1984. Although production has increased in major brewing states, the most rapid expan- sion has occurred in countries entering the Community as small brewers.
Community spirits production is dominated by the output of whisky from the United Kingdom and of brandy and aniseed products from France and the Federal Republic of Germany. Production of spirits increased in all member states between 1970 and 1980, particularly in countries with low production levels.
Most European Community wine is produced in France, the Federal Republic of Germany and Italy. Total Community wine production increased steadily from 1961 under the Wine Programme. However, output has declined since 1980 in countries that produce mainly table wines. About 70% of all wine produced in the European Community is table wine.
Table 2. Beer production in the European Community, 1965 -1984 (in thousands of hectolitres)
Country Year
1965 1970 1975 1980 1984
Belgium 11 092 13 015 13 797 14 291 14311 Denmark 4655 7087 9039 8169 8499 France 19 795 20 255 22 316 21 684 20 288 Germany, Fed. Rep. of 73 170 87 051 93 457 92 342 92 583 Greece 530 779 1 377 2 500 2 829a Ireland 4159 5040 6120 6000 5423 Italy 4 558 5959 6 463 8 569 9141 Luxembourg 499 541 805 729 6306 Netherlands 5402 8724 12434 15684 17048 United Kingdom 48433 55148 64566 64830 60105
EC 10c 172293 203599 230374 234798 230857
Portugal 3 665 Spain 21 833
a Estimate of Greek production at 2829 - Dutch Distillers. 6 1983 figure - Dutch Distillers.
c European Community of ten.
Source: Powell (15).
7
Table 3. Spirits production in the European Community, 1970 to 1982/1983
(in thousands of hectolitres of pure alcohol)
Country Year
1970 1975 1980 1982/1983
Belgium Denmark France
52 48a
2100
61
63a 2819
80 68a
2830
79
94 1781
Germany, Fed. Rep. of 1 198a 1 339a 1 342a 1 061
Greece 49a 83a 119a,b
Ireland 93 88 208 117 Italy 660 822a 923a 684 Luxembourg - - - 1
Netherlands 274 461 419 331
United Kingdom 4180 4446 4907 3305c
EC 10d 8 495 10185 10 898 - Portugal 89 Spain 1 150
a Actual pure alcohol content unspecified; assumed an average strength of 35% alcohol.
b 1979 figure.
c 1983/1984 figure.
d European Community of ten.
Source: Powell (15).
Data on alcohol consumption have been used as major indicators of the need for government alcohol control policies across the world. The changing pattern of alcohol consumption in various European countries is shown in Table 5. A general trend towards more homogeneous consumption can be seen after 1960. Those countries recording the lowest levels of per capita consumption for any type of drink show the fastest growth in consumption. Per capita consumption of beer and spirits has grown in all countries, but wine consumption has decreased in the two main wine -producing nations, France and Italy. Disparity between the countries has declined, with an overall increase in alcohol consumption.
Per capita consumption data are derived from statistics produced by member states on volume sold or released for consumption. The data do
8
Table 4. Winea production in the European Community, 1961 -1984 (in thousands of hectolitres)
Country Average over 4 wine years Wine year
1961/1965 1971/1975 1976/1980 1980/1981 1983/1984
Belgium 4 6 4 4 2 France 60 594 68 278 67 699 69 598 67 523 Germany, Fed. Rep. of 5184 8 222 8315 4 867 13 000 Greece - 5115 5 366 5 395 4 734 Italy 62 253 69 561 74 024 83 950 81 848 Luxembourg 135 145 93 50 185 United Kingdom - 1 2 2 11
EC 10b 128170c 152328 155503 163866 167303
Portugal 8 300 Spain 30400
a Production of all wines of various quality before distillation into wine alcohol.
b European Community of ten.
c European Community of six only.
Source: Powell (15).
o
Table 5. Per capita alcohol consumption (in litres) in the European Community of ten, 1960 -1984
Country Drinka Year
1960 1970 1980 1985
Belgium B 112.0 132.4 131.3 121.0 W 7.8 14.2 20.6 22.7 S 0.8 1.3 2.4 2.1
Denmark B 71.4 108.5 121.6 121.2 W 3.1 6.0 14.0 20.7 S 0.6 1.3 1.5 1.6
France B 35.3 41.3 44.3 40.1 W 126.9 109.1 91.0 80.0 S 2.0 2.3 2.5 2.3
Germany, Fed. Rep. of B 95.7 141.14 145.7 145.5 W 10.8 17.2 25.5 25.6 S 1.9 3.0 3.1 2.4
Greece B 5.5 9.4 26.3 33.9 W 40.8 40.06 42.5
0.66 1.3b 1.3b
Ireland B 67.3 100.6 121.8 108.4 W 2.0 3.3 3.6 3.5 S 0.8 1.5 2.0 1.8
Italy B 5.1 11.3 16.7 21.6 W 108.3 113.7 92.9 84.8 S 1.0 1.8 1.9 1.2
Luxembourg B 116.4 127.0 114.4 120.0 W 31.4 37.0 48.2 57.3 S 1.0 1.9 9.0 8.0
Netherlands B 23.8 57.4 86.4 84.5 W 1.9 5.2 12.9 15.0 S 1.1 2.0 2.8 2.2
United Kingdom B 85.1 101.6 117.1 108.9 W 1.6 2.9 7.2 10.0 S 0.7 1.0 1.8 1.7
a B = beer, excluding ciders; W = wine and fortified wine; S = spirits as 100% alcohol.
b Minimum estimates.
Source: Powell (15) and Brewers' Society international handbook.
not record consumption of home -produced alcohol, duty-free purchases, alcohol released from stocks, or the non -recorded beverages such as ciders in France. They relate only to drinks recorded as wines, beers or spirits, and therefore underestimate consumption. However, it is also
10
possible that some of the figures overestimate consumption by domestic populations. For example, in 1984 Luxembourg had the highest rate of spirits consumption per head of population in Europe. It is likely that this figure is vastly inflated by the large numbers of tourists and other visitors who purchase alcohol in Luxembourg every year.
The overall change in per capita consumption of pure alcohol must be calculated from bulk volume series by assuming average alcohol strengths. There are no consistent series estimating approximate strengths for beers, wines or spirits consumed in different countries. Series derived from production figures will not necessarily reflect the strength of drinks consumed in any country.
In some countries customs and excise data, which record for tax purposes the total amounts of beer, spirits and wines retained for consumption, are available for long periods of time. In the United Kingdom for example, customs and excise records have been collected with only brief interruptions since 1684. Fig. 1 (16) shows that the United Kingdom has had several waves of increased alcohol consump- tion in the past 300 years, and that the present rise is small compared to those of the 1750s and 1870s.
Unrecorded Consumption
Routinely collected production and tax data do not include data about unrecorded consumption of alcohol. There are three important reasons for documenting unrecorded consumption: first, to have complete statistical accuracy in total alcohol consumption figures; second, be- cause variations in unrecorded consumption may indicate important changes in drinking patterns (an increase in the production of home -made wines or beers may point to a growth in domestic hobbies); and third, because unrecorded consumption is important for studies on the inter- action between alcohol policies and public attitudes and behaviour.
The Social Research Institute of Alcohol Studies in Finland has documented unrecorded consumption in that country (17). Data were collected under four headings: unrecorded or home production, unre- corded imports, unrecorded consumption by alcohol industry employees, and consumption of non -beverage alcohol. The data came from five sources: government control and crime statistics on medicines, smuggled spirits, home -distilled liquors and denatured spirits; sales statistics on raw materials and supplies, such as yeast, distilling equip- ment, and crushed barley malt for home -made beer; estimates by experts; observations; and surveys. The fmdings are given in Table 6. The sum total of unrecorded consumption remained fairly constant throughout the study period of the 1950s to the 1970s. However, unrecorded consump- tion as a proportion of recorded consumption decreased, due to a huge growth in recorded consumption.
11
800
co
> 600
a c o
â 400 CL)a c ä 200
10
8
6
Fig. 1. Alcohol consumption in the United Kingdom, 1680 -1975
Beer OG = original gravity 450
1350 T
a F,72'
-1 250 °
CD"
as brewed - 150 Jat OG 1055
at OG 1055 I I
50
6
Spirits
4
10
8
6
4
I700 I 750 1800 1S50 1900
Source: Spring & Buss (16).
1950 1975
Routinely Collected National Data
In a number of countries government departments routinely collect data on alcohol use (18). In the United Kingdom, for example, there are two
12
annual surveys, the General Household Survey ( 19) and the Family Expenditure Survey (20 ). The General Household Survey, conducted by the Office of Population Censuses and Surveys, has been running since 1971. Each year all adults (those aged over 16) in approximately 10 000 private households are questioned on core topics related to social policy. Questions on drinking, using a quantity frequency format, have been included biennially since 1978 (Table 7). The response rate is 82-84%.
Table 6. Unrecorded and recorded consumption of alcohol in Finland in the 1950s, 1968-1969 and 1976
Period
Item
1950s 1968-1969
Breakdown of unrecorded consumption (in litres of 100% ethanol)
Sahti8 150000 Ki/jub 250000
Home-made wines 400000
Pontikkac 300 000 -450 000
Imported by travellers 50 000 -200 000
Smuggled alcohol 120 000 -600 000
Consumed by alcohol industry employees negligible
Medicines containing alcohol 400 000-500000
Spiritus fortis d ?
Other rectified alcohol ? _ Cosmetic products
containing alcohol 8000-120000
Strongly denatured alcohol 50000
Total unrecorded consumption 1 800 000-2 720 000
Recorded consumption (in millions of I it res of 100% ethanol) 6 .9-8.4
Unrecorded consumption as a percentage of recorded 21.4-39.4
a Traditional home-brewed beer .
b Sugar-fermented home-made alcohol .
c "Moonshine".
280000
130000
400000
25000
400000
180000
negligible
negligible
75000
?
negligible
280000
1 770000
1968: 13.5 1969: 19.8
1968: 13 .1 1969: 8.9
d Surgical and rectified spirits provided to pharmacists by Aiko .
Source: Makela (17).
1976
270000
80000
400000
250000
1 200000
50000
negligible
negligible
75000
?
negligible
negligible
2325000
29.8
7.8
13
Table 7. Drinking habits in the United Kingdom,
Type of drinkera
abstainer occasional infrequent light frequent light moderate heavier
Sample size (v 100 %)
1978 and 1982
Men Women
1978 1982 1978 1982
( %) (%) ( %) ( %)
5 6 11 12 9 10 25 23
11 12 19 20 34 37 39 40 15 14 4 4 25 21 2 1
10 015 8(780 11 650 101185
a Persons aged 18 or over only.
Source: Office of Population Censuses and Surveys (19).
The Family Expenditure Survey, begun in 1957, provides infor- mation on private households in the United Kingdom and their expendi- ture patterns. Responders keep a diary in which they make a detailed record of expenditure over 14 consecutive days, including spending on alcoholic drinks (Table 8). Some 11 000 households take part in the study, and response rates of 68-71% are achieved.
Ad Hoc Surveys
A number of countries obtain information on alcohol consumption from ad hoc surveys on either national or regional sampling frames (21-26). For example, random samples of the Dutch population of age 20 and over were interviewed in 1958, 1970 and 1981 on, among other things, alcohol consumption (26). Changes in the distribution of consumption in various subpopulations are shown in Table 9. Between 1958 and 1981 the increase in per capita consumption in the Netherlands was more than 300 %. The surveys show that this increase in consumption was due neither to a decrease in the proportion of abstainers nor to a decrease in the differences in alcohol consumption between different subpopulations.
Tables 10 and 11 show drinking patterns in England & Wales for women and men, respectively. The results were obtained by detailed questioning about drinking during the week before interview (21). They
14
show that there are major differences between the amounts consumed by the two sexes, and it is younger adults, particularly young men, who are most likely to drink heavily. The survey also showed that there were no consistent variations in alcohol consumption between different social classes in England & Wales, although workers in the construction and drinks industries drank more than those in other industries. This study also demonstrated regional differences in consumption patterns, people in the north of the country being the heavier consumers.
It has been found that most drinking surveys cover only 40-60% of total alcohol consumption as indicated by taxation figures (27-30). There may be many reasons for this deficiency. For example, the validity of a survey may be undermined if it either misses or inadequately samples the target population. In many studies the pool of respondents is selected from electoral registers; heavy drinkers may cluster within certain districts, therefore the likelihood of their being sampled in a random survey is small. Moreover, drinkers of this type may live in institutions such as the armed forces, hospitals, prisons, colleges and so on, or they may be homeless; in neither case will they appear in the register.
It is also argued that the heavier drinkers included in a sampling frame are not only harder to locate but also more likely to refuse an interview. Various health and preventive studies in Scandinavia have compared participating and non -participating middle -aged men using data drawn from medical, police, forensic, temperance and taxation registers. These studies showed that non -participants had higher rates of alcohol -related morbidity and mortality and were more likely to be unmarried or divorced, and also poorer, than participants (31). However, it was shown that non -participants in a British survey who were later interviewed by post did not differ substantially from participants in either sociodemo- graphic characteristics or self- reported consumption levels (32).
The respondent's forgetfulness about alcohol consumption increases or decreases according to the drinking measure used in the survey. Respondents tend to underestimate the frequency of their drinking, and to overestimate the quantity they have consumed on a typical drinking occasion. Several researchers have estimated memory loss for the week prior to interview by assuming complete recall of the previous day and comparing that answer with responses for the other days. Sixteen per cent of all drinking occasions were forgotten in a Canadian study (27), as were 9% of occasions and 8% of consumption in an English study (28).
Several studies have dealt with memory loss over longer periods. A Finnish study showed that estimates of daily consumption recorded in diaries over a period of six weeks were 60% higher than estimates given in answer to repeat questionnaires (33).
Deliberate underreporting of alcohol consumption may occur, be- cause of the stigma associated with alcohol abuse and its behavioural effects. It seems to be particularly pronounced among respondents who are male, young and employed and among heavier drinkers. The extent
15
Table 8. Consumer expenditure in the United Kingdom, 1976 -1984
1984
1976 1977 1978 1979 1980 1981 1982 1983 Indices/ Current
percentages prices (m£)
Indices at constant 1980 prices Food 97 96 98 100 100 99 99 101 99 28 448 Alcoholic drink 95 95 100 104 100 97 94 98 100 14 416 Tobacco 100 95 103 103 100 93 86 85 82 6 621 Clothing and footwear 85 86 95 101 100 99 103 110 116 13 158 Housing 92 94 95 98 100 101 103 104 106 29 239 Fuel and power 95 98 99 104 100 100 98 98 97 9 574 Household goods and services
Household durables 94 88 94 105 100 98 101 109 112 7 016 Other 100 97 104 103 100 100 101 106 109 6 182
Transport and communication Purchase of vehicles 83 73 93 107 100 100 102 122 116 9 536 Running of vehicles 92 93 97 98 100 101 104 105 107 13 578 Other travel 90 90 93 98 100 100 96 99 106 6 457 Post and telecommunications 73 77 85 96 100 101 102 105 113 3 528
Recreation, entertainment and education
TV, video, etc. 82 84 90 99 100 111 124 140 152 4 875 Books, newspapers, etc. 99 98 99 100 100 97 94 91 90 2 724 Other 88 91 96 99 100 99 98 99 102 10 157
Other goods and services Catering (meals, etc.) 97 99 98 101 100 92 91 98 100 11 048 Other goods 104 106 112 112 100 101 104 103 107 5 879 Other services 88 91 93 97 100 103 110 119 126 8 880
Less expenditure by foreign tourists, etc. in the United Kingdom
Household expenditure abroad Final expenditure by
non -profit bodies
107 53
96
122 51
94
114 63
96
110 80
97
100 100
100
91
106
102
89 106
103
96 107
108
102 106
112
4 866 4 224
3 999
Consumer expenditure 91 91 96 100 100 100 100 104 106 194 673
Percentage of total consumer expenditure at current prices
Food 18.4 18.6 18.0 17.2 16.7 15.9 15.4 15.0 14.6 28 448
Alcoholic drink 7.6 7.6 7.3 7.3 7.3 7.3 7.2 7.3 7.4 14 416
Tobacco 4.1 4.2 3.9 3.6 3.5 3.6 3.5 3.4 3.4 6 621
Clothing and footwear 7.7 7.7 7.9 7.8 7.2 6.7 6.6 6.6 6.8 13 158
Housing 13.4 13.4 13.2 13.2 13.7 14.8 15.5 15.0 15.0 29 239
Fuel and power 4.7 4.9 4.6 4.5 4.6 5.1 5.2 5.2 4.9 9 574
Household goods and services 7.6 7.3 7.6 7.6 7.3 6.9 6.7 6.8 6.8 13 198
Transport and communication 14.9 14.7 15.5 16.4 16.6 16.7 16.6 17.1 17.0 33 099
Recreation, entertainment and education 9.1 9.3 9.4 9.2 9.2 9.2 9.3 9.1 9.1 17 756
Other goods, services and adjustments 12.6 12.4 12.7 13.1 13.8 13.8 14.0 14.5 15.0 29 164
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 194 673
Source: United Kingdom National Accounts, Central Statistical Office.
Table 9. Consumption levels of different Dutch subpopulations in 1958, 1970 and 1981 (percentages)
1958 1970 1981
Ab- 5 3 4-12 13-21 2 22 Ab- S 3 4-12 13-21 222 Ab- S 3 4-12 13-21 222 stainers glasses glasses glasses glasses stainers glasses glasses glasses glasses stainers glasses glasses glasses glasses
Sex
Men 11.6 62.18 1938 5.08 2.08 13.7 2825 33.5 13.95 10.75 13.2 20.3c 32.4c 182c 15.7c
Women 28.8c 65.28 7.18 1.88 0.2 31.3 44.25 19.0b 5.1b 0.75 30.3 32.6c 26.1c 8.6c 2.4c
Men
21-40 years 11.1 58.88 22.1a 5.78 2.3a 8.8 23.6 33.7 19.4 14.5 11.3 18.4c 35.3c 18.4c 16.6c
241 years 12.18 65.18 16.78 438 1.88 19.8 333b 31.6 8.4b 6.9b 15.2 22.2c 29.5c 18.1c 14.9c
Women
21-40 years 19.5 68.88 10.38 1.48 - 22.8 42.4 27.6 6.2 1.05 27.1c 36.7c 23.6c 9.0c 3.5c
241 years 30.78 62.38 4.6a 2.2 0.3 38.2 43.35 13.6b 4.4b 0.5 33.7 28.2° 28.8c 8.0c 1.2
Men
More educated 13.68 60.58 19.78 4.8 1.48 19.9 33.95 28.3 8.7b 9.1 15.3 22.8c 30.6c 17.4c 13.9c
Less educated 9.2 63.98 18.98 5.28 2.88 10.5 15.4b 36.1 16.5 11.65 11.6 18.4c 33.9c 182c 172c
Women
More educated 28.98 64.78 4.48 2.1 - 44.45 41.1 11.1b 2.4b 1.0 35.2 35.5c 21.1c 6.5c 1.7c
Less educated 19.9 66.28 12.18 1.38 0.4 22.6 462b 23.9b 6.8b 0.4 24.8 29.3c 31.8c 10.9c 32c
Men
No religious denomination 8.9 61.56 23.7 5.28 0.78 14.0 26.1 31.3 15.0 13.7 132 202c 33.3c 16.9c 16.5c
Roman Catholic 9.1 59.8a 22.08 5.46 378 13.2 23.7 33.8 16.9 12.4b 9.8 17.3c 31.6c 222c 19.1c
Protestant 16.0 67.96 11.78 3.76 0.88 13.7 34.9b 35.6 9.9 6.0 13.0 24.4c 38.2c 16.0c 8.4c
Women
No religious denomination 27.8 63.26 7.6a 1.4a 0.0 27.9 42.3b 22.4 6.6 1.2 24.8 33.0c 30.3c 10.6c 1.4
Roman Catholic 22.0 67.56 7.8a 2.28 0.4 27.6 46.9b 18.8 5.9 0.8b 28.0 32.0c 27.1c 8.4c 4.4c
Protestant 27.88 64.3a 6.2a 1.7 - 37.2 43.5 16.1 326 - 352 32.4c 22.5° 7.7° 1.6
Men
(Total: 2035) 63 337 27 11 117 242 287 119 92 84 129 206 116 100
Women
(Total: 2095) 171 433 47 12 1 238 338 145 39 5 202 217 174 57 15
8 Significant difference between 1958 and 1970.
b Significant difference between 1970 and 1981.
c Significant difference between 1958 and 1981.
Note. Two -sided t -test significant at P 5 0.05.
Source: Knbbe et al. (26).
Table 10. Alcohol consumption in the previous week, by age, in England & Wales - females
Type of consumption Age group (years)
18-24 25-34 35-44 45-54 55-64 65
( %) ( %) ( %) ( %) ( %) ( %)
Nondrinker 5 6 8 8 11 24
Occasional drinker (nothing to drink in previous week) 17 25 27 33 41 39
1 -5 units 38 41 38 33 33 25
6 -10 units 12 11 13 10 7 6
11 -20 units 18 14 10 12 7 4
21 -35 units 6 2 2 3 1 1
36 -50 units - 1 1 1 - - 51 -75 units 2 - 1 - - - 76 units or more 2 - - - - -
100 100 100 100 100 100
Sample size 125 222 179 157 158 221
Source: Wilson (21).
of underreporting is influenced by specific aspects of the interview, including the characteristics of the interviewee (30).
Underreporting may also occur when the questions are inappropriate. In a Finnish study higher consumption estimates were obtained from alcohol -dependent individuals when questions focusing on high con- sumption were used in place of questions concerning low or moderate consumption which were normally used for non -dependent respon- dents (34).
* * *
Although drinking surveys underestimate the total amount of alcohol consumed, therefore, when compared to taxation figures, the biases are likely to be consistent over time, so that surveys do allow the study of changes in drinking patterns and of differences between the various age and sex groups. The next chapter examines the reasons behind an individual's drinking level.
20
Table 11. Alcohol consumption in the previous week, by age, in England & Wales - males
Type of consumption
Age group (years)
18-24 25-34 35-44 45-54 55-64 >65
( %) ( %) ( %) ( %) ( %) ( %)
Nondrinker 2 5 5 4 10 9
Occasional drinker (nothing to drink in previous week) 5 7 13 19 22 37
1-5 units 13 18 18 21 25 21
6 -10 units 14 16 14 16 11 9
11 -20 units 17 20 21 15 13 13
21 -35 units 25 15 15 11 9 8
36 -50 units 11 10 9 10 6 2
51 -75 units 8 5 6 4 3 1
76 units or more 5 3 1 1 1 - 100 100 100 100 100 100
Sample size 123 177 151 166 143 173
Source: Wilson (21).
21
2
Why we drink
In recent years a new framework has been developed, by the British Psychological Society (35) in particular, for understanding the reasons why people drink certain amounts. According to this framework, drinking is seen as spread along a continuum, from harmfree drinking at one end to harmful drinking at the other. An individual's drinking behaviour is learned and modified by experience; at any stage it is determined by a balance of the advantages and disadvantages, the pleasure and the harm. All drinkers, whatever their current level of drinking, also have the choice of moving forward or backward along the continuum.
If a cross -section of people, including those who are concerned about their drinking and those who are not, are asked why they drink, they will give a very mixed bag of answers (36):
to feel more relaxed in company because it goes well with meals to make me feel more relaxed to pick me up when I feel tired to help me go to sleep to relieve a stressful situation
at home I like the taste to relieve boredom to quench my thirst
There may also be deeper reasons or expressed:
to reduce threats to one's feelings of adequacy
to protect against depression to relieve internal conflict prompted by one's dependence on alcohol
to relieve a hangover to perform sexually to have a good laugh to get drunk to feel good only because I'm offered a drink because it's the social custom for no particular reason I wouldn't miss it if it wasn't
there
which are not so easily recognized
to achieve peer status to relieve role -strain in one's job
to enhance fantasies of personal power
as self -reward
23
to express rebellion against as self -punishment parents or others in authority as sedation
to ease the tensions of an to relieve sex -role conflict unhappy home life
These lists are incomplete, but their length and variety illustrate a number of things. First, like other drugs and activities that can be used for psychological purposes - such as eating or gambling - alcohol can serve a wide variety of functions (37). Taken in different doses and consumed over varying periods of time, it can have very different psychopharmacological effects. Furthermore, it is so widely available in so many different forms that its use can change according to the concen- tration of alcohol in a particular drink, the time of day, the company in which it is drunk, the place where it is drunk, and the meaning of the occasion (a celebration, a negotiation, a last fling, a drink before a meal, and so on). Not only this, but its effects also depend on personality and on an individual's expectations. Experiments have shown that, at least in moderate doses, whether a drink produces laughter, sexual arousal or further drinking depends not on what it contains but on whether the consumer was told that it contained alcohol (38). Hence, as with all psychoactive drugs, expectation plays a role.
Incentives
Given this variety of functions that alcohol can serve and the complexity of its psychopharmacology, it is no surprise that different people derive different kinds of benefit from it, depending upon their age, sex, stage in their life cycle and role. The same substance that among young people can serve to increase social confidence, enhance status among friends, give the courage to rebel, and relieve boredom or sexual anxiety can help a middle -aged professional man to face the stresses brought about by an unhappy marriage, rebellious children, a tiring, highly stressful and frustrating job, or feelings of mortality and mid -life crisis. Women who drink in a way that puts them at risk are less likely than their male counterparts to refer to the positive social functions of drinking and more likely to refer to the strains and role conflicts of being wives and mothers or the tensions of combining responsibilities inside and outside the home (39).
It is important to remember that the determinants of drinking behavi- our are as much social, cultural and environmental as they are personal. Almost all surveys of the drinking behaviour of young people find that involvement in drinking is correlated with the behaviour of their friends. The peer group appears to be the single most important determinant at least of early drinking patterns in adolescence and young adulthood (37). (The same is true for cigarette smoking and the use of other drugs.)
24
Drinking is largely a social and recreational activity, so it is understand- able that friends have a major influence on drinking habits, and not only in the case of young people. Women in particular continue to be highly influenced by the drinking practices of their male companions, and it is known that the husbands of women who drink excessively or harmfully are likely to be heavy drinkers themselves (40).
Although excessive drinking may become a solitary affair for some people later on in their lives, for most people - and particularly for men - drinking remains a social phenomenon for most of their drinking careers. It is more the rule than the exception to find in the drinking histories of excessive drinkers that some period has been spent living or working in an environment where alcohol was more than usually readily available, and where heavy drinking was the norm (41). Not only are individuals at risk because of the personal functions that heavy drinking may serve for them, but certain environments are risky for the individuals who inhabit them. For example, life in France carries a higher risk of cirrhosis of the liver than life in Norway (Fig. 2). In the United Kingdom, entering adulthood in the early years of this century was more risky in terms of drinking than immediately after the Second World War (Fig. 3). Being brought up in England by first - generation Irish immigrants is riskier than being brought up in England by indigenous English parents (43). Working in a brewery or a public house is riskier than being an accountant (Table 12).
On this last point, there are clear links between alcohol -related problems and occupation. In the United Kingdom, for example, publi- cans have a mortality rate from cirrhosis of the liver of 15 times the average, and fishermen 6 times. The reasons for these differences lie within the realms of easy availability of drink, its relative cheapness, social pressures to conform, separation from normal social and family restraints, opportunities for unsupervised drinking, stress, and also the selection and self -selection of high -risk individuals. In England & Wales the construction industry had the highest proportion (19 %) of men drinking over 50 units weekly (21), compared to only 6% in this category in the male population as a whole. Men in the drinks industry had the highest consumption per person employed - 38 units weekly, compared to 20 units weekly for the whole male population.
In recent years awareness has also grown that risky drinking is not just a matter of individual psychology or pharmacology or occupation, but also of public health. There is a direct relationship between public controls of alcohol consumption such as price manipulation on the one hand, and overall consumption of alcohol and rates of alcohol -related problems on the other. National consumption and death rates from cirrhosis of the liver, for example, are highly correlated (1). There is also considerable evidence that the whole drinking continuum in a population can be shifted by external factors such as price increases and availability.
25
Fig. 2. Alcohol consumption and death rates from cirrhosis of the liver in selected countries (mid- 1970s)
Cirrhosis of the liver
40 30 20 10
Deaths from cirrhosis per 100000 population
Source: Alcohol - reducing the harm (42).
0
Iceland
Norway
Sweden
Finland England & Wales
Poland
Netherlands
Alcohol consumption
German Democratic) Republic f
Yugoslavia
Denmark
Czechoslovakia
Belgium
Switzerland
Hungary
Austria Germany, Federal Republic of
Spain
France
Since 1950 -1952
+ 236%
+ 105%
0 5 10 IS
Litres of pure alcohol per capita
+ 48%
+ 191%
+ 74%
+ 165%
+ 337%
+ 337%
+ 230%
+ 130%
+ 88%
+ 55%
+ 56%
+ 123%
+ 107%
+ 247%
+ 73%
-6% J 20
Fig. 3. Alcohol consumption by type, United Kingdom, 1900 -1984
10
0.3 -
0.2 -
Spirits
Wine
0.1 t t t t l t t i t
1900 1910 1920 1930 1940 1950 1960 1970 1980
Source: Alcohol - reducing the harm (42).
27
Table 12. Mortality from liver cirrhosis in England & Wales, 1970 -1972
Occupation Standardized mortality rate
Publicans, innkeepers 1576
Deck officers, engineering officers, ships' pilots 781
Barmen, barmaids 633 Deck and engine -room ratings, barge- and boatmen 628 Fishermen 595 Proprietors and managers in boarding- houses and hotels 506 Finance brokers, insurance brokers, financial agents 392 Restaurateurs 385 Lorry drivers' mates, van guards 377 Armed forces (British and overseas) 367 Cooks 354 Shunters, pointsmen 323 Winders, reelers 319 Electrical engineers 319 Authors, journalists and related workers 314 Medical practitioners 311
Garage proprietors 294 Signalmen and railway- crossing keepers 290 Maids, valets and related service workers 281
Tobacco preparers and product- makers 269 Metallurgists 266
Source: Plant (44).
In a study done in Edinburgh, a sample of 500 members of the public were interviewed about their drinking and alcohol -related problems (45). The subjects were first interviewed in 1978 and then in late 1981 and early 1982, following a substantial rise in the price of alcoholic drinks brought about by the March 1981 Budget. It was found that not only had the sample's average alcohol consumption decreased, but the number of alcohol -related problems had also fallen. The most important finding, however, was that the heavy drinkers and those suspected of being dependent on alcohol reduced their consumption just as much as people who drank more moderately.
A part of the answer to the question of why people drink, then, is that people are subject to a variety of individual and social factors that influence their disposition to drink. Some people are affected by factors such as cultural background, peer group, occupation, stress, genetic makeup and so on that put them at risk of drinking much or drinking often
28
(the two are not necessarily the same, since drinking patterns vary) whilst others are affected by factors that put them at much lower risk.
Disincentives
There is one important respect in which the picture given so far is incomplete. It shows only the attractions or incentives for drinking, and has nothing to say about the restraints, the disincentives, the reasons why individuals do not drink, or do not drink more than they do. There are a whole host of disincentives or discouragements that influence people's drinking behaviour. These include unpleasant physiological responses to alcohol: there is evidence, for example, that some Orientals have an unpleasant flushing response to quite small doses of alcohol (46). Other disincentives may be financial restraint, lack of time and effort to devote to drinking because of preoccupation with other interests and activities, disapproval by family, friends or colleagues, a philosophical preference for an aesthetic rather than a hedonistic way of life, or membership of religious, cultural or other groups that proscribe the excessive or even any use of alcohol. Some people may never have been exposed to the use of alcohol, or not have learned to drink during their upbringing.
Reinforcing Influences
The framework for understanding drinking is made all the more compli- cated by the fact that human beings and their motivations rarely stand still, but are subject to change and development during the course of a lifetime. One study of the development of young adults' drinking behaviour over a four -year period gives a good example of this (47). It was found that whether a young person was a drinker or not was correlated with a number of factors, including the person's conformity or non -conformity, and the number of close friends who were drinkers. These factors were not simply causal factors, however. They changed over a period of four years, as did the drinking: the young people who became less conformist and more likely to be drinkers were also more likely to have friends who drank, as time went on. Furthermore, it was also shown that becoming a drinker at a particular stage was associated with a reduction in conformity both before and after the onset of drinking. This study shows that a change in behaviour such as drinking does not occur in a psychological vacuum, but as part of a group of changing beliefs, preferences and habits, and that drinking behaviour cannot be divorced from the demands, both biological and social, of particular stages in the life cycle.
Plant's study of the drinking habits of employees in the drinks trade (41) demonstrates the same point. Plant was interested to know whether
29
being employed in this trade was risky in terms of drinking because of factors inherent in the job, or whether it was a matter of self -selection, with people who were already heavy drinkers opting to enter that environment. In fact, it turned out to be both. As a group, people who enter the drinks trade are heavier drinkers than others, but they also become heavier drinkers still, once they are on the job.
Both the students in the first study and employees in the second were subject to a process of positive feedback. The older the students became, or the older the employees were on entering a new job, the more likely they were to drink. The more likely they were to drink, the more they lost their innocence. The more they lost their innocence, the more likely they were to drink.
There are a number of other developmental processes that have a great deal to do with the development of habitually excessive or risky drinking. One of these is the process of learning, whereby behaviour that is rewarded or reinforced sufficiently often becomes habitual and diffi- cult to eradicate. This process is much aided by conditioning, whereby formerly neutral stimuli such as the sights and sounds of a public house or cafe, the smell of a favourite drink, and all the paraphernalia associated with a pleasant drinking occasion take on emotionally positive conno- tations because of their associations with the rewarding results of drink- ing. The whole process may then be bolstered by positive mental images or thoughts such as "What !really need now is a good drink "; "I'm a real man if I can hold my drink "; or "People who don't drink heavily are boring" . These processes in combination are immensely powerful (47).
Other reinforcing processes take effect in later stages of the drinking career. One is the development of an altered psychobiological response to drinking. Increased tolerance, the presence of withdrawal symptoms when blood alcohol levels fall, and the discovery that the malaise can be relieved by further drinking, create an additional source of motivation for regular and excessive drinking that makes the habit more difficult to break. Increased tolerance to the effects of alcohol is acquired as a result of a history of drinking. It relates to the amount drunk and the length of time drinking. It is acquired gradually, is relatively greater for some functions and abilities than for others, and may be reduced during periods of abstinence or much lighter drinking. Both increased tolerance and withdrawal symptoms which may be relieved by further drinking are sometimes quite rapidly reinstated, within a few days, if drinking is resumed after a period of abstinence or lighter drinking. This increased tolerance should not be confused with reduced (or reversed) tolerance, which usually develops after a much longer history of risky drinking. Then, quite moderate levels of drinking may give rise to much greater than usual effects and damage, probably because of brain and /or liver damage. The late stages of a long drinking history may also be complicated by some degree of cognitive impairment caused by damage
30
to the central nervous system, which can then affect the ability to make choices about future drinking.
There are social and personal processes that have the same effect. Increasingly heavy drinking may tend to lead a person towards the company of other heavy drinkers, and away from the company of moderate drinkers. It may lead the individual to seek employment in which drink is more easily available. Some of the harmful effects of excessive drinking such as losing a job, or becoming estranged from family, may themselves cut the person off from some of the major constraints to heavy drinking. The loss of self- confidence and self - respect and the increase in worry and tension often associated with heavy drinking themselves add weight to the pressure towards heavier drinking.
Moderating Influences
As well as these reinforcing processes, there exists a parallel set with a moderating effect. The financial burden of heavy consumption, for instance, may cause the drinker to cut back on drinking; or the awareness that it is affecting work may lead to a resolve to drink less or not at all for a period. Advice that gastritis and overweight are in large part attribu- table to excessive drinking may help a patient to take immediate correc- tive action; or again the realization that their drinking is getting out of control induces some people to seek expert advice.
The role of the family in moderating drinking cannot be overempha- sized. Particularly for people who live in a family setting - and this includes the majority of excessive drinkers - the family plays a major part in helping or hindering the achievement of a lower level of drinking. By encouraging excessive drinking, or unwittingly contributing to a downward spiral of increased family tension and disengagement, a family may make it more difficult for one of its members to drink less. On the other hand, the family may become the principal cause for change by influencing the drinker in favour of moderate drinking, and by continuing to give constructive care and affection (48).
An important implication of the argument developed in this chapter is that no fundamental difference exists between spontaneous and thera- peutic improvement. There is good evidence that people with alcohol problems often treat themselves and can move away from harmful alcohol use by drinking less. Vaillant, for example, reported the results of a longitudinal study of 456 Boston boys aged 14 years who were followed up for 35 years from 1940 (49). During this period 110 of them developed symptoms of alcohol abuse, but 48 of these subsequently achieved at least one year of abstinence, and 22 were able to return to social drinking. About one third of the 48 who became abstinent and 9 of the 22 who returned to social drinking did so with the aid of professional treatment, and about one third of the abstainers had also been
31
helped by Alcoholics Anonymous. Most, however, helped themselves. A number of factors enabled these subjects to become abstinent: in particular, 48% of them had developed a medical problem that was instantly made worse by further drinking and so reminded them con- stantly of the need to change their drinking habits.
* * *
An individual's position, then, on the continuum which runs from abstinence at one end to excessive and risky drinking at the other depends on the balance struck between a whole host of factors, some of which incline towards drinking and others that restrain it. For every individual there is an attraction/deterrence equation that determines drinking behav- iour. Another way of expressing this is to say that everyone has a balance sheet with entries on one side representing factors that incline him or her to drink or to drink more, while the entries on the other side incline the person to drink less (Tables 13 and 14).
Table 13. Hypothetical balance sheet of a moderate drinker
Payoffs from drinking
Positive Negative
Feelings "High"; stimulated after a few drinks
Headache, dry mouth and mildly depressed next morning if I have drunk a lot
Performance Increased energy Reduced concentration at and motivation work in the afternoon immediately after lunch if I drink at lunchtime
Relationships Closer, less tense with - with others work colleagues
Economic - Leaves money short at the weekend if I drink a lot on Friday night
Other Part of enjoyable relaxation at snooker club and at home with family and friends
Source: Robertson et al. (35).
32
Table 14. Hypothetical balance sheet of a heavy drinker
Pay -offs from drinking
Positive Negative
Feelings
Performance
Relationships with others
Economic
Other
Helps cope with family and job worries, relaxes
Can face working after a few drinks
Meet several other heavy drinkers in the local who are good company; able to assert myself
Feel guilty about drinking so much
Making mistakes at work; one or two near -misses in car
Family complaining about not seeing me much; have embarrassed them a few times; they say I'm a changed character after drinking
Can't afford what I'm spending on drink
I've put on a lot of weight
Source: Robertson et al. (35).
It is within this framework of a balance sheet of advantages and disadvantages of drinking and a continuum along which an individual may move, forwards or backwards, at different stages of life that the primary health care worker' s role can be considered. Being uniquely well placed and well qualified to detect signs of risky and harmful drinking and to influence those who are drinking to excess, primary health care workers have a crucial role to play.
33
3
Damage
In recent years there has been a fundamental reappraisal of the nature of the damage done by alcohol. The old belief, that "alcoholics" were different from the rest of the drinking population and the cause of society's problems, has been replaced by the idea that drinking and the harm done by it range along a continuum from minimum alcohol consumption with little damage and slight risk, to heavy consumption with a high probability of damage and high risk. So, broadly speaking, alcohol can be seen as a risk factor. Anyone who drinks is at risk, but by and large the more alcohol consumed, the greater the risk. In this respect alcohol is similar to blood pressure and serum cholesterol, both of which range from low to high and are risk factors for ill health. The higher the level of blood pressure the greater the risk of cerebrovascular disease, and the higher the serum cholesterol level the greater the risk of coronary heart disease.
National Data
A large amount of data is collected routinely on indicators of alcohol - related damage. Mortality data, collected from death certificates written by attending physicians, include mortality from cirrhosis and other alcohol -related conditions as well as from alcoholism and alcoholic psychosis. These data vary considerably in both accuracy and the recording rates for alcohol -related conditions on death certificates. It is possible that incorrect entries are common, due either to negligence or to diagnostic error. For example, ischaemic heart disease may be recorded instead of cardiomyopathy of alcoholic origin, and conditions related to chronic alcoholism are sometimes omitted. Such figures, important though they are, are not enough to show the scale of the problem. Excessive drinking is a contributory or determining factor in many diseases or deaths attributed to other causes such as cancer of the upper
35
respiratory tract, the digestive system and the oesophagus, or deaths in road and industrial accidents.
Other routinely collected data include hospital admissions for con- ditions such as liver cirrhosis, alcoholism, alcoholic psychosis and in- toxication, and data on charges for drunkenness and drinking -and- driving. Some countries routinely collect data for both hospitals and primary care services.
Many of these data are also collected on a regional basis. However, it can be very difficult to interpret regional differences in damage indicators. In the United Kingdom, for instance, many indices of alcohol problems show regional variations, with higher figures in the north of England and in Scotland than in the south (50,51). Part of the difference can probably be attributed to differences in detection, recording and the provision of services (52 -54).
The consumption /damage relationship The idea that alcohol consumption and damage are related had its origin in the work of Ledermann (55). He made two assertions: first, that in a homogeneous population the distribution of alcohol consumption is a log -normal curve (Fig. 4), and second, that the number of people who drink a certain amount can be calculated if the average consumption is known. Although Ledermann's work, which is essentially theoretical, has been severely criticized and is the subject of much debate (56 -58) nevertheless the curves of distribution of alcohol consumption produced by various surveys in different countries, although not exactly log- normal, are similar and are always skewed and unimodal (59,60).
The evidence that consumption and damage are related depends less on theory than on empirical evidence, however. Because of tax and excise, many countries have good records of national alcohol consump- tion. They do not record home -made alcohol, but until recently in most countries this was only a small part of total consumption. Some countries also have systems of death certification going back over 100 years. Putting together the figures for consumption and damage produces striking correlations that convince most people of the link between the two. Table 15 gives figures for consumption and alcoholic deaths in Britain for five -year periods from 1885 to 1934 (61). The correlation is clear. More recent evidence both from England & Wales (Table 16) and Finland (11,62) (Table 17) links consumption not only with alcoholic deaths but also with convictions for drunkenness, hospital admissions for alcoholism, drunken driving, alcohol -related accidents and crimes of assault. The comparison of alcohol consumption and deaths from cirrhosis in various countries (Fig. 5) provides further evidence of the link between consumption and damage (42). There is also some evidence, supported by surveys, that an increase in consumption will produce a disproportionate increase in damage. An increase in consumption of 50% between 1965 and 1974 in the Camberwell district of London was
36
Fig. 4. Ledermann's hypothetical curve
0 1.0 80 120 160 200 21.0 280 320 360 Alcohol consumption (ml absolute alcohol per day)
Table 15. Alcohol consumption per capita and number of deaths certified as being due to
cirrhosis, delirium tremens or chronic alcoholism in the United Kingdom, 1885 -1934
Average Average Five -year annual consumption annual number period (In litres of of deaths
proof spirit) per million population
1885 -1889 17.3 154
1890 -1894 18.2 168
1895 -1899 19.1 182
1900 -1904 18.6 193
1905 -1909 16.4 156
1910-1914 15.5 131
1915 -1919 10.5 81
1920 -1924 10.5 59
1925 -1929 9.1 55
1930 -1934 7.3 42
Source: Royal College of Psychiatrists (61).
37
Table 16. Alcohol consumption, convictions for public drunkenness, cirrhosis deaths and alcohol -related hospital admissions in England & Wales, 1950 -1976
Year
Annual per caput consumption of persons
aged 15 and over in litres of
100% ethanol
Convictions for public drunkenness
per 10 000 population aged 15 years
and over
Cirrhosis deaths with and without
mention of alcohol per million population
Hospital admissions with primary diagnosis of alcoholism or
alcoholic psychosis
1950 5.2 14.0 23
1951 5.3 15.8 25 512
1952 5.3 15.8 26 668
1953 5.1 15.7 26 775
1954 5.2 15.5 26 799
1955 5.3 15.8 26 1 053
1956 5.3 17.4 26 1 385
1957 5.3 19.3 27 1 535
1958 5.3 18.7 26 1 595
1959 5.6 18.6 27 2 044
1960 5.8 19.3 28 2 479
1961 6.2 21.0 30
1962 6.1 23.3 28
1963 6.2 22.8 28
1964 6.5 21.0 28 5 423
1965 6.5 19.8 29 5 774
1966 6.5 19.0 29 6 088
1967 6.7 20.3 28 6 232
1968 7.0 21.2 30 6 391
1969 7.0 21.2 32 6 689
1970 7.3 21.6 28 8 091
1971 7.7 22.9 32 9 230
1972 7.7 23.7 34 10 167
1973 7.9 25.9 37 11 565
1974 8.9 26.8 36 12 495
1975 9.4 27.0 37 12 751
1976 9.7 28.0
Source: Royal College of Psychiatrists (61).
Table 17. Alcohol consumption per capita, arrests for drunkenness, crimes of assault and battery, cases of drunken driving, alcohol -related traffic accidents, deaths from liver cirrhosis and
deaths from alcohol poisoning, per 100 000 population in Finland, 1950 -1975
Year Consumption
in litres of
100% ethanol
Arrests for
drunkenness
Crimes of assault and
battery
Cases of drunken
driving
Alcohol- related road traffic
accidents
Deaths from liver
cirrhosis
Deaths from alcohol
poisoning
1950 1.73 3668 148 20
1951 1.79 3349 148 37 21 2.3 2.2
1952 1.87 3387 145 50 25 2.5 2.5
1953 1.85 3222 139 50 24 2.4 2.5
1954 1.88 3030 142 46 25 3.2 2.1
1955 1.97 3070 133 43 25 3.3 2.5
1956 1.83 2927 123 49 24 3.0 2.8
1957 1.72 2923 121 49 23 3.5 3.1
1958 1.62 2763 119 58 23 3.6 3.0
1959 1.72 2947 127 75 27 3.2 2.7
1960 1.85 2964 125 96 28 3.3 2.4
1961 2.01 3157 126 116 35 3.5 2.9
1962 2.11 2933 125 119 40 3.4 2.9
1963 2.17 3049 120 128 42 3.5 2.4
1964 2.21 2916 119 135 48 3.5 2.7
1965 2.35 3029 126 144 51 3.4 3.0
1966 2.49 3157 131 152 51 3.2 3.0
1967 2.64 3337 139 154 46 3.2 4.8
1968 2.88 3185 155 147 45 3.6 5.2
1969 4.21 2966 212 178 53 4.1 4.3
1970 4.30 3722 237 197 59 4.2 4.6
1971 4.72 4415 251 215 64 4.1 4.9
1972 5.10 4421 265 243 70 4.3 5.0
1973 5.60 4920 279 289 78 4.5 3.7
1974 6.45 6098 289 350 77 5.4 5.5
1975 6.19 5842 277 379 75 6.3 4.3
Source: Osterberg (11).
Fig. 5. Liver cirrhosis death rates and alcohol consumption in various countries in the mid -1970s
France
Spain
Germany, Federal Republic of
Austria
Hungary
Switzerland
Belgium
Czechoslovakia
Denmark
Yugoslavia
German Democratic Republic
Netherlands
Poland
England & Wales
Finland
Sweden
Norway
Iceland
Cirrhosis deaths per 100000 population I 1
0 10 20 30 CO
! / D O D / O / U // / / / / U U / U/ / . 9 ' / G t d ï / i 1 / / A/ , / WIZï U U D 6 ' / / G ,
G /OD/ D / i '
//D
7// /%///r,//////
%D'//I////UD//////U/////DDU//r i/'/UUDG.
iff/U U D / D / O D D D
WO' U / G y // / D// // / / U/// / l / / D / //U rU/UU /
.11
%/D / % ///D DD A
VIE/ /D / l / / / /D D// / / / // / / D
%U/ /D / / Off/ /U / / /// / D/ //UD/DD/
DD/U!/0/O/UR//.
0 5 10 15 20 Litres of pure alcohol per capita /d
Source: Alcohol - reducing the harm (42).
associated with a threefold increase in the number of people falling into the highest drinking categories (63).
The general rule that consumption is related to damage continues to apply in smaller groups, but the pattern is not so neat. A study of four
42
Scottish towns - Inverness, Aberdeen, Glasgow and Ayr - found that although the towns with the higher consumption had more damage, there were exceptions to the general rule (60). First, the town with the highest average consumption, Inverness, did not have as many "heavy" heavy drinkers as Glasgow. This was partly explained by Glasgow having the most abstainers. Second, small variations in consumption were associ- ated with large variations in problems. For example, average consump- tion in Inverness was only 49% higher than in Ayr, and yet crime rates were more than 1000% higher, hospital admission rates were about 800% higher, and mortality was twice as high. Many factors must be involved in explaining these differences. Consistent heavy drinking every day, as in France, gives high cirrhosis rates, while "binge" drinking ", as in Inverness, leads to more problems associated with drunkenness.
There is good evidence linking changes in alcohol consumption with changes in alcohol -related disorders. The relationship between alcohol consumption and deaths from cirrhosis is clearly established (64) (Fig. 6). In the United Kingdom, the cirrhosis death rate rose by 3% a year from 23 per million in 1950 to 44 per million in 1979. The relationship also holds good over time, in regions in other countries, from one country to another (65), and for other causes of death, including causes related to intoxication (66 -68).
Furthermore, when alcohol consumption decreases, so does the number of problems (Fig. 7). In the year 1981 -1982, for the first time in postwar Britain, consumption of alcohol fell, from 10.4 litres of pure alcohol per adult to 9.2 litres. This fall was associated with an 11% reduction in convictions for drunkenness, an 8% fall in drinking -and- driving convictions, and a 4% fall in deaths from liver cirrhosis (69).
Similar relationships between declining alcohol consumption and alcohol -related problems have been observed in other countries. In Sweden, for example, sales of alcohol dropped 17% from 1976 to 1982 (70). Mortality from cirrhosis of the liver declined between 1979 and 1982 by 28% in men and 29% in women (Fig. 8). During the same period mortality from pancreatitis declined by 30% in men and 36% in women. The decline in alcohol -related problems was greatest among young people (71). Analysis of county figures confirm these changes. In Stockholm County a computer -based inpatient care register has covered 97 -99% of all hospital discharges since 1973. This has made it possible to study the utilization of inpatient care and mortality simultaneously in a metropolitan area during a period of decreased alcohol sales. Between 1976 and 1984 in Stockholm County there was a 20% fall in the sale of alcohol. Over the same period there was a decline in inpatient care for liver cirrhosis and pancreatitis for both sexes, and in alcoholic psychosis, alcoholism and alcohol intoxication for men. The mortality for liver cirrhosis and pancreatitis also dropped, and there was a levelling -off of mortality due to alcoholic psychosis, alcoholism and alcohol intoxication.
43
Fig. 6. Deaths from alcoholism and cirrhosis. Offences for drunkenness and consumption of alcohol
in England & Wales, 1860 -1978
O CL O O ',L- C) cß
O
ô 0N D (]
300
200
100
50
40
n \
. y/
; Offences of - Jr drunkenness
Deaths from alcoholism and cirrhosis
!-- ô ° 30r
â a) 20
Û C
ô 10
C aC>
o 5
o ,
1
1860
Alcohol consumption
1880 1900
Source: Alcohol - reducing the harm (42).
1920 1940 t
1960
1300
:1200
-I 100
50
7 40
1 30
7 202
10
5
4
3
2
1980
Social cost The overall cost of alcohol consumption to any society will be deter- mined by a number of factors. Included in this are the total amount of alcohol consumption and the patterns of drinking. In England & Wales
44
Fig. 7. Alcohol consumption, drunkenness convictions, alcoholism admissions and cirrhosis mortality, 1970-1982
(all per person aged 15 or over)
United Kingdom drunkenness convictions (r = 0.93) English first admissions with alcohol dependence (r = 0.875) Cirrhosis mortality (England & Wales) (r = 0.83)
Alcohol consumption
1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982
Source: Kendell (69).
it has been estimated that 700 000 people (2% of the total adult popu- lation) have serious problems related to alcohol, and 3 million (8 %) are heavy drinkers, drinking at levels leading to detectable biochemical abnormalities (42). Heavy drinkers have a mortality rate over twice that of the normal population. In Britain, although only 3000 death certifi- cates a year mention alcohol, the true premature mortality for which alcoholic intoxication or psychosis could be blamed is probably in the order of 5 -10 thousand a year. In the Malmö Preventive Population Programme, which followed up a cohort of 7935 middle -aged men in Sweden for three to eight years, alcohol was the cause of death in 25% of the 218 premature deaths, compared with 28% due to cancer and 23% due to coronary heart disease (72).
An estimate based on data published in 1976 concerning individuals in alcohol treatment units suggested that the excess mortality from alcohol in England & Wales was 8000 a year (73). An updated suggestion based on population studies is that there are 40 000 deaths due to alcohol in the United Kingdom each year, compared with 100 000 deaths due to cigarette smoking (Table 18) (74 -85).
45
Fig. 8. Mortality from cirrhosis of the liver in Sweden, 1973 -1982, by year and sex related to sale of alcohol in litres of 100% ethanol
for each subject aged over 14
- T / Men./
- Women
1973 1976 1979 1982 Year
Source: Romelsjö & Agren (70).
The financial costs of alcohol in terms of lost production, and costs to the medical and social services in caring for individuals with alcohol problems, can be calculated. A conservative estimate for England & Wales gives the cost as at least £1600 million a year (Table 19) (85). Additional indirect costs, such as the costs of alcohol -related crime, fire and inefficient work in many fields, are hard to quantify.
A number of estimates have been made of the costs of alcohol consumption to the health services, although most of the figures used are recognized to be underestimates (86). A number of studies have shown that up to one in five patients admitted to medical wards in the United Kingdom have problems related to alcohol (87,88).
In addition to the workload for accidents, a Scottish study indicated that one in five male admissions to a general medical ward was related to the patient's use of alcohol (89). In another Scottish study 15% of female emergency admissions to a general medical unit were alcohol -related (90,91).
Individual Data
Before discussing individual types of damage related to alcohol use, it is necessary to consider the diagnostic classifications and terminology used
46
Table 18. Estimate of proportion of deaths attributable to alcohol, England & Wales, age 15 +, 1984
Percentage of deaths
Men Women
Malignant neoplasms (ICD 140 -239) 4 3 Cerebrovascular disease (ICD 430 -438) 12 3 Respiratory disease (ICD 460 -519) 11 2 Digestive disease (ICD 520 -579, excluding 571) 12 3 Chronic liver disease (ICD 571) 80 80 Injuries and poisonings (ICD 800 -899) 40 40 Other 6 1
All deaths 12 3
Source: Kagan et al. (74,75), Kozarevich et al. (76,77), Dyer et al. (78,79), Rothman (80), Holtermann & Burchell (81), Adelstein & White (82), Marmot (83), Klatsky et al. (84), McDonnel & Maynard (85).
to describe alcohol -related disabilities. Both the concepts and the terminology have changed considerably over the last few years. For much of the first half of this century problems resulting from alcohol use were regarded as complications of a single disease - "alcoholism" - which was considered to have a predominantly genetic basis and a predictable natural history (92). This concept of a disease has been criticized by many workers, who instead have favoured the idea that a complex of alcohol- related disabilities are associated with a certain level of alcohol consumption (93,94).
The disease concept of "alcoholism" has been adopted particularly in North America. In 1980 the American Psychiatric Association, in their Diagnostic and statistical manual of mental disorders, made the distinc- tion between "alcohol abuse" and "alcohol dependence ". The criteria for alcohol abuse were three:
- continuous or episodic use of alcohol for at least one month;
- social complications of alcohol use; and
- psychological dependence (e.g. compulsion to drink) or patho- logical patterns of alcohol use, or both.
For a diagnosis of alcohol dependence, the additional criterion of either tolerance or experience of withdrawal symptoms was applied.
Edwards & Gross (93) took the converse approach in their description of the alcohol- dependence syndrome. They conceived the syndrome as being a psychobiological state characterized by a reorientation of life around alcohol, awareness of a compulsion to drink, and drinking to
47
Table 19. Total resource costs of alcohol misuse, England & Wales, 1983 prices
Cm
Social cost to industry Sickness absence 641.51 Housework services 42.23 Unemployment 144.74 Premature death 567.70
Social cost to the National Health Service Psychiatric hospitals, inpatient costs (alcoholic psychosis,
alcohol dependence syndrome, non -dependent abuse of alcohol) Non -psychiatric hospitals, inpatient costs (alcoholic psychosis,
alcohol dependence syndrome, alcoholic cirrhosis and liver disease)
Other alcohol -related diseases inpatient costs General practitioner visits
17.90
7.87 68.58
1.51
Society's response to alcohol -related problems Expenditure by national alcohol bodies 0.55 Research 0.49
Social cost of material damage Road traffic accidents (damage) 89.20
Social cost of criminal activities Police involvement in traffic offences (excluding
road traffic accidents) 4.54 Police involvement in road traffic accidents (includes
Judiciary and Insurance administration) 11.89 Drink- related court cases 15.79
Total (including unemployment and premature death) 1614.50
Total (excluding unemployment and premature death) 902.06
Source: McDonnel & Maynard (85).
avoid the discomfort of its absence. They distinguished between this syndrome and the broader range of problems that result from harmful drinking, which were termed "alcohol- related disabilities" (94). The crucial point is that both the alcohol- dependence syndrome and alcohol - related disabilities were considered to vary in their degree of severity.
The terms harmful alcohol consumption and hazardous consumption are relatively new, and are included in the provisional recommendations for classification in the Tenth Revision of the International Classification of Diseases. Harmful alcohol consumption denotes consumption that is causing harm to the psychological or physical wellbeing of the individ- ual. Hazardous alcohol consumption is defined as a level of consumption
48
or a pattern of drinking that is likely to result in harm, should present drinking habits persist.
There are two types of alcohol- related disabilities: disabilities relating to intoxication and disabilities related to regular heavy consump- tion (Tables 20 and 21). There is considerable overlap between the two tables. For example, both intoxication and regular heavy drinking are associated with a risk of stroke.
An important aspect of damage related to intoxication is that the population of individuals who suffer it is not static. Drinkers who are intoxicated on any one day will not necessarily be at risk of damage on a different day. It is likely that the majority of drinkers will at some stage of their lives experience some problems due to intoxication. The type and nature of the problems will vary from individual to individual, and also according to the circumstances in which the alcohol is drunk, for example when working or when driving.
For convenience, it is useful to consider alcohol- related damage under the three headings of social, psychological and physical. In reality, of course, an individual's experience may involve a combination of all three. Heavy drinking may lead to marital difficulties (social damage), which in turn may cause unhappiness (psychological damage). This may be followed by even heavier drinking, harming the liver (physical damage).
Social damage The idea of social damage implies failure on the part of an individual to perform adequately in any role expected of him or her, for example in the family or at work. It may also include behaviour which transgresses social rules - crime, for example, or sexual deviance. Social damage, of course, depends very much on social norms, which may be different for men and women, for different age groups, for different social classes, and certainly for different countries.
Both intoxication and regular heavy drinking are associated with a wide range of problems involving families and children. Excessive drinking is a frequent cause of marital disharmony and divorce. In one study of 100 battered wives in the United Kingdom, 52 of the victims reported that their partners frequently drank heavily (95). Financial stress will almost inevitably result from heavy consumption, affecting the wellbeing of the rest of the family. Children are especially at risk, and the results can be devastating (96 -98). Neglect is related to both intoxication and regular heavy drinking; the same may be true for child abuse (99 -101). Heavy drinking in one member of a family seems to impose a greater load of illness on others in that close environment.
An adverse impact on school work is common; in adolescence a son or daughter may be ashamed to invite friends home, so escapes by spending little time there. The emotional harm done in childhood can result in disabilities continuing into adult life (102 -104).
49
Table 20. Problems relating to intoxication
Social problems Psychological problems Physical problems
Family arguments Insomnia Hepatitis Domestic violence Depression Gastritis Child neglect/abuse Anxiety Pancreatitis Domestic accidents Amnesia Gout Absenteeism from work Attempted suicide Cardiac arrythmia Accidents at work Suicide Accidents Inefficient work Trauma Public drunkenness Strokes Public aggression Acute alcohol poisoning Football hooliganism Failure to take prescribed Criminal damage medication Theft Impotence Burglary Fetal damage Assault Homicide Drinking and driving Taking and driving away Road traffic accidents Sexually deviant acts Unwanted pregnancy
Table 21. Problems relating to regular heavy drinking
Social problems Psychological problems Physical problems
Family problems insomnia Fatty liver Divorce Depression Hepatitis Homelessness Anxiety Cirrhosis Work difficulties Attempted suicide Liver cancer Unemployment Suicide Gastritis Financial difficulties Changes in personality Pancreatltis Fraud Amnesia Cancer of mouth, larynx, Debt Delirium tremens oesophagus Vagrancy Withdrawal fits Cancer of breast ( ?) Habitual convictions Hallucinosis Cancer of colon ( ?)
for drunkenness Dementia Nutritional deficiencies Gambling Obesity Misuse of other drugs Diabetes
Cardiomyopathy Raised blood pressure Strokes Brain damage Neuropathy Myopathy Sexual dysfunction Infertility Fetal damage Haemopoietic toxicity Reactions with other drugs
50
People in certain occupations have exceptionally high rates of alcohol -related problems. High -risk jobs include those in the drinks trade, catering, the armed forces, the merchant navy, fishing and journal- ism. In all jobs excessive drinking may result in sacking, repeated sackings, and then virtual unemployability. But it can also lead to more subtle and insidious processes: inefficiency, getting in people's way, leaving others to do a job, creating unpleasant situations, and so on. Medical practitioners may see this happening in their practices or in hospitals, and know how easily collusion and evasion develop.
There is reason to believe that unemployment may lead to increased drinking, since it is accompanied by five factors that are associated in employed people with a high risk of heavy alcohol consumption: easy availability of alcohol; freedom from supervision; very high (redun- dancy) pay or very low income; strains, stresses and hazards; and preselection of high -risk individuals. However, there is little evidence to show that unemployment in itself leads to heavy drinking. Although a number of population surveys have indicated that there is a higher prevalence of heavy drinking among the unemployed, it is not possible to tell from the data whether heavy drinking is the result of becoming unemployed, or vice versa (105,106).
The bulk of alcohol -related crime consists of petty offences commit- ted by people caught up in a way of life characterized by social instabil- ity - people who are unskilled, who do not stay for long in one job, who are homeless and often itinerant between cities, and who are in many ways socially and personally handicapped. Studies of prisoners in England & Wales have suggested that between one half and two thirds of men and about 15% of women have a serious problem related to alcohol (107).
A recent investigation in England revealed that 64% of those arrested had been drinking in the four hours prior to their arrest (108). Between the hours of 10 p.m. and 2 a.m. some 93% of all arrested persons were intoxicated. Alcohol use in the previous four hours was associated with 78% of all assaults, 80% of breaches of the peace and 88% of arrests for criminal damage. In some cases intoxication may predispose people to break the law. Others report drinking before committing a crime so as to reduce anxiety.
The association of drinking with hooliganism has led to controls on the availability of alcohol at football matches in some countries. Loss of self -control may be related to some sexual crimes, including rape, and is associated with some crimes of violence. In about half of all murder cases the assailant was intoxicated at the time, and often the victim would have been drinking (109).
The final point about drinking and crime concerns convictions for drunkenness. The rates for this type of conviction run parallel to changes in per capita alcohol consumption. A high proportion of convictions for drunkenness are recurrent convictions for the same individual.
51
Rates for drinking- and -driving offences also run parallel to changes in per capita alcohol consumption. (Of course, conviction rates are related to the degree of police activity as well as to the amount of drinking.) A mass of evidence has now accumulated that demonstrates the relationship between drinking- and -driving and accidents. The most conclusive comes from a survey conducted by the Police Department in Grand Rapids, Michigan, USA (110). For every person who had an accident the blood alcohol level was assessed. Control information was obtained by stopping motorists at the same accident point and checking their blood alcohol levels. At 80 mg per 100 ml of blood alcohol, the accident risk was twice the level of those who were sober; at 150 mg per 100 ml the risk was 10 times and at 200 mg per 100 ml it was 20 times the normal.
Furthermore, most traffic accidents in which alcohol plays a part seem to occur in regular heavy drinkers rather than among lighter drinkers who simply happen to have been caught. A recent study among motorists arrested for drinking- and -driving in the Tyneside region of Scotland demonstrated that although there was a relationship between blood alcohol concentrations and accidents among young drivers, the relationship did not hold for older drivers (111). There was, however, a relationship between blood y- glutaryltranspeptidase levels and accidents in older offenders. Young drivers are generally inexperienced with both alcohol and driving, and the acute effects of alcohol may make the dominant contribution to accident risk in this age group. Older drivers may be more experienced and relatively more resistant to the acute effects of alcohol. Accidents in the older group could therefore be due to a combination of acute and chronic deterioration in driving skills, the latter resulting from alcohol -induced neuropsychological deficiencies.
The strong association between raised y- glutaryltranspeptidase ac- tivity and accidents in drivers over 30 years of age indicates that a large proportion of these accidents may be accounted for by heavy drinkers. Particularly disturbing in this study was the high prevalence of raised enzyme activity found among drivers of heavy goods and public service vehicles.
Countries such as Finland that carry out random breath- testing have demonstrated that it is an effective deterrent, leading to large reductions in both the number of drunken drivers on the road and deaths from road traffic accidents (112).
Psychological damage Psychological damage merges imperceptibly into social and physical damage and there are of course no hard and fast divisions between these three groups. For example, there is obvious overlap between social difficulties in the family, and psychological mood and the effects of conflict. The same is true of cognitive impairment and damage to the nervous system.
52
Most people are familiar with acute intoxication, and have experi- enced it to some degree at one time or another. Slurred speech and impairment of coordination, thinking and memory often occur. Ulti- mately, drowsiness results. Respiratory depression and inhalation of vomit can kill. Tolerance to some of these effects is acquired with regular heavy consumption, and whereas a blood -alcohol level of 150 -200 mg per 100 ml may cause an inexperienced drinker to be obviously intoxi- cated, some regular heavy drinkers may appear superficially "normal" with a blood alcohol level of 500 mg per 100 ml.
One of the effects of intoxication is loss of judgement. Even though psychopharmacologically alcohol acts as a depressant, people paradoxi- cally feel stimulated, at least after the first few drinks. This may mean, for example, that a person feels able to drive better, even though the evidence is that driving accidents are more likely even at blood -alcohol levels below 80 mg per 100 ml. Similarly, many people who feel they need to project a more attractive and confident appearance think that having a few drinks helps them to do so. In fact, the reverse is often the case. People become boring, loquacious, irritable and sometimes violent.
Alcohol is sometimes used to relieve unpleasant feelings such as anxiety and depression. There is, however, evidence that persistent heavy drinking, rather than relieving these feelings, actually exacerbates them. An individual may find his or her depression or anxiety getting worse, and mistakenly drink more in an effort to cope with these feelings. This is an example of one of many vicious circles that can be set up by drinking to excess. It is often very difficult to determine to what extent anxiety and depression are the result of heavy alcohol consumption, and to what extent they are the cause of it.
For someone who is beginning to become aware that his or her drinking is causing harm, or for someone who is well aware of that harm but finds it difficult to control the drinking, another set of vicious circles arises due to associated feelings of conflict and guilt. When people feel guilty about their behaviour, they have a tendency to minimize its extent and the harm it is causing, to try to cover it up, to become more secretive about it, and to rationalize it. It is important to appreciate that when this occurs, it is a natural psychological response to the real distress which the patient is feeling. Some of the more extreme forms of behaviour that are occasionally found in association with excessive drinking, such as abnormal jealousy and impulsive risk -taking, may have the same origins.
A feeling of low self- esteem is universal among people who are drinking to excess. The effect of this, combined with increased anxiety and depression as well as conflict and guilt, undoubtedly contributes to the very high rate of attempted and successful suicide among heavy drinkers.
Quite apart from impairment of judgement during acute intoxication and the effects of persistent drinking on mood and behaviour just
53
discussed, regular heavy drinking may produce more general cognitive impairment. "Morning- after" amnesia quite often accompanies very heavy bouts of drinking, but frequent and more lasting periods of amnesia give warning of a serious risk of progressive damage, as well as being alarming for the person who has them.
As many as half of all the superficially normal heavy drinkers in alcohol treatment units manifest a detectable impairment of cognition and memory when subjected to formal psychological testing (113). They recover these faculties partly if they abstain, but age and the length of the drinking history increase the degree of impairment. It is not yet clear whether sustained but only moderate drinking leads to mental impairment (114).
Anyone could in certain circumstances become tolerant to alcohol and experience withdrawal symptoms. The main factor is exposure to prolonged heavy doses of alcohol. Although delirium tremens can develop within a few days of alcohol being withdrawn or severely cut down, and fits occur after 24 hours of abstention, primary care physicians are much more likely to be faced with the early features of tolerance and withdrawal. These occur typically on waking after the previous night's drinking, and extend from slight anxiety, anorexia and nausea to severe retching and vomiting. There may be tremor, ranging from slight hand movements to shaking of the whole body, and sweatiness, ranging from mild moistness of the hands to soaking sweats that drench the bedclothes.
Use of other drugs Particularly in people with easy access to other drugs, such as doctors, nurses and pharmacists, the heavy use of alcohol may be linked with overuse of tranquillizers, hypnotics and other drugs. Young people perhaps alternate between using amphetamines, cannabis or other fashionable and illegal drugs and heavy drinking. There is a marked as- sociation between heavy smoking with its attendant risks and drug and alcohol consumption.
Physical damage Both acute intoxication and regular heavy drinking can have an adverse effect on physical health. Alcohol can damage nearly every organ and system of the body, and lead to premature death.
Alcohol provides 7.1 kilocalories per grain, so that a standard bottle of 70° proof spirit provides 1500 calories. It contributes substantially to the obesity of many moderate drinkers, but on the other hand prolonged heavy drinking may lead to malnutrition and reduced levels of circulating vitamins. Although poor dietary intake and poor socioeconomic back- ground contribute to malnutrition, this is not the whole story. In a study of middle -aged, middle -class heavy drinkers in the United Kingdom, 29% showed evidence of malnutrition (115). There was no correlation between nutritional status, dietary intake and the severity of liver disease.
54
Impaired intestinal absorption occurs in heavy drinkers, and may be due to impaired intestinal function and inhibited biliary and pancreatic secretions. Such malnutrition contributes to many of the alcohol -related diseases.
Alcohol has a direct toxic effect on developing erythroblasts, leading to macrocytosis which can occur in up to 90% of very heavy drinkers (116). It also inhibits the production and function of white blood cells, contributing to an increased susceptibility to infection. Megaloblastic anaemia occurs only in those who have nutritional folate deficiency, and so is more common in people with a poor dietary intake and in those who drink wines and spirits. Both contain negligible amounts of folic acid as compared to beer, which contains 100 micrograms per litre.
Alcohol exacerbates heartburn, and is a common cause of gastritis. Although cirrhotic patients have a high frequency of peptic ulcer, it does not seem that the ulceration is actually caused by the alcohol intake. Moreover, there is no noticeable difference in the healing and relapse rates of the ulcers, whether the patient continues to drink or stops (117).
A heavy alcohol consumption increases the risk of cancer of the mouth (excluding the lip) and pharynx threefold, of the larynx fourfold, of the oesophagus twofold (118). This effect seems to be irrespective of the type of beverage and is independent of cigarette smoking. However, alcohol and smoking together multiply the risk: the relative risk for cancer of the oesophagus may be 150 times higher in a heavy drinker and heavy smoker. A heavy alcohol intake may also be associated with an increased incidence of cancer of the colon and rectum (119).
Although they are rare, cancers associated with alcohol are among the few types of cancer whose rates have been increasing in recent years in countries where alcohol consumption has also gone up (120).
There is also an association between alcohol consumption and both acute and chronic pancreatitis (121).
Excess alcohol consumption can lead to a wide range of liver diseases, from fatty liver, hepatitis and cirrhosis to primary hepato- cellular carcinoma. Mortality from cirrhosis is 10 times the average in heavy drinkers. Liver injury is unrelated to the type of beverage consumed; it is related only to its alcohol content. Women develop liver disease after drinking less and for a shorter time than men, and at present seem to have relatively more severe liver disease (122).
The steady daily drinker is more at risk than the "spree" drinker whose total alcohol intake may be no less. In two studies on defined populations in France, the relative risk of cirrhosis compared to an alcohol consumption of 0-2.5 units per day was 6 times greater at 5 -8 units per day and 14 times greater at 8 -10 units per day (123). Above this level,