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Chemistry and Pharmacology

Chemical determination has discovered five separate forms of alcohol that have little molecular variation, but enough variation to produce substantial differences in their characteristics. Occurring naturally through the fermentation of fruits, vegetables and grains exposed to the bacteria in the air, alcohol production can be expedited by producing conditions conducive to the environmental needs of the alcohol producing organisms. The form of alcohol produced intentionally for use is ethyl alcohol, also called ethanol.

People do not drink pure ethanol. Most drinks with alcoholic content do not exceed an 8 percent concentration, such as beer. Most wines do not exceed 15 percent, and most liquors are still below 50 percent, or, in the terms of the United States, 100 proof by weight or volume. Furthermore, alcoholic beverages are often diluted by water before they are consumed.

CHEMISTRY

Ethanol has a very simple molecular structure, C₂H₆O. It is composed of only two carbon atoms, six hydrogen atoms, and one oxygen atom, yet its precise mechanism of action is not fully understood. Although it is commonly believed that ethanol is useful in a number of physical ailments (as medicinal alcohol, the medieval elixir of life), in reality its uses are not therapeutic—and its chronic use is toxic.

EFFECTS ON THE BODY AND THERAPEUTIC USES

Ethanol is a general central nervous system depressant, producing sedation and even sleep at higher doses. The degree of this depression is proportional to its concentration in the blood; however, this relationship is more predictable when ethanol levels are rising than three or four hours later, when blood levels are the same but ethanol levels are falling. This variance occurs because during the first fifteen or twenty minutes after an ethanol dose, the peripheral venous blood is losing ethanol to the tissues while the brain has equilibrated with arterial blood supply. Thus, brain levels are initially higher than the venous blood levels, and since all blood samples for ethanol determinations are taken from a peripheral vein, the ethanol concentrations are appreciably lower than a few hours later, when the entire system has achieved equilibrium.

The reticular activating system of the brain stem is the most sensitive area to ethanol's effects; this accounts for the loss of integrative control of the brain's higher functions. Anecdotal reports of a stimulating effect, especially at low doses, are likely due to the depression of the mechanisms that normally control speech and other behaviors that evolved from training or prior experiences. However, there may be a genetic basis for this initial stimulating effect, since rodents differing genetically show differences in the degree of initial stimulation or excitement. Upon drinking a moderate amount of ethanol, humans may quickly pass through the "stimulating" phase. Memory, the ability to concentrate, and insight are affected next whereas confidence often increases as moods swing from one extreme to another. If the dose is increased, then neuromuscular coordination becomes impaired. It is at this point that drinkers may be most dangerous, since they are still able to move about but reaction times and judgment are impaired—and sleepiness must be fought. The ability to drive an automobile or operate machinery is compromised. With higher doses, general (sleep) or surgical (unconsciousness) anesthesia may develop, but respiration is dangerously depressed.

Ethanol is believed by many to have a number of medicinal (therapeutic) uses; these are mostly based on anecdotal reports and have few substantiated claims. One example of a well-known but misguided use is to treat hypothermia—exposure to freezing conditions. Although the initial effects of an alcoholic beverage appear to "warm" the patient, ethanol actually dilates blood vessels, causing further loss of body heat. Another example is its effects on sleep—it is believed that a nightcap relaxes one and puts one to sleep. Acute administration of ethanol may decrease sleep latency, but this effect dissipates after a few nights. In addition, waking time during the latter part of the night is increased, and there is a pronounced rebound insomnia that occurs once the ethanol use is discontinued. Except as an emergency treatment to reduce uterine contractions and delay birth, the therapeutic use of oral ethanol is confined to treating poisoning from methanol and ethylene glycol. Most of ethanol's therapeutic benefits are derived from applying it to the skin, since it is an excellent skin disinfectant. Ethanol can lessen the severity of dermatitis, reduces sweating, cools the skin during a fever and, when added to ointments, helps other drugs penetrate the skin. These therapeutic uses for ethanol are for acute problems only.

Until recently, it had been felt that the chronic drinking of ethanol led only to organ damage. Recent evidence suggests that low or moderate intake of ethanol (1-2 drinks per day) can indirectly reduce the risk of heart attacks. The doses must be low enough to avoid liver damage. This beneficial effect is thought to be due to the elevation of high-density lipoprotein cholesterol (HDL-C) in the blood which, in turn, slows the development of arteriosclerosis and, presumably, heart attacks. This relationship has not been proven, but has been culled from the results of several epidemiological studies.

Several mechanisms have been proposed to explain how oral ethanol exerts its effects. One is thought to be its ability to alter the fluidity of cell membranes—particularly neurons. This disturbance alters ion channels in the membrane resulting in a reduction in the propagation of neuronal transmission. The anesthetic gases share this property with ethanol. Furthermore, it has been shown that the degree of membrane disordering is directly proportional to the drug's lipid solubility. It has also been argued that such membrane effects occur only at very high doses. More recently, scientists have reported that ethanol may augment the activity of the neurotransmitter GABA by its actions on a receptor site close to the GABA receptor. The effect of this action is to increase the movement of chloride across biological membranes. Again, this effect would alter the degree to which neuronal transmission is maintained.

PHARMACOKINETICS AND DISTRIBUTION

Ethanol is quickly and rapidly absorbed from the stomach (about 20%) and from the first section of the small intestines (called the duodenum). Thus the onset of action is related in part to how fast it passes through the stomach. Having food in the stomach can slow absorption because the stomach does not empty its contents into the small intestines when it is full. However, drinking on an empty stomach leads to almost instant intoxication because the ethanol not absorbed in the stomach passes directly to the small intestines. Maximal blood levels are achieved about thirty to ninety minutes after ingestion. Ethanol mixes with water quite well, and so once it enters the body it travels to all fluids and tissues, including the placenta in a pregnant woman. After about twenty to thirty minutes for equilibration, blood levels are a good estimate of brain levels. Ethanol freely enters all blood vessels, including those in the small air sacs of the lungs. Once in the lungs, ethanol exchanges freely with the air one breathes, making a breath sample a good estimate of the amount of ethanol in one's body. A breathalyzer device is often used by police officers to detect the presence of ethanol in an individual.

Between 90 and 98 percent of the ethanol dose is metabolized. The amount of ethanol that can be metabolized per unit of time is roughly proportional to the individual's body weight (and probably the weight of the liver). Adults can metabolize about 120 mg/kg/hr which translates to about thirty ml (one ounce) of pure ethanol in about three hours. Women generally achieve higher alcohol blood concentrations than do men, even after the same unit dose of ethanol, because women have a lower percentage of total body water but also because they may have less activity of alcohol-metabolizing enzymes in the wall of the stomach. The enzymes responsible for ethanol and acetaldehyde metabolism—alcohol dehydrogenase and aldehyde dehydrogenase, respectively—are under genetic control. Genetic differences in the activity of these enzymes account for the fact that different racial groups metabolize ethanol and acetaldehyde at different rates. The best-known example is that of certain Asian groups who have a less active variant of the aldehyde dehydrogenase enzyme. When they consume alcohol, they accumulate higher levels of acetaldehyde than do Caucasian males, for example; this causes a characteristic response called "flushing," actually a type of hot flash with reddening of the face and neck. Some experts believe that the relatively low levels of alcoholism in such Asian groups may be linked to this genetically based aversive effect.

TOXIC EFFECTS

Chronic consumption of excessive amounts of ethanol can lead to a number of neurological disorders, including altered brain size, permanent memory loss, sleep disturbances, seizures, and psychoses. Some of these neuropsychiatric syndromes, such as Wernicke's encephalopathy, Korsakoff's psychosis, and polyneuritis can be debilitating. Other, less obvious problems also occur during chronic ethanol consumption. The chronic drinker usually fails to meet basic nutritional needs and is often deficient in a number of essential vitamins, which can also lead to brain and nerve damage.

Chronic drinking also causes damage to a number of major organs. Permanent alterations in brain function have already been discussed. By far, one of the most important causes of death in alcoholics (other than by accidents) is liver damage. The liver is the organ that metabolizes ingested and body toxins; it is essential for natural detoxification. Alcohol damage to the liver ranges from acute fatty liver to hepatitis, necrosis, and cirrhosis. Single doses of ethanol can deposit droplets of lipids, or fat, in the liver cells (called hepatocytes). With an accumulation of such lipid, the liver's ability to metabolize other body toxins is reduced. Even a weekend drinking binge can produce measurable increases in liver fat. It was found that liver fats doubled after only two days of drinking; blood ethanol levels ranged between twenty and eighty mg/dl, suggesting that one need not be drunk in order to experience liver damage.

Alcohol-induced hepatitis is an inflammatory condition of the liver. The symptoms are anorexia, fever, and jaundice. The size of the liver increases, and its ability to cleanse the blood of other toxins is reduced. Cirrhosis is the terminal and most dangerous type of liver damage. Cirrhosis results after many years of intermittent bouts with hepatitis or other liver damage, resulting in the death of liver cells and the formation of scar tissue in their place. Fibrosis of the blood vessels leading to the liver can result in elevated blood pressure in the veins around the esophagus, which may rupture and cause massive bleeding. Ultimately, the cirrhotic liver fails to function and is a major cause of death among alcoholics. Although only a small percentage of drinkers develop cirrhosis, it appears that a continuous drinking pattern results in greater risk than does intermittent drinking, and an immunological factor may be involved.

The role of poor nutrition in the development of some of these disorders is well recognized but not very well understood. Ethanol provides 7.1 kilocalories of energy per gram. Thus, a pint of whiskey provides around 1,300 kilocalories, which is a substantial amount of raw energy, although devoid of any essential nutrients. These nutritional disturbances can exist even when food intake is high, because ethanol can impair the absorption of vitamins B₁ and B 12 and folic acid. Ethanol-related nutritional problems are also associated with magnesium, zinc, and copper deficiencies. A chronic state of malnutrition can produce symptoms that are indistinguishable from chronic ethanol abuse.

Fetal alcohol syndrome (FAS) was recognized and described in the 1980s. Children of chronic drinkers are born deformed; the abnormality is characterized by reduced brain function as evidenced by a low IQ and smaller than usual brain size, slower than normal growth rates, characteristic facial abnormalities (widely spaced eyes and flattened nasal area), other minor malformations, and developmental and behavioral problems. Fetal malnutrition caused by ethanol-induced damage to the placenta can also occur, and fetal immune function appears to be weakened, resulting in the child's greater susceptibility to infectious disease. Depending on the population studied, the rate of FAS ranges from 1 in 300 to 1 in 2,000 live births; however, the incidence is 1 in 3 infants of alcoholic mothers. Even today, it is not known if there is a safe lower limit of ethanol that can be consumed by pregnant women without risk of having a child with FAS. The lowest reported level of ethanol that resulted in FAS was about 75 ml (2.5 oz.) per day during pregnancy. Among alcoholic mothers, if drinking during pregnancy is reduced, then the severity of the resulting syndrome is reduced.

TOLERANCE, DEPENDENCE, AND ABUSE

Tolerance, a feature of many different drugs, develops rather quickly to many of ethanol's effects after frequent exposure. When tolerance develops, the dose must be increased to achieve the original effect. Ethanol is subject to two types of tolerance: tissue (or functional) tolerance and metabolic (or dispositional) tolerance. Metabolic tolerance is due to alterations in the body's capacity to metabolize ethanol, which is achieved primarily by a greater activity of enzymes in the liver. Metabolic tolerance only accounts for 30 to 50 percent of the total response to alcohol in experimental conditions. Tissue tolerance, however, decreases the brain's sensitivity to ethanol and may be quite extensive. The development of tolerance can take just a few weeks or may take years to develop, depending on the amount and pattern of ethanol intake. As with other central nervous system depressants, when the dose of ethanol is increased to achieve the desired effects (e.g., sleep), the margin of safety actually decreases, as the dose comes closer to producing toxicity and the brain's control of breathing becomes depressed.

Like tolerance, dependence on ethanol can develop after only a few weeks of consistent intake. The degree of dependence can be assessed only by measuring the severity of the withdrawal signs and symptoms observed when ethanol intake is terminated. Victor and Adams (1953) provided perhaps one of the best descriptions of the clinical aspects of ethanol dependence. Patients typically arrive at the hospital with the "shakes," sometimes so severe that they cannot perform simple tasks by themselves. During the next twenty-four hours of their stay in the hospital, an alcoholic might experience hallucinations, which typically are not too distressing. Convulsions, however, which resemble those in people with epilepsy, may occur in susceptible individuals about a day after the last drink. Convulsions usually occur only in those who have been drinking extremely large amounts of ethanol. If the convulsions are severe, the individual may die. Many somatic effects, such as nausea, vomiting, diarrhea, fever, and profuse sweating are also part of alcohol withdrawal. Some sixty to eighty-four hours after the last dose, there may be confusion and disorientation; more vivid hallucinations may begin to appear. This phase of withdrawal is often called the delirium tremens, or DTs. Before the days of effective treatment, a mortality rate of 5 to 15 percent was common among alcoholics whose withdrawal was severe enough to cause DTs.

TREATMENT FOR ALCOHOL DEPENDENCE

The first step in treating alcoholics is to remove the ethanol from the system, a process called detoxification. Since rapid termination of ethanol (or any other central nervous system depressant) can be life threatening, people who have been using high doses should be slowly weaned from the ethanol by giving a less toxic substitute depressant. Ethanol itself cannot be used because it is eliminated from the body too rapidly, making it difficult to control the treatment. Although barbiturates were once employed in this capacity, the safer benzodiazepines have become the drugs of choice. Not only do they prevent the development of the potentially fatal convulsions, but they reduce anxiety and help promote sleep during the withdrawal phase. New medications are constantly being tested for their abilities to aid in the treatment of alcohol withdrawal.

Once a person has become abstinent, various methods can be used to maintain abstinence and encourage sobriety—some are pharmacologic and others are through social-support networks or formal psychological therapies. One type of treatment involves making drinking an adverse toxic event for the individual, by giving a drug such as DISULFIRAM (Antabuse) or citrated CALCIUM CARBIMIDE, which inhibits the metabolism of acetaldehyde and causes facial flushing, nausea, and rapid heartbeat. When ethanol is ingested by someone on disulfiram, the acetaldehyde levels rise very high, very quickly. Disulfiram has not been successful in maintaining abstinence in all patients, however.

Many support groups are available to help people remain abstinent. ALCOHOLICS ANONYMOUS (AA) is one of the most widely known and available; it is structured around a self-help philosophy. The AA program emphasizes total avoidance of alcohol and any medication. Instead it relies on a "buddy" or "sponsor" system, providing support partners who are personally experienced with alcoholism and alcoholism recovery. A number of other types of psychological and behavioral approaches to treatment also exist.

(SEE ALSO: Accidents and Injuries from Alcohol; Alcoholism; Fetus, Effects of Drugs on; Complications; Social Costs of Alcohol and Drug Abuse)

SCOTT E. LUKAS

REVISED BY ANDREW J. HOMBURG

Complications

Through their ethanol (alcohol) content, alcoholic beverages significantly affect the body's cellular function as well as its cognitive actions. Many of these effects are the consequence of a complex set of biochemical reactions, long-term exposure to ethanol with an accumulation of damage that is manifested in diverse ways, or the result of increased incidence or severity of major disease states, including AIDS, CANCER, or heart disease. However, some effects of ethanol are immediate and do not require prolonged exposure, nor are they induced as the end product of many physiological changes. For example, ethanol induces changes in cell membranes' fluidity by mixing with the lipids there. The membrane changes inhibit neurological functions and thus can cause car ACCIDENTS. All of these can occur with a single exposure and thus could be considered a direct effect of the ethanol in alcoholic beverages.

ALCOHOL METABOLISM

Ethanol Absorption and Metabolism.

Because the ethanol molecule has a hydroxyl group, its metabolism involves dehydrogenase enzymes. After some metabolism in the stomach and intestine, it is transported to the liver for further metabolism. Alcohol dehydrogenase produces acetaldehyde, which causes many of the indirect effects attributed to ethanol. Because females metabolize alcohol less efficiently in the stomach wall than males, their exposure can be higher, with more direct consequences, from the same amount of alcohol consumption. Ethanol is also metabolized by the liver cells' MEOS system. Ethanol also affects the transportation of proteins across membranes in the cell. Thus aldehyde dehydrogenase's transportation into the mitochondria from the cell's cytoplasm is retarded. This reduces the oxidation of acetaldehyde to acetic acid, and increases ethanol's indirect effects by altering its metabolism and that of its metabolites. Acetaldehyde is very reactive with proteins. Thus increased levels result in damage to proteins with which it reacts. As many are vital for cell function, cell death or dysfunction occurs. This damage persists for the life of the protein or cell.

Alcohol and Nutrition.

Alcohol has major effects when consumed frequently or in high amounts by affecting the frequency and quality of foods consumed. This directly affects the amounts of vitamins and minerals that are consumed and available for absorption. The long-term consequences involve undernutrition, nutritional deficiencies, and ultimately malnutrition. Ethanol also directly affects the absorption of vitamin A, betacarotene (a vitamin A precursor), vitamin B₁ (thiamine), folate, vitamin E, vitamin D, and folate. Vitamins are critical for many enzymatic reactions, so ethanol causes indirect effects by altering vitamin levels. Acute alcohol ingestion changes many vitamin metabolic pathways. Folate and vitamin A metabolism can cause increased urinary excretion. Thiamine deficiency is responsible for a severe neurological consequence of excessive alcohol use—WERNICKE ' SYNDROME.

ACTIONS OF ALCOHOL ON THE BRAIN

The molecular site of alcohol's action on neurons is unknown. Alcohol may work by perturbing lipids in the cell membrane of the NEURON, interacting directly with the hydrophobic region of neuronal membrane proteins, or interacting directly with a lipid-free enzyme protein in the membrane. Ethanol alters the function of neuron-specific proteins. For example, evidence suggests that the activity of the chloride ion channel linked to the A-type receptor of the GABA NEUROTRANSMITTER increases during exposure to intoxicating amounts of alcohol. Acute exposure to alcohol effects the actions of GLUTAMATE, the major excitatory transmitter in the mammalian central nervous system. Chronic exposure to alcohol can result in TOLERANCE for and PHYSICAL DEPENDENCE on the drug. Tolerance is recognized as a chronic drinker's ability to consume increasing amounts of alcohol without displaying gross signs of intoxication. Alcohol's effects on stress may be regulated by the combination of its effect on information processing. Thus it can decrease internal conflicts and block inhibitions, thereby making social behaviors more extreme.

Free Radical Generation by Alcohol.

Free radicals are a highly reactive oxygen species. They are important components of the body's host defense, yet in high levels can cause tissue damage. Cytochrome P-450 is an oxidizing system that generates free radicals from ethanol. The reactive oxygen species include superoxide and hydrogen peroxide. They react with DNA, protein, and lipids. Products of the free radical reactions include lipid peroxides; thus alcohol's production of free radicals indirectly initiates cancer, heart disease, and other major health problems. Free radicals are produced in higher levels when ethanol and acetaldehyde begin to accumulate in cells and saturate dehydrogenases. Then other products, such as free radicals and cocaethylene (when cocaine is present), are produced.

Cholesterol and Fatty-Acid Production from Alcoholic Beverages.

Excessive ethanol intake leads to formation of ethanol- and fatty-acid-containing ethyl esters, produced by synthases. Thus tissues containing large amounts of synthases, such as the heart, would be more likely to be damaged. These products can adversely affect protein synthesis, alter cell membranes that contain large amounts of normal lipids, and suppress energy production by the cells' mitochondria. Cholesterol esterase connects cholesterol to fatty acids, thus producing fatty-acid cholesterol esters. When ethanol is present, the esterase produces fatty-acid ethyl esters with a reduction of cholesterol. Ethanol consumption modifies components of cell membranes, phospholipids, through the phospholipase D. The importance of these changes is poorly defined and understood.

Cocaethylene and Drug Metabolism.

When alcohol and cocaine are ingested together, the "high" is accentuated. Ethanol can react with CO-CAINE via the enzyme cocaine esterase, producing a potentially toxic product, COCAETHYLENE. This enzyme inactivates cocaine in the absence of ethanol. Metabolism of cocaine and other drugs occurs in large part via cytochrome P-450 IIEI. It is increased by chronic alcohol consumption. This cytochrome oxidizes ethanol in the liver as well as many other compounds, including cocaine and the pain killer acetaminophen. Oxidative products of cytochrome P-450 are more toxic than the parent compounds, and thus can accentuate liver damage.

Metabolism of Protein.

Consumption of alcoholic beverages affects the metabolism of ethanol and other alcohols, and alters the NADH/NAD ratio—the ratio of reduced nicotinamide adenine dinucleotide to oxidized nicotinamide adenine dinucleotide—which influences lipid, vitamin, and protein metabolism, membrane composition and function, and energy production. Such changes lead to indirect effects including cell damage, undernutrition, and weight loss. Chronic alcohol beverage use reduces type II muscle fibers, reducing the capacity for prolonged muscle activity and thus the ability to exercise, run, or do physical work. Loss of this fiber produces muscle pain, weakness, and damage. Reduced type II fibers may be due to lower RNA, which would indicate less protein synthesis.

Metabolism of Lipids and Fats.

Fat and lipid functions and metabolism are altered by alcohol consumption. High alcohol intakes result in changes in the ratio of NADH/NAD +, which rduces breakdown of fats and lipids. The accumulated lipids are stored in the liver, producing a fatty liver. The NADH/NAD + ratio also inhibits synthesis of cholesterol and related steroid hormones. Thus production of progesterone and and rostenedione are reduced by alcohol use. Such changes may be the cause of hypogonadism in males who consume alcohol chronically. Lipoprotein lipase is inhibited by ethanol, thus reducing removal of long acyl chains from lipids. In heart muscle this reduces available energy and could be a component of heart disease. Lipoproteins are transport molecules for fats, including cholesterol, in plasma fluids. Alcohol increases both low- and high-density lipoproteins, which could be beneficial and damaging, respectively, to the heart.

Lipids in the Function and Composition of Cell Membranes.

Membranes have lipids and proteins as major components. Ethanol clearly affects lipids and membranes directly and indirectly. Alcohol affects cell membranes directly by its entry into them. Its physical characteristics modify arrangement of lipids in the cell membrane, and hence should affect cell function directly. For example, electrolyte balance within all cells is produced by sodium and potassium ion transportation. High alcohol intake reduces the ion transporters, which causes cells to take up water and thus to swell, affecting function. In addition, cells respond to hormones and other chemicals in the plasma outside the cell membrane by signal transduction. These signals regulate the functions of the various cell types, affecting overall physiology of the body. Important enzymes in this process include phospholipases. Ethanol acts like hormones and signal molecules, changing membrane phospholipases, which should modify cell function.

ALCOHOL TRAUMA, ACCIDENTS, AND BEHAVIORAL EFFECTS

Alcohol is directly involved in injuries by altering neurological function in ways that lead to motor vehicle ACCIDENTS, plane crashes, drownings, SUICIDE, and homicide. It appears to play a role in both unintentional and intentional injuries. Nearly one-fourth of suicide victims, one-third of homicide victims, and one-third of unintentional injury victims have high BLOOD ALCOHOL CONCENTRATIONS. Alcohol was a factor in half of fatal traffic crashes and 5 percent of all deaths. It causes premature mortality (not including deaths from indirect, biochemical changes induced by long-term exposure).

Alcohol and Auto Accidents.

Alcohol consumption directly and promptly impairs many perceptual, cognitive, and motor skills needed to operate motor vehicles safely. Although in 1989 traffic fatalities involving at least one intoxicated driver or nonoccupant (pedestrian or other) decreased by half, 22,413 people were killed in alcohol-related motor vehicle crashes, representing approximately half of all traffic fatalities. The decrease in alcohol's involvement may be partially attributed to changes in MINIMUM DRINKING AGE LAWS. WOMEN drivers are involved in half as many alcohol-related car accidents as men. Impaired drivers arrested are significantly more hostile; they have greater psychopathic deviance, nontraffic arrests, and frequency of impaired driving, and they drink more than drunk drivers caught in roadblocks. Thus, impaired driving and alcohol-related accidents are part of problematic behaviors that can be directly modified by ethanol.

Alcohol and Airplane Accidents.

Alcohol has not been shown to have caused a U.S. commercial airline accident. However, it plays a direct and prominent role in general aviation accidents. Pilot function is impaired by cognitive, perceptual, and psychomotor changes due to ethanol use. Positional alcohol nystagmus may contribute to many aviation crashes involving spatial disorientation.

Alcohol and Water Accidents.

Alcohol is associated with between half and two-thirds of adult drownings. Alcohol is also important in water-related spinal cord injuries.

Alcohol and Sexual Behavior.

Via neurological changes, alcohol impairs rational thought, thus decreasing behavioral inhibitions. Alcohol is an excuse for behavior that violates social norms. Problem drinking behavior is associated with sexually transmitted disease.

Alcohol and Violence.

High alcohol consumption reduces inhibition, impairs moral judgment, and increases aggression; thus there is greater likelihood of homicide or assault resulting from fights. Frequently, alcohol use has occurred in situations that emerge spontaneously from personal disputes. Alcohol is linked to a high proportion of violence, with perpetrators more often under the influence of alcohol than victims. Very high rates of problem drinking are reported among both property and violent offenders.

(SEE ALSO: Accidents and Injuries from Alcohol; Complications)

RONALD R. WATSON

History of Drinking

The key to the importance of alcohol in history is that this simple substance, presumably present since bacteria first consumed some plant cells nearly 1.5 billion years ago, has become so deeply embedded in human societies that it affects their religion, economics, age, sex, politics, and many other aspects of human life. Furthermore, the roles that alcohol plays differ, not only from one culture to the next but even within a culture over time. A single chemical compound, used (or sometimes emphatically avoided) by a single species, has resulted in a complex array of customs, attitudes, beliefs, values, and effects. A brief review of the history of this relationship illustrates both unity and diversity in the ways people have thought about and treated alcohol. Special attention is paid to the United States as a case study of particular interest to many readers.

THE QUESTION OF ORIGINS

Ethanol, the form of alcohol desired for use to produce favorable effects, is both created naturally, in the fermentation of exposed fruits, vegetables, and grains that have become overripe, and through the intervention of people who accelerate the process by controlling the conditions of fermentation. If we assume that it is ethanol that produces a host of presumed favorable effects, as well as alcohol-related problems, then the logic of labeling some drinks "alcoholic" can be justified. It is important to remember, however, that labels are merely a social convention. No matter how great its alcohol content may be, wine is thought of as "food" in much of France and Italy—as is beer in Scandinavia and Germany. Similarly, in the United States, many people who regularly drink beer in considerable quantities do not think of themselves as using alcohol. Some fruit juices, candies, and desserts come close to having enough alcohol to be so labeled, but they are not. Thus many of the concerns that people have about alcohol relate more to their expectations than to the actual pharmacological or biochemical impact that the substance would have on the human body.

According to the Bible, one of the first things Noah did after the great Flood was to plant a vineyard (Genesis 9:21). According to the predynastic Egyptians, the great god Osiris taught people to make beer, a substance that had great religious as well as nutritional value for them. Similarly, early Greeks credited the god Dionysus with bringing them wine, which they drank largely as a form of worship. In Roman times, the god Bacchus was thought to be both the originator of wine and always present within it. It was a goddess, Mayahuel, with 400 breasts, who supposedly taught the Aztecs how to make pulque from the sap of the century plant; that mild beer is still important in the diet of many Indians in Mexico, where it is often referred to as "the milk of our Mother." In each of these instances, whether the giver was male or female, alcohol was viewed as supernatural, reflecting deep appreciation of its important roles in nourishing and comforting people.

Anthropologists often treat myths as if they were each people's own view of history, but clearly it would be difficult to take all myths at face value. We cannot know when or where someone first sampled alcohol, but we can imagine that it might well have been just an attempt to make the most of an overripe fruit or a soured bowl of gruel. The taste, or the feeling that resulted, or both, may have been pleasant enough to prompt repetition and then experimentation. Probably it happened not just once but various times, independently, at a number of different places, just as did the beginnings of agriculture.

PREHISTORY AND ARCHEOLOGY

Although it is impossible to say where or when Homo sapiens first sampled alcohol, there is firm evidence, from chemical analysis of the residues found in pots dating from 3500 B.C., that wine was already being made from grapes in Mesopotamia (now Iran). This discovery makes alcohol almost as old as farming, and, in fact, beer and bread were first produced at the same place at about the same time from the same ingredients. We know little about the gradual process by which people learned to control fermentation, to blend drinks, or to store and ship them in ways that kept them from souring, but the distribution of local styles of wine vessels serves as a guide to the flow of commerce in antiquity.

It would be misleading to think of early wines and beers as similar to the drinks we know today. In a rough sense, the distinction between them is that a wine is generally derived from fruits or berries, whereas a beer or ale comes from grain or a grain-based bread. Until as recently as A.D. 1700, both were often relatively dark, dense with sediments, and extremely uneven in quality. Usually handcrafted in small batches, home-brewed beers tend to be highly nutritious but to last only a few days before going sour (i.e., before all the fermenting sugars and alcohol are depleted and become vinegar). By contrast, homemade wines have relatively little in the way of vitamins or minerals but can last a long time if adequately sealed.

In Egypt between 2700 and 1200 B.C., beer was not only an important part of the daily diet; it was also buried in royal tombs and offered to the deities. Many of the paintings and carvings in Egyptian tombs depict brewing and drinking; early papyri include commercial accounts of beer, a father's warning to his student son about the danger of drinking too much, praises to the god who brought beer to earth, and other indications of its importance and effects.

The earliest written code of laws we know, from Hammurabi's reign in Babylon around 2000 B.C., devoted considerable attention to the production and sale of beer and wine, including regulations about standard measures, consumer protection, and the responsibilities of servers.

In ancient Greece and Rome (roughly 800 B.C.-A.D. 400), there was wider diffusion of grape-growing north and westward in Europe, and wine was important for medicinal and religious purposes, although it was not yet a commonplace item in the diet of poor people. The much-touted sobriety of the Greeks is presumably based on their custom of diluting wine with water and drinking only after meals, in contrast to neighboring populations who often sought drunkenness through beer as a transcendental state of altered consciousness. Certainly heavy drinking was an integral part of the religious orgies that, commemorating their deities, we now call "Dionysiac" (or, in the case of Rome, "Bacchic"). The temperate stereotype also overlooks the infamous chronic drunkenness of Alexander the Great. Born in Macedon, in 356 B.C., he managed to conquer most of the known world in his time, by 325 B.C., bringing what are now Egypt and most of the Middle East under the rule of Greece before he died in 323 B.C.

Romans were quick to point out how their relative temperance contrasted with the boisterous heavy drinking of their tribal neighbors in all directions, whom they devalued as the bearded ones, "barbarians." To a remarkable degree, the geographic spread of Latin-based languages and grape cultivation coincided with the spread of the Roman Empire through Europe and the accompanying diffusion of the Mediterranean diet—rich in carbohydrates and low in fats and protein—with wine as the usual beverage. In striking contrast were non-Latin speakers, who were less reliant on bread and pasta and without olive oil; they drank beers and meads, with drunkenness more common. Plato considered wine an important adjunct to philosophical discussion, and St. Paul recommended it as an aid to digestion.

The Hebrews established a new pattern around the time of their return from the Babylonian exile, and the construction of the Second Temple (c. 500 B.C.). Related to a new systematizing of religious practices was a strong shift toward family rituals, in which the periodic sacred drinking of wine was accompanied by a pervasive ethic of temperance, a pattern that persists today and often marks drinking by religious Jews as different from that of their neighbors. Early Christians (many of whom had been Jews), praised the healthful and social benefits of wine while condemning drunkenness. A majority of the many biblical references to drinking are clearly favorable, and Jesus' choice of wine to symbolize his blood is perpetuated in the solemn rite of the Eucharist, which has become central to practice in many Christian churches as Holy Communion.

In the Iron Age in France (c. 600 B.C.), distinctive drinking vessels found in tombs strongly suggest that political leadership involved the redistribution of goods to one's followers, with wine an important symbol of wealth. Archeologists have learned so much about the style and composition of pots made in any given area that they can often trace routes and times of trade, military expansion, or migrations by noting where fragments of drink containers are found. Although we know little about Africa at that time, we assume that mild fermented home brews (such as banana beer) were commonplace, as they were in Latin America. In Asia, we know most about China, where as early as 2000 B.C. grain-basedbeer and wine were used in ceremony, offered to the gods, and included in royal burials. Most of North America and Oceania, curiously, appear not to have had any alcoholic beverages until contact with Europeans.

Alcohol in classical times served as a disinfectant and was thought to strengthen the blood, stimulate nursing mothers, and relieve various ills, as well as to be an ideal offering to both gods and ancestral spirits. Obviously, drink and drinking had highly positive meanings for early peoples, as they do now for many non-Western societies.

FROM 1000 TO 1500

The Middle Ages was marked by a rapid spread of both Christianity and Islam. Large-scale political and economic integration spread with them to many areas that had previously seen only local warring factions, and sharp social stratification between nobles and commoners was in evidence at courts and manors, where food and drink were becoming more elaborate. National groups began to appear, with cultural differences (including preferred drinks and ways of drinking) increasingly noted by travelers, of whom there were growing numbers. Excessive drinking by poor people was often criticized but may well have been limited to festive occasions. With population increases, towns and villages proliferated, and taverns became important social centers, often condemned by the wealthy as subverting religion, political stability, and family organization. But for peasants and craftspeople, the household was still often the primary economic unit, with home-brewed beer being a major part of the diet.

During this period, hops, which enhanced both the flavor and durability of beer, were introduced. In Italy and France, wine became even more popular, both in the diet and for expanding commerce. Distillation had been known to the Arabs since about 800, but among Europeans, a small group of clergy, physicians, and alchemists monopolized that technology until about 1200, producing spirits as beverages for a limited luxury market and for broader use as a medicine. Gradual overpopulation was halted by the Black Death (a pandemic of bubonic plague), and schisms in the Catholic church resulted in unrest and political struggles later in this period.

Across northern Africa and much of Asia, populations, among whom drinking and drunkenness had been lavishly and poetically praised as valuable ways of altering consciousness, became temperate and sometimes abstinent, in keeping with the tenets of Islam and the teachings of Buddha and of Confucius. China and India both had episodes of prohibition, but neither country was consistent. In the Hindu religion, some castes drank liquor as a sacrament, whereas others scorned it—vivid proof that a culture, in the anthropological sense (as a set of beliefs and practices that guide one through living), is often much smaller than a religion or a nation, although we sometimes tend to think of those larger entities as more homogenous than they really are.

As the Middle Ages gave way to the Renaissance, both the population and the economy expanded throughout most of Europe. Because the Arabs (who had ruled from 711 to 1492) had been expelled from Spain and Portugal, they cut off overland trade routes to Asia; European maritime exploration therefore resulted in increasing commerce all around the coasts of Africa. The so-called Age of Exploration led to the startling encounter with high civilizations and other tribal peoples who had long occupied North America, Central America, and South America. Ironically, alcoholic beverages appear to have been totally unknown north of Mexico, although a vast variety of beers, chichas, pulques, and other fermented brews were important in Mexico as foods, as offerings to the gods and to ancestral spirits, and as shortcuts to religious ecstasy—if we assume that Native Americans then lived much as those who were soon to be described by the European conquerors and missionaries.

Throughout sub-Saharan Africa, we assume, home-brewed beers were plentiful nutritious, and symbolically important, as they came to be described in later years.

During the Middle Ages, drinking was treated as a commonplace experience, little different from eating, and drunkenness appears to have been infrequent, tolerated in association with occasional religious festivals and of little concern in terms of health or social welfare. Alcoholic beverages themselves were becoming more diverse but still were thought to be invigorating to humans, appreciated by spirits, and important to sociability.

FROM 1500 TO 1800

Wealth and extravagance were manifest in the rapidly growing cities of Europe, but so were poverty and misery, as class differences became even more exaggerated. The Protestant Reformation, which set out to separate sacred from secular realms of life, seemed to justify an austere morality that included injunctions against celebratory drunkenness. If the body was the vessel of the spirit, which itself was divine, one should not desecrate it with long-term heavy drinking. Puritans viewed intoxication as a moral offense—although they drank beer as a regular beverage and appreciated liquor for its supposed warming, social, and curative properties. Public drinking establishments evolved, sometimes as important town meeting places and sometimes as the workers' equivalent of social clubs, with better heat and lighting than at home, with news and gossip, games and companionship. COFFEE, TEA, and CHOCOLATE were also introduced to Europe at this time, and each became popular enough to be the focus of specialized shops. But each was also suspect for a time, while physicians debated whether they were dangerous to the health; clergy debated their effects on morality; and political and business leaders feared that retail outlets would become breeding places of crime, labor unrest, and civil disobedience. Brandies (brantwijns, liquor distilled from wines to be shipped as concentrates) spread among the aristocracy, and champagne was introduced as a luxury beverage (wine), as were various cordials and liqueurs. Brewing and wine-making grew from cottage industries to major commercial ventures, incorporating many technical innovations, quality controls, and other changes.

The "gin epidemic" in mid-eighteenth-century London is sometimes cited as showing how urban crowding, cheap liquor, severe unemployment, and dismal working conditions combined to produce widespread drinking and dissolution, but the vivid engravings by William Hogarth may exaggerate the problem. At the same time, the artist extolled beer as healthful, soothing, and economically sound. In France, even peasants began to drink wine regularly. In 1760, Catherine the Great set up a state monopoly to profit from Russia's prodigious thirst, and Sweden followed soon after.

Throughout Latin America and parts of North America, the Spanish and Portuguese conquistadors found that indigenous peoples already had home brews that were important to them for sacred, medicinal, and dietary purposes. The Aztecs of Mexico derived a significant portion of their nutritional intake from pulque but reserved drunkenness as the prerogative of priests and old men. Cultures throughout the rest of the area similarly used chicha or beer made from maize, manioc, or other materials. The Yaqui (in what is now Arizona) made a wine from cactus as part of their rain ceremony, and specially made chicha was used as a royal gift by the Inca of Peru. Religious and political leaders from the colonial powers were ambivalent about what they perceived as the risks of public drunkenness and the profits to be gained from producing and taxing alcoholic beverages. A series of inconsistent laws and regulations, including sometime prohibition for Indians, were probably short-lived experiments, affected by such factors as local revolts and different opinions among religious orders.

As merchants from various countries competed to gain commercial advantage in trading with the various Native American groups of North America, liquor quickly became an important item. It has become popular to assume that Native Americans are genetically vulnerable to alcohol, but some tribes (such as Hopi and Zuni) never accepted it, and others drank with moderation. The Seneca, in New York state, are an interesting case study, because they went from having no contact with alcohol through a series of stages culminating in a religious ban. When brandy first arrived, friends would save it for an unmarried young man, who would drink it ceremoniously to help in his required ritual quest for a vision of the animal that would become his guardian spirit. In later years, drinking became secular, with anyone drinking and boisterous brawling a frequent outcome. In 1799, when a tribal leader, who was already alcoholic, had a very different kind of vision, he promptly preached abstention from alcohol, an end to warfare, and devotion to farming—all of which remain important today in the religion that is named after him, Handsome Lake.

Throughout the islands of the Pacific, local populations reacted differently to the introduction of alcohol, sometimes embracing it enthusiastically and sometimes rejecting it. Eskimos were generally quick to adopt it, as were Australian Aborigines, to the extent that some interpret their heavy drinking as an attempt to escape the stresses of losing valued parts of their traditional ways of life. Detailed information about the patterns of belief and behavior associated with drinking among the diverse populations of Asia and Africa vividly illustrates that alcohol results in many kinds of comportment—depending more on sociocultural expectations than any qualities inherent in the substance.

In what is now the United States, colonial drinking patterns reflected those of the countries from which immigrants had come. Rum (distilled from West Indies sugar production) became an important item in international trade, following routes dictated by the economic rules of the British Empire. In the infamous Triangle Trade, captive black Africans were shipped to the West Indies for sale as slaves. Many worked on plantations there, producing not only refined sugar, a sweet and valuable new faddish food, but also molasses, much of which was shipped to New England. Distillers there turned it into rum, which was in turn shipped to West Africa, where it could be traded for more slaves. During the American Revolution (1775/6-1783), however, that trade was interrupted and North Americans shifted to whiskey. Farmers along what was then the frontier, still east of the Mississippi, were glad to have a profitable way of using surplus corn that was too bulky to bring to distant markets. After the war, when the first federal excise tax was imposed (on whiskey) in 1790, to help cut the debt of the new United States, producers' anger about a tax increase was expressed in the Whiskey Rebellion of 1794. To quell the uprising, federal troops (militia) were used for the first time. At about the same time, Benjamin Rush, a noted physician and signer of the Declaration of Independence, started a campaign against long-term heavy drinking as injurious to health.

Evidently, alcohol plays many roles in the history of any people, and changes in attitudes can be abrupt, illustrating again the importance that social constructions of reality have in relation to drinking.

THE 1800s

The large-scale commercialization of beer, wine, and distilled liquor spread rapidly in Europe as many businesses and industries became international in scope. Large portions of the European proletariat were no longer tied to the land for subsistence, and new means of transportation facilitated vast migrations. The industrial revolution was not an event but a long process, in which, for many people, work became separated from home. The arbitrary pace imposed by wage work contrasted markedly with the seasonal pace of traditional agrarianism.

In some contexts neighbors still drank while helping each other—as, for example, in barn-raising or reciprocal labor exchange during the harvest. But for the urban masses, leisure and a middle class emerged as new phenomena. Drinking, which became increasingly forbidden in the workplace as dangerous or inefficient, gradually became a leisure activity, often timed to mark the transition between the workday and home life. As markets grew, foods became diverse, so that beers and ciders (usually hard) lost their special value as nourishing and energizing.

In Europe, political boundaries were approximately those of the twentieth century; trains and steamships changed the face of trade; and old ideas about social inequality were increasingly challenged. Alcohol lost much of its religious importance as ascetic Protestant groups, and even fervent Catholic priests in Ireland, associated crime, family disruption, unemployment, and a host of other social ills with it, and taxation and other restrictions were broadly imposed. In Russia, the czar ordered prohibition, but only briefly as popular opposition mounted and government revenues plummeted. Those who paid special attention to physical and mental illnesses were quick to link disease with long-term heavy drinking, although liquor remained an important part of medicine for various curative purposes. A few institutions sprang up late in the nineteenth century to accommodate so-called inebriates, although there was little consensus about how or why drinking created problems for some people but not for others, nor was there any systematic research.

A wave of mounting religious concern that has been called the "great awakening" swept over the United States early in the 1800s, and, by 1850, a dozen states had enacted prohibition. Antialcohol sentiment was often associated with opposition to slavery. The local prohibition laws were repealed as the Civil War and religious fervor abated, and hard drinking became emblematic of cowboys, miners, lumberjacks, and other colorful characters associated with the expanding frontier. Distinctions of wealth became more important than those of hereditary social status, and a wide variety of beverages, of apparatus associated with drinking, and even of public drinking establishments accentuated such class differences.

Near the end of the century, another wave of sentiment against alcohol grew, as large numbers of immigrants (many of them Catholic and anything but ascetic) were seen by Protestant Yankees as trouble—competing for jobs, changing the political climate, and challenging old values. Coupled with this attitude was enthusiasm for "clean living," with an emphasis on natural foods, exercise, fresh air and water, loose-fitting clothing, and a number of other fads that have recently reappeared on the scene.

Native American populations, in the meantime, suffered various degrees of displacement, exploitation, and annihilation, sometimes as a result of deliberate national policy and sometimes as a result of local tensions. The stereotype of the drunken Indian became embedded in novels, news accounts, and the public mind, although the image applied to only a small segment of life among the several hundred native populations. Some Indians remained abstinent and some returned to abstinence as part of a deliberate espousal of indigenous values—for example, in the Native American Church, using PEYOTE as a sacrament, or in the sun dance or the sweat lodge, using asceticism as a combined religious and intellectually cleansing precept.

From Asia, Africa, and Oceania, explorers, traders, missionaries, and others brought back increasingly detailed descriptions of non-Western drinking practices and their outcomes. It is from such ethnographic reports—often sensationalized—that we can guess about the earlier distribution of native drinks and can recognize new alcoholic beverages as major commodities in the commercial exploitation of populations. Although some of the sacramental associations of traditional beverages were transferred to new ones, the increasing separation of brewing from the home, the expansion of a money-based economy, and the apparent prestige value of Western drinks all tended to diminish the significance of home brews. In African mines, Latin American plantations, and even some U.S. factories, liquor became an integral part of the wage system, with workers required to accept alcohol in lieu of some of their cash earnings. In some societies where drinking had been unknown before Western colonization, the rapid spread of alcohol appears to have been an integral part of a complex process that eroded traditional values and authority.

THE TWENTIETH CENTURY

It has been said that the average person's life in 1900 was more like that of ancestors thousands of years earlier than like that of most people today. The assertion certainly applies to the consumption of liquor. Pasteurization, mass production, commercial canning and bottling, and rapid transport all transformed the public's view of beer and wine in the twentieth century. The spread of ideas about individualism and secular humanism loosened the hold of traditional religions on the moral precepts of large segments of the population. New assumptions about the role of the state in support of public health and social welfare now color our expectations about drinking and its outcomes. Mass media and international conglomerates are actively engaged in the expansion of markets, especially into developing countries.

World War I prompted national austerity programs in many countries that curtailed the diversion of foodstuffs to alcoholic beverages but didn't quite reach the full prohibition for which the United States became famous. Absinthe was thought to be medically so dangerous that it was banned in several European countries, and Iceland banned beer but not wine or liquor. Sweden experimented with rationing, and the czar again tried prohibition in Russia. The worldwide economic depression of the 1930s appears to have slowed the growth of alcohol consumption, which grew rapidly during the economic boom that followed World War II. The Scandinavian countries, beset by a pattern of binge drinking, often accompanied by violence, tried a variety of systems of regulation, including state monopolies, high taxation, and severely restricted places and times of sale, before turning to large-scale social research.

While several Western countries were expanding their spheres of influence in sub-Saharan Africa, they agreed briefly on a multinational treaty that outlawed the sale of alcoholic beverages there, although they did nothing to curtail production of domestic drinks by various tribal populations. A flurry of scientific analyses of indigenous drinks surprised many by demonstrating their significant nutritional value, and more detailed ethnographic studies showed how important they were in terms of ideology, for vows, communicating with supernatural beings, honoring ancestors, and otherwise building social and symbolic credit—among native societies not only in Africa but also in Latin America and Asia. Closer attention to the social dynamics of drinking and other aspects of culture showed that the impact of contact with Western cultures is not always negative and that for many peoples the role of alcohol remained diverse and vital.

In the United States, a combination of religious, jingoistic, and unsubstantiated medical claims resulted in the enactment of nationwide prohibition in 1919. Often called "the noble experiment," the Eighteenth Amendment to the Constitution was the first amendment to deal with workaday behavior of people who have no important public roles. It forbade commercial transaction but said nothing about drinking or possession. Most authorities agree that, during the early years, there was relatively little production of alcoholic beverages and not much smuggling or home production. It was not long, however, before illegal sources sprang up. Moonshiners distilled liquor illegally, and bootleggers smuggled it within the U.S. or from abroad. Speakeasies sprang up as clandestine bars or cocktail lounges, and a popular counterculture developed in which drinking was even more fashionable than before prohibition. Some entrepreneurs became immensely wealthy and brashly confident and seemed beyond the reach of the law, whether because of superior firepower or corruption or both. The government had been suffering from the loss of excise taxes on alcohol, which accounted for a large part of the annual budget. The stock-market crash, massive unemployment, the crisis in agriculture, and worldwide economic depression aggravated an already difficult situation, and civil disturbances spread throughout the country. Some of the same influential people who had pressed strongest for prohibition reversed their stands, and the Twenty-first Amendment, the first and only repeal to affect the U.S. Constitution, did away with federal prohibition in 1933. Although the national government retained close control over manufacturing and distribution to maximize tax collection, specific regulations about retail sales were left up to the states. An odd patchwork of laws emerged, with many states remaining officially dry, others allowing local option by counties or towns, some imposing a state monopoly, some requiring that drinks be served with food and others expressly prohibiting it, some insisting that bars be visible from the street and others the opposite, and so forth. The last state to vote itself wet was Mississippi, in 1966, and many communities remain officially dry today. The older federal law prohibiting sales to Indians was not repealed until 1953, and many Indian reservations and Alaska native communities remain dry under local option.

The experience of failed prohibition in the U.S. is famous, but a similar combination of problems with lawlessness, corruption, and related issues led to repeal, after shorter experiments, in Iceland, Finland, India, Russia, and parts of Canada, demonstrating again that such drastic measures seem not to work except where supported by consensus and religious conviction (e.g., Saudi Arabia, Iran, and Ethiopia). It is ironic that some Indian reservations with prohibition have more alcohol-related deaths than those without. A more salutary recent factor is the growth of culturally sensitive programs of prevention and treatment that are being developed, often by the communities themselves, for Indian and other minority populations.

In the middle decades of the twentieth century, a number of alcoholics formed a mutual-help group, modeled on the earlier Washingtonians, and ALCOHOLICS ANONYMOUS has grown to be an international fellowship of individuals whose primary purpose is to keep from drinking. At about the same time, scientists from a variety of disciplines started studying various aspects of alcohol, and our knowledge has grown rapidly. Because of the large constituency of recovering alcoholics, the subject has become politically acceptable, and the disease concept has overcome much of the moral stigma that used to attach to alcoholism. Establishment of a National Institute on Alcohol Abuse and Alcoholism in 1971 signaled a major government commitment to the field, and its incorporation among the National Institutes of Health in 1992 indicates that concerns about wellness have largely displaced theological preoccupations.

Consumption of all alcoholic beverages increased gradually in the U.S. from repeal until the early 1980s, with marked increase following World War II, although it never reached more than one-third of what is estimated for the corresponding period a century earlier. Around 1980, sales of spirits started dropping and have continued to do so. A few years later, wine sales leveled off and have gradually fallen since; beer sales also appear to have passed their peak even more recently. These reductions occurred, despite increasing advertising, along with a return of the "clean living" movement and another shift toward physical exercise, less-processed foods, and concern for health. Linked with the reduction in drinking, what some observers call a "new temperance movement" has emerged, in which individuals not only drink less but call for others to do the same; the decline would be enforced by laws and regulations that would increase taxes, index liquor prices to inflation, diminish numbers and hours of sales outlets, require warning labels, ban or restrict advertising, and otherwise reduce the availability of alcohol. Such a "public health approach" is by no means limited to the U.S.; its popularity is growing throughout Europe and among some groups elsewhere, even as alcohol consumption continues to rise in Asia and many developing countries.

CURRENT IMPLICATIONS

A quick review of the history of alcohol lends a fresh perspective to the subject. The vast literature on ethnographic variation among populations demonstrates the different ways in which peoples, widely separated geographically and historically, have used and thought about alcohol. The idea of alcohol as being implicated in a set of problems is peculiar to the recent past and is not yet generally accepted in many areas.

What some observers call the "new temperance movement" and others call "neoprohibitionism" is a recent phenomenon that grew out of Scandinavian social research. The conclusion, on the basis of transnational comparisons, was that there appeared to be some relationship between the amount of alcohol people drink and a broad range of what the researchers called "alcohol-related problems" (including spouse abuse, child neglect, social violence, psychiatric illness, a variety of organic damages, and traffic fatalities). The vague and general findings gradually came, through a process of misquotation and paraphrasing, to be treated as a pseudoscientific iron-clad law, to the effect that problems are invariably proportionate to consumption, so that the most effective way to diminish problems would be to cut drinking. This approach is sometimes called the "control of consumption model," or the "single distribution model" (referring to the fact that heavy drinkers are on the same distribution-of-consumption curve as low and moderate drinkers, with no clear points that would objectively divide the groups).

This movement is not restricted to the U.S. and Scandinavia, however. The World Health Organization of the United Nations called for a worldwide reduction, by 25 percent, of alcohol consumption during the last decade and a half of the twentieth century, recommending that member countries adopt similar policies. Throughout most of central and western Europe and North America, sales have fallen markedly, although the opposite trend can be seen in much of the third world. An ironic development has been recent loosening of controls in Scandinavian countries, traditionally the exemplars of that approach, while controls are being introduced and progressively tightened in southern Europe, where drinking has traditionally been an integral part of the culture.

The European Community standardization of tariffs may result in further changes soon. A more realistic way of lessening whatever problems may be related to alcohol consumption would appear to be the "sociocultural model" of prevention, emphasizing, on the basis of cross-cultural experience, that people can learn to drink differently, to expect different outcomes from drinking, and actually to find their expectancies fulfilled. This program would not be quick or easy, requiring intensive public education, but it seems more feasible than simply curtailing availability—in which case those who enjoy moderate drinking would be inconvenienced but those who insist on drinking heavily would continue to do so. Concern over policy is not only directed at helping individuals who may have become dependent; it also has the aim of making life safer and more pleasant for all. The history of alcohol indicates that problems are by no means inherent in the substance but, rather, are mediated by the individual user and by social norms.

(SEE ALSO: Beers and Brews; Temperance Movement; Treatment, History of)

DWIGHT B. HEATH

REVISED BY ANDREW J. HOMBURG

Psychological Consequences of Chronic Abuse

Chronic alcohol abuse (heavy drinking over a long period) can lead to numerous adverse effects—to direct effects such as impaired attention, increased ANXIETY, depression, and increased risk-taking behaviors—and to indirect affects such as impaired cognitive abilities, which may be linked to nutritional deficiencies from long-term heavy drinking.

A major difficulty in describing the effects of chronic alcohol abuse is that many factors interact with such consumption, resulting in marked individual variability in the psychological consequences. In addition, defining both what constitutes chronicity and abusive drinking in relation to resulting behavioral problems is not simply a function of frequency and quantity of alcohol consumption. For some individuals, drinking three to four drinks per day for a few months can result in severe consequences, while for others, six drinks per day for years may not have any observable effects. One reason for this variability is related to genetic differences in the effects of alcohol upon an individual. While not all of the variability can be linked to genetic predispositions, it has been demonstrated that the interactions between individual genetic characteristics and environmental factors are important in determining the effects of chronic alcohol consumption.

Other factors to consider when assessing the effects of chronic drinking relate to the age and sex of the drinker. In the United States, heavy chronic drinking occurs with the greatest frequency in white men, ages nineteen to twenty-five. For the majority of individuals in this group, heavy drinking declines after age twenty-five to more moderate levels and then decreases to even lower levels after age fifty. As might be expected, the type and extent of psychological consequences depend on the age of the chronic drinker. Research has indicated that younger problem drinkers are more likely to perform poorly in school, have more arrests, and be more emotionally disturbed than older alcoholics. Also, younger drinkers have more traffic accidents, which may result from a combination of their heavy drinking and increased risk-taking behavior. Many of the more serious consequences of chronic alcohol use occur more frequently in older drinkers—individuals in their thirties and forties; these include increased cognitive and mental impairments, divorce, absenteeism from work, and suicide. Chronic drinking in women tends to occur more frequently during their late twenties and continuing into their forties—but the onset of alcohol-related problems appears to develop more rapidly in women than in men. In a study of ALCOHOLICS ANONYMOUS members, women experienced serious problems only seven years after beginning heavy drinking, as compared to an average of more than eleven years for men.

Black and Hispanic men in the United States tend to show prolonged chronic drinking beyond the white male's reduction period during his late twenties. Thus, for many of the effects of chronic drinking discussed below, age, sex, and duration of drinking are important factors that mediate psychological consequences.

NEGATIVE CONSEQUENCES

In the early 1990s, it was estimated that between 7 and 10 percent of all individuals drinking alcoholic beverages will experience some degree of negative consequences as a result of their drinking pattern. Most people believe that chronic excessive drinking results in a variety of behavioral consequences, including poor work/school performance and inappropriate social behavior. These two behavioral criteria are used in most diagnostic protocols when determining if a drinking problem exists. Several surveys have found that heavy chronic drinking does produce a variety of school- and job related problems. A survey of personnel in the U.S. armed services found that for individuals considered heavy drinkers, 22 percent showed job-performance problems. Health professionals also show high rates of alcohol problems, with a late 1980s British survey indicating that physicians experience such problems at a rate of 3.8 times that of the general population. A variety of surveys have consistently shown that chronic excessive drinking leads to loss of support by moderate-drinking family and friends. The dissolution of marriage in couples in which only one member drinks is estimated to be over 50 percent. Often the interpersonal problems that surround a problem drinker can lead to family violence; a 1980s study found that more than 44 percent of men with alcohol problems admitted to physically abusing their wives, children, or significant-other living partners. Survey data also indicate that people who use alcohol frequently are more likely to become involved with others who share their drinking patterns—particularly those who do not express concern about the individual's excessive and altered behavior that results from drinking. This increased association with fellow heavy drinkers as one's main social-support network can itself result in increased alcohol use.

The interaction between the social setting and the individual, the current level of alcohol intoxication, and past drinking history all play a role in the psychological consequences of chronic heavy drinking. It is impossible to determine which changes in behavior result only from the use of alcohol.

Depression.

One major psychological consequence resulting from heavy chronic drinking for a subpopulation of alcohol abusers (predominantly women) is the feeling of loss of control over one's life, commonly manifested as depression. (While not conclusive, some studies suggest that the menstrual cycle may be an additional factor for this population.) In many cases, increased drinking occurs as the depression becomes more intense. It has been postulated that the increased drinking is an attempt to alleviate the depression. Unfortunately, since this "cure" usually has little success, a vicious drinking cycle ensues. While no specific causality can be assumed, research on suicide has indicated that chronic alcohol abuse is involved in 20 to 36 percent of reported cases. The level of suicide in depressed individuals with no alcohol abuse is somewhat lower—about 10 percent. At this time, it is not clear if the chronic drinking results in depression or if the depression is a pre-existing psychopathology, which becomes exacerbated by the drinking behavior. The rapid improvement of depressive symptoms seen in the majority of alcoholics within a few weeks of detoxification (withdrawal) suggests that, for many, depressive symptoms are reflective of toxic effects of alcohol. Regardless of the mechanism, it appears that the combination of depression and drinking can be a potent determinant for increasing the potential to commit suicide.

Aggression.

For another subpopulation of chronic alcohol abusers (mainly young men), an increase in overall aggressive behaviors has been reported. Again, there is an indication that these individuals represent a group that has an underlying antisocial personality disorder, which is exacerbated by chronic alcoholic drinking.

Sex Drive.

Although it is often assumed that alcohol increases sexual behavior, chronic excessive use has been found to decrease the level of sexual motivation in men. In some gay male populations, where high alcohol consumption is also associated with increased high-risk sexual activity, this decrease in sex drive does not appear to result; however, for many chronic male drinkers, a long-term consequence of heavy drinking is reduced sexual arousal and drive. This may be the combined result of the decreased hormonal levels produced by the heavy drinking and the decline of social situations where sexual opportunities exist.

Cognitive Changes.

Perhaps the best-documented changes in psychological function resulting from chronic excessive alcohol use are those related to cognitive functioning. While no evidence exists for any overall changes in basic intelligence, specific cognitive abilities become impaired by chronic alcohol consumption. These most often include visuo-spatial deficits, language (verbal) impairments, and in more severe cases, memory impairments (alcoholic amnestic syndrome). A specific form of dementia, alcoholic dementia, has been described as occurring in a small fraction of chronic alcohol abusers. The pattern and nature of the cognitive effects, as measured on neuropsychiatric-assessment batteries in chronic alcohol abusers, exhibit a wide variety of individual patterns. Also, up to 25 percent of chronic alcoholics tested show no detectable cognitive deficits. Although excessive alcohol use has been clearly implicated in such deficits, a variety of coexisting lifestyle behaviors might be responsible for the cognitive impairments observed. For example, poor eating habits leading to vitamin deficiencies result in cognitive deficits similar to those observed in some alcohol abusers. Head trauma from accidents, falls, and fights (behaviors frequent in heavy drinkers) may also produce similar cognitive deficits. Therefore, it is extremely difficult to determine the extent to which alcohol abuse is directly responsible for the impairments—or if they are a result of the many alterations in behaviors that become part of the heavy-drinker lifestyle.

The specific psychological consequences of chronic drinking are complex and variable, but there is clear evidence that chronic abuse of alcohol results in frequent and often disastrous problems for the drinker and for those close to him or her.

(SEE ALSO: Aggression and Drugs: Research Issues; Complications)

HERMAN H. SAMPSON

NANCY L. SUTHERLAND

REVISED BY ANDREW J. HOMBURG